Kidney surgery

1. Kidney surgery • Kidney surgeries are undergone to • Remove obstruction: tumors and calculi • Insert tube for draining (nephrostomy, urterostomy) • Remove kidney, nephrectomy • Kidney transplantation

2. Preoperative consideration • Assess and maintain renal function • Encourage fluid intake to remove waste products, unless contraindicated • Manage infection, antibiotics with extreme care because they are toxic • Coagulation studies: PT, PTT, Platelet counts, if has history of bleeding • Assist patients to express concerns; reinforce confidence • Perioperative concerns: • Flank approach; Lumber approach; Thoracoabdominal approach (figure 44-10, P. 1553) • Read Nursing Care Plan for Kidney Surgery. Chart 44-9, P. 1555-1558.

3. Postoperative management • Immediate postoperative care • Respiratory status; Circulatory status; Pain • Hemorrhage and shock are chief complications • Fluid & blood replacement is necessary immediately after surgery; to manage intra-operative loss • Abdominal distention & paralytic ileus are common due to: reflex paralysis of peristalsis; manipulation of colon • Relieved by decompression through nasogastric tube • Oral fluid are permitted when passage of flatus is noted • Infection, culture and antibiotic; consider nephrotoxicity • Low-dose heparin, to prevent thromboembolism

4. Postoperative assessment • Assess respiratory • Location of incision-causes pain on inspiration & coughing • Lung sounds, rate, pattern of breathing • Cardiovascular status: • VSs arterial blood pressure CVP • Skin color & temperature, urine out put • Surgical incision & drainage tubes for evidence of bleeding • Pain: incisional pain, abdominal distention--discomfort • Patency and adequacy of urinary drainage system • Decreased or absent drainage should be promptly reported

5. Nursing diagnoses • Ineffective airway clearance • Ineffective breathing pattern • Acute pain • Urine retention related to pain, immobility, anesthesia • Potential complications • Bleeding • Pneumonia • Infection • Fluid disturbances • Deep vein thrombosis

6. Nursing interventions • Maintaining airway clearance and breathing pattern • Relieve pain: Patient controlled analgesia • Promoting urinary elimination • Monitor urine output & drainage • Accurate record fluid from each tube separately • Strict asepsis when manipulating tubes, drainage system • Hand hygiene before touching any part of the system • Use closed drainage system to avoid contamination • Assess drainage volume, color; urine analysis and culture • Urinary bag below bladder and off the floor; irrigation performed carefully with a sterile solution

7. Monitoring & managing potential complications • Bleeding: monitoring; suspected if urine output is less than 30 ml/hr and fatigue • Pneumonia—incentive spirometer • Infection: prevention and monitoring • Fluid imbalance: observe for Wt gain, edema, urine below 30 ml /hr, adventitious sound • Fluid excess—fluid restriction; give lasix; dialysis may be needed • DVT: elastic compression stockings, monitoring symptoms of thrombosis; leg exercise, heparin • Read Chart 44-12, PP. 1348-1350

8. Catheterization Purpose • Relieve urinary tract obstruction • Assist with postoperative drainage • Mean to monitor accurate urine output • Promote drainage in patients with NB dysfunction or urine retention • Prevent urinary leakage in stages III, IV of pressure ulcer Complications: • UTI • Bladder spasm • Uretheral stricture • Pressure necrosis

9. Catheterization • Indwelling catheter; • Use closed drainage system • In transuretheral prostate surgery; the most common is triple lumen catheter; attached to sterile closed drainage system • Bacteria may enter from the port of the urinary bag; keep the bag below the bladder, minimize the risk of contamination • Suprapubic catheter: A measure to divert urine from urethera • To remove: clamp the catheter for 4 hrs; patients void; measure residual; if less than 100ml in 2 occasions, morning and evening; remove catheter • Require fluids to prevent encrustation, wound-ostomy care • Problems: bladder stone, infection,

10. Nursing management during catheterization Assessing patient and the system • Assess drainage system, color, odor, and volume of urine • Accurate intake & output • Observe the catheter position, no necrosis • Assess for signs of UTI infection; hematuria, fever, anorexia in high risk population Prevent infection • Gentle cleansing to remove encrustation • Fluid intake • Urine culture; • see chart 45-10 P. 1374

11. Nursing management Minimizing trauma • Use appropriate size • Adequate lubrication • Insert far in the bladder • Secure the catheter properly • Minimize manipulation • Prevent pressure on urethera • Consider confused patients

12. Nursing managementbladder retraining • During catheterization: • Detrusor does not actively contract the bladder • Detrusor does not respond to bladder filling, when catheter is removed—result in retention or incontinence • Known as post catheterization detrusor instability • management: Retraining of the bladder; void every 2-3 hrs; • Then measure residual urine; using portable ultrasonic bladder scanner; if not completely empty—immediate cath; take few days; see chart 45-10, P1589. • Intermittent self-catheterization in spinal cord injury • Patient teaching: Use of septic technique • Every 4-6 hrs, and just before the bed time. Read p1375.

