Staghorn Calculi, Left Kidney

A Case Presentation Presented to

The Faculty of the College of Nursing and School of Midwifery
BAGUIO CENTRAL UNIVERSITY

In Partial Fulfillment
Of the Requirements for the
Degree of Bachelor of Science in Nursing

Liza M. Puroc

DECEMBER 2021
 I. PATIENTS PROFILE
Name: Ferlina Baiwes
Age: 29 years old
Sex: Female
Civil status: Single
Address: Buguias, Benguet
Occupation: N/A
Nationality: Filipino
Religion: Roman Catholic
Date and time of Admission: December 5, 2021 3:40 pm
Ward & Bed no: Surgery ward Room 411-C
Admitting Diagnosis: Staghorn Calculi, Left kidney
Chief complaints: Left flank pain on and off for 6 months
Status: Post op (Open Nephrolithotomy) combined epidural and open renal
stone surgery with endotracheal anesthesia

II. HISTORY OF PRESENT ILLNESS 

The patient presented to the hospital with complaints of left flank pain on and off
for 6 months

III. 13 AREAS OF ASSESSMENT/ REVIEW OF SYSTEM 

I. Psychosocial Status
Patient Ferlina Baiwes, a female and is 29 years old and from Buguias, benguet.
As a catholic, she has a strong belief that God can intervene in his recovery and be
back as to how her daily activity was.

II. Mental and Emotional Status

With regards to his level of consciousness, she is alert and responds a wide range
of stimuli. She has a good intellectual development. She can easily understand
and follow instructions and has the ability to comprehend.

III. Environmental status

She has an appropriate state of mobility to her age and aware of the potential
danger hazard. She has no sensory deficit and is properly oriented to time and
place. Patient and family members has no any history of any infectious disease as
evidenced of their negative RTC-PCT test. Her resting moment is quite disturbed
duet to taking of her vital signs.
 IV. Sensory Status
Vision: She has the ability to distinguished objects or persons wwihtout using
any correctibe device
Hearing : She can also distinguish voice even from a distance, loud or soft. No
corrective auditory deficits. And no auditory device noted being used by the
patient
Smell: The patient is able to discriminate an odor from the other
Taste: The patient is able to discriminate sweet, sour, salty and bitter tastes from
each other
Tactile: She was able to determine and discriminate sharp and dull, light and
firm touch, able to perceive heat, cold, pain in proportion to stimulus, able to
differentiate common objects by touch by doing necessary procedure

V. Motor status
In general, all body parts are well coordinated and he can move with ease, but
with limited movement especially in her incision site.

VI. Nutritional Status

Prior to admission, patient consumes full meal 3x a day. Shee eats meals on time
and a balanced diet.
During hospitalization, he was instructed with a full diet

VII. Elimination Status

She was inserted with an IFC. No pain felt during urination and defecation.

VIII. Fluid and Electrolytes Status

Prior to admission, she has a good skin turgor that indicates good hydration. He
usually consumes 3L of fluid a day. She has no signs of dehydration and fluid
overload.
She has an ongoing IVF of PLRS x 1L regulated at 31 to 32 gtts/min.

IX. Circulatory Status

The cardiac rate of patient L.M ranges from 75-92beats per minute. During the
rotation there is no abnormal cardiac rate noted. The normal cardiac rate of an
adult is 60-100 bpm.

December 9, 2021 Cardiac Rate

8 am 75 bpm NORMAL
12 pm 84 bpm NORMAL
December 10, 2021
8 am 88 bpm NORMAL
 12 pm 92 bpm NORMAL
December 11, 2021
8 am 89 bpm NORMAL
12 pm 88 bpm NORMAL

X. Respiratory Status
The table below shows the patient’s respiratory rate ranging from 13-20 cycles
per minute are all in normal as 12-20 cycles is the normal. The oxygen saturation
ranges from 96%-98% where the normal value for oxygen saturation is 95%-
100%.

December 9, 2021 Respiratory Oxygen

Rate saturation
8 am 21 cpm NORMAL 96% NORMAL
12 pm 19 cpm NORMAL 97% NORMAL
December 10, 2021
8 am 21 cpm NORMAL 96 % NORMAL
12 pm 20 cpm NORMAL 96% NORMAL
December 11, 2021
8 am 21 bpm NORMAL 95% NORMAL
12 pm 16 bpm NORMAL 97% NORMAL

XI. Temperature Status

During the rotation patient f.Baiwes is afebrile. No sign of profuse sweating
noted.

December 9, 2021 Temperature

8 am 36.6 NORMAL
12 pm 36.3 NORMAL
December 10, 2021
8 am 36.5 NORMAL
12 pm 36.8 NORMAL
December 11, 2021
8 am 36.8 NORMAL
12 pm 36.4 NORMAL

XII. Integumentary Status

The skin is warm to touch. No lesion and cracks and no signs of inflammation
and bruises. Just the incision site with a new dressing.
XIII. Rest and Sleep Pattern

She uses diversional activities such as conversing to his mom and by using her
cellphone. She has a comforting rest periods and sleep regardless of the regular
checking of her vital sign. She was ordered with complete bed rest without
bathroom privileges.

