I. INTRODUCTION:

Nephrolithiasis (kidney stones) is a disease affecting the urinary tract. Kidney stones are small deposits that build up in the kidneys, made of calcium, phosphate and other components of foods. They are a common cause of blood in urine. Some types of stones tend to run in families. Some types may be associated with other conditions such as bowel disease, ileal bypass for obesity, or renal tubule defects. A personal or family history of stones is associated with increased risk of stone formation. Other risk factors include renal tubular acidosis and resultant nephrocalcinosis. Kidney stone formation may result when the urine becomes overly concentrated with certain substances. These substances in the urine may complex to form small crystals and subsequently stones.

Stones may not produce symptoms until they begin to move down the ureter, causing pain. The pain is severe and often starts in the flank region and moves down to the groin. The size of the renal stone will dictate the natural history of this condition.

If the stone is less the 5mm in diameter, then it will most likely pass on future urination. If the stone is larger than 5mm, urological procedures may be required to remove the stone. Surgical intervention will be required in any patient whose urinary tract in completely obstructed. This situations represents a surgical emergency. Symptoms of renal stone disease may include:

Pain : unilateral or bilateral flank or back pain. Is is normally severe and colicky (spasm-like) in nature, radiating to the pelvis, groin and/or genitals.

Nausea , Vomiting, Urinary frequency/urgency , Haematuria (blood in the urine) , Abdominal pain, Dysuria (painful urination), Nocturia (excessive at night), Urinary hesitancy, Fever , Chills and Abnormal urine color or smell.

A number of blood and urine tests will be required to detect the presence of infection and test the function of the kidneys. Urinary tests may also allow the type of stone to be identified, allowing further guidance of therapy.

When urinary stones are suspected, a x-ray of the abdomen is also required to detect the stones or any other problem causing a similar set of symptoms.

Kidney stones are painful but usually are excreted without causing permanent damage. They tend to recur, especially if the underlying cause is not found and treated.

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II. PATIENT’S PROFILE:

Name: Rodel Garcia

Age: 25 years old

Sex: Male

Civil Status: Married

Religion: Roman Catholic

Address: Ilocos Norte

Occupation: Soldier

Current Diagnosis:

Nephrolithiasis left

II. CHIEF COMPLAINTS:

The patient complains of pain at right lower quadrant area radiating to flank

right.

III. HISTORY OF PRESENT ILLNESS:

Patient came in with an ultrasound result of nephrolithiasis left hence,

admission.

IV. PAST MEDICAL HISTORY:

At the year of 2004 she underwent TAHBSO because of ovarian cyst at

Veterans Hospital. And in 2007 she was hospitalized because of diabetes.

Pt. has no allergies with medications prescribed to her. She has no

injuries or accidents incurred. Pt. is hypertensive and diabetic.

V. SOCIAL AND ENVIRONMENTAL HISTORY:

Mrs. R.M 52 years old mother of 6 children admits that at the age of 18

she began to smoke 5 sticks per day then stopped at year 2009 but started to

drink occasionally for socialization purposes. She is fond of eating high salt and

high sugar foods with a bottle of acidic beverages. Almost everyday, she eats

junk foods, softdrinks and loves to eat in fast food restaurants like jollibee, KFC,

and Mcdo.

The client is a housewife, and is a high school graduate. She is friendly

and loves to mingle with others. Due to her kindness, generosity, and friendly

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attitude, she is loved by many and is always visited by her neighbors, friends,

and relatives in their house and they used to have snacks.

Their house is sited along the street and was surrounded by mango trees.

She loves to eat mango with fish sauce/ “alamang,” then loves to take a sip on it.

VI. FAMILY HISTORY:

The patient’s father died because of stroke and hypertension. The mother

was deceased with a history of diabetes and hypertension. They had nine

siblings, two were twins; our patient was the second child. Two of her sisters was

also diabetic and most of them were hypertensive. According to her, their

relatives from the mother side have the same illness also and some relatives

passed away with the same health problem.

VII. PHYSICAL EXAMINATION:

GENERAL SURVEY

Pt is 5’2” in height and 73kgs in weight, she is overweight. Pt. has a good

posture and gait but her movement was quite limited because of discomfort in

her inflamed left foot due to accident before admission. She, during our duty,

sometimes complains of on and off pain at the RLQ radiating to back rated as 5-

8/10, from a scale of 0-10, 10 being the highest.

Appears clean and neat, practices good hygiene. Mrs. R.M is cooperative

and coherent.

She has an ongoing IVF of D5LRS infusing well at the left hand.

2. HEAD, EYES, EARS, NOSE, THROAT

a. HEAD

The client’s head is symmetrical and no fracture observed with a

smooth short black evenly distributed hair without flakes, lesions, masses,

tenderness and head lice noted on scalp. Face is symmetrical, no pain and

tenderness on the temporomandibular joint upon palpation.

b. EYES

Eyes are symmetrical with evenly distributed hair in the eyebrows

and eyelashes. Eyelids can close properly and no difficulty. No

discharges, lesions, redness, swelling noted on both eyes. Sclera appears

white and palpebral conjunctiva appears pink in color. Pupils are black

and symmetrical, pupil is dilated and reactive to light at 2-3 mm. The client

has no known deficits such as color blindness. She was not able to read

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magazines or newspaper at a distance of 36 cm without using reading

glass.

c. EARS

Auricles are symmetrical and the same color as facial skin, has a

clean external auditory canal without lesions or discomfort noted. She can

hear at a distance of about 2 feet by repeating what we said as requested

her to do so. And using the watch tick test she was able to hear ticking

and hearing is intact.

d. NOSE

External nose color is same as facial skin, symmetrical nares, moist

pink mucosal wall without discharges and lesions noted. Has a patent

nasal cavities and no masses noted. Can differentiate odors since when

asked to close her eyes and discriminate orange and coffee, she was able

to distinguish the odors of the two.

e. THROAT

The throat was not edematous and no lesions observed.

