Respond to these 2 presentations and these 2 discussion questions, in at least 125 words.
1. https://youtu.be/RUXUPaL9wbo
2. https://www.youtube.com/watch?v=oCuJQ_XwFIU
3. This information presented in the case study of our patient Mr V. the 56 y/o transgender male with hepatitis, S/P liver transplant. Whom is now having multiple complications post surgical intervention to include renal failure, anemia probably related to blood loss, and low white blood cell count which will be further declined with immunosupressant therapy. The medical diagnosis of intraabdominal hypertension and adbdominal compartment syndrome are potentially life threatening as it contributes to the reduced venous return, reduced cardiac output, and domino effect of organ dysfunction, leading to death ( Prasad et al, 2017). In this case the patient is already exhibit injury to the renal system in realtion to his decreased urinary output, increased heart rate, and his serum creatinine. As the kidneys are a major contributor in the human body to maintain homeostatsis.
From a surgical standpoint this patient is most probably the most the adequate surgical candidate. American Society of Anesthesiologists (ASA) Physical Status Classifcation System has been used to assess pre-anesthesia comorbid conditions for over 60 years. This tool helps the provider of anesthesia grade the candidate on a scale based on comorbidies and percieved outcomes. Just based on the weight of 452 pounds would put the paitend of risk of hard intubation or difficult airway which coulc be life threatening in the operating room. Based on his other issues realted to his hepaitis and disease progression, he would almost benefit from a pallative care referal to help keep him comfortable until his demise.
This also be demonstrated by his inability to breath on his own post surgical intervention. The priority in my opinion would be the pallative care aspect as with his comorbidies this could be inoperable. As a future provider my interventions would include treatment of his thrombocytopenia, anemia and maybe even start and keep the renal replacement therapy to diminish the hepatic encephalopathy to reduce the BUN and ammonia levels in the patients blood stream. I would definately keep him monitored in the ICU due to his need for intubation and until the patient is able to adequately breathe on his own. Would also want to keep him safe to monitor critical lab values to return to baseline with hydration, medications to reduce or relieve symptoms directly related with the acute hepatorenal failure.
His transgender status may include his ingestion of hormonal replacement therapies which could put him at risk for increased blood clots, and therefore should consider his medication of Warfarin monitored closely to keep his levels therapuetic. His weight is definately a factor that would have and should have made him not to be an ideal surgical candidate to begin with. His other issues should have been put as a priority prior to considering a liver transplant. Other considerations in regards to weight control, he should have been sent to nutritional consult to see if his weight could be reduced on a strict management of food regiment.
Recommendations for a transplant patient would include to make sure immunosuppression medications are adhered to appropriately. Monitorung of his vital sigs due to increased risk of liver transplant patients to developing a new onset of heart failure according to Sharma et al (2018).Monitoring of the signs and symptoms of organ rejection should be explained in detail, notify the patient of potential reoccurence of their primary disease, monitoring for other illness such as diabetes due to the increaed use of steriods, to monitor for any possible signs or symptoms of infections while on immunosuppression agents.
This patient seems like a medical diasaster but unfortunately due to this day in age and our nations epidemic on obesity and comorbidies due to lifestyles this type of scenario is real life. As practitioners we will be able to identify the needs of the patient and provide holistic care.
4.Major priorities for this patient immediately postoperative is to ensure the patient is hemodynamically stable and maintain graft function. This patient will require a mutlidisciplinary team apporach. Careful coordination of care amongst providers such as the intensivist, attending, surgeon, nephrologist, hepatologist, nurses, nurse aid, respiratory therapist, dietitian, social work, and case management. The patient will require a delicate balance of fluids to provide adequate graft function. Increased cardiac filling or hypovolemia can cause a decline in gas exchange and decrease graft perfusion. The patient requires strict monitoring of the cardiocirculatory system, including cardiac output, preload, afterload, transpulmonary pressure, and pulmonary vascular resistancefurthermore, titration of vasoactive drugs ensures adequate perfusion. Examples of pharmacological agents include low-dose noradrenaline for vasoconstriction and dopamine to increase inotropic function. A negative fluid balance is appropriate for the first day postoperative to decrease the rate of pulmonary complications and improve graft oxygen delivery (Feltracco et al., 2011).
