COLLEGE OF NURSING

Silliman University
Dumaguete City

RESOURCE UNIT ON NEPHRECTOMY

Prepared by:
Laura Ashley R. Paduganao

Facilitator:
Asst. Prof. Veveca Bustamante
Topic: Nephrectomy
Topic Description: The topic will focus on the surgical procedure Nephrectomy: its purpose, process, and medical management (pre-operative and post-operative) as well as the
possible health condition that would require this specific procedure
Time Allotment: 1 hours and 10 minutes
Central Objective: At the end of this lecture, the level III student nurses will be able to integrate the knowledge on the management and purpose about Nephrectomy, which will
assist them in the nursing profession in preparation for their nursing duties leading to an improvement in their skills as a student nurse.
SPECIFIC CONTENT TIME TEACHING- EVALUATI
OBJECTIVES ALLOTM LEARNING ON
ENT ACTIVITIES
After the discussion, the
students will…

I. Recall the parts of I. The Urinary System 5 minutes Video Q&A

the urinary system
and their functions
a. Kidneys Explanation Discussion
i. Characteristics for 5 minutes
1. The kidneys are a pair of bean-shaped, brownish-red structures minimum
located retroperitoneally (behind and outside the peritoneal cavity)
on the posterior wall of the abdomen—from the 12th thoracic
vertebra to the 3rd lumbar vertebra in the adult
2. Average Weight [Adult]: 113-170g
3. 1 million nephrons located within the renal parenchyma and
responsible for the formation of filtrate that will become urine
a. If < 20% of normal functional then renal replacement
therapy will be considered
b. Types: cortical (80%-85%) and juxtamedullary (15%-20%)
c. Composed of: glomerulus (filter) and tubular component
(Bowman capsule -> Loop of Henle -> distal tubule ->
collecting ducts)
ii. Function(s)
1. Urine formation
2. Excretion of waste products
3. Regulation of electrolytes
4. Regulation of acid–base balance
5. Control of water balance
6. Control of blood pressure
7. Renal clearance
 8. Regulation of red blood cell production
9. Synthesis of vitamin D to active form
10. Secretion of prostaglandins
b. Ureters
i. Characteristics
1. long fibromuscular tubes that connect each kidney to the bladder
(Hall, 2016). These narrow tubes, each 24 to 30 cm long, originate
at the lower portion of the renal pelvis and terminate in the trigone
(tissue between the opening of the ureters and urethra) of the
bladder wall.
2. 3 narrow areas which are prone to obstruction by renal calculi
(kidney stones): sacroiliac junction, ureteropelvic junction, and
ureterovesical junction
a. Obstruction of ureteropelvic junction leads to high risk for
associated kidney dysfunction
ii. Function(s)
1. Move the urine from each renal pelvis into the bladder by
peristaltic contraction of the smooth muscles in the ureter wall
2. Urothelium prevents reabsorption of urine
c. Urinary Bladder
i. Characteristics
1. Distensible muscular sac located just behind the pubic bone (Weber
& Kelley, 2014). The usual capacity of the adult bladder is 400 to
500 mL, but it can distend to hold a larger volume. The bladder is
characterized by its central, hollow area, called the vesicle, which
has two inlets (the ureters) and one outlet (the urethra).
2. Angle of the ureterovesical junction creates downward movement
of urine, which prevents backward movement of urine
3. The bladder neck contains bundles of involuntary smooth muscle
that form a portion of the urethral sphincter known as the internal
sphincter.
ii. Function(s)
1. Maintain continence
2. Excrete urine
d. Urethra
i. Characteristics
1. Arises from the base of the bladder
a. Male: passes through the penis
i. prostate gland lies below the bladder neck and
 surrounds the urethra posteriorly and laterally
b. Female: opens just anterior to the vagina
ii. Function(s)
1. Provides pathway for the urine to leave the body

II. Types & Methods Lecture with

II. Define and a. Types 3 minutes Video or
describe the 3 i. Radical Nephrectomy YouTube
different types and 1. The surgeon removes the whole kidney, the fatty tissues Video
methods of surrounding the kidney and a portion of the tube connecting the Demonstration
nephrectomy kidney to the bladder (ureter). The surgeon may remove the adrenal
gland that sits atop the kidney if a tumor is close to or involves the
adrenal gland. In some cases lymph nodes or other tissues are
removed as well.
ii. Partial Nephrectomy
1. Also called kidney-sparing (nephron-sparing) surgery — the
surgeon removes a cancerous tumor or diseased tissue and leaves in
as much healthy kidney tissue as possible.
iii. Simple Nephrectomy
1. Removal of an entire kidney by itself
b. Methods
i. Open Surgery
1. The urologic surgeon makes a cut (incision) along your side or on
your abdomen. This open approach allows surgeons to perform
some surgeries that still can't be performed safely with less invasive
approaches.
ii. Laparoscopic Surgery
1. Minimally invasive procedure, the surgeon makes a few small
incisions in your abdomen to insert wandlike devices equipped with
video cameras and small surgical tools. The surgeon must make a
slightly larger opening if your entire kidney needs to be removed.

