title: Assistance continuity from primary care in an inter-level nursing plan for a case of pediatric liver transplant.
abstract: Spain is one of the countries where most solid organ transplants are performed each year, in the year 2014 a 2.7% of them were given in childhood. Given the complexity and severity of this disease it is necessary to establish a care plan that covers both pre-transplant and post-transplant, with close cooperation between different levels of care, to approach the several problems that can appear and assure continuum of care. In the following example, a Gambian teen with risk of social exclusion fostered a collaboration between the primary care nurse and transplant nurse that was the key to continuum care. Multiple strategies were used in the care plan to ensure better adherence and compliance of the treatment. However, the knowledge of the culture of origin must be deepened to establish more individualized care plans and thus improve results. The care plan included problems according to the NANDA, NOC, NIC taxonomy.
authors.affiliation: Atención Primaria, Sabadell Est, Sabadell, Barcelona, España. Electronic address: vvalls.mn.ics@gencat.cat.
authors.forename: Victoria
authors.initials: V
authors.lastname: Valls-Ibáñez
authors.affiliation: Hospital Materno-Infantil Vall d'Hebron, Barcelona, España.
authors.forename: Matilde
authors.initials: M
authors.lastname: Fernández-Obispo
authors.affiliation: Corporació Sanitària Parc Taulí, Institut Universitari Parc Taulí-UAB, Sabadell, Barcelona, España.
authors.forename: Jordi
authors.initials: J
authors.lastname: Torralbas-Ortega
authors.affiliation: Atención Primaria, Sabadell Est, Sabadell, Barcelona, España.
authors.forename: Montserrat
authors.initials: M
authors.lastname: Bernal-Jiménez
mesh_terms: D000293:Adolescent; D003266:Continuity of Patient Care; D005260:Female; D006801:Humans; D016031:Liver Transplantation / Q000451:nursing*; D010347:Patient Care Planning; D011320:Primary Health Care; D013030:Spain
keywords: Atención de enfermería; Continuidad de la atención al paciente; Continuity of patient care; Liver transplantation; Patient care planning; Pediatrics; Pediatría; Trasplante hepático