nephrectomy
DESCRIPTION
case study on nephrectomyTRANSCRIPT
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• Doctor’s diagnosis : Kidney stone on Lt. kidney• Doctor’s 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 childrenEx-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. He’s 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)No clubbing nail at both hand and footNo deformity of UL,LL and body posturePlaster noted at abdominal region.type of incision : nil
plaster
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:
Interpretation: normal
Level Right Left
Upper lobe Resonance Resonance
Middle lobe Resonance -
Lower lobe Resonance Resonance
Interpretation: reduce chest expansion at bibasal d/t reduce thoracic mobility
Lobes Good/mod/poor
Rt Lt
Symmetrical/ asymmetrical
Appical
Middle/
Lingula
Basal
Good Good
Good Good
Mod Mod
Symmetrical
Symmetrical
Symmetrical
Chest Expansion:
Interpretation: reduce chest expansion at bibasal d/t reduce
thoracic mobility
Ratio : 1 : 2 : 1
Chest Expansion measurement:
POINT Average
Differences Rest Insp. Exp.
Manubriosternal jt.
83cm 84cm 83cm 1 cm
Xiphisternal jt.
79cm 81cm 79cm 2 cm
10th ribs 77cm 78cm 77cm 1 cm
Range of Motion:
Limb Left Right
Generally UL
Generally LL
AFROM
AFROM
AFROM
AFROM
Interpretation: Active range of motion for all joint at
UL and LL
Manual Muscle Testing:
Limb Left Right
Generally UL
Generally LL
5/5
5/5
5/5
5/5
Interpretation: normal muscle power at both UL & LL
• Special testTriflow : 1200cc
Int: normal• Bed mobility
- Supine to sd. ly.- Sd. Ly. To sitt. Able to perform independently- Sitt. To stand
- Ambulation – able to walk independently to the toilet
PHYSIOTHERAPIST’S 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/minInt : 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 shortness 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.