RUNNING HEAD: LIVER TRANSPLANT CASE STUDY
Case Study: Liver Transplant
Module 1 Activity
Essential Syllabus Elements
Presented to
Dr. Stephens
THE UNIVERSITY OF TEXAS
SCHOOL OF NURSING AT GALVESTON
In Partial Fulfillment
Of the Requirements for the Course
GNRS 5310 Educator: Advanced Clinical
By
Caroline Wesonga RN BSN
February 16th, 2014
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Module one Case Study
Introduction
Ms B. M. is a 66 year old African American female with a history of Liver Cirrhosis
secondary to Hepatitis C, therefore; diagnosed with chronic liver failure. Chronic liver failure
occurs as a result of impaired liver function greater than 6 months. This patient is status post
liver transplant because of end stage liver disease secondary to liver cirrhosis. Liver disease
related to chronic viral hepatitis is the leading indication for liver transplantation (Lewis et al.,
2007, pg. 1117). Liver transplant is the replacement of a sick liver with a healthy donated liver.
Liver failure is responsible for approximately 2000 deaths a year and about 5% of all liver
transplant in the United States (Baird et al. 2005, p. 427). Liver transplant allocation is based on
Model for End-Stage Liver Disease (Meld Score). Meld has been adopted since 2002 for organ
allocation to patients listed for liver transplantation in the United States (Durand & Valla, 2008).
This model uses three tests to predict survival. The tests are bilirubin which measures the liver's
ability to process and remove bile, international normalized ratio (INR) which measures the
liver's ability to make clotting factors and creatinine level for kidney function evaluation. The
Meld score range is from 6 (less ill) to 40 (gravely ill) (Durand & Valla, 2008). Mrs. B's Meld
score was 11. The sources of the information for this case study were obtained from the sister,
primary nurse, doctors on their rounds, social workers and via electronic medical record.
Chief Complaint
Mrs. B. M. presents to the Transplant ICU post liver transplant.
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Present Illness
a) Patient's exploratory Model
Mrs. B. M. was diagnosed with end stage liver disease as a result of hepatitis C infection.
The sister states she was aware that the liver failure occurred as a result of hepatitis C infection,
however, she has no idea of where and how her sister contacted the disease because she didn't
share with her that information. She is looking forward to her sister living without complications
from a failing liver. They have no idea who the donor is, but will pursue to know who the
donor's relatives are if they are willing to be contacted.
b) Inpatient Medication
1) Basiliximab 20mg IV once. Used in prevention of acute organ rejection. Used with
corticosteroids and cyclosporin (Deglin & Vallerand, 2003).
2) Carvedilol 12.5mg PO Q 12 hours. Used for hypertension (Deglin & Vallerand,
2003).
3) Methyprednisolone 40mg IVP one time POD 5, 80mg POD 4, 125mg POD (Post
operative day) Used with other immunosuppressants in the prevention of organ
rejection transplant (Deglin & Vallerand, 2003).
4) Mycophenolate Mofetil 1000mg PO BID. Prevention of rejection in allogenic renal,
hepatic and cardiac transplantation (Deglin & Vallerand, 2003)
5) Pantoprazole 40mg IVP daily. Diminish accumulation of acid in the gastric lumen,
with lessened acid reflux (Deglin & Vallerand, 2003)
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6) Tacrolimus 4mg IV BID. Prevention of organ rejection in patient who have
undergone allogenic liver transplantation, used with corticosteroids (Deglin & Vallerand,
2003).
7) Ciprofloxacin 750mg PO once a week. Used to treat various infections (Deglin &
Vallerand, 2003)
8) Cefazolin 1gram Q8hrs IV. Perioperative and post-operative prophylaxis (Deglin &
Vallerand, 2003)
9) Fentanyl 1000mcg in 20ml IV (Titrate as directed) continuous- sedation of
mechanically intubated (Deglin & Vallerand, 2003)
10) Dextrose 5% with 0.225% NaCl IV (D51/4NS) at 125ml/hr-Used as a means of
tissue hydration and parenteral nutrition (Deglin& Vallerand, 2003).
11) Insulin regular 100unit +Sodium Chloride 0.9% IV(Titrate) Per ICU protocol.
Lower blood sugar (Deglin & Vallerand, 2003).
c) Allergies-Penicillin causes rashes and Codeine causes bradycardia
d) Tobacco-Never smoked
e) Alcohol/Drugs-Used alcohol occasionally, quit 6 years ago, has never used drugs
Past History
a) Childhood diseases
1) Medical: Ms. B. M. had mumps, chicken pox and whooping cough as a child.
