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A 56-year-old male just received a liver transplant for end-stage liver cirrhosis after being on the transplant wait list for 11 months. He was removed from mechanical ventilation 12 hours after surgery and is breathing normally on 2 L/min O2 by nasal cannula. A central venous catheter has been placed in the left internal jugular vein for intravenous fluids and medications; two Jackson-Pratt drains are emerging from his large abdominal incision, and a Foley urinary catheter is in place. Prior to surgery, significant protein malnutrition (muscle wasting), fatigue, ascites, and hepatic encephalopathy limited his mobility and quality of life. Postoperatively, the ascites and encephalopathy are slowly resolving, but lower extremity and scrotal edema persists. Relevant medications for immunosuppression include: Prograf  (tacrolimus), prednisolone, and cyclosporine. The transplant surgeon has asked the physical therapist to perform an evaluation and treatment today on postoperative day 1 (POD 1). In addition, there are orders for the patient to be out of bed beginning POD 1.

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Based on his health condition, what do you anticipate may be the contributors to activity limitations?

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What are possible complications interfering with physical therapy?

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What precautions should be taken during physical therapy examination and/or interventions?

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What is his rehabilitation prognosis?

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  • ASCITES: Accumulation of fluid in the peritoneal cavity surrounding the intestines; associated with scrotal and bipedal edema
  • CIRRHOSIS: Progressive replacement of normal hepatocytes with fibrotic nodular tissue that impairs liver function
  • ESOPHAGEAL VARICES: Extremely dilated submucosal veins in the esophagus due to portal vein hypertension
  • HEPATIC ENCEPHALOPATHY: Confusion and decreased level of consciousness due to factors resulting from chronic liver disease
  • PORTAL VEIN HYPERTENSION: Increased pressure at the portal vein (carries venous blood to the liver from stomach, intestines, pancreas, and spleen) due to scarring of liver tissue and thrombosis
  • VALSALVA MANUEVER: Sudden increase in intra-abdominal pressure due to attempted forceful exhalation with a closed airway

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  1. Describe protein energy malnutrition that occurs as a result of liver cirrhosis.

  2. Identify outcome measures of functional strength and performance in the patient post-liver transplant with protein energy malnutrition.

  3. Identify critical laboratory values that should be checked prior to treating the patient.

  4. Understand the precautions associated with treating this patient population.

  5. Prescribe a program of resistance exercise to assist in the reversal or mitigation of muscle wasting.

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PT considerations during management of the individual status/post liver transplant due to chronic liver cirrhosis:

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  • General physical therapy plan of care/goals: Prevent or minimize skin breakdown, loss of range of motion, and the risk of atelectasis, pneumonia, and infection; maximize functional mobility and improve quality of life
  • Physical therapy interventions: Bed mobility and transfer training, ambulation and gait training, posture training, breathing exercises, endurance activities, muscle strengthening
  • Precautions during physical therapy: Avoid Valsalva maneuver to prevent risk of bleeding from esophageal varices ...

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