Urology – Catheter Insertion and Management, Bladder Irrigation, Nephrectomy and Trans Urethral Prostatectomy (turp)

Section 12 – Management of patients undergoing a Percutaneous Nephrolithotomy

To provide guidelines for the pre and post operative management of patients undergoing a Nephrolithotomy, i.e., surgical removal of a kidney stones via a percutaneous tract using laparoscopic equipment

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.
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’).
If respirations are twelve 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. Please check surgeon’s preference regarding placement of Statlock, securement of drains and post operative pain management.
Nephrostomy drainage catheter

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  Do not instil more than 10 ml of Sodium Chloride 0.9% at one time (See NSW Agency for Clinical Innovation. ACI Urology Network 2012, p. 8).
  
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  Flush the tube very slowly. Do not apply force as over distension of the renal pelvis could cause renal tissue damage.
  

On admission:

Equipment:

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  Alcohol based hand rub (ABHR)
  
• 
  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:

1. 
   Patient usually attends preadmission clinic (PAC) and is admitted the on the day of surgery (DOSA). Investigations attended in the PAC are as follows
   
2. 
   Bloods – UEC, FBC, COAG’s, X – MATCH (two to four units)
   
3. 
   ECG, CXR, KUB (kidneys, Ureters and Bladder-confirm position of calculi) X-ray as required
   
4. 
   Additional bloods, CT, MRI as required
   
5. 
   Micro urine (MSU)
   
6. 
   Consent completed reflecting the Consent to Treatment Procedure
   
7. 
   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/PDD), i.e., commencement of Discharge Planning.
   
8. 
   Explain the process and purpose of the Patient Accountability and Care Plan
   
9. 
   Patient identification and allergy band are checked against clinical notes/ stickers
   
10. 
    Document findings from patient Admission including Risk Assessments and management plans in clinical records, provide education and pamphlets to patient and family
    
11. 
    Attend to height, weight and ward urinalysis and document in clinical records, care plan and Observation Chart
    
12. 
    Obtain baseline observations, Usual systolic BP and MEWS Score
    
13. 
    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
    
14. 
    Inform Pharmacist of patient’s admission and request Medication Reconciliation is completed
    
15. 
    Day before surgery, Nil by Mouth from Midnight or as per Urologist’s orders
    

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 0600
  

Before the patient is transferred from PACU to the ward:

PACU 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
  

Ward Nursing Staff to ensure:

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  Patient bed area has been cleaned
  
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  All emergency equipment is functioning and available, including oxygen and suction
  

Receiving patient from PACU:

1. 
   Don PPE as required
   
2. 
   Patient identification and allergy band are checked against clinical notes/stickers. Practice to reflect Patient Identification Checklist Procedure, Patient Identification Band Procedure, Patient Identification and Procedure Matching Policy and Procedure
   
3. 
   Check patient’s airway is clear and observe for effort of breathing (i.e. use of accessory muscles)
   
4. 
   If airway is compromised place the patient in the lateral position (if not contraindicated), and consider Medical Officer review
   
5. 
   Ensure the oxygen is attached to wall oxygen outlet
   
6. 
   Confirm flow rate as ordered (PACU staff responsibility on arrival at ward – checked by ward staff to ensure correct flow rate)
   
7. 
   Ensure equipment has been plugged in and cords are positioned safely under bed or off the floor
   
8. 
   Transfer of care must reflect Clinical Handover Procedure
   
9. 
   Clarify the operative procedure performed. All actions to reflect Procedure Matching Policy and Procedure
   
10. 
    Discussion of patient medical history and impacting co morbidities should occur whilst ensuring privacy
    
11. 
    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:
    
12. 
    Review of post operative vital signs, including any interventions required for stabilisation
    
13. 
    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)
    
14. 
    Urinary drainage devices e.g. Indwelling Catheters (IDC), Urostomies, Nephrostomy tubes etc (ensure hand hygiene is attended after contact with these devices)
    
15. 
    IDC to be anchored with Statlock unless the surgeon specifically requests Statlock not to used as per Urinary Catheter Management Procedure
    