Hemodynamics need to be monitored with serial CBC as well as fluid and electrolytes with serial BMP. Possible correction of coagulopathy with platelet transfusion and monitor for any signs of bleeding.
Another consideration is postoperative airway maintenance. Some patients may be able to extubate immediately after surgery. However, some patients may need to remain vented until stabilized in the ICU and ensure adequate graft function (Feltracco et al., 2011).
The major long-term priorities for this patient are to increase life expectancy and improve quality of life (Norris, 2019).
What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?
One intervention to promote optimal functioning, safety, and well-being is good follow-up care with the patient. Makes sure the patient is adhering to all medication regimens.
Another intervention is to refer the patient to a physical therapist to ensure they are able to function optimally and to help with devising a safe exercise regimen. Also, referring the patient to a dietitian to develop a dietary plan. The provider can also counsel on the importance of weight loss, adhering to diet plans, and exercise. Since the patient is transgender and liver failure affects the endocrine system, testosterone replacement may be needed in hypoandrogenic states. Education is also needed with the use of vaccines. Liver transplant patients and their households should not receive live attenuated vaccines due to the patients immunocompromised status. Vaccines that can be safely administered are human papillomavirus, pertussis, Haemophilus influenza type b, diphtheria, tetanus, pneumococcal, meningococcal, inactivated influenza, hepatitis A, and hepatitis B (Bhat et al., 2014). Lastly, assessing the patients mental well-being and the possible need for referral for behavioral counseling.
Considering his gender and weight, what specific considerations are needed?
Mr. Vs weight is 452 pounds. Without his height, one can assume that he is morbidly obese. According to Moctezuma-Velazquez et al. (2019), obesity increase the risk of postoperative complications. Complications include infections, surgical wound infections, 30-day mortality, increased hospital length of stay, and cardiopulmonary events. Therefore, meticulous care should be incorporated to prevent complications. This includes encouraging incentive spirometry, fluid management, cardiac monitoring, antibiotic prophylaxis, monitoring for infections, to name a few. Once discharged, the patient should be encouraged to lose weight through pharmacological therapy, diet, exercise, and possibly bariatric surgery. Immunosuppression therapy should be tailored to reduce the risk of metabolic complications. Complications include diabetes, dyslipidemia, and hypertension (Moctezuma-Velazquez et al., 2019).
In regards to Mr. V identifying as a transgender male, it is important for health care providers to provide culturally sensitive care. According to Klein et al. (2018), it is important to address the patient correcting including their chosen name and proper use of pronouns.
What are some recommendations for a transplant patient on discharge?
According to Bhat et al. (2014), after a liver transplant, patients will be on immunosuppression therapy. Therapy includes prednisone, tacrolimus, cyclosporine, mycophenolate mofetil, Azathioprine, and rapamycin. Furthermore, liver transplant patients may be prescribed antihypertensive medications and antihyperglycemic agents. Providers will need to educate the patient on each medication and side effects. Moreover, education is needed on complications of liver transplants and when to seek medical attention. Complications include liver graft dysfunction, infection, recurrent hepatitis C infection, hypertension, diabetes, dyslipidemia, biliary disease, nutritional status, bone density, and kidney disease. Liver transplant patients should also be counseled on weight loss, diet, exercise, and smoking cessation. A referral for a dietitian can help devise a dietary plan for a transplant patient. Encourage supplements such as 1500 mg of calcium, 800 IU of vitamin D, and bisphosphonates to help bone mineral density loss (Bhat et al., 2014).
Last Completed Projects
| topic title | academic level | Writer | delivered |
|---|