器官移植的护理(台湾长庚大学).ppt

按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,*,*,Nursing management of clients with Organ Transplantation,長庚大學 護理系,翁麗雀,1/31/2026,1,Review of History,年代,事項,西元前 扁鵲 心臟互換(列子湯問篇)心臟陰陽失調,1946,發現移植失敗是因免疫,1953 腎移植成功,(,Hume,Hamburger,Murray,諾貝爾,醫學獎),1959-1962 淋巴器官做放射線治療,1962,Murray,use,Imuran,1963,Starzl,use,Imuran,+,prednisolone,1962,Hamburger,:Tissue typing,1966,Kissmeyer,:,Crossmatch,1973,Opelz,&,Terasaki,:,移植前輸血,1978,Ting Morris,:,HLA-DR,1978,Calne,Use,cyclosporine,1967,Barnard,:Heart transplantation,1/31/2026,2,1968,李俊仁,第一例腎移植,1984台灣 腦死即死亡,1984,陳肇隆,第一例肝臟移植,1984,第一例胰臟移植(,IDDM),1987,朱樹勳,心臟移植,1988,胚胎腦移植應用到人體,1989澳洲 首例活體肝移植,199-,陳肇隆,活體肝移植,2000 基因轉殖技術,2004 不同血型的移植,(,plasmapheresis,),1/31/2026,3,Criteria for transplantation,The presence of end-stage disease in a transplantable organ,Failure of conventional therapy to treat the condition,Progression of problems associated with the organ failure which in themselves may be fatal,The absence of disease that would attack the transplanted tissue,The absence of untreatable malignancy or irreversible infection,Ability of the clients to survive the surgical procedure,1/31/2026,4,移植的適應症及禁忌症(以肝臟移植為例),適應症,不可逆性末期慢性肝病,先天性膽道閉鎖,Wilson disease(,銅代謝異常),原發性肝硬化,猛爆性肝炎肝臟惡性腫瘤局限在肝臟,1/31/2026,5,禁忌症,絕對禁忌,肝膽系外的活動性感染,肝膽系的轉移性癌,末期心肺疾病,AIDS,相對禁忌,年齡在60歲以上,末期腎病,1/31/2026,6,Donor procurement and preparation,活體,Living donor:liver(adult to child，adult to adult),renal,bone marrow,cornea,.,屍體,Cadavers:heart,liver,pancreas,cornea,skin,bone,lung,small bowel,United Network for Organ Sharing(UNOS),財團法人器官捐贈移植登錄中心,1/31/2026,7,器官保存：,Cadavers organ preserved at 4 electrolyte solution,warm,ischaemic,and cold,ischaemic,Transplanted as soon as possible.,倫理法律考量(人體器官移植條例),Living donor,：,成人捐贈不損及健康,五親等血親(肝臟移植可為姻親,滿18歲即可)，不能涉及買賣,Cadaver,：,生前同意，最近親屬同意,1/31/2026,8,死亡判定,死亡定義,*心肺死：心跳停止、呼吸停止,腦幹死：腦幹功能喪失(不會自行呼吸、心跳漸下降)，病人必定死亡,*判定死亡的時間提早，死亡的過程仍持續進行,*植物人並非腦死,*,Non-Heart-Beating organ donation-non recoverable brain injury,but has not been declared brain dead,1/31/2026,9,腦死判定程序,先決條件：,*病人呈深度昏迷不能自行呼吸需要使用人工呼吸器,*導致昏迷的原因已確定,*遭受無法醫治原發性的腦部結構損壞,排除可逆性的昏迷：,*新陳代謝障礙、藥物中毒、低體溫,*不明原因的昏迷,1/31/2026,10,在使用人工呼吸器之狀態下至少觀察12小時，呈現深度昏迷、不能自行呼吸且無自發性運動,腦幹功能測試：頭眼反射、瞳孔對光反射、眼角膜反射、前庭動眼反射、疼痛刺激無反應、作嘔反射、呼吸測試(增加,PaCo2 