16. 
    Maintain Nephrostomy tube patency as per Drain Management Procedure
    
17. 
    Nephrostomy to be anchored with Statlock device
    
18. 
    Urine output is to be recorded hourly for 48 hours postoperatively
    
19. 
    Check flank for swelling, bruising or ooze and ensure adequate pain relief
    
20. 
    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
    
21. 
    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
    
22. 
    Ensure all output is documented on Fluid Balance Chart
    
23. 
    Medications administered and documented on medication chart review
    
24. 
    Any intravenous medications ordered and given (e.g. antibiotics, antihypertensive)
    
25. 
    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
    
26. 
    Pain management devices such as Patient Controlled Analgesia (PCA), to be managed as per appropriate PCA procedures
    
27. 
    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)Ensure all of the above are completed prior to PACU nurse leaving ward area and patient care is accepted
    
28. 
    Complete Patient Care and Accountability Plan and action appropriately
    
29. 
    Record in the patient's clinical record all post-operative nursing care provided and the patients response
    
30. 
    Offer and attend to bed bath
    
31. 
    Dress in personal nightwear if desired
    
32. 
    Offer and attend to mouth care, replacing dentures if applicable
    
33. 
    Position the patient in accordance to post operative instructions
    
34. 
    Ensure that the call bell is within reach and
    
35. 
    Lower bed and bed rails to maintain patient safety if required. Note: where patients are disorientated consider hi low bed
    
36. 
    Educate and encourage deep breathing and leg exercises
    
37. 
    Ensure 2/24 Pressure area care and skin integrity checks and repositioning performed (off affected side)
    
38. 
    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
    
39. 
    Record in the patient's clinical record all post-operative nursing care provided and the patients response
    

Ward Nursing Staff:

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  Check patients clinical record for any medical orders
  
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  Explain the process and purpose of the dressing change
  
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  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):

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  On return to ward, then
  
• 
  Half hourly for two hours (30mins x two hours), if MEWS ≥4 continue half hourly (Refer to Vital Signs and Early Warning Score Procedure)
  
• 
  When MEWS <4, hourly for four hours (60 mins x four hours), then
  
• 
  Fourth hourly for a minimum of 48 hours
  
• 
  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:

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  Check patient clinical records for medical orders
  
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  Update diet when reviewed by medical team, if dietary status changed, inform Food Services via DIETpas and update Bed card
  
• 
  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 PCA
  
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  Assist patient with shower
  
• 
  Attend perineal/ penile care
  
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  Observe the wound dressing for ooze or blood loss fourth hourly
  
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  Sit patient out of bed
  
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  Reapply TEDs
  
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  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
  
• 
  Monitor tolerance to diet and progression to full diet
  
• 
  Inform Food Services of changes via DIETpas and update Bed Card
  
• 
  Maintain fourth hourly vital signs
  
• 
  Maintain observations as required with PCA- may be removed if tolerating fluids at the discretion of the APS.
  
• 
  Assist patient with shower
  
• 
  Attend Perineal/ penile care
  
• 
  Observe the wound for swelling, ooze and/ or redness fourth hourly. Dress as per medical orders and as per Drain Management Procedure
  
• 
  Encourage patient mobilisation with stand by assistance
  
• 
  Continue discharge planning
  
• 
  Document drain output-amount, consistency, colour, odour etc
  
• 
  Change drainage bag at midnight
  
• 
  Medical Officer may order a Nephrostogram to confirm the patency of the urinary tract post-operatively
  
• 
  Depending on Nephrostogram results the Medical Officer may request the Nephrostomy tube to be clamped for six to eight hours prior to removal
  
• 
  When Nephrostomy tube clamped-observe patient for pyrexia and flank pain
  
• 
  Contact the Medical Officer if either occur
  

Consecutive post operative days continue as Day 2, drains will be removed at the discretion of medical officer

Discharge planning:

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  Ensure 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 of Nephrostomy tube site care post removal of Nephrostomy tube at daily MDT meeting
  
• 
  Follow-up appointment is usually four to six weeks in the Outpatient Urology Clinic or in the VMO’s private rooms, please clarify this before patient is discharged
  
• 
  Educate the patient regarding the VMO’s post-operative instructions – no strenuous activity for four to six weeks until reviewed. Ensure adequate fluid intake i.e. two litres per day
  

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