RENAL NEW GROWTH

A Clinical Case Study Presented to the

Faculty of the College of Nursing
Our Lady of Fatima University
Valenzuela City

In Partial Fulfilment of the Requirements in NCM 103 RLE

Submitted To:
Mrs. Edna Co, MAN, RN

Submitted By:
Cruz, Mary Angelou
Duazo, Angelica Marie
Ellazar, Deane Lexzandra
Enriquez, Patricia Anne
Fernandes, Michaella Ann
 OBJECTIVES

General

This study aims to broaden the students’ knowledge about renal new growth, and it is
designed to promote skills, gain understanding and provide nursing care management towards
handling patients with Renal New Growth.

Specific

▪ To gain knowledge and understanding about renal new growth.

▪ To apply necessary assessments and discuss the pathophysiology of the affected
system.
▪ To implement the necessary nursing care plans and prioritize responsibilities to
improve patients’ condition.
▪ To develop an effective nursing care plan in which the patient may benefit.
▪ To provide health teaching to the patient and significant others about renal new
growth.
 RENAL NEW GROWTH

Renal masses are a biologically heterogeneous group of tumors ranging from benign
masses to cancers that can be indolent or aggressive. A malignant tumor is cancerous, meaning
it can grow and spread to other parts of the body. A benign tumor means the tumor can grow
but will not spread.

Approximately 20% of surgically resected renal masses are benign, and more than 6000
benign renal masses are removed each year. A non-cancerous (benign) tumor of the kidney is
a growth that does not metastasize to other parts of the body. Non-cancerous tumors are not
usually life-threatening. They are typically removed with surgery and does not usually come
back. There are various types of non-cancerous tumors and conditions of the kidney such as
Papillary Renal Adenoma, Oncocytoma and Angiomyolipoma.

Various treatments can be done such as active surveillance, partial and radical
nephrectomy, and ablation. Certain symptoms can indicate that a tumor is the possible cause,
including blood in the urine, pain in the side, abdomen or back that doesn't go away, a lump in
your abdomen, anemia and fatigue.

Kidney tumor is the ninth most commonly occurring cancer in men and the 14th most
commonly occurring cancer in women worldwide. There were over 400,000 new cases in 2018.
Belarus had the highest rate of kidney cancer in 2018, followed by Latvia. In the Philippines,
there are about 1,116 reported cases of kidney cancer last 2015. (American Institute for Cancer
Research and PH Cancer Facts and Estimates)

Our group had chosen renal new growth as our case study because it is unique and we
are so much interested about it. Our clinical instructor also said that it is an interesting case
because it is not a common case we can encounter in the area we are assigned to. We want to
gain better understanding about the disease and its concept so that we can apply this knowledge
when providing care to our patients.
 PATIENT’S PROFILE

NAME: F.T.B.
GENDER: Female
AGE: 67 years old
DATE OF BIRTH: October 26, 1951
ADDRESS: Sipac Almacen, Navotas City
RELIGION: Roman Catholic
DATE ADMITTED: September 11, 2019
Chief Complaint: Gross Hematuria

History of Present Illness:

Five months prior to consultation, patient F.T.B. have a palpable mass at the right upper
quadrant approximately 4x4cm with associated episodes of hematuria was noted.
Two months prior to consultation, there was an increase in the size of the palpable mass
approximately 5x5cm with associated loss of appetite and weight loss. Consultation to URO
OPD was done.
CT Scan result noted to large lobulated exophytic mass with scattered calcifications in
the right kidney approximately 10.4 x 12.5 x 13.5cm.

History of Past Illness

Patient F.T.B. have hypertension and diabetes and had undergone ligation on 1979.

Family History
Patient F.T.B. have family medical history of seizure, cancer, heart and liver disease.

