Davao Doctors College, Inc.

General Malvar St., Davao City

Nursing Program

Nursing Management of a Patient with

Nephrectomy
A Case Study Presented to the Nursing Clinical Instructors
of Davao Doctors College, Inc.

In Partial Fulfillment of the Requirements in

NRG405: Intensive Nursing Practicum

by:
Sieras, Jasmin C.

March 29, 2022

1
 TABLE OF CONTENTS

I. Introduction..................................................................................................3
II. Anatomy and Physiology.............................................................................................
III. Pathophysiology...........................................................................................................
IV. Medical Management...................................................................................................
V. Diagnosis......................................................................................................................
VI. Procedure Proper (with Instrumentation) ..................................................................
VII. Roles of Circulating and Scrub Nurse .......................................................................
VIII. Nursing Management.................................................................................................
a. Nursing Care Plan
i. Pre-Operative....................................................................................................

ii. Intra-Operative..................................................................................................

iii. post-Operative..................................................................................................

IX. Pharmacology............................................................................................................
i. Pre-Operative...............................................................................................
ii.Intra-Operative.............................................................................................
iii. Post-Operative...........................................................................................
X. Bibliography ..............................................................................................................

2
 INTRODUCTION

A nephrectomy is a surgical surgery in which a kidney or a part of a kidney is

removed. A little piece of the kidney or the complete organ and surrounding tissues
may be removed during a nephrectomy. Only the damaged or contaminated kidney
is removed in partial nephrectomy. The entire kidney, a piece of the tube leading to
the bladder (ureter), the gland that sits above the kidney (adrenal gland), and the
fatty tissue around the kidney are all removed during radial nephrectomy. The kidney
and a piece of the connected ureter are removed during a simple nephrectomy for
living donor transplant procedures.

Throughout 1998 and 2010, the incidence in the United States was predicted
to be over 27,000 instances. The majority of cases involved infants (under the age of
one year) (36 percent ). In children, the most common reason for nephrectomy was
benign problems (58.8%–73.8%), such as ureteropelvic junction blockages (UPJO),
multicystic dysplastic kidney (MCDK), and ureterocele. In Saudi Arabia, there are
just a few studies on nephrectomy in children. Only two research have addressed
the topic of nephrectomy in children to our knowledge. Only two out of 71 children
diagnosed with nephrolithiasis between 1982 and 1991 required nephrolithiasis
surgery, according to Al-Rasheed et al. The other study, on the other hand, looked at
the indications for nephrectomy in adults. As a result, the rationale for nephrectomy
and the outcomes in the Saudi population are not well understood. The goal of this
study was to assess the indications for nephrectomy in children in Riyadh, Saudi
Arabia's King Fahad Medical City (KFMC).

Kidney illnesses, particularly End Stage Renal Disease (ESRD), are now the
Philippines' seventh largest cause of death. Every hour, one Filipino, or around 120
Filipinos per million population, suffers chronic renal failure. Approximately 1.1
million people worldwide are on renal replacement treatment, including over 5,000
Filipino patients undergoing dialysis. According to reliable predictions, the number of
these patients will double in 2010.

3
 II. ANATOMY AND PHYSIOLOGY

Location of the Kidney

There are two kidney which lie retroperitoneally in the lumbar area. The right kidney
is lower that the left due to displacement by the liver.

Connective tissue anchors the kidney to surrounding structures and helps maintain
their normal position.

Each kidney is bean shaped and measures approximately 11cm x 6cm x 3cm and
weighs 120-170gram. The kidneys are enclosed by a fibrous capsule and the
parenchyma consists of a cortex and medulla. Within the medulla approximal 80-18
triangular structures called renal pyramids are found, and the base of these pyramid
renal papillae are directed toward the center of the kidney. Together the cortex and
renal pyramids constitute the parenchyma of the kidney and structurally the
parenchyma of each kidney consist of approximately 1 million nephrons which are
the functional units of the kidney.

4
Renal Blood Supply

The kidneys receive their blood supply from the renal arteries which branch to
the left and right from the abdominal aorta. This blood supply to the kidney is equal
to 21% of cardiac output and 99% of the cardiac output returns to the general body
circulation via the renal vein. The remaining 1% undergoes further processing in the
nephron resulting in urine.

The Nephron

The function units of the kidney are the nephron, and each nephron contains
two components:

 Glomerulus and Bowmans capsules (Renal Corpuscle)

 Tubular component

5
III. PATHOPHYSIOLOGY

6
 IV. MEDICAL MANAGEMENT

Nonsurgical treatments

Small kidney cancers are sometimes destroyed using nonsurgical treatments, such
as heat and cold. These procedures may be an option in certain situations, such as
in people with other health problems that make surgery risky.

