Discharge Summary for 32-Year-Old Female Following Pyeloplasty
Early mobilization, multimodal pain management, and monitoring for urinary complications are essential components of post-pyeloplasty care to optimize recovery and reduce morbidity.
Patient Information
- 32-year-old female
- Procedure: Pyeloplasty
- Date of Surgery: [Insert Date]
- Date of Discharge: [Insert Date]
Postoperative Care Instructions
Wound Care
- Keep surgical incision clean and dry
- Shower allowed after 24-48 hours; gently pat the incision area dry
- No tub baths, swimming, or soaking until cleared at follow-up visit
- Monitor for signs of infection (redness, increased pain, purulent drainage, fever)
Pain Management
- Multimodal approach recommended:
- Acetaminophen 650-1000 mg orally every 6 hours as needed
- NSAIDs (if not contraindicated): Ibuprofen 400-600 mg orally every 6 hours with food
- Avoid opioids when possible to prevent ileus and respiratory depression 1
- If breakthrough pain occurs, use prescribed opioid medication sparingly
Activity
- Early mobilization is strongly recommended starting day of surgery 2
- Day 0: At least 2 hours out of bed
- Day 1 and beyond: At least 6 hours out of bed daily
- Gradually increase walking distance daily
- Avoid heavy lifting (>10 pounds) for 4-6 weeks
- No driving while taking narcotic pain medications
- Return to work: typically 2-4 weeks depending on job requirements
Diet and Hydration
- Resume normal diet as tolerated
- Early oral nutrition is recommended starting immediately after surgery 2
- Maintain adequate hydration (2-3 liters of fluid daily)
- Avoid alcohol consumption for at least 4 weeks 2
Urinary Catheter Management
- If discharged with urinary catheter or stent:
- Keep drainage bag below level of bladder
- Empty drainage bag when half full
- Monitor urine output and color
- Stent removal typically scheduled 4-6 weeks post-surgery
- If catheter removed before discharge:
- Monitor for normal urination
- Report difficulty urinating, painful urination, or blood in urine
Medications
- Take all prescribed medications as directed
- Antibiotics (if prescribed): Complete full course
- Blood thinners (if prescribed): Take as directed for thromboembolism prevention 2
- Resume home medications as instructed
Follow-up Appointments
- Urology follow-up: [Insert Date/Time]
- Imaging studies (if ordered): [Insert Details]
- Stent removal appointment (if applicable): [Insert Date/Time]
Warning Signs - Seek Immediate Medical Attention for:
- Fever >101°F (38.3°C)
- Severe pain not controlled with prescribed medications
- Significant bleeding or drainage from incision
- Inability to urinate or severe burning with urination
- Persistent nausea/vomiting
- Shortness of breath or chest pain
- Calf pain, swelling, or redness (possible DVT)
Prevention of Complications
Venous Thromboembolism (VTE) Prevention
- Continue prescribed thromboprophylaxis if indicated 2
- Early and frequent ambulation
- Compression stockings if prescribed
Infection Prevention
- Hand hygiene before and after wound care
- Take antibiotics exactly as prescribed
- Monitor temperature daily for first week
Fluid Balance
- Maintain near-zero fluid balance 2
- Monitor for signs of dehydration (dry mouth, decreased urine output, dizziness)
- Report persistent nausea/vomiting that prevents adequate fluid intake
Contact Information
- Urology office: [Insert Phone Number]
- After hours/Emergency: [Insert Phone Number]
This discharge plan follows Enhanced Recovery After Surgery (ERAS) principles to optimize recovery and reduce complications following pyeloplasty 2.