ANATOMY AND PHYSIOLOGY

(AS BACKGROUND KNOWLEDGE)
The kidneys are a pair
of organs located in the
back of the abdomen.
Each kidney is about 4
or5 inches long --
about the size of a fist.

PARTS OF THE
KIDNEY
Renal hilus:
 The renal hilus is an
indentation near to
the centre of the
concave area of the
kidney.This is the
area of the kidney
through which the
ureter leaves the
kidney and the
otherstructures
including blood
vessels (illustrated),
lymphatic vessels,
and nerves
enter/leavethe
kidney.

Renal capsule:
 The renal capsule is a smooth, transparent, fibrous membrane that surrounds,
encloses, and protects the kidney. Each kidney has it's own renal capsule
(outer layer), which helpsto maintain the shape of the kidney as well as
protecting it from damage.The renal capsule is itself surrounded by a mass of
fatty tissue that also helps to protectthe kidney by damage by cushioning it in
cases of impact or sudden movement.
Renal cortex:
 The renal cortex is the outer part of the kidney and has a reddish colour
(shown as verypale brown above). It has a smooth texture and is the location
of the Bowman's Capsules and the glomeruli, in addition to the proximal and
distal convoluted tubules and theirassociated blood supplies (these structures
are part of the kidney nephrons - describedin further detail on the page
about  kidney nephrons).

Renal medulla:
 The renal medulla is the inner part of the kidney. "Medulla" means "inner
portion". Thisarea is a striated (striped) red-brown colour.

Renal pyramids:
 There are approx. 5 - 18 striated triangular structures called "Renal Pyramids"
within therenal medulla of each kidney. The apperance of striations is due to
many straight tubulesand blood vessels within the renal pyramids.

Renal pelvis:
 The renal pelvis is the funnel-shaped basin (cavity) that receives the urine
drained fromthe kidney nephrons via the collecting ducts and then the (larger)
papillary ducts..

Renal artery:
 The renal artery delivers oxygenated blood to the kidney. This main artery
divides intomany smaller branches as it enters the kidney via the renal hilus.
These smaller arteriesdivide into vessels such as the segmental artery, the
interlobar artery, the arcuate arteryand the interlobular artery. These
eventually seperate into afferent arterioles, one ofwhich serves each nephronin
the kidney.

Renal vein:
 The renal vein receives deoxygenated blood from the peritubular veins within
the kidney.These merge into the interlobular, arcuate, interlobar and
segmental veins, which, in turn,deliver deoxygenated blood to the renal vein,
through which it is returned to the systemicblood circulationsystem.

Interlobular artery:
 The interlobular artery delivers oxygenated blood at high pressure to the
glomerularcapillaries.

Interlobular vein:
 The interlobular vein receives deoxygenated blood (at lower pressure) that it
drains awayfrom the glomerular filteration units and from the Loops of Henle.

Kidney nephron:
 Kidney nephrons are the functional units of the kidneys. That this, it is the
kidneynephrons that actually perform the kidney's main functions. There are
approx. a millionnephrons within each kidney. To find out more about these,
visit the page about KidneyNephrons. 
 h
m
k
I
u
w
L
D
x
S
g
A
s
r
t
c
e
l
b
a
f
i
d
M
-
n
o
N
IV.
Collecting Duct (Kidney):
 The collecting duct labelled in the diagram above is part of the kidney nephron

Ureter:
shownmuch enlarged). The distal convoluted tubules of many nephrons empty
into a single collecting duct. Many such collectingducts unite to drain urine
extracted by the kidney into papillary ducts, then into a minorcalyx, then the
major calyx (at the centre of the kidney), and finally into the ureter
throughwhich the urine leaves the kidney en-route to the urinary bladder.

 The ureter is the structure through which urine is conveyed from the kidney to
the urinarybladder.

PATHOPHYSIOLOGY
V. LABORATORY FINDINGS 
LABORATORY TEST NORMAL VALUES ABNORMAL INTERPRETATION
FINDINGS
BLOOD TEST 4%-5.6% WITHIN NORMAL
RANGE

APPTT 30-40 seconds WITHIN NORMAL

Activated Partial RANGE
Thromboplastin Clotting
Time
Creatinine 0.7-1.3 mg/dl WITHIN NORMAL
RANGE

