Orders, Surgical Consent and Patient Information
for
Percutaneous Nephrostolithotomy
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Enter surgeon last name: Nejd Alsikafi, M.D.
Enter patient first name: sma
Enter patient last name: housston
Enter patient medical record number: 234
Enter patient medical record number again: 234
Enter the diagnosis: kidney stone
Which kidney has the stone(s)? Left
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Nejd Alsikafi, M.D.
2160 South First Avenue
Maywood, IL 60153
Loyola Medicine
Department of Urology
Phone
FAX
Order for Testing
Name:
housston, sma
708/216-6266
708/216-6585
Date:
Diagnosis: kidney stone
CBC
BMP
PT/PTT – INR
Urinalysis [dip stick]
Urine culture & sensitivity
Chest x-ray
EKG
Type and cross ___ Units P.R.B.C.
Nejd Alsikafi, M.D.
12 February 2016
Loyola University Medical Center
Consent for Surgery
Name:
housston, sma
MR#: 234
1. I hereby authorize Dr. Nejd Alsikafi, M.D., attending physician, and such assistants and associates as may be elected by him/her
to perform the following procedure(s) upon: sma housston
Patient’s Name
Procedures:
Percutaneous Left Nephrostolithotomy [removing a kidney stone or kidney stones through a
tube placed through the skin of the flank into the kidney pelvis (drain system)
2. I understand that this procedure(s) appears to be indicated by the diagnostic studies and/or clinical observations already performed
regarding the following condition:
Condition requiring the procedure(s):
3. I authorize the administration of anesthesia as may, in the exercise of good professional judgment, be necessary or advisable by
the physician responsible for administering anesthetics.
4. I authorize the administration of blood and blood components as may be considered necessary or advisable in connection with
the procedure(s) described above.
5. The nature, purpose, and possible complications of the procedures and medical services described above, the risks and benefits
reasonably to be expected, and the alternative methods of treatment and the risks/benefits of no treatment have been explained to me
by my physician.
Possible Complications:
Failure to remove all stones or stone fragments, bleeding, infection, injury to
the kidney, pneumothorax (air in the chest outside the lung), hydrothorax (water in the chest outside
the lung), inability to remove all of the tumor, others
6. I recognize that during the operation unexpected conditions may be revealed which require my doctors to perform additional or
different procedures than those described above. Since I may be under anesthesia or otherwise unable to give my consent to this
treatment during the procedure(s) described above, I hereby authorize and request that the physician performing these procedure(s) and
his assistants or designees perform such other procedures as are, in the exercise of good professional judgment, necessary and
desirable. I understand that these procedures may include surgery as well as other forms of treatment. The authority granted in this
paragraph shall extend to remedy all conditions found during the operation that require treatment, and that are not known at the time
the procedure is commenced.
7. I acknowledge that I have received no warranties or guarantees with respect to the benefits to be realized or consequences of the
aforementioned procedure.
8. I consent to the filming or recording of the procedure to be performed, including appropriate portions of my body, for scientific or
educational purposes which arenot related to diagnosis or treatment of my condition, provided my identity is not revealed by the
pictures or by descriptive texts accompanying them. I understand that I can revoke this consent for filming/recording by notifying my
attending physician within five days of my surgery or procedure. In the event of revocation, I understand that any prior us of film or
recordings up to the date of revocation may not be retracted.
9. For the purpose of advancing medical education, I consent to the participation of residents, fellows and health care students in the
surgery or procedure and to the admittance of observers to the room in which the surgery or procedure(s) are performed. These
observers may include representatives from medical device manufacturing companies who are demonstrating or providing technical
support for new procedures or equipment.
10. I consent to the disposal by hospital authorities of any tissues, body parts or implants which may be removed.
11. I acknowledge that I have read this document in its entirety and that I fully understand it, that all blank spaces have been
completed and that any disagreeable sections have been crossed off and initialed prior to my signing.
12. I understand that I have the right to cancel my surgery at any time, even after I have signed this consent form. I understand that I
am under no obligation to proceed with the surgery.
13. I have had a full discussion about the proposed procedure with my physician and have consented to the procedure described on
this form. I further understand that if I have questions about my proposed surgery or procedure, I have the right to have those
questions answered before surgery or procedure.
Date
Print Name
Time
Print Name
Signature of Patient
Signature of Consenting Party
Relationship to Patient
AFFIRMATION OF INFORMED CONSENT BY PHYSICIANS
I have informed the above-named patient or the patient’s authorized representative, of the condition requiring
treatment(s), therapy(s) or procedure(s) described to on the front page of this Consent Progress Note and I have,
consistent with my best medical judgment, fully explained the nature and purposes of all the treatment(s),
therapy(s) or procedure(s), possible alternative methods of treatment(s), therapy(s) or procedure(s), the risks
involved and the possibility of complications in the treatment(s), therapy(s) or procedure(s) consented to and in
alternative treatment(s), therapy(s) and procedure(s), and that, after the foregoing information had been
explained, the patient or representative indicated that he/she understood that information and consented to such
treatment(s), therapy(s) or procedure(s).
Date
INTERPRETER
I affirm that I acted as interpreter or translator for the patient or the patient’s representative and accurately and
completely translated into the _________________________ language both the statements contained on this
form as well as the statements made by the physician, Nejd Alsikafi, M.D., to the patient and/or the patient’s
representative and that the patient or the patients representative stated that he or she understood all of the
statements and consented to the treatment and/or other procedures described in those statements.
