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The Eleanor Mann School of Nursing The Eleanor Mann School of Nursing
Undergraduate Honors Theses

5-2021

Post-Operative Nursing Care of the Renal Transplant Patient

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Smith, E. (2021). Post-Operative Nursing Care of the Renal Transplant Patient. The Eleanor Mann School
of Nursing Undergraduate Honors Theses Retrieved from https://scholarworks.uark.edu/nursuht/138

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Running Head: RENAL TRANSPLANT NURSING CARE 1

Post-Operative Nursing Care of the Renal Transplant Patient

Emily Smith

Eleanor Mann School of Nursing

Reflective Journal

Since November of 2020, I have been working in the Renal & Organ Transplant unit at a

major metropolitan hospital. The purpose of this position is to orient myself to patient care in a

hospital setting and learn about holistic patient care surrounding solid organ transplants including

kidneys, livers, and lungs. This experience allowed me to answer questions for my future career

as a nurse. Some of these questions included: How will this experience impact where I want to

work long term? Will this experience direct me toward graduate school? How can I best teach

and promote compliance in my patients?

Working as a nurse associate will greatly impact my future profession and desire to return to

graduate school. This experience has increased my confidence working with patients and their

families, as well as collaborating with interdisciplinary teams. It began to teach me time

management and prioritization skills that will be required of me as a nurse. This position has also

taught me technical skills including charting, phlebotomy techniques, and use of equipment such

as bladder scanners and suctioning equipment. This experience has made me realize my desire to

continue my education in the future to be in a better position to care and advocate for my

patients. Graduate school would provide me with a deeper understanding of evidence-based

practices and allow more autonomy when caring for patients.

Working as a nurse associate was also important for fostering professional and personal

growth. It has allowed me to have a better understanding of what the role of a professional nurse

looks like and has allowed me to apply the knowledge I have gained during my time as an

undergraduate and nursing student. It also has allowed me the opportunity to practice interacting

with patients and communicating effectively with them. Building a trusting professional

relationship with a patient is a learned skill that requires significant practice. With this
RENAL TRANSPLANT NURSING CARE 3

experience, I have had over 120 hours of patient contact and my confidence communicating with

patients has greatly increased. This experience has allowed me to learn from other nurse

associates, certified nursing assistants, and nurses. I learn something new each shift that I will be

able to take with me and apply to my career as I transition into the professional practice.

The most significant responsibilities I performed during my honors internship were

monitoring and assessing patients. Every four hours I would assess and monitor anywhere from

nine to twenty patients. During these rounds, every four hours, I would assess both physical well-

being and psychological needs. These assessments included vital signs, strict intake and output,

physical comfort and pain levels, surgical wound drains, and reactions to medications and

treatments including blood transfusions and insulin drips. Once I gathered data from my patients,

I would have to analyze if any abnormalities were present, document my findings, and report to

the patient’s care team if needed.

Keeping transplant patients safe is a huge task and often a challenge. The unit has meticulous

rules to prevent falls and protect patients. Many patients receiving pain medications through

epidurals or IVs are very weak after surgical procedures, or from end stage organ failure. Fall

bundles include sensitive bed and chair alarms, gait belts and assistive devices, non-slip socks,

and mandatory levels of staff assistance (i.e., assist X1, assist X2, stand by assistance, and up ad

lib). Many patients were not compliant with this unit policy and some patients refuse fall

bundles. This makes it difficult to ensure their safety and was always a concern for those at risk

for falls. For these patients, I often conducted more frequent wellness checks to ensure they were

ambulating safely and there has been no change in their condition.

Patient teaching post-transplant is difficult due to considerable physical discomfort and

emotional stress after surgery. Many patients feel completely overwhelmed due to their physical
RENAL TRANSPLANT NURSING CARE 4

limitations and weakness after surgery. I have seen these patients become overwhelmed very

easily, so they need very simple, direct, and small amounts of teaching and reinforcement at a

time.

One very important lesson I have learned through my position as a nurse associate is how to

connect with patients and care for them in times of need. I have also learned how to own up to

and learn from my mistakes and admit when I do not know the answer. I have found I learn the

most through patient interactions as well as watching other co-workers interacting with patients.