13. Lower urinary tract infection • Bladder sterility is maintained by • Physical barrier of urethera; urine flow • Competence of Ureterovesical junction • Antibacterial enzymes & antibodies • Antiadherent effects of mucosal cells of bladder • Infection • Bacteria must gain access and colonize epithelium of the urinary tract, to avoid washed out with voiding • Many UTIs results from fecal organisms that ascend from perineum

14. UTI • Glycosaminoglycan, a hydrolic protein, has nonadherent protective effect, it forms a water barrier that serves as a defensive layer between urine and the bladder • Urethrovesical reflux: backflow of urine to the bladder—by negative pressure; effect of sneezing • Ureterovesical reflux, when impaired, bacteria may reach kidneys • Uropathogenic: Bacteriuria is 105 colonies of bacteria per milliter of urine—clean-catch midstream—distinguishes bacteriuria from contamination in women • In men, bacteriuria is 104

15. LUTI • ROUTES OF INFECTION • Transuretheral, ascending infection, most common—fecal contamination, sexual intercourse • Hematogenous, blood stream • Dierect extension, fistula from intestine • Assessment / Clinical manifestations: • 50% report no symptoms; in noncomplicated • Cystitis: Burning urination; frequency; urgency; nocturia • Incontinence; suprapubic or pelvic pain, hematuria; • Complicated: may develop septic shock • Urine culture

16. LUTI management • Acute pharmacological therapy • Antibiotics with minimal effects on fecal or vaginal flora • Thereby; minimizes the incidence of vaginal yeast infection; yeast viginities • The trends is to shorten the course of therapy, an average 3 days. • In institutional case 7-10 days, in complicated Cephlosporin • Read p. 1574 for antibiotcs use in UTI • Instruct to take the doses prescribed • Long-term doses for pyelonephritis, • hospitalizationand IV are occasionally necessary

17. LUTI management • Long term pharmacological therapy: • With short-term therapy relapse may occur in 20%; • relapse may be due to • upper UTI , source of infection • Treatment is inadequate; • Administered for a short period • Reinfections with new bacteria occurs in 90% in women

18. Relapse- management • If no pathological abnormalities: • Women is instructed to use antibiotics on their own when symptoms occurs and; To consult healthcare providers • When symptoms persist; Fever occurs • No. of treatment episodes exceeds 4 in 6 months • If infection recurs after completing the course, another short course (3-4 days) of full dose, followed by a regular bedtime dose • If no recurrence, every other night for 6-7 months • Preventive therapy after sterilization of urine, trimethoprim at bedtime • Inconclusive evidence about the effect of cranberry juice

19. LUTI Nursing Interventions • Relieving pain • Relieved once antibiotics are initiated; • Antispasmodic to relieve bladder irritability • Analgesics and application of heat to the perineum • Liberal amounts of fluids, water, to promote blood flow and wash bacteria • Avoid urinary tract irritants, alcohol, coffee, tea, cola • Encourage frequent voiding, every 2-3hrs

20. LUTI Nursing Interventions • Monitoring and managing potential complications • Goal of early treatment is to prevent renal failure; and other complications: urosepsis, strictures, obstructions • Teach a prompt recognition of early symptoms; test for bacteriuria, initiate medications as prescribed • Avoid urinary catheter; if necessary specific nursing intervention to prevent infection p. 1577 • Assess vital signs, blood test culture, WBCs

21. Upper urinary tract infection • Pylonephritis is a bacterial infection of renal pelvis, tubules, interstitial tissue of one or both kidneys • Causes; ascending bacteria or systemic circulation • Obstruction or incompetent ureterovesical reflux increases the susceptibility • Acute: enlarged kidney, interstitial infiltration of inflammatory cells; abscesses on the renal capsule and at corticomedullary junction; • Eventually, atrophy and destruction of tubules and glomeruli may occur • Chronic: kidney becomes scarred, contracted and non-functioning; a cause of CKD

22. Acute pyleonephritis • Assessment: • The patient is acutely ill with chills, fever, leukocytosis, bacteriuria, pyuria • Low back pain, flank pain, nausea and vomiting, headache, malaise, painful urination • Pain and tenderness in costovertebral angle • Urgency & frequency in urination • CT to locate any obstruction • Blood, WBCs; urine culture

23. Acute Pyelonephritis • Medical management • On outpatient basis, if no dehydration, symptoms of sepsis • Be sure that drugs are taken as prescribed • A 2-week course of antibiotic: ciprofloxacin, gentamicin with or without ampicillin; • Hospitalization for pregnant women for parenteral antibiotics; and oral medications once the patient is afebrile, showing clinical improvement • 6-month of antibiotic if recurs, with urine culture 2 weeks after completion of antibiotic • Hydration to flush urinary tract

24. Chronic pyelonephritis • Assessment: • May has no symptoms unless acute exacerbations occur • Noticeable symptoms, fatigue, headache, polyuria, excessive thirst, poor appetite, Wt. loss • IV urogram, creatinine clearance, blood BUN, creatinine level, bacteria in urine • Complications: ESRD, hypertension, stones • Management: long-term prophylactic antimicrobial with careful evaluation of kidney function

25. Nursing management • Careful evaluation of renal function • Intake and output • Unless contraindicated 3-4 L of fluid / day • Assess temp ever 4 hrs and give antipyretic • Bed rest • Teaching about infection prevention by • Fluid intake • Perineal hygiene • Regular urination • Stress importance of medications