Personal and Social History

Patient do not smoke nor drink.
 Anatomy and Physiology

The Kidneys are the primary functional organ of the renal system. They are essential in
homeostatic functions such as the regulation of electrolytes, maintenance of acid–base balance,
and the regulation of blood pressure. They serve the body as a natural filter of the blood and
remove wastes that are excreted through the urine.
They are also responsible for the reabsorption of water, glucose, and amino acids, and will
maintain the balance of these molecules in the body. In addition, they also produce hormones
including calcitriol, erythropoietin, and the enzyme renin, which are involved in renal and
hemotological physiological processes.
The kidneys are a pair of bean-shaped, brownish-red organs about the size of your fist. It
is located retroperitoneally on the posterior wall of the abdomen from the 12th thoracic vertebra
to the 3rd lumbar vertebra in the adult. They are covered by the renal capsule, which is a tough
capsule of fibrous connective tissue. Adhering to the surface of each kidney are two layers of
fat to help cushion them.
An adult kidney weighs 120 to 170 g and is 12 cm long, 6 cm wide, and 2.5 cm thick.
The kidneys are well protected by the ribs, muscles, Gerota’s fascia, perirenal fat, and the renal
capsule, which surround each kidney.
External Anatomy of the Kidneys
The hilum is the rounded outer convex surface of each kidney. Each hilum is penetrated
with blood vessels, nerves, and the ureter.

Layers of tissue surrounding the kidney

The deep layer, the renal capsule, is a smooth, transparent sheet of dense irregular
connective tissue that is continuous with the outer coat of the ureter. It serves as a barrier against
trauma and helps maintain the shape of the kidney.

The middle layer, the perirenal fat, is a mass of fatty tissue surrounding the renal
capsule. It also protects the kidney from trauma and holds it firmly in place within the
abdominal cavity.

The superficial layer, the renal fascia, is another thin layer of dense irregular
connective tissue that anchors the kidney to the surrounding structures and to the abdominal
wall. On the anterior surface of the kidneys, the renal fascia is deep to the peritoneum.

Internal Anatomy of the Kidneys

The kidney consists of two distinct regions, the renal parenchyma and the renal pelvis.
The renal parenchyma, the functional portion of the kidney, is divided into the cortex and the
medulla.
 The renal medulla is the darker reddish-brown inner region of the kidney. It consists
of several cone-shaped renal pyramids. The base each pyramid faces the renal cortex, and its
apex, called a renal papilla, points toward the renal hilum.

The renal cortex is the smooth-textured area extending from the renal capsule to the
bases of the renal pyramids and into the spaces between them. It contains the glomeruli,
proximal and distal tubules, and cortical collecting ducts and their adjacent peritubular
capillaries. It is divided into an outer cortical zone and an inner juxtamedullary zone. Those
portions of the renal cortex that extend between renal pyramids are called renal columns.

The papillary ducts drain into cuplike structures called minor and major calyces. Each
kidney has 8 to 18 minor calyces and 2 or 3 major calyces. A minor calyx receives urine from
the papillary ducts of one renal papilla and delivers it to a major calyx. Once the filtrate enters
the calyces it becomes urine because no further reabsorption can occur. The reason for this is
that the simple epithelium of the nephron and ducts becomes transitional epithelium in the
calyces. From themajor calyces, urine drains into a single large cavity called the renal pelvis
and then out through the ureter to the urinary bladder.

The hilum expands into a cavity within the kidney called the renal sinus, which
contains part of the renal pelvis, the calyces, and branches of the renal blood vessels and nerves.
 The Nephrons are the functional units of the kidneys. Each of the kidneys contains
about 1 million nephrons. Each nephron consists of two parts: a renal corpuscle, where
blood plasma is filtered, and a renal tubule into which the filtered fluid (glomerular filtrate)
passes. The two components of a renal corpuscle are the glomerulus (capillary network) and
the glomerular capsule or Bowman’s capsule, a double-walled epithelial cup that surrounds
the glomerular capillaries.
{{

Blood plasma is filtered in the glomerular capsule, and then the filtered fluid passes into
the renal tubule, which has three main sections. In the order that fluid passes through them,
the renal tubule consists of a (1) proximal convoluted tubule (PCT) (2) nephron loop (loop
of Henle), and (3) distal convoluted tubule (DCT). The distal convoluted tubules of several
nephrons empty into a single collecting duct (CD)

Nephrons are structurally divided into two types: cortical and juxtamedullary. Cortical
nephrons are found in the cortex of the kidney, and juxtamedullary nephrons sit adjacent to
the medulla. The juxtamedullary nephrons are distinguished by their long loops of Henle and
the vasa recta, long capillary loops that dip into the medulla of the kidney.

