758 UNIT VII / Responses to Altered Urinary Elimination
NURSING CARE OF CLIENT HAVING A NEPHRECTOMY
PREOPERATIVE CARE • Provide the following home care instructions for the client
• Provide routine preoperative care as outlined in Chapter 7. and family.
• Report abnormal laboratory values to the surgeon. a. Teach the importance of protecting the remaining kid-
Bacteriuria, blood coagulation abnormalities, or other signifi- ney by preventing UTI, renal calculi, and trauma. See
cant abnormal values may affect surgery and postoperative Chapter 26 for measures to prevent UTI and calculi.
care. Damage to the remaining kidney by UTI, renal calculi, or
• Discuss operative and postoperative expectations as indi- trauma can lead to renal failure.
cated, including the location of the incision (Figure 27–4) and b. Maintain a fluid intake of 2000 to 2500 mL per day. This
anticipated tubes, stents, and drains. Preoperative teaching important measure helps prevent dehydration and main-
about postoperative expectations reduces anxiety for the client tain good urine flow.
and family during the early postoperative period. c. Gradually increase exercise to tolerance, avoiding heavy
lifting for a year after surgery. Participation in contact
POSTOPERATIVE CARE sports is not recommended to reduce the risk of injury
to the remaining kidney. Lifting is avoided to allow full tis-
• Provide routine postoperative care as described in Chapter 7. sue healing. Trauma to the remaining kidney could seri-
• Frequently assess urine color, amount, and character, noting ously jeopardize renal function.
any hematuria, pyuria, or sediment. Promptly report oliguria d. Teach care of the incision and any remaining drainage
or anuria, as well as changes in urine color or clarity. Preserving tubes, catheters, or stents. This routine postoperative in-
function of the remaining kidney is critical; frequent assessment struction is vital to prepare the client for self-care and pre-
allows early intervention for potential problems. vent complications.
• Note the placement, status, and drainage from ureteral e. Instruct to report signs and symptoms to the physician,
catheters, stents, nephrostomy tubes, or drains. Label each including manifestations of UTI (dysuria, frequency, ur-
clearly. Maintain gravity drainage; irrigate only as ordered. gency, nocturia, cloudy, malodorous urine) or systemic
Maintaining drainage tube patency is vital to prevent potential infection (fever, general malaise, fatigue), redness,
hydronephrosis. Bright bleeding or unexpected drainage may in- swelling, pain, or drainage from the incision or any
dicate a surgical complication. catheter or drain tube site. Prompt treatment of postoper-
• Support the grieving process and adjustment to the loss of a ative infection is vital to allow continued healing and pre-
kidney. Loss of a major organ leads to a body image change and vent compromise of the remaining kidney.
grief response. When renal cancer is the underlying diagnosis,
the client may also grieve the loss of health and potential loss
of life.
are removed. Regional lymph nodes may also be resected. Al- Costal blocks, patient-controlled analgesia (PCA), or routine
though nephrectomy can be done using a laparoscopic approach, analgesic administration can effectively relieve the discomfort.
laparotomy primarily is used for radical nephrectomy. Nursing Nursing care focuses on assessing pain relief, providing sup-
care for the client having a nephrectomy is summarized above. portive measures to enhance analgesia, and ensuring that pain
No effective treatment is available for advanced renal carci- or the fear of pain does not lead to respiratory complications.
noma with metastases. Biologic therapies such as interferon
or interleukin-2 have been used, but rarely achieve a durable ef- • Assess frequently for adequate pain relief. Use a standard
fect. No chemotherapy drug consistently causes tumor regres- pain scale and nonverbal signs such as grimacing, tense body
sion in > 20% of clients (Braunwald et al., 2001). position, apparent dozing, elevated pulse, change of blood
pressure, or rapid, shallow respirations. Notify the physician
of inadequate pain relief. The client may assume that pain is
Nursing Care to be expected or may fear becoming addicted to analgesics.
Careful questioning and assessment allow effective pain
Nursing Diagnoses and Interventions management. Responses to analgesics are individual, and
Nursing care for the client with renal cancer focuses on needs re- the prescribed dose may need to be adjusted.
lated to the cancer diagnosis and to the surgical intervention. Post- • Assess the incision for inflammation or swelling and
operative pain may be significant and the risk for respiratory com- drainage catheters and tubes for patency. An obstructed
plications is high. The remaining kidney must be protected from catheter can lead to hydronephrosis, hematoma, or abscess,
damage to preserve renal function. Psychologically, the client increasing incisional pain.
may grieve the loss of a major organ and the diagnosis of cancer.
Pain PRACTICE ALERT Assess for adominal distention, tender-
The size and location of the incision used for a radical nephrec- ness, and bowel sounds. Intra-abdominal bleeding, peritonitis, or para-
tomy (Figure 27–4 ■) make pain management a challenge. lytic ileus can cause pain that may be confused with incisional pain. ■
