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I. INTRODUCTION
Kidneys that are failing have scars. Irreversible scars. Once a kidney is damaged you
cannot get that kidney function back. Kidneys do much more than filter urine. They get
rid of the toxins in our blood that we build up in our body such as CO2. They help
produce red blood cells so we can have oxygen flow through our body. If it wasn't for our
kidneys the rest of the organs in our body would die from being poisoned. This is just the
icing on the cake.
The kidneys are an essential part of the body's urinary system. Each kidney is
composed of about one million microscopic "filtering packets" called glomeruli. The
glomeruli remove uremic waste products from the blood. Each glomerulus connects to a
long tube, called the tubule. Urine made by the glomerulus moves down the tubule.Together, the glomerulus and the tubule form a unit called a nephron. Each nephron
connects to progressively larger tubular branches, until it reaches a large collection area
called the calyx. The calices form the funnel-shaped portion of the upper ureter (renal
pelvis). Urine moves from the renal pelvis to the ureters, the large tubes that connect the
kidney to the bladder.
The kidneys produce three important hormones: erythropoietin (EPO), which triggers
the production of red blood cells in bones; renin, which regulates blood pressure; and
vitamin D, which helps regulate the body's metabolism of calcium necessary for healthy
bones.
Chronic kidney failure is not caused by an obstruction. Acute renal failure can be
caused by a kidney stone blocking the ureter into the bladder. That can be reversed by
surgery or lithotripsy. Chronic Renal Failure is usually caused by an underlying disease
such as diabetes, hypertension, PKD, or autoimmune diseases to name a few.
Kidney tumors form when cells overgrow within a kidney. Usually, older cells die and
are replaced by new cells. When this process goes awry, the old cells don't die off, and
new cells grow when they are not needed, creating a tumor. When a kidney tumor is
benign, it is not cancerous and it does not spread to other body parts. However, tumors
can sometimes impair organ function, so they may be removed surgically.
Much more serious is a malignant kidney tumor, which is cancerous and can spread
to other areas in a person's body. This type of kidney tumor is potentially life threatening.
Renal cell carcinoma, transitional cell carcinoma, and Wilms' tumor are the most
frequently diagnosed cancerous kidney tumors. In adults, renal cell carcinoma develops
most frequently. Children are more likely to develop Wilms' tumor cancer
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Incidence and Prevalence of Kidney Cancer
According to the National Cancer Institute, the highest incidence of kidney
cancer occurs in the United States, Canada, Northern Europe, Australia, and New
Zealand. The lowest incidence is found in Thailand, China, and the Philippines.
In the United States, kidney cancer accounts for approximately 3% of all adult cancers.
According to the American Cancer Society, about 32,000 new cases are diagnosed and
about 12,000 people die from the disease annually. Kidney cancer occurs most often in
people between the ages of 50 and 70, and affects men almost twice as often as
women.
Smokers develop renal cell carcinoma about twice as often as nonsmokers and
develop cancer of the renal pelvis about 4 times as often. Not smoking is the most
effective way to prevent kidney cancer and it is estimated that the elimination of smokingwould reduce the rate of renal pelvis cancer by one-half and the rate of renal cell
carcinoma by one-third.
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II. OBJECTIVES
a. General Objective
After this case presentation, the students will be able to gain knowledge regarding
the general health and disease condition of a patient with Nephrolithiasis. its disease
process, possible complications, and treatment plan, medical and nursing interventions.
b. Specific Objectives
At the end of this case presentation, the students will be able to:
Skills
Accurately present a thorough general assessment of the client which includes
physical assessment and family history taking. Discuss the responsibility of the nurse in caring patient with Nephrolithiasis.
Develop a good communication skills toward patient, folks as well as to other
members of the health team.
Perform nursing procedures effectively and correctly to attain his optimum level of
wellness.
Knowledge
Know what Nephrolithiasis is, causes and its risk factors.
Review the anatomy and physiology of the organ affected.
Effectively identify signs and symptoms exhibited by a patient with Nephrolithiasis.
Understand the pathophysiology of the disease.
Describe the important of pharmacological treatments and giving details about
their actions.
Efficiently make appropriate nursing diagnosis in line with the clients medical
condition and skillfully formulate nursing care plans for the problems identified.
Attitude
Promote therapeutic interpersonal relationships through demonstration of positive
attitude to the client.
Understands patient feelings towards his condition.
