Chapter 36 Organ Donation and Transplantation

A patient is admitted with a massive head trauma. The patient is unresponsive and on mechanical ventilation. The electroencephalogram (EEG) is negative for brain waves. The family has agreed to organ donation. How would this organ donor be classified? a.Brain-dead donor b.Donation after cardiac death c.Living related donor d.Living unrelated donor

ANS: A A brain-dead donor is a donor declared dead by neurologic criteria for brain death. Donation after cardiac death is when the donor is declared dead by circulatory criteria for death. A living related donor is a family member related by blood who donates a kidney, portion of the liver, pancreas, intestine, or lung to another family member. A living unrelated donor (directed or nondirected) is a living individual not related to a patient requiring a transplant who donates a kidney, portion of the liver, pancreas, intestine, or lung to that patient. The donor may be anonymous or altruistic.

A patient who has received a transplant is being taught about azathioprine. Which statement made by the patient would indicate the teaching was effective? a."I will notify my health care provider if my gums start to bleed." b."I will make sure to increase the amount of fiber in my diet." c."I realize I may have an increase in hair growth." d."I know the flulike symptoms will go away as I get used to the drug."

ANS: A A common adverse effect is the suppression of other rapidly proliferating cells, resulting in leukopenia, thrombocytopenia, and anemia. The dose of the drug is adjusted to keep the white blood cell (WBC) count between 3000 and 5000 cells/mm3, thus protecting the patient from an increased risk of infection.

A patient has had a kidney transplant. The nurse knows that monitoring of which parameter would have the highest priority? a.Fluid volume b.Electrolytes c.Complete blood count d.Temperature

ANS: A Adequate hydration is an absolute necessity for continued graft function in the immediate postoperative period. Hypovolemia can lead to compromised blood flow to the kidney, acute tubular necrosis, and possible graft failure. The new kidney will produce large amounts of urine, and replacement fluids, usually maintained at a ratio of 1:1 mL, must be sustained.

The nurse is caring for a patient after a heart transplant. Which finding would the nurse anticipate after cardiac transplantation? a.Two P waves on the electrocardiogram (ECG) b.High cardiac output c.Anginal pain d.Resting heart rate of 60 to 70 beats/min

ANS: A An electrocardiogram (ECG) abnormality unique to a transplanted heart is the presence of a second P wave generated by the native sinoatrial (SA) node left in the atrial cuff. Because this impulse does not cross the suture line, it is capable of conducting only through the remnant of the native recipient atria. However, this is not seen in hearts transplanted using the bicaval technique because the native right atrium and therefore the SA node is removed.

After a pancreatic transplant with bladder exocrine drainage, the nurse would anticipate which order? a.Continuous bladder irrigation b.Intermittent insulin injections c.Removal of the nasogastric tube as soon as the patient is alert d.Daily hematocrit and hemoglobin levels

ANS: A An increased potential for urinary catheter occlusion exists for pancreas recipients who have undergone a urinary diversion procedure. The exocrine pancreatic enzymes make the urine more viscous, and they irritate the anastomosis site on the bladder, causing an increased risk of bleeding. Continuous bladder irrigation may be necessary to keep the catheter patent.

Who determines the medical suitability of the patient for organ donation? a.The organ procurement organization (OPO) coordinator b.The patient's family c.The admitting health care provider d.The transplant team

ANS: A Determining medical suitability is solely the responsibility of the organ procurement organization (OPO). Speaking to the family about donation is also the responsibility of the OPO unless designated requestors at the hospital have been trained to do so.

Which nursing problem would be appropriate for a patient who has received a kidney transplant? a.Deficient fluid volume b.Excess fluid volume c.Urinary retention d.Decreased cardiac output

ANS: A Hypovolemia can lead to compromised blood flow to the kidney, acute kidney injury, and possible graft failure. The new kidney will be producing large amounts of urine, and fluid replacement, usually maintained in a 1:1 ratio, must be sustained.

A nurse is preparing a patient for a liver transplant. The patient asks which stage of the procedure is the longest and most difficult. What would the nurse tell the patient? a.Stage 1—recipient hepatectomy b.Stage 2—vascular anastomoses c.Stage 3—biliary anastomosis d.Stage 4—induction therapy

ANS: A Liver transplant surgery can be divided into three stages: (1) recipient hepatectomy (the longest and most difficult part of the surgery), (2) vascular anastomoses with donor liver, and (3) biliary anastomosis. Induction therapy, which refers to the first in any series of therapeutic measures taken to treat a disease, would be administered after the transplant and is not part of the procedure.

