Radical Nephrectomy with Inferior Vena Cava (IVC) Thrombectomy: Implications for Post-operative Nursing Care

Implications for Post-operative Nursing Care

Janee Klipfel, BSN, RN, CURN; Therese M. Jacobson, MSN, APRN-BC, CWOCN; Michelle Havel, BSN, RN, CURN

Disclosures

Urol Nurs. 2010;30(6):347-352. 

In This Article

Post-operative Nursing Care

The urologic nurse engages the nursing process to develop a comprehensive care plan specific to the needs of the patient. The nurse seeks to understand the individual with respect to health status, abilities, and priorities (Society of Urologic Nurses and Associates [SUNA], 1997). The nursing process begins with holistic assessment of the patient's physical and psychosocial health. The nurse interprets these cumulative data to identify diagnoses and expected outcomes.

Interventions are planned and implemented according to the patient's developmental and cultural needs to help the patient achieve defined outcomes. Collaboration is essential to ensure quality care. The urologic nurse works together with the patient, family, and other health care providers to coordinate and implement the patient's plan of care (SUNA, 1997). A patient's experience is dynamic, making ongoing evaluation vital to providing timely and appropriate nursing care.

Post-operative care of the patient following radical nephrectomy with IVC thrombectomy involves assessment of all body systems with an emphasis on pain control, early mobilization, and management of respiratory and cardiovascular status. Nursing management also includes monitoring fluid and drain status, surgical wounds, and bowel function. Related nursing diagnoses include acute pain, impaired gas exchange, risk for imbalanced fluid volume, dysfunctional gastrointestinal motility, and impaired skin integrity. Targeted interventions focused on these issues promote recovery and help prevent potential complications.

Post-operative Pain Management

Post-operative pain can be a problem for this patient due to the location and size of the surgical incision, positioning in the operating room, internal manipulation, stretching of muscles, and possible abdominal distention. Assessment should include patient report of location, severity, quality, and duration of the pain. Other signs of pain may include restlessness, facial expressions, guarding, and changes in vital signs. It is helpful to complete this assessment before and after pharmacologic as well as non-pharmacologic interventions. Individuals will have different comfort goals; therefore, it is ideal to establish this with each patient prior to surgery.

Multiple approaches to pain management are used with this patient population. During surgery, a single intrathecal opioid dose may be administered because it has been shown to be effective in decreasing the use of intravenous opioids post-operatively. Postoperative patients are immediately started on an acetaminophen schedule and given an opioid patient-controlled analgesia (PCA) pump while they remain nothing by mouth (NPO). As the diet is advanced, patients are given oral opioids as needed and are weaned from the PCA pump. Non-pharmacologic pain management techniques, such as positioning, distraction, relaxation, imagery, massage, and splinting of the incision, are often used in combination with medications.

Respiratory Management

The type of surgical approach used, the pain experienced by the patient, and the general anesthesia all may contribute to the risk of respiratory complications. Respiratory assessment should include auscultation of breath sounds and monitoring rate, depth, and pattern of respirations. Oxygen saturations and oxygen requirements are assessed, documented, and closely monitored for trends enabling the nurse to intervene promptly as needed. Patients should be encouraged to cough, perform deep breathing exercises, use an incentive spirometer, change positions frequently, and ambulate as early as feasible postoperatively. Optimal pain management is essential in assuring patients are able to perform these activities. Each of these interventions will assist in maintaining adequate respiratory function by maximizing lung inflation, facilitating gas exchange, loosening secretions, and preventing atelectasis.

Fluid Management

Fluid management is also crucial to post-operative management. The patient may be at risk for fluid deficit or excess. Close monitoring to ensure adequate renal and cardiac function can identify changes early and prevent or minimize complications. Accurate recording of all intake and output, daily weights, blood pressure, and pulse assessments, and monitoring of serum creatinine and blood urea levels provide important information on renal status. The most sensitive indicator of fluid loss or gain is daily weight (Smeltzer, Bare, Hinkle, & Cheever, 2008).

Urethral catheters commonly remain indwelling for two days to allow for close monitoring of urinary output. In the immediate post-operative period, urine output is measured hourly for a minimum of eight hours. The total urine output should be greater than 30 ml/hour unless other parameters are ordered. Additional fluid status assessment includes monitoring of vital signs, auscultation of the heart and lungs, and assessment for edema. Edema is commonly noted in the scrotum and lower extremities post-operatively. Any affected areas can be elevated as tolerated. In addition to elevation, edema of the scrotum may be treated by applying an ice pack as needed. It is important to reassure the patient that edema is temporary and will gradually resolve.

Management of GI Function

Motility of the gastrointestinal tract may be decreased as a result of surgical manipulation of the intestine, anesthetics, opioid administration, and decreased physical activity. Post-operatively, bowel sounds are assessed along with nausea, vomiting, abdominal distention, and patient reports of flatus and bowel movements. Early post-operative physical activity stimulates the return of peristalsis. Patients are also encouraged to chew gum. A small study by Schuster, Grewal, Greaney, and Waxman (2006) involving elective open sigmoid colectomy patients demonstrated that gum chewing speeds recovery by stimulating bowel motility. A nasogastric tube may be placed to provide gastric drainage and decompression of the intestines. Oral intake is held until bowel function returns. Patients are started on sips of clear liquids, and diets are advanced as tolerated. Intravenous fluids are given until oral intake is adequate. Stool softeners and rectal suppositories are administered to stimulate bowel function. Bowel function usually returns within three to four days.

Surgical Wound Care

Surgical dressings should be assessed frequently for drainage, with documentation of the amount, color, and consistency. The Centers for Disease Control and Prevention recommend that a surgical incision be covered with a sterile dressing for 24 to 48 hours (Mangram et al., 1999). After the surgical dressing is removed, incisions should be left open to air unless drainage is noted. Incisions are monitored for signs of infection, wound approximation, active bleeding, and drainage. Surgical drains may be placed during the procedure to monitor for bleeding. The kidney is a highly vascularized organ; therefore, blood loss is a major concern.

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