Establish rapport and therapeutic communication in order to gain information
about the patient which includes the medical and family health history,
expectations of his condition to him gather significant data from the patients
chart and to his family and etc.; and for the betterment of nursing care.
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III. ANATOMY AND PHYSIOLOGY
Urinary System is a group of organs in the body concerned with filtering out excess fluid
and other substances from the bloodstream
COMPOSED OF:
KIDNEY - A pair of purplish-brown organs located below the ribs toward the
middle of the back. Each kidney is about 4 or 5 inches long-about the size of a
fist.
URETER - the ureters are muscular ducts that propel urine from the kidneys to
the urinary bladder.
BLADDER - The urinary bladder is the organ that collects urine excreted by
the kidneys prior to disposal by urination. It is a hollow muscular, and distensible
(or elastic) organ, and sits on the pelvic floor.
URETHRA - is a tube which connects the urinary bladder to the outside of the
body. The urethra has an excretory function in both sexes to pass urine to the
outside, and also a reproductive function in the male, as a passage
for semen during sexual activity.
Kidney
The kidneys are two bean-shaped organs, each measuring the size of your fist. These
organs function as 24-hour cleaning machines for your blood.
Each Kidney is enclosed in a transparent membrane called the renal capsule which
helps to protect them against infections and trauma. The kidney is divided into two main
areas a light outer area called the renal cortex , and a darker inner area called the renal
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medulla . Within the medulla there are 8 or more cone-shaped sections known as renal
pyramids . The areas between the pyramids are called renal columns .
The most basic structures of the kidneys, are nephrons . Inside each kidney there are
about one million of these microscopic structures. They are responsible for filtering theblood and removing waste products.
Functions of Kidney:
Remove waste products from the blood.
Remove extra fluid.
Adjust level of minerals and other chemicals.
Produce hormones.
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IV. TEXTBOOK DISCUSSION
A nephrectomy is asurgical procedure for the removal
of a kidney or section of a kidney.
Nephrectomy may involve
removing a small portion of the
kidney or the entire organ and
surrounding tissues. In partial
nephrectomy, only the diseased or
infected portion of the kidney is
removed. Radical nephrectomy
involves removing the entire kidney, a section of the tube leading to the bladder (ureter),
the gland that sits atop the kidney (adrenal gland), and the fatty tissue surrounding the
kidney. A simple nephrectomy performed for living donor transplant purposes requires
removal of the kidney and a section of the attached ureter.
Purposes
It is performed on patients with severe kidney damage from disease, injury, or
congenital conditions. These include cancer of the kidney (renal cell carcinoma);
polycystic kidney disease (a disease in which cysts, or sac-like structures, displace
healthy kidney tissue); and serious kidney infections. It is also used to remove a healthy
kidney from a donor for the purposes of kidney transplantation
Types of Nephrectomy
Open nephrectomy
In a traditional, open nephrectomy, the kidney donor is administered general
anesthesia and a 610 in (15.225.4 cm) incision through several layers of muscle is
made on the side or front of the abdomen. The blood vessels connecting the kidney to
the donor are cut and clamped, and the ureter is also cut between the bladder and
kidney and clamped. Depending on the type of nephrectomy procedure being performed,
the ureter, adrenal gland, and/or surrounding tissue may also be cut. The kidney is
removed and the vessels and ureter are then tied off and the incision is sutured (sewn
up). The surgical procedure can take up to three hours, depending on the type of
nephrectomy being performed.
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Laparoscopic nephrectomy
Laparoscopic nephrectomy is a form of minimally invasive surgery that utilizes
instruments on long, narrow rods to view, cut, and remove the kidney. The surgeon
views the kidney and surrounding tissue with a flexible videoscope. The videoscopeand surgical instruments are maneuvered through four small incisions in the abdomen,
and carbon dioxide is pumped into the abdominal cavity to inflate it and improve
visualization of the kidney. Once the kidney is isolated, it is secured in a bag and pulled
through a fifth incision, approximately 3 in (7.6 cm) wide, in the front of the abdominal
wall below the navel. Although this surgical technique takes slightly longer than a
traditional nephrectomy, preliminary studies have shown that it promotes a faster
recovery time, shorter hospital stays, and less post-operative pain.