III. List at least 3 of III. Indications

the indications a. Benign tumours (rare) 3 minutes Lecture with
b. kidney cancer PowerPoint
c. Uncontrollable renal hemorrhage, for example severe blunt renal trauma or Presentation
complications of
d. renal biopsy
 e. Multiple cysts
f. Renal calculi
g. Malignant hypertension (bilateral and rare)

IV. List at least 3 of h. Removal of a health kidney for transplantation (living donor)
the 3 minutes
contraindications IV. Contraindications
a. Risk of Kidney Failure
i. Poor kidney health of the remaining kidney
ii. Decreased glomerulus filtration rate
b. Bleeding Disorders
i. Possible risk for hemorrhage during or after surgery
c. Decompensated Heart Failure (DHF)
i. Already have reduced kidney function
d. Decompensated Diabetes Mellitus
i. Increased blood glucose
e. Anticoagulation Medications
V. Recognize at least i. Possible risk for hemorrhage during or after surgery
2 of the possible
complications of V. Complications 7 minutes
nephrectomy a. Hypertension
b. Chronic Kidney Disease
c. Infections
d. Hemorrhage
e. Post-operative pneumonia
f. Allergic reactions to anesthesia
g. Death
h. Blood clots
i. Leakage of urine

VI. Describe the 1 minute

intended outcome VI. Outcome
of the surgery a. Overall kidney function decreases after a nephrectomy, the remaining kidney
tissue usually works well enough for a healthy life.