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2) Surgical: No surgery during childhood
b) Adulthood Illnesses
1) Medical: Esophageal Varices, Anxiety, Depression, Gerd, Hyperlipidemia,
Hypertension, Hepatic encephalopathy
2) Surgical: Colon resection in 1990, polypectomy 5/22/12
3) OB/GYM: Hysterectomy
4) Psychiatric: Anxiety, Depression
5) Accidents & Injuries: Non
Current Health Status
a) Immunization: Records indicate patient did not receive flu vaccine this year. Had
pneumonia vaccine in the past
b) Screening: TB Screening negative
c) Environmental Hazards: Sister states no environmental hazard at her house
d) Use of safety measures: Patient will have to avoid large crowds and children due to
immunocompromised status.
e) Exercise and Leisure activities: Sister states she walked 30 minutes 3 times a day and
likes reading books, travelling and listening to music.
f) Sleep Patterns: Sister has no idea of Ms. B's Sleep pattern
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g) Diet: Regular diet
h) Stress patterns/stressful life events: Diagnosis with liver cirrhosis
g) practices to promote health and prevent illnesses: Will have to avoid crowds, hand
washing, Keep doctor's appointments, take medications as directed.
Family History
 Mother, Father and all sister and brother have hypertension
 Aunt had colon cancer
 Grandmother had diabetes
Psychosocial History
Patient is single, has no children but has been in relationships in the past. She has history
of depression and take medications for it, sister admits she's had stressful life events she was
unwilling to share details out of her sick sister's respect. She lives alone in an apartment and
currently retired. Support network include 3 sisters who live here in the Houston area. She is
retired from MD Anderson where she was working in the laboratory. Sister denies any drug use
or smoking by Ms. B.
Review of Systems/Subjective
Patient is non-verbal at this time. Is now admitted in ICU post Liver Transplant. Very
difficult to obtain due to patient's clinical status, family member present is very emotional.
Physical Examination/Objective
Ms. B. is a 66 year old overweight African American female. She is sedated at this time. V/S:
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98.4, BP: 129/73, Apical Pulse: 112. Wt: 200.2lbs per bed-scale. Height: Not measured at
this time but records indicate157cm.
General: Mrs. B. is Intubated and Sedated with bloody aspirate from NG Tube
Skin: Warm and dry. Vertical abdominal incision with staples open to air.
Head, Nose, Throat (HENT): Normocephalic, ETT in place, NGT in place with bloody
aspirate, Tympanic membranes are clear, oral mucosa dry.
Eyes: Pupils equal, round and reactive to light. Yellowing of the sclera noted
Neck: Supple, no lympadenopathy
Respiratory: Lung sounds are clear to auscultation, symmetrical chest wall expansion
Cardiovascular: S1 and S2 ausculstated, Regular rhythm, Tachycardia at 112 Beats per minute
Gastrointestinal: Distended, slightly firm. Vertical suprapubic incisions open to air appear
clean, dry and intact. Hypoactive bowel sounds. One T-tube with greenish drainage and two
Jackson Pratt drains with bloody drainage.
Genitourinary: Foley catheter in place draining dark yellow urine, approximately 200ml in the
bag.
Musculoskeletal: Slight edema +1 to bilateral lower extremities.
Psychiatric: Unable to assess
Neurologic: Sedated, unable to follow any verbal commands. Gag reflex intact.
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Diagnostic studies
CT of the Abdomen and Pelvis shows cirrhosis. Previously seen lesions in the right lobe
measuring 0.3cm.
Liver Ultrasound shows liver markedly shortened, echogenicity is course with nodular contour
compatible with cirrhosis. Within the right hepatic lobe mass measuring 4.9X3.7X3.6 is seen.
Discharge Medications
Patient does not have discharge medications at this time but the primary nurse states that
most of the patients go home on Methylprednisolone, mycophenolate mofetil, and Tacrolimus.
According to Lewis et al (2007), medications prescribed for liver transplant recipients include
tacrolimus (prograf, FK506), mycophenolate mofetil (Cellcept), sirolimus (Rapamune), and
corticosteroids.
Impact of illness
a. Biological, Psychological & Social
Chronic illness have an influence on biological, psychological and social factors.
Immense burden is imposed upon the immediate family members when a loved one has a
chronic illness. It contributes to financial burden incurred from medical expenses and reduced
earnings as the ill individual is no longer able to earn any income. Social factors could be
influenced by interpersonal relationships that existed prior to illness, the ill individual may be
treated based on this. Caregiver who have had a positive relationship with care recipients are
less likely to become abusive (Labkin & Larsen, 2013). Living conditions may have to be
changed to accommodate the needs of the ailing family member based on the available financial
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resources. Ms B. will have to move from her apartment to live with family member to help take
care of her. Under these circumstances, sometimes an adult caregivers may not be available to
provide care shifting this responsibility to the children. This so called sandwich generation is
often not available to provide care for family member, which creates a new level of caregiverschildren and adolescents (Lubkin & Larsen, 2013). This interferes with the normal functioning
of families resulting in high level of depression and caregiver role strain. Symptoms of
psychological distress affect more than half of family members exposed to the patient's chronic
illness (Hickman & Douglas, 2011).
b. Impact on Family – Short Term and Long Term
Short Term Impact on Family
Financial resources are affected by reduced income and cut down employment hours, the
care givers may have to reduce their hours at work t meet the needs of the ill individual. The
ailing individual depends on the other family members for assistance if they are not eligible to
receive public finance and have no out of pocked finances to carter for the financial costs.