A modified laparoscopic technique called hand-assisted laparoscopic nephrectomy may
also be used to remove the kidney. In the hand-assisted surgery, a small incision of 35
in (7.612.7 cm) is made in the patient's abdomen. The incision allows the surgeon to
place his hand in the abdominal cavity using a special surgical glove that also maintains
a seal for the inflation of the abdominal cavity with carbon dioxide. This technique gives
the surgeon the benefit of using his hands to feel the kidney and related structures. The
kidney is then removed by hand through the incision instead of with a bag.
Diagnosis/Preparation
Prior to surgery, blood samples will be taken from the patient to type and
crossmatch in case transfusion is required during surgery. A catheter will also be
inserted into the patient's bladder. The surgical procedure will be described to the
patient, along with the possible risks.
Aftercare
Nephrectomy patients may experience considerable discomfort in the area of the
incision. Patients may also experience numbness, caused by severed nerves, near or on
the incision. Pain relievers are administered following the surgical procedure and during
the recovery period on an as-needed basis. Although deep breathing and coughing may
be painful due to the proximity of the incision to the diaphragm, breathing exercises are
encouraged to prevent pneumonia. Patients should not drive an automobile for aminimum of two weeks.
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Risks
Possible complications of a nephrectomy procedure include infection, bleeding
(hemorrhage), and post-operative pneumonia. There is also the risk of kidney failure in a
patient with impaired function or disease in the remaining kidney.
RENAL ABSCESS
A renal or kidney abscess is a pus -filled hole in a kidney that forms when the
tissues of that kidney begin to break down due to a bacterial infection. It is a rare
disease, but if it is not treated, it may be fatal. If a kidney abscess occurs, it is typically
the result of a severe kidney infection or a urinary tract infection that was left untreated.
Some people are more prone to kidney abscesses than others. For example,
people plagued by kidney stones are often susceptible to the condition. In addition,
people with kidney inflammation and urinary tract infections may suffer from the disease
if they are not promptly treated. Individuals with abscesses in their skin due to the abuse
of intravenous drugs or other health issues may also be at risk for kidney abscesses.
Signs and Symptoms
Symptoms Manifested by patient Fever Chills Kidney tenderness Abdominal spasm /
abdominal
pain
Back pain Blood in urine Pus in urine Weight loss
Cause
Medical conditions involving some type of pathogen, such as a virus or bacteria.
Any condition affecting the kidneys.
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Medical conditions affecting the abdominal region.
Medical conditions affecting urination, urinary organs or the urinary system.
DIagnostic Procedures
On ultrasound the abscess can appear similar to a cyst, but with some internal
echoes or wall irregularity; as a solid mass, and mimic a renal neoplasm; or the echo
pattern of an abscess may be indistinguishable from adjacent renal parenchyma. On CT,
the abscess appears as a heterogeneous low-attenuation mass. There is often an
irregular, enhancing wall. Wall enhancement is secondary to hyperaemia or granulation
tissue formation. A bulge in the renal cortex is typically present, if the abscess is
peripheral. Inflammatory changes are seen in the adjacent fat. On contrast-
enhanced MRI, a liquefied portion of the abscess and enhancing wall are suggestive of
the diagnosis. The preferred treatment is image-guided percutaneous drainage, often
performed under CT guidance.
NEPHROLITHIASIS
Nephrolithiasis specifically refers to calculi in the kidneys, but this article
discusses both renal calculi (see the first image below) and ureteral calculi
(ureterolithiasis; see the second image below). Ureteral calculi almost always originate in
the kidneys, although they may continue to grow once they lodge in the ureter.
Although nephrolithiasis is not a common cause of renal failure, certain problems,
such as preexisting azotemia and solitary functional kidneys, clearly present a higher risk
of additional renal damage. Other high-risk factors include diabetes, struvite and/or
staghorn calculi, and various hereditary diseases such as primary hyperoxaluria, Dent
disease, cystinuria, and polycystic kidney disease. Spinal cord injuries and similar
functional or anatomical urological anomalies also predispose patients with kidney
stones to an increased risk of renal failure.
Recurrent obstruction, especially when associated with infection and tubular
epithelial or renal interstitial cell damage from microcrystals, may activate the fibrogenic
cascade, which is mainly responsible for the actual loss of functional renal parenchyma.
Etiology
A low fluid intake, with a subsequent low volume of urine production, produces
high concentrations of stone-forming solutes in the urine. This is an important, if not the
most important, environmental factor in kidney stone formation. The exact nature of the
tubular damage or dysfunction that leads to stone formation has not been characterized.