Options may include:

 Treatment to freeze cancer cells (cryoablation). During cryoablation,

a special hollow needle is inserted through your skin and into the kidney
tumor using ultrasound or other image guidance. Cold gas in the needle
is used to freeze the cancer cells.

 Treatment to heat cancer cells (radiofrequency ablation). During

radiofrequency ablation, a special probe is inserted through your skin
and into the kidney tumor using ultrasound or other imaging to guide
placement of the probe. An electrical current is run through the needle
and into the cancer cells, causing the cells to heat up or burn.

Treatments for advanced and recurrent kidney cancer

Kidney cancer that comes back after treatment and kidney cancer that spreads to
other parts of the body may not be curable. Treatments may help control the cancer
and keep you comfortable. In these situations, treatments may include:

 Surgery to remove as much of the kidney cancer as possible. If the

cancer can't be removed completely during an operation, surgeons may
work to remove as much of the cancer as possible. Surgery may also be
used to remove cancer that has spread to another area of the body.

 Targeted therapy. Targeted drug treatments focus on specific

abnormalities present within cancer cells. By blocking these
abnormalities, targeted drug treatments can cause cancer cells to die.
Your doctor may recommend testing your cancer cells to see which
targeted drugs may be most likely to be effective.

7
 Immunotherapy. Immunotherapy uses your immune system to fight
cancer. Your body's disease-fighting immune system may not attack
your cancer because the cancer cells produce proteins that help them
hide from the immune system cells. Immunotherapy works by interfering
with that process.

 Radiation therapy. Radiation therapy uses high-powered energy beams

from sources such as X-rays and protons to kill cancer cells. Radiation
therapy is sometimes used to control or reduce symptoms of kidney
cancer that has spread to other areas of the body, such as the bones
and brain.

 Clinical trials. Clinical trials are research studies that give you a chance
to try the latest innovations in kidney cancer treatment. Some clinical
trials assess the safety and effectiveness of potential treatments. Other
clinical trials try to find new ways to prevent or detect disease. If you're
interested in trying a clinical trial, discuss the benefits and risks with your
doctor.

8
 V. DIAGNOSIS

Kidney cancer staging

Once your doctor identifies a kidney lesion that might be kidney cancer, the
next step is to determine the extent (stage) of the cancer. Staging tests for kidney
cancer may include additional CT scans or other imaging tests your doctor feels are
appropriate.

The stages of kidney cancer are indicated by Roman numerals that range from I to
IV, with the lowest stages indicating cancer that is confined to the kidney. By stage
IV, the cancer is considered advanced and may have spread to the lymph nodes or
to other areas of the body.

Severe trauma

Injured patients rarely require laparotomy solely for the treatment of renal injury. With
the broad success of nonoperative management of solid organ injury, those patients
who undergo laparotomy tend to be more seriously injured and in need of more
aggressive interventions. Patients who require nephrectomy after trauma tend to be
the most severely injured and hemodynamically unstable, and warrant nephrectomy
as part of the damage control paradigm in order to optimize the opportunity for
survival.

Renal Cancer

Renal cancer accounts for about 5% of all cancers in the United States (American
Cancer Society [ACS], 2015), where the incidence of renal cancer at all stages has
increased in the past two decades. The incidence of renal cell carcinoma is higher in
both men and women with an increased body mass index. Tobacco use continues to
be a significant risk factor (see Chart 54-3). American Indians and Alaskans have a
higher mortality rate from renal carcinoma compared to other races and population
groups. The most common type of renal carcinoma arises from the renal epithelium
and accounts for more than 85% of all kidney tumors (ACS, 2015). These tumors

9
may metastasize early to the lungs, bone, liver, brain, and contralateral kidney. One
quarter of patients have metastatic disease at the time of diagnosis. Although
enhanced imaging techniques account for improved detection of early-stage kidney
cancer, it is unknown why the rate of late-stage kidney cancers is high.

Polycystic Kidney Disease

Polycystic kidney disease (PKD) is a genetic disorder characterized by the growth of

numerous fluid-filled cysts in the kidneys, which destroy the nephrons. PKD cysts
can profoundly enlarge the kidneys while replacing much of the normal structure,
resulting in reduced kidney function an leading to kidney failure. PKD can also cause
cysts in the liver and problems in other areas, such as blood vessels in the brain and
heart. The number of cysts and the resulting complications help distinguish PKD
from the usually harmless cysts that can form in the kidneys in later years of life. In
the United States, PKD and cystic diseases are a leading cause of kidney failure.
Two major inherited forms of PKD exist: Autosomal dominant PKD is the most
common inherited form. Symptoms usually develop between 30 and 40 years of age,
but they can begin earlier, even in childhood. About 90% of all PKD cases are
autosomal dominant PKD. Autosomal recessive PKD is a rare inherited form.
Symptoms of autosomal recessive PKD begin in the earliest months of life or in
utero. When autosomal dominant PKD causes kidneys to fail, which usually happens
after many years, the patient requires dialysis or kidney transplantation.
Approximately one half of individuals with autosomal dominant PKD progress to
stage 5 CKD, requiring renal replacement therapy.

