MedSurg II - Pulm HTN, Organ Transplant

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)

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

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


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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