The glomerulus is composed of three filtering layers: the capillary endothelium, the
basement membrane, and the epithelium. The glomerular membrane normally allows filtration
of fluid and small molecules yet limits passage of larger molecules, such as blood cells and
albumin.
 PHYSICAL ASSESSMENT

Date: September 12, 2019

BODY PARTS ACTUAL FINDINGS
▪ Temperature: 36.4
▪ Pulse rate: 111 bpm
▪ Respiratory rate: 20 cpm
▪ Blood Pressure: 105/76
GENERAL STATUS
▪ O2 Saturation: 98%
▪ Weight: 71 kg
▪ Height: 5 feet
▪ BMI: 31
SKIN ▪ Dry, rough, and pale skin

HEAD AND NECK

▪ Symmetrical
▪ Non-palpable nodules
▪ No masses
EYES
▪ PERRLA
▪ Pale palpebral conjunctiva
EARS
HEENT
▪ (-) discharges/drainage
▪ (-) swelling/redness
NOSE
▪ Patent nares
▪ Non-tender
▪ (-) discharges
MOUTH & THROAT
▪ Lips are pale and dry
▪ (-) Tonsillar enlargement
▪ Symmetrical chest expansion
THORAX ▪ Clear breath sounds
▪ No signs of difficulty of breathing
▪ No murmur is heard
HEART
▪ Regular heart rhythm
▪ Soft and flabby
ABDOMEN ▪ Hypoactive bowel sounds
▪ Palpable mass on right upper quadrant
▪ Palms and soles are pallor in color
EXTREMITIES
▪ Pale nail beds
NEUROLOGIC ▪ Alert, coherent, and oriented
 Pathophysiology of Renal New Growth
Predisposing Factors Precipitating Factors

- Female - Diabetes type 2

- 67 years old Unknown etiology - Hypertension
- Family History of: Heart - Obesity
Disease, Liver
- Disease, Seizures, Cancer
Changes in mitochondrial
cells

Proliferation of oncocytes in the right

kidney’s collecting ducts

Formation of tumor

Palpable mass on right Loss of appetite Hematuria

upper quadrant of the
abdomen

Weight loss
 LABORATORY RESULTS
Date: August 25, 2019

COMPLETE BLOOD COUNT

LABORATORY REFEERENCE
RESULT IMPLICATION
TEST RANGE
Hemoglobin 12.0-15.0 ↓ 11.6 Microcytic Anemia

Hematocrit 35-49 ↓ 34 Microcytic Anemia

RBC 3.80- 5.20 4.35 Normal

MCV 80-100 ↓ 78 Microcytic Anemia
MCH 26-34 27 Normal
MCHC 32-36 34 Normal
WBC 3.6-10.6 4.9 Normal
Platelet Count 150-450 204 Normal
MPV 7.0-12.0 12 Normal
RDW 11.5-14.5 14.4 Normal
DIFFERENTIAL COUNT
Neutrophil 35-66 56.7 Normal
Lymphocytes 24-44 24.3 Normal
Basophil 0-2 0.4 Normal

Monocytes 3-6 ↑ 10.4 Severe Bacterial Infection

Eosinophil 1-3 ↑ 8.2 Bacterial Infection

CLINICAL CHEMISTRY
Date: August 25, 2019

REFERENCE
TEST RESULT POSSIBLE IMPLICATION
RANGE
Creatinine 62.0-106.0 83.1 Normal
Sodium 137.0-145.0 139.1 Normal
Potassium 3.5-5.1 4.2 Normal
 HEMATOLOGY
Date: August 25, 2019

ABO Type: A

RH Type: POSITIVE

COAGULATION
REFERENCE
TEST RESULT POSSIBLE IMPLICATION
RANGE

APTT 25.0-33.8 28.40 Normal

APTT
30-40 25.9 Normal
Control
PT 9.8-14.0 11.90 Normal

PT% 70-100 91.90 Normal

PT INR Less than 1.20 0.99 Normal

PT Control 10-14 11.6 Normal

 DRUG STUDY

Pre-operative Medications

Drug Mechanism of Action Rationale Possible Side Effects Nursing consideration

Omeprazole Inhibits proton pump To prevent of recurrence - Headache - Monitored the patient and
activity by binding to of gastric or duodenal - Nausea report any severe headache,
40mg IV once NPO
hydrogen-potassium ulcers, gastric mucosal - Pain fever, chills and diarrhea.
adenosine protection against - Diarrhea
triphosphatase, located damage caused by non- - Vomiting
at secretory surface of steroidal anti- - Fever
gastric parietal cells to inflammatory drugs. - Chills
suppress gastric acid
secretion.