Nephrotic Syndrome

Nephrotic syndrome is a type of kidney disease characterized by increased

glomerular permeability and is manifested by massive proteinuria (Grossman &
Porth, 2014). Clinical findings include a marked increase in protein (particularly
albumin) in the urine (proteinuria), a decrease in albumin in the blood
(hypoalbuminemia), diffuse edema, high serum cholesterol, and low-density
lipoproteins (hyperlipidemia). The syndrome is apparent in any condition that
seriously damages the glomerular capillary membrane and results in increased
glomerular permeability to plasma proteins. Although the liver is capable of

10
increasing the production of albumin, it cannot keep up with the daily loss of albumin
through the kidneys.

VI. PROCEDURE

Laparoscopic radical nephrectomy (LRN) at the authors' institution is mostly

performed transperitoneal. The procedure can be divided into the following 8 steps
critical to success:

1. Patient positioning and equipment check

2. Veress needle and trocar placement
3. Mobilization of the colon
4. Identification of the ureter and gonadal vein
5. Renal hilar dissection
6. Remaining renal attachments
7. Specimen removal
8. Closure

Patient positioning and equipment check

An important aspect of laparoscopy that is often overlooked is the preoperative

equipment check. In few areas of surgery does the surgeon depend more on
technology for the procedure. The carbon dioxide tanks must be full, and the
insufflator, light source, camera, and cautery need to be in good working order.
Having ready access to both the argon beam coagulator and the harmonic scalpel or
the LigaSure system is useful if intraoperative hemorrhage is encountered. Finally,
the desired instruments (eg, trocars, Endoshears, staplers, clips) must be available,
with the surgical technician having knowledge of each device. Generally, a
laparoscopic procedure should not be started unless all instrumentation is functional.

After general anesthesia is administered, a urinary catheter and orogastric tube are
placed. The patient is placed in a 45° modified flank position with the top of the iliac

11
crest at the top of the kidney rest and the table flexed. The arms are typically taped
over a folded pillow, although an armrest is satisfactory. The patient is then securely
taped to the operative table to allow banking of the table during surgery. All
appropriate areas are padded to include the axilla, knees, elbows, and ankles. A
wide sterile preparation and drape is performed in the event that open conversion is
necessary. Pneumatic compression devices to the lower extremities help prevent
thromboembolic phenomena.

Veress needle and trocar placement

Initial pneumoperitoneum can be achieved with the Veress needle to 15 mm Hg.

This can be performed at either the umbilicus or lateral to the umbilicus at the
midclavicular line. Often, the patient's prior abdominal scars dictate which area is
optimal because, as a rule, staying as far away as possible from these scars is better
to avoid inadvertent bowel injury from adhesions. Alternatively, a Hassan technique
may be used with S-retractors to cut down to the peritoneum under direct vision (this
is currently the authors' preferred method). An Optiview or Visiport may also be used
with a 0° camera to enter the abdomen in a controlled fashion after just a skin
incision.

The initial 10-mm trocar is placed under vision at or near the umbilicus for both left-
sided and right-sided procedures. Subsequent trocars are placed under vision with
the 10-mm laparoscope in the umbilical trocar. For left-sided tumors, a 5- to 12-mm
trocar is placed lateral to the umbilical port at the edge of the left rectus abdominus
muscle. Finally, a third 5-mm trocar is placed midway between the xiphoid and the
umbilicus. For right-sided tumors, the 5- to 12-mm trocar is placed midway between
the xiphoid and the umbilicus, and the 5-mm trocar is placed lateral to the umbilical
port at the edge of the rectus. If necessary, an additional 5-mm trocar is placed
laterally at the anterior axillary line, below the ribcage for liver retraction. The first
image below depicts trocar placement for the left-sided procedure; the second image
shows placement for the right-sided procedure.

12
Several scenarios call for different port placements. The first is in the presence of
prior abdominal surgery when the initial ports need to be adjusted to allow for lysis of
adhesions. This varies with each patient and challenges even the most experienced
laparoscopist. The next scenario involves patients who are obese and in whom port
placement as described would complicate lateral and superior dissection. Therefore,
in these patients, all ports are moved laterally as needed to allow better purchase of
instruments for dissection. Finally, in patients who are very tall, move ports superiorly
for similar reasons.

Mobilization of the colon

The following description of LRN is for a right-sided procedure; variations for a left-
sided approach are provided.