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Most research on the etiology and prevention of urinary tract stone disease has
been directed toward the role of elevated urinary levels of calcium, oxalate, and uric acid
in stone formation, as well as reduced urinary citrate levels.
Hypercalciuria is the most common metabolic abnormality. Some cases of hypercalciuria are related to increased intestinal absorption of calcium (associated with
excess dietary calcium and/or overactive calcium absorption mechanisms), some are
related to excess resorption of calcium from bone (ie, hyperparathyroidism), and some
are related to an inability of the renal tubules to properly reclaim calcium in the
glomerular filtrate (renal-leak hypercalciuria).
Magnesium and especially citrate are important inhibitors of stone formation in the
urinary tract. Decreased levels of these in the urine predispose to stone formation.
The following are the 4 main chemical types of renal calculi, which together are
associated with more than 20 underlying etiologies:
Calcium stones-
Calcium stones account for 75% of renal calculi. Recent data suggest that a low-
protein, low-salt diet may be preferable to a low-calcium diet in hypercalciuricstone formers for preventing stone recurrences. [4]Epidemiological studies have
shown that the incidence of stone disease is inversely related to the magnitude of
dietary calcium intake in first-time stone formers.
Struvite (magnesium ammonium phosphate) stones
Struvite stones account for 15% of renal calculi. They are associated with chronic
urinary tract infection (UTI) with gram-negative rods capable of splitting urea into
ammonium, which combines with phosphate and magnesium. Usual organismsinclude Proteus, Pseudomonas, and Klebsiella species. Escherichia coli
is not
capable of splitting urea and, therefore, is not associated with struvite stones.
Urine pH is typically greater than 7.
Uric acid stones
Uric acid stones account for 6% of renal calculi. These are associated with urine
pH less than 5.5, high purine intake (eg, organ meats, legumes, fish, meat
extracts, gravies), or malignancy (ie, rapid cell turnover). Approximately 25% of
patients with uric acid stone have gout.
Cystine stones
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Cystine stones account for 2% of renal calculi. They arise because of an intrinsic
metabolic defect resulting in failure of renal tubular reabsorption of cystine,
ornithine, lysine, and arginine. Urine becomes supersaturated with cystine, with
resultant crystal deposition.
Imaging studies
Calcium-containing stones are relatively radiodense , and they can often be
detected by a traditional radiograph of the abdomen that includes the kidneys, ureters,
and bladder .Some 60% of all renal stones are radiopaque. In general, calcium
phosphate stones have the greatest density, followed by calcium oxalate and
magnesium ammonium phosphate stones. Cystine calculi are only faintly radiodense,
while uric acid stones are usually entirely radiolucent.
A noncontrast helical CT scan with 5 millimeters (0.20 in) sections is the
diagnostic modality of choice in the radiographic evaluation of suspected
nephrolithiasis. All stones are detectable on CT scans except very rare stones composed
of certain drug residues in the urine, such as from indinavir .
An intravenous pyelogram (IVP) may be performed to help confirm the diagnosis
of urolithiasis. The IVP involves intravenous injection of a contrast agent followed by a
KUB film. Uroliths present in the kidneys, ureters or bladder may be better defined by the
use of this contrast agent. Stones can also be detected by a retrograde pyelogram ,
where a similar contrast agent is injected directly into the distal ostium of the ureter
(where the ureter terminates as it enters the bladder).
Ultrasound imaging of the kidneys can sometimes be useful as it gives details
about the presence of hydronephrosis, suggesting the stone is blocking the outflow of
urine. Radiolucent stones, which do not appear on CT scans, may show up on
ultrasound imaging studies. Other advantages of renal ultrasonography include its low
cost and absence of radiation exposure . Ultrasound imaging is useful for detecting
stones in situations where x-rays or CT scans are discouraged, such as in children or
pregnant women. Despite these advantages, renal ultrasonography is not currently
considered a substitute for noncontrast helical CT scan in the initial diagnostic evaluation
of urolithiasis. The main reason for this is that compared with CT, renal ultrasonography
more often fails to detect small stones (especially ureteral stones) as well as other
serious disorders that could be causing the symptoms.