I have also discovered that the patient’s greatest need is to be listened to. Many patients feel as

though care providers do not understand their needs and what goes through their heads when

receiving care at a hospital. A major part of patient satisfaction, creating and reaching common

goals, and ensuring quality patient outcomes is assessing and listening to the needs and thoughts

of the patient.

My course work at the Eleanor Mann School of Nursing prepared me very well for this

experience. I was able to adapt and catch on fairly quickly. During our pre-nursing semester, I

had an informatics class that has greatly helped me navigate and understand how to use the

electronic health record system. Health assessment class and clinicals have taught me how to

chart and document assessments, as well as identify what is abnormal when assessing patients.

Pathophysiology and Med-Surg have allowed me to understand physiologic processes behind

disease and use critical thinking to understand interventions and possible findings when I am

assessing patients. Mental health has allowed me to better communicate with patients

professionally in times of great emotional and physical distress.

Abstract

Kidneys are the most commonly transplanted organ in the United States. All patients who

receive a renal transplant must be on lifelong immunosuppressants to prevent rejection of the

donor organ. The majority of patients do not take their immunosuppressant medications as

instructed, making noncompliance a huge issue for medical professionals. The purpose of this

literature review is to explore what evidence-based techniques nurses should employ to increase

the long-term compliance of immunosuppressants in renal transplant patients. A literature review

was performed of fifteen studies to identify interventions that nurses can employ to increase

immunosuppressant compliance. CINAHL and Medline were searched using Boolean phrases,

and studies were sorted using search limiters and inclusion and exclusion criteria. All studies

included in this literature review are peer-reviewed academic journals.

Nurses can assess motivating factors and barriers to learning prior to teaching renal

transplant patients about immunosuppressant therapy using evidence-based tools and

questionaries. While teaching, nurses should promote self-advocacy and accountability to

prevent both intentional and unintentional noncompliance to long-term immunosuppressant

medications. Increased compliance can be achieved with the use of mHealth applications and the

SystemsCHANGE approach. Intentional noncompliance can be reduced with thorough teaching

of correct medication use, side effects, and results of noncompliance. Nurses can use

individualized assessments, tools, and technology to increase immunosuppressant compliance

and decrease long term complications associated with noncompliance. Future research regarding

compliance with immunosuppressants is needed to provide nurses with evidence-based

interventions, and quantitative longitudinal studies could provide insight to the effects of

interventions long term.

Introduction

In 2019 alone, there were 23,401 kidney transplants performed, making it the most

transplanted organ in the United States (UNOS, 2020). The number of renal transplants increases

significantly each year. Between 2018 and 2019, there was a 10.6% increase in the number of

renal transplants (UNOS, 2020). Due to the increased prevalence of this procedure, need for

post-transplant evidence-based practices (EBPs) are vital to increase quality patient outcomes

and reduce risk for transplant rejection. Researching and implementing evidence-based nursing

care surrounding immunosuppressant compliance is critical to preventing patient complications

and promoting quality of life. Noncompliance of immunosuppressant medications increases the

risk of transplant rejection and decreases quality of life for renal transplant patients. Studies have

shown 76% of renal transplant patients are considered noncompliant with immunosuppressive

treatment. Of these noncompliant patients, 63% are unintentionally noncompliant and 13% are

intentionally noncompliant (Griva et al., 2018).

Therefore, the primary goal of this literature review is to explore what evidence-based

education techniques nurses should employ to increase the long-term compliance of

immunosuppressants in renal transplant patients.

Methods

Study Design

A literature review was performed related to the question: “What evidence-based

education techniques should nurses employ to increase the long-term compliance of

immunosuppressants in renal transplant patients?” The databases searched to answer this

research question were CINAHL Complete and Medline Complete. The Boolean phrases “renal

transplant” or “kidney transplant,” “medication compliance,” and “ nursing care” were used to
RENAL TRANSPLANT NURSING CARE 7

search these databases. To further refine search results, the following search limiters were used:

full text, academic journals, peer reviewed, English language, and year limits from 2001 to 2021.

