7SA

SBAR/IPASS

(S) Situation: What is the situation you are calling about? * Identify self, unit, patient, room number.o Briefly state the problem, what is it, when it happened or started, and how severe. (B) Background: * Pertinent background information related to the situation could include the following:o The admitting diagnosis and date of admission List of current medications, allergies, IV fluids, and labs Most recent vital signs Lab results: provide the date and time test was done and results of previous tests for comparison Other Clinical Information Code Status (A) Assessment: * What is the nurse's assessment of the situation? (R) Recommendation: * What is the nurse's recommendation or what does he/she want? Examples: Notification that the patient has been admitted The patient needs to be seen nowo Order change -Illness Severity Stable, "watcher," unstable -Patient Summary Summary Statement Events leading up to admission or care transition Hospital course or treatment plan Ongoing assessment Contingency plan -Action List To-do list Timelines and ownership -Situation Awareness & Contingency Planning Know what's going on Plan for what might happen -Synthesis by Receiver Receiver summarizes what was heard Asks questions Restates key actions/to-do items

Liver and Kidney Transplant Workshop pt 5

)Cause of Allograft Dysfunction: DGF ischemia Reperfusion Injury or Post ischemic Acute Tubular injury - Mean perioperative MAP <70 mm HG is associated with delayed graft function * Mean Map >93 mm HG was associated with better graft outcomes Cause of Allograft Dysfunction: Renal Artery Thrombosis * Surgical emergency ( Graft can rupture since there is no outflow) * Occurs early post transplant * Presents with anuria acute cessation of UO) * NO flow is seen on Doppler US * In the majority of cases the kidney graft cannot be saved unless caught very early & thrombectomy is performed * Occurs in 0.3-3% * More common than arterial thrombosis * Could be due to surgical technique, thrombotic disorders, postoperative hypotension * Could present with pain over graft, anuria * Doppler US shows swollen kidney, reversal of renal arterial diastolic flow and no flow in the renal vein Dialysis Indications A - Acidosis E - Electrolyte abnormalities I- Intoxication O- Overload U- Uremia (a raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys), uremic platelets, pericardial rub Cause of Allograft Dysfunction: Hypovolemia - Fluid restriction to prevent interdialytic weight gain and HT. Consequently, they encounter difficulty in adjusting to liberal fluid intake after transplantation *Polyuria post transplant - Prevention * advise patients to drink at least 2.5 L per day or more, to match their urine output - Eval and Management * review the patient's fluid intake and urine output * Inquire about symptoms of hypotension obtain orthostatic VS * Encourage fluid intake * Consider giving IV fluids

Potassium

- 10 meq = 1hr

Work Tings

- 8 non scheduled days - OT can turn into vaca times - Workload check in times on chat * 1000, 1300, 1700, 2200, 0100, 0500 - 7SA vaca book is in the report room (it is based on FTE of 7 per month for vacation)

Central Lines (CVC)

- Able to use all lumens for medications - Red lumen used for blood draws Tips and tricks - You can use anchor to hold them down

UW medicine homepage

- Access to policies - Health online (teaching source for patients) * Search for things like glucose and it will pop up printable teachings for patients. EX: Self administration pen indicator for teaching, hypoglycemia, hyperglycemia - Ordering materials 1) Go to UWMC quick links "UW MC supply chain" 2) Find work day number 3) For stock on yellow order 4) Write in name of item 5) Put patient label 6) Tube to materials 7) You can check stock of available items

Pancreatectomy/Whipples/ HIPEC

- Amylase level in labs to check if pancreas is working

Standard Prescribed OTC's (transplant patients) & Other Common drugs

- Antacid * Famotidine (pepcid) or other alternative * Duration: 3 months unless you have a need for continued therapy - Prevent constipation * Miralax and Senna * Duration: PRN - Vitamin supplement * One a day women's multivitamin * Duration: Indefinitely - Prevent osteoporosis * Calcium citrate & Cholecalciferol (Vitamin D3) * Duration: Indefinitely - Magnesium * Helps cells to work, especially muscle and nerves * Deficiency commonly caused by tacrolimus * May contribute to decreased energy and cramps * Dose 1-3 tablets 2-3 times daily ~~Mag oxide 400mg tab = 240mg elemental ~~ MG Plus Protein 133 mg tab= 133mg elemental ~~ QTC "Magnesium" usually refers to elemental * SE: diarrhea - Ursodiol * Hydrophilic bile acid found in humans and other animals * Thin bile, prevents stones, sludge * 250 mg BID= low prevention dose * 10-15 mg/kg/day = treatment dose (PSC, PBC) * SE: diarrhea

Night shift

- Ask pt's about upcoming meds to avoid waking them up

Chest Tube

- Assess (Site) * Dressing: Change every 48 hrs or if loose, soiled or wet * Sutures: Intact and secure (not loose) * Subcutaneous emphysema: new or increased * Skin breakdown or pressure areas - Trace system from skin to drian canister * Taped connections are hand tight * Tubing without kinks, dependent loops, or cracks and off the floor * Chest tube or extension tubing unclamped unless ordered by provider * Canister secure below the level of the patient's chest --If the chest tube is ordered "to suction": * A: is the dial set to the prescribed amount? * B: Is the canister connected to wall suction, at least -80 mmHg? * C: Are the orange bellows expanded? *D: Is the water seal chamber filled to 2 cm line? - Output-- Fluid: * Note color, character, and amount of fluid drainage * Track output by marking date and time on the canister at regular measurement intervals - Output-- Air: * Note bubbling in the water seal chamber. Bubbles indicate the presence of an "air leak" * Ask patient to take a deep breath then cough for detection of intermittent air leak - Prepare * Call Provider when ~Patient respiratory status acutely worsens ~ Sudden increase in drainage out ~ New or increased air leak or subcutaneous emphysema ~ Chest tube becomes dislodged * Clamp chest tube when: ~ Chest tube disconnects from extension tubing - Rules * Check water seal vs suction (portable suction containers in equipment storage) * Replace canister if it falls or its full * With a new canister use syringe of water to add to air leak seal (not 100% sure) * Mark Q8 hrs for I/O - Safety considerations * 3 way occlusive dressing * Clamp if it disconnects canister; then get another canister to reconnect to immediately * 100 ml/hr alarm provider (might be due to ascites getting trapped)

Phones

- Call the paging by using "0" on big phones or call paging

Discharge (education, care plan, and charting not needed)

- Deaccess central line (PICC removal, HD lines, and other CVC's) - Remove IV's - Rx status (go to navigator ---> discharge) * Used to verify meds (ready to dispense) - Let charge know if pt is leaving at 1500 or 1900 - Instructions (make sure pt has ride to location to another place) * Teach new meds ("Start" means new meds on discharge papers) * Instruct to call if emergency *Double check equipment *Lifting restrictions *Incision care * Highlight numbers for questions (calling clinic) *Symptoms (go over) *How to administer meds *Ask "What questions do you have?" * Get patient to sign papers for discharge (put pt label and give to PSS or in front of pt chart) - Discharge Notes * Discharge notes required after pt leaves * "We did this, they were taught this, and left with this" **EX: they left with PICC line (we know if they don't show up with PICC line it's odd) **EX: JP (if they don't come back without it) *"Pt verbalized or demonstrated understanding" *Chart when they left * Chart who they were with and where they were discharged too * Aox4, VSS, on RA. Pt talked to by team and provider for clearance of discharge. Med list given by pharmacist and also cleared for discharge. Pt agreed to discharge & has been given written information on discharge papers for teaching. Pt taught about medication, insulin administration, hypoglycemia, and contacts for the clinic. Pt showed understanding of discharge teaching by demonstration, teach back, and verbalization. - Rules * 2 pieces of education should be attached * Check notes to see what was went over with the patient * Check to see if meds to beds was done * Give discharge signature to PSS with patient label sticker * Teach pt meds day of discharge at morning or night med pass (walk them through it) - Tips * You can edit meds for non-trans

NG Decompression

- Definition * For decompression, a double-lumen, rigid tube is used with one large lumen used for suction and a smaller lumen to act as a sump. (A sump allows air to enter to prevent suctioning of the gastric mucosa into the eyelets at the distal tip of the tube or obstruction when the stomach is fully collapsed.) These tubes are often referred to as "Salem Sump." Their bore size ranges from 6 to 18 French, with those most commonly inserted being 14 to 16 French. A blue pigtail on this type of tube is the air vent, so it should never be clamped, connected to suction, or used for irrigation. * Can be used for feedings but usually not - Rules * Measure ear→nose→sternum when placing NG tube * When measuring for Qshift you start at the end of the nares and go down to end of the tube (not the purple portion used for feeds) * Stop when giving meds for 1 hr * Clamp trial ( see if they can tolerate) 4 hrs then 30 min tracking to see if stomach is emptying naturally (low output is good) - Safety considerations * Deviated septum * Switch nares upon reinsertion - Suction * Put on regular suction for a little bit before patient goes into surgery (instead of LIS) - Meds * Given through 60mL syringe - Emptying * No larger than 700mL - Bridal for NG tube * Goes towards the ears not up towards the eyes * Used to prevent pressure injuries

NG Tube Feeds

- Definition * NG tubes used for administration of medications or feeding are single lumen and are softer than those used for decompression. They have a smaller bore with a size ranging from 8 to 12 French. NG tubes placed for feeding or medication administration may be a Levin tube or a Dobhoff tube. A Levin tube is a simple small diameter NG tube. A Dobhoff tube is a special type of NG tube that is small-bore and flexible, so it is more comfortable for the client than a standard NG tube. The tube is inserted with the use of a guide wire, called a stylet, that is removed after correct tube placement is confirmed. A Dobhoff tube also has weight on the end to allow gravity and peristalsis to help advance the end of the tube past the pylorus, providing an additional barrier to reduce aspiration risk of nutrition or medications administered. - Rules * Call "FOOD" for tube feeds or patient doesn't get dinner (can't do it online) * Feeds are in the med room * Nepro can be in small bottles or ordered bigger bottles * Call early as it can take more than 1 hr to get tube feeding sent up * Usually tube feedings are at 1800 & 0600 - Set up Kangaroo * If cyclic feed there needs to be new tubing/feeds hung every time * Two bags and many bottles are ordered to come up * Hung w/ water * Flush with auto-prime * Hourly rate * Volume - Caution * Pt should be pooping out feeds (liquid) * Flush with warm water * If patient is hurting you want to slow down feeds or if having a lot of BM's - Insertion * Put in ice to stiffen up NG before insertion so NG doesn't coil (usually done on smaller NG tubes such as Levin yellow tube) * Order chest x-ray for KUB confirmation (at bedside) - Meds * Given through 60mL syringe