Potassium 3.6-5.2 mmol/l WITHIN NORMAL

RANGE

Sodium 135-145 meq/l WITHIN NORMAL

RANGE

PTPA 11-13.5 seconds WITHIN NORMAL

Prothrombin time RANGE

DIAGNOSTIC DESCRIPTION FINDINGS NURSING

TEST RESPONSIBILITIES
Chest xray Chest X-rays is a Normal Chest Findings Before Chest X-ray:
painless, non-  Remove all
invasive test and is metallic
the most commonly objects. Items
preferred diagnostic such as jewelry,
examination to pins, buttons
produce images of etc can hinder
heart, lungs, the
airways, blood visualization of
vessels and the the chest.
bones of the spine  No preparation
and chest is
Used to diagnose required. Fastin
pulmonary diseases
and disorder of g or medication
mediastinum. And restriction is
bony thorax, to not needed
evaluate heart unless directed
condition by the health
care provider.
 Ensure the
patient is not
pregnant or
suspected to be
pregnant. X-
rays are usually
not
recommended
for pregnant
women unless
the benefit
outweighs the
risk of damage
to the mother
and fetus.
 Assess the
patient’s ability
to hold his or
her
breath. Holding
one’s breath
after inhaling
enables the
lungs and heart
to be seen more
clearly in the x-
ray.
 Provide
appropriate
clothing. Patien
ts are instructed
to remove
clothing from
the waist up
and put on an
X-ray gown to
wear during the
procedure.
 Instruct patient
to cooperate
during the
procedure. The
patient is asked
to remain still
because any
 movement will
affect the clarity
of the image.
After Chest X-ray
 No special
care. Note that
no special care
is required
following the
procedure
 Provide
comfort. If the
test is
facilitated at the
bedside,
reposition the
patient
properly.
Ultrasound The process of Small hepatic BEFORE procedure:
imaging deep hyperochoic-focus, R  Before an
structures of the lobe probably a ultrasound, the
body by measuring hemangioma patient needs a
and recording the Mltiple good
reflection of pulsed nephrolithiasis(staghorn explanation of
or continuous high- calculi) with mild what will
frequency sound hydronephrosis happen. Also
waves. It is valuable Functional cyst, right tell her that it is
in many medical ovary safe for the
situations, including husband to
the diagnosis of fetal remain in the
abnormalities, room during
gallstones, heart the test.
defects, and tumors.  To ensure that
Also the patient has
called sonography a full bladder at
the time of the
procedure, she
should drink a
full glass of
water every 15
minutes
beginning an
hour and a half
before the
procedure.
 Instruct the
patient to void
before the
procedure.
 DURING
procedure:
 Explain to
patient the
procedure and
its purpose.
 The ultrasound
technician may
apply a clear gel
to the skin in
order to hlp the
transducer
moree freely
over the body
 Ask the patient
to relax while
the procedure is
going on
AFTER procedure:
 Allow the
patient to void.