Laboratory examination
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microscopic examination of the urine, which may show red blood cells ,
bacteria, leukocytes , urinary casts and crystals;
urine culture to identify any infecting organisms present in the urinary tract
and sensitivity to determine the susceptibility of these organisms to specific
antibiotics;
complete blood count (CBC), looking for neutrophilia (increased neutrophil
granulocyte count) suggestive of bacterial infection, as seen in the setting of struvite
stones;
renal function tests to look for abnormally high blood calcium blood levels
(hypercalcemia );
24 hour urine collection to measure total daily urinary volume, magnesium,
sodium, uric acid, calcium, citrate, oxalate and phosphate ;
collection of stones (by urinating through a Stone Screen kidney stone collection
cup or a simple tea strainer ) is useful. Chemical analysis of collected stones can
establish their composition, which in turn can help to guide future preventive and
therapeutic management
Prevention
Dietary measures
Increasing fluid intake of citrate -rich fluids (especially citrate-rich fluids such
as lemonade and orange juice ), with the objective of increasing urine output to more
than 2 liters per day
Attempt to maintain a calcium (Ca) intake of 1000 1200 mg per day
Limiting sodium (Na) intake to less than 2300 mg per day
Limiting vitamin C intake to less than 1000 mg per day
Limiting animal protein intake to no more than 2 meals daily, with less than 170
230 gram per day (A positive association between animal protein consumption and
recurrence of kidney stones has been shown in men, but not yet in women.)
Limiting consumption of foods containing high amounts of oxalate (such
as spinach , strawberries , nuts , rhubarb , wheat germ , dark chocolate , cocoa ,
brewed tea )
Urine alkalinization
The mainstay for medical management of uric acid stones is alkalinization
(increasing the pH) of the urine. Uric acid stones are among the few types
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amenable to dissolution therapy, referred to as chemolysis . Chemolysis is usually
achieved through the use of oral medications, although in some cases
intravenous agents or even instillation of certain irrigating agents directly onto the
stone can be performed, using antegrade nephrostomy or retrograde
ureteral catheters . Acetazolamide (Diamox ) is a medication that alkalinizes the
urine. In addition to acetazolamide or as an alternative, certain dietary
supplements are available that produce a similar alkalinization of the urine. These
include sodium bicarbonate , potassium citrate , magnesium citrate , and Bicitra (a
combination of citric acid monohydrate and sodium citrate dihydrate). Aside from
alkalinization of the urine, these supplements have the added advantage of
increasing the urinary citrate level, which helps to reduce the aggregation of
calcium oxalate stones.
Increasing the urine pH to around 6.5 provides optimal conditions for dissolution
of uric acid stones. Increasing the urine pH to a value higher than 7.0 increases
the risk of calcium phosphate stone formation. Testing the urine periodically
with nitrazine paper can help to ensure that the urine pH remains in this optimal
range. Using this approach, stone dissolution rate can be expected to be around
10 millimeters (0.39 in) of stone radius per month
Diuretics
One of the recognized medical therapies for prevention of stones is
the thiazide and thiazide-like diuretics , such as chlorthalidone or indapamide .
These drugs inhibit the formation of calcium-containing stones by reducing urinary
calcium excretion. Sodium restriction is necessary for clinical effect of thiazides,
as sodium excess promotes calcium excretion. Thiazides work best for renal leak
hypercalciuria (high urine calcium levels), a condition in which high urinary
calcium levels are caused by a primary kidney defect. Thiazides are useful for
treating absorptive hypercalciuria, a condition in which high urinary calcium is a
result of excess absorption from the gastrointestinal tract.
Allopurinol
For people with hyperuricosuria and calcium stones, allopurinol is one of the fewtreatments that has been shown to reduce kidney stone recurrences. Allopurinol
interferes with the production of uric acid in the liver . The drug is also used in
people with gout or hyperuricemia (high serum uric acid levels). Dosage is
adjusted to maintain a reduced urinary excretion of uric acid. Serum uric acid level
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at or below 6 milligrams/100 milliliters) is often a therapeutic goal. Hyperuricemia
(high serum uric acid levels) is not necessary for the formation of uric acid stones;
hyperuricosuria can occur in the presence of normal or even low serum uric acid .
Some practitioners advocate adding allopurinol only in people in whom
hyperuricosuria and hyperuricemia persists despite the use of a urine alkalinizing
agent such as sodium bicarbonate or potassium citrate
Management
Medical
Analgesia
Management of pain often requires intravenous administration of NSAIDs or
opioids. Orally-administered medications are often effective for less severe discomfort.
Intravenous acetaminophen also appears to be effective.