Antithymocyte globulin rabbit (ATG) **TBD

- Definition * Antithymocyte Globulin (ATG) is a concentrated anti-human T-lymphocyte immunoglobulin preparation derived from rabbits after immunization with a T-lympoblast cell line. ATG is an immunosuppressive product for the prevention and treatment of acute rejection following organ transplantation. ATG reduces the host immune response against tissue transplants or organ allografts. - Rules * Since medicine is very expensive and has a shorter half-life you must request ATG then once you have ATG in hand you premedicate * Only hang as a primary (it comes with its own filter) * It is weight based * Check VS before hanging * Bethamexatrate might be used in the OR P: T: D: SE: AE: - CT: * Have ATG in hand before starting immunosuppression with other meds like methylprednisolone and benadryl

Intravenous (IV)

- Definition * Into a vein - Rules * 2 tries per unit (give one try then have another person on unit try) then escalate upwards (vascular team) * Point IV catheter at heart * Offer lidocaine to pt's before administration * Use 20 gauge needle -Tips * Don't pick a vein that rolls * AC a good spot for IV's (watch out for tendons) * Give 10 mins for patient to have warmed up arms (hot packs or blankets). Tell pt to have hand in dependent position * Rubbing alcohol pads up on vein can engage veins * Tell pt to squeeze hands * Start at 45 degree angle then lower (45 gets under a bigger layer of fat as well) * You can shave arms (use the shaver used for pure wicks) - Safety considerations * Veins on top of hand, wrist, and back of arm hurt * Don't put near valves (thicker veins) * Can put into hand if need be but bigger gauges can blow IV * No bolus on hand or wrist (this will blow IV) * Infiltration can happen if IV used for a long time (check date of IV) * Call charge for drug antidote or infectious disease. Stop and pull IV if dangerous med * Elevate and heat (check high risk med spreadsheets and mark extravasation)

Epidural

- Definition * above the dura - Rules * Set rate * No ketamine on alaris pump * Yellow band and yellow pump for epidural * Make sure to check epidural placement with safety checks in the morning as when pt's move it can come out. You also need to check dermatomes to see where pt is feeling sensation & where they don't (verification that epidural is working) * Pharmacy mixes bag so when beeping happens it is getting close to being done & you need to message pharmacy for new bag * Chart on epidural tab for dermatomes * When transitioning to oral meds you don't take out epidural you just lock it * Lower extremity checks (gas pedal, push, pull, lift legs, bend knees * Measure dermatomes by using ice or cotton starting at clavicle * 3 dots = 15cm at skin

Sepsis

- Definition *Dangerous infection of the blood - Rules * You get cultures---> start antibiotics---> start fluids

PCA (patient controlled analgesia)

- Definition *Device that allows the client to control the delivery of intravenous or subcutaneous pain medication in a safe, effective manner through a programmable pump - Vitals * Q4 - Rules * Clear with I/O's and track amount administered by 1400 * Push with NS fluids * Waste by going into pyxis when PCA is taken down * Chart cumulative amount when going off of shift and taking PCA down * Check for Continuous on dPCA on or off with safety check - Clinical Bolus * You can go into settings and set clinical bolus * You can give whatever is set which is usually the normal amount given with a push (0.2 mg --> 0.2 mg administration for bolus) * You can stack up what you give by giving bolus and pt also clicking button * You can give them every 5 mins but you have to give the bolus within 1 hr of starting * Get VS before every bolus and then order shows how often to get vitals when on bolus * You need to wait 4hrs after 1hr administration of bolus to give more - Settings * Typically a 0.2 mg push rate, per 6 mins, and 6mg 4hr lockout * You can push count (what pt pushed) & actual amount given (shows potential pain control given)

Chest Tube (Urgent responses and tasks) Pt 3

- Dressing change (every other day or if loose or soiled) * Remove current dressing * Clean site with saline-moistened gauze * Apply skin prep to surrounding skin * Apply 4x4 gauze under and over or use drain gauze * Cover with foam tape or Primapore dressing * Mark date and time - Replacement of canister * Prepare the new canister by instilling 45 ml of sterile water form the prefilled ampoule (attached ot the back of the canister) into the suction port. This will fill the water seal chamber to the 2 CM line * Set the suction control dial to the ordered amount of suction 8 Remove the extension tubing form the new canister * Clamp the extension tubing attached to the patient's chest tube * Disconnect extension tubing from the old canister at the connection closest to the canister * Connect to the new canister and unclamp extension tubing * Connect suction tubing from wall suction regulator to the suction port of the canister * Assess for air leak, patient tolerance, and proper suction

Liver

- ETOH * More challenging * Have a harder recovery - Hepatic encephalopathy * Numbers test (1-20) in big drawer to check cognition (ammonia) * Q4 neuro checks

New Kidney

- Fluids * Combine numbers of fluids given such as NS+LR (ex: 50NS+50LR=100) * Titration is based on UO hourly & orders set in MAR -Rules * Check for discontinued meds that are given only in PACU by searching up Orders * Call family/Emergency contact - Rounding * Q1 checks for new kidneys for up to 48hrs post op - Safety considerations * If patient output of urine is at 4L in a 24 hr period you need to get a recheck in labs for electrolyte imbalance (potential loss of electrolytes). Most common electrolytes checked is Mg, Phosphorus, and Sodium * Check CMP for S/S's of hyperkalemia (as pt are at higher risk) * Watch for S/S's of blood loss: low H & H; Increased HR & Decreased BP; Later signs like increased oxygen demand; 350 mL in a unit of blood, if JP emptied more than 3's they might need blood as one JP has 100 mL's * New onset edema shows that kidneys aren't functioning properly * Outline saturated dressing to compare

Falls

- Found in post fall navigator - Also sheet (put pt label) * Goes to nurse manager

Enteral Tube Feeding (Peg: J-peg; G-tube; J-tube)

- Function * Bumper (inner pulls stomach to skin); skin grows around - Rules * Rotate 180 Q shift * 3 way valve in med room * 60 ml syringe narrow valve tube used to meds and flush (cone way valve for older system) - Peg or G-tube 1) If peg tube or G-tube you may want to check gastric residual volume GRV). If GRV is really elevated you may not want to pump more food in. 2) You want to insert the piston syringe (make sure to pinch site so no residual comes out) 3) Then you withdraw on the plunger until nothing happens. Some facilities want you to waste the GRV and some want you to reinsert onto pt stomach (look at policy) 4) If GRV is over 500 might want to reconsider feed (type of feed or rate as well) 5) You want to open port and flush while holding the syringe up (use warm water). Gravity will flush it 6) Then after flushing pour formula slowly into piston syringe and use gravity to administer (you can change the rate by raising it higher)

IV bags/General

- General * 24 hr labels * Change tubing monday & thursday * Green curos caps on central lines (e.g. ports, HD lines, CVC, PICC's) when hanging bags * TKO flush: 10 ml for PIV's & 20 ml for central lines (volume 999) - IV meds * Prioritize antibiotics > Electrolytes * Check for good IV access when giving higher risk meds like antirejection, chemo meds, and vesicant meds

Whipple

- Head of pancreas, stomach, and gallbladder are partially removed and frankenstein together - Rules * Don't strip drains (causes pressure on surgical site) - Whipple Diet (After surgery) * GO SLOW! * Start 1/2 cup of soft food * Eat 5 to 6 small meals a day * Eat every 2 to 3 hrs * Stop eating when you feel full * Start with soft, bland foods that are low fat and low fiber * Avoid foods that are spicy, greasy, fatty or fried * Eat foods high in protein to help your body heal * Have protein shakes between meals * Chew your food well before swallowing * Don't drink much fluid while eating * Drink fluids between meals * Walk after eating to help with digestion --Foods to start with: * Yogurt * Kefir * Cottage cheese * Scrambled eggs * Protein shakes * Chicken noodle soup * Mashed potatoes * Cream of wheat

General Stuff

- Heating pads will be sent up front in cart

Blood sugars

- High BS increases risk for infection - Give sharps for patient who will discharge with self-administration

Pulmonary congestion (can help with spike in temp post-op)

- IS - Acapella w/ RT - ABG can be done by RT

Labs

- Look at trends for lab orders - Track tacro levels before giving - Track vanco levels - Look at pt tests and diagnostics (current)

I/O

- Message provider for low UO like 10 ml (less than expected 30 ml/hr)

Restraints (Keys on Code Cart)

- Non aggressive (pulling at IV, foley, confused, etc) * Restraints is for 24 hrs (you need a doctor's order within 1 hr) * 2hr full assessments - Aggressive restraints (biting, hitting, spitting, etc) * Need doctors order within 1 hr * 15 min safety checks 2hr full assessment's * Needs to updated every 4 hrs (if it's still necessary) & have a face to face every 24 hrs * You have to remind doctors to write a "Significant note" after application of restraints - Restraint rules (let family know when pt restrained) * Two finger check on restraints (beside mitten which is one finger) * Taking off restraints and putting them back on (for non toileting reasons) needs a new order * If a patient can take off restraints (no order is needed) * If cognitively impaired or physically impaired (you need order) aka they can't take off restraints themselves * Speciality beds with 4 guardrails aren't restraints * Stretcher with 4 guardrails doesn't equal restraint * Pt request 4 guardrails up isn't restraint * Seizure pads aren't a restraint - Restraints locations (on patient) * You want to use either opposite restraints on opposite sides (one hand and one foot) usually its a min of 3 (two on the top or two on the bottom, then one on the top) * With two restraints you do opposite sides, ankle and wrist usually - Self-release waist belt * Mainly positional tool (if on the front and not behind the chair), its meant to hold the patient upward in a chair * Contradictions for patients with stomach issues (ascites, surgery, COPD, etc) - Key restraint * You can use key to adjust tightness * Blue is for wrists and red is for ankles

Skin care

- Nutrition can impact skin (less nutrition can increase breakdown) * Skin can be thinning

Ostomy (one piece)

- One piece * The main difference is the wafer and ostomy are already attached 1) Removal is the same as above 2) Application * You cut out the wafter * Then you just peel off part of the adhesive protectant apply half on the stoma * Lastly take off another portion of the adhesive protectant then apply the other half

Lidocaine (transdermal) **TBD

- P: - T: Topical Analgesic - D: - SE: - AE: - CT: * This medicine is given by placing a special round device on your skin. The device pushes the medicine into the skin, and does not use a needle to do this. You or your child will hear a popping sound when the medicine is given. This medicine is for use on the skin only. It will not be used on skin areas that have cuts or scrapes.