3. RESPIRATORY SYSTEM

Mrs. R.M has clear breath sounds, no adventitious sound heard

upon auscultation with a respiratory rate of 20 bpm which is within normal

range. She is not suffering from any form of respiratory disress.

4. CARDIOVASCULAR SYSTEM

The patient’s blood pressure ranges from 140/60 up to 160/100

mmHg at the left arm while on lying position. Extremities are warm to

touch and peripheral pulses are present, regular and palpable but weak at

the radial. Apical pulse is 62 bpm which is within normal.

5. GASTROINTESTINAL SYSTEM

The abdomen is globular in shape; non distended, soft, no direct

and rebound tenderness. Tympanic sound is heard upon percussion over

the bladder.

6. GENITO-URINARY SYSTEM

The client eliminates at comfort room. His urine output ranges from

100-1000ml, amber in color for 12hrs and has bowel movement one to two

times a day. No bladder distention upon assessment at the hypogastric

region.

7. MASCULO- SKELETAL SYSTEM

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The client is not in complete bed rest without bathroom privileges

and needs minimum assistance in moving and performing ADL because of

inflamed left foot. Client is able to perform flexion, extension, abduction

and adduction independently. No other deformities observed.

8. INTEGUMENTARY SYSTEM

The client has a pink palpebral conjunctiva. Skin is moist and warm

to touch. No lesion, cracks, signs of inflammation and bruises noted. The

client has a short, smooth well comb black hair. No dandruff and parasites

observed. Nails are clean and well trimmed.

9. NERVOUS SYSTEM

Orientation of three areas (time, place and date) was not limited

because the client was able to communicate well. Can communicate well

by verbalization, understands simple to complex instruction, able to write

and read. It is evident that intellectual development is appropriate on his

age.

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VIII. DIAGNOSTIC:

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DATEDIAGNOSTIC PROCEDURE DESCRIPTION PURPOSE RESULT IMPRESSION

March 7, 2010

KUB X rays are a form of radiation that can

penetrate the body and produce an

image on an x-ray film. Another name

for x ray is radiograph.

Consist of two views, the frontal view (referred to as

posterioranterior or PA) and the lateral

(side) view. It is preferred that the

patient stand for this exam, particularly

when studying collection of fluid in

the lungs.

Used to evaluate organs and

structures within the chest for symptoms of

diseases. Chest x-ray include views of the lungs, heart,

small portion of the GIT, thyroid gland and the bones of the chest area

Hazy opacities are seen on the right middle lobe

Heart is not enlarged Pulmonary vascularity is

within normal. Visualized osseous

structures are unremarkable.

Pneumonitis, right middle lobe

DATEDIAGNOSTIC PROCEDURE DESCRIPTION PURPOSE NORMAL RESULT IMPRESSION

March 11, 2010

CBC Is a series of test used to evaluate the

composition and concentration of the cellular components

of blood.

As a preoperative test to ensure both adequate

oxygen carrying capacity and hemostasis

WBC= 5.0-10.0

10.2x10^9/L White blood cells help fight infection. It also help produce, transport and distribute antibodies to build the body’s immune system.A high count indicates not a specific disease by itself but indicates infection, systemic illness, inflammation, allergy and leukemia, too much of mental stress also increases the count of the white blood cells in the body. Also, once the count of white blood cell is on the higher side, the risk of cardiovascular mortality also increases.

Granulocytes= 2.0-7.0

7.2x10^9/L When the number is high, it indicates an infection or inflammation somewhere in the urinary tract.

Granulocytes (%)=50.0-70.0

70.5% When the number is high, it indicates an infection or inflammation somewhere in the urinary tract.

MCV= 82.0-95.0

96.8 fL Increased with B12 and Folate deficiency; decreased with iron deficiency and thalassemia

MCH=27.0-31.0

31.9 pq Mirrors MCV results

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DATEDIAGNOSTIC PROCEDURE DESCRIPTION PURPOSE RESULT INTERPRETATION

March 13,, 2010

ECG A test that checks for problems with the

electrical activity of your heart.

An electrocardiogram is done to know if:

The heart's electrical activity.

The cause of unexplained chest pain

The cause of symptoms of heart disease

How well medicines are working and whether they are causing side effects

PR= .18 Normal ( 0.12-0.20 sec)QRS=.06 Duration should not exceed 0.10

second. A widened complex indicates ventricular

enlargement QT=.34

DATEDIAGNOSTIC PROCEDURE DESCRIPTION PURPOSE RESULT IMPRESSION

March 13,, 2010

Troponin I Troponin tests are primarily ordered for people who have chest pain to see if

they have had a heart attack or other damage to

their heart. Either a troponin I or a troponin T test can be

performed; usually a laboratory will offer one test

or the other.

The troponin test is used to help diagnose a heart attack, to detect and evaluate mild to severe heart injury, and to distinguish chest pain that may be due to other causes.

negative Normally, cardiac troponin levels are so low that they cannot be measured. Even slight elevations may indicate some degree of damage to the heart. When a patient has significantly elevated troponin concentrations, then it is likely that the patient has had a heart attack or some other form of damage to the heart

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DATEDIAGNOSTIC PROCEDURE DESCRIPTION PURPOSE RESULT NORMAL IMPRESSION

March 22, 2010

Creatinine Test is used to assess kidney function.

