A patient may undergo surgery to remove obstructions that affect the kidney (tumors or calculi), to insert a tube for draining the kidney (nephrostomy, ureterostomy), or to remove the kidney involved in unilateral kidney disease, renal carcinoma, or kidney transplantation.
Surgery is performed only after a thorough evaluation of renal function. Patient preparation to ensure that optimal renal func-tion is maintained is mandatory. Fluids are encouraged to promote increased excretion of waste products before surgery, unless con-traindicated because of preexisting renal or cardiac dysfunction. If kidney infection is present preoperatively, wide-spectrum anti-microbial agents may be prescribed to prevent bacteremia. Anti-biotic agents must be given with extreme care because many are toxic to the kidneys. Coagulation studies (prothrombin time, par-tial thromboplastin time, platelet count) may be indicated if the patient has a history of bruising and bleeding.
Because many patients facing kidney surgery are apprehensive, the nurse encourages the patient to recognize and express any feelings of anxiety. Confidence is reinforced by establishing a re-lationship of trust and by providing expert care. Patients faced with the prospect of losing a kidney may think that they will be dependent on dialysis for the rest of their life. It is important to teach the patient and family that normal function may be main-tained by a single healthy kidney.
Renal surgery requires various patient positions to expose the sur-gical site adequately. Three surgical approaches are common: flank, lumbar, and thoracoabdominal (Fig. 44-10). During surgery, plans are carried out for managing altered urinary drainage and drainage systems. Plans may include inserting a nephrostomy or other drainage tube or using ureteral stents.
Because the kidney is a highly vascular organ, hemorrhage and shock are the chief complications of renal surgery. Fluid and blood component replacement is frequently necessary in the im-mediate postoperative period to treat intraoperative blood loss.
Abdominal distention and paralytic ileus are fairly common after renal and ureter surgery and are thought to be due to a re-flex paralysis of intestinal peristalsis and manipulation of the colon or duodenum during surgery. Abdominal distention is re-lieved by decompression through a nasogastric tube. Oral fluids are permitted when the passage of flatus is noted.
If infection occurs, antibiotic agents are prescribed after a cul-ture reveals the causative organism. The toxic effects that anti-biotic agents have on the kidneys (nephrotoxicity) must be kept in mind when assessing the patient. Low-dose heparin therapy may be initiated postoperatively to prevent thromboembolism in patients who had any type of urologic surgery.
Almost all patients undergoing kidney and urologic surgery, as well as patients with other kidney and urologic disturbances, have drains, tubes, or catheters in place. All catheters and tubes must be kept patent (eg, draining) to prevent obstruction by blood clots, which can cause infection, kidney damage, or severe pain (similar to renal colic) when they pass along the ureter.
A nephrostomy tube is inserted directly into the kidney for tem-porary or permanent urinary diversion. It can be inserted either percutaneously or through a surgical incision. A single tube or a self-retaining U loop or circular nephrostomy tube may be used and is attached to a closed drainage system or to a urostomy appliance. Nephrostomy drainage may be required to provide drainage from the kidney after surgery or to bypass an obstruc-tion in the ureter or lower urinary tract. Permanent nephrostomy tubes are usually changed every 3 months.
Percutaneous nephrostomy is the insertion of a tube through the skin into the renal pelvis. This procedure is performed to pro-vide external drainage of urine from an obstructed ureter, to create a route for inserting a ureteral stent (see following discussion), to dilate strictures, to close fistulas, to administer medications, to allow insertion of a brush biopsy instrument and nephroscope, or to perform selected surgical procedures.
The skin site is prepared and anesthetized, and the patient is asked to inhale and hold his or her breath while a spinal needle is advanced into the renal pelvis. Urine is aspirated for culture, and a contrast agent may be injected into the pyelocalyceal system. An angiographic catheter guide wire is introduced through the nee-dle to the kidney. The needle is withdrawn and the tract dilated by the passage of tubes or guide wires. The nephrostomy tube is introduced and positioned within the kidney or ureter, fixed by skin sutures, and connected to a closed drainage system.
Before a percutaneous nephrostomy tube is inserted, several precautions should be taken. The patient should receive a broad-spectrum antibiotic to prevent infection. Bleeding disorders and uncontrolled hypertension should be corrected. Also, anticoagu-lant agents and aspirin should be discontinued and bleeding study results (prothrombin time, partial thromboplastin time, platelet count) should be normal to decrease the chance of devel-oping a perirenal hematoma or renal hemorrhage. Chart 44-12 describes postsurgical nursing care of the patient with a nephros-tomy tube (also see Chart 44-13).
A ureteral stent is a self-retaining tubular device that helps main-tain the position and patency of the ureter. Stents are used to maintain urine flow in patients with ureteral obstruction (from edema, stricture, fibrosis, calculi, or tumors), to divert urine, to promote healing, and to maintain the caliber and patency of the ureter after surgery (Fig. 44-11). Stents are usually removed 4 to 6 weeks after surgery in an outpatient setting without the need for general anesthesia or risk of ureteral injury.
The stent, usually made of soft, flexible silicone, may be inserted through a cystoscope or nephrostomy tube or by open surgery. Complications include infection, inflammation secondary to a for-eign body in the genitourinary tract, tube encrustation, bleeding or clot obstruction within the stent, and migration or displacement of the stent (Lehmann & Dietz, 2002).
Several stents are designed to avoid some of these problems. The double-J ureteral stent has a J-shaped curve molded into each end that prevents upward or downward migration. This stent can be used in place of a nephrostomy for short- or long-term urinary drainage. The double-pigtail ureteral stent has a pigtail coil at each end; this permits placement of the upper coil (pigtail) in the renal pelvis, with the lower coil at the ureteral orifice. The coils prevent the stent from moving and allow free body movement.
Nursing interventions related to the care of a patient with a ureteral stent include monitoring the patient for bleeding, assess-ing and measuring urine output, assessing the patient for signs of urinary tract infection or retroperitoneal infection from leakage of urine, and monitoring the patient for stent displacement, which is evidenced by colicky pain and a decrease in urine out-put. An indwelling stent may produce a local ureteral reaction, including mucosal edema, which can cause temporary obstruc-tion of the ureter and intense pain.
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