The lateral line of Toldt is identified and incised with either the harmonic scalpel or a
hook electrode approximately 1 cm from the colon. At this point, care is taken not to
allow dissection to stray too deep. Only the thin layer of peritoneum over the anterior
surface of the kidney is mobilized from the iliac vessels to the hepatic flexure of the
colon (see image below). If the dissection is too deep, the Gerota fascia is entered
and the bowel mesentery is more difficult to roll medially.

Colon mobilization for a right laparoscopic radical

This plane is bluntly dissected by dividing the colorenal ligaments until the colon has
rolled medially. The 5-mm suction irrigator is particularly useful in this dissection.
Small vessels that are encountered are either cauterized or clipped with a 5-mm clip
applier. An alternative is to use either the harmonic scalpel or the LigaSure system to
control these vessels. Remaining in the correct plane between the colonic mesentery
and Gerota fascia is important. Care should be taken to avoid entering the bowel
mesentery, as hemorrhage would ensue. Once the colon has rolled medially, the
duodenum is rolled medially. This allows identification of the inferior vena cava. To
fully visualize the upper pole of the right kidney under the liver, dividing the right
triangular ligament and part of the anterior coronary ligament is usually necessary.

13
For a left-sided LRN, the procedure begins in similar fashion at the line of Toldt. The
phrenicocolic, splenocolic, and splenorenal ligaments at the splenic flexure of the
colon are divided to allow the upper pole to drop into view.

Identification of the ureter and gonadal vein

The correct identification of the ureter and gonadal vessels is one of the crucial steps
for a successful LRN. Understanding the relationship of these structures at various
levels aids in this dissection. At the level of the lower pole of the kidney and proximal
ureter, the gonadal vessels are medial to the ureter. As they proceed inferiorly, they
cross the ureter and course laterally as they exit the internal inguinal ring.
Understanding this relationship is important for correct identification of the ureter and
ease of subsequent identification of the renal hilum.

Additional methods to help identify the ureter include pinching with atraumatic
grasping forceps to observe peristalsis and noting the color differences between
structures. Generally, the gonadal vein appears blue, while the ureter appears white.
If neither structure is identified, it is occasionally necessary to begin the dissection
medially along either great vessel and to extend laterally on top of the psoas until the
ureter or gonadal vessels are identified.

Once the ureter and gonadal vein are identified, the next step for a right-sided LRN
is following these structures superiorly to identify both the lower pole of the kidney
and the renal hilum. This is accomplished by lateral retraction of these structures
with the left hand using the grasping forceps or the 5-mm suction/irrigator and
dissecting with the right hand using the harmonic scalpel or LigaSure.

The branching of the right gonadal vein from the inferior vena cava is controlled with
two 5-mm clips on either side and divided. The distalmost aspect of the right gonadal
vein can be divided, if necessary; however, leaving the ureter intact to provide
inferior retraction during the remainder of the nephrectomy is important. For a left-
sided LRN, the gonadal vein and the ureter are again used to identify the renal hilum

14
by dissecting superiorly. Following the gonadal vein leads the surgeon directly into
the left renal vein. The branching of the left gonadal vein is double clipped and
transected, if necessary, for retraction or hilar dissection.

At this point in the procedure, the lower pole dissection is easily performed. The
surgeon uses the left hand to retract the kidney anterolaterally, and attachments
between the lower pole and the psoas muscle or the posterior body wall are taken
down. During this portion of the procedure for a right-sided LRN, the placement of a
fourth 5-mm trocar for liver retraction is usually unnecessary. However, once the
surgeon proceeds to the right renal hilar dissection, this additional trocar placement
may be necessary. This can be placed at the anterior axillary line subcostally or in
the midline superior to the upper 5-mm trocar. A 5-mm laparoscopic snake retractor
is introduced into this trocar, and the liver is retracted superiorly.

Renal hilar dissection

Once the ureter and gonadal vein are secure and the inferior pole of the kidney is
dissected free posteriorly, proceed with the renal hilar dissection. The left hand, once
again, is used to hold 5-mm grasping forceps to provide lateral and superior
retraction of the kidney. The right hand is used to divide the tissue planes gently until
the renal vein is identified. Small lymphatic channels can be controlled with either
clips or cautery.

If lateral retraction proves difficult, introducing a large silk suture on a Keith needle
through the patient's flank is useful. This is then hooked around the ureter, and the
needle is passed outside the body. The suture is secured with forceps to tent the
ureter against the interior body wall; this provides excellent lateral retraction and
frees a hand to aid in the hilar dissection. On the right side, the renal hilar dissection
is slightly easier because the renal vein has no branches. This is dissected
circumferentially until enough of its length is free to allow division with the
laparoscopic EndoGIA stapler with a vascular load. The renal artery posterior to the
renal vein is identified and dissected in a similar fashion. Dividing the artery first is
customary.