Corticosteroids

- P: - T: Used for induction, maintenance and rejection - D: - SE: *Short term: Emotional changes, mood swings, disturbed sleep, increased BP, increased BG, weight gain (fluid retention), Slowed wound healing, Face welling ("moon face"), and blurred vision * Longer term: Muscle/joint weakness, Osteoporosis (bone loss), Skin dryness/weakness, Increased blood sugar, Weight gain (increased appetite), Round shoulders ("buffalo hump"), Cataracts, Increased cholesterol, acne - AE: - CT: * Avoid infection (hand hygiene, food safety, be smart about contagious diseases, and stay up to date on vaccines * Do not take medications not on your list without approval of transplant team (high risk of drug interactions) including OTC's, herbals, and dietary supplements * Monitor BP, weight, temp, and S/S's of infection or rejection at home * Healthy diet and exercise to minimize risk of high BP, cholesterol and diabetes

Tacrolimus (Prograf, FK 506)

- P: Calcineurin inhibitor - T: Immunosuppressant (rejection prevention) - D: 0.5 mg, 1 mg, 5 mg - SE: * Reduced kidney function * Shakiness'' or tremor * Higher BP * Higher blood K+ * Lower blood Mg * Higher BS * Diarrhea * N/V * Upset stomach * Numbness & tingling in hands/feet * Insomnia * Headache * Higher blood cholesterol * Greater chance of infections * Hair loss - AE: * Tacro can be toxic & lead to altered LOC (make pt's act a little crazy) * Can cause tremors in toxic amounts - CT: * Taken every 12 hrs with or without food * Trough-level monitoring, blood should be drawn 12 hr's after the last dose (i.e., immediately before the next dose). Do NOT take before blood draw! * Avoid grapefruit, pomegranate, & star fruit increases levels of tacrolimus in the blood * Range is 6-10 * Some kidneys might not clear tacro as easily * Numbers are easier to manipulate

Fluconazole (Difulcan)

- P: Ergosterol synthesis inhibitor - T: Antifungal - D: 100mg, 200mg - SE: * Nausea * Rash * Diarrhea * Abdominal pain - AE: - CT: * Taken once daily or once weekly as instructed by your provider * May increase tacrolimus levels * Do NOT stop taking unless instructed by provider * Usually taken for 3 months after transplant

Trimethoprim or Sulfamethoxazole (Bactrim, Septra, Cotrimoxazole, Trim, Sulfa, TMP, SMX)

- P: Folate synthesis inhibitor - T: Antibiotic * It can treat infections, including urinary tract and ear infections - D: 80-400 mg Single Strength (SS) - SE: * Rash * Nausea * Lowered WBC * High K+ level * Sensitivity to sun - AE: - CT: * Tell pt to report any rash to doctor * Taken once daily at bedtime * Usually taken for 6 months after transplant

Valganciclovir (Valcyte)

- P: Ganciclovir is a synthetic analogue of 2-deoxyguanosine; Ganciclovir triphosphate inhibits viral DNA synthesis. - T: Antiviral - D: 450 mg - SE: * Lowered WBC * Nausea * Lowered kidney function * Headache - AE: - CT: * Taken once daily (depending on kidney function). * Usually taken for 3-6 months after transplant

Prednisone (Deltasone)

- P: Glucocorticoid (corticosteroids) - T: Immunosuppressant (rejection prevention); Anti- Inflammatory - D: 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50 mg - SE: * Stomach upset, ulcer * Heartburn * Mood wings * High blood sugar * Sleeping problems, insomnia, dreams * Night sweats * Weight gain & swelling * Increased appetite * Slower wound healing - AE (long- term effects): * Muscle weakness * Osteoporosis (weak bones) * Joint weakness or pain * High BS (diabetes) * Puffy face ("moon face") * Weak, thin, or dry skin * Rounded shoulders * Increased hair growth * Cataracts * Higher cholesterol - CT: * Usually taken once daily in the morning with food

Acyclovir (Zovirax)

- P: Herpesvirus Nucleoside Analog DNA Polymerase Inhibitor - T: Antiviral - D: 400 mg - SE: * Nausea * Lower kidney function * Headache * Lowered WBC - AE: - CT: * Taken once or twice daily * Usually taken for 3 months after transplant

Clotrimazole (Mycelex)

- P: Imidazoles - T: Antifungal - D: 10 mg - SE: * Bad taste in mouth * Dry or chalky mouth * Nausea - AE: - CT: * Taken twice daily to prevent oral yeast infection (thrush) * May increase tacrolimus levels * Do NOT stop taking or change how often you take, unless instructed by your provider * Usually taken for 2 months after transplant

Mycophenolate Sodium or Mycophenolic Acid (Myfortic) Mycophenolate Mofetil (MMF, Cellcept)

- P: Inosine-5'-monophosphate dehydrogenase Inhibitor - T: Immunosuppressants (rejection prevention) - D: Myfortic 360 mg, Myfortic 180 mg ( DR and no IV form), MMF & Cellcept 500mg, MMF & Cellcept 250 mg ( IV and oral suspension available ) - SE: * Lowers WBC * N/V * Diarrhea * Abdominal pain * Greater risk of infection * Lowers RBC * Lowers platelet count * May cause birth defects * Contact your care provider if you are pregnant or planning to become pregnant - AE: * Teratogenic - CT: * Taken every 12 hrs with or without food * Trough-level monitoring, blood should be drawn 12 hr's after the last dose (i.e., immediately before the next dose). Do NOT take before blood draw!

Lasix (furosemide)

- P: Loop Diuretic - T: Diuresis; Lowering BP - D: 80 mg max for IV (then needs to be piggyback - SE: Dehydration - AE: * hypochloremia, hypokalemia, hypomagnesaemia, hyponatremia, hypovolemia, metabolic alkalosis * The risk for ototoxicity is increased in clients with kidney failure and with higher doses of loop diuretics or concurrent use of other ototoxic medications (eg, aminoglycoside antibiotics, chemotherapy, high-dose salicylates). Loop diuretics can damage the inner ear (eg, cochlea), leading to sensorineural hearing loss that may be irreversible. Hearing loss typically begins with high-frequency sounds. A new onset of muffled hearing and difficulty understanding speech in a client recently prescribed furosemide requires follow-up with the health care provider. In clients with compromised renal function, the nurse should administer IV furosemide slowly, especially when prescribed in high doses to prevent ototoxicity - CT: *Monitor for thirst, dry mouth, lethargy, weakness, hypotension, oliguria and notify physician. * Monitor K+, Ca++, Mg. Can increase BUN, glucose and creatinine, TAKE WITH FOOD

Dapsone

- P: Sulfones - T: Antibiotics; Anti-inflammatory * It can treat leprosy and dermatitis herpetiformis in its oral form (as it stops bacterial growth). It can also treat severe acne in its topical form - D: 100 mg - SE: * Rash * Sensitivity to the sun * Nausea * Lowered WBC or RBC - AE: - CT: * Report rash to provider * Taken once daily * An alternative to Bactrim or Septra * Usually taken for 6 months after transplant

Nurses role in transplant education

- Pre-transplant (POD -1 to 0) * Encourage patient to bring list of meds or medications themselves and keep in room until reviewed by medication history technician or pharmacist * Provide CareMap patient handout ~~ Kidney transplant ~~ Living donor nephrectomy - Early post-op Discharge Planning ( POD 0-1) * Discuss importance of transplant teaching with coordinator, dietician, and pharmacist * Caregiver should be available for 2+ hrs between 8 am and 4pm 1-3 days prior to day of discharge for teaching * Medication education at each med pass can begin immediately when on acute care * Provide Large pill box organizer to patient (under prn meds for liver recipients) - Teaching during stay (POD 1-3) * Use visual medication guide or patient specific med list as tool to review medications ~~ Names ~~ Purpose ~~ Dosage ~~ How to take ~~ SE * Ask patient to tell you what they know ! * Support patient in updating list with pencil if changes are made (mirrors process at home) - Diabetes education * Order glucometer and supplies (nursing order) * If new to insulin, have transplant APP place self administered insulin orders ~~ Demonstrate pen technique ~~ Make sure they know to prime needles (2 units air!) ~~ Use new needle each time * Insulin teaching on health online

Hanging meds

- Primary as a solution (NS, LR, D5 ½ NS, Dextrose, etc) + other med - You can connect another med as primary and connect at the Y port (med with more volume that takes longer)

Insulin (self-administration)

- Prime with 2 units and squeeze it out then administer

PICC (peripherally inserted central catheter)

- Purpose * It is for long term medications or if patient is unable to have a peripheral intravenous catheter • Used for total nutritional needs, prolonged antibiotics, continuous pain, to measure central venous pressure * Use red cap for blood draws - Insertion * Enters at antecubital fossa and ends in superior vena cava or subclavian or axillary vein - Duration *Can be used up to a year * Patients with TPN may go home with a PICC line - Safety considerations * NO migration (more than 2 cm) * Measurement of PICC is needed (numbers on PICC line, starts at 0) * If migration occurs it becomes a midline and blood can't be drawn * Sterile procedure when changing PICC line * Make sure to place PICC for x-ray if pt leaves hospital and comes back * Also with extra migration of 2cm pt needs an X-ray as it could be considered a midline now - Care * Clean downward - Removal * Vascular access team takes out PICC or a trained nurse * Materials: Big gauze; small 4x4 gauze; Tegaderm dressing; Adhesive remover; CHG cleaner * Steps: 1) Remove dressing 2) CHG clean 3) Remove PICC 4) Pull out 5) Look at bevel 6) Make sure length = Total length (count PICC length after pulling out and look at paper usually put on wall) 7) Apply pressure while removing w/ big gauze 8) Hold pressure for a few mins (based off bleeding risk, INR, PT, and PTT) 9) Put tegaderm dressing 10) Instruct on no heavy lifting for 24 hrs & no shower