A nurse is caring for a patient who is receiving sirolimus. The nurse knows to monitor the patient for what side effect? a.Bleeding b.Diarrhea c.Rigors d.Hypotension

ANS: A Other primary side effects of this medication include hyperlipidemia and myelosuppression. Most of the myelosuppressive effect is directed at platelets, and severe thrombocytopenia can result, making it necessary to discontinue the medication.

The nurse is caring for a patient with a pancreas transplant. Which statement made by the patient indicates the need for further teaching? a."I no longer need to monitor my blood glucose levels." b."I will need to have periodic pancreas biopsies." c."I may feel the urge to urinate frequently." d."I will give urine samples to monitor for rejection."

ANS: A Patients with functional pancreas grafts continue to need glucose monitoring at home but often forget to continue this practice after they no longer require insulin. Continued monitoring with frequent clinic visits is required for several months after pancreas transplantation.

The Model for End-Stage Liver Disease (MELD) formula is used to calculate risk of 3-month mortality in patients 12 years old or older. What criteria is part of the MELD formula? a.Whether the patient has undergone hemodialysis at least twice in the past 2 weeks b.The number of organs in which metastasis has occurred following hepatocellular carcinoma c.The presence or absence of intractable pruritus d.The number of hours the patient is expected to live without a transplant

ANS: A The Model for End-Stage Liver Disease (MELD) formula is used in all U.S. transplant centers to calculate the risk of 3-month mortality in patients 12 years old or older. The MELD objective criteria include serum total bilirubin, serum creatinine, prothrombin time, international normalized ratio, and whether the patient has undergone hemodialysis at least twice in the past 2 weeks. Patients who have hepatocellular carcinoma that meet specific tumor criteria are automatically given a MELD score of 22 because the risk of metastasis outside the liver within 3 months is high. Once metastasis occurs, the patient is no longer deemed a transplant candidate. Intractable pruritus and number of hours to live are not part of the MELD formula.

Which statement would indicate that a patient who has received an organ transplant understands the teaching about immunosuppressive medications? a."My drug dosages will be lower because the medications enhance each other." b."I will be less prone to side effects because I will be taking more than one drug." c."Lower doses of these medications put me at greater risk for infection." d."Taking more than one medication will put me at risk for developing allergies."

ANS: A These "triple-drug" regimens are designed to prevent rejection while reducing the toxicity of the individual medications.

A patient is admitted after a lung transplant. The nurse knows the patient is at risk for developing pneumonia. What parameter would be a priority for the nurse to monitor? a.Oxygen saturation b.Chest tube output c.Intake and output d.Blood pressure

ANS: A These patients are at risk for developing pneumonia. Aggressive postoperative pulmonary toilet is essential to promote airway clearance because surgical denervation of the lungs diminishes the cough reflex after surgery. Thus it is important to monitor oxygen saturation levels.

The nurse is caring for a patient after a lung transplant. Which intervention would be a priority for the nurse? a.Wean the patient from the ventilator. b.Maintain hypotensive levels. c.Start corticosteroid therapy. d.Initiate pulmonary function studies.

ANS: A Ventilation settings are determined partially by the underlying disease process and patient progression. Regular suctioning of secretions is crucial to maintain airway clearance. Extubation is performed after satisfactory gas exchange and lung mechanics are accomplished, and most patients are extubated within 24 to 48 hours. Evaluation for graft dysfunction, reperfusion injury, gas trapping, and phrenic nerve injury is ongoing. Early mobilization after extubation is essential for improved pulmonary toilet and helps prevent reintubation.

Potential recipients are matched with donors based on what factors? (Select all that apply.) a.Blood type b.Human leukocyte antigen c.Race d.Socioeconomic status e.Severity of illness f.Location of recipient g.Waiting time on the list

ANS: A, B, E, F, G Potential recipients are matched with the donor based on blood type, height, weight, human leukocyte antigen, distance from the donor, waiting time on the list, and severity of illness. The national system in place for organ allocation is fair and equitable for those requiring a transplant. The list does not reference race, gender, or socioeconomic status.

