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MedSurg II - Pulm HTN, Organ Transplant

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olanjones's version from 2017-03-09 17:23

Pulmonary HTN

Question Answer
Pulmonary HTN↑pulm artery pressure from ↑blood flow through pulm circulation (nl = 12-16 mmHg; pulm htn = >25 mmHg)
Secondaryseen in COPD pt w/ RV hypertrophy/Cor Pulmonale/MVS
WHO ClassificationI: PH w/no limitations in activity
II: slight activity limitation (DOE, fatigue, CP, near syncope), comfortable at rest
III: Pronouced activity limitation (less than ordinary activity causes symptoms), comfortable at rest
IV: Any activity causes symptoms, s/s RHF, may have symptoms at rest
S/Sdyspnea on exertion/fatigue, dizziness, exertional chest pain (↓cardiac output, ↑O2 demand)
Tx for primaryrelieve symptoms, ↑quality of life, prolong life; drugs to promote dilation of pulm vessels, ↓RV overload, reverse remodeling; also diruetics, anticoag, O2 (candidate for lung transplant)
Tx for secondarytreat underlying problem (ex: COPD); O2, diruetics, bronch/vasodialtors, ↓sodium diet, CCB, anticoag (also lung transplant)
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Organ Transplant

Question Answer
Common transplantscorneas, skin, bone marrow, heart valves, bone, & connective tissues; heart, lung, liver, kidney, pancreas, & intestine (organ transplant may be whole or parts)
Contraindication for transplantHIV, Hep B & C, Cancer in past 2 years, liver/renal failure, poor nutritional status, poor rehabilitation status
Matching donor & recipientABO blood (do not need same Rh) & HLA typing (some organs require closer histocompatibility than others), medical urgency, time on the waiting list, & geographic location
Panel of Reactive antibodiesrecipient’s sensitivity to various HLAs before receiving a transplant; recipient’s serum is mixed with a randomly selected panel of donor lymphocytes to determine reactivity
Crossmatchserum from the recipient mixed with donor lymphocytes to test for any preformed anti HLA antibodies to the potential donor organ; positive crossmatch indicates that the recipient has cytotoxic antibodies to the donor and is an absolute contraindication to transplantation
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Transplant Tx

Question Answer
Transplantation ComplicationsSurgical (bleeding, vascular thrombosis, anastamosis leakage), Graft Rejection-Hyperacute, Acute, Chronic. Infection, Organ Dysfunction, Malignancy, Medication Related: Hypertension, Nephrotoxicity, Hepatotoxicity, Osteoporosis, Diabetes, Weight gain, Bone Marrow Suppression
Post-op Nursing ConsiderationsHemodynamic Stability- Pressure, CVP monitoring, hypothermia, bleeding, EKG readings, drains, strict I & O, Monitor for s/s of infection- Meticulous hand washing! Look to remove tubes and drains as soon as possible, Monitor for s/s of rejection, Start immunosuppressive meds, Start patient & family teaching
Hyperacute Rejection Occurs minutes to hours after transplantation because the blood vessels are rapidly destroyed; occurs because the person had preexisting antibodies against the transplanted tissue or organ; There is no treatment for hyperacute rejection- transplanted organ is removed
S/S Lung Transplant Rejection Fever/Malaise, Dyspnea, Nonproductive Cough, ↓O2 sats (5-10 days post tx); biggest concern is infection d/t immunosuppression (35% will get bacterial infection in 1st year) – most rejections will look similar to this
Acute Rejection Occurs w/in first 6 months- 40-50% experience, mediated by the recipient’s lymphocytes; Usually reversible w/ additional immunosuppressive therapy, may include ↑corticosteroid doses or polyclonal or monoclonal antibodies
Chronic Rejection Occurs over months or years and is irreversible; Transplanted organ is infiltrated with large numbers of T&B cells in an ongoing, lowgrade, immune-mediated injury; results in fibrosis & scarring
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Immunosuppression

Question Answer
Immunosuppressive TherapyGoal: immunocompromise the patient enough so that they do not reject the transplanted organ, but not so much that they develop infection or neoplasm (↑risk for both – most long-term tx pts die of cancer); most pts on initially on triple therapy (calcineurin inhibitor, a corticosteroid, and mycophenolate mofetil), may be weaned off the steroid after a few years
Calcineurin inhibitorfoundation of most immunosuppression regimens; these drugs prevent a cell-mediated attack against the transplanted organ but do not cause bone marrow suppression or alter normal inflammatory response (grapefruit prevents metabolism of this drug, can ↑toxicity
Mycophenolate mofetillymphocyte-specific inhibitor of purine synthesis w/ suppressive effects on both T&B lymphocytes; has been shown to ↓incidence of late graft loss (major limitation of drug- GI toxicities, inc N&V, diarrhea)
Monoclonal antibodiesused to prevent & treat acute rejection episodes; anti-antigen receptor antibody that interferes w/ function of T lymphocyte, the pivotal cell in the response to graft rejection (SE: fever, rigors, headache, myalgias, &GI disturbances)
Polyclonal antibodiesused as induction therapy or to treat acute rejection; drug is made by immunizing horses w/ human lymphocytes. The antibody made against the human lymphocytes is then purified & administered IV (SE: fever, arthralgias, tachycardia- can usu be attenuated by slow admin (4 -6 hrs) & premed w/acetaminophen, diphenhydramine & methylprednisolone
Corticosteroids(Solumedrol & Prednisone) Suppress inflammatory response. Inhibit cytokine production, Tcell activation & proliferation. SE: ↑BS, weight gain, bone disorders, muscle weakness, delayed healing, ↑infection risk
Graft vs Host diseaseoccurs when an immunoincompetent pt receives immunocompetent cells - the graft (donated tissue) rejects the host (recipient) tissue; occurs 7 - 30 days after transplantation once started little can be done to stop it; immunosuppressive agents (e.g., methotrexate, cyclosporine) has been most effective to prevent rather than to treat (target organs for GVHD – skin, liver, GI tract)
Biggest problem with GVHDInfection, with different types of infections seen in different periods (bacterial & fungal immediately after transplant; concern of interstitial pneumonitis later in the course of the disease)
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