This test measures how effectively your kidneys are filtering small molecules

88.4 umol/L Normal: 44.2-150.28 umol/L

Increased creatinine levels in the blood suggest diseases or conditions that affect kidney function. These can include:

Low blood levels of creatinine are not common, but they are also not usually a cause for concern. They can be seen with conditions that result in decreased muscle mass.

DATEDIAGNOSTIC PROCEDURE DESCRIPTION PURPOSE RESULT IMPRESSION

March 23, 2010

Ultrasound of Kidneys, Urinary Bladder

A kind of ultrasound scan of the abdomen and pelvis

Identify suspected problems in the urinary system, such as a kidney stone or blockage in the intestine

Right kidney: 10.60x5.07 cmCortical thickness: 2.18

Left kidney: 9.63x4.88cmCortical thickness: 1.37

Both kidneys are normal in size with smooth borders and homogenous parenchymal echopattern.

The right cental renal echocomplex is slightly separated. Both cortical thickness are within normal. Multiple hyperechoic foci are seen at the right interpolar area with the largest

Multiple nephrolithiasis with mild hydronephrosis.

Right kidney sonographically normal left kidney and urinary bladder.

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measuring 2.3cm. Perinephric regions are unremarkable.

DATEDIAGNOSTIC PROCEDURE DESCRIPTION PURPOSE RESULT IMPRESSION

April 3, 2010

Urinalysis Urinalysis is a test that evaluates a sample of your urine. Urinalysis is used to detect and assess a wide range of disorders, including urinary tract infection, kidney disorders and diabetes.

They detect the byproducts of normal and abnormal metabolism, cells, cellular fragments, and bacteria in urine.

Color Yellow Normal urine is straw yellow to amber in color. Abnormal colors include bright yellow, brown, black (gray), red, and green. These pigments may result from medications, dietary sources, or diseases.

Ph 6.0 pH level indicates the amount of acid in urine. Abnormal pH levels may indicate a kidney or urinary tract disorder. normally 5 to 7

Specific gravity

1.03 Specific gravity shows how concentrated particles are in your urine. Higher than normal concentration often is a result of dehydration, rather than another underlying medical condition. But, it may indicate a kidney disorder.normally 1.003 to 1.030

Sugar + 1 normally the amount of sugar (glucose) in urine is too low to be detected. Any detection of sugar on this test usually calls for follow-up testing for diabetes.

Appearance

Slightly turbid

Normal urine is transparent. Turbid (cloudy) urine may be caused by either normal or abnormal processes. Normal conditions giving rise to turbid urine include precipitation of crystals, mucus, or vaginal discharge. Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria.

Pus cells

1-3 Normal (Normal value for pus cells in urine is 0-5/hpf)

RBC 4-6 Red blood cells (erythrocytes) may be a sign of kidney disorders, blood disorders or another underlying medical condition, such as bladder cancer.

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DATEDIAGNOSTIC PROCEDURE DESCRIPTION PURPOSE RESULT IMPRESSION

April 11., 2010

Urinalysis Urinalysis is a test that evaluates a sample of your urine. Urinalysis is used to detect and assess a wide range of disorders, including urinary tract infection, kidney disorders and diabetes.

They detect the byproducts of normal and abnormal metabolism, cells, cellular fragments, and bacteria in urine.

Color Light yellow

Normal urine is straw yellow to amber in color. Abnormal colors include bright yellow, brown, black (gray), red, and green. These pigments may result from medications, dietary sources, or diseases.

Appearance

Slightly turbid

Normal urine is transparent. Turbid (cloudy) urine may be caused by either normal or abnormal processes. Normal conditions giving rise to turbid urine include precipitation of crystals, mucus, or vaginal discharge. Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria.

pH 5.0 pH level indicates the amount of acid in urine. Abnormal pH levels may indicate a kidney or urinary tract disorder. normally 5 to 7

RBC 1-15 Red blood cells (erythrocytes) may be a sign of kidney disorders, blood disorders or another underlying medical condition, such as bladder cancer.

Protein Trace Increase in protein usually aren't a cause for concern. Larger amounts of protein in the urine may indicate a kidney problem.

Pus 1-2 Normal (Normal value for pus cells in urine is 0-5/hpf)Specific gravity

1.005 Specific gravity shows how concentrated particles are in your urine. Higher than normal concentration often is a result of dehydration, rather than another underlying medical condition. But, it may indicate a kidney disorder.normally 1.003 to 1.030

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Sugar Negative

Normally the amount of sugar (glucose) in urine is too low to be detected. Any detection of sugar on this test usually calls for follow-up testing for diabetes.

DATEDIAGNOSTIC PROCEDURE DESCRIPTION PURPOSE RESULT NORMAL IMPRESSION

April 14, 2010 SGPT Is found in serum and in various bodily tissues, but is most commonly associated with the liver.

typically used to detect liver injury

20.5 u/l Normal: 5-35u/l elevated levels of SGPT often suggest the existence of other medical problems

such as viral hepatitis, congestive heart failure, liver damage, bile duct problems, infectious mononucleosis, or

myopathy.HgbA1c Is a form of hemoglobin used

primarily to identify the average plasma glucose

concentration over prolonged periods of time. It is formed in a non-enzymatic pathway by

hemoglobin's normal exposure to high plasma

levels of glucose.