Inclusion/Exclusion Criteria

Articles must have met the following criteria to be included in the literature review: (A)

the journal topic must have been about renal transplant patients; (B) patient education, medical

adherence, or long-term immunosuppressant noncompliance must have been a topic addressed;

(C) scholarly journal article or peer reviewed journal, (D) published in the last 20 years; (E) full

text was available. Articles were excluded from the literature review if (A) the interventions or

assessments explained in the article was not within the nursing scope of practice, and (B) studies

included participants other than renal transplant patients.

Search Results

Fifteen articles were chosen from the search of both CINAHL and Medline databases

(twelve from CINAHL and three articles from Medline). Original search results from CINAHL

populated 441 search results. Articles were removed according to the inclusion and exclusion

criteria listed above until twelve articles remained. Original search results from Medline

populated 5,735 search results. Articles were removed according to the inclusion and exclusion

criteria listed above until three articles remained. Of the fifteen articles, two were cross sectional

studies, six were quantitative studies, and seven were qualitative studies.

Results

Assessment of Barriers and Protective Factors

Results from the literature review confirm that nursing interventions may increase the

compliance of long-term immunosuppressant use in renal transplant patients. Consistently,

researchers found that identifying barriers to education and compliance, as well as identifying
RENAL TRANSPLANT NURSING CARE 8

motivating factors of the individual patient is critical to ensuring compliance with

immunosuppressant therapies (Chisholm et al., 2005; Cossart et al., 2019; Griva et al., 2018;

Hass, 2016; Leite et al., 2018).

Before a plan of teaching can be made for a patient, assessment of both these factors must

be completed. To assess barriers and motivators, nurses can use scales like the Transplant Effects

Questionnaire, Beliefs about Medications Questionnaire, Multidimensional Scale of Perceived

Social Support, Depression and Anxiety Scale, and Medication Adherence Reports Scale (Griva

et al., 2018) and take into consideration socioeconomic factors like ability to pay for medications

and social support they have (Hass, 2016). Nurses can also specifically assess motivation or

protective factors of each patient. The results of one study indicated the following characteristics

as protective factors: female sex, younger age, lower average income, and had transplants more

recently (Chrisholm, 2005).

Forgetfulness

Studies have found that the majority of patients, 76%, are unintentionally noncompliant

with their immunosuppressant medications, and the majority of those who are unintentionally

noncompliant do so because of forgetfulness (Griva et al., 2018). Studies provided evidence of

the effectiveness of mobile health (mHealth) applications as a service that provides medication

reminders to patients. These mHealth applications also promote self-advocacy and empowerment

by allowing individuals to monitor and manage their health after renal transplant much like a

chronic disease is managed (O’Brien, 2020). These applications allow patients to monitor self-

care, medication adherence, and set goals for their health (O’Brien, 2020). While study

participants report general chronic illness apps as helpful, an app specifically designed for renal

transplant recipients has been identified as necessary.

Intentional Noncompliance

While the majority are unintentionally noncompliant, 13% of patients are intentionally

noncompliant. Griva et al. (2020) determined that many patients who are intentionally

noncompliant with immunosuppressants do so because of medication side effects. Education

must include side effects and possible ways to improve these side effects to encourage patients to

remain compliant. Intentional noncompliance can also occur when the patient has

misconceptions about their condition or does not have the proper resources to obtain

medications. Assessment of patient’s beliefs and knowledge about their condition, as well as

resources available to them, can reduce intentional noncompliance due to these factors.

Systematic Approach

A systematic approach can be used to plan, provide interventions, assess, and follow up

with outcomes (Russell et al., 2020). Russell et al. (2020) introduced the SystemCHANGE

approach as a way to manage compliance after transplants. The planning set of this approach

entails setting up electronic self-monitoring, setting medication compliance goals, listing

solutions to possible problems, and assessing an individual’s daily habits. The nurse and patient

then complete the teaching and follow the plan outlined in step one. Lastly, there is a follow up

with the patient at one, two, three, four, and five months. During this follow up, tracked

compliance is assessed and interventions are changed according to what is working and what is

not (Russell et al., 2020).