VII. Summarize the 5 minutes

reason for the VII. Kidney cancer (Sporadic Renal Cell Carcinoma) Concept Map
requirement of a. Case Scenario Presentation
nephrectomy in i. Patient Z.K., an African American, 55 years old man, was admitted to the
the hypothetical hospital for lower right back pain rated at a 8/10 on the pain scale, a fever
scenario of a of 37.8 C, and blood reported in his urine (hematuria) that has been
patient with ongoing for 4 days. Patient Z.K.’s fever persisted for more than 5 days
kidney cancer even when taking antipyretics during the time of his fever. Upon initial
inspection of Patient Z.K.’s lower right back a moderate size mass was
found
b. Etiology and Risk Factors
i. Risk Factors
1. Precipitating
a. Chronic Smoker – 35 years (35 Pack-Year)
b. Blood Pressure – Stage 1 Hypertensive
2. Predisposing
a. Gender – Male
b. Race – African American
c. Pathophysiology
i. Mutation of the short arm of Chromosome 3 directly affecting the VHL
gene which will prevent the expression of the von Hippel-Lindau Tumor
Suppressor Protein (pVHL)
ii. IGF-1, growth factor, will increase drastically causing dysregulated cell
growth and hypoxia-inducing factors
iii. The increase of hypoxia-inducing factors will lead to an increase for
vascular endothelial growth factor (VegF) and receptors, which lead to
increase formations of new blood vessels
iv. The new blood vessels and dysregulated cell growth will form tumors in
the kidney
v. Tumor growth starts in the epithelial cells of the proximal convoluted
tubule of the kidney, which are found in the cortex of the kidney
d. Assessment and Diagnostic Findings
i. Medical History
1. Last known complete medical check-up was 3 years ago; only goes
during medical emergency
2. Incident of Kidney Stones and Bladder Infection 6 months ago
3. Currently on hypertensive medications amlodipine and losartan
ii. Physical Assessment
1. Localized pain in the lower right back rated an 8/10 on the pain
scale
2. Mass on lower right back
3. Appeared tired and restless
4. Signs of pallor
 5. Fever of 37.8 C
iii. Diagnostic Testing
1. Urinalysis – evidence of possible kidney problem
2. Physical Exam – Mass on Kidney when Inspecting Abdomen
3. CBC – detects the number of RBCs for evidence of Anemia or
Polycythemia
4. Blood Chemistry Tests – kidney cancer can affect the levels of
certain chemicals in the blood: high levels of liver enzymes and
high blood calcium levels or measure kidney function
5. CT Scan – provides information on the size, shape, and location of
the tumor and the cancer’s spread to lymph nodes or to organs and
tissues outside of the kidney
6. MRI Scan – done if individual cannot get a CT Scan due to
allergies or poor kidney function and to observe for cancer growth
into major blood vessels, brain, and spinal cord
7. Ultrasound – detects kidney mass and determines its quality being
solid or filled with fluid
8. Angiography – observes blood vessels by injecting a contrast dye
into the renal artery in order to identify and map the blood vessels
that feed a kidney tumor
e. Clinical Manifestations
i. Hematuria
ii. Lower Right back pain
iii. Mass size on lower right back
iv. Fatigue
v. Fever of 37.8 C
vi. Anemia
f. Management
i. Nonsurgical
1. Cryoablation/Cryotherapy – uses extreme cold to destroy the
kidney tumor and is performed under local anesthesia as an
outpatient procedure
a. Hollow probe (needle) is inserted into the tumor either
through the skin or during laparoscopy, where very cold
gases are passed through the probe, creating an ice ball that
destroys the tumor
2. Radiofrequency ablation – uses image guidance to place a needle
through the skin into a kidney tumor
a. High-frequency electrical currents are passed through an
 electrode in the needle, creating a small region of heat
ii. Surgical
1. Nephrectomy
a. Radical – removal of the kidney (and tumor), adrenal gland,
surrounding perinephric fat and Gerota fascia, and lymph
nodes
b. Partial/Nephron-Sparing Surgery (NSS) – surgical removal
of the tumor; preserves kidney function and lowers the risk
of the development of chronic kidney disease after surgery
2. Regional lymphadenectomy – removes nearby lymph nodes to see
if they contain cancer; done with radical nephrectomy
iii. Pharmacological
1. Immunotherapy
a. Pembrolizumab (Keytruda) and Nivolumab (Opdivo)
i. Targets PD-1, which is a protein on immune system
cells that normally help keep these cells from
attacking other cells in the body; boosts immune
response against kidney cancer cells leading to
shrink or slow growth of the tumor
1. Nivolumab: IV every 2,3, or 4 weeks
a. Used for advanced kidney cancer that
starts growing again after targeted
drug treatments
2. Pembrolizumab: IV every 3 weeks
a. Used with targeted drug axitinib as
the first treatment for advanced
kidney cancer
b. Avelumab (Bavencio)
i. Targets PD-L1, which is a protein related to PD-1
that is found on some tumor cells and immune cells;
boosts immune response against cancer cells leading
to shrink or slow growth of the tumor
1. Avelumab: IV every 2 weeks
a. Used with the targeted drug axitinib
as the first treatment for advanced
kidney cancer
c. Ipilimumab (Yervoy)
i. Boosts immune response by blocking CTLA-4,
which is a protein found on T-Cells that normally
 helps keep them in check
1. Ipiplimumab: IV every 3 weeks for 4
treatments
a. For intermediate or poor risk
advanced kidney cancer who have
not received any treatment
b. Can be given with nivolumab *PD-1
inhibitor)
d. Interleukin-2 (IL-2)
i. Small proteins that boost the immune system in a
general way that can cause kidney cancers to shrink
ii. Given to healthy enough individuals that can tolerate
the side effects and the cancers aren’t responding to
the targeted drugs or other types of immunotherapy
2. Chemotherapy
a. Typically, is not standard treatment for kidney cancer
b. Some chemo drugs given are cisplatin, 5-fluorouracil (5-
FU), and gemcitabine; helps a small number of patients
3. Radiation therapy
a. Used if the individual is not healthy enough to have surgery
or only has one kidney
i. External Beam Therapy – focuses radiation on the
cancer from a source outside the body; palliative
care
VIII. Explain the VIII. Phases
nursing a. Pre-operative Phase 15 minutes
management tasks i. Stop cigarette smoking Lecture with
done for the ii. Physiotherapy assessment PowerPoint
patient from the iii. Elimination Presentation
pre-operative iv. Monitoring of the urinary output
phase to the post- v. Ensure adequate fluid intake and electrolyte balance
operative phase vi. Educate the patient regarding postoperative care
1. Breathing and coughing exercises
2. Use of an incentive spirometer
3. Splinting of the wound
4. Pain control
5. Urinary catheter
6. Wound incision line – for both open and laparoscopic procedures
7. The possible presence of a wound drain with an open procedure
 8. Leg exercises and use of antithrombosis stockings and
anticoagulants
9. Fasting, intravenous therapy, oral fluids and then a light diet
b. Post-operative Phase
i. Monitor patient status and laboratory values
1. Respiration
2. Colour
3. Level of consciousness and appearance
4. Pulse oximetry for oxygen saturation levels
5. Signs of respiratory complications, e.g. spontaneous pneumothorax
or atelectasis (changes in respiration and oxygen saturation levels)
ii. Administer prescribed oxygen
iii. Place in a semi-Fowler’s position
iv. Ensure regular use of an incentive spirometer
v. Use pillows to splint the wound when conducting breathing and coughing
exercises
vi. Monitor for signs of hypovolemic shock due to hemorrhage
1. Vital signs
2. Color
3. Skin
4. Wound dressing (check that no blood has seeped round to the back)
5. Wound drainage
vii. Monitor pain
1. Assess the level of pain (open versus laparoscopic): following a
open nephrectomy, the patient will have a large surgical wound
(with or without a wound drain), and the pain will be more intense
than in patients whose procedure was carried out via a laparoscopic
approach
2. With laparoscopic procedures, shoulder pain and a bloated
abdomen may occur and can be alleviated by pain medication and
mobilization
viii. Administer analgesia (PCA) and assess its effectiveness
ix. Monitor I/O and characteristics of excretions
1. Urinary output, and record this on the fluid balance chart
2. The colour and odour of the urine
3. The administration of prophylactic intravenous antibiotics prior to
removal of the urinary catheter
4. The postoperative voiding patterns
5. Renal function, e.g. serum creatinine level
 6. Bowel sounds
7. Possible paralytic ileus
x. Commence oral fluids followed by a light diet
xi. Prevent constipation
1. Early mobilization
2. A high-fibre diet and oral fluids
xii. Monitor wound
1. Monitor for signs of infection
2. Remove the wound drain (if present), usually at 48–72 hours
3. Remove sutures/staples (if present) at 7–10 days – the patient can
return to the outpatients department or attend a community
healthcare provider for this
xiii. Monitor for abdominal distention
xiv. Discharge advice
1. Monitor urinary output and signs of UTI
2. Ensure a fluid intake of 2 L/day
3. Care of the incision site(s)
4. Follow-up care in relation to renal function
5. Avoid strenuous exercises in the initial recovery phase
6. Avoid lifting weights for 6–8 weeks
7. As the patient has only one functioning kidney, they are advised to
avoid contact sports in the future
8. Details of medication and its impact on kidney function
9. For renal cancer:
a. Cancer support groups
b. Follow-up treatment and care