Expulsion therapy
The use of medications to speed the spontaneous passage of ureteral calculi is referred
to as medical expulsive therapy.Several agents including alpha adrenergic
blockers (such as tamsulosin ) and calcium channel blockers (such as nifedipine ) have
been found to be effective. A combination of tamsulosin and a corticosteroid may be
better than tamsulosin alone.These treatments also appears to be a useful adjunct to
lithotripsy.
Surgical
Extracorporeal shock wave lithotripsy
Extracorporeal shock wave lithotripsy (ESWL) involves the use of a lithotriptor machine
to deliver externally-applied, focused, high-intensity pulses of ultrasonic energy to causefragmentation of a stone over a period of around 3060 minutes.
Ureteroscopic surgery
Ureteroscopy has become increasingly popular as flexible and
rigid fiberoptic ureteroscopes have become smaller. One ureteroscopic technique
involves the placement of a ureteral stent (a small tube extending from the bladder, up
the ureter and into the kidney) to provide immediate relief of an obstructed kidney.
More invasive operations
Percutaneous nephrolithotomy or, rarely, anatrophic nephrolithotomy is the treatment of
choice for large or complicated stones (such as calyceal staghorn calculi) or stones that
cannot be extracted using less invasive procedures.
http://en.wikipedia.org/wiki/Hypouricemiahttp://en.wikipedia.org/wiki/Tamsulosinhttp://en.wikipedia.org/wiki/Nifedipinehttp://en.wikipedia.org/wiki/Ureteroscopyhttp://en.wikipedia.org/wiki/Optical_fiberhttp://en.wikipedia.org/wiki/Lithotomyhttp://en.wikipedia.org/wiki/Hypouricemiahttp://en.wikipedia.org/wiki/Tamsulosinhttp://en.wikipedia.org/wiki/Nifedipinehttp://en.wikipedia.org/wiki/Ureteroscopyhttp://en.wikipedia.org/wiki/Optical_fiberhttp://en.wikipedia.org/wiki/Lithotomy -
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V. VITAL INFORMATION
Name Mrs. I.C.
Sex Female
Age 44 yrs old
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Address Cuartero Capiz
Date and time
admitted
November 11,2011
10:00am
Chief
complaint
Flank pain
Ward Blessed Rendu ward
Diet Soft diet
Room 105
Religion Roman Catholic
Admitting
diagnosis
Acute Pyelonephritis
Final
diagnosis
Renal abscess, Pelvic lithothiasis r/o Renal
Tumor Operation
Performed
Nephrectomy Right
Surgeon Dr. P. ADr. A. B
Attending
physician Dr. R.H.
VI. CLINICAL ASSESSMENT
A. Past Medical History
Mrs. I.M. is a known hypertensive. Shes currently taking Atorvastatin (Lipitor) as
her maintenance for the past 3 years now.
Mrs. I.M. was known to be allergic to seafoods. She has not experienced any
serious illness aside from common colds, cough and fever.
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B. Family History
The mother of Mrs. I.M. was asthmatic. Her father also as hypertension and died
because of stroke.
Nursing History
3 months prior to admission, Mrs. I.M. was admitted at St. Anthony College
Hospital because of UTI. She had undergone several test and it was found out in
the ultrasound that she has urinary stone. She was given Sambong as a remedy.
Two months after her follow up checkup it was found out that the stone
progresses. One week prior to admission, she experienced severe flank pain. Shewas rushed to St. Anthony College Hospital. She then undergo Nephrectomy.
VII. CLINICAL INSPECTION
A. Vital Signs
Upon Admission
Temperature 37.8 ocCardiac Rate 90bpm
Pulse Rate 88 bpmRespiration Rate 26 bpmBlood Pressure 160/80
During Care
Vital Signs 4:00pm 6:00pm 10:00pmTemperature 36.5 0C 36.8 0C 36.9 0CRespiration 26 bpm 24 bpm 20 bpm
Cardiac Rate 88 bpm 89 bpm 86 bpmPulse Rate 86 bpm 87bpm 84 bpm
Blood Pressure 140/100 mmHg 150/80 mmHg 130/90 mmHg
B.Physical Assessment (Cephalocaudal)
General Appearance
She was lying on bed with present IVF of PNSS IL x 60cc/hr. regulated as drops per
minute, with foley catheter attached to urobag. She had the urge to void while the tubing is
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clamped. She is healthy, tall and well-nourished, with a well-groomed appearance. She
appears restless but cooperative and is able to follow instructions.