Discussion

Evidence-based techniques nurses can employ to increase the long-term compliance of

immunosuppressants in renal transplant patients include interventions to assess for barriers,

motivating factors, and daily habits. Assessment of these factors is a major component of
RENAL TRANSPLANT NURSING CARE 10

effective patient teaching and creating individualized medication plans. Nurses can create an

environment of empowerment for their patients by educating them on how medications are to be

taken as well as why the meds are to be taken, side effects, and possible solutions to medication

issues. Nurses can empower patients to keep tract of medication compliance using technology

such as mHealth applications. Nurses can also employ systematic approaches to create a

collaborative way to manage immunosuppressant adherence, using procedures like

SystemCHANGE.

This review is limited by the use of self-reported data in many of the studies. Researchers

in many of the studies used tools and assessments that require patients to self-report habits and

compliance to medications. This allows for the possibility of false or fabricated reports, which

would skew results. There were a limited number of available articles on immunosuppressant

compliance post-renal transplant. Therefore, this study is limited by studies and articles available

on this topic. Additionally, few of the available studies are quantitative studies. This is a

limitation due to lack of data that could show statistical significance or insignificance of the

interventions employed. There are many underexplored areas for immunosuppressant

compliance and nursing interventions. Some of these gaps include lack of data on long-term

compliance after evidence-based teaching methods have been employed, and how rates of kidney

rejection are affected by proper immunosuppressant teaching and use. There is a need for future

research to include long term studies of targeted interventions that are believed to increase

immunosuppressant compliance.

Numerous implications exist for evidence-based nursing interventions that promote

immunosuppressant compliance. First, nurses can use these interventions to increase compliance,

therefore decreasing hospital readmission rates and rejection of the transplanted kidneys. Second,
RENAL TRANSPLANT NURSING CARE 11

nurses can use these interventions to build trust and rapport with patients, which increases

quality patient outcomes. Lastly, proper teaching empowers patients to manage their conditions

and advocate for their health. To increase immunosuppressant compliance, hospital policies,

protocols, and training for staff must occur. Hospital policies and procedures should require

assessment of barriers and protective factors of patient learning. Policies and procedures should

also include key teaching interventions and topics that should be emphasized with the patient.

Training and education for nurses and other care coordinators should be provided to address

these policies and procedures. Increased use of care coordinators can bridge gaps in patient care

and keep patients on track with their treatment plan. These care coordinators can ensure the

patient has consistent follow up care to reassess the patient and provide needed interventions.

Conclusion

Kidneys are the most commonly transplanted organ in the United States and each year the

number of renal transplants performed is increasing significantly. Effective interventions to

increase immunosuppressant compliance are vital to improving patient outcomes and decreasing

the morbidity and mortality due to transplant rejection. Previous studies outline evidence-based

interventions that can be employed to improve long-term immunosuppressant compliance. These

interventions can be translated into the professional nursing practice by enforcement through

hospital policies, procedures, and employee education.

References

Adhikari, U. R., Taraphder, A., Hazra, A., & Das, T. (2017). Medication Adherence in Kidney

Transplant Recipients in an Urban Indian Setting. Indian Journal of Nephrology, 27(4),

294–300. https://doi.org/10.4103/0971-4065.202835

Andersen, M. H., Wahl, A. K., Engebretsen, E., & Urstad, K. H. (2019). Implementing a tailored

education programme: renal transplant recipients’ experiences. Journal of Renal

Care, 45(2), 111–119. https://doi.org/10.1111/jorc.12273

Axelrod, D. A., Kynard-Amerson, C. S., Wojciechowski, D., Jacobs, M., Lentine, K. L.,

Schnitzler, M., Peipert, J. D., & Waterman, A. D. (2017). Cultural competency of a

mobile, customized patient education tool for improving potential kidney transplant

recipients’ knowledge and decision-making. Clinical Transplantation, 31(5).

https://doi.org/10.1111/ctr.12944

Chisholm MA, Lance CE, & Mulloy LL. (2005). Patient factors associated with adherence to

immunosuppressant therapy in renal transplant recipients. American Journal of Health-

