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Nursing in slush surgery
Nursing in slush surgery B K McPherson, RN, R A Shank, UPA R E Duncan, MD, A T Evans, MD Preservation of renal function is the primary aim of renal calculus surgery. The use of localized kidney hypothermia and ischemia in anatrophic nephrotomy has been devised to offer a blood-free surgical field, decreased blood loss, and extended kidney operative time while avoiding continued impairment of compensated renal function.’ To obtain the maximal effectiveness of the slush technique, an understanding of the procedure and its complications must be relayed to both
Brenda K McPherson, R N , is a graduate of the Community Hospital School of Nursing, Springfield, Ohio. She is head nurse, urology, University of Cincinnati Medical Center, Cincinnati. Biographical information on the three additional authors accompanies the article “Slush technique in renal surgery” appearing in this Journal.
operating room and ward personnel. Knowledge of possible complications can be utilized in care planning to reduce the likelihood of their occurrence. Preoperatively patients a t the University of Cincinnati Medical Center undergo a regimen of diagnostic evaluation. There is no single test of renal function; therefore, optimum findings are the results of a number of clinical determinations. Renograms and scans may be performed in addition t o excretory urography. These tests are repeated postoperatively to insure kidney function was not impaired by the slush technique. Blood studies including serum electrolytes, serum creatinine, and blood urea nitrogen determinations offer a baseline of renal function. Twenty-four-hour creatinine clearance tests are usually done two days consecutively. Preoperative coagulation studies are of great importance because the patient may receive heparin prior to the clamping of the renal artery during the operative procedure.2 These blood studies are repeated immediately after surgery, the following day, and usually about every two days thereafter. Urine is sent to the laboratory for culture, sensitivity, and colony count so that a course of proper antibiotic therapy may be instituted before the surgery. Birch and Mims report that 37% of
AORN Journal, February 1977, V o l 2 5 , N o 2
227
patients undergoing renal hypotherIn addition, drains and tubes placed mia contracted pulmonary complicaa t the time of operation in and around tions po~toperatively.~ Pneumothorax the kidney may also become a source has been reported on the operative of infection to the patient. Closed side. The position of the patient during drainage systems should be mainthe surgical procedure produces comtained for nephrostomies, catheters, pression of the lung contralateral to and stents. Meticulous care of the surgical incision, which may prodressings and drains should be exerduce areas of atelectasis. Pulmonary cised in an effort to prevent contamitoilet should be exercised preoperanation. If an indwelling Foley catheter tively. This provides a time to teach is maintained in the bladder postoperthe patient effective coughing and atively, meatal care is essential. We suggest a povidone-iodine wash foldeep breathing exercises as well as proper usage of the respiratory lowed by a povidone-iodine ointment therapy equipment. Intermittent posiapplication t o the urethral meatus of tive pressure breathing treatments are both males and females twice a day.6 initiated preoperatively using 3 to 5 cc Postoperative ileus is common after renal surgery. The patient should be of normal saline a t 20 cm pressure about four times a day, each treatment assessed for abdominal distention. Oral intake is deferred until adequate being 15 to 20 minutes in duration. Postoperative treatments should be bowel sounds are audible and flatus is expressed indicating peristalsis has every four hours. resumed. When oral intake is permitDuring surgery and in the imted we begin with tap water and promediate postoperative period the pagress as tolerated. Often our patients tient’s body temperature may drop to 95 F (35 C). Body temperature shows a are placed on bowel emollients twice a day when fluid intake resumes. Supdownward trend during the operation but tends to stabilize after two h o ~ r s . ~ positories may also be used as needed. It is unknown how patients maintain Early activity should be encouraged. This will decrease the risk of venous their temperature since they are unthrombosis of the lower extremities able to shiver to produce body heat. Systemic hypothermia has not posed a and possible subsequent pulmonary emboli. major postoperative problem and Attentiveness to prevention of posthyperthermia may be used during the operative complications is not limited surgical and postoperative periods. to the ward staff. Operating room Infection is a common problem in teams are equally responsible and urinary tract disease. As noted earlier, urine cultures should be done preoperhave a significant impact on the paatively and proper antimicrobial tient’s postoperative course. In addition to providing efficient and knowltherapy instituted as necessary to produce a sterile urine. A high incidence edgeable surgical assistance, extreme of infection is associated with renal care must be taken to maintain strict calculi.5 We initiate antimicrobial aseptic technique. The preparation of therapy prior to surgery and continue the iced saline slush is the unique responsibility of the operating room this through a full course. Many difstaff. Several steps are involved in the ferent drugs are employed depending slush preparation prior to its use in on specific bacterial susceptibility testthe operative incision. A break in ing.