15
For a left-sided LRN, dissection proceeds in the same manner until the renal vein is
encountered. The gonadal vein has already been transected, but the adrenal and
lumbar veins must be identified. Once these 3 branches are visualized and
controlled, the remainder of the vein is dissected circumferentially, and the artery is
identified just posterior to the vein.

The authors' approach is to use a stapler to divide the renal artery and then the vein
although most surgeons clip and divide the artery first. This stapler applies 3 rows of
titanium staples on either side of a divided vessel and is very effective in controlling
the hilar vessels. One caveat is to keep the vessel clamped in the stapler for at least
10-15 seconds prior to deploying the staples. This allows for the tissue to release
third-space fluid and to become thinner, resulting in a better seating of the staples.
The renal artery and vein may be stapled en bloc, when necessary. [14] Although
this is not advocated for routine use, the authors feel it is reasonable in lieu of open
conversion if a complex or bleeding hilum can be controlled in this manner.

No arteriovenous fistulas have been reported in humans when the stapling device is
used. Historical reports of arteriovenous fistula seem to have occurred mainly in the
setting of an inflammatory process involving sutures. The 3 rows of titanium staples
likely confer an advantage to sutures, although the authors would still exercise
caution in the setting of an inflammatory renal condition. After the hilum is taken,
leaving the closed stapler in its trocar and using this instrument to bluntly dissect the
medial portion of the upper pole can be useful. This large instrument provides
excellent purchase and bluntly dissects tissue effectively.

On the right side, if an adrenalectomy is being performed, the medial dissection

continues along the inferior vena cava superiorly until the adrenal vein is
encountered, which is usually controlled with clips. The dissection then proceeds
superiorly around the adrenal gland. Small adrenal arterial branches may be
effectively divided with the harmonic scalpel or LigaSure. For a left-sided
adrenalectomy, the adrenal vein already has been transected, and dissection
continues superiorly around the gland.

If an adrenalectomy is not indicated, the surgeon bluntly dissects along the plane
between the adrenal gland and the superior pole of the kidney. If small vessels are
encountered in this fatty plane, they are divided easily with various cautery devices.

16
Remaining renal attachments

All that should be left holding the kidney in situ is the lateral attachments to the body
wall, the superior attachments lateral to the adrenal gland, and the ureter. These
attachments are dissected free with a combination of sharp and blunt dissection
using the cautery device of choice, with the grasping forceps for counter traction.
The ureter may be divided before or after the lateral attachments are completely
freed. The authors typically place two 5-mm clips on the ureter and transect it. The
specimen is now completely dissected and placed on either the liver or the spleen in
anticipation of its removal.

Specimen removal

Two options exist for removing the kidney—morcellation or intact removal. A

Pfannenstiel or expanded port site (eg, vertical periumbilical) incision may be used
for intact removal. A recent study suggests decreased pain, incisional hernia rate,
and hospital stay among patients who underwent a Pfannenstiel incision compared
with the expanded port site. [15]

The 15-mm EndoCatch is used for intact kidney removal. Under vision, it is placed
through a small opening in the peritoneum at the incision site. (A seal may then be
created around the instrument shaft to allow for pneumoperitoneum by placing the
adjacent abdominal wall tissue in an Allis clamp or towel clip.) The bag is advanced
until it springs open. Grasping forceps are used to place the kidney into the bag
under direct vision. Visualizing completely around the ring of the EndoCatch opening
to ensure that no bowel is being included with the specimen is important. The string
is detached and pulled so that the bag closes, and the ring that held the bag open is
retracted under direct visualization.

The opening of the bag is now brought out through the incision site. The incision is
extended to approximately 5 cm, and the fascial incision is extended to

17
approximately 7 cm. This usually allows easy removal of most kidneys. If necessary,
the incision can be extended. Once the kidney is removed, the fascia is closed with a
running No. 1 PDS suture. Pneumoperitoneum is reestablished, and the renal fossa
and inferior and superior extent of the resection are examined for hemorrhage.

An alternative method to remove the specimen is by tissue morcellation. The LapSac

(Cook Urological, Spencer, Ind) is introduced through the umbilical site. Prior to
placement, the scrub technician prepares it by placing a nitinol wire doubly rapped
through its cuff to allow for better spontaneous opening of the bag once inside. The
tails of the wire are maintained outside the incision after the port is replaced. It is
then held open at the inferior edge of the liver or spleen with two 5-mm grasping
forceps. The kidney is dropped into the sack, which is closed. The neck is then
brought out through the umbilical site. The skin and fascial incision are extended a
few millimeters. A second sterile drape is place over the site with a small hole
through which to allow the neck of the LapSac to pass. The sack is then opened and
a ring forceps and large Kelly clamp or scissors are used to morcellate manually and
to remove pieces of kidney and tumor.

