Ns. Heri Kristianto, MKep.,Sp.Kep.

MB

FP: Kidney Surgery

A patient may undergo surgery

to 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
CONSIDERATIONS
evaluation

of renal function
Fluids are encouraged to promote
increased excretion of waste
products before surgery
If kidney infection wide-spectrum
antimicrobial agents may be
prescribed to prevent bacteremia
Coagulation studies (prothrombin
time, partial thromboplastin time,
platelet count)

Education
Anxiety
Confidence

is reinforced by
establishing a relationship of trust
and by providing expert care
Dialysis
It is important to teach the patient
and family that normal function may
be maintained by a single healthy
kidney.

PERIOPERATIVE
CONCERNS
Renal

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
MANAGEMENT
Hemorrhage

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

Drainage Tubes
Almost

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

patent

must be kept

(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 ureter

Nephrostomy Drainage
Nephrostomy

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

Jenis
Percutaneous

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

Percutaneous Nephrostomy
Tube

Nephro-Uretero Stent

 Permanent

nephrostomy tubes are

usually changed every 3 months.

Before procedure
Broadspectrum

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.

Procedure
The

skin site is prepared and anesthetized

The 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 Stents
A

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 include
1. Infection
2. inflammation secondary to a foreign body in
the genitourinary tract
3. Bleeding
4. Clot obstruction within the stent
5. Migration or displacement of the stent

Indikasi
Relief

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;

Procedure
Under

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

Ns. Heri Kristianto, MKep.,Sp.Kep.MB

NC: Kidney Surgery

Assessment
assessment of all body systems
respiratory and circulatory status
pain level
fluid and electrolyte status
patency and adequacy of urinary
drainage systems

RESPIRATORY STATUS
risk of respiratory
complications
Respiratory 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,
the
patient tends to splint the chest wall and
take shallow respirations.
Auscultation is performed to assess normal
and adventitious breath sounds
Anesthesia

CIRCULATORY STATUS AND

BLOOD LOSS
The

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.

PAIN
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.

URINARY DRAINAGE
Urine

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 DIAGNOSES
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 during
surgery, and abdominal distention
Urine retention related to pain,
immobility, and anesthesia

COLLABORATIVE PROBLEMS/
POTENTIAL COMPLICATIONS
Bleeding
Pneumonia
Infection
Fluid

disturbances (deficit or excess)

Deep vein thrombosis

Planning and Goals

The

major goals for the patient

include maintenance of effective
airway clearance and breathing
pattern
relief of pain and discomfort
maintenance of urinary elimination
absence of complications

NI: MAINTAINING AIRWAY CLEARANCE

AND BREATHING PATTERNS
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 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 secretions

NI: RELIEVING PAIN

Massage
Moist

heat
Analgesic medications provide relief.
Patient-controlled analgesia may be
effective in controlling pain and
enabling the patient to ambulate,
cough, and breathe deeply

NI: PROMOTING URINARY

ELIMINATION
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: hand hygiene, closed

drainage systems
Urinalysis and urine cultures
The bag must be kept off the floor to prevent
contamination
Most 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.

Bleeding
The

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.

Pneumonia
Incentive

spirometer, adequate pain

control, and early ambulation.
Early signs of pneumonia include
fever, increased heart and
respiratory rates, and adventitious
breath sounds.

Fluid imbalanced
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
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.

Evaluasi
Achieves effective airway clearance
Exhibits

clear and normal breath

sounds, normal respiratory rate, and
unrestricted thoracic excursion
Performs deep-breathing exercises,
coughs every 2 hours, and uses the
incentive spirometer as directed
Demonstrates normal temperature
and vital signs

Reports progressive
decrease in pain
Requires

analgesic medications at
less frequent intervals
Turns, coughs, and takes deep
breaths as suggested
Ambulates progressively

Maintains urinary elimination

Demonstrates

unobstructed urine flow from drainage

Tubes
Exhibits

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 site
Exhibits cautious handling of drainage system
Uses hand hygiene before and after handling drainage
system, and handles it only when necessary
States rationale for use and maintenance of a closed
drainage system

Experiences no complications
Demonstrates

normal vital signs and arterial and

central venous pressures, normal skin turgor,
temperature, and color
Exhibits 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 loss
Has clear breath sounds and no shortness of breath
Excretes urine at a rate of at least 30 mL per hour

Studi Kasus & Simulasi

Kasus Kidney
Injury
Skenario
Askep
Simulasi
Video
(tiap
kelompok
ambil 1
tindakan
keperawatan)