228
AORN Journal, February 1977, V o l 2 5 , N o 2
asepsis in any o f these steps can lead t o contamination o f t h e slush and may i n i t i a t e serious postoperative complications. The operative technique i s a n additional source of possible postoperative complications. Although many are unavoidable and inherent t o any surgical procedure, a l i n e of communication f r o m t h e operating room team t o t h e ward staff i s often helpful in t h e management of t h e patient after surgery. Valuable information regarding drains, tubes, blood loss, u r i n e output, the r e n a l ischemia period, medications and fluids administered, and surgical difficulties encountered can be relayed t o t h e ward staff. This information may t h e n be used in establishing a care p l a n for t h e patient.
Regional accreditation committees formed Barbara Gruendemann, RN, MS, AORN vice-president, has been appointed to the West Regional Accrediting Committee (RAC) of the National Accreditation Board of the American Nurses’ Association (ANA). Five Regional Accrediting Committees have been established as part of an accreditation system that monitors the quality of continuing education offerings and facilitates the interstate transferability of continuing education contact hours. The committee will be directly responsible to the National Accreditation Board. Regional Accrediting Committees participate in a review and evaluation process for accrediting continuing education programs in nursing within universities and colleges. They also accredit state nurses associations, specialty nursing organizations, federal nursing services, and state boards of nursing to offer such programs and to approve offerings of sponsors and constituents. RACs also approve programs or offerings of national organizations and commercial firms.
The slush technique i s a new surgical adaptation and with t h e incorporat i o n of t h e guidelines presented can be an effective and safe adjunct t o the armamentarium of t h e urologic surgeon. Notes 1. P J Metzner, W H Boyce, “Simplified renal hypothermia: An adjunct to conservative renal surgery,” British Journal of Urology 44 (1972)76. 2. J S Taylor, “Kidney cooling in partial nephrectomy,” Urology 5 (1975)456. 3. A A Birch, G R Mims, “Anaesthesia considerations during nephrolithotomy with slush,” Jour-’ nal of Urology 1 13 (1 975)433. 4. Ibid. 5. A T Evans, “Infections of the kidney and bladder in the adult,” in Urology, L Karafin, A R Kendall, eds. (Hagerstown, Md: Harper & Row, 1976)Chapter 14:l-77. 6./bid.
Chosen for their expertise in specific areas of nursing, RAC members will serve two-year terms. The West Regional Accrediting committee serves the states and territories of Alaska, Hawaii, Guam, Washington, Oregon, California, Nevada, Arizona, Utah, Idaho, and Montana: the Mountain Regional Accrediting Committee covers the states of Wyoming, Colorado, New Mexico, Texas, Oklahoma, Kansas, Missouri, Nebraska, South Dakota, and North Dakota; the Southeast Regional Accrediting Committee serves the states and territories of Arkansas, Louisiana, Mississippi, Alabama, Florida, Georgia, South Carolina, North Carolina, Tennessee, and Canal Zone; the Northeast Regional Accrediting Committee serves the states and territories of Maine, Vermont, New Hampshire, New York, Maryland, Virgin Islands, Delaware, Massachusetts, New Jersey, District of Columbia, Connecticut, and Rhode Island; and the North Central Regional Accrediting Committee serves the states of Minnesota, Iowa, Wisconsin, Illinois, West Virginia, Indiana, Kentucky, Ohio, Michigan, Virginia, and Pennsylvania.