Heparin infusions

- Q6 anti-Xa checks (blood draws) * Goal 0.5-0.7 (varies based on order) - INR goal 3.5-4.5 * Then put on coumadin

Isolation (TB, shingles, COVID)

- Room isolation * Positive (ante on outside of pt room) * Negative pressure (in the room)

Ostomy (two piece)

- Rules * Emptying (when 1/3 full) * Cut starting in the middle * Daraperm for extra seal & protection * If large output you may start fluids at 1/2 rate of ostomy output - Two piece ostomy application 1) Removal * Wafer is adhered to the skin so you want to push down on the skin and gently move the wafer (do gently) then discard 2) Asess * Make sure it is beefy red * No S/S of ischemia or skin breakdown in the peristomal area 3) Clean * Get damp warm washcloth and clean around the area of the ostomy * Make sure it dries completely before new system is put in place 4) Measure stoma * Use measuring device as reference or the one already in the room (you want something slightly bigger than the stoma) * Too big will cause leakage and too small will constrict bloodflow * 1/8 th of an inch around the stoma itself 5) Cutting out wafer * Now put the referenced size over the wafer (mark it) then cut circle out * You cut by starting in the middle of the empty space and working your way around (cutting off a piece) * Then after you are done you remove the backing of it * If using adapt slim paste you want to apply around the opening of the stoma on the ostomy or directly on the pt skin (make sure its flat and not too tight around skin) 7) Putting on ostomy * Put on preparatory (Cavilon?) to make it easier for adhesive to come off * Completely remove all adhesive protectants on the wafer & place wafter around stoma * Then you snap the portion of the other piece on the ostomy (match rings and pinch along the ring, not against the pt abdomen)

Tracheostomy

- Rules * Uses a FR system * Suction as you pull out * You can use a fish (saline) when trying to clear up secretions (into the trach) but it should be done as pt can tolerate to prevent cutting off too much oxygen * Always have extra trach kit in room * Hook pt up to suction on reg (around 200+) * Occlusive dressing over trache call rapid

Insulin drip

- Rules * Usually doesn't piggy back with anything * Needs fluids * Make sure to chart in the comments the BG every time taken * Change the rate by clicking channel select then changing rate (Q2 or Q1 BG checks)

Wound Care

- Rules * 4x4 used for observable wounds * Do a wet to dry on dry wounds & just a dry dressing on wet wounds * Put abdominal pad on top to cover after dressing change * Date all wound changes either on the mepilex with T (therapy for treatment of wound) or P (prophylaxis of wound) * Wound assessments LxWxH * Pressure dressing for central lines - Tips * Foam tape is good to create pressure * Gauze sponges for wound care + paper tape (less moisture for skin breakdown) * Abdominal pad also option for more reabsorption but can cause skin breakdown (can be dressing over to cover other dressings)

Nursing Notes

- Rules * All notes due by 5 * Go to notes and click new notes (type in "nursing notes") *Click "addendum" to edit after submitting *You can hide notes with a heart on top right *You can pend notes by clicking pend

Foley

- Rules * At 300 cc's you might want to straight cath (check orders) * 14 FR, 16 FR, 18FR ( Increased based on size of patient) * Use sterile gloves * Pt's may go home with 10 day foley bag * Don't keep in if pt is able to ambulate and won't be at risk for retention

Blood Transfusions (Need 2 RN's)

- Rules * Blood must be administered within 20- 30 mins of receiving it (notify blood bank when you are ready and have 30 mins of time) * Blood must be transfused over 2- 4hrs from start (as the blood can develop bacteria if not administered in that time period) * If hemoglobin falls to less than 7 then they need blood * O can donate to everyone * AB can receive from everyone * You give one unit of blood at a time (350 ml) * Consent lasts 1 yr (or if from procedure then it lasts until hospital stay is done) * Type & screen lasts 3 days * Dialysis blood can be given in 1 hr - Pre-transfusion 1) Ask patient about known reactions to transfusions & how many transfusions were received (with many transfusions , antibodies can be built up from the past so the doctor might want to premedicate with some immunosuppressants patient) 2) Check to see if patient is in fluid overload because this could set them up for TACO( renal patients or HF patients). Doctors might give lasix before hand to get rid of some fluid (you can also let doctor know) 3) Check for patent IV site for administration (20 gauge). Smaller gauge needles can cause blood to lysis. Also try to get at least 2 sites of access for other medications to run 4) Double-check chart has signed informed consent which is found on the media tab in the chart review or on transfusion on sidebar 5) Make sure patient has recent type and screen for blood (look at policy). Also on transfusion on sidebar 6) Release blood from blood tab in flowsheet then release from blood bank when you wan't to administer the blood (the blood bank will call and send the blood up) 7) Prime Y-tubing with NS (which is the only fluid used). Connect NS with the spike that has a drip chamber OR just prime with blood 8) Then connect primed tubing that has NS with patient OR wait to connect blood

Nebulizer

- Rules * Bronchodilators first

Dressing changes

- Rules * Every 7 days or PRN - Cautions * IV 3000 for CHG/Tegaderm replacement *Biopatch (CHG potential replacment) * HD lines may or may not be sutured they can move and a cuff is needed (sterile procedure if no cuff)

Handoff

- Rules * ICU nurses handoff at bedside * ED should call (or call ED) for handoff of new patient - Status of patient * Watcher (stat watch) * Fair (smaller issues) * Stable (good to go) - Action items = for next shift - Look at docs note to update patient summary

Operations (OR procedural areas tab for procedures)

- Rules * In OR means meds given, "on call OR" (means to give once called by OR) - Anesthesia * Obese pt's might need extra support for airway support (might need more anesthesia) & pt's with sleep apnea - Pre-op (you can call OR if they don't call) * 2 CHGs before * Pt should be in gown and underwear * Write a note for patient going down to operating RM (gives idea of pt status before being sent down) * Check for dentures, glasses, jewelry, allergy band that should be on and etc * Ask when the last time they ate or drank (NPO) * GIVE REPORT: Report LDA's (port, fistula, IV's); when patient had dialysis last; If patient family is at bedside (emergency contacts) * Check for consent in chart (make sure patient has been talked too by doctor) - Workups * Notify team they need to know to intervene * Order set waiting * Get workup packet * CHG * "on call meds" give when called -Post-op * Ask about PCA (most if not all pt's will have PCA post-op) * Check sign and held orders * Check PACU meds (not to give just for immediate post op) * Get pt back to RA (or whatever they were before they went down) *CMP & CBC are done in PACU, they will do dialysis if chemistries are off (if nights ICU will take pt do dialysis) * Check urine with decreased output it can be the first sign of blood loss (also check urine more frequently)

OT/PT/Nutrition

- Rules * Need doctor orders for inpatient consult (can obtain from doctor by messaging) * You can call if there is a consult

Doctors Orders

- Rules * Need orders for many things * Bolus requires order

Port

- Rules * Some people will have double ports in which both need to be accessed even if just using one * You can order sterile syringes from utility management (so access and dressing change can be done by yourself) * Some patients want lidocaine when port is being accessed which can be ordered on order tab - Accessing * If there are two ports you need to access both * Offer numbing med or lidocaine (offer it to the patient). Do this right before accessing port for best effects - Deacessing * Push on white wings for leverage and then pull out * May needed to be heparin locked (flushing with heparin)

Tap Water Enema

- Rules * Use lukewarm water for enema * Comes with a bucket, tube, and prelubed tip (clamp bucket when filling water) - Steps 1) Have patient on left side 2) Prime tubing before putting in patient 3) Insert tip into patient and start high then go low/hip level 4) Hold 30 mins on left side (or as long as pt can tolerate w/ chucks)

TPN

- Rules * Use w/ filter * Cylinder filter for TPN * Other filter for fat emulsion

Admit

- Rules * You make sure to do a full head to toe assessment * Watch for pressure injuries * Walk through guided questions on admit section (admission screening) * Release sign and held orders (in the order tab) * Call ED for admit if they haven't called for report

C- Diff

- Rules (Clostridium difficile) * Take off bowel meds for 2 days * Need to be put on Isolation * 3 loose stools * NO laxative, tub feeds or oral contrast for 48 hrs

Emergency/Rapid/Decompensation

- Set up for emergency * Ambo bag * Suction * Fluids (NS or LR bolus) * CPR ( Pull bed away from wall, put down back board)

Post Mortem care

- Steps *Navigator ----> Pt "expiration" * Contact doctor * Contact organ donation * Get "Pt expiration bag" from PCT room * Remove drains * Put printed note on top of pt * Bag pt twice and put chucks under bottom * Call morgue after sling put under pt

Transplant Team & Discharge

- Team * Patients usually seen by OT, PT, and Pharmacy before leaving * You can chat with social work for other home care needs - General rules * Must live within 2hrs for first 3 months of transplant (even in temporary living like a hotel or air bnb) * HTN can destroy donor sites with pressure * Hypotension can decrease perfusion to site * Laxatives helps prevent constipation helps with appetite * Nausea meds + "zoles" helps with eating for wound healing - All Transplant patients * Blood pressure cuff (pharmacy) * Thermometer (Pharmacy) * Scale * Cleared by PT/OT (Ambulatory needs) ~Supplies ordered as needed * Nutrition teaching ~ avoid grape fruit star fruit, aged cheese, probiotics, don't eat at a buffet, etc * Pharmacy teaching ~ Updated med list ~ Pharmacy to check box after filling * Urinal or hat to measure urine (kidney transplant) - As Needed: * Drain teaching (alc wipes, teach about more than emptying 3 bulbs 350 cc's) ~ Drain cup ~ Log sheet ~ lanyard * Wound care supplies (3-day supply) * Glucometer supplies ~ Teaching and return demonstration ~ ISS dosing sheet filled out * Leg bag teaching

Chest Tube (Urgent responses and tasks) Pt 2

- The chest tube becomes dislodged * Cover site with gauze and tape on 3 sides if chest tube completely out * Partially dislodged apply an occlusive dressing * Assess patient for any changes in respiratory status * Notify team * Anticipate STAT X-ray and chest tube replacement - The chest tube disconnects from extension tubing and canister * Clamp chest tube and have someone bring you a new canister with extension tube with alcohol or chlorhexidine * Connect new canister and unclamp * If a new canister is not immediately available or patient cannot tolerate chest tube clamping submerge the end of the chest tube into a bottle of sterile water and hold in place. Ideally the end of the tube would be submerged in 2-3 cm of water until a new prepped canister is ready * Assess patient, notify team, and obtain order for X-ray

