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- 2. POST-OPERATIVE PERIOD Starts when the patient leaves the operating room and involves the time up to the discarge
- 3. POST-OPERATIVE CARE Operation impairs the hemostatic balance of the body as it is both physiological and psychological source of stress MAIN AIM OF THE POST OPERATIVE CARE; is reorganize the hemostatic balance
- 4. AIM OF A QUANTITATIVE NURSING CARE Maintain the vital functions of the patient Minimum pain A post-operative period without complication Ensure the return to normal life in a short time
- 6. HISTORY The first scientific documentation; 1964 Ecuador 1996 Louisville hand transplantation team 1997 Louisville, international symposium The first short-time successful patient is French 29 months
- 7. HISTORY 1999 Louisville The first long-term case Firework accident 2000 France Dubernard The first double-hand transplantation July 2008 Germany Arm transplantation March 2009 bilateral hand and face ; bereavement
- 8. HISTORY 36 patients 50 hand transplantations 14 bilateral 22 unilateral
- 9. INDICATIONS Unilateral or bilateral amputations over the wrist or below the elbow Over the elbow? healthy 18-65years Child?
- 10. THE FIRST BILATERAL ARM TRANSPLANTATION IN TURKEY Prof. Dr. Ömer Özkan Prof. Dr. A. Ramazanoğlu Assoc. Prof. Dr. Murat Yılmaz Assoc. Prof. Dr. Özlenen Özkan Assoc. Prof. Dr. Ayhan Dinçkan Nurse Fatma Duman Nurse Ayşe Kocaçoban Nurse Gülizar Sarı Nurse Nihal Karataş Nurse Özlem Akar Nurse Rukiye Buyrukçu
- 11. RECIPIENT 28 years Silage machine 2 years ago Right forearm 1/3 proximal forearm Left forearm 1/3 distal forearm Static prosthesis Routine pretransplant examination Stabile family stracture Mental stability General condition is good Informed consent
- 12. BEFORE THE OPERATION Communication with the centre where the organ was removed Permission for cadaver donor, offical paper documents about the functional information of the organ Credentials of recipient and donor Histocompatibility control
- 13. OPERATION The 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
- 14. PREPARATIONS IN THE INTENSIVE CARE UNIT Assessment of the enviroment Sterilized bedclothes were used The bed was heated by blanket Restrictions for visitors Light source Number of nurses Security measures were taken
- 17. INTENSIVE CARE ADMISSION Entubeted and sedated patient was brought to the AICUII by a team. Elevation was achieved while maintaining the position of the arms Was taken to the bed which was heated by blanket Was connected to the mechanical ventilation 5 leed ecg Arterial blood pressure Spo2 Body temperature Cvp monitoring was done
- 18. FLUID AND ELECTROLYTE BALANCE Fluid replacement therapy Intense monitoring of blood gases hipotensive in the admission to the ICU -Inotrope medication (dopamine inf) -48x1 TA monitoring AÇT/FIO(following of input/output ) 48x1 Strict/intense monitoring and recording
- 19. HEMODYNAMIC MONITORING In the operation area -circulation and bleeding monitoring -early circulation support heating by light source Adequate oxygenation Fluid and electrolyte balance Stop the inotrop support extübation in the post-op 12. hours
- 20. HEMODYNAMIC MONITORING NURSE IN THE INTENSIVE CARE UNIT For hemodynamic stabilization ; Should pay attention to Hypervolemia Hypovolemia Hypertantion Hypotantion Electrolyte imbalances
- 21. BLEEDING Operation area was followed-up Drugs which enhance the bleeding were controlledly used (anticoagulants) Laboratory findings were revealed Avoided from IM ınjection Oral treatment was performed with a soft toothbrush Aspirator pressure was reduced Avoided from jerk
- 22. RESPIRATORY/VENTILATION Mv modes were adjusted (respiratory frequency, tidal volumes, findings of blood gases, SpO2 were evaluated) Weaning was started The patient was extubeted 12 hours after the operation
- 23. 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 run Steam was given
- 24. INFECTION Protective 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
- 25. INFECTION Attention 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 properly Entracheal cuff pressure was controlled.
- 26. SAFETY ENVIROMENT Immobile patient Bed borders were raised upward Alarm/warning limits of devices and monitors were set-up. Catheters and foley catheters were fixated properly.
- 27. HYGIENE Daily personel care 3x1 ( eye care, oral care, foley catheter care...) Perineal care was done Bedclothes were changed in every 24 hours
- 28. SKIN INTEGRITY To 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 prominences Paid attention that bedclothes were clean and neat Measures were taken to protect the upper side of ear aganist the mask after extubation
- 29. FOR PAIN Explanations were done for all interventions The patients was put in a comfortable position Stimuli 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 damage Nonpharmalogical methods like relaxation movements were performed. Appropriate analgesics were administered to the patient prior to painfull invasive interventions according to physicion’s order
- 30. COMMUNICATION Inform the patient after extubation - he was in ICU - operation was finished/over and ıt was successful The patient was provided to express himself frequently The patient was allowed to have short-term interviews with his relatives
- 31. URINARY İntestinal sounds were evaluated Care was taken to the privacy Avoided to be wet and dirty Moisturizing ointements were used Scaled sterile urine bags were used for evacuation of urinary system Foley catheter was fixated to his leg Color of urine, dysuria and pain were monitorized. Urine bags were drained out before they were brimful
- 32. FEAR, ANXIETY Confidence was provided Touch and body language were used to communicate Collaboration/cooperation with family was provided Supportive treatment for adoptation (psychiatry) was used Provided visits from family members’ and relatives’
- 33. HYPOTHERMI Supported with heater Was covered with a blanket He was cleaned with warm and wet cotton He was dressed in white socks because ıt didn’t hurt Temperature of enviroment was set up
- 34. SLEEP Measurement 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
- 35. FEEDING The patients who had been feed paranterally because of entubation was feed orally after the extubation For feeding, at first liquid and soft foods, then solid foods were given Appropriate calorie count was made Attention was paid to eat all meals During and after feeding, the patient’s head was put in upright position (35-45 degrees) in the bed.
- 36. EDUCATION Take the medicine timely and carefully Attention to hygiene Recommened to take care of preventive measures (mask) especially in the first months Not to consume convenience food or if there is a doubt about the sanitation Regular physiotherapy and check-up Follow up for rejection Alcohol, cigarette ??? Not to be in crowded, public places.
- 37. DRUGS Immunusuppressive 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 μg/ml -Mycophenolate mofetil (Cell Cept, 2 g/day) -Prednisolone: 20 mg/day
- 38. DRUGS ASİST AMP 2x1 IV ZANTAC AMP 4x1 IV TAZOSİN FLK 3x1 gr IV VANCO FLK 4x500 mg IV GASİKLOVİR TB 1x400 mg PO CLEXANE 0,4 2x1 SC
- 39. TRANSPLANTATION The 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 belongings The 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
- 40. RESULT In general, ıt has been seen that patient’s satisfaction and post operative functional recovery were always better than previous prosthesis.