A small compilation of nurse anesthesia care plans

These anesthesia care plans are meant to inspire nurse anesthesia residents when they are making their care plans. Always make sure you fully understand and "own" your care plan. Your plan must be specific for your patient and should always be with the most up-to-date information.

Nephrectomy

Etiology

Adenoma of the kidney - erythrocytosis (polycythemia), hypercalcemia, hypertension, and nonmetastatic hepatic dysfunction.

Pt of any age, depending on the etiology of abnormality

Many may have renal insufficiency due to underlying problems or renovascular HTN.

Elderly may have preexisting conditions such as CAD, CHF, PVD, COPD, renal impairment, and cerebrovascular disease

Procedures

Simple nephrectomy

Benign conditions such as chronic hydronephrosis, hypoplastic kidney (small kidneys that contain a reduced number of normally developed filtering elements), renovascular HTN (renal artery stenosis), and double collecting system

Flank or prone position.

Partial nephrectomy

Surgical excision of part of the kidney with pathology; renal-cell carcinoma, double collecting system

Flank position

Radical nephrectomy

Surgical kidney excision with surrounding perinephritic fat, Gerota's fascia (connective tissue capsule), proximal 2/3 of the ureter, and paracaval or para-aortic lymphadenectomy

Renal-cell carcinoma, non-functioning kidney due to infection or obstruction, kidney donation

Flank or supine position.

Laparoscopic Simple or Radical Nephrectomy

Pneumoperitoneum with CO2 insufflation to 14-16 mmHg, 3-4 trochars placed

It can be a transperitoneal or retroperitoneal approach

Flank position

Anesthetic considerations

  • Increased postop pulmonary complications due to incision location; may need postop respiratory therapy depending on medical history
  • Consider the possibility of renal HTN
  • Consider preop blood donation for autologous transfusion if pt has polycythemia
  • Electrolytes, BUN, Cr, others per H&P
  • GETA due to awkward positioning, leading to increased pt discomfort and pain
  • If intraperitoneal or laparoscopic approach, limit or avoid N2O to avoid bowel distention and operative field interference
  • If cross-clamping of renal arteries, mannitol (0.5 g/kg) is often given before occlusion (20 minutes maximum)
  • Decreased BP
    • Possibly due to vena cava obstruction due to lateral position with kidney rest and table flexion
  • Axillary roll if lateral

Complications

  • Pneumothorax with increased RR, increased PIP, hypoxemia, and hypercarbia
    • Do CXR if in doubt
  • Postnephrectomy syndrome
    • Due to retractor injury
    • L1 nerve root damage resulting in pain, dysesthesia (bad sensation), and sensory loss in the L1 dermatome distribution
  • Brachial Plexus injury
  • Atelectasis/pneumonia
  • Eye injury if prone