Blood Transfusions (Need 2 RN's) pt 2

- Transfusion (once blood in hand from blood bank) 1) Look at blood (consistency, bag being in intact, color, etc), verify order, & check expiration date 2) Do a read back where the primary RN looks at transfusion request slip and bag of blood while the other RN looks at blood bank wristband while doing the read back. Then sign and initial request slip (Name spelled out, account number, MR number, DOB, blood type, unit number) 3) Do initial set of VS, tell patient what you are about to do, and notify of S/S's of transfusion reaction (sweating, chills, chest pain, SOB, headache, itching, back pain, N/V) 4) Spike blood into other Y-tubing (no need to prime blood). Make sure to clamp NS so blood doesn't backflow into NS bag. Then you unclamp the blood bag. OR just be ready with prime blood tubing

Liver and Kidney Transplant Workshop pt 6

- Type of fluid (LR vs 0.9% NS) * No differences in overall potassium levels between 0.9% saline and LR groups * More hyperkalemia >6meq/L in the 0.9 normal saline group ~ 19% patients in the 0.9 saline group versus non in the LR group had potassium concentrations >6 mEq/L requiring treatment for hyperkalemia * More metabolic acidosis in the 0.9% normal saline group ~ 31% patients in the 0.9% saline group versus ()%) patients in the LR group were treated for metabolic acidosis * Study was terminated early because of safety concerns with higher rate of hyperkalemia in the 0.9% saline group - Hypervolemia * Over infusion results to tissue edema * Tissue edema---> pulmonary edema gut edema illeus infection --> decreased tissue oxygenation --> MI or renal injury Hyperkalemia Management: - Membrane stabilizers ( Calcium gluconate) * Dose: 100 mg (10ml of 10 percent solution) infused over 2-3 mins * Onset: Immediate * Duration: 30-60 mins - Shifters ( Insulin + glucose & Albuterol) * I + G dose: 10 units regular insulin with 50 ml of 50% dextrose * I + G onset & duration: 20 mins & 4-6 hrs * Albuterol dose: 10-20 mg in 4ml of normal saline nebulized over 10 mins * Albuterol onset & duration: 30 mins & 2 hrs - Excreters (Furosemide, Sodium bicarb, and sodium polystyrene sulfonate) * Furosemide dose: 40-80 mg IV * Furosemide onset & duration: 30 mins & 2-3 hrs * Sodium bicarb dose: 150 mmole/L drip * Sodium bicarb onset & duration: Hours & duration f infusion * Sodium polystyrene dose: 15-30 g in 15-30 ml * Sodium polystyrene onset & duration: >2 hrs & 4-6 hrs - Definitive * Hemodialysis

Tegaderm

- Used for dressing changes - CHG specific dressing

Code Gray

- When * Combative person who is trying to hurt themselves or others (destructive or dangerous * If pt has weapons or drugs in hospital * If pt is throwing things, kicking things, hitting, biting, etc * Trying to leave the hospital AMA (when they aren't, which is usually seen on pt care plan in EPIC) - De-escalation techniques * Keep everyone safe is priority * Remove others * Remove objects * Call for help - Debrief * Group huddle after code gray to check in

BERT

- When * Called on those who are starting to ramp up on agitation or are becoming disruptive (used to de escalate) * If pt is pacing, fidgeting, rapid breathing, crying, rocking verbally aggressive, yelling, name calling, arguing, etc - De-escalation techniques * Find the distress, relieve distress * Listen * Talk * 360 scan and set limits * Offer choices * Test for cooperation

Orders

- You can check VS parameters in order - Discontinue orders if okay in order panels

Alaris pumps

- You can restore to put previous settings back - Air in line * Flick line to get it to the top. You can either pull from of the ports (the air bubbles) or flick it to the secondary line * Disconnect from the patient then drain by making it free flowing. Clamp secondary to not waste medication.

Pyxis (general)

- You can take meds out earlier than 1 hr but can't scan to give - You pull meds from central pharmacy (by clicking override) - Meds can be found in the front, in the med room by the pyxis, in the non-refrigerator, and in the refrigerator - Some meds might need to be requested from a pharmacy (e.g. premixes, ATG, bethamexmab, Insulin, Epidural,). If it says PMIS it needs to be requested for the use of the patient such as insulin pens and/or glucometers - You can pull a med then hit cancel and pyxis won't count it - You can also pull extra meds if needed

Dialysis

-General * Check mag, phos, other electrolytes, and weight (if increased will likely due dialysis) - Report * On tele * Mobility * Oxygen * Incontinent * Meds - Dialysis changing meds (always check in with HD nurse anyways) 1) Go into MAR (*move daily meds & infrequent meds) * Click the top column (AM meds). Keep check marks on what you want to move 2) Move to past dialysis time (ex: 1300 if morning "click move meds") * If patient has dialysis in the afternoon then you give morning meds. EX: Microfelnate, prednisone, tacrolimus, Check for cardiac meds

Oxygen Delivery

-Nasal cannula: 1-6 L/min. use humidification for flow rate >4 L/min (FiO2 24-44%) * Prongs towards the patient * Also use protection around ears if prolonged oxygen therapy (putting cushion on ears such as 4x4) -Simple face mask: 5-8 L/min -Partial rebreather mask: 6-10 L/min. ensure reservoir bag is 1/3 to 1/2 full on inspiration -Nonrebreather: >15 L/min. keep reservoir bag 2/3 full; bag must fully inflate (FI)2: 60-80% * No humidification * Short term, for acute increased FiO2 demands * Call Rt if newly starting on patient * Assess valve, flap hourly -Venturi mask: 3-15 L/min. MOST PRECISE O2 DELIVERY (FiO2 24-60%) * Directions usually in mouth package * Use green adaptor for lower oxygen demands: FiO2 24-30% (RT can help with this) * White adaptor Fio2 35-50% * No humidification -Aerosol ( Face Mask, Trach collar, Face tent): 3-15 L/min (FiO2 21-100%, not reliable after 50% * Good for patients with facial trauma or burns; provides high humidification (cool mist or can be heated)

Organizing day (see patients that are harder, by acuity, and/or procedure)

1) Look at LDA's, Active orders, flowsheets (in summary tab for overall look), lab trends (HxH below 7 or 20%), MAR ( PCA, heparin, insulin, continuous infusion, and verify) and notes 2) Give report to PCT 3) Create personal tasks 4) Med pass (listen to heart and lungs)--> glance at VS 5) Assessments (by 10 am if possible) 6) Chart

Drawing blood

1) Print label 2) Click complete collection 3) Flush with 10 ml 4) Pull 10 ml and waste 5) Take 10 ml for lab 6) Flush with 20 ml 7) Put sample in tube with transfer needle (multiple tubes might be needed) 8) Put patient label which is on the first row on the right side - Tips * If drawing blood from central line you can tell the pt to cough, lift arm up, and/or move (helps blood come out if none)

Manual Blood Pressure Measurement

1. Locate your pulse. Locate your pulse by lightly pressing your index and middle fingers slightly to the inside center of the bend of your elbow (where the brachial artery is). If you cannot locate your pulse, place the head of the stethoscope (on a manual monitor) or the arm cuff (on a digital monitor) in the same general area. 2. Secure the cuff. Related:Life With Pulmonary Hypertension: Living to the Fullest Slide the cuff onto your arm, making sure that the stethoscope head is over the artery (when using a manual monitor.) The cuff may be marked with an arrow to show the location of the stethoscope head. The lower edge of the cuff should be about 1 inch above the bend of your elbow. Use the fabric fastener to make the cuff snug but not too tight. Place the stethoscope in your ears if you are using a manual monitor. Tilt the ear pieces slightly forward to get the best sound.

Manual Blood Pressure Measurement pt 2

3. Inflate and deflate the cuff. If you are using a manual monitor: *Hold the pressure gauge in your left hand and the bulb in your right. *Close the airflow valve on the bulb by turning the screw clockwise. *Inflate the cuff by squeezing the bulb with your right hand. You may hear your pulse in the stethoscope. *Watch the gauge. Keep inflating the cuff until the gauge reads about 30 points above your expected systolic pressure. At this point, you should not hear your pulse in the stethoscope. *Keeping your eyes on the gauge, slowly release the pressure in the cuff by opening the airflow valve counterclockwise. The gauge should fall only 2 to 3 points with each heartbeat. (You may need to practice turning the valve slowly.) *Listen carefully for the first pulse beat. As soon as you hear it, note the reading on the gauge. This reading is your systolic pressure (the force of the blood against the artery walls as your heart beats). *Continue to slowly deflate the cuff. *Listen carefully until the sound disappears. As soon as you can no longer hear your pulse, note the reading on the gauge. This reading is your diastolic pressure (the blood pressure between heartbeats). *Allow the cuff to completely deflate.