Although more tedious than an electric morcellator, this technique results in bigger
pieces that allow for better pathologic diagnosis and staging. The LapSac is the
preferred bag for tissue morcellation because it has been shown in animal studies to
be impermeable to cells and its nylon reinforced plastic is more durable and resistant
to perforation. Morcellation provides the advantage of improved cosmesis and
decreased incision-related morbidity (eg, hernia, adhesions) and is safe when
performed with the proper technique and bag. To date, no cases of port-site seeding
clearly related to the morcellation process have been reported with the use of the
LapSac.

Closure

Once the specimen is removed, the umbilical fascia closed, and pneumoperitoneum
achieved, the renal fossa and inferior and superior extent of the dissection are
examined for hemorrhage. Pneumoperitoneum, once again, is decreased to 5 mm

18
Hg for a few minutes and hemostasis is confirmed. The 5-mm trocars are removed
under laparoscopic vision. Finally, the last 10-mm trocar is directed into the
corresponding upper quadrant, and as much carbon dioxide as possible is vented.
The trocar is then removed with the laparoscope inside to prevent bowel entrapment.
Finally, all skin edges are approximated with Monocryl suture, skin staples, or
Dermabond adhesive.

VII. ROLES OF CIRCULATING NURSE AND SCRUB NURSE

Circulating Nurse

One sort of operating room (OR) nurse is a circulating nurse, who operates on
the perimeter of the operating room, monitoring patient care, assuring sterility, and
keeping track of equipment and sponges. Perioperative nurses also assist patients in
preparing for surgery and provide important care and monitoring after their
procedures are completed. Scrub nurses are just as crucial as the surgeons who do
the cutting.

A circulating nurse is a surgical nurse who circulates throughout the operating

room to keep an eye on the procedure. He or she serves as a patient advocate,
ensuring that the operating area is kept as safe and hygienic as possible. Circulating
nurses also do a variety of additional activities, such as assisting in the setup of the
operating room for surgery and filling out operation-related paperwork. Circulating
nurses must be present and active during a surgery, which necessitates a high level
of attention to detail and stamina.

DUTIES OF CIRCULATING NURSE

 Before an operation • Checks all equipment for proper functioning such as

cautery machine, suction machine, OR light and OR table

19
  Make sure theater is clean •
 Arrange furniture according to use •
 Place a clean sheet, arm board (arm strap) and a pillow on the OR table
 Provide a clean kick bucket and pail
 Collect necessary stock and equipment
 Turn on aircon unit • Help scrub nurse with setting up theater
 Assist with counts and records

During the Induction of Anesthesia

 Turn on OR light Assist the anesthesiologist in positioning the patient

 Assist the patient in assuming the position for anesthesia
 Anticipate the anesthesiologist’s needs If spinal anesthesia is contemplated

After the patient is anesthetized

 Reposition the patient per anesthesiologist’s instruction

 Attached anesthesia screen and place the patient’s arm on the arm boards •
 Apply restraints on the patient •
 Expose the area for skin preparation
 Catheterize the patient as indicated by the anesthesiologist
 Perform skin preparation

During Operation

 Remain in theater throughout operation Focus the OR light every now and
then Connect diatherapy, suction, etc.
 Position kick buckets on the operating side Replenishes and records sponge/
sutures
 Ensure theater door remain closed and patient’ s dignity is upheld
 Watch out for any break in aseptic technique

20
End of Operation

1 -Assist with final sponge and instruments count.

2 -Signs theater register.

3 -Ensures specimen are properly labeled and signed.

After an Operation

1. Hands dressing to the scrub nurse.

2. Helps remove and dispose of drapes.

3. Helps to prepare the patient for the recovery room.

4. Assist the scrub nurse, taking the instrumentations to the service

(washroom).

5. Ensures that theater is ready for the next case.

ROLE OF CIRCULATING NURSE

Observes the surgery and surgical team from a broad perspective and assists the
team in creating and maintaining a safe and comfortable environment for the patient.
Assesses the patient's condition before, during, and after the operation to ensure an
optimal outcome for the patient that must be able to anticipate the needs of the
surgical team with other care providers necessary for the completion of surgery

Scrub Nurse

A scrub nurse is a particularly trained nurse who works in the operating room
with surgeons and the medical team. Scrub nurses are important members of the
surgical team because they provide support in the operating room as well as patient
care outside of it. Nursing occupations are continually expanding due to the growing
demand for these critical health care workers, and they may be quite demanding but
also very rewarding. Some scrub nurses, particularly experienced scrub nurses who

21
are knowledgeable with a wide range of operations, become highly sought-after
members of surgical teams.