40mmHg,以上,無法刺激自行呼吸),4小時再進行腦幹功能測試一次,1/31/2026,11,腦死判定,腦幹功能第二次測試後，仍無腦幹反射及無法自行呼吸則判定病人腦死,判定醫師資格,具神經內外科、內科外科急診醫學科小兒科或麻醉科專科醫師資格,接受衛生署認可知腦死判定相關研習持有證明文件者,參與腦判定人員：原主治醫師及符合資格醫師二人,1/31/2026,12,移植方式,Orthotopic,(,正位):受贈者(,recipient),的器官移除，捐贈者(,donor),的器官置入正常的解剖位置,Heterotopic,(,異位):保留受贈者的器官，捐贈者的器官置入身體另一位置,如腎移植,Laparoscopic,donor,nephrectomy,1/31/2026,13,Single-lung,1/31/2026,14,1/31/2026,15,1/31/2026,16,1/31/2026,17,1/31/2026,18,1/31/2026,19,移植的影響,生理方面,心血管系統:,hemorrhage,coronary artery disease,hypertension,呼吸系統,:,atelectasis,腎:,renal failure,神經及精神狀態:,depression,seizure,ANS,(denervation,),腸胃系統:,ulcer,免疫系統:,nosocominal,infection,1/31/2026,20,排斥,(,Rejection),第四型延遲型過敏反應，,T,淋巴球過度活化,接受者的免疫系統免疫反應，導致移植物的破壞。,體內對抗外來物的正常免疫反應，但在移植時卻不希望其發生。,Type IV delayed hypersensitivity reaction,sensitized T lymphocytes,1/31/2026,21,1/31/2026,22,Pathophysiology,of rejection,細胞免疫,(,T cell,cell-mediated)：,細胞組織間隙水腫、淋巴球浸潤、但在血管內無,IgG,等免疫球蛋白沉澱。,體液免疫(,B cell,antibody-mediated)：,血管內皮細胞腫脹、,IgG,、,IgM,、,補體會沉澱在血管內,Antibody-antigen reaction,WBC release,lysozyme,which destroy blood flow and thrombosis of the graft,.,1/31/2026,23,Cellular immunity(cell-mediated),T cell,T,D,T,K,T,H,T,S,rejection,GVHD,skin test,infection:virus,fungi,mycobacteria,Humoral,immunity(antibody-mediated),B cell plasma cell,rejection,bacteria infection,1/31/2026,24,Types of rejection,如何得知(確定)有排斥發生：,Tissue biopsy,Type of rejections:,1.,Hyperacute,rejection(,超急性)：,Within minutes,may be observed during the operative procedure.,2.Accelerated rejection(,加速型)：,Within 2-5days,the mechanism is unclear.,1/31/2026,25,3.acute rejection(,急性)：,Episodes,10-60days(years),4.chronic rejection(,慢性)：,Months or even years,Antibody-mediated.There is currently no treatment for this type of rejection.,1/31/2026,26,移植排斥的反應及徵象(以腎臟移植為例),反應：多形核白血球過度增生，抗原抗體複合體沉積在血管阻塞腎絲球及腎小管的微血管腎血流減少組織壞死腎功能停止,徵象：不舒適、疲倦、移植處紅腫壓痛、尿量少於30,ml/hr、,血壓升高20,mmHg、,體溫升高、白血球數增加、蛋白尿、血中,BUN、,creatinine,增加、移植側下肢出現凹陷性水腫(腎功能減退),1/31/2026,27,Medical management of rejection,Pre-transplantation：,ABO matching,HLA(human leukocyte antigen)typing:,A,B,C,DR,mismatch,recipient serum with donor lymphocyte,crossmatch,Antibody screen(panel of reactive antibodies,PRA.PRA,越高,越難找到相符的捐贈者),1/31/2026,28,Immunosupressant,免疫抑制劑,減少排斥,最低劑量發揮最高效果,移植後馬上使用，終生服用,Double therapy or Triple therapy,個別性藥物計劃,用免疫抑制劑常思考：在排斥及感染之間維持平衡，並注意病人的身體狀況1/31/2026,29,Immunosuppressive drug therapy,(Table 13-17),*,Induction therapy,1.Monoclonal antibodies,a.Anti-CD25,ab,(,抑制,IL-2,的釋放,):,Simulect,Zanapax,b.CD3,ab,:OKT3,2,.Polyclonal,antibodies,ATG,(anti,thymocyte,globulin),1/31/2026,30,*Maintain therapy,1.,calcineurin,inhibitors,cyclosporine,(sandimmune1983)(,neoral,1995),環孢靈:,block T-helper