NURSING PROCESS: THE PATIENT UNDERGOING KIDNEY SURGERY
Immediate care of the patient who has undergone surgery of the kidney includes assessment of all body systems. Respiratory and circulatory status, pain level, fluid and electrolyte status, and pa-tency and adequacy of urinary drainage systems are assessed.
As with any surgery, the use of anesthesia increases the risk of res-piratory complications. Noting the location of the surgical inci-sion assists the nurse in anticipating respiratory problems and pain. Respiratory status is assessed by monitoring the rate, depth, and pattern of respirations. The location of the incision fre-quently causes pain on inspiration and coughing; therefore, the patient tends to splint the chest wall and take shallow respira-tions. Auscultation is performed to assess normal and adventi-tious breath sounds.
The vital signs and arterial or central venous pressure are moni-tored. Skin color and temperature and urine output provide in-formation about circulatory status. The surgical incision and drainage tubes are observed frequently to help detect unexpected blood loss and hemorrhage.
Postoperative pain is a major problem for the patient because of the location of the surgical incision and the position the patient assumed on the operating table to permit access to the kidney. The location and severity of pain are assessed before and after analgesic medications are administered. Abdominal distention, which increases discomfort, is also noted.
Urine output and drainage from tubes inserted during surgery are monitored for amount, color, and type or characteristics. De-creased or absent drainage is promptly reported to the physician because it may indicate obstruction that could cause pain, infec-tion, and disruption of the suture lines.
Based on the history and assessment data and the type of surgical procedure performed, some major nursing diagnoses for the pa-tient include the following (additional diagnoses and interven-tions appear in the Plan of Nursing Care):
· Ineffective airway clearance related to the location of the surgical incision
· Ineffective breathing pattern related to surgical incision and general anesthesia
· Acute pain related to the location of the surgical incision, the position the patient assumed on the operating table dur-ing surgery, and abdominal distention
· Urine retention related to pain, immobility, and anesthesia
Based on assessment data, potential complications that may de-velop include the following:
· Fluid disturbances (deficit or excess)
· Deep vein thrombosis
The major goals for the patient include maintenance of effective airway clearance and breathing pattern, relief of pain and dis-comfort, maintenance of urinary elimination, and absence of complications.
The surgical approaches to the kidney predispose the patient to respiratory complications and paralytic ileus. If the pleural cavity has been entered during surgery, a pneumothorax may occur, ne-cessitating insertion of a chest tube. The incision is generally close to the diaphragm, and with a substernal incision, the nerves may be stretched and bruised. These factors can lead to pain and lim-ited chest movement during inspiration; breathing patterns are altered or ineffective when the chest cannot fully expand. If the patient cannot generate an effective cough, either because of pain at the incision site and restricted movement or because of anes-thesia, ineffective airway clearance may result.
Adequate use of analgesic medications is necessary to relieve pain so that the patient can take deep breaths and cough. When the analgesia is administered at regular, frequent intervals, the pa-tient can perform deep-breathing and coughing exercises more effectively. The incentive spirometer may be used to help maximize lung inflation. The patient is encouraged to cough after each deep breath to loosen secretions.
In addition to pain at the incision site, the patient may experience pain and discomfort from distention of the renal capsule (by tumor or blood clot), ischemia (from occlusion of blood vessels), and stretching of the intrarenal blood vessels. Muscle aches and pain stemming from the position the patient assumed on the op-erating table, which places anatomic and physiologic stresses on the body, are also common. Massage, moist heat, and analgesic medications provide relief. Patient-controlled analgesia may be effective in controlling pain and enabling the patient to ambu-late, cough, and breathe deeply.
The nurse closely monitors urine output and drainage to identify complications and to preserve and protect remaining kidney function (by preventing obstruction and infection). The output from each urinary drainage tube is recorded separately; accurate output measurements are essential in monitoring renal function and ensuring the patency of the urinary drainage system.