Date
Signature
Relationship to Patient
Print Name
Patient
or Consenting Party
signed this form in my presence
or consented by telephone
If an RN is witnessing the signature, a properly executed Consent Progress Note must be in the medical record.
Witness (print name and title)
Signature
Date
Additional Witness (For telephone consent, interpreter or, translator or if patient signs with an “X”)
Signature
Date
Information for Patients about
Percutaneous
Nephrostolithotomy
How is a kidney stone removed?
Your surgeon recommends a surgical procedure called
percutaneous [through the skin] nephrostolithotomy
[tube in the kidney, removal of stone] There are usually
three connections to the kidney: an artery (a blood
vessel that carries blood from the heart to the kidney), a
vein (a vessel that carries filtered blood from the kidney
back to the heart) and a ureter (the drainage tube that
carries urine to the bladder).
The surgery to remove a kidney stone can be done
through a tube placed through the flank into the kidney
pelvis. In order to place the tube, a needle is passed
through the skin into the pelvis of the kidney. A wire is
passed through the needle and then a dilator is used to
stretch the size of the opening until it is large enough to
accept a tube about the size of a little finger. A
telescope is passed through the tube and smaller stones
or stone fragments are grasped with an instrument that
resembles a pickle fork and then removed. For larger
stones, a laser or a shock wave generator is used to
break the stone into small pieces. After the stone is
removed, sometimes a catheter [drain tube] is left in the
kidney. This tube will be removed either before you
leave the hospital or in the clinic.
What are the possible complications of having a kidney stone removed?
Although we try our best to do everything possible to make the surgery safe, there are potential complications of the procedure.
The most common complication of a kidney stone removal is failure to remove the stone or pieces of the stone. We cannot
guarantee that every time we attempt to remove a kidney stone that we will be successful. Bleeding is also possible. This can
occur when the needle is placed, when the tract into the kidney is dilated or when the stone is removed. If bleeding occurrs, a
blood transfusion or another procedure may be necessary. This is relatively uncommon. Infection is also possible following
major surgery such as this. If an infection occurred following a kidney stone removal, antibiotics may be necessary. It might
also be necessary to place a drain catheter or to perform a second surgery to drain an infection pocket.
Because other organs lie near the kidney, it is possible that those organs (the lung, the spleen, stomach, intestine, etc.) could be
injured during the surgery. If so, a repair surgery may be required. This is quite rare. If air leaks through the tube entering the
kidney into the space around the lung, it may be necessary to place a drain tube into the chest. During the surgery water is used
to allow us to see in the kidney pelvis. If this water leaks into the space around the lung, it may be necessary to place a drain
tube into the chest.
As with any major surgery, it is possible that a blood clot in the leg, a blood clot traveling to the lung, or pneumonia could
develop following kidney donation. We take special precautions to try to prevent such complications. This includes having the
patients cough and take deep breaths regularly to keep the lungs opened up. We also encourage patients to walk starting the
day following the surgery. Other more rare complications could also occur. If you have specific questions, please ask your
surgeon.
How long will I stay in the hospital?
Most kidney patients are ready to leave the hospital 1-2 days after surgery. Of course, each patient is unique, so your hospital
stay could be longer. When you are eating regular food, when your pain is controlled with pain pills and when you are able to
do the physical activities necessary at home, you will be ready to leave the hospital.
How much pain will I have? What can you do to control the pain? How long will the pain last?
These are some of the most difficult questions to answer because each person experiences pain in a different way. Following
your surgery, you will be given pain medicine (pills or through an intravenous line). We will give you a prescription so that you
can take the pain medication at home. Because each person is unique, it is impossible to predict how long you’ll need to take
pain pills.
When will I be able to eat?
After surgery you can drink liquids if you feel up to it. Starting in the evening after surgery you can eat your normal diet.
Many patients notice that their appetite isn’t as strong for a few days following surgery.
When can I drive again?
We recommend that you not drive until you no longer need narcotic pain medication.
When can I go back to work?
You can probably return to work in 1 – 3 weeks. Some patients are ready to go back to work sooner and some are ready later.
You will need to listen to your body to know when you are ready. It may be helpful to return to work part-time or doing light
work at first. If you need a letter for your employer, let us know.
What physical activities can I do following the surgery?
After you get home from the hospital, you should plan to do a little walking every day. Start slowly and gradually build up your
endurance. If you overdo it, you will be sore. Listen to your body and use your head. Starting 1-2 weeks following the
surgery, you may begin to do some stretching exercises that will help you to stay limber. Starting two weeks following the
surgery, you may begin to do some light exercise. Gradually build up your exercise plan over the next two weeks.
When can I shower?
You can take a brief shower (5-10 minutes) starting the day following the surgery.
Will I need to eat a special diet after the surgery?
No. You can eat anything you would like. Of course, we recommend that you eat a healthy diet including plenty of fresh fruits
and vegetables.
What if I have other questions?
We’re happy to answer all of your questions. It may be best to write down questions as you think of them. Please call your
surgeonr with any questions you may have.
Department of Urology
Loyola University Medical Center
2160 S. First Avenue
Maywood, IL 60153
Office:
Appointments:
Central Scheduling (all clinics)
708/216-4076
708/216-8563