Ceftriaxone Inhibits cell wall To treat a wide variety - Diarrhea - Instructed the patient to report
synthesis, promoting of bacterial infections. - Pain any pain at IV site.
1g IV (-) ANST
osmotic instability;
usually bactericidal.

Felodipine Unknown. A To lower the blood - Headache - Instructed the patient to drink it
dihydropyridine- pressure. - Peripheral edema with a sips of water.
5mg OD with sips of
derivative calcium - Abdominal pain - Monitored blood pressure for
water
channel blocker that - Nausea response.
prevents entry of
calcium ions into
vascular smooth muscle
and cardiac cells.

Gliclazide Lower blood glucose by To lower the blood - Abdominal pain - Monitored the signs and
stimulating the release glucose in diabetic - Diarrhea symptoms of hypoglycemia.
30mg OD
of insulin from the patiens. - Nausea
 pancreas and increasing - Vomiting
sensitivity to insulin at - Rashes
receptor sites.

Intra-operative Medications

Drug Mechanism of Action Rationale Possible Side Effects Nursing consideration

Midazolam May potentiate the To induce sleepiness or - Involuntary - Monitored blood pressure, heart
Versed effects of GABA, drowsiness and relieve movements and rhythm, respirations airway
1mg IV depress the CNS and apprehension. - Variations in integrity and arterial oxygen
suppress the spread of blood pressure saturation during procedure.
seizure activity. and pulse rate
- Decreased
respiratory

Fentanyl Unknown. Binds with To provide analgesia - Dry mouth - Monitored circulatory and
opioid receptors in the and sedation - Increase blood respiratory status.
Duragesic CNS, altering perception pressure - Monitored postoperative Blood
of an emotional response - Respiratory pressure, respiratory rate and
50mg IV to pain. depression pulse rate.
- Monitored O2 saturation.

Propofol Unknown. Rapid acting To induce anesthesia - Dystonia - Monitored vital signs specially
I.V sedative hypnotic. - Hypotension blood pressure
Diprivan - Hypertension
- Apnea

Bupivacaine Used to numb parts of Used for epidural block - Hypotension - Monitored cardiac symptoms
the body during surgery in abdominal operations - Heart attack during rest.
Marcaine
in all ages. requiring complete - Alerted for new seizures
0.2% muscle relaxation.
 - Assessed heart rate, ECG and
heart sounds

Sevoflurane Induces a state in which To induced and - Shivering - Monitored vital signs
the CNS is altered so maintenance of general - Monitored continuous of pulse
Ultane
that varying degrees of anesthesia. oximetry
pain relief depression of
consciousness, skeletal
muscle relaxation and
reflex reduction are
produced

Post-Operative Medications

Drug Mechanism of Action Rationale Possible Side Effects Nursing consideration

Morphine Sulfate Selective mu agonist To decrease the severity - Respiratory - Monitored patient’s circulatory,
that produces analgesia of pain. depression respiratory, bladder and bowel
Roxanol
and sedation by binding - Hypotension functions carefully.
Via epidural cath 12hrs with the mu opioid - Urine retention
x 4 doses receptor. - Nausea - Prepared opioid antagonist and
- Vomiting resuscitation equipment.
- Altered level of
consciousness

Paracetamol May cause analgesia by To relieve mild to - Stomach pain - Assessed patients fever or pain
inhibiting CNS moderate pain. - Loss of appetite - Assessed allergic reaction
Tamin
prostaglandin synthesis. - Dark urine
600mg IV q 6hrs for - Jaundice
24hrs
 NURSING CARE PLAN: Fluid Volume Deficit
DATE: September 12, 2019

