Kidney Surgery

FP: Kidney SurgeryNs. Heri Kristianto, MKep.,Sp.Kep.MBA patient may undergo surgeryto remove obstructions that affect the kidney (tumors or calculi)to insert a tube for draining the kidney (nephrostomy, ureterostomy)to remove the kidney involved in unilateral kidney disease, renal carcinoma, or kidney transplantation.PREOPERATIVE CONSIDERATIONSevaluation of renal functionFluids are encouraged to promote increased excretion of waste products before surgeryIf kidney infection wide-spectrum antimicrobial agents may be prescribed to prevent bacteremiaCoagulation studies (prothrombin time, partial thromboplastin time, platelet count)EducationAnxietyConfidence is reinforced by establishing a relationship of trust and by providing expert careDialysis It is important to teach the patient and family that normal function may be maintained by a single healthy kidney.PERIOPERATIVE CONCERNSRenal surgery requires various patient positions to expose the surgical site adequately. Three surgical approaches are common: flank, lumbar, and thoracoabdominal

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.

POSTOPERATIVE MANAGEMENTHemorrhage and shock Fluid and blood component replacement is frequently necessary in the immediate postoperative period to treat intraoperative blood lossAbdominal distention and paralytic ileusIf infection occurs, antibiotic agents are prescribed after a culture reveals the causative organismLow-dose heparin therapy may be initiated postoperatively to prevent thromboembolism in patients who had any type of urologic surgery

Drainage TubesAlmost 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 ureterNephrostomy DrainageNephrostomy merupakan salah satu bentuk dari therapeutic puncture site yang bertujuan mengeluarkan urine dari ginjal. Prosedur ini dilakukan karena adanya sumbatan pada ureter sehingga urine tidak bias keluar menuju bladder. Selain untuk pengeluaran urine nephrostomy juga dilakukan untuk mengeluarkan batu dari ginjalJenisPercutaneous Nephrostomy Tube (PNT) PNT adalah sistem pengeluaran urine dengan kateter yang dimasukkan dalam ginjal (nephron). Pemasangan PNT dilakukan secara invasif diruang operasi.Nephro-Uretero Stent (NES)NES adalah sistem pengeluaran urine dengan menggunakan kateter yang dimasukkan ke dalam ginjal sampai dengan bladderPercutaneous Nephrostomy Tube

Nephro-Uretero Stent

Permanent nephrostomy tubes are usually changed every 3 months.

Before procedureBroadspectrum antibiotic to prevent infection. Bleeding disorders and uncontrolled hypertension should be corrected.Anticoagulant 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 developing a perirenal hematoma or renal hemorrhage. ProcedureThe skin site is prepared and anesthetizedThe 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 needle 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

Ureteral StentsA ureteral stent is a self-retaining tubular device that helps maintain 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 includeInfectioninflammation secondary to a foreign body in the genitourinary tractBleedingClot obstruction within the stentMigration or displacement of the stentIndikasiRelief of ureteral obstruction (stones, cancer, stricture) and provide drainage;Promote healing of the ureter by providing internal support aftera ureteral procedure or anastomotosis;Prevent potential complications by helping place a guidewire into the ureter;Assist in dilating the ureter before the next ureteroscopy;Bypass obstructions, either frominternal or external causes;

ProcedureUnder general anesthesia in a cystoscopy suite, the ureteroscope is introduced into the bladder through the urethra;The ureteral orifice is identified and an open ended stent is intoduced into the orifice;A flexible guide wire can be used to pass the stent up into the bladder, under direct vision through a cystoscope or under fluoroscopic guidance;The guidewire is removed after documenting the stent is in the proper position;

Stent Removal:Remove in 2-3 days after ureteroscopy in uncomplicated cases;Remove in 1-2 weeks in cases of ureteral perforation or persisting concern of obstruction;Can beremoved in the office with topical anesthesia with a flexible ureteroscope and grasper;Can be removed in the cysto suite under anesthesia for patients unable to tolerate topical anesthesia;If required for long term use (extrinsic compression by tumor, stricture), stents should be changed every 6 months

