The immediate post-operative period following lung transplantation: mapping of nursing interventions

OBJECTIVES: to investigate the principle nursing interventions/actions, prescribed in the immediate post-operative period for patients who receive lung transplantation, recorded in the medical records, and to map these using the Nursing Interventions Classification (NIC) taxonomy. METHOD: retrospective documental research using 183 medical records of patients who received lung transplantation (2007/2012). The data of the patients' profile were grouped in accordance with the variables investigated, and submitted to descriptive analysis. The nursing interventions prescribed were analyzed using the method of cross-mapping with the related interventions in the NIC. Medical records which did not contain nursing prescriptions were excluded. RESULTS: the majority of the patients were male, with medical diagnoses of pulmonary fibrosis, and underwent lung transplantation from a deceased donor. A total of 26 most frequently-cited interventions/actions were found. The majority (91.6%) were in the complex and basic physiological domains of the NIC. It was not possible to map two actions prescribed by the nurses. CONCLUSIONS: it was identified that the main prescriptions contained general care for the postoperative period of major surgery, rather than prescriptions individualized to the patient in the postoperative period following lung transplantation. Care measures related to pain were underestimated in the prescriptions. The mapping with the taxonomy can contribute to the elaboration of the care plan and to the use of computerized systems in this complex mode of therapy.


Introduction
Lung transplantation is a fundamental therapeutic option for the treatment of serious non-neoplasic pneumopathies such as advanced Chronic Obstructive Pulmonary Disease (COPD), pulmonary fibrosis, cystic fibrosis, and pulmonary hypertension in the final stage and when the predicted life expectancy is below two years (1) .  (2) .
The success of the process -from procuring organs through to the transplants -depends on the involvement and on the work of the multidisciplinary team, promoting the comprehensiveness of the care provided by the team to this patient in the perioperative period (3) . This model of multidisciplinary work makes the relationship of nursing with the process of organ donation and transplantation clear, evidencing the role of the nurse in both the care role and the role of transplant coordinator (4) .
It stands out that both patients who need lung transplants and those who have already received this organ are in a situation of vulnerability. In the pre-transplantation period, these are weakened because they present dyspnea and fatigue in activities which require minimum effort, compromising their activities of daily living, and sometimes leading them to be hospitalized while on the waiting list (5) . In the postoperative period following lung transplantation, the patients are recovering from an invasive and complex procedure which evidences the need for intensive care, besides the physiological complications themselves to which the procedure exposes them, such as: reperfusion edema, acute rejection, chronic rejection, infection by cytomegalovirus (CMV) and cryptogenic organising pneumonia, as well as dehiscence or bronchial anastomatic stenosis (6) .
In order to facilitate critical reflection on the care practiced by the nurses, to underscore the assistance which the same provide to the patients, and to contribute to effectiveness in the communication and documentation of the clinical practice, the use of scientific taxonomies such as the Nursing Interventions Classification (NIC) in search of excellence of practice in nursing (7)(8) has been strengthened.
It is understood that nursing interventions cover "any treatment based in the judgment and the clinical knowledge undertaken by the nurse in order to improve the patient/client outcomes" (9) .
In order to research the actions undertaken and documented by the nurse, the use of cross-mapping has increasingly spread in the field of nursing, as it allows the data present in the nursing process as non-standardized diagnoses, results and interventions to be analyzed and compared with the scientific references and taxonomies indicated (10) .
The use of standardized language, and the close relationship of nursing with the recipient, find scientific support for interlinking them, with the objective of providing better assistance, principally in the most delicate period of this process, during the immediate postoperative period, when the patient is admitted to the Intensive Care Unit (ICU).
Based on access to this information, emphasis is placed on the need to investigate the nursing care measures which are most relevant to the assistance provided to the patient in the immediate postoperative period following lung transplantation, mapping them in accordance with the NIC. Thus, the comparison of the care steps prescribed by the professionals with the taxonomy indicated by academics confers greater credibility on the nurse's work, facilitating the insertion of this language in the nursing process undertaken in their day-to-day (11) .
The present study aims to investigate the principal nursing interventions/actions prescribed in the immediate postoperative period for patients who received lung transplants, based on records made in the medical records, and to map these with the NIC taxonomy.
As a result, the topic's relevancy is justified by the

Results
In relation to the profile of the patients who received lung transplantation between the years of 2007 and 2012, it was identified that the majority were male (60.63%), with a mean age of 49.28 (±15.29) years old, the youngest patient being nine years old, and the oldest, 73. The most prevalent medical diagnosis was pulmonary fibrosis (31.57%). This profile can be seen in Table 1. Duarte RT, Linch GFC, Caregnato RCA. Of the actions mapped, Figure 1 presents only those related to the care prescribed by the nurses in the immediate postoperative period following lung transplantation.
The interventions related to pain, such as: "evaluate pain" and "administer prescribed analgesics following the nurse's evaluation" were found in fewer than 16 (14%) prescriptions, representing, respectively, 7.89% and 6.14%. As they had a representativity below 30% in the sample, they were not mapped with the NIC actions.

Discussion
The profile found in this study for the patients who received lung transplants showed a mean age among the patients of 50.19 (± 15.29) years old, and prevalence of the male sex (60.63%). The most prevalent base pathologies were: pulmonary fibrosis (35.63%), emphysema (20.62%) and COPD (4.3%), these being in accordance with other studies undertaken with the same target public (12)(13)(14) .
It was identified that the main actions prescribed   care with catheters, and surveillance of blood losses (22)(23) .
In this study, the care measures mentioned above were mapped with the following interventions: and Invasive hemodynamic monitoring (4210).
Nursing care in the postoperative period must be individualized, but can follow the same clinical reasoning, based on signs and symptoms, for providing safe care (24) . For this, hemodynamic monitoring, recognition of hypovolemia, control of the ventilatory strategy, aspiration of secretions and pain management must be taken into consideration.
The management of the pain was underestimated in many prescriptions, in spite of being frequently mentioned in many studies as the principal postoperative care measure following major surgery.
Pain is considered the fifth vital sign to be evaluated, and lung transplantation is major surgery, with combined anesthesia and maintenance of the peridural catheter in the Immediate Postoperative Period (IPP) (15,22,24) .
However, in the present study only 16 prescriptions were undertaken in relation to pain, representing 14% of the care measures prescribed.
In spite of it being recommended that care with immunosuppression should start in the preoperative period, the need is noted for maintaining and improving these care measures in the postoperative period: in the same way that we must be alert for signs of acute rejection, reperfusion injuries, bleeding, arrhythmias, and signs of infection, especially in the first 48 hours (25) .
However, based on the undertaking of the cross-