VI. DRUG STUDY 

I. She is on a maximum
dose of metformin 1 g
BD, insulin glargine
50 units at night,
Amlodipine
 II. 5mg OD, Captopril
25 mg BD and
Simvastatin 40mg at
nigh
III. She is on a maximum
dose of metformin 1 g
BD, insulin glargine
50 units at night,
Amlodipine
IV. 5mg OD, Captopril
25 mg BD and
 Simvastatin 40mg at
nigh
V. She is on a maximum
dose of metformin 1 g
BD, insulin glargine
50 units at night,
Amlodipine
VI. 5mg OD, Captopril
25 mg BD and
Simvastatin 40mg at
nigh
 VII. She is on a maximum
dose of metformin 1 g
BD, insulin glargine
50 units at night,
Amlodipine
VIII. 5mg OD, Captopril
25 mg BD and
Simvastatin 40mg at
nigh
NAME OF MECHANIS INDICATIO SIDE ADVERSE NURSING
THE DRUG M OF N/ EFFECTS EFFECTS IMPLICATION
ACTION CONTRAIND
ICATION:
GENERIC ACTION:  INDICATIO Gas or Body as a Be aware that patient
NAME:  NSAID that N: bloating. Whole: Back may be at increased risk
Celecoxib exhibits Acute and Sore throat. pain, for CV events, GI
antiinflammat long-term Cold peripheral bleeding; monitor
BRAND ory, analgesic, treatment of symptoms. edema. accordingly.
NAME: and antipyretic signs and Constipation. Increased risk Administer drug with
Celebrex activities. symptoms of Dizziness. of food or after meals if GI
Unlike rheumatoid Dysgeusia. cardiovascular upset occurs.
CLASSIFICA ibuprofen, arthritis and events.  Establish safety
TION inhibits osteoarthritis GI: Abdomina measures if CNS, visual
Anti- prostaglandin Reduction of l pain, disturbances occur.
inflammator synthesis by the number of diarrhea, Arrange for periodic
y NSAIDS inhibiting colorectal dyspepsia, ophthalmologic
cyclooxygenas polyps in flatulence, examination during
e-2 (COX-2), familial nausea.  long-term therapy.
but does not adenomatous CNS: Dizzines If overdose occurs,
inhibit polyposis s, headache, institute emergency
cyclooxygenas (FAP) insomnia.  procedures—gastric
e-1 (COX-1). Management Respiratory:  lavage, induction of
of acute pain Pharyngitis, emesis, supportive
FREQUENC Treatment of rhinitis, therapy.
Y/ DOSAGE/ primary sinusitis, URI.  Provide further comfort
ROUTES: dysmenorrhea Skin: Rash. measures to reduce pain
200 mg BID Relief of signs (eg, positioning,
PO and symptoms environmental control)
of anklylosing and to reduce
spondylitis inflammation (eg,
Relief of signs warmth, positioning, and
and symptoms rest).
of juvenile Take drug with food or
rheumatoid meals if GI upset occurs.
arthritis Take only the prescribed
dosage; do not increase
CONTRAIND dosage.
ICATION: You may experience
Hypersensitivi these side effects:
ty including Dizziness, drowsiness
those in whom (avoid driving or the use
attacks of of dangerous machinery
angioedema, while taking this drug).
rhinitis and Report sore throat, fever,
urticaria have rash, itching, weight
been gain, swelling in ankles
precipitated by or fingers; changes in
aspirin, vision.
NSAIDs or
sulfonamides.
Severe hepatic
impairment;
severe heart
failure;
inflammatory
bowel disease;
peptic ulcer;
renal
impairment
(CrCl <30
ml/min);
pregnancy and
lactation.
GENERIC ACTION:  Indication: Burning, CNS: SEIZUR Be alert for new seizures
NAME:  Local Bupivacaine is crawling, ES, anxiety, or increased seizure
Bupivacaine anesthetics indicated for itching, dizziness, activity. Document the
such as the production numbness, headache, number, duration, and
BRAND bupivacaine of local or prickling, irritability.  severity of seizures, and
NAME: block the regional "pins and EENT: blurre report these findings
Exparel, generation and anesthesia or needles", or d vision, immediately to the
Kenalog, the conduction analgesia for tingling tinnitus.  physician.
Marbeta, of nerve surgery, for feelings. CV: CARDIOV Monitor cardiac
Marcaine, impulses, oral surgery Change or ASCULAR symptoms at rest and
Marcaine presumably by procedures, for loss of taste. COLLAPSE, ar during exercise, and be
With increasing the diagnostic and Chest pain or rhythmias, alert for signs of severe
Epinephrine threshold for therapeutic discomfort. bradycardia, cardiac insufficiency due
, Marvona electrical procedures, Continuing hypotension.  to cardiac arrest
Suik excitation in and for ringing or GI: nausea, (cardiovascular
the nerve, by obstetrical buzzing or vomiting.  collapse). Seek
CLASSIFICA slowing the procedures. other GU: urinary immediate medical
TION:   propagation of Bupivacaine is unexplained retention. Der assistance if symptoms
Central the nerve indicated to noise in the m: pruritus.  of cardiac arrest develop,
Nervous impulse, and induce post- ears. F and including sudden chest
System by reducing surgical Decrease in E: metabolic pain, pain radiating into
Agent; Nonnar the rate of rise analgesia in the frequency acidosis.  the arm or jaw, shortness
cotic of the action adults for up to and amount Neuro: circu of breath, dizziness,
Analgesic, potential. 72 hours of urine. moral sweating, anxiety, and
Antipyretic Bupivacaine following Difficult or tingling/numb nausea.
prevents arthroscopic painful ness, tremor.  Monitor signs of allergic
depolarization subacromial urination. Misc: allergic reactions, including
by bindng to decompression Increased reactions, pulmonary symptoms
the by thirst. fever. (laryngeal edema,
intracellular administration bronchospasm,
portion of into the wheezing, cough,
sodium subacromial dyspnea) or skin
channels and space under reactions (rash, pruritus,
blocking direct urticaria). Notify
sodium ion arthroscopic physician or nursing staff
influx into visualization. immediately if these
neurons. In reactions occur.
general, the Contraindica Assess heart rate, ECG,
progression of tion: and heart sounds,
anesthesia is Glucose-6- especially during
related to the phosphate exercise Report an
diameter, dehydrogenase unusually slow heart rate
myelination (G6PD) (bradycardia) or signs of
and deficiency. other arrhythmias,
conduction Methemoglobi including palpitations,
velocity of nemia, a type chest discomfort,
affected nerve of blood shortness of breath,
fibers. disorder. fainting, and
Clinically, the Second degree fatigue/weakness.
order of loss of atrioventricula Be alert for other signs of
nerve function r heart block. systemic toxicity,
 is as follows: slow heartbeat. including confusion,
(1) pain, (2) Significantly nervousness, tremor,
temperature, low blood headache, blurred or
(3) touch, (4) pressure. double vision, nausea,
proprioception Severe liver vomiting, slurred speech,
, and (5) disease. ringing in ears, tremors,
skeletal muscle twitching, difficulty
tone. The breathing, hypotension,
analgesic severe dizziness or
effects of fainting, and unusually
Bupivicaine slow heart rate. Report
are thought to these signs to the
potentially be physician or nursing staff
due to its immediately.
binding to the Monitor signs of
prostaglandin metabolic acidosis,
E2 receptors, including headache,
subtype EP1 lethargy, stupor,
(PGE2EP1), seizures, vision
which inhibits disturbances, increased
the production respiration, cardiac
of arrhythmias, weakness,
prostaglandins and GI symptoms
, thereby (nausea, vomiting,
reducing fever, and/or abdominal pain).
inflammation, Notify physician or
and nursing staff
hyperalgesia. immediately if these
signs occur.
FREQUENC If used postsurgically for
Y/ DOSAGE/ continuous nerve block,
ROUTES use appropriate pain
50 mg scales and sensory
Epidural testing to document level
of local anesthesia.
Assess dizziness that
might affect gait,
balance, and other
functional activities
Report balance problems
and functional
limitations to the
physician and nursing
staff, and caution the
patient and
family/caregivers to
guard against falls and
trauma.
GENERIC ACTION:  INDICATIO dizziness or Body as a Determine history of
NAME:  Semisynthetic N: lightheadedn Whole: Prurit hypersensitivity
Ceftriaxone third- Infections ess us, fever, reactions to
 generation caused by salty or chills, pain, cephalosporins and
BRAND cephalosporin susceptible metallic induration at penicillins and history of
NAME: antibiotic. organisms in taste, or IM injection other allergies,
Rocephin Preferentially lower decreased site; phlebitis particularly to drugs,
binds to one or respiratory ability to (IV site).  before therapy is
CLASSIFICA more of the tract, skin and taste GI: Diarrhea,  initiated.
TION penicillin- skin cough abdominal Lab tests: Perform
Antiinfective;  binding structures, fast heartbeat cramps, pseud culture and sensitivity
Antibiotic; Thi proteins (PBP) urinary tract, excessive omembranous tests before initiation of
rd-Generation located on cell bones and tiredness colitis, biliary therapy and periodically
Cephalosporin walls of joints; also sludge.  during therapy. Dosage
susceptible intra- Urogenital:  may be started pending
organisms. abdominal Genital test results. Periodic
This inhibits infections, pruritus; coagulation studies (PT
third and final pelvic moniliasis. and INR) should be
stage of inflammatory done.
bacterial cell disease, Inspect injection sites for
wall synthesis, uncomplicated induration and
thus killing the gonorrhea, inflammation. Rotate
bacterium. meningitis, sites. Note IV injection
and surgical sites for signs of phlebitis
FREQUENC prophylaxis. (redness, swelling, pain).
Y/ DOSAGE/ Monitor for
ROUTES: CONTRAIND manifestations of
2g IV OD ICATION: hypersensitivity (see
Hypersensitivi Appendix F). Report
ty to their appearance
cephalosporins promptly and
and related discontinue drug.
antibiotics; Watch for and report
pregnancy signs: petechiae,
(category B). ecchymotic areas,
epistaxis, or any
unexplained bleeding.
Ceftriaxone appears to
alter vitamin K–
producing gut bacteria;
therefore,
hypoprothrombinemic
bleeding may occur.
Check for fever if
diarrhea occurs: Report
both promptly.
Report any signs of
bleeding.
IX. She is on a maximum
dose of metformin 1 g
BD, insulin glargine
50 units at night,
Amlodipine
X. 5mg OD, Captopril
25 mg BD and
Simvastatin 40mg at
nigh
VII. NCP PROPER
Time Chart
7:00- F> Continuity of care
3:00 D> Received lying on bed with an IVF of PLRS, with IFC and is infusing well
pm A>Assessed and monitored VS every 4 hours. Provided rest periods to facilitate
comfort, sleep and relaxation. Administered NSAID medication for pain control.
Replaced and regulated IVF. Instructed So to report any untoward signs and
symptoms to nurses or press the call bell.
R> Receptive to care