Preoperative nurses are more properly known as scrub nurses. Preoperative

nursing is concerned with the care of patients before to, during, and after surgery.
The scrub nurse is literally "scrubbed in" for the surgery, which means he or she has
used special detergents and is wearing sterile garments so that the nurse can
operate adjacent to the operative field. A scrub nurse assists the surgeon by passing
instruments to him and keeping an eye on the patient's condition. Scrub nurses are
also conversant with emergency department procedures and equipment.

Before an operation

 Ensures that the circulating nurse has checked the equipment

 Ensures that theater has been cleaned before the trolley is set
 Prepares the instruments and equipment needed in the operation
 Uses sterile technique for scrubbing, gowning and gloving
 Receives sterile equipment via circulating nurse using sterile technique
 Performs initial sponges, instruments and needle count, checks with
circulating nurse

When surgeon arrives after scrubbing

 Perform assisted gowning and gloving to the surgeon and assistant

surgeon as soon as they enter the operation suite
 Assemble the drapes according to use. Start with towel, towel clips, draw
sheet and then lap sheet. Then, assist in draping the patient aseptically
according to routine procedure
 Place blade on the knife handle using needle holder, assemble suction tip
and suction tube
 Bring mayo stand back table near the draped patient after draping is
completed
 Secure suction tube and cautery cord with towel clips or allis

22
  Prepares sutures and needles according to use

During an operation

 Maintain sterility throughout the procedure.

 Awareness of the patient’s safety.
 Adhere to the policy regarding sponge/ instruments count/ surgical needles.
 Arrange the instrument on the mayo table and on the back table.

Before the Incision Begins

 Provide 2 sponges on the operative site prior to incision

 Passes the 1st knife for the skin to the surgeon with blade facing downward
and a hemostat to the assistant surgeon Hand the retractor to the assistant
surgeon Watch the field/ procedure and anticipate the surgeon’s needs
 Pass the instrument in a decisive and positive manner
 Watch out for hand signals to ask for instruments and keep instrument as
clean as possible by wiping instrument with moist sponge
 Always remove charred tissue from the cautery tip
 Notify circulating nurse if you need additional instruments as clear as possible
 Keep 2 sponges on the field Save and care for tissue specimen according to
the hospital policy
 Remove excess instrument from the sterile field
 Adhere and maintain sterile technique and watch for any breaks

End of Operation

 Undertake count of sponges and instruments with circulating nurse.

 Informs the surgeon of count result.
 Clears away instrument and equipment.
 After operation helps to apply dressing.
 Removes and siposes of drapes.
 De-gown.

23
  Prepares the patient for recovery room.
 Completes documentation.
 Hand patient over to recover room.

ROLE OF SCRUB NURSE

• Works directly with surgeon within the sterile field, passing instruments, sponges
and other items needed during the procedure. Members of the surgical team who
prepares and preserves a sterile field in which the operation can take place.
Responsible for the sponge counts, the blades and needles and instruments check
throughout the operation. Has a job requiring anticipation, quick reaction and
conscientious observation as well as knowledge of anatomy and of operative
procedures.

VIII. NURSING MANAGEMENT

a. Nursing Care Plan

i. Pre-Operative

 discuss procedure including incision location (flank incision on affected

side) and possible tubes, drains and stent use during/after procedure
with the patient
 inform patient about possible muscle aches following surgery due to
side-lying positioning during surgery
 help in reducing surgery-related anxiety in the patient and family
members by answering to any arising questions
 ensure adequate fluid intake
 ensure a normal electrolyte balance
 report significant abnormal laboratory values such as bacteriuria
(bacteria in the urine) and blood coagulation abnormalities

ii. Intra-Operative
 Maintain patient in the comfortable position throughout the surgery
 Monitor patient vital sign to have a baseline data

24
iii. Post-Operative
 Provide routine postoperative care
 Frequently assess urine color, amount, and character, noting
any hematuria, pyuria, or sediment. Promptly report oliguria
or anuria, as well as changes in urine color or clarity. Preserving
function of the remaining kidney is critical; frequent assessment
allows early intervention for potential problems.
 Note the placement, status, and drainage from ureteral
catheters, stents, nephrostomy tubes, or drains. Label each
clearly. Maintain gravity drainage; irrigate only as ordered.
Maintaining drainage tube patency is vital to prevent potential
hydronephrosis. Bright bleeding or unexpected drainage may
indicate a surgical complication.
 Support the grieving process and adjustment to the loss of a
kidney. Loss of a major organ leads to a body image change and
grief response. When renal cancer is the underlying diagnosis,
the client may also grieve the loss of health and potential loss
of life.
 Provide the following home care instructions for the client and
family.
a. Teach the importance of protecting the remaining kidney by
preventing UTI, renal calculi, and trauma.
b. Maintain a fluid intake of 2000 to 2500 mL per day. This
important measure helps prevent dehydration and maintain good
urine flow.
c. Gradually increase exercise to tolerance, avoiding heavy lifting
for a year after surgery. Participation in contact sports is not
recommended to reduce the risk of injury to the remaining kidney.
Lifting is avoided to allow full tissue healing. Trauma to the
remaining kidney could seriously jeopardize renal function.