Strict asepsis is used when manipulating the drainage catheter and tube. Hand hygiene is mandatory before and after touching any parts of the system. Use of closed drainage systems is essen-tial to avoid contamination of the system and infection. Urinary drainage is monitored closely for changes in volume, color, odor, and components. Urinalysis and urine cultures are indicated to follow the patient’s progress. Care is taken to ensure that the col-lection bag is suspended below the bladder to prevent reflux of urine into the urinary tract. The bag must be kept off the floor to prevent contamination.
Most urinary drainage systems do not require routine irrigation. If irrigation is necessary and prescribed, however, it should be performed carefully, with the use of sterile solution; with minimal pressure, consistent with the physician’s instructions; and with strict asepsis without interruption of the closed drainage system.
Bleeding is a major complication of kidney surgery. If undetected and untreated, bleeding can result in hypovolemia and hemor-rhagic shock. The nurse’s role is to observe for these complica-tions, to report their signs and symptoms, and to administer prescribed parenteral fluids and blood and blood components if complications occur. Monitoring of vital signs, skin condition, urinary drainage system, surgical incision, and level of conscious-ness is necessary to detect evidence of bleeding, decreased circu-lating blood, and fluid volume and cardiac output. Frequent monitoring of vital signs (initially monitored at least at hourly intervals) and urinary output is necessary for early detection of these complications.
If bleeding goes undetected or is late in being detected, the pa-tient may lose significant amounts of blood and may experience hypoxemia. In addition to hypovolemic shock due to hemorrhage, this type of blood loss may precipitate a myocardial infarction or transient ischemic attack. Bleeding may be suspected when the pa-tient experiences fatigue and when urine output is less than 30 mL per hour. As bleeding persists, late signs of hypovolemia occur, such as cool skin, flat neck veins, and change in level of con-sciousness or responsiveness. Transfusions of blood components are indicated, along with surgical repair of the bleeding vessel.
Pneumonia may be prevented through use of an incentive spirometer, adequate pain control, and early ambulation. Early signs of pneumonia include fever, increased heart and respiratory rates, and adventitious breath sounds.
Preventing infection is the rationale for using asepsis when changing dressings and preparing catheters, other drainage tubes, central venous catheters, and intravenous catheters for adminis-tration of fluids. Insertion sites are monitored closely for signs and symptoms of inflammation: redness, drainage, heat, and pain. Spe-cial care must be taken to prevent urinary tract infection, which is associated with the use of indwelling urinary catheters. Catheters and other invasive tubes are removed as soon they are no longer needed.
Antibiotic agents are commonly administered postoperatively to prevent infection. If antibiotic agents are prescribed, serum creatinine and blood urea nitrogen levels must be monitored closely because many antibiotic agents are toxic to the kidney or can accumulate to toxic levels if renal function is decreased.
Preventing fluid imbalance is critical when caring for a patient undergoing kidney surgery, because both fluid loss and fluid excess are possible adverse effects of the surgery. Fluid loss may occur during surgery as a result of excessive urinary drainage when the obstruction is removed, or it may occur if diuretic agents are used. Such loss may also occur with gastrointestinal losses, with diar-rhea resulting from antibiotic use or with nasogastric drainage. When postoperative intravenous therapy is inadequate to match the output or fluids lost, a fluid deficit results. Fluid excess, or overload, may result from cardiac effects of anesthesia, adminis-tration of excessive amounts of fluids, or the patient’s inability to excrete fluid because of changes in renal function. Decreased urine output may be an indication of fluid excess.
Astute assessment skills are needed to detect early signs of fluid excess (such as weight gain, pedal edema, urine output below 30 mL/h, and slightly elevated pulmonary wedge pressure, if available) before they become severe (appearance of adventitious breath sounds, shortness of breath).
Fluid excess may be treated with fluid restriction and admin-istration of furosemide (Lasix) or other diuretic agents. If renal insufficiency is present, these medications may prove ineffective; therefore, dialysis may be necessary to prevent heart failure and pulmonary edema.