Time Chart
7:00- F> Continuity of care
3:00 D> Received lying on bed, not in distress and cooperative
pm A>Assessed and monitored VS every 4 hours. Administered prescribed medication for
pain control. Assisted in removal of penrose drain by the ROD. Assisted in changing
th e dressing. Provided rest periods to facilitate comfort, sleep and relaxatiob.
Encouraged semi-fowlers position to promote lung expansion. Encourage deep
breathing exercise. Emphasized importance in compliance to medication. Instructed
SO to report any untoward sign and symptomss to nurses or press the call bell.
R> Receptive to care

Time Chart
7:00- F> Discharge health teaching
3:00 D> Received lying on bed, not in distress and cooperative
pm A> Monitored and assisted vital signs. Administered prescribed medication for pain
control. Encourage deep breathing exercise. Emphasized importance in compliance to
medication. Instructed to continue and follow the right instruction or prescribed
home medication. Instructed to clean and change the dressing.
R> Patient acknowleged discharge teachings imparted.

  
I. BRIEF DISCUSSION OF THE PROPOSED
OPERATION

 OPEN NEPHROLITHOTOMY WITH

COMBINED EPIDURAL AND ENDOTRACHEAL
SURGERY
What is an Open
Nephrolithotomy?
 An Open
Nephrolithotomy is
a surgical procedure
to remove a stone
from the kidney.
The kidney is
opened so that the
stone can be
removed in one or
more piece.

Why do I need an Open

Nephrolithotomy?
 An Open
Nephrolithotomy is
performed to
 remove a kidney stone that is causing problems with urine drainage resulting in
pain or recurrent urinary infections. This type of procedure is chosen when the
stone is too large or difficult to be removed using less invasive methods. If you
would like more information on kidney stone formation, please ask your nurse
for a copy of the Kidney Stone Patient Information Sheet.
 A stone(s) that is causing problems with efficient urine drainage from your
kidney presents an ongoing risk to your health. It may be that the size or location
of the stone(s) makes removal by other methods difficult.