Which federal laws regulate the medical and surgical therapy involved with organ transplantation? (Select all that apply.) a.Omnibus Budget Reconciliation Act b.Uniform Anatomical Gift Act c.Hospital Conditions of Participation-Organ Donations d.Medical Examiner Laws e.Uniform Determination of Death Act

ANS: A, C The Uniform Anatomical Gift Act, Uniform Determination of Death Act, and Medical Examiner Laws Restricting Ability of Medical Examiner or Coroner to deny organ donation are all state laws.

The nurse is caring for a patient who has had a recent heart transplant. Which signs and symptoms would alert the nurse that the patient is rejecting the transplant? (Select all that apply.) a.Shortness of breath b.Tolerance of exercise c.Disturbance in mood d.Decreased weight e.Pulmonary crackles f.Onset of hypertension g.Sudden onset of edema

ANS: A, C, E, G Signs and symptoms of heart transplant rejections include intolerance to exercise, increased weight, and onset of hypotension.

Which statement made by a patient who has received an organ transplant indicates that the teaching was effective? a."I will finally be able to eat a regular diet." b."I will establish a routine for checking any skin changes." c."I will check my blood pressure regularly to make sure it's not too high." d."After my drug regimen is established, I won't have to worry about rejection."

ANS: B Immunosuppressed patients are at greater risk for developing skin cancer. After transplantation, such a patient needs to monitor for hypotension and eat a diet that is low in sodium, fat, and cholesterol.

The organ procurement organization coordinator writes orders to initiate standard donor care. Which interventions are parts of standard donor care? (Select all that apply.) a.Continue administration of osmotic agents and diuretics. b.Maintain head of bed at 30 to 40 degrees elevation. c.Continue routine pulmonary suctioning and side-to-side body positioning. d.Warming blanket to maintain body temperature above 36.5° C. e.Maintain mean arterial pressure less than 70 mm Hg.

ANS: B, C, D Standard donor care includes: maintain head of bed at 30 to 40 degrees elevation, continue routine pulmonary suctioning and side-to-side body positioning, and warming blanket to maintain body temperature above 36.5° C. Osmotic agents and diuretics should be discontinued. Mean arterial pressure should be maintained above 70 mm Hg.

Many barriers exist to increasing the number of organ donors to meet today's growing need. Which barriers are related to hospital factors? (Select all that apply.) a.Limited resources b.Lack of interest c.Failure to approve protocols d.Nurses' attitudes e.Delay in termination of life support

ANS: B, C, D, E A recent study of hospital donation practices and their impact on organ donation outcomes revealed gaps in knowledge of organ donation; brain death; referral criteria; and at times, a poor relationship between the hospital and the organ procurement organization. It is important that nurses are knowledgeable about the organ donation process. Nurses must assess their own beliefs that pertain to organ donation because the attitude of the nurse and care given to the family can impact the outcome of the donation.

Not every patient with end-stage liver disease is a candidate for receiving a transplant. Which conditions are contraindications to a kidney transplant? (Select all that apply.) a.Malignancy during the past 5 years b.Active infectious process c.Advanced cardiopulmonary disease d.Recreational drug use e.Nonadherence to current medical regimen

ANS: B, C, D, E Contraindications to kidney transplantation include malignancy during the past 3 years, active infectious process, advanced cardiopulmonary disease, high risk for surgery, nonadherence to current medical regimen, recreational drug use, and other serious contributing disease processes.

The nurse is caring for a patient after a liver transplant. Which finding would be of most concern to the nurse? a.Increased serum glucose b.Low aspartate aminotransferase (AST) and alanine aminotransferase (ALT) c.Elevated prothrombin time d.Decreased blood urea nitrogen and creatinine

ANS: C A patient with suspected primary nonfunction of a liver graft demonstrates (1) hemodynamic instability, (2) progressive deterioration of kidney function, (3) coagulopathies and abnormal serum liver function laboratory test results, (4) hypoglycemia, (5) continued ventilatory dependence, and (6) an inability to awaken from anesthesia.

A patient is admitted with massive head trauma. The patient is unresponsive and on mechanical ventilation. The electroencephalogram (EEG) is negative for brain waves. The family has agreed to organ donation. Which organs would not be considered for transplant? a.Heart b.Lung c.Liver d.Kidney

ANS: C Brain death is an absolute contraindication for a liver transplant.