Blood Transfusions (Need 2 RN's) pt 3

5) You give the blood at a rate of 60 mLs for the first 15 mins (chart on blood tab) 6)Make sure pt is not having a negative reaction. If patient is having a negative reaction you stop the blood administration then take out the tubing. You also add new tubing with NS to keep the IV open for potential administration of medications (eg, corticosteroids, fluids, antihistamines, antipyretics, vasopressors, diuretics, etc) . Check VS every 5 mins. Get labs (for clotting, DIC, electrolytes, blood levels, renal function) and urine to assess ( free hemoglobin) Lastly you send the blood back to lab or blood bank to see what went wrong & document on event (time it happened, what you did, what labs were drawn, and how patient is doing) 7) Take 15 min vitals after blood has started. Then you can increase rate if it has been slowed down so it can finish in 2-4 hrs which is typically 150mL (look at rates per gauge for requirements) & make sure to chart in blood tab the rate change as well as "No" for reaction 8) Then you take vitals after transfusion. Chart in blood tab that the transfusion has been completed. 9)Flush tubing after transfusion is complete and throw away blood in red bin or hazard bag

Transplant Pharmacology pt 2

Adherence interventions - Promote health literacy * Tach about meds with every med pass * When caregiver available, focused teaching with pharmacist - hr - Medication organizer * Fill box with 7 days of meds before discharge - Set alarms - Clear instructions, written and verbal - Avoid discrepancies in instructions - Reinforcement --> Again and Again and Again Induction immunosuppression - Anti-thymocyte globulin (rabbit) aka rATG * Brand: Thymoglobulin * Mechanism: Destroys T-lymphocytes (T cells) * Dosing: 1-1.5 mg/kg IV infusion over 4-12 hrs x 3-7 doses (goal 3-5 mg/kg total) - Methylprednisolone * Brand name: Solu-Medrol * Mechanism: Regulate gene expression, broad immune inhibitor, reduces migration of PMNs and membrane permeability * Dosing: 40-1000 mg IV as push or IVPB - Basiliximab * Brand name: Simulect * Blocks T-cell activation at IL-2 receptor: CD25 * Dosing: 20 mg IVPB x2 doses rATG - Polyclonal preparation made in animals by inoculating them with human thymocytes - Cocktail of antibodies directed at a variety of targets present on T-lymphocytes and other cells - First dose often in OR, Continued on floor * First dose over 12 hrs, sometimes rate slowed down if infusion reactions * Subsequent doses over~ 6 hrs if first well tolerated - Infusion reactions * Fever, chills, Rigors, Itching, Hypotension) * Anaphylaxis * Serum sickness * Pulmonary edema rATG - Dose 1-1.5 mg/kg. rounded to nearest 25 mg vial size, prepared as IVPB, slow infusion rate - Diluted in either 250 ml saline for central infusion or 500 ml saline with heparin for peripheral infusion - Central administration always preferred even if prepared in 500 ml volume - If giving peripherally, choose largest bore IV (i.e. 16 G) to minimize risk of thrombophlebitis

Heparin

Anticoagulant found in blood and tissue cells * Shots on abdomen

Liver Transplant Care pt 3

Anxiety and Depression - Risk Factors * Prior history of anxiety or depression * Major life event * Financial strain * Far from family and friends - Resources * Transplant psychiatry * Support groups Noncompliance - Causes * Accidental: Miss doses frequently due to forgetfulness/lack of habit in medication administration * Decisive: Although educated on the risks, have made the decision to stop immunosuppression medications * Other: Access/insurance changes/cost * Pediatric patients have the highest risk for noncompliance perhaps driven by combination of accidental and decisive - Management * Maintain a positive and trusting relationship * Provide clear communication * Continue to education * Support groups/mentorships - Cost * Hospital admission * Diagnostic eval (Biopsy) * Treatment * Infection risk * Not a candidate for re-transplant General guidelines - Avoid OTC medications (NSAID's) - Avoid grapefruit, pomegranate, and star fruit - NO live vaccines - No sexual restrictions * Birth control and mycophenolate * STI's Other surgical complications - Wound infection - Wound dehiscence - Constipation - Pain Smoking and alcohol - Do not smoke anything * increased risk of pneumonia - NO alcohol * Violation of drug and alcohol policies may make a patient ineligible for re-transplantation Pet Guidelines - keep and love dogs and cats * Mindful of infeciton * Up to date vaccines/flea/tick meds * No kitty litter box cleaning (toxoplasmosis) - Avoid * Birds chicken coups (caged, chicken coups) * Fish * reptiles (turtles, snakes, lizards) * Exotic pets (monkeys) * Horses and barns General Role of a Transplant Social Worker - Patient education - Emotional suport - Refferals to community agencies - Patient care with other team members - Assists with concrete services

Lactulose (Cephulac)

Category: Laxative, ammonia detoxicant, Use: Chronic constipation, portal-system encephalopathy, Precautions: nausea, vomiting, and cramps, Can give enema P: T: D: SE: AE: - CT: * If not given orally there are other routes * Encourage 3-5 BM's

Lovenox

Classification: Anticoagulant Causes the inhibitory effect of anti-thrombin on factor Xa and thrombin Therapeutic Effects: Prevention of deep vein thrombosis (DVT) and PE. Antidote = protamine sulfate Adverse Reactions & side effects: Bleeding, anemia, thrombocytopenia, erythema at injection site, pain. Use only 1 heparin product at a time Nursing Implications & teaching: * Assess for bleeding, CBC, platelet count, neurological impairment. * Note pkg info for prefilled syringe- keep air lock. "Lovenox in the love handles"-no aspiration or massage. * High Alert Medication * Shots on abdomen * Patients maybe discharge with it so give instructions & sharps container

Liver Transplant Care pt 2

Common Causes for Readmission - Infection - Rejection - Lab abnormalities - Fluid imbalance - Acute kidney - Nausea/Vomiting/Diarrhea - Failure to thrive Self Monitoring - Blood pressure cuff * BP and pulse twice per day Report SBP>160 or <90 - Thermometer * Temperature twice per day report feeling feverish or temp 101 immediatley - Scale * Weight once per day * call with a gain of 2 lbs in 24 hrs - Wound care * Keep the incision clean and dry * Do not apply lotions or antibacterial creams * Shower daily General Activity - No lifting more than 5-10 pounds, straining, pushing, pulling for the first three months - Do not drive for 6 weeks or until cleared by MD - Walk, Walk, Walk! Wound Care - Keep the incision clean and dry - Do not apply lotions or antibacterial creams - Shower daily with soap and water - Report signs of infeciton - Staples removed in clinic about 3 weeks fater surgery - No soaking in the bath, hot tubs, pools for 3 months Common Complications - Rejection - Biliary and/or vascular Strictures - Opportunistic infections (CMV, EBV, fungal, bacterial, HSV) - Anxiety and depression - Noncompliance - General surgical complications Rejection - Highest risk in the first year - Higher risk in positive crossmatch are previous episodes of rejection - Can be acute or chronic - Medical non-compliance - Increase in AST/ALT will lead to biopsy - Symptoms may include fever and pain - Many times asymptomatic - Acute can be treated, chronic may lead to the need for a re-transplant Opportunistic infections - All patients will be discharged on an antiviral, antifungal, and antibiotic - Cytomegalovirus (monitored weekly x3 months) - EBV (Monitored for high risk) - can increase risk for PTLD

Transplant Patient Care Map pt 2

Diabetes/ Blood sugar control - Glucose levels controlled 100-180 w/ insulin - Insulin teaching give per order * Glucometer given and teaching * Teaching S/S of hypo/hyperglycemia * Teach back of insulin use Social Work - Social worker is.. - Full time care-giver identified - Housing plan in place - Transportation arranged for discharge - Transportation plan in place for getting to outpatient appointments Care After discharge (Transplant RN coordinator - Transplant teaching with Transplant Nurse Coordinator Prior to discharge, patient is able to state: - How to care for self at home; what to monitor for - How to contact transplant coordinator - How to contact on-call team outside regular business hours - When to call 9/11 - Date/time/location of follow-up appt Other - Plan for outpatient central line care - Plan for outpatient dialysis - Paper lab slips if discharging on weekend - No anticoagulation issues or plan in place

Liver and Kidney Transplant Workshop pt 2

Drains in Liver Transplant - At the end of the procedure 2 drains are placed in RUQ around the graft * To identify post-operative bleeding * To drain ascites * To monitor for bile leak - Roux tube Doppler- blood flow monitor Post Operative Course - ICU * Intubated (4-8 hrs) - Stabilization * Weaning off vasoactive medications * Resuscitation * Correction of coagulopathy * Monitoring of labs (hct, INR, lactate, pH) - Doppler US of the liver * HA, portal vein , hepatic vein flow * Fluid collections * Administration of induction immunosuppression: steriod, Basiliximab (simulect), ATG ( anti-thymocyte globulin) Transfer to Acute Care floor - Post operative complications * Vascular complications * Biliary complications * AKI * Infection Transfer to Acute Care Floor - Liver Doppler US * Living donor- daily * Deceased donor -Day ) and POD 4 * As needed when Liver enzymes are elevated - Nutrition * Need to record percent of meals consumed * Dietician consult - Mobility * OT/PT consults - Glycemic control-teaching - Medication teaching Ascites After Transplant - Expected to resolve within 2-4 weeks as portal hypertension resolves as portal hypertension resolves - Causes * Outflow obstruction * Rejection (both acute and chronic) * Infection * Renal dysfunction * HF Chylous Ascites - Milky appearance of peritoneal fluid --->TG >110--> Postoperative chylous ascites---> MCT or low-fat diet * Measure TG level in asities Vascular Complications - HA thrombosis * Acute/Early HAT * Incidence <5% in adults * Diagnosed on doppler US (no arterial flow visualized) - HAT presentation * Elevated LFT's * Infection, sepsis * Biliary complications * Fulminant hepatic necrosis (like PNF) - Treatment * OR- thrombectomy restoration of flow * Relisting if not successful

Nutrition after transplant pt 2

Electrolyte Management - Affected by kidney function and transplant meds - High potassium * Avoid high potassium foods (fruit and vegs), consider diet order change * Consider Lokelma * EX: Apricots and dried fruit Tree fruits — such as avocados, apples, oranges and bananas leafy greens — such as spinach, kale and silverbeet Vine fruits — such as tomatoes, cucumbers, zucchini, eggplant and pumpkin Root vegetables — such as carrots, potatoes and sweet potatoes Legumes — such as beans and peas milk, yoghurt, meat and chicken, as well as fish — such as halibut, tuna, cod, snapper - Low Magnesium * Start PO supplement (may cause diarrhea) * Include more high Mag foods - Low or High phosphorous * Include/avoid high phosphorous foods * Consider binders if elevated and poor kidney function Blood Sugar Management - Post-op hyperglycemia is expected d/t stress and meds - Medications may have short and long term affects on BG control - Patients may need teaching on how foods affect BG - Encourage * Limiting high sugar foods like juice, soda, and desserts * Mindful of serving size of starchy foods * Not cutting out all carbs Transplant Nutrition Guidelines * Cover previous topics tailored to each patient's individual needs * Avoid grapefruit, pomegranate, starfruit, and pomelo * Food safety basics: ~~ Wash all fruits and veggies, no raw sprouts ~~ Only eat fully cooked meat, eggs, and seafood; heat lunch meats ~~ Avoid unpasteurized products, probiotics, and homemade fermented foods ~~Avoid buffets and salad bars; only cooked produce at restaurants x3 months ~~ Food storage: refrigerate within 2 hrs, keep only for 3-4 days , thaw in fridge