AORN Journal, February 1977, Vol25, NO 2
229
Brenda K McPherson, R N , is a graduate of the Community Hospital School of Nursing, Springfield, Ohio. She is head nurse, urology, University of Cincinnati Medical Center, Cincinnati. Biographical information on the three additional authors accompanies the article “Slush technique in renal surgery” appearing in this Journal.
operating room and ward personnel. Knowledge of possible complications can be utilized in care planning to reduce the likelihood of their occurrence. Preoperatively patients a t the University of Cincinnati Medical Center undergo a regimen of diagnostic evaluation. There is no single test of renal function; therefore, optimum findings are the results of a number of clinical determinations. Renograms and scans may be performed in addition t o excretory urography. These tests are repeated postoperatively to insure kidney function was not impaired by the slush technique. Blood studies including serum electrolytes, serum creatinine, and blood urea nitrogen determinations offer a baseline of renal function. Twenty-four-hour creatinine clearance tests are usually done two days consecutively. Preoperative coagulation studies are of great importance because the patient may receive heparin prior to the clamping of the renal artery during the operative procedure.2 These blood studies are repeated immediately after surgery, the following day, and usually about every two days thereafter. Urine is sent to the laboratory for culture, sensitivity, and colony count so that a course of proper antibiotic therapy may be instituted before the surgery. Birch and Mims report that 37% of
AORN Journal, February 1977, V o l 2 5 , N o 2
227
patients undergoing renal hypotherIn addition, drains and tubes placed mia contracted pulmonary complicaa t the time of operation in and around tions po~toperatively.~ Pneumothorax the kidney may also become a source has been reported on the operative of infection to the patient. Closed side. The position of the patient during drainage systems should be mainthe surgical procedure produces comtained for nephrostomies, catheters, pression of the lung contralateral to and stents. Meticulous care of the surgical incision, which may prodressings and drains should be exerduce areas of atelectasis. Pulmonary cised in an effort to prevent contamitoilet should be exercised preoperanation. If an indwelling Foley catheter tively. This provides a time to teach is maintained in the bladder postoperthe patient effective coughing and atively, meatal care is essential. We suggest a povidone-iodine wash foldeep breathing exercises as well as proper usage of the respiratory lowed by a povidone-iodine ointment therapy equipment. Intermittent posiapplication t o the urethral meatus of tive pressure breathing treatments are both males and females twice a day.6 initiated preoperatively using 3 to 5 cc Postoperative ileus is common after renal surgery. The patient should be of normal saline a t 20 cm pressure about four times a day, each treatment assessed for abdominal distention. Oral intake is deferred until adequate being 15 to 20 minutes in duration. Postoperative treatments should be bowel sounds are audible and flatus is expressed indicating peristalsis has every four hours. resumed. When oral intake is permitDuring surgery and in the imted we begin with tap water and promediate postoperative period the pagress as tolerated. Often our patients tient’s body temperature may drop to 95 F (35 C). Body temperature shows a are placed on bowel emollients twice a day when fluid intake resumes. Supdownward trend during the operation but tends to stabilize after two h o ~ r s . ~ positories may also be used as needed. It is unknown how patients maintain Early activity should be encouraged. This will decrease the risk of venous their temperature since they are unthrombosis of the lower extremities able to shiver to produce body heat. Systemic hypothermia has not posed a and possible subsequent pulmonary emboli. major postoperative problem and Attentiveness to prevention of posthyperthermia may be used during the operative complications is not limited surgical and postoperative periods. to the ward staff. Operating room Infection is a common problem in teams are equally responsible and urinary tract disease. As noted earlier, urine cultures should be done preoperhave a significant impact on the paatively and proper antimicrobial tient’s postoperative course. In addition to providing efficient and knowltherapy instituted as necessary to produce a sterile urine. A high incidence edgeable surgical assistance, extreme of infection is associated with renal care must be taken to maintain strict calculi.5 We initiate antimicrobial aseptic technique. The preparation of therapy prior to surgery and continue the iced saline slush is the unique responsibility of the operating room this through a full course. Many difstaff. Several steps are involved in the ferent drugs are employed depending slush preparation prior to its use in on specific bacterial susceptibility testthe operative incision. A break in ing.