Deep vein thrombosis may occur postoperatively because of surgical manipulation of the iliac vessels during surgery. Elastic compression stockings are applied, and the patient is monitored closely for signs and symptoms of thrombosis and encouraged to exercise the legs. Heparin may be administered postoperatively to reduce the risk of thrombosis. Specific nursing interventions for the patient undergoing kidney surgery are presented in the Plan of Nursing Care.
If the patient has a drainage system in place, measures are taken to ensure that both patient and family understand the importance of maintaining the system correctly at home and preventing infec-tion. Verbal and written instructions and guidelines are provided to the patient and family at the time of hospital discharge. The pa-tient may be asked to demonstrate management of the drainage system to ensure understanding. The importance of strategies to prevent postoperative complications (urinary tract infection and obstruction, deep vein thrombosis, atelectasis, and pneumonia) is stressed to the patient and family. Those signs, symptoms, prob-lems, and questions that should be referred to the physician or other primary health care provider are reviewed by the nurse with the patient and family.
The need for postoperative assessment and care after renal surgery continues regardless of setting: the home, subacute care unit, out-patient clinic or office, or rehabilitation setting. Referral for home care is indicated for the patient going home with a urinary drainage system in place. During the home visit, the home care nurse re-views the instructions and guidelines given to the patient at hospi-tal discharge. The nurse assesses the patient’s ability to carry out the instructions in the home and answers questions that the patient or family has about management of the drainage system and the surgical incision.
Additionally, the home care nurse obtains vital signs and as-sesses the patient for signs and symptoms of urinary tract infection and obstruction. The nurse also ensures that pain is adequately controlled and that the patient is complying with recommenda-tions. The home care nurse encourages adequate fluid intake and increased levels of activity. Together the nurse, patient, and family review the signs, symptoms, problems, and questions that should be referred to the physician or other primary health care provider. If the patient has a drainage tube in place, the nurse assesses the site and the patency of the system and monitors the patient for com-plications, such as deep vein thrombosis, bleeding, or pneumonia.
Because it is easy for the patient, family, and health care team to focus on the patient’s immediate disorder to the exclusion of other health issues, reminding the patient and family about the importance of participating in health promotion activities, in-cluding health screening, is key.
Expected patient outcomes may include:
1) Achieves effective airway clearance
a) Exhibits clear and normal breath sounds, normal respi-ratory rate, and unrestricted thoracic excursion
b) Performs deep-breathing exercises, coughs every 2 hours, and uses the incentive spirometer as directed
c) Demonstrates normal temperature and vital signs
2) Reports progressive decrease in pain
a) Requires analgesic medications at less frequent intervals
b) Turns, coughs, and takes deep breaths as suggested
c) Ambulates progressively
3) Maintains urinary elimination
a) Demonstrates unobstructed urine flow from drainage tubes
b) Exhibits normal fluid and electrolyte balance (normal skin turgor, serum electrolyte levels within normal range, absence of symptoms of imbalances)
c) Reports no increase in pain, tenderness, or pressure at drainage site
d) Exhibits cautious handling of drainage system
e) Uses hand hygiene before and after handling drainage system, and handles it only when necessary
f) States rationale for use and maintenance of a closed drainage system
4) Participates in self-care activities
5) Experiences no complications
a) Demonstrates normal vital signs and arterial and cen-tral venous pressures, normal skin turgor, temperature, and color
b) Exhibits no signs or symptoms of bleeding, shock, or hypovolemia (eg, decreased urine output, restlessness, rapid pulse)
c) Exhibits no signs or symptoms of infection (eg, fever or pain) or evidence of deep vein thrombosis (tenderness or redness of calves)
d) Maintains normal fluid balance, without rapid weight gain or loss
e) Has clear breath sounds and no shortness of breath
6) Excretes urine at a rate of at least 30 mL per hour
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