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.Jenis stent

Double pigtail

double-J ureteral stent

NC: Kidney SurgeryNs. Heri Kristianto, MKep.,Sp.Kep.MBAssessmentassessment of all body systemsrespiratory and circulatory statuspain levelfluid and electrolyte statuspatency and adequacy of urinary drainage systemsRESPIRATORY STATUSAnesthesia risk of respiratory complicationsRespiratory status is assessed by monitoring the rate, depth, and pattern of respirations. The location of the incision frequently causes pain on inspiration and coughing; therefore, thepatient tends to splint the chest wall and take shallow respirations.Auscultation is performed to assess normal and adventitious breath soundsCIRCULATORY STATUS AND BLOOD LOSSThe vital signs and arterial or central venous pressure (CVP) are monitored.Skin color and temperature and urine output provide information about circulatory status.The surgical incision and drainage tubes are observed frequently to help detect unexpected blood loss and hemorrhage.PAINPostoperative 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.URINARY DRAINAGEUrine output and drainage from tubes inserted during surgery are monitored for amount, color, and type or characteristics. Decreased or absent drainage is promptly reported to the physician because it may indicate obstruction that could cause pain, infection, and disruption of the suture lines.NURSING DIAGNOSESIneffective airway clearance related to the location of the surgical incisionIneffective breathing pattern related to surgical incision and general anesthesiaAcute pain related to the location of the surgical incision, the position the patient assumed on the operating table during surgery, and abdominal distentionUrine retention related to pain, immobility, and anesthesiaCOLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONSBleedingPneumoniaInfectionFluid disturbances (deficit or excess)Deep vein thrombosisPlanning and GoalsThe major goals for the patient include maintenance of effectiveairway clearance and breathing patternrelief of pain and discomfortmaintenance of urinary eliminationabsence of complicationsNI: MAINTAINING AIRWAY CLEARANCE AND BREATHING PATTERNSAdequate 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 patient 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 secretionsNI: RELIEVING PAINMassageMoist heatAnalgesic medications provide relief. Patient-controlled analgesia may be effective in controlling pain and enabling the patient to ambulate, cough, and breathe deeplyNI: PROMOTING URINARY ELIMINATIONMonitors 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: hand hygiene, closed drainage systemsUrinalysis and urine culturesThe bag must be kept off the floor to prevent contaminationMost urinary drainage systems do not require routine irrigation.Irrigation : sterile solution; with minimal pressure, consistent with the physicians instructions; and withstrict asepsis without interruption of the closed drainage system.BleedingThe nurses role is to observe for these complications, 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 consciousness is necessary to detect evidence of bleeding, decreased circulating blood, and fluid volume and cardiac output. Bleeding may be suspected when the patient 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 consciousness or responsiveness. Transfusions of blood components are indicated, along with surgical repair of the bleeding vessel.PneumoniaIncentive spirometer, adequate pain control, and early ambulation.Early signs of pneumonia include fever, increased heart and respiratory rates, and adventitious breath sounds.Fluid imbalancedFluid 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 diarrhea 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, administration of excessive amounts of fluids, or the patients inability to excrete fluid because of changes in renal function. Decreased urine output may be an indication of fluid excess.EvaluasiAchieves effective airway clearanceExhibits clear and normal breath sounds, normal respiratory rate, and unrestricted thoracic excursionPerforms deep-breathing exercises, coughs every 2 hours, and uses the incentive spirometer as directedDemonstrates normal temperature and vital signsReports progressive decrease in painRequires analgesic medications at less frequent intervalsTurns, coughs, and takes deep breaths as suggestedAmbulates progressivelyMaintains urinary eliminationDemonstrates unobstructed urine flow from drainageTubesExhibits normal fluid and electrolyte balance (normal ) skin turgor, serum electrolyte levels within normal range, absence of symptoms of imbalances)Reports no increase in pain, tenderness, or pressure at drainage siteExhibits cautious handling of drainage systemUses hand hygiene before and after handling drainage system, and handles it only when necessaryStates rationale for use and maintenance of a closed drainage systemExperiences no complicationsDemonstrates normal vital signs and arterial and central venous pressures, normal skin turgor, temperature, and colorExhibits no signs or symptoms of bleeding, shock, or hypovolemia (eg, decreased urine output, restlessness, rapid pulse)Exhibits no signs or symptoms of infection (eg, fever or pain) or evidence of deep vein thrombosis (tenderness or redness of calves)Maintains normal fluid balance, without rapid weight gain or lossHas clear breath sounds and no shortness of breathExcretes urine at a rate of at least 30 mL per hourStudi Kasus & SimulasiKasus Kidney InjurySkenario AskepSimulasi Video(tiap kelompok ambil 1 tindakan keperawatan)