ACKNOWLEDGEMENT

First, we would like to thank God for giving us the strength and knowledge,

wisdom and perseverance to finish this study. We would like to express our

deepest gratitude to all the people who gave us the possibility to complete this

study, And to all or parents, for their financial and emotional support.

 

            We would also recognize Mrs. Maria Celeste M. Miranda, RN, our RLE

clinical instructor for giving us enough time to prepare and finish this study.

 

            Our group would also like to acknowledge our Nursing Care Management

lecturer, Mrs. Syrilla Joan Domingo-Valdez II, in developing our knowledge in

order to go through this study. The staff nurses of St. Cabrini Medical Center, for

helping and guiding us all throughout our clinical duty. Above all, we extend our

deepest gratitude to our Dean Ritchie Villasanta. We thank her for continuously

developing activities that are very helpful for us, nursing students. The school

curriculum is very beneficial to us as our institution is developing responsible and

excellent health care practitioners.

1

INTRODUCTION

Kidney stones are painful urinary disorders that start as salt/chemical crystals

which precipitate out from urine. Under normal circumstances, the urine contains

substances that prevent crystallization but for patients with this condition, these

inhibitory substances are ineffective. Tiny crystals will pass out along with the

urinary flow without causing problems. At least 1% of people will pass a kidney

stone during their lifetime, producing some of the most severe pain possible.

Urolithiasis (urinary tract calculi or stones) and nephrolithiasis (kidney calculi or

stones) are well-documented common occurrences in the general population of

the United States. The etiology of this disorder is mutifactorial and is strongly

related to dietary lifestyle habits or practices. Proper management of calculi that

occur along the urinary tract includes investigation into causative factors in an

effort to prevent recurrences. Urinary calculi or stones are the most common

cause of acute ureteral obstruction. Approximately 1 in 1,000 adults in the United

States are hospitalized annually for treatment of urinary tract stones, resulting in

medical costs of approximately $2 billion per year

2

SIGNIFICANCE OF STUDY

   

 

PURPOSE OF THE STUDY

            Our study would primarily benefit the nursing students in our institution. 

This paper would serve as their resource material if they are conducting research

related to ours. 

            It would also help the next generation of student nurses in proposing

projects that would combat health issues in their course.  They can borrow our

paper and study it as they develop projects for their subordinates.  The fact that

our study is accurate, it would serve as an important basis and tool.

            The private and public hospitals can also use our paper as they come up

with health missions. They could analyze our data gathered; determine health

cases, what health concern to focus to and what actions to be developed to fight

health problems.

Our paper would also help the professors in our institution.  They could

have this as their material in imparting learning to their students

3

Related Literature

The literature reflects the incidence of kidney (renal) stone formation to be

greater among white males than black males and three times greater in males

than females. Although kidney stone disease is one-fourth to one-third more

prevalent in adult white males, black males demonstrate a higher incidence of

stones associated with urinary tract infections caused by urea-splitting bacteria.

Kidney stones are most prevalent between the ages of 20 to 40, and a

substantial number of patients report onset of the disease prior to the age of 20.

The lifetime risk for kidney stone formation in the adult white male approaches

20% and approximately 5% to 10% for women. The recurrence rate for kidney

stones is approximately 15% in year 1 and as high as 50% within 5 years of the

initial stone.

4

Anatomy and Physiology of the Urinary Tract

The urinary tract is made up of the kidneys, two ureters, the bladder, and urethra.

The major components are the kidneys, a pair of bean-shaped organs located

below the ribs near the middle of one's back. The kidneys comprise a complex

filtration system made up of individual nephrons that work together to remove

waste products from the blood, which are eliminated from the body in the form of

urine. The kidneys also function to maintain a stable balance of salts and other

substances in the blood, as well as to produce a hormone erythropoietin, which

triggers the production of red blood cells in the bone marrow. 

The ureters are tube-like structures that transport the urine from the kidneys to

the bladder where the urine is stored. Muscles called sphincters tighten around

the urethra to prevent urine from leaking out. There are two sphincters: the

internal is not controlled consciously, while the external sphincter is under

voluntary control. The bladder is elastic and expands as it fills with urine. When

the bladder reaches a certain capacity, which differs for each individual, the brain

sends impulses to the internal sphincter to relax and other impulses to a muscle

called the detrusor to contract and expel the urine out the urethra. This process is

under the voluntary control of the individual, who can hold the urine until social

circumstances allow for urination. (Loss of this control is urinary incontinence.) 

Urine is normally "sterile," meaning that it usually contains no bacteria. The body

accomplishes this through several methods. First, the two sphincter muscles that

5

prevent urine leaking from the bladder to the urethra, also prevent the bacteria

that normally colonize the skin from ascending through the meatus (the opening

in the urethra) into the bladder. Second, the length of the urethra makes it difficult

for bacteria to get to the bladder.

The fact that women have a much shorter urethra than men accounts for the five-

fold increase of UTIs among women compared to men. Finally, if bacteria do

make it to the bladder, the body is equipped with valves where the ureters empty

into the bladder, a region known as the trigone. These valves prevent the "reflux"

of urine, and any bacteria present, back up into the kidneys. Further, the bladder

almost completely empties when urination occurs, so that any bacteria present

should be excreted as well. Nevertheless, despite all these defense mechanisms,

infections sometimes occur.

6

Pathophysiology of Nephrolithiasis

Escherichia coli is the most common microorganism implicated