Potential Complications
 All urological surgical procedures carry a small risk of postoperative bleeding and
wound, chest and urinary tract infection. You will be monitored for these risks and
treated promptly if they occur.
o Excessive bleeding. Your wound, drain(s) and vital signs (blood pressure and
pulse) will be monitored for signs of excessive bleeding.
o Infection. Your chest, wound and urine will be monitored for early signs of
infection and intervention will be put in place if it occurs. To reduce the risk of
infection antibiotics are given directly into your bloodstream during your
operation and continued post-operatively if necessary. You can also assist with
the prevention of infection by maintaining good hygiene and doing your deep
breathing exercises. Early mobilisation also helps.
o Incisional hernia. As a wound heals, scar tissue forms creating a bond between
the two sides of the incision. The scar tissue is strong but can still occasionally
tear or give way. This leads to a bulge developing along the scar (incisional
hernia) usually within one to five years after surgery. A hernia may not cause any
discomfort but if it is troublesome it may require repair.

Length of Stay
 The usual length of stay is five to seven days. However, if you need to stay longer for a
medical reason, your doctor will discuss this with you.

Before Surgery
Informed consent
 After consultation with the doctor you will be asked to sign a form to give written
consent for the surgeon to perform the operation and for an anaesthetic to be
administered. Relevant sections of the form must also be completed if you agree to a
blood transfusion and/or if your particular surgery involves the removal of a body part
and you wish to have this returned. Our expectation is that you feel fully informed about
all aspects of your surgery before giving written consent. The following health
professionals are available to help you with this process.

Medical staff
 Your surgeon will explain the reason for the Open Nephrolithotomy and the risks
associated with the surgery. Your doctors will visit you every day while you are in
hospital to provide medical care and answer questions about your surgery and progress.
Nurses
 A nurse will explain what to expect before and after surgery. Please ask questions and
express your concerns; your family or people close to you are welcome to be involved.
 When you are discharged from hospital your nurse will arrange for you to receive
ongoing support, advice and practical help, if needed.

Tests
 Blood samples. Samples of your blood will go the laboratory to check your general
health before surgery.
 Blood transfusions. A sample of your blood will go to the blood bank to identify your
blood type so this can be matched with donated blood. This donated blood is then ready
for transfusion during or after surgery if required. We will need your written consent
before a transfusion is able to take place.
 Midstream urine. A sample of your urine is sent to the laboratory to check for the
presence of bacteria. You may be started on antibiotics before surgery if bacteria are
found in the urine.
 Chest x-ray. If requested by the doctor or anaesthetist, a chest x-ray will be performed
to check on the health of your lungs.
 ECG. An electrocardiogram (ECG) of your heart may be required depending on your age
and any diagnosed heart conditions.

Other measures
 Nil by mouth. As your stomach should be empty before an anaesthetic, you must not
eat anything or drink milk products six hours prior to surgery. You may, however, be
able to drink clear fluids up to two hours before surgery - the Pre-Admission Clinic or
ward nurse will clarify this with you.
 Bowels . If required for your surgery, you will have been given an enema to use at
home. This empties the lower bowel and helps to prevent constipation after your surgery.
 Breathing exercises. Breathing exercises will be taught to you by your nurse or
physiotherapist pre-operatively or post-operatively. They are important as they help to
keep your lungs clear of fluid and prevent chest infection. They should be carried out
regularly after surgery by supporting your abdomen with a soft pillow, taking four to five
deep, slow breaths, then one deep cough.
 Leg exercises. Leg exercises help keep muscle tone and promote the return of blood in
your leg veins to your heart. These include pedalling the feet, bending the knees and
pressing the knees down into the mattress. Do not cross your legs - this squashes
your veins causing obstruction to the blood circulation
 Anti-embolus stockings. These are special stockings that help prevent clotting of the
blood in your veins while you are less mobile. The stockings are used in combination
with leg exercises and are fitted by your nurse before your surgery. If you currently have
leg ulcers, please let your nurse know as the stockings may not be suitable for you.

After Surgery
 You are transferred to the Recovery Room next to the theatre. Your condition is
monitored and when you are awake and comfortable a nurse and an orderly will escort
you back to the ward on your bed.
On the ward
 Your nurse will check the following regularly:
o Vital signs - your blood pressure, pulse, respiration rate and temperature
o The severity and location of any pain or discomfort
o The amount of urine you are producing
o The wound site and wound drains The level of numbness that an epidural is
producing
o The effectiveness of pain relief
o
The amount of oxygen in your blood
You may have
 Intravenous fluids. A small tube (leur) is placed into a vein in the forearm to give you
fluids and medications.
 Oxygen . Oxygen is often given for the first 24 hours after surgery via nasal prongs or a
facemask to help with breathing and healing.
 Urinary catheter . You will have a tube in the urethra that will drain the urine from
your bladder. This can be secured to your leg for comfort. After surgery your nurse will
monitor your urine output closely as it has involved major trauma to your kidney.
 Wound drains. You may have one or more wound drains. These will drain blood and
fluids from your operation site thereby promoting healing.
 Ureteric stent. You may have a small internal plastic tube in the ureter from the
kidney to the bladder. This will keep the ureter open while it is healing and ensure urine
drains down the ureter.
Pain relief after your surgery.
 Your nurse will work alongside your doctors and the anaesthetist to keep your pain at a
minimum.
 The PAIN SCORE is a way of your nurse establishing how much pain you are
experiencing by asking you to grade your pain from 0 to 10 where 0 = no pain and 10 =
the worst pain you can imagine. The following methods of pain relief may be used singly
or in combination with each other.
o Patient controlled analgesia (PCA)
This infusion machine has a button you press each time you need pain relief. It
will help your pain by immediately delivering a specific amount of pain relief into
your blood stream. The pump is programmed according to your anaesthetist’s
instructions.
o Epidural
An epidural is a very small tube inserted by your anaesthetist into the epidural
space in your back. A local anaesthetic is infused through this tube via a pump for
the first few days after surgery relieving pain at your operation site by numbing it.
o Intravenous (IV) pain relief
Intravenous pain relief can be administered to supplement a PCA or epidural or
on its own to manage pain that is not controlled by tablets or suppositories alone.
 o Rectal pain relief
Pain may also be controlled by the insertion of suppositories whilst you are not
able to take tablets orally.
o Oral pain relief
When you are able to drink, you may have tablets by mouth (orally).