Monitoring the HbA1c in type-1 diabetic patients

may improve treatment

7.8% 4.8%-6.9% In poorly controlled diabetes, its 8.0% or above,

and in well controlled patients it's less than 7.0%

IX. MEDICAL DIAGNOSIS:

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Nephrolithiasis right, HPN, DM 2, Obese

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X. COMPREHENSIVE PATHOPHYSIOLOGY:

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XI. TREATMENT and MANAGEMENT:

A.) Drug study

TRADE AND GENERIC NAME

CLASSIFICATION MECHANISM OF ACTION

SIDE EFFECTS NURSING INTERVENTIONS

Trade Name:Zydol

Generic name:Tramadol

Pharmacologic class: Opioid agonist

Therapeutic class: Analgesic

Inhibits reuptake of serotonin and norepinephrinein CNS

CNS: dizziness, headache,drowsiness, anxiety, confusionEENT: visual disturbancesGI: nausea, constipationabdominal pain, dyspepsia,flatulence, dry mouthGU: urinary retention and frequency,proteinuria, menopausal symptomsSkin: pruritus, sweatingOther: physical or psychological drugdependence, drug tolerance

Patient monitoring● Assess patient’s response to drug 30 minutes after administration.● Monitor respiratory status.Withhold drug and contact prescriber if respirations become shallow or slower than12 bpm.● Monitor for physical and psychological drug dependence. Report signs to prescriber.Patient teaching● Tell patient drug works best when taken before pain becomes severe.● Inform patient (and significant other as appropriate) that drug may cause respiratory depression if used with alcohol.Recommend abstinence.● Tell patient drug interacts with many common OTC

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drugs andherbal remedies. Instruct him to consult prescriber before taking these products.

TRADE AND GENERIC NAME

CLASSIFICATION MECHANISM OF ACTION

SIDE EFFECTS NURSING INTERVENTIONS

Trade Name:Rocephin

Generic name:Ceftriaxone

Pharmacologic class: Third-generationCephalosporin

Therapeutic class: Anti-infective

Interferes with bacterial cell-wall synthesisand division by binding to cellwall, causing cell to die.

CNS: headache, confusion, hemiparesis,CV: hypotensionGI: nausea, abdominal crampsHematologic: lymphocytosis, eosinophilia,bleeding tendency, hemolyticanemiaMusculoskeletal: arthralgiaSkin: urticariaOther: pain at I.M. injection site

Patient monitoring● Monitor coagulation studies.● Assess CBC and kidney function test results.● Be aware that cross-sensitivity to penicillins and cephalosporins may occur.Patient teaching● Instruct patient to report persistent diarrhea, bruising, or bleeding.● Caution patient not to use herbs unless prescriber approves.

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TRADE AND GENERIC NAME

CLASSIFICATION MECHANISM OF ACTION

SIDE EFFECTS NURSING INTERVENTIONS

Trade Name:Toradol

Generic name:ketorolac tromethamine

Pharmacologic class: Nonsteroidalanti-inflammatory drug (NSAID)

Therapeutic class: Analgesic, antipyretic,anti-inflammatory

Interferes with prostaglandin biosynthesisby inhibiting cyclooxygenase pathwayof arachidonic acid metabolism;also acts as potent inhibitor of plateletaggregation

CNS: drowsiness, headache, dizzinessCV: hypertensionEENT: tinnitusGI: nausea, vomiting, diarrhea, constipation,flatulence, dyspepsia, epigastricpain, stomatitisHematologic: thrombocytopeniaSkin: rash, diaphoresisOther: excessive thirst, injection site pain

Patient monitoring● Check I.M. injection site for hematoma and bleeding.● Monitor fluid intake and output.Patient teaching● Inform patient that drug is meant only for short-term pain management.● Advise patient to minimize GI upset by eating small, frequent servings of healthy foods.● Instruct patient to avoid aspirin products and herbs during therapy.● Caution female patient not to takedrug if she is breastfeeding.especiallythose related to the drugs, tests, andherbs mentioned above.

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TRADE AND GENERIC NAME

CLASSIFICATION MECHANISM OF ACTION

SIDE EFFECTS NURSING INTERVENTIONS

Trade Name:Januvia

Generic name:sitagliptin phosphate

Pharmacologic class: Dipeptidyl peptidase4 (DPP-4) inhibitor

Therapeutic class: Hypoglycemic

Inhibits DPP-4 and slows inactivationof incretin hormones, helping to regulateglucose homeostasis through increasedinsulin release and decreased glucagon levels

CNS: headacheEENT: nasopharyngitisGI: abdominal pain, nauseaRespiratory: upper respiratory tract infectionOther: hypersensitivity reactions

Patient monitoring● Monitor blood glucose and hemoglobin levels periodically during therapy.● Monitor patient for signs andsymptoms of hypersensitivity reactions and immediately stop drug and institute emergency measures if such reactions occur.● Check for diabetes signs and symptoms and disease progression routinely during therapy.Patient teaching● Instruct patient to take drug with or without food.● Teach patient about signs and symptoms of hypoglycemia (such as blurredvision, sweating, excessivehunger, drowsiness, and fast

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heart rate).● Teach patient about signs andsymptoms of hypersensitivity reactions and to immediatelycontact prescriber if these occur.● Instruct patient to routinely monitorblood glucose levels at home.

TRADE AND GENERIC NAME

CLASSIFICATION MECHANISM OF ACTION

SIDE EFFECTS NURSING INTERVENTIONS

Trade Name:Fortamet

Generic name:metformin hydrochloride

Pharmacologic class: Biguanide

Therapeutic class: Hypoglycemic

Increases insulin sensitivity by decreasingglucose production and absorptionin liver and intestines and enhancingglucose uptake and utilization

GI: diarrhea, nausea, abdominal bloatingMetabolic: lactic acidosisOther: unpleasant metallic taste, decreased vitamin B12 level

Patient monitoring● Monitor blood glucose level closely. ● Monitor kidney and liver function tests.● Watch for signs and symptoms of lactic acidosis. Stop drug if acidosis occurs. To aid differential diagnosis,check electrolyte, ketone, glucose, blood pH, lactate, and metformin blood levels.Patient teaching● Teach patient about diabetes and importance of

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proper diet, exercise, weight control, and blood glucose monitoring.● Inform patient that drug may cause diarrhea, nausea, and upset stomach. Advise him to take it with meals to reduce these effects, and tell him that adverseeffects often subside over time.