Body Parts Methods of
Assessment
Findings Interpretation
Skin Inspection
Palpation
Brown in color
generally
uniformed.
Hot, flushed skin.
T= 38.1 C
Poor skin turgor,
wrinkled.
Smooth and firm,
with an even
surface.
This is due to
invasion of
pathogens
leading toinfection.
This is due to
physiologic
changes
associated
with aging.
NORMAL
Hair Inspection
Black colored hair
Has a thin hair,
silky and resilient.
No infections andinfestations.
Has a variable
amount of body
hair.
NORMAL
Nails Inspection
Palpation
Convex curvature,
angle is about
160 degrees.
Nails do not
promptly return to
usual color upon
There is
slow
capillary
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performing Blanch
test. Capillary refill
= 4 seconds.
nail bed
refill
because
of poor
arterial
circulatio
n.Skull and Face Inspection
Palpation
Normocephalic
and symmetric
with frontal,
parietal and
occipitalprominences.
Symmetric facial
movements.
Smooth skull
contour.
Absence of
nodules and
masses.
NORMAL
Eyes Inspection Eyebrows are
symmetrically
aligned to the
pinna of the ears.
Red conjunctiva.
No discharge anddiscoloration.
Pupils are equally
rounded and
reactive to light
and
accommodation.
Pupil size: 3mm
Due to
increase in
RBCproduction.
Ears Inspection Auricles are
aligned to the
outer canthus of
the eye.
Pinna recoils after
NORMAL
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it is folded.
No discharges.Nose and Sinuses Inspection
Palpation
Symmetric
No discharges
and nasal flaring.
Nasal septum is
intact and in
midline.
Not tender
maxillary and
frontal sinuses.
NORMAL
Mouth and
Oropharynx
Inspection
Lips are dry and
crack
Present gag
reflex.
The ovula rises
upon talking.
NORMAL
Neck Inspection
Palpation
Muscles equal insize; head
centered.
Coordinated,
smooth
movements with
no discomfort.
No palpable
lymph nodes.
The trachea is in
the midline.
NORMAL
Breasts and Axillae Inspection
Palpation
Breasts are even
with the chest
wall.
Nipples are
everted.
No discharges.
No masses and
palpable lymph.
NORMAL
Respiratory Inspection
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System
Auscultation
Spine vertically
aligned.
Chest wall intact;
no tenderness, no
masses.
Use of accessory
muscles in
breathing.
(+) non-productive
cough.
Crackles noted
upon auscultation
both on the lower
lung field.
23 - 26 breaths
per minute.
This may
due to the
presence of secretions in
the lungs.
Cardiovascular
System
Auscultation (+) Chest pain.
(+) weak
peripheral pulses. Cardiac rate of
90-103 beats per
minute.
Blood pressure of
160/90 mmHg.
Jugular vein is not
distended.
Gastrointestinal
System
Inspection
Palpation
Auscultation
Flat, measured 74
cm in diameter.
Penrose Drain
No tenderness.
Relaxed abdomen
with smooth,
consistenttension.
Audible
hypoactive bowel
sounds.
Surgical
Procedure
This is due to
decrease
peristalsis
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associated
with decrease
activity.
Genitor-urinarySystem
Inspection Scant amount of hair.
Penile skin intact.
She has a foley
catheter attached
to urobag with a
moderate amount
of urine outputdraining yellow
colored urine.
NORMAL
Muscoloskeletal
System
Inspection Symmetric
muscles.
NORMAL
General Appraisal:
Speech:
She could speak in Aklanon, Filipino and understands English. She
could speak clearly with a moderate tone of voice.
Hearing:
She has a good hearing acuity.
Mental Status:
She has a stable mental status. She is cooperative to directions but
he is irritable. She is alert to time, place, and person.
Emotional Status:
She is irritable. She shows a positive attitude, and fights the pressure
of her illness. There are times she gets bored lying all the time on
bed.
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VIII. LABORATORY AND DIAGNOSTIC DATA
CHEST X-RAY (PA View) November 11, 2011
Impression:
Bibasal Pneumonia
X-RAY (KUB) November 11, 2011
Impression:
Pelvic Lithiasis Right Kidney
Examination Result Normal Values Significance of
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Abnormal ResultDATE: Novemeber 10, 2011
Blood Chemistry
(Creatinine)
119 umol/L 53-115 mmol/LIncreased creatinine
levels in the blood
suggest diseases or
conditions that affect
kidney function. Such as
infection, and altered
kidney function.