lymphocyte,FK506,(Tacrolimus1994),2,.corticosteroids,prednisolone,Methylprednisolone(solu,-,medrol,),3,.Antimetabolites,Cellcept(mycophenolate mofetil,1995),Immuran(azathioprine,),4.TOR(target of,rapamycin,)inhibitors,Rapamune,斥消靈,1/31/2026,31,Cyclosporine,CSA),(sandimmune,neoral,),Binding to,immnophilins cyclophilin,and inhibits,gerneration,of IL2,always take at 8Am and 8Pm(q 12 hrs),side effects:,血壓升高、尿量減少、毛髮增生、牙齦腫脹、手顫抖、頭痛,、,(腸胃不適)、腎毒性、高脂血症,每日5-10,mg/kg(,因人而異),以肝腎功能及血中治療濃度來調整劑量,避免與葡萄柚同吃,因會干擾肝臟排泄藥物,使藥物濃度升高,1/31/2026,32,CSA trough level,Kidney 100-200ng/ml,liver 300-400ng/ml,lung 250-350ng/ml,heart 200-300ng/ml,FK506 5-20ng/ml,1/31/2026,33,Corticosteroid,Prednisone,methylprednisolone(solu-medrol,),Suppressive inflammatory response,inhibit cytokine production and T cell activation,Side effects:peptic ulcer,osteoporosis,acne,moon face,buffalo appearance,easy bruising,hyperglycemia,increased appetite,mood alteration,cataracts,hyperlipidemia,5-10mg,daily,withdrawal after,Tx,or early avoidance,1/31/2026,34,免疫抑制劑,FK506:,作用機轉與,neoral,CSA,幾乎相同但作用更強，副作用也幾乎一樣(除毛髮增生及牙齦增生)。不可與,CSA,併用，因會加重副作用,cellcept,:,副作用腹瀉,Immuran,:,副作用骨髓抑制,OKT3:,注射用，非常強效，伺機感染機會增加,1/31/2026,35,Nursing care for patient with rejection,依醫囑給予免疫抑制劑治療、監測藥物副作用,密切監測生命徵象、肝腎功能,密切監測排斥的症狀及徵象,密切監測感染的症狀及徵象,給予病人情緒支持,協助病人接受檢查,護理人員必須敏感警覺性高，持續觀察,1/31/2026,36,感染,原因：,a.,手術及侵入性的治療及管路,b.,長期與大量使用免疫抑制劑,c.,暴露的外在環境感染如空氣、水,d.,來自移植體或病人本身原有的感染,Unusual presentations(signs),unusual sites,unusual organisms,種類：,cytomegalovirus,(CMV),tuberculoris,fungal(yeast),herpes simplex,Epstein Barr virus,normal flora,1/31/2026,37,CMV infection,(,巨細胞病毒感染),一旦感染會一直存在(潛伏)，對免疫功能正常者而言無影響，但免疫功能受抑制時會發作,傳播方式：唾液,尿液,血液，器官移植者可能是經由移植器官或輸血所感染,症狀：發燒、鼻塞、肝炎、肺炎、腸炎,白血球數目下降,亦會侵犯眼睛等,影響新器官的功能,It is important to remember that any significant infection may reactive CMV.,處理：住院觀察、藥物使用、調整免疫藥物劑量,術前篩檢,1/31/2026,38,Virus infection,Cytomegalo,virus:3-8wks,often after treatment for rejection,Herpes simplex:Any time,Epstein Barr:Most common in first 2months,Adenovirus:3-4wks,Hepatitis B:Onset usually after 4-6wks,graft remained infected,Hepatitis A:No experience to date,Hepatitis C:Usually after 4 week,1/31/2026,39,感染症狀徵象評估,Unusual signs:fever,fatigue,cough,change in WBC count：,增高-可能是因使用,prednisolone,或 細菌感染；減低-可能是骨髓抑制或病毒感染,Laboratory test:culture,CNS infection：headache,conscious change,fever,vomiting,epilepsy,1/31/2026,40,抗感染藥物,Mycostatin,:anti-fungal infection,Gancyclovir,:anti-CMV infection,Lamivudine,:anti hepatitis B virus,Acyclovir,:anti