TRADE AND GENERIC NAME

CLASSIFICATION MECHANISM OF ACTION

SIDE EFFECTS NURSING INTERVENTIONS

Trade Name:Micardis

Generic name:Telmisartan

Pharmacologic class: Angiotensin IIreceptor antagonist

Therapeutic class: Antihypertensive

Inhibits vasoconstricting effects andblocks aldosterone-producing effectsof angiotensin II at various receptorsites, including vascular smooth muscleand adrenal glands

CNS: dizziness, headache, fatigueCV: chest pain, peripheral edema, hypertensionEENT: sinusitis, pharyngitisGI: nausea, vomiting,dyspepsia, abdominal painMusculoskeletal: myalgia, back and leg painOther: pain, flu or flulike symptoms

Patient monitoring● Watch for signs and symptoms of hypotension.Patient teaching● Tell patient to take 1 hour before or 2 hours after meals.● Caution patient not to remove tablet from blister pack until just before taking.● Advise patient to report swelling or chest pain.● Teach patient to measure blood pressure regularly and report significant changes.

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● As appropriate, review all other significant adverse reactions and interactions, especially those related to the drugs, tests, and foods mentioned above.

TRADE AND GENERIC NAME

CLASSIFICATION MECHANISM OF ACTION

SIDE EFFECTS NURSING INTERVENTIONS

Trade Name:Catapres

Generic name:Clonidine

Pharmacologic class: Centrally actingSympatholytic

Therapeutic class: Antihypertensive

Stimulates alpha-adrenergic receptorsin CNS, decreasing sympathetic outflow,inhibiting vasoconstriction, andultimately reducing blood pressure.Also prevents transmission of pain impulsesby inhibiting pain pathway signals

CNS: drowsiness, dizzinessCV: hypotension palpitationsGI: nausea, constipation, dry mouthGU: urinary retention, nocturiaMetabolic: sodium retentionSkin: rash, sweatingOther: weight gain

Patient monitoring● Monitor patient for signs and symptoms of adverse cardiovascular reactions.● Frequently assess vital signs, especially blood pressure and pulse.● Monitor patient for drug tolerance and efficacy.Patient teaching● Instruct patient to move slowly when sitting up or standing, to avoid dizziness or light-headedness caused by sudden blood pressure decrease.

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in brain.

B. IV Fluids

COMPONENT CLASSIFICATION

EFFECTS/ USES SIGNIFICANCE

PNSS ISOTONICo Used to replace fluids in

dehydrationo Used frequently in intravenous

drips (IVs) for patients who cannot take fluids orally and have developed or are in danger of developing dehydration or hypovolemia

o Used to replace fluids in dehydration, go with blood transfusions, hyponatremia, and burn victims, it is isotonic,( same osmolarity as our body fluids

o Replacement & maintenance of fluid & electrolytes.

o Restores the blood volume rapidly.o The first fluid used when hypovolemia

is severe enough to threaten the adequacy of blood circulation and has long been believed to be the safest fluid to give quickly in large volumes.

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COMPONENT CLASSIFICATION EFFECTS/ USES SIGNIFICANCE

PLRS ISOTONICo When administered intravenously,

these solutions provide sources of water and electrolytes. Their electrolyte content resembles that of the principal ionic constituents of normal plasma and the solutions therefore are suitable for parenteral replacement of extracellular losses of fluid and electrolytes.

o For replacement of acute extracellular fluid losses without disturbing normal electrolyte relationships.

XII. NURSING DIAGNOSIS

ACTUAL PROBLEM 1: Acute pain related to presence of obstruction or movement of stone within the urinary system secondary to nephrolithiasis

Assessment Explanation of the problem Objective Intervention Rationale Evaluation

S: “nagsakit daytoy ko”(pointing her abdominal and flank area)>rated pain as 8 with 10 being the highest O:>w/ guarding behavior noted

Nephrolithiasis: The process of forming a kidney stone, a stone in the kidney (or lower

down in the urinary tract).

Kidney stones are a common cause of blood in the urine and pain in the abdomen,

flank, or groin. Kidney stones occur in 1 in 20 people at

some time in their life.

STO:  After 2 to 4 hours of nursing interventions the patient will verbalize relief of pain from a scale of 8/10 to 3-5/10

Dx:>observed non verbal cues of pain    >assessed level of pain noting its characteristics, location, quality, intensity, and precipitating factors

>observation may/may not be congruent with verbal reports or may be an indicator of present complaint when client is unable to verbalize>to rule out worsening of underlying condition/development

Goal met since After 2-4 hours of nursing interventions the patient was able to report relief of pain from 8/10 to 4/10

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>complains of pain upon palpation on the RLQ of abdomen>facial mask of pain observed>prefers to position self in side lying

A>Acute pain related to presence of obstruction or movement of stone within the urinary system secondary to nephrolithiasis

The development of the stones is related to decreased

urine volume or increased excretion of stone-forming

components such as calcium, oxalate, urate, cystine,

xanthine, and phosphate. The stones form in the urine

collecting area (the pelvis) of the kidney and may range in

size from tiny to staghorn stones the size of the renal

pelvis itself.

The cystine stones (below) compared in size to a quarter were obtained from the kidney

of a young woman by percutaneous

nephrolithotripsy (PNL), a procedure for crushing and

removing the dense stubborn stones characteristic of

cystinuria.