Benadryl (diphenhydramine)

H1 receptor antagonist (1st Generation) antihistamine/makes you sleepy Treats: N/V, allergic reactions Effects #1 = dry mouth IM --> Z track, deep injection Antihistamines = prevent release of histamine by blocking H1 receptor sites on the mast cells in nasal cavity. - Don't push too fast

Basiliximab (Simulect)

IL-2 receptor antibody Inhibits IL-2 mediated T-lymphocyte proliferation. Induce immunosuppression to prevent rejection of transplanted organs Lower incidence of drug-related adverse reactions than pan T-cell Abs P: T: D: SE: AE: - CT: * Run as secondary with NS

Liver and Kidney Transplant Workshop

Indications for Liver Transplantation in ESLD - Fulminant Hepatic Failure - Alcoholic Liver disease - Chronic Hep C & B - Non-alcoholic steatohepatitis - Autoimmune Hepatitis - Primary Biliary Cirrhosis - Primary Sclerosing Cholangitis - Hepatic tumors - Metabolic and genetic disorders Organ Allocation- MELD score - MELD * Model for ESLD * Ranges from 6-40 * Determines rank on waiting list * Calculates (Bilirubin, Serum sodium, INR, serum creat,) How are organ allocated - When a deceased organ donor is identified * UNOs' computer system generates a ranked list of transplant candidates who are suitable to receive each organ * UNOS matches individuals waiting for a transplant with compatible donor organs MELD exceptions - MELD exception are listed with what is known as MMaT-3 - MMMat stands for Median Meld at Transplant - Hepatocellular carcinoma - Hepatic hydrothorax - Hereditary Hemorrhagic Telangiectasia - Multiple Hepatic Adenomas - Neuroendocrine Tumors (NET) -Polycystic Liver disease (PLD) - Porto pulmonary HTN - Primary Sclerosing Cholangitis (PSC) - Post- Transplant Complications, Including small for size Syndrome, Chronic Rejection, - Diffuse Ischemic Cholangiopathy, and Late Vascular Complications Types of Liver donors - Deceased - Living - Deceased donors * Brain-Death Donor (DBD * Donors after circulatory Death (DCD) - Living related - Living unrelated Operative Course - Operation lasts 6-8 hrs - Anesthesia prepares patient placing monitoring devies * A-line-- Placed after intubation * Cordis/ A central line/ Introduces sheath * A catheter/ pulmonary artery catheter * TEE Transesophageal echocardiography- not routinely used - Three critical phases of surgery * Pre-an hepatic, an hepatic, and neo-hepatic phase

Liver Transplant Care

Indications for liver transplant - Chronic Liver Disease * Hep C cirrhosis (HCV) * Hep B cirrhosis (HBV) * Alcoholic cirrhosis * Autoimmune hepatitis (AIH) - Chronic Cholestatic Liver Disease * Primary biliary cirrhosis * Primary sclerosing cholangitis - Hepatic Malignancy * Hepatocellular carcinoma (HCC) * Cholangiocarcinoma - Metabolic Liver Disease * Nonalcoholic steatohepatitis (NASH) * Wilson's disease (peds mainly) * Alpha 1 antitrypsin deficiency - Acute/Fulminant Liver failure * Drug toxicity (Tylenol, antibiotics) * Alcohol * Toxins (mushrooms) * Cryptogenic Transplant Coordinator Role - Provide patient educaiton - Primary point of contact for transplant related needs - Care coordination - Lifelong transplant management Barriers to Discharge - Plan for 24-hr caregiving is not in place - Local housing not set up - Not cleared by PT/OT or does not have supplies - Does not have self monitoring supplies - Inadequate understanding of educaiton Outpatient Clinic - Typical surgical post op period is approximately 3 months * WE manage all aspects at medical care during this time - Clinic visits every Tuesday and Friday morning * Located in Medical Specialties on 3rd floor * Seen by surgeons, dietician, pharmacy * Bring mediset, Pill bottles, medication list, and education book with logs - Come to UWMC ER for emergencies - Check out visits occur approximately 3 months post-op * This is when they can return home Lab Monitoring - Labs prior to every clinic visit * 7 AM prior to immunosuppression medications * Should be timed for a 12-hour trough - Typical schedule * 0-3 months: 2x per week- weekly (must use UWMC lab) * 3-6 months: Every 2 weks * 6-12 months: Monthly * > 12 months: Quarterly * Potentially more frequent as indicated

Liver and Kidney Transplant Workshop pt 4

Kidney Allograft Dysfunction - Pre Renal * Volume depletion * Sepsis * HRS CRS * Medication/Toxicities * Renal Artery Stenosis (Transplant-specific causes of AKI) * CNI Toxicity (Transplant-specific causes of AKI) Intrinsic - ATN - GN - Contrast Induced Nephropathy - AIN - UTI/Pyelonephritis - DGF- Ischemia Reperfusion Injury (Transplant-specific causes of AKI) - Rejection (Transplant-specific causes of AKI) - Recurrent GN (Transplant-specific causes of AKI) - BK nephropathy (Transplant-specific causes of AKI) - Adenovirus (Transplant-specific causes of AKI) - CMV (Transplant-specific causes of AKI) - PTLD (Transplant-specific causes of AKI) Post Renal - Obstruction from stone, prostate/bladder outlet obstruction, extrinsic/intrinsic mass, etc - Bladder dysfunction - Extrinsic mass compression - Ureteral stricture (Transplant-specific causes of AKI) - bladder outlet obstructions - Bladder dysfunction (Transplant-specific causes of AKI) - Fluid collection from hematoma, seroma, lymphocele, or urinoma (Transplant-specific causes of AKI) Cause of allograft Dysfunction: DGF (delayed graft function) - Definition: need for dialysis within the first 7 days post kidney transplant - DGF occurs in approximately 10-30% of deceased donor and 2-4% of live donor kidney transplants Cause of Allograft Dysfunction: DGF ischemia Reperfusion Injury or Post ischemic Acute Tubular injury - Risk increases with * Long cold ischemia time (CIT): usually when more than 24 hrs (static storage) Sensitized patients * Donor history of HTN (higher perfusion pressure may be needed by the graft) - Prevention * Reduce CIT * Pump perfusion in transport * Maintain BP/ Avoid hypotension

Transplant Patient Care Map

Labs & Vital Signs - Learn important lab values - Learn normal VS values ( BP, HR, temp, weight) * How to take and log at home for clinic * Need obtain BP cuff, thermometer, and scale for home Respiratory - Q1 IS use - Wean off oxygen - Baseline breathing with no issues or plan in place Pain - Go off dPCA to oral meds - Able to participate in AD's - Pain manageable for at home Mobility ( PT & OT) - SCD's - Seen by PT and/or OT - Pass orthostatic - Be able to participate in ADL's and cleared by PT/OT - Have equipment if needed and/or equipment has been ordered Diet/Nutrition (Dietician - Tolerating appropriate diet order (liquids or solids) - Passing gas - Meet with dietician for initial nutrition consult and nutrition education - Tolerate regular meals and meeting calorie/protein needs - BM's Surgical Site & Drain Care - Foley care * Remove Foley and check PVR * Foley care w/ Theraworx if needed & Foley bag care - Monitoring incision and drain sites * Drains removed or plan in place for discharge care * 3 days of wound supplies, drain cup, drain record, and urinal/hat on discharge Medications (Pharmacist) - Start learning names and purpose of medications with RN - Has plan for filling prescriptions - Rn reinforces patient education with self-administered medications (SAM's) - Meds to beds * Bed box filled by patient and checked by pharmacy

Transplant Pharmacology pt 4

Opportunistic infection prevention - Candida species * Drug name: Fluconazole or Clotrimazole * Duration: 2-3 months * Counseling give consistently timed with tacrolimus as may boost levels * Dissolve clotrimazole in mouth, no food or drink for 30 mins afterward - Herpes simplex, Varicella zoster, Cytomegalovirus * Acyclovir or Valganciclovir * Duration: 3-6 months * Counseling: Require adjustment for kidney function ; Neutropenia with valganciclovir - Pneumocystis Jiroved, urinary tract infection, Toxoplasmosis * Drug name: Bactrim * Duration: 6 months * Counseling: Whipping boy of transplant; May rarely cause hyperkalemia, liver dysfunction, pancytopenia; sun sensitivity; allergic reactions

Liver Transplant Care pt 4

Organ procurement and Transplant Network (OPTN) Region 6 Longer Term Follow-Up (LTFU) - Day 0... Liver transplant - Day 7-14 Discharge from the hopsital - Day 15 Surgery clinic on Tuesday and Friday - Day 90 First visit with surgery clinic - 6 months First day visit with long term hepatology - 12 months One year anniversary visit with hepatology - Annual Long term follow up visit with hepatology

Liver and Kidney Transplant Workshop pt 7

Other complication: urine leak - Urine leak is an early post op complication after kidney transplantation and occurs in 1.2-8.9% of cases - Presents with * Increased JP drain output * Excruciating pain at allograft site - Testing * JP creatinine is higher than serum * Serum urea and creatine elevated * Imaging US shows collection - Management: * Foley cath * Reconstruction - Other info * Hypovolemia is a common cause of decreased allograft function immediate post transplant. Match UO of I's & O's * Hypervolemia is harmful and can also result to allograft dysfunction and other complications like Pulmonary edema and cardiac a stress * Hematuria is normal immediate post op but still important to note if worsening or if UO declines possibly from a clot * Monitor closely after Foley cath removal. Retention can lead to a urine leak.