IX. Nursing Diagnosis

a. Ineffective airway clearance related to pain of high abdominal or flank incision, 5 minutes
IX. State 2 out of the 5 abdominal discomfort, and immobility
possible nursing b. Risk for ineffective breathing pattern related to high abdominal incision
diagnosis c. Acute pain and discomfort related to surgical incision, positioning, and stretching
of muscles during kidney surgery
d. Fear and anxiety related to diagnosis, outcome of surgery, and alteration in urinary
function
e. Impaired urinary elimination related to urinary drainage
f. Risk for infection related to altered urinary drainage
g. Risk for imbalanced fluid volume related to surgical fluid loss, altered urinary
output, parenteral fluid administration
 X. Nursing Interventions
a. Improve airway clearance
X. Explain the i. Assess respiratory status 5 minutes
appropriate 1. Rate
nursing 2. Breath sounds
interventions used ii. Administer analgesic agent as prescribed
in each respective iii. Splint incision with hands or pillow to assist patient in coughing
nursing iv. Assist patient to change positions frequently
diagnosis/problem v. Encourage the use of incentive spirometer if indicated or prescribed
vi. Assist with and encourage early ambulation
b. Relieve pain and discomfort
i. Assess level of pain
ii. Administer analgesic agents as prescribed
iii. Splint incision with hands or pillow during movement or deep breathing
and coughing exercises
iv. Assist and encourage early ambulation
v. Offer and educate patient how to use appropriate nonpharmacologic
interventions
vi. Educate the patient on proper positioning in the post-operative phase based
on incision location
c. Reduce fear and anxiety
i. Assess patient’s anxiety and fear before surgery if possible
ii. Assess patient’s knowledge about procedure and expected surgical
outcome preoperatively
iii. Evaluate the meaning of alterations resulting from surgical procedure for
the patient and family or partner
iv. Encourage patient to verbalize reactions, feelings, and fears
v. Encourage patient to share feelings with spouse or partner
vi. Offer and arrange for visit from member of support group
d. Maintenance of urinary elimination; infection free urinary tract
i. Assess urinary drainage system immediately
ii. Assess adequacy of urinary output and patency of drainage system
iii. Assess pertinent laboratory values
iv. Use asepsis and hand hygiene when providing care and manipulating
drainage system
v. Maintain closed urinary drainage system
vi. Assist patient in turning and moving in bed and when ambulating to
prevent displacement or inadvertent removal of urinary stent or ureteral
 catheters if in place
vii. Observe urine color, volume, odor, and components
viii. Minimize trauma and manipulation of catheter, drainage system, and
urethra
ix. Clean catheter gently with soap during bathing, avoiding any-to-and-fro
movement of catheter
x. Anchor drainage tube
xi. Maintain adequate fluid intake
e. Maintain normal fluid balance
i. Weigh patient daily
ii. Take accurate intake and output measurements
iii. Place all parenteral therapy on an infusion pump
iv. Monitor amount and characteristics of urine
v. Monitor vital signs: temperature, pulse, respirations, and blood pressure
vi. Auscultate heart and lungs every shift

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