POST-OPERATIVE CARE PROCESS IN THE ARM AND FACE TRANSPLANTATION

POST OPERATVE CARE PROCESS THE ARM TRANSPLANTATIONNURSE:FATMA YILMAZ14.11.2014

POST-OPERATIVE PERIOD

Starts when the patient leaves the operating room and involves the time up to the discarge

POST-OPERATIVE CARE

Operation impairs the hemostatic balance of the body as it is both physiological and psychological source of stressMAIN AIM OF THE POST OPERATIVE CARE; is reorganize the hemostatic balance

AIM OF A QUANTITATIVE NURSING CARE

Maintain the vital functions of the patientMinimum painA post-operative period without complication Ensure the return to normal life in a short time

ARM TRANSPLANTATION 26.09.2010

HISTORYThe first scientific documentation;1964 Ecuador1996 Louisville hand transplantation team 1997 Louisville, international symposium

The first short-time successful patient is French29 months

HISTORY1999 LouisvilleThe first long-term caseFirework accident

2000 France Dubernard The first double-hand transplantation

July 2008 GermanyArm transplantation

March 2009 bilateral hand and face ; bereavement

HISTORY36 patients50 hand transplantations14 bilateral22 unilateral

INDICATIONS

Unilateral or bilateral amputations over the wrist or below the elbowOver the elbow? healthy18-65yearsChild?

THE FIRST BILATERAL ARM TRANSPLANTATION IN TURKEY Prof. Dr. mer zkanProf. Dr. A. RamazanoluAssoc. Prof. Dr. Murat YlmazAssoc. Prof. Dr. zlenen zkanAssoc. Prof. Dr. Ayhan DinkanNurse Fatma DumanNurse Aye KocaobanNurse Glizar SarNurse Nihal KarataNurse zlem AkarNurse Rukiye Buyruku

RECIPIENT28 yearsSilage machine 2 years agoRight forearm1/3 proximal forearmLeft forearm1/3 distal forearmStatic prosthesisRoutine pretransplant examinationStabile family stractureMental stabilityGeneral condition is goodInformed consent

BEFORE THE OPERATION

Communication with the centre where the organ was removedPermission for cadaver donor, offical paperdocuments about the functional information of the organ Credentials of recipient and donorHistocompatibility control

OPERATIONThe patient was operated by a team of 40 persons

The operation lasted 7 hours

The patient was admitted to the intensive care unit by 4 nurses, 3 lecturers, 2 anaesthesia residents, 1 respiratory physiotherapist and 2 staff

PREPARATIONS IN THE INTENSIVE CARE UNITAssessment of the enviromentSterilized bedclothes were usedThe bed was heated by blanketRestrictions for visitorsLight sourceNumber of nursesSecurity measures were taken

INTENSIVE CARE ADMISSIONEntubeted and sedated patient was brought to the AICUII by a team. Elevation was achieved while maintaining the position of the armsWas taken to the bed which was heated by blanketWas connected to the mechanical ventilation 5 leed ecgArterial blood pressureSpo2 Body temperatureCvp monitoring was done

FLUID AND ELECTROLYTE BALANCE Fluid replacement therapyIntense monitoring of blood gaseshipotensive in the admission to the ICU -Inotrope medication (dopamine inf) -48x1 TA monitoringAT/FIO(following of input/output ) 48x1 Strict/intense monitoring and recording

HEMODYNAMIC MONITORINGIn the operation area -circulation and bleeding monitoring -early circulation support heating by light source

Adequate oxygenation

Fluid and electrolyte balance

Stop the inotrop support extbation in the post-op 12. hours

HEMODYNAMIC MONITORINGNURSE IN THE INTENSIVE CARE UNITFor hemodynamic stabilization ; Should pay attention to Hypervolemia HypovolemiaHypertantion HypotantionElectrolyte imbalances

BLEEDINGOperation area was followed-upDrugs which enhance the bleeding were controlledly used (anticoagulants)Laboratory findings were revealedAvoided from IM njection Oral treatment was performed with a soft toothbrushAspirator pressure was reducedAvoided from jerk

RESPIRATORY/VENTILATION

Mv modes were adjusted (respiratory frequency, tidal volumes, findings of blood gases, SpO2 were evaluated)Weaning was startedThe patient was extubeted 12 hours after the operation

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RESPIRATORY/VENTILATION

Preparations were performed before the extubation (oxygen system, nasal oxygen cannula, reservoir oxygen mask, bronchodilators, etc. )Deep breathing and coughing exercises after the extubation were planned and performed Triflo/trifluoromethyl was runSteam was given

INFECTIONProtective treatment for infection -prophylactic antibiotic therapy - sterile interventions - avoiding from frequent contact

Risk factors the patients was exposed during the ICU stay (invasive catheters, entubation, mechanical ventilation devices, etc) were determined

INFECTIONAttention to comply with the surgical aseptic technique for all invasive interventions was paid. All members of the health care team were provided to wash their hands with the proper technique. cleaning and disinfection of devices as monitor connections that were attached to the patient, aspirator and ventilator were performed properlyEntracheal cuff pressure was controlled.