228
AORN Journal, February 1977, V o l 2 5 , N o 2
asepsis in any o f these steps can lead t o contamination o f t h e slush and may i n i t i a t e serious postoperative complications. The operative technique i s a n additional source of possible postoperative complications. Although many are unavoidable and inherent t o any surgical procedure, a l i n e of communication f r o m t h e operating room team t o t h e ward staff i s often helpful in t h e management of t h e patient after surgery. Valuable information regarding drains, tubes, blood loss, u r i n e output, the r e n a l ischemia period, medications and fluids administered, and surgical difficulties encountered can be relayed t o t h e ward staff. This information may t h e n be used in establishing a care p l a n for t h e patient.
Regional accreditation committees formed Barbara Gruendemann, RN, MS, AORN vice-president, has been appointed to the West Regional Accrediting Committee (RAC) of the National Accreditation Board of the American Nurses’ Association (ANA). Five Regional Accrediting Committees have been established as part of an accreditation system that monitors the quality of continuing education offerings and facilitates the interstate transferability of continuing education contact hours. The committee will be directly responsible to the National Accreditation Board. Regional Accrediting Committees participate in a review and evaluation process for accrediting continuing education programs in nursing within universities and colleges. They also accredit state nurses associations, specialty nursing organizations, federal nursing services, and state boards of nursing to offer such programs and to approve offerings of sponsors and constituents. RACs also approve programs or offerings of national organizations and commercial firms.
The slush technique i s a new surgical adaptation and with t h e incorporat i o n of t h e guidelines presented can be an effective and safe adjunct t o the armamentarium of t h e urologic surgeon. Notes 1. P J Metzner, W H Boyce, “Simplified renal hypothermia: An adjunct to conservative renal surgery,” British Journal of Urology 44 (1972)76. 2. J S Taylor, “Kidney cooling in partial nephrectomy,” Urology 5 (1975)456. 3. A A Birch, G R Mims, “Anaesthesia considerations during nephrolithotomy with slush,” Jour-’ nal of Urology 1 13 (1 975)433. 4. Ibid. 5. A T Evans, “Infections of the kidney and bladder in the adult,” in Urology, L Karafin, A R Kendall, eds. (Hagerstown, Md: Harper & Row, 1976)Chapter 14:l-77. 6./bid.
Chosen for their expertise in specific areas of nursing, RAC members will serve two-year terms. The West Regional Accrediting committee serves the states and territories of Alaska, Hawaii, Guam, Washington, Oregon, California, Nevada, Arizona, Utah, Idaho, and Montana: the Mountain Regional Accrediting Committee covers the states of Wyoming, Colorado, New Mexico, Texas, Oklahoma, Kansas, Missouri, Nebraska, South Dakota, and North Dakota; the Southeast Regional Accrediting Committee serves the states and territories of Arkansas, Louisiana, Mississippi, Alabama, Florida, Georgia, South Carolina, North Carolina, Tennessee, and Canal Zone; the Northeast Regional Accrediting Committee serves the states and territories of Maine, Vermont, New Hampshire, New York, Maryland, Virgin Islands, Delaware, Massachusetts, New Jersey, District of Columbia, Connecticut, and Rhode Island; and the North Central Regional Accrediting Committee serves the states of Minnesota, Iowa, Wisconsin, Illinois, West Virginia, Indiana, Kentucky, Ohio, Michigan, Virginia, and Pennsylvania.
AORN Journal, February 1977, Vol25, NO 2
229