System Pharmacy, 62(17), 1775–1781. https://doi.org/10.2146/ajhp040541

Constantiner, M., Rosenthal-Asher, D., Tedla, F., Salifu, M., Cukor, J., Wyka, K., Hartono, C.,

Serur, D., de Boccardo, G., & Cukor, D. (2018). Differences in Attitudes Toward

Immunosuppressant Therapy in a Multi-ethnic Sample of Kidney Transplant

Recipients. Journal of Clinical Psychology in Medical Settings, 25(1), 11–19.

https://doi.org/10.1007/s10880-017-9524-9

Cossart, A. R., Staatz, C. E., Campbell, S. B., Isbel, N. M., & Cottrell, W. N. (2019).

Investigating barriers to immunosuppressant medication adherence in renal transplant

patients. Nephrology (Carlton, Vic.), 24(1), 102–110. https://doi.org/10.1111/nep.13214

de Fátima Cruz de Morais, R., de Lima Sardinha, A. H., Nunes Costa, F. D., de Jesus Castro

Câmara, J., Alves Viegas, V. L., & Melo Santos, N. (2016). Adherence to

Immunosuppressive Therapy Adherence in Kidney Transplant Recipients. Ciencia,

Cuidado e Saude, 15(1), 141–147. https://doi.org/10.4025/cienccuidsaude.v15i1.28029

da Silveira Maissiat, G., Marin, S. M., & Fuzinatto, C. R. D. (2013). Adherence to

immunosuppressive treatment in post-renal transplant patients: a descriptive-exploratory

study. Online Brazilian Journal of Nursing, 12(2), 1.

Griva, K., Neo, H. L. M., & Vathsala, A. (2018). Unintentional and intentional non-adherence to

immunosuppressive medications in renal transplant recipients. International Journal of

Clinical Pharmacy, 40(5), 1234–1241. https://doi.org/10.1007/s11096-018-0652-6

Haas, K. (2016). CNE. Responses to a Survey on the Perceived Barriers to Effective Discharge

Planning in Renal Transplant Recipients. Nephrology Nursing Journal, 43(6), 521–526.

Kim, S., Ju, M. K., Son, S., Jun, S., Lee, S. Y., & Han, C. S. (2020). Development of video-

based educational materials for kidney-transplant patients. PloS One, 15(8), e0236750.

https://doi.org/10.1371/journal.pone.0236750

Leite, R. F., Máximo Silva, A. C., de Oliveira, P. C., Giunta da Silva, L. M., de Abreu Pestana, J.

M., Schirmer, J., & de Aguiar Roza, B. (2018). Measurement of adherence to

immunosuppressive drugs in renal transplant recipients. Acta Paulista de

Enfermagem, 31(5), 489–496. https://doi.org/10.1590/1982-0194201800069

O’Brien, T. (2020). Preferred Features in Mobile Health Applications for Kidney Transplant

Recipients: A Qualitative Approach. Nephrology Nursing Journal, 47(6), 529–536.

https://doi.org/10.37526/1526-744X.2020.47.6.529
RENAL TRANSPLANT NURSING CARE 14

Russell, C. L., Hathaway, D., Remy, L. M., Aholt, D., Clark, D., Miller, C., Ashbaugh, C.,

Wakefield, M., Ye, S., Staggs, V. S., Ellis, R. J., & Goggin, K. (2020). Improving

medication adherence and outcomes in adult kidney transplant patients using a personal

systems approach: SystemCHANGE™ results of the MAGIC randomized clinical

trial. American journal of transplantation : official journal of the American Society of

Transplantation and the American Society of Transplant Surgeons, 20(1), 125–136.

https://doi.org/10.1111/ajt.15528

Williams, A., Low, J. K., Manias, E., & Crawford, K. (2016). The transplant team’s support of

kidney transplant recipients to take their prescribed medications: a collective

responsibility. Journal of Clinical Nursing (John Wiley & Sons, Inc.), 25(15–16), 2251–

2261. https://doi.org/10.1111/jocn.13267