The pain with kidney stones is usually of sudden onset, very severe and colicky (intermittent), not improved by changes in position, radiating from the back, down the flank, and into the groin. Nausea

>assessed for referred pain    Tx:>applied hot compress to flank area >provided comfort measure like backrub measures, quiet environment and calm activities>ambulated patient as much as possible >administered PRN analgesics as ordered

Edx:>encouraged use of relaxation techniques such as focused breathing and guided imagery>encourage/assist with frequent ambulation as indicated and increased fluid intake of at least 3–4 l/day within cardiac tolerance.

of complication>to help determine possibility of underlying condition or organ dysfunction requiring treatment >to reduce pain and promote comfort

>to promote non pharmacological pain management >to facilitate passage of stone through the urinary system>to maintain acceptable level of pain   >promotes relaxation, reduces muscle tension,and enhances coping.

>renal colic can be worse in the supine position. vigorous hydration promotes passing of stone, prevents urinary

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and vomiting are common. Resources: http://www.medterms.com/script/main/art.asp?articlekey=6806

>discussed impact of pain on lifestyle/independence and ways  to maximize level of functioning>explained cause of pain and importance of notifying caregivers of changes in pain occurrence/characteristics

stasis, and aids in prevention of further stone formation>to promote wellness

>provides opportunity for timely administrationof analgesia and alerts caregivers to possibility of passing of stone/developing complications. suddencessation of pain usually indicates stone passage.

ACTUAL PROBLEM 3: Impaired urinary ilimination r/t decreased renal perfusion secondary to nephrolithisis

ASSESSMENTEXPLANATION OF

THE PROLEMGOAL/OBJECTIVE INTERVENTION RATIONALE EVALUATION

S: “di ako masyadong umiihi, dalawa hanggang tatlong beses lng sa isang araw”

Excessive amounts of calcium in the urine makes the urine more alkaline and the calcium salts precipitate out as a

After 8 hours of nursing intervention the patient will be able to have a urine output of

independent-monitored i&o and characteristics of urine.

-provides information about kidney function and presence of complications, e.g.,

Goal met since after 8 hours of nursing intervention the patient was able

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O- 150 cc urine collected for 8 hours-w/ a yellow to brownish colored urine-no crystals or blood observed-goes to comfort room once or twice per shift

Ax: Impaired urinary elimination r/t decreased renal perfusion secondary to nephrolithisis

crystals to form renal calculi (stones ). The stone usually develops in the renal pelvis and pass thru the ureters into the bladder. As the stones pass along the long, narrow, ureters, they causes extreme pain, and bleeding and can sometimes obstruct the urinary tract. Obstruction in the urinary tract causes urinary retention (accumulation of urine in the bladder), bladder distention and urinary incontinence. When urine is not being excreted the bladder gradually becomes distended with urine. The bladder may stretch excessively, eventually inhibiting the urge to void. When bladder distention is considerably, some involuntary urinary “ dribbling ” may occur. Over distention of the bladder causes poor

25-30cc/hour or void in normal amounts and usual pattern.

-determined patient’s normal voiding pattern and note variations.

-encouraged increased fluid intake.

-strained all urine. Document any stones expelled and send to laboratory for analysis.

-investigated reports of bladder fullness; palpate for suprapubic distension. Note decreased urine output, presence of periorbital/dependent edema.

-observed for changes in mental status, behavior, or level of consciousness.

collaborative-monitored laboratory studies, e.g., electrolytes, bun, cr.

-obtained urine for culture and sensitivities.

infection and hemorrhage.-calculi may cause nerve excitability, which causes sensations of urgent need to void.usually frequency and urgency increase as calculus nears ureterovesical junction.- increased hydration flushes bacteria, blood, and debris and may facilitate stone passage.- retrieval of calculi allows identification of type of stone and influences choice of therapy.- urinary retention may develop, causing tissue distension (bladder/kidney), and potentiatesrisk of infection, renal failure- accumulation of uremic wastes and electrolyte imbalances can be toxic to the cns.

- elevated bun, cr, and certain electrolytesindicate presence/degree

to have a urine output of 25-30cc/hour or void in normal amounts and usual pattern.

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contractility of the detrusor muscle, further impairing urination. And urinary retention causes overflow voiding or incontinence.

Ref: fundamentals of nursing pp.1070-1071 7th edition by kozier

Edx: > taught the patient kegel’s exercise >emphasized importance of keeping area clean and dry(perineum)>emphasized importance of healthy lifestyle likesmoking cessation>instructed on proper application and care of appliancefor urinary diversion>instructed the family members and the patient on voiding techniques.

of kidney dysfunction.- determines presence of uti, which may be causing/ complicating symptoms.

>help restore tone and minimize incontinence>to reduce risk for infection and skin breakdown >cigarette smoking can be a source of bladder irritation >to promote odour control  >knowledge of the procedure and rationale reduce anxiety and promotes comfort as well as prevent the patient from developing further complications

ACTUAL PROBLEM 3: Knowledge deficit related to lack of information to present condition as evidenced by questions and statement of misconceptionsASSESSMENT EXPLANATION OF

THE PROLEM OBJECTIVE INTERVENTION RATIONALE EVALUATION

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S>``kasatnu ba agkakaroon ti bato? ´´

O> asks questions about her condition>first time to have this condition in the family>unfamiliar with the things that contributes to her condition like salty foods>requested for a list of contraindicated foods

A> Knowledge deficit related to lack of information to present condition as evidenced by questions

Knowledge deficit is a lack of cognitive information or psychomotor skills required for health recovery, maintenance, or health promotion. Teaching may take place in a hospital, ambulatory care, or home setting. The learner may be the patient, a family member, a significant other, or a caregiver unrelated to the patient. Learning may involve any of the three domains: cognitive domain (intellectual activities, problem solving, and others); affective domain (feelings, attitudes, beliefs); and psychomotor domain (physical skills or procedures). In the case of this client, she has kidney stones in which she didn’t know

STO: After 2 hours of nursing intervention patient will verbalize understanding of her disease process and potential complications.

independent-reviewed disease process and future expectations.