Pantoprazole (Protonix)

Proton pump inhibitor (PPI) (ulcers, GERD, h. pylori infection) - Push slow or can cause seizure PIs are used to suppress gastric acid secretion in common conditions such as peptic ulcer disease and gastroesophageal reflux disease (GERD). Adverse effects include: Clostridioides difficile-associated diarrhea: Although the exact mechanism is unknown, it may be related to a change in gastric pH that allows for disruption of the normal gastrointestinal flora Fractures of the spine, hip, and wrist due to decreased bone density from decreased calcium absorption. Pneumonia due to alteration of upper gastrointestinal flora. Hypomagnesemia caused by decreased intestinal magnesium absorption, which can lead to tremors, muscle cramps, seizures, and dysrhythmias.- prescribed for gastroesophageal reflux disease, and ulcer treatment and prophylaxis. The IV preparation is administered when the oral route is contraindicated- Calcium is best absorbed in an acidic environment. Long-term therapy with PPIs may decrease calcium absorption and lead to an increased risk for osteoporosis and bone fractures

Nutrition after transplant

RD's role in post-op recovery? - Assessment of baseline nutrition status - Evaluation of nutrition goals and PO intake, strategies to meet goals - Education and reinforcement of goals with patient - Communication of patient's progress and need for nutrition support - Coordination with outpatient nutrition Nutrition priorities after transplant - Calories and protein - Hydration - Electrolyte management - Blood glucose control - Understanding of nutrition guidelines Calories and Protein - Recommend 15-40% more calories and 50-100% more protein 2-3 months - Aim for unrestricted General diet to optimize PO unless... * K, BG or fluid imbalance (w/ high intake) - Adequate PO and other indication - Common strategies to increase PO * Frequent meals and snacks * Prioritize high calorie and protein foods * Nutrition supplements Nutrition Supplements - High cal * Ensure Plus * Nepro - Low potassium * Nepro renal * Ensure clear - Low carb * Ensure Calorie counts - Charting % of meals eaten and supplements in flowsheets saves time for RD's and RN's (improves pt care) - Formal calorie counts are often unnecessary unless: * No data is available in flowsheets * Eating outside food or many snacks from nourishment room * Ordering very large meals but only eating small items ** RD's know what patients ordered from the kitchen but not how much they ate Hydration - Hydration goal varies based on fluid status and daily OP - If no restriction, recommend 2-3 L daily to promote healing - Always prioritize fluids that provide protein * Milk/Soy milk * Nutrition Supplements - Give strategies to encourage or discourage extra fluids

Flaps

Restrictions - Act like a "Zombie" * No abducting more than 45 degrees * No hands above your heads * Elbows in * No scratching back * Don't pull on wires Tips and tricks - If doppler doesn't make noise change out doppler before telling team * You can augment by having pt cough, move or by touching area

Incentive Spirometer

STEPS 1) Set the goal for the patient with the yellow marker. 2) Sit up and exhale completely 3) Seal mouth around the mouthpiece tightly 4) Inhale slowly and deeply while making sure to keep yellow indicator within normal range. 5) Keep inhaling until no longer able to do so 6) Then hold breath for 6 seconds and exhale slowly while allowing piston to fall completely. - Do 10 times per hour (during every commercial break or so)

CPR

Steps - First check responsiveness - Check for pulse & breathing - Yell for help & pull code blue - Start CPR

Transplant Pharmacology pt 3

The balancing act - Risks * Malignancy * Toxicity * Infection - Benefits * Quality of life * Avoid rejection * Graft function * Survival Maintenance Immunosuppression - Drug: Calcineurin inhibitors (inhibitors of T-cell activation early; Block IL-2 production) * Tacrolimus * Cyclosporine - Drug: Antimetabolite ( Inhibitors of T-cell production; Block DNA nucleotide synthesis * Mycophenolate * Azathioprine - Drug: Corticosteroid ( Non-specific inhibitors of immune function; Blocks IL-1 production) Calcineurin inhibitors (CNIs) - Backbone of modern immunosuppression regimens - 1980's, Cyclosporine * Lauded for potent antirejection effect * Corticosteroid sparing effects - 1900's, Tacrolimus * Nearly completely replaced cyclosporine as preferred CNI - Most transplant recipients will take a calcineurin inhibitor indefinitely - Reduce IL-2 production --> block t-cell activation and proliferation CNI principles - Give at 0800 and 2000, consistent timing - Trough level monitoring, ideally just before morning dose - Low bioavailability, high variability - Side effects * Renal dysfunction * Tremor (~50%) * Headache * Paresthesia * Hyperkalemia * Hypomagnesemia * Nausea/Vomiting * Diarrhea * HTN * Hyperlipidemia * Seizure * Vivid Dreams * Hirsutism (Cyclosporine) * Hyperglycemia (with tacro) * Gingival hyperplasia (cyclosporine) * Alopecia (tacro) CNI Counseling Points - Consistently, with or without food, 12 hrs apart - Call transplant if missed or late by several hours - Take AFTER - Avoid grape fruit, pomegranate, star fruit - No NSAIDS, take APAP instead - Narrow therapeutic range: 15-25

Liver and Kidney Transplant Workshop pt 3

Vascular Complications - Portal vein thrombosis * Incidence <3% * Graft failure, elevated liver enzymes - Portal vein stenosis * Ascites - Outflow obstruction * Ascites * LE edema * Elevated LFT's Biliary complications - Choledocho-choledochostomy -Hepatico jejunotomy * PSC * Cholangiocarcinoma * Bile leak repair * Re-transplantation * Incidence 5-25% - Bile dust stenosis is more common than bile duct leak - Therapy * ERCP with stenting * ERCP is more challenging in hepatico jejunostomy * PTC if ERCP is not possible Ischemic Cholangiopathy * 15%-20% of DCD grafts * Less common in DBD donors Acute Kidney Injury after Liver Transplant - Patients after liver transplantation are at major risk to develop acute kidney injury (AKI) - Factors that contribute to AKI are * Preoperative hepatorenal syndrome * Caval clamping during transplant with increase in venous pressures * Large blood transfusions * Perioperative hypotension - Liver Nephrology Service Infections - Postop infections * Surgical site infections * Intra-abdominal infections, abscesses * Urosepsis * Blood stream infections * Central line infections * Pneumonia * C.diff * Donor-transmitted diseases

Endoscopic Retrograde Cholangiopancreatography (ERCP)

What is ERCP? Endoscopic retrograde cholangiopancreatography, or ERCP, is a procedure to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. It combines X-ray and the use of an endoscope—a long, flexible, lighted tube. Your healthcare provider guides the scope through your mouth and throat, then down the esophagus, stomach, and the first part of the small intestine (duodenum). Your healthcare provider can view the inside of these organs and check for problems. Next, he or she will pass a tube through the scope and inject a dye. This highlights the organs on X-ray. You may need ERCP to find the cause of unexplained abdominal pain or yellowing of the skin and eyes (jaundice). It may be used to get more information if you have pancreatitis or cancer of the liver, pancreas, or bile ducts. Other things that may be found with ERCP include: Blockages or stones in the bile ducts Fluid leakage from the bile or pancreatic ducts Blockages or narrowing of the pancreatic ducts Tumors Infection in the bile ducts Some possible complications may include: Inflammation of the pancreas (pancreatitis) or gallbladder (cholecystitis). Pancreatitis is one of the most common complications and should be discussed with your provider ahead of time. Keep in mind, though, that ERCP is often performed to help relieve the disease in certain types of pancreatitis. Infection Bleeding A tear in the lining of the upper section of the small intestine, esophagus, or stomach Collection of bile outside the biliary system (biloma) You may not be able to have ERCP if: You have pouches in your esophagus (esophageal diverticula) or other abnormal anatomy that makes the test difficult to perform. Sometimes the ERCP is modified to make it work in these situations.

Transplant Pharmacology

Why Immunosuppression? - Genetic differences between donors and recipients trigger the recipient immune system to attack the donated organ, causing rejection - Lifelong immunosuppression is necessary for graft acceptance - We can easily destroy the immune system * I.e. chemotherapy or total irradiation * Limited by subsequent toxicity or overwhelming infection - Modern immunosuppression requires balancing the need to prevent rejection with the potential toxic effects of the therapy, including the risk for infection Efficacy and adherence - Even if taken as prescribed, rejection rates from 5-20%, more common during first year after transplant - If caught early by proactive monitoring, can be treated and reversed - Late rejection typically caused by non-adherence * Not getting labs on time * Not taking medications * Takin medications incorrectly * Education is essential Phases of immunosuppression - Induction * Prevent early acute rejection * IV agents, biologics * Higher risk of opportunistic infections - Maintenance * Establish life-long regimen * Minimize toxicity while maximizing graft longevity * Adherence is crucial - Rejection treatment * Can occur during either of above phases * Can re-evaluate maintenance regimen and adherence * Steroids' vs biologics vs procedures (plasmapheresis) Non-adherence - Common after transplantation - 28-52% of organ recipients have some degree of nonadherence - Risk factors * Younger age * Unmarried * Low social support - Odds of graft failure 7x higher - Among liver recipients, 10% died due to nonadherence Adherence SMURF - System * Prior authorizations * transportation - Motivation * Behavior change * Health beliefs - Understanding * Medication knowledge - Recall * Forgetful * Busy schedule - Financial * Copays * Competing needs

Nutrition after transplant pt 3

Your role in Post-Op Nutrition - Encourage intake - Assist patients with meal ordering - Record % PO intake and nutrition supplements - Request nutrition consults - Reinforce education - Communicate with team (MD, PA, RD) When to Contact RD - Consistently poor PO intake - Inability to safely take PO (AMS, dysphagia) - Taste changes, early satiety, severe anorexia - Prolonged persistent nausea, vomiting, diarrhea - Tube feeding and total parental nutrition - Additional education needed Extra: - Inflammation from surge can cause low labs and albumin has a half life of 3 weeks. These labs are not necessarily indicative of poor nutritional status in the post-op period

Enteral Tube Feeding

_ NG * If NG you may want to check pH of gastric contents (depending on policy) - Continuous feed 1) Make sure pt is sitting at least at a 30-45 degree angle before starting or continuing feed (risk for aspiration) 2) Clamp the tubing or spike the bag as first steip 3) Pour ordered amount of tube feeds in bag & put tap water into other bag (or spike bottle) 4) Some ppl change tubing of feeds every time 5) Make sure to verify rate, bag type (ex: nepro), and date bag with time 6) Prime tubing (usually auto prime). Tubing comes in bags that are Y'd together 7) Put tubing into kangaroo machine as directed 8) You can then either keep the settings or clear setting on kangaroo 9) Click auto prime or you can click hold to prime flush then hold to prime feed (never prime when its connected or you will put air into patient) 10) Check orders then adjust feed (feed rate and feed VTBO which is volume of bag but you should go a little lower than total volume to get alert before its empty like 50ml before) 11) Then click done 12) You will then click the flush volume (check if pt is fluid restriction) put in 20 mL usually (check orders) 13) Then click flush interval and set based on order (ex: Q4) 14) For I/Os you want to watch the amount fed and clear volume for the next shift 15) Hold if patient is laying flat