herpes simplex,broad spectrum antibiotics,1/31/2026,41,其他生理影響,體液容積過多或不足,電解質不平衡：新器官是保存在電解質溶液(仿細胞內液),精神神經狀態：免疫用藥、重大手術壓力,心臟血管疾病:高血壓,高血脂,糖尿病,免疫抑制劑的副作用,癌症易感性:以腎移植而言發生率約6%是一般人的100倍,1/31/2026,42,心理方面,性別角色改變：接受不同性別的器官,角色轉換,未來不確定感：長期服藥、排斥陰影,矛盾感：生死、後悔抉擇,身體心像改變：體重增加、毛髮增生、青春痘、骨質疏鬆,憂鬱,1/31/2026,43,無法接受新的器官,調適過程的轉變(,transition),從他人到自我:異物期、部份體化、完全體化,病程轉變:否認期、手術後蜜月期、憂鬱期,1/31/2026,44,社會方面,工作及經濟：失業、轉業、重入職場,婚姻及性生活：角色關係、生理障礙,與家人的關係：獨立-依賴、疏離,與社會的關係：社交隔離、娛樂減少,1/31/2026,45,其他,對醫療藥物的依循性遵從性(,adherence,compliance):,taking medication not prescribed,not completing a course of medication and clinical visit,deviation from the dose and frequency of prescription.,不依循是導致移植體功能失敗的原因之一,1/31/2026,46,護理處置,Nursing Assessment,醫師、護理人員、精神科醫師、社工師、器官移植協調師,心理、社會背景、環境、經濟、宗教信仰,心、肺、肝、腎、腦功能檢查結果,現存疾病的病程、健康問題的監測及處理,有意義的他人,1/31/2026,47,護理處置,維持血液動力學穩定,維持體液電解質平衡,維持呼吸道通暢,減輕疼痛不適,監測手術後合併症,監測新器官功能,(以肝臟為例)：,膽汁滯留、,AST,ALT,升高、黃疸、嚴重凝血異常、代謝性酸中毒、腎衰竭,1/31/2026,48,預防感染,觀察：皮膚及口腔黏膜完整性，各種引流管的部位，引流物性質，傷口，是否出現感染徵象,口腔護理,傷口及引流管照護，遵守無菌,清潔環境及用物:以清潔劑清潔,限制訪客，避免鮮花植物,依醫囑執行各種培養監測,保護隔離,的設備及環境,1/31/2026,49,Impact of,protection isolation,on the incidence of infection after heart transplantation,Single room,sterile gown,cap,mask,shoe covers,Hand washing,gloves,1/31/2026,50,監測免疫抑制劑的副作用,腎毒性、腸胃不適,血糖增加：,prednisolone,FK506,血壓增高:,neoral(cyclosporine,),高血脂症:,cyclosporine,類似重感冒症狀(,flu like):OKT3,1/31/2026,51,注意病人的心理調適,確認及滿足病人及家屬的需要，適當的轉介,確認調適過程,環境、小組成員、檢查治療手術前後注意事項之指導,支持及傾聽：經濟諮詢及社會工作者,*監測術後神經精神併發症,1/31/2026,52,相關知識的指導,Drug:,a.,教導免疫抑制劑及其他藥物藥名、目的、劑量、途徑、作用及副作用,b.,不可私自停藥、調劑量或購買成藥,c.,洗牙、拔牙等應先用抗生素(經醫師醫囑),Exercise:,a.,漸進性、休閒性：散步,b.,避免進出公共場所或公共游泳池溫泉,Sexual life:,術後8-10週內禁止，女性病人勿使用口服避孕藥，懷孕*(多數免疫抑制劑並不會致畸形),1/31/2026,53,Nutrition:,a.,維持理想體重,b.,若血壓增高應採低鈉低脂及低膽固醇飲食,c.,若血糖偏高應採低糖飲食,d.,避免生食、路邊攤、加工過的食物,e.,均衡營養,f.,食慾控制,*健康食品,1/31/2026,54,Prevent infection,a.,教導造成感染的原因及徵象,b.,避免到人多擁擠之處,c.,戴口罩,d.,避免感冒,e.,避免養貓狗等寵物(人畜共通疾病),f.,維持居家環境清潔，保護措施(手套口罩),g.,有任何不適的徵象應立即回診,h.,常洗手,I.,監測身體皮膚變化,1/31/2026,55,健康檢查：,牙科:因易口腔感染,眼科:因使用類固醇製劑可能導致白內障,疫苗注射:不可以接受活體減毒疫苗，但像流行感冒疫苗是可以接受。注意不要接觸剛接受口服小兒麻痹疫苗的幼兒,防癌篩檢：本身原有疾病，以及因接受免疫抑制劑，免疫功能受阻(無法處理致癌病源體及易感染致癌病毒)-癌症的易感性增加,1/31/2026,56,教導排斥徵象及監測,教導自我監測技巧:測量體重、血壓及血糖,spirometry,有些腎臟移植後病人不會立刻取出,AVF or CAPD,所以仍需持續照顧,書寫日誌攜帶醫療警示或病房聯絡電話,器官移植病友會,1/31/2026,57,OPD follow up(,手術後3個月到半年最重要),a.CBC,biochemistry,b.Immune drug level,c.Signs and Symptoms,當有任何不適或疑問，儘快與醫護人員聯絡，小小的症狀都有可能是大合併症的前兆,1/31/2026,58,結語,Long term care,Quality of life,Organ donation,2005/12/26,等待器官移植人數6971人,Adherence and Compliance,1/31/2026,59,