SAFETY ENVIROMENT

Immobile patientBed borders were raised upwardAlarm/warning limits of devices and monitors were set-up. Catheters and foley catheters were fixated properly.

HYGIENEDaily personel care 3x1 ( eye care, oral care, foley catheter care...)

Perineal care was done

Bedclothes were changed in every 24 hours

SKIN INTEGRITYTo avoid the deterioration of skin integrity, regions under pressure and heels and points of shoulders were supported wiht air bearing bed and gel pads, respectively. Air bearing bed was open at the appropriate pressure. Massage was done on bony prominencesPaid attention that bedclothes were clean and neatMeasures were taken to protect the upper side of ear aganist the mask after extubation

FOR PAINExplanations were done for all interventionsThe patients was put in a comfortable positionStimuli in the enviroment were reduced and tried to prevent unnecessary noise Lead connections of the devices attached to the patient were checked and avoid the damageNonpharmalogical methods like relaxation movements were performed. Appropriate analgesics were administered to the patient prior to painfull invasive interventions according to physicions order

COMMUNICATION Inform the patient after extubation - he was in ICU - operation was finished/over and t was successful

The patient was provided to express himself frequently

The patient was allowed to have short-term interviews with his relatives

URINARYntestinal sounds were evaluatedCare was taken to the privacy Avoided to be wet and dirtyMoisturizing ointements were usedScaled sterile urine bags were used for evacuation of urinary system Foley catheter was fixated to his legColor of urine, dysuria and pain were monitorized. Urine bags were drained out before they were brimful

FEAR, ANXIETYConfidence was providedTouch and body language were used to communicateCollaboration/cooperation with family was provided Supportive treatment for adoptation (psychiatry) was usedProvided visits from family members and relatives

HYPOTHERMISupported with heaterWas covered with a blanketHe was cleaned with warm and wet cottonHe was dressed in white socks because t didnt hurtTemperature of enviroment was set up

SLEEPMeasurement of the physological parameters which might disturb the sleep while performing at night were done carefully Speeking in a low voice in the unit, working noiseless and reducing the unnecessary voice in the surronding area were provided. Lighting of bedside was reduced after a determineted time at night

FEEDINGThe patients who had been feed paranterally because of entubation was feed orally after the extubationFor feeding, at first liquid and soft foods, then solid foods were given Appropriate calorie count was madeAttention was paid to eat all mealsDuring and after feeding, the patients head was put in upright position (35-45 degrees) in the bed.

EDUCATION Take the medicine timely and carefullyAttention to hygieneRecommened to take care of preventive measures (mask) especially in the first monthsNot to consume convenience food or if there is a doubt about the sanitation Regular physiotherapy and check-upFollow up for rejection Alcohol, cigarette ???Not to be in crowded, public places.

DRUGSImmunusuppressive protocol - ATG infusion: 100-300 mg/g 10 days - Prednisolone: 1000 mg IV..20 mg/g

maintenance -Tacrolimus (Prograf, 0.2 mg/kg/day; blood level 15 and 20 g/ml-Mycophenolate mofetil (Cell Cept, 2 g/day)-Prednisolone: 20 mg/day

DRUGSASST AMP2x1 IVZANTAC AMP4x1 IVTAZOSN FLK3x1 gr IVVANCO FLK4x500 mg IVGASKLOVR TB1x400 mg POCLEXANE 0,42x1 SC

TRANSPLANTATIONThe patient who would be discharged from the ICU weaned from the monitoring devices and arrangemenets about the transport were performed. The patients was transfered to the ward with his belongingsThe patient was refered to the ward with a nurse epicrisis report which included drugs that patient had been using, care and treatment plan, states of catheters and vital signs

RESULT

In general, t has been seen that patients satisfaction and post operative functional recovery were always better than previous prosthesis.

THANKS...