BACKGROUND NURSING
ASSESSMENT DIAGNOSIS PLANNING RATIONALE EVALUATION
KNOWLEDGE INTERVENTIONS

Objective: Fluid volume Unknown After 2 hours of 1. Assessed the vital 1. To detect signs After 2 hours of
deficit related etiology nursing signs of the patient of fluid volume nursing intervention
- Dry skin to active fluid intervention the Noted the loss or the patient was able
- Pale palms volume loss patient will be decreasing blood hypovolemia to partially maintain
- BP: 102/64 Changes in able to maintain pressure and rapid fluid volume at a
- PR: 118 mitochondrial fluid volume at a heartbeat. functional level as
- Suction cells functional level her vital signs
Collection as evidenced by 2. Estimated 2. To evaluate increased but still
container normal vital procedural fluid degree of fluid below normal level.
contains 2.5 Proliferation of signs. losses of the deficit.
L of blood oncocytes in the patient BP: 105/76
right kidney’s PR: 111
collecting ducts
3. Assisted in the 3. To replace Goal partially met.
administration of fluid loss.
Formation of IV fluids.
tumor
4. Rechecked the 4. To ensure
blood products for giving the
Nephrectomy the patient. correct blood
(Right) to the patient.

5. Assisted in blood 5. To replace the

Bleeding during transfusion. blood loss.
the procedure
 OPERATIVE TECHNIQUE

Pre-operative and Post-Operative Diagnosis:

▪ Renal New Growth

Operation performed:

▪ Nephrectomy (Right)

Time began: 7:32 AM

Time finished: 10:35 AM

Anesthesia: General Anesthesia

Technique of Operation:

1. Patient in supine position under general anesthesia.

2. Chevron incision made and taken into the peritoneal, right retroperitoneal space.
3. Packed and retracted liver and gallbladder superiorly
4. Incised post parietal peritoneum from common iliac artery to the hepatic flexure.
5. Dissected between the anterior renal fascia and the mesentery of the ascending colon.
6. Mobilized the hepatic flexure of the colon.
7. Kocher maneuver done.
8. Incised the anterior renal fascia on the medial aspect of the kidney and identified
inferior vena cava.
 9. Dissected anteriorly on the inferior vena cava, both cranially and caudally, until the left
renal vein, right renal vein and right gonadal vein were exposed.
10. Dissected the renal vein and placed a vessel loop around it.
11. Palpated the vein and inferior vena cava for thrombus – negative.
12. Isolated the right renal artery
13. Bluntly dissected on the posterior pararenal space then the interior pole of the kidney.
14. Identified and double ligated the ureter with 2.0
15. Divided the ureter between the ligatures.
16. Dissected the infero-medial kidney away from the IVC until it was free up until the
renal hilum superiorly
17. Gently pulled the kidney caudally into the wound to expose the upper pole attachments.
18. Dissected cranial attachments laterally to medially.
19. Removed the adrenal glands enbloc with the kidneys.
20. Divided renal vein and renal artery.
21. Removed the kidney.
22. Irrigation of the renal fossa.
23. Coagulation of bleeders.
24. Placed a drain on the renal fossa and right gutter
25. Exterior distal end of the drain and anchored into the skin.
26. Closure of incision by 2 layers continuous interlocking sutures.
27. Closure of skin by layers.
28. Patient tolerated the procedure well.

Specimen removed: Right kidney

 RECOMMENDATIONS

▪ Morphine Sulfate via epidural catheter 12 hrs x 4 doses

MEDICATIONS
▪ Paracetamol 600mg IV q 6hrs for 24 hrs

▪ Encouraged the patient for early ambulation

EXERCISE ▪ Assisted the patient in Range of motion exercise

▪ Instructed the patient to drink his medicine as part of his

TREATMENT
treatment regimen.

▪ Encouraged the patient to maintain personal hygiene to

HEALTH avoid risk for infection.
TEACHING ▪ Advised patient to have adequate rest periods.

▪ Instructed patient to inform her physician if any of the

following are manifested.

- Redness and swelling of the incision

OBSERVATION
- If you feel chills report to the physician
- Trouble of breathing and sudden chest pain
- Trouble in bowel movement and urination
- Dressing becomes soak

▪ Advised the patient to eat more fruits and vegetables and

increased fluid intake.
DIET
▪ The patient’s diet is low fat, low sodium diet
▪ Avoid alcohol and smoking

▪ Emphasized to the patient the importance of prayer.

Spiritual ▪ Encouraged the patient and his family for spiritual
guidance like praying together.