Primary Nursing Diagnosis

Altered urinary elimination related to renal tissue destruction

OUTCOMES. Urinary continence; Urinary elimination; Knowledge: Medication; Disease process; Treatment regime; Symptom severity

INTERVENTIONS. Urinary elimination: Management; Fluid management; Medication prescribing; Urinary catheterization; Anxiety reduction; Pain management

U PLANNING AND IMPLEMENTATION Collaborative

Depending on the stage, surgical intervention and further staging is the primary treatment for renal cell cancer. A radical nephrectomy (removing the whole kidney, the attached adrenal gland, and fatty tissue that surrounds the kidney), sometimes with lymph node removal, offers the patient the best chance for cure. The procedure is the treatment of choice for localized cancer or in patients with tumor extension into the renal vein and vena cava. Surgical intervention is not curative for disseminated disease. Because of the proximity of the kidney to the diaphragm, the surgeon may explore the pleura on the surgical side. The patient could therefore return from surgery with a chest tube placed to remove blood and air from the pleural space. A partial nephrectomy is reserved for those patients with very small renal cell tumors, those who have cancer in both kidneys, or those who only have one kidney.

Nephrectomies involve large blood vessels and place the patient at risk for postoperative hemorrhage. Frequent assessment and serial vital signs to monitor for shock are part of postoperative management. Patients undergoing a nephrectomy experience moderate to severe pain; for this reason, the anesthesiologist may place an epidural catheter during surgery for pain management with morphine sulfate or other appropriate analgesia. Monitor the patient's urinary output through the Foley catheter for adequate volume and color and consistency of urine; if the patient's urine output decreases below 40 mL per hour, notify the physician.

Depending on the final stage of the kidney cancer, the surgeon may refer the patient for follow-up care by an oncologist. Kidney cancer is resistant to radiation therapy, which is used in high doses only when metastases have occurred into areas such as the perinephric region and the lymph nodes. Chemotherapy and hormonal therapy do not affect tumor growth. Although several experimental or alternative medications are being tested, they usually have many side effects or are of limited usefulness. Cytokines, proteins that activate the immune system are currently being investigated as an approach to treat renal cell cancer by boosting the immune system to destroy cancer cells. Also being investigated are "targeted therapies" which include antiangio-genesis drugs, which kill cancer cells by cutting off their blood supply.

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