Section 11 – Pre and Post Operative Management of patients undergoing a Nephrectomy
To provide guidelines for the pre and post operative management of patients undergoing a Nephrectomy, i.e., surgical removal of a kidney
Alerts:
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On transfer to ward, all observations should be attended in the presence of the PACU nurse to ensure any abnormalities may be identified and managed as soon as possible. If the patient meets the MET criteria, activation of MET should occur.
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A full set of Vital signs includes Respiratory Rate, Oxygen Saturations, Temperature, Blood Pressure, Pulse, Level of Consciousness and Urine Output. A full set of Vital Signs must be performed every time vital signs are taken in the post transfer from ICU (Refer to ‘Adult Vital Signs and Early Warning Scores’).
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If respirations are twelve (12) or less per minute or if the patient complains of headache following spinal or epidural anaesthetic within the first 24 hours, notify the Anaesthetist or Anaesthetic Registrar immediately and document in the patient’s clinical record.
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Please check surgeon’s preference regarding placement of Statlock, securement of drains and post operative pain management.
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Determine if the patient is currently on medication and enquire if the patient has brought any medication to the hospital. If possible, family members must take all personal medications home after the sighting by the medical officer. If this is not possible, place the medications in a patient’s own medication green plastic bag, label and retain in the patient’s own medication cupboard until the patient is discharged- Patients Own Medication- Management Procedure
On admission:
Equipment:
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Alcohol based hand rub (ABHR)
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Patient clinical notes and observation charts
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Personal protective equipment (PPE) including safety goggles or shield and clean gloves
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Stethoscope
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Watch with a second hand
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Sphygmomanometer (blood pressure cuff)
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Oxygen saturation monitor
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Thermometer
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Intravenous (IV) pole – mobile
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Emesis bag
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Bedside emergency equipment
Procedure:
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Patient usually attends preadmission clinic (PAC) and is admitted the day before surgery or at times, on the day of surgery (DOSA). Investigations attended in the PAC are as follows
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Bloods – UEC, FBC, COAG’s, X – MATCH (2-4 units), LFT’s, and serum ferreting assessment.
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ECG, CXR, as per hospital policy. Additional bloods, CT, MRI and or bone scan to determine probability of metastasis to the body and the skeleton. Micro urine (MSU)
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Consent completed reflecting the Consent to Treatment Procedure
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Check reason for admission Inpatient’s clinical record and length of stay as per Request for Admission form to predict estimated date of discharge (EDD), i.e., commencement of Discharge Planning.
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Obtain verbal consent
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Explain the process and purpose of the Patient Accountability and Care Plan
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Patient identification and allergy band are checked against clinical notes/ stickers
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Document findings from patient Admission including Risk Assessments and management plans in clinical records, provide education and pamphlets to patient and family
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Attend to height, weight and ward urinalysis and document in clinical records, care plan and Observation Chart
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Obtain baseline observations, Usual systolic BP and MEWS Score
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Provide patient with verbal and CHHS information booklet regarding Patient’s Pressure Injury, Falls and VTE Risks and management. Document Inpatient Progress notes findings and actions
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Inform Pharmacist of patient’s admission and request Medication Reconciliation is completed
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Day before surgery, clear fluids until mid-night. Fast from midnight. Inform Food Services via DIETPas
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Bowel preparation if ordered
Preoperative:
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Attend to all documentation including Pre-op Checklist
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Measure and fit knee length Anti-embolic stockings and ensure documentation on Medication Chart
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Ensure patient has early morning shower and dressed in theatre gown
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Usual medications are given at 0600Hrs
Before the patient is transferred from PACU/ICU to the ward:
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PACU/ICU Nursing staff to ensure:
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Receiving ward is aware of and has accepted patients admission
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Patient oxygen delivery system has the patients identification label on it
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Ward Nursing Staff to ensure:
Receiving patient from PACU/ICU
Equipment:
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Don PPE as required
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Patient identification and allergy band are checked against clinical notes/stickers. Practice to reflect Patient Identification Checklist Procedure, Patient Identification Band Procedure, Correct Patient, Correct Site, Correct Procedure
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Check patient’s airway is clear and observe for effort of breathing (i.e. use of accessory muscles)
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If airway is compromised place the patient in the lateral position (if not contraindicated), and consider Medical Officer review
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Ensure the oxygen is attached to wall oxygen outlet
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Confirm flow rate as ordered (PACU staff responsibility on arrival at ward – checked by ward staff to ensure correct flow rate)
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Ensure equipment has been plugged in and cords are positioned safely under bed or off the floor
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Transfer of care must reflect Clinical Handover Procedure
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Clarify the operative procedure performed. All actions to reflect Correct Patient, Correct Site, Correct Procedure
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Discussion of patient medical history and impacting co morbidities should occur whilst ensuring privacy
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The PACU nurse hands over verbally to the ward nurse at the patient bed side. At the completion of handover the PACU observation chart should be signed and dated by both the PACU and ward nurse. Handover should include:
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Review of post operative vital signs, including any interventions required for stabilisation
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Review the Fluid Balance Chart, check intravenous fluid insitu, received in PACU and continuing orders, check IV device site e.g. CVC, PICC, IVC (date of insertion, patency, site, and is appropriately secured) Monitor intravenous therapy and record IVT on fluid balance chart)
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Urinary drainage devices e.g. Indwelling Catheters (IDC), Urostomies, etc (ensure hand hygiene is attended after contact with these devices)
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IDC to be anchored with Statlock unless the surgeon specifically requests Statlock not to used as per Urinary Catheter Management Procedure
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Urine output is to be recorded hourly for 48 hours postoperatively
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Check any drains insitu e.g. wound drains and output (ensure hand hygiene is attended after contact with these devices). Drainage bags to be changed and output documented on FBC and Inpatient progress notes daily at midnight
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Check output of nasogastric tube for drainage or feeding. Ensure orders are clearly documented in the notes as to purpose, use and position of tube (ensure hand hygiene is attended when in contact with these devices)
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Ensure all output is documented on Fluid Balance Chart
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Medications administered and documented on medication chart review
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Any intravenous medications ordered and given (e.g. antibiotics, antihypertensive)
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Observe the wound dressing for ooze or blood loss. Note colour, amount and odour (if any), reinforce wound if required. Do not remove theatre dressing
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Any pain management devices including Patient Controlled Analgesia (PCA), Epidurals, Pain Busters, Continuous Opioid infusions, regional local anaesthetic infusions, etc and single shot analgesia technique without pain management device i.e. single shot local anaesthetic block or intrathecal/epidural morphine single dose administration for post operative pain relief (refer to appropriate Pain Management Unit procedures)
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Perform and document a full set of Vital signs and Modified Early Warning Score (MEWS)
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All observations are to be recorded on the Modified Early Warning Score (MEWS) charts and appropriate adjunct charts (i.e. neurovascular, neurological, PCA, Epidural, Intrathecal/ epidural morphine etc)
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Ensure all of the above are completed prior to PACU nurse leaving ward area and patient care is accepted
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Complete Patient Care and Accountability Plan and action appropriately
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Record in the patient's clinical record all post-operative nursing care provided and the patients response
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Offer and attend to bed bath
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Dress in personal nightwear if desired
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Offer and attend to mouth care, replacing dentures if applicable
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Position the patient in accordance to post operative instructions
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Ensure that the call bell is within reach and
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Lower bed and bed rails to maintain patient safety if required. Note: where patients are disorientated consider hi low bed
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Educate and encourage deep breathing and leg exercises
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Ensure 2/24 Pressure area care and skin integrity checks and repositioning performed (off affected side)
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Document all observations on the appropriate charts, e.g. MEWS, fluid balance chart, in the Patient clinical record and escalate if required according to MEWS and MET criteria
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Record in the patient's clinical record all post-operative nursing care provided and the patients response
Ward management:
Ward Nursing Staff:
Check patients clinical record for any medical orders
Ensure Privacy
Explain the process and purpose of the dressing change
Obtain verbal consent for any interventions
General/ Epidural/ Spinal Anaesthetic:
Perform and document a Full set of Vital Signs and Modified Early Warning Score (MEWS):
On return to ward, then
Half hourly for two hours (30mins x two hours), if MEWS ≥ 4 continue half hourly (See ‘Adult Vital Signs and Early Warning Score SOP’) (excluding Day Surgery Unit)
When MEWS <4, hourly for four (4) hours (60 mins x four hours), then
Fourth hourly for a minimum of 48 hours
Where an Epidural is in situ patient assessment is performed Following the guidelines of the Epidural (Adult and Paediatric ) Chart and Insert Documents and Procedure
The Patient Accountability and Care Plan must be commenced within the postoperative period
Risk Assessments for Pressure Injury, Falls, VTE, Mobility/Manual Handling and Discharge must be completed, actioned and documented in the patient progress notes within the postoperative period as reflected in the Patient Accountability and Care Planning Procedure
Ward Management Day 1:
Check patient clinical records for medical orders
Remains NBM until reviewed by medical team, if dietary status changed, inform Food Services via DIETpas and update bed card
Commence diet and fluids as ordered (continue to monitor tolerance of diet)
Maintain IV Fluids
Maintain hourly urine output measures
Document drain output and change drainage bag at midnight
Maintain strict Fluid Balance Chart
Ensure second hourly pressure area care and skin integrity checks are offered and performed
Maintain fourth hourly vital signs
Maintain observations as required with Epidural/ PCA
Assist patient with sponge in bed
Attend perineal/ penile care
Observe the wound dressing for ooze or blood loss fourth hourly
Sit patient out of bed
Reapply TEDs
Notify physiotherapist
Continue discharge planning with Discharge Liaison Nurse (DLN) and allied health team as appropriate
Ward Management Day 2:
Check patient clinical records for medical orders
May progress to Free Fluids to Light Diet if passed flatus and approved by medical staff
Inform Food Services of changes via DIETpas and update Bed Card
Maintain fourth hourly vital signs
Maintain observations as required with Epidural/PCA- may be removed if tolerating fluids at the discretion of the APS. Motor Block observations maintained for 24 hours post removal of Epidural
Assist patient with shower
Attend Perineal/ penile care
Observe the wound for swelling, ooze and/ or redness fourth hourly. Dress as per medical orders
Encourage patient mobilisation with stand by assistance
Continue discharge planning
Document drain output and change drainage bag at midnight
Consecutive post operative days continue as Day 2, drains will be shortened and/ or removed at the discretion of medical officer. Patient usually discharged on day six to eight depending on progress
Discharge planning:
Ensure Medical Officer (MO) has documented discharge Inpatient clinical record
Ensure discharge medications are scanned to pharmacy
Inform patient of usual discharge procedure, i.e., transfer to Discharge Lounge by 1000 on the day of discharge
CNC to refer to the Discharge Liaison Nurse for wound care and/or staple removal at daily MDT meeting
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