25
 d. Teach care of the incision and any remaining drainage tubes,
catheters, or stents. This routine postoperative instruction is vital to
prepare the client for self-care and prevent complications.
e. Instruct to report signs and symptoms to the physician, including
manifestations of UTI (dysuria, frequency, urgency, nocturia,
cloudy, malodorous urine) or systemic infection (fever, general
malaise, fatigue), redness, swelling, pain, or drainage from the
incision or any catheter or drain tube site. Prompt treatment of
postoperative infection is vital to allow continued healing and
prevent compromise of the remaining kidney.

IX. PHARMACOLOIGY

i. Pre-Operative
 ANTICHOLINERGICS: glycopyrrolate (robinal) decreases
respiratory secretions.
 ANTIANXIETY: lorazepam (ativan) reduces anxiety
 HISTAMINE-2 RECEPTOR ANTAGONIST: cimetidine (Tagamet)
decreases gastric acidity and volume
 NARCOTICS: Demerol (meperidine) decreases the amount of
anesthesia needed to sedate the client.
 SEDATIVES: midazolam (versed) promotes sleep or conscious
sedation and decrease anxiety
 ANTIBIOTICS: kanamycin (kantrex) destroy enteric microorganism

26
ii. Intra-operative

During the intra-operative procedure, the patient undergoes under

control of anesthesia. The following are the types of anesthesia:

 General Anesthesia (inhales or intravenously) refers to drug –

induced depression of the central nervous system that produces
analgesia, amnesia, and unconsciousness (affects whole body).
 Regional anesthesia is a form of local anesthesia that suspends
sensation and motion in body region or part: the client remains
awake. Continuous monitoring is required in the event the block is
not totally effective and the client experiences pain or reaction to
blocking agents (e.g., nausea, cardiovascular collapse). Regional
anesthesia differs in terms of location and size of the anatomic area
anesthetized and the volume and type of anesthesia agent used.
 Spinal Anesthesia is local anesthesia injected into the subarachnoid
space at lumbar level to block nerves and suspend sensation and
motion to the lower extremities, perineum, and lower abdomen.
 Conduction Blocks suspend sensation and motion on various
groups of nerves such as epidural block (i.e., anesthetic into space
around the dura mater); Para vertebral block (i.e. produces
anesthesia of the chest, abdominal wall and extremities) and Tran
sacral (caudal) block (i.e. anesthesia of the perineum).

iii. Post-operative
 Epidural analgesia is considered as most effective for the
treatment of postoperative pain after open nephrectomy, but after
laparoscopic operation parenteral and enteral opioids combined
with paracetamol (acetaminophen) usually offer adequate
postoperative pain relief. However, the need for opioids
postoperatively may be high and side effects, such as sedation and
nausea, are common. On the other hand, epidural analgesia has
some contraindications and risks for serious complications.
Nevertheless, inadequately treated acute postoperative pain is

27
 considered as one of the main risk factors for persistent
postoperative pain.

X. BIBLIOGRAPHY

Hinkle, J. & Cheever, K. (2018). Brunner and Suddarth's textbook of medical-surgical

nursing (14th ed.). Wolters Kluwer

What are the steps to perform a transperitoneal laparoscopic radical nephrectomy

(LRN)? (2021, October 17). Nephrectomy.

https://www.medscape.com/answers/445458-186342/what-are-the-steps-to-

perform-a-transperitoneal-laparoscopic-radical-nephrectomy-lrn

Nephrectomy (kidney removal) - Mayo Clinic. (2018, May 17). Nephrectomy.

https://www.mayoclinic.org/tests-procedures/nephrectomy/about/pac-

28
 20385165#:%7E:text=Most%20often%20a%20nephrectomy%20is,diseased

%20or%20seriously%20damaged%20kidney.

Nephrectomy in Philippines. (2019). Health Tourism. https://www.health-

tourism.com/nephrectomy/philippines/

Patard, J. J., Shvarts, O., Lam, J. S., Pantuck, A. J., Kim, H. L., Ficarra, V., Cindolo,

L., Han, K. R., De La Taille, A., Tostain, J., Artibani, W., Abbou, C. C., Lobel,

B., Chopin, D. K., Figlin, R. A., Mulders, P. F., & Belldegrun, A. S. (2004).

Safety and efficacy of partial nephrectomy for all T1 tumors based on an

international multicenter experience. The Journal of urology, 171(6 Pt 1),

2181–2435. https://doi.org/10.1097/01.ju.0000124846.37299.5e

29