The nurse is teaching a patient about antiviral medications. The patient asks what is the most common viral infection in transplant recipients. What should the nurse tell the patient? a.Influenza b.Respiratory syncytial virus c.Cytomegalovirus (CMV) d.Parainfluenza

ANS: C Cytomegalovirus (CMV) is the most common viral infection in transplant recipients. CMV may occur within the first few months after transplantation and may occur later on. Other common viruses after transplant include respiratory syncytial virus, influenza, adenovirus, human metapneumovirus, and parainfluenza. These are not treated prophylactically but as they occur.

A patient is admitted with massive head trauma. The patient is unresponsive and on mechanical ventilation. The electroencephalogram (EEG) is negative for brain waves. The family has agreed to organ donation. When the nurse turns the patient's head quickly from side to side, the patient's eyes do not move. The nurse knows this is the result of the loss of what reflex? a.Oculovestibular b.Corneal c.Oculocephalic d.Pupillary

ANS: C Oculocephalic reflex: Ocular movements are lost with brain death. The oculocephalic reflex, also described as doll's eyes, involves fast turning of the head to both sides. In brain death, this should not generate any eye movements. Oculovestibular reflex: Because the oculovestibular reflex is tested using iced water or normal saline, it is sometimes called cold calorics. The head of the bed is elevated 30 degrees, and approximately 50 mL of ice water or normal saline is injected into the ear; no movement of the eye toward the side of the stimulus should be present. It is recommended that the patient be observed for up to 1 minute after each ear irrigation, and 5 minutes should be allowed before testing the opposite ear. Corneal and jaw reflexes: Facial sensory and motor responses are elicited by testing for corneal and jaw reflexes. Stroking a cotton-tipped swab gently across the cornea tests the corneal reflexes. Pupillary reflexes: Pupillary signs are evaluated by absence of the light reflex, which is consistent with brain death. Most often the pupils are round, oval, or irregularly shaped, although dilated pupils may remain even after brain death has occurred.

1. What happens to patients that meet criteria for imminent death? a.They are placed on life support and referred to the organ procurement organizations. b.They are referred to the organ procurement organizations at the time of their death. c.They are referred to the organ procurement organizations in a timely manner. d.They are referred to a practitioner to make the decision if they are candidates for organ donation.

ANS: C The Centers for Medicare and Medicaid Services guidelines, the Joint Commission standards, and hospital policies require that patients meeting criteria for imminent death and cardiac death be referred to an organ procurement organization in a timely manner.

Rejection that occurs within hours after the transplantation and results in immediate graft failure is referred to as what type of rejection? a.Acute b.Intermediate c.Chronic d.Hyperacute

ANS: D Hyperacute rejection is a humoral-mediated response, which occurs within hours after transplantation and results in immediate graft failure. Acute rejection tends to occur weeks to months after transplantation but can occur at any time. Chronic rejection occurs at varying times after transplantation and progresses for years until it leads to ultimate failure of the transplanted organ.

A patient with liver failure manifested by portal hypertension and ascites is hospitalized and waiting for a liver transplant. Which order should the nurse question? a.Low-sodium diet b.Low-protein diet c.ABO typing d.Human leukocyte antigen tissue typing

ANS: D Liver failure is managed with a low-protein diet to decrease the risk of hepatic encephalopathy. A low-sodium diet is ordered to help manage the ascites. Blood type and body size are used to match a liver donor, not human leukocyte antigen tissue testing.

A patient is admitted with a massive head trauma. The patient is unresponsive and on mechanical ventilation. The electroencephalogram is negative for brain waves. The family has agreed to organ donation. How would the nurse check for the absence of cerebral motor reflexes? a.Performing a sternal rub b.Applying needle pricks to fingers and toes c.Clapping hands near the ears d.Applying pressure to the nail beds or supraorbital ridge

ANS: D These motor responses can be stimulated by the application of pressure to the nail beds or supraorbital ridge.

A patient who has received a transplant is being taught about cyclosporine. Which statement made by the patient would indicate the teaching was effective? a."I know this drug prevents my immune system from working." b."If I find the capsules are hard to swallow, I'll take the liquid." c."I will need to watch for bruising." d."I will need to monitor my blood pressure."

ANS: D This drug can cause hypertension. Capsules and liquid form are not interchangeable. The immune system still has some ability to work. Cyclosporine does not affect the bone marrow.