-stressed importance of increased fluid intake, e.g., 3–4l/day or as much as 6–8 l/day.-encourage patient to notice dry mouth and excessive diuresis/diaphoresis and to increase fluid intake whether or not feeling thirsty.-review dietary regimen, as individually appropriate:

*low-purine diet, e.g.,limited lean meat, legumes, whole grains, alcohol *low-calcium diet,

-provides knowledge base from which patient can make informed choices.-flushes renal system, decreasing opportunityfor urinary stasis and stone formation.-increased fluid losses/ dehydration require additional intake beyond usual daily needs.

-diet depends on the type of stone. understanding reason for restrictions provides opportunity for patient to make informed choices, increases cooperation with regimen, and may prevent recurrence.-decreases oral intake of uric acid precursors.

-reduces risk of calcium stone

>Goal met since after 2 hours of nursing intervention patient was able to verbalize understanding of her disease process and its potential complications.

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up until she was diagnosed, Therefore she doesn’t know much about her condition.

e.g., limited milk, cheese, green leafy vegetables, yogurt; *low-oxalate diet, e.g., restrict chocolate, caffeine-containing beverages, spinach.-discuss medication regimen; avoidance of otc drugs, and reading all product/food ingredient labels.

-encourage regular activity/exercise program. active-listen concerns about therapeutic regimen/lifestyle changes.

-identify s/sx requiring medical evaluation, e.g., recurrent pain, hematuria, oliguria.

formation.

-reduces calcium oxalate stone formation.

-drugs will be given to acidify or alkalize urine, depending on underlying cause of stoneformation. ingestion of products containingindividually contraindicated ingredients (e.g., calcium, phosphorus) potentiates recurrence of stones.-inactivity contributes to stone formation through calcium shifts and urinary stasis. -helps patient work through feelings and gain a sense of control over what is happening.-with increased probability of recurrence of stones,

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prompt interventions may prevent serious complications

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POTENTIAL PROBLEM 1: Risk for infection related to stasis of urine secondary to nephrolithiasis

Assessment Explanation of the problem

Objectives Nursing intervention Rationales Expected outcome

O- 150 cc urine collected for 8 hours-w/ a yellow to brownish colored urine-no crystals or blood observed-goes to comfort room once or twice per shift

A>Risk for infection related to stasis of urine secondary to nephrolithiasis

Calculi traumatize the walls of the urinary tract and irrigate the cellular lining, causing pain as violent contraction of the ureter develops to pass the stone along. But the urethral spasm may just as easily hold a stone in place.If a stone totally or partially obstructs the passage urine beyond its location,pressure increases in the area above the stone.The pressure contribute to the pain and urinary stasis promotes secondary to infection The retained urine distend the renal pelvis.Eventually there may be compression of the glomeruli and tiny arterioles that supply to the kidney which result in permanent damage.

LTO: After 2-3 days of nursing intervention the patient will be able to understand and identify interventions to prevent and reduce risk of infection

Dx>Monitor and record vital sign especially the temperature

>monitor intake and output

>explore causative factors,review laboratory data and non verbal cuesTx>maintain hydration and voiding schedule

>Provide regular urinary catheter and perineal care

>maintain sterile technique for all invasive procedure such as IV and urinary

>establishe a baseline for comparison.Changes to baseline data may indicate the presence of infection.Fever usually is the first and only sign of infection>diuretic therapy may result in sudden excessive fluid loss even though edema remains>knowledge of causative factors influences of intervention >to prevent bladder distention and urinary stasis which can contribute to the multiplication of pathogens>reduces risk of ascending urinary tract infection >reduces risk for infection

LTO:goal met if after 2-3 days of nursing intervention the patient will take the following measures

A. follow appropriate given instruction.B. demonstrate understanding to given measures c.apply given instructions in everyday routine

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catheter Edx>encourage to increase intake to at least 3.5 to 4 liter per day.>encourage verbalization of feelings and any significant change to the condition>emphasize necessity of taking antivirals and antibiotics as directed

>emphasize consulting with the physician before self-administering any over the counter medication

>to maintain normal hydration and prevent urinary stasis>for immediate access nursing intervention

>premature discontinuation of treatment when client begins to feel well may result in return of infection and potentiate drug resistant strains>over the counter medication can contribute to the illness which may result for further complication to the condition

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POTENTIAL PROBLEM 2: Risk for infection related to stasis of urine secondary to nephrolithiasis

Assessment Explanation of the problem

Objective Intervention Rationale Evaluation

O-150 cc urine collected for 8 hours-w/ a yellow to brownish colored urine-no crystals or blood observed-goes to comfort room once or twice per shift-scheduled operation is on Monday, April 19-w/ good skin turgor

A> risk for deficient fluid volume r/t post obstructive diuresis

Nephrolithiasis, the process of forming a kidney stone, a stone in the kidney(or lower down in the urinary tract). Kidney stones are a common cause of blood in the urine and pain in the abdomen, flank, or groin. One of the management for this would be to surgically remove the stones in the kidney. In that reason, patient may suddenly lose retained fluids that was obstructed before by the stones. The body may not adopt with it immediately thus causing our patient at risk for fluid volume

LTO: After 2-3 days of nursing intervention and after operation the patient will be able to maintain adequate fluid balance as evidenced by vital signs and weight within patient’s normal range, moist mucous membranes, and good skin turgor.

independent-monitor i&o. document incidence and note characteristicsand frequency of vomiting and diarrhea, as well as accompanying or precipitating events.

