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.