Wound site - What to expect

 Your wound will be a horizontal flank incision about 15cms long directly below your ribs.

Comfort cares after your surgery

 To help keep you comfortable your nurse will give you bed washes, linen changes and
move you around in the bed regularly.
 Medications are available for the relief of nausea and vomiting, if they occur. You will be
given mouthwashes and ice to suck if you are not eating or drinking yet.
 You will be reminded about and assisted with deep breathing exercises. These should be
performed every hour while you are awake.

Food and fluids

 After your surgery your food and fluid intake will be increased as your bowel function
returns to normal. Resumption of a full diet will be gradual starting with sips and
progressing to light meals over a day or so. It is important to eat a balanced diet and
chew thoroughly and eat slowly. If you have any special dietary needs, a dietician will be
involved to assist in your recovery.

Mobility
 You will usually be up in a chair for a short time and assisted to walk a short distance
within a day or two of your surgery. Your level of activity will increase as you recover.

Removal of drips and drains

 Intravenous fluid
This is removed when you are drinking normally. The leur (plastic tube) is removed
when you no longer require intravenous medications.
 Urinary catheter
This is usually removed a day or two after surgery when close monitoring of your urine
output is not so critical.
 Wound drains
These are removed when the amount of drainage is minimal and the operation area is
healing.
 Sutures (stitches or staples)
For this surgery, most suture material used is dissolvable and does not require removal.
However, if non-dissolving suture material has been used, this will need to be removed
 approximately seven to ten days after surgery. If you are not going to be in hospital at
this time, you will be given a date for you to arrange for your GP, Practice nurse or
District nurse to remove them.
 Stent
If you have a stent you will receive an appointment to attend the Urology Outpatient
Department after discharge so that it can be removed. The stent is removed under local
anaesthetic using a flexible telescope inserted into the urethra. If you have not received a
stent removal appointment date within one month of discharge, please contact the Stent
Register Administrator via the Urology Outpatient Department. If you are unsure
whether you have a stent in place, please check with your nurse prior to discharge.

Discharge Advice
 See your GP promptly if you experience chills, fever or pain in your bladder or back, or
your urine is cloudy and offensive smelling. These symptoms may be indicative of a
urinary tract infection and require treatment.
 Drink two to three litres of fluid daily to help prevent the formation of new stones.
 Avoid strenuous activity, heavy lifting and straining for four to six weeks post surgery.
This includes such things as contact sports, mowing lawns, gardening, vacuuming and
lifting heavy washing baskets.
 Sexual activity may be resumed when you feel comfortable to do so.
 Your hospital doctor will provide your first sickness benefit certificate/medical
certificate and will advise you when you are able to return to work.

Follow-up
 Discharge letter
You and your GP will receive a copy of a letter outlining the treatment you received
during your hospital stay. This will be posted to you if it is not completed by the time you
leave hospital.
 GP (Family doctor)
When you are discharged from hospital you will be under the care of your GP who will
look after your general health and monitor your progress.
  OPEN RENAL SURGERY
Open nephrectomy is rarely
required but is also done under
general anesthesia. The surgeon
makes a cut (incision) in the
abdomen or in the side of the
abdomen (flank area). A rib may
need to be removed to perform
the procedure. The ureter (the
tube that carries urine from the
kidney to the bladder) and the
blood vessels are cut away from
the kidney and the kidney is
removed. The incision is then
closed with stitches.