-increase fluid intake to 3–4 l/day within cardiac tolerance.-monitor vital signs. evaluate pulses, capillary refill, skin turgor, and mucous membranes.

-comparing actual and anticipated output mayaid in evaluating presence/degree of renal stasis/impairment. -documentation may help rule out otherabdominal occurrences as a cause for pain orpinpoint calculi.-maintains fluid balance for homeostasis and“washing” action that may flush the stone(s)out. dehydration and electrolyte imbalancemay occur secondary to excessive fluid loss(vomiting and diarrhea).

Goal met if after 2-3 days of nursing interventions and after pt’s operation the patient will be able to maintain adequate fluid balance as evidenced by vital signs and weight within patient’s normal range, moist mucous membranes, and good skin turgor.

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deficit r/t post obstructive dieresis.

-weigh daily.

collaborative-monitor hb/hct, electrolytes.

-administer iv fluids.

-provide appropriate diet, clear liquids, bland foods as tolerated.

-administer medications as indicated:antiemetics, e.g., prochlorperazine(compazine).

indicators of hydration/circulating volume and need for intervention. -rapid weight gain may be related to water retention.-assesses hydration and effectiveness of/needfor interventions.-maintains circulating volume (if oral intake isinsufficient), promoting renal function. -easily digested foods decrease gi activity/irritation and help maintain fluid andnutritional balance.-reduces nausea/ vomiting.

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XIII. DISCHARGE PLAN:

CRITERIA HEALTH TEACHING a.DIET Drink adequate amount of water

Eat food low in protein, nitrogen and sodium.

Restrict intake of oxalate-rich foods, such as chocolate, nuts, soybeans and spinach plus maintenance of an adequate intake of dietary calcium.

Take some fruit juices , such as orange, and cranberry. Orange juice may help prevent calcium oxalate stone formation, and cranberry may help with UTI-caused stones.

Limit intake of caffeinated beverages, such as coffee.

Avoid cola beverages.

Avoid large intake doses of vitamin c

b.ACTIVITIES Increased mobility if possiblec.MEDICATION Take all your medications as

prescribed by your doctor. Keep a list of your medications with

you at all times.

If you have questions or concerns, call your doctor

o Do not stop or change the dose of any of your medications without first talking with your doctor.

o Do not take any new medications — including vitamins, over-the-counter medications or herbal remedies — without first talking with your doctor.

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XIV. CONCLUSION AND RECOMMENDATIONS:

The case is focused on the importance of precipitating factors that could lead to

complicated diseases.

The group recommends that during any health teachings, they should

emphasize on the importance of seeking medical advice when feeling not good. With

these, complicated diseases should be minimized or prevented as well.

Furthermore, the group would like to emphasis to these nurses that proper health

teaching to the client with the same situation and those similar needs. Health teachings

are very important for the patient and his significant others for them to understand and

realize that cooperation is very important in the prevention of disease and improvement

of his status.

XV. LIST OF REFERENCES

1. Books

a.) Pathophysiology by Catherine Paradiso (2nd edition)

b.) Medical-Surgical nursing by Suzane C O’Connell Smeltzer

c.) Understanding Pathophysiology by Sue E. Huether and Kathryn L. McCance

(2nd edition)

d.) Nurse’s Pocket Guide by Doenges (11th edition)

e.) Drug hand book by Lippincott

f.) Anatomy and Physiology by Tortora

g.) Anatomy and Physiology by Seeley, et al.

h.) Fundamentals of Nursing by Kozier,

2. Websites

a. http://www.nlm.nih.gov/medlineplus/ency/article/000077.htmb.http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?

plan=01

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XVI. APPENDICES

A) Interview Guide

University of the CordillerasCollege of Nursing

CASE PRESENTATION FORMATSY 2009-2010

I. General Profile/Information-name, age, sex, marital status occupation,

address, religion

II. Chief Complaint/s- main complaint of the patient why s/he seek consultation

and hence, admitted.

III. History of present illness

IV. Past medical history

V. Social and environmental history

VI. Family history

VII. Physical examination

VIII. Diagnostics

IX. Medical diagnosis- final or principal diagnosis

X. Comprehensive Pathophysiology and Management

XI. Treatment and Management

XII. Nursing Diagnosis

XIII. Discharge Plan

XIV. Conclusions and Recommendations

XV. List of References

XVI. Appendices

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B) Request Letter

University of the CordillerasCollege of Nursing

Dr. Marian Grace GasconDean, College of Nursing

Ms. Petelyn PangketClinical Coordinator Level III

Dear Ma’am,

We the BSN III-6D would like to submit the case of Ms. M with a diagnosis of Nephrolithiasis. This was chosen by the group from the East Surgical ward, BGH last April 15-17, 2010 during the 3-11shift.

The group agreed that nephrolithiasis would be a good case.

Since we had our duty at BGH we knew that we will cater to a limited number of patients and that we had difficulty in looking for a good case. When we came across this case, we grabbed it because we found it interesting and that this would be a good study.

Your approval is highly appreciated. Thank you for your kind consideration.

Sincerely yours,

ATTING, Jeri MaeBLANCIA, JeanyCANABE, Jenny LouDAGUYEN, KatrinaDEGAMO, Cielo CheenESPERA, Erik JohnGONZALES, RowenaNASUNGAN, AliseusSAGUN, RasiYOCOGAN, Jay

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Noted by:

Ms. Cindy joy GoClinical Instructor

Ms. Petelyn PangketClinical Coordinator Level III

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