Long Term Impact on Family
Family members may be forced to resign from their jobs to care for the ailing individual.
Strain and stress occurs based on personality, the intensity of care provided and support from
other members of the family. Usually this occurs if there is lack of support from the other family
member to the primary caregiver, this can be prevented by providing respite care. Psychiatric
disorders such as anxiety and depression may occurs in the long term.
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Common problems, Education
Below is a list of common problems for patients with Liver Transplant.
1) Infection: The weakened immune system coupled with the surgical site could become
infected. Care givers and patients should be encouraged to use aseptic technique, assess for signs
of infections such as erythema, drainage, warmth or fever and alert the physician as soon as
possible.
2) Preventing pulmonary complications: Patients should be encouraged to cough, deep breath,
use incentive spirometer.
3) Organ rejection: This occurs when the immune system recognize the new liver as foreign and
begin attacking it. This can be minimized by taking the immunosuppressants as prescribed.
3) High blood pressure: Long term use of immunosuppressants can cause high blood pressure
and high cholesterol. This can be prevented by exercising and eating healthy diet.
4) Anxiety and depression: Patient should be encouraged to use global community resources
where they can meet other people with common interest for support. They can also see a
physician for anti-depressants and anti-anxiety medications.
Community Agencies/ Resources to assist patient
Patients leaving the hospital are given resources to help them when they leave the
hospital. The America Liver Transplant association (ALT) has a help line given to all patients,
1-800-465-4837 it provides emotional support to both the patient and family at their point of
crisis. The help line can have their questions answered about their liver disease and wellness.
The ALT has partnership with Inspire, a global community resource where the patients and their
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families can connect to share their experiences, information and support. The patients are also
given a drug discount card that can help them save up to 80% off the cost of prescriptions.
Needymeds is a non-profit organizations with information on programs that can assist people
who are unable to afford their medications and healthcare cost. According to the liver
foundation website (2014), the needymeds website has data on over 5,000 sources of assistance
an over 12,000 free/low-cost sliding scale clinics
Ethics, Legal and Economic Factors
Organ donation affects liver transplant donors and recipients. The Uniform Anatomical
Gift Act of 1968 also referred to as "Opting in" or "expressed volunteerism" was introduced to
address donor preference. This statute authorizes competent adults to specify their preference
regarding organ donation (Anderson-Shaw et. al, 2013). The Statue ameliorates fear to
recipients since they will be aware that the organ donation is harvested from consenting
individuals. Liver transplant recipients will have to take immunosuppressive drugs for the rest of
their lives, their survival is influenced by income, access to healthcare and the ability to afford
prescription. The patient must have either insurance or financial resources to cater for medical
checkup and prescription. At times, the doctors are faced with ethical dilemma to do all they can
to benefit the patients with limited economic resources to support them.
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References
Anderson-Shaw, L., Brown, S., R. & Travis, A., C. (2013) Ethical Issues in Liver
Transplantation. Retrieved from Https://www.uptodate.com/contents/ethical-issues-inlivertransplation.
Baird, S., M., Keen, H., J. & Swearingen, L., P. (2005). Manual of Critical Care Nursing:
Nursing Interventions and Collaborative Management (5th Ed.). Mosby: Elsevier.
Deflin, H., J. & Vallerand, H., A. (2003). Davis's Drug For Nurses (9th Ed.) F. A. Davis
Company
Durand, F. & Valla, D. (2008). Assessment of Prognosis of Cirrhosis. Seminar in Liver Disease
28(1) 110-122.
Hickman, R., L. & Douglas, S.,L. (2011) Impact of Chronic Illness on Psychological Outcomes
of Family members. Retrieved February 20th 2014 from
Http://www.ncbi.nlm.nih.gov/pm/articles/pmc3037826
Lewis, L., S., Heitkemper, M., M., Dirksen, R., S. & Bucher, L. (2007). Medical Surgical
Nursing: Assessment and Management of Clinical Problem (7th Ed.). Mosby: Elsevier
Lubkin, M., I. & Larsen, D., P. (2013). Chronic Illness: Impact and Interventions (8th Ed.)
Jones & Barlett.