After care and recovery

 Immediately after surgery, your health care team will carefully watch your blood
pressure, electrolytes and fluid balance. These body functions are controlled in part by
the kidneys. You will most likely have a urinary catheter (tube to drain urine) in your
bladder for a short time during your recovery.
 You may have discomfort and numbness (caused by severed nerves) near the incision
area. Pain relievers are given after the surgical procedure and during the recovery period
as needed. Although deep breathing and coughing may be painful because the incision is
close to the diaphragm, breathing exercises are important to prevent pneumonia.
 You will probably remain in the hospital for 1 to 7 days, depending on the method of
surgery used. You will be encouraged to return to light activities as soon as you feel up to
it. Strenuous activity and heavy lifting should be avoided for 6 weeks following the
procedure.
 Your doctor will give you more detailed instructions about your post-operative activities,
restrictions and diet.
Risks and complications of nephrectomy surgery
All surgery has certain risks and complications. Possible complications of nephrectomy surgery
include:
 Infection
 Bleeding (hemorrhage) requiring blood transfusion
 Post-operative pneumonia
 Rare allergic reactions to anesthesia
 Death
 There is also the small risk of kidney failure in a patient with lowered function or disease
in the remaining kidney.
 Quick Fact: You are born with two kidneys, but you really only need one. A single
healthy kidney can work as well as two kidneys, but if both kidneys are removed, dialysis
or a transplant is necessary to maintain life.
 The risks of donor nephrectomy for kidney transplantation are very small. This is likely
because almost all living donors undergo careful pre-op testing and evaluation to make
sure they are healthy enough for surgery. Most studies report death rates for donor
nephrectomy in the range of 1 or 2 per 10,000 donor surgeries. About 1 or 2 per 100
patients may experience a post-operative wound infection or complication and about half
of these patients may require re-operation for a complication.
 The vast majority of kidney donors live long and healthy lives with one kidney.

Care of the remaining kidney

 Tests will be done on a regular basis to check how well the remaining kidney is working.
A urinalysis (urine test) and blood pressure check should be done every year, and kidney
function tests (creatinine, glomerular filtration rate [GFR]) should be checked every few
years (or more often if abnormal results are found). Regular urine tests for protein
should be performed as well. The presence of protein in the urine may mean that the
kidney has some damage.
 People with one kidney should avoid sports that involve higher risks of heavy contact or
collision. This includes, but is not limited to, boxing, field hockey, football, ice hockey,
lacrosse, martial arts, rodeo, soccer and wrestling. This may also include extreme
activities such as skydiving. Anyone with a single kidney who decides to participate in
these sports should be extra careful and wear protective padding. He or she should
understand that losing the remaining kidney is a very serious situation.
How can you care for yourself at home?
 Activity
o Rest when you feel tired. Getting enough sleep will help you recover.
o Try to walk each day. Start by walking a little more than you did the day before.
Bit by bit, increase the amount you walk. Walking boosts blood flow and helps
prevent pneumonia and constipation.
o Avoid exercises that use your belly muscles and strenuous activities, such as
bicycle riding, jogging, weight lifting, or aerobic exercise, until your doctor says it
is okay.
o For at least 4 weeks, avoid lifting anything that would make you strain. This may
include a child, heavy grocery bags and milk containers, a heavy briefcase or
backpack, cat litter or dog food bags, or a vacuum cleaner.
o Hold a pillow over the cut the doctor made (incision) when you cough or take
deep breaths. This will support your belly and decrease your pain.
 o Do breathing exercises at home as instructed by your doctor. This will help
prevent pneumonia.
o Ask your doctor when you can drive again.
o You will probably need to take 4 to 6 weeks off from work. It depends on the type
of work you do and how you feel.
o You may be able to take showers (unless you have a drainage tube near your
incision). If you have a drainage tube, follow your doctor's instructions to empty
and care for it. Do not take a bath for the first 2 weeks, or until your doctor tells
you it is okay.
o Ask your doctor when it is okay for you to have sex.
 Diet
o You can eat your normal diet. If you were on a special diet for your kidneys before
surgery, follow that diet until your doctor tells you to stop.
o If your stomach is upset, try bland, low-fat foods like plain rice, broiled chicken,
toast, and yogurt.
o Drink plenty of fluids (unless your doctor tells you not to).
o You may notice that your bowel movements are not regular right after your
surgery. This is common. Try to avoid constipation and straining with bowel
movements. You may want to take a fibre supplement every day. If you have not
had a bowel movement after a couple of days, ask your doctor about taking a mild
laxative.
 Medicines
o Your doctor will tell you if and when you can restart your medicines. He or she
will also give you instructions about taking any new medicines.
o If you take aspirin or some other blood thinner, ask your doctor if and when to
start taking it again. Make sure that you understand exactly what your doctor
wants you to do.
o Take pain medicines exactly as directed.
o If the doctor gave you a prescription medicine for pain, take it as prescribed.
o If you are not taking a prescription pain medicine, take an over-the-counter
medicine that your doctor recommends. Read and follow all instructions on the
label.
o Do not take aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve), or other non-
steroidal anti-inflammatory drugs (NSAIDs) unless your doctor says it is okay.
o If you think your pain medicine is making you sick to your stomach:
o Take your medicine after meals (unless your doctor has told you not to).
o Ask your doctor for a different pain medicine.
o If your doctor prescribed antibiotics, take them as directed. Do not stop taking
them just because you feel better. You need to take the full course of antibiotics.
 Incision care
o If you have strips of tape on the incision, leave the tape on for a week or until it
falls off.
o Wash the area daily with warm, soapy water and pat it dry. Don't use hydrogen
peroxide or alcohol, which can slow healing. You may cover the area with a gauze
bandage if it weeps or rubs against clothing. Change the bandage every day.
o Keep the area clean and dry.
 Follow-up care is a key part of your treatment and safety. Be sure to make and
go to all appointments, and call your doctor or nurse call line if you are having problems.
It's also a good idea to know your test results and keep a list of the medicines you take.