Examination Result Normal Values Significance of
Abnormal ResultDATE: Novemeber 11, 2011
Blood Chemistry
Cholesterol
5.7 mmol/L 0 5.2 mmol/LHigh levels of cholesterol
in the blood may indicate
an increase risk for
coronary heart disease.
LDL 4.2 mmol/L 0 3.9 mmol/L High levels of LDL
indicates a buildup of
cholesterol in the arteries.
Cholesterol Risk
Factor
5.4 mmol/L 0 -4 mmol/L
High levels of cholesterol
risk factor indicates an
increase risk for coronaryheart disease.
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IX. PATHOPHYSIOLOGY
Predisposing FactorAge
GenderLifestyle
Precipitating FactorLow fluid intake andexcessive intake of protein, salt and oxalate
Hypertension
Uric acid, ammonia phosphate andcalcium oxalate stone materialdeposition on proximal renal
tubule
Super saturation of urineby stone
formingconstituents
Allowing crystallites to bedeposited and trapped
forming calculi or stones
Nephrocalcinosis onproximaltubule
Randalls plaque
Increase production of WBC
Progression of stonesinLoop of Henle
Accumulation of stones &increasing in size
Super saturation of urineby stone forming
constituents
Urinary Tract Infectioncaused by urea
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Stones formation
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X. MEDICAL MANAGEMENT
XI. NURSING MANAGEMENT
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XII. DISCHARGE PLANNING
MEDICATIONS
Take the entire course of all prescribed medications, even until feeling well.
Monitor for adverse effects of such drugs, e.g., tachycardia, cardiac
arrhythmias, central nervous system stimulation, and hypertension.
Medications:
1. Sambong 500mg 1tab
2. Fluticasone 5mg 1tab
3. Lipitor 10mg
4. Diflucan 50mg 2cap5. Flagyl
EXCERCISE
Get plenty of rest. Bed rest may help to avoid stress. Adequate rest is
important to maintain progress toward full recovery and to avoid relapse.
Discuss and demonstrate relaxation exercises to reduce stress, tension, and
anxiety. Reemphasize the importance of graded exercise and physicalconditioning programs. Advise to do gradual walking and breathing exercises.
Avoid strenuous activities that may precipitate conditions like, chest pain,
extreme dyspnea or undue fatigue. May have assistance and support if
activities are not tolerated alone.
TREATMENT
Advised patient and family members to seek medical advice if any unusuality
arises.
Instructed to comply with the medications prescribed.
Control your blood pressure by adhering fully to medications, and refraining
from eating foods high in cholesterol.
HOME TEACHINGS
Encourage the guardians to wash patients hands before and after contact with
the patient. The hands come in daily contact with germs that can cause
infection. Washing hands thoroughly and often can help reduce the risk.
Tell guardians to avoid exposing the patient to an environment with too much
pollution (e.g. smoke). Smoking damages ones lungs natural defenses
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against respiratory infections. Encourage the patient to quit from smoking as
well as drinking alcoholic beverages to prevent further complications.
OUT-PATIENT FOLLOW UP
Review with the patient the objectives of treatment and nursing management.
Keep all of follow-up appointments. Consult with the physician at least once a
month for the progress of condition. Emphasized the importance of regular
follow-up check-ups and as instructed by the physician.
Always provide patients safety to prevent injury. Warn patient to stay out of
extremely hot or cold weather and to avoid aggravating bronchial obstruction
and sputum obstruction. Warn patient to avoid persons with respiratoryinfections, and to avoid crowds and areas with poor ventilation.
DIET
Eat nutritious foods such as fruits and vegetables. Avoid eating foods which
can cause the patient to acquire other health problems.
Avoid saturated fat and cholesterol in diet.
Include fruits and vegetables in the diet.Eat fewer foods that are high in salt, like canned and packaged soups, pickles,
and processed meats.
Eat smaller portions and never skip meals. Drink milk every day.
SPIRITUALITY
The most rapid and effective healing takes place when we correct our wrong
beliefs. This does not include that we give new thought to the condition, but
rather new thought to the positive opposite of the unfortunate condition.
Encourage the patient to pray spiritually by giving gratitude and thanks to the
LORD for all the wonderful gifts HE had given to him.
Encouraged to continue to seek Gods guidance and enlightenment.
Encouraged to continue to have a positive outlook in life.
Encouraged to keep faith in God and not to give up easily when hard times
come.