Nephrectomy

Surgical incision in the abdomen or side

or through a series of small incisions in
the abdomen .
To treat kidney cancer or to remove a
seriously damaged or diseased kidney.
Types of incision :
Antero-lateral

Nephrectomy - types
Partial nephrectomy
-Only part of kidney is removed.
-Indications : pt with poor kidney function or only one
kidney.
Radical nephrectomy
-Removal of the kidney and adrenal gland/or the
ureter
-Indications : cancer of the kidney, transplantation
Simple nephrectomy
-Removal of the kidney only, the adrenal gland is left
behind and the ureter is tied.
-Indications : kidney stones, lack of blood supply,
abnormal kidney structure.

Symptom
Pain:in the back, side part of the body, or
testicle, can occur at night or during
urination, can be sharp, dull, or sudden in
the abdomen, severe or mild
Urinary:frequent urination, persistent
urge to urinate, excessive urination, or
blood in urine
Whole body:sweating, nausea, or chills
Also common:burning sensation or
vomiting

Nephrectomy-Post op Physio
Mx

Respiratory training
Mobilization
Supported coughing
Education-correct lifting technique

CASE STUDY

CASE STUDY

Name

: Mr. T

R/N

: xxxxxx

Age

: 38 years old

Sex

: male

Race: chinese

D.o.ad : 27/04/2015
D.o.ax : 5/05/2015
Doctors diagnosis : Kidney stone on Lt. kidney
Doctors management :
Operative : Post. Lt. Nephrectomy on
29/4/15
Conservative : Medication & refer physio

SUBJECTIVE ASSESSMENT
Pt. c/o : c/o pain @ abdomen during cough &
activity such as walking
VAS : 1/10 ( on rest )
Area of pain : incision site at abdominal
Agg : Body movt, VAS : 2/10
Ease : Rest, (Pain reduce in 1 minutes)
24 Hr : am : on. movt.
pm : on movt.
Night : Did Not disturb sleep
Irritability : Low
Severity : Low

 Current Hx:
POD7 nephrectomy.
Past Hx:
h/o sudden onset of pain at left abdominal region on 2/2/2015 .
Went to HSI for check up and CT scan on 10/2/2015.on
30/03/2015 after the result of CT scan, pt was diagnosed to have
kidney stone @ Lt. kidney. Pt then scheduled for operation at
HSA on 29/4/2015.
Past Medical Hx: Nil
Past Surgical : Nil
Medication Hx : - T. Pantoprazole 40mg BD

T. Bisolven 8mg tdc

C. Tramol 50mg QID

T. Paracetamol 1g QID
Social Hx:
Married, 2 children
Ex-smoker (6 stick/day) stop 1/12 ago. Alcoholic (sometimes)
Occupation: Offshore worker. ( nature of work : need to lifting
heavy object)
Family Hx: Nil

 Investigation:
i) chest x-ray : latest taken on 29/4/2015 (PA view)
Finding :
-lungs clear no hazziness
- Normal heart size
- sharp costophrenic angle
ii) Arterial Blood Gas: nil

iii) Vital sign :

H/Rate: 90 beats/min
(normal)

R/Rate: 19/ min (normal)

B/P: 110/73 mmHg
(normal)
Temperature:
37(normal)
Interpretation: Normal
vital sign

OBJECTIVE ASSESSMENT
General Observation :
Moderate size, chinese man sup. Ly. on bed,pt.
alert, concious, and cooperative. Hes alone.
pt. comfortable under RA. Branula on Rt. Side of
distal forearm
Local Observation:
No oedema at both peripheral limb (UL and LL)
No cynosis at both peripheral limb (UL and LL)
plaster

No clubbing nail at both hand and foot

No deformity of UL,LL and body posture
Plaster noted at abdominal region.
type of incision : nil

Breathing pattern: normal

Breathing level: diaphragmatic
Breathing ratio: insp:exp - 1:2 (normal)
Chest deformities: NA
Coughing : effective, not productive, no chest pain
Sputum : nil
Palpation:
No swelling at UL & LL
No increase temp. at abdomen, UL & LL
No abdominal distended soft on palpation
Auscultation:
Lungs clear
Equal a/e on both lungs

 Percussion note:
Level

Right

Left

Upper lobe

Resonance

Resonance

Middle lobe

Resonance

Lower lobe

Resonance

Resonance

Interpretation: normal

Chest Expansion:
Lobes

Good/mod/poor Symmetrical/
Rt
Lt asymmetrical

Appical
Middle/
Lingula
Basal

Good
Good

Good Symmetrical
Good Symmetrical

Mod

Mod Symmetrical

Interpretation: reduce chest expansion at

bibasal d/t reduce thoracic mobility

Chest Expansion measurement:

POINT

Average

Differences

Rest

Insp.

Exp.

Manubri
osternal
jt.

83cm

84cm

83cm

1 cm

Xiphiste
rnal jt.

79cm

81cm

79cm

2 cm

10th ribs

77cm

78cm

77cm

1 cm

Interpretation: reduce chest expansion at bibasal d/t reduce

thoracic mobility
Ratio : 1 : 2 : 1

Range of Motion:
Limb
Generally UL
Generally LL

Left
AFROM
AFROM

Right
AFROM
AFROM

Interpretation: Active range of motion for all joint at

UL and LL

Manual Muscle Testing:

Limb
Generally UL
Generally LL

Left
5/5
5/5

Right
5/5
5/5

Interpretation: normal muscle power at both UL & LL

 Special test
Triflow : 1200cc
Int: normal
Bed mobility
- Supine to sd. ly.
- Sd. Ly. To sitt.
independently
- Sitt. To stand

Able to perform

- Ambulation able to walk independently to

the toilet

PHYSIOTHERAPISTS IMPRESSION
Pain at abdomen d/t post operation
Reduce chest expansion at both
lower lobe d/t reduce thoracic
mobility

SHORT TERM GOALS

To reduce pain @ abdominal region
during cough and walking within 1/7
To improve chest expansion within
3/7
To maintain clear airways
To maintain A/E
To maintain ROM @ UL & LL
To maintain muscle power @ UL & LL

LONG TERM GOALS

To prevent secondary lung cx such as
atelactasis
To maximize functional ability such
as able to work again

PLAN OF TREATMENT
Supported coughing
Breathing exercise
Deep breathing exercise
Thoracic expansion exercise
Thoracic mobility exercise

Circulatory exs.
Strengtening exs
Ambulation
Patient education

Intervention
Supported coughing Crk. Ly./sd.ly./forward
lean sitt., support abdomen with hand/small
pillow/towel during cough
DBE High sitt. Ask pt. to take deep breath in
through nose and breath out through mouth
(5 reps/hourly)
TEE high sitt. Hand. at lateral abdominal to
stimulate expansion of the lower lungs
(10reps/hourly)
TME high sitt. Elevate sh. Through flex
during inspiration and lift down the sh. during
exhalation (10reps/hourly)
Active exs for UL & LL

 Circulatory exs-ankle plantarflex/dorsiflex

advice pt. to do triflow (10reps/2 hourly)
Pt. education :
advice pt. to do breathing exs such as DBE,TEE
and TME hourly
-avoid bending, avoid heavy lifting

Evaluation
Pt. able to do all exs given within pain
limit
Vital sign after trx :
- RR : 19/min
- PR : 82/min
Int : Normal vital sign

Review

To re-check vital sign

To reassess pt. pain scale
To reascultate pt.
To test triflow
To reassess chest expansion
measurement
To test 6 minutes walking test
To re-check exs

Evidence base
Breathing exercises
Respiratory illnesses often take shallow breaths
causing chest muscle weakness, reduced oxygen
circulation, shortness of breath and fatigue.
Proper breathing exercises help to reduce these
symptoms as well as strengthen muscles, improve
posture and mental ability.
strengthens the chest wall and abdominal muscles
and when practiced regularly, can relieve shortnes
s of breath and improve breathing control
Michaud M. (2009)

 Pursed-lip breathing helps to reduce trapped air

in the lungs by increasing the length of
expiration.
Pursing the lips provides some resistance and
helps breath exit slowly;
Diaphragmatic breathing has been described as
breathing predominantly with the diaphragm
while minimizing the action of accessory muscles
that may assist with inspiration.

 However, it has been suggested that persons with

moderate to severe COPD and marked
hyperinflation of the lungs without adequate
diaphragmatic movement and increase in tidal
volume during DB .
Cahalin L.P., Braga M., Matsuo Y. and Hernandez
E.D. (2002)
Diaphragmatic breathing (DB) on blood gases,
breathing pattern, pulmonary mechanics and
dyspnoea in severe hypercapnic chronic
obstructive pulmonary disease (COPD) patients
recovering from an acute exacerbation
Vitacca M., Clini E., Bianchi L. and Ambrosino N.
(1998)

References
Kuipers EJ,Blaser MJ.Acid peptic disease. IN :
Goldman L,Schafer Al,eds.Cecil medicine(2010)
Michaud M. (2009)
Cahalin L.P., Braga M., Matsuo Y. and Hernandez
E.D. (2002)
Vitacca M., Clini E., Bianchi L. and Ambrosino N.
(1998)
Asher MI,Pardy RL,Coates AL 1982 The effects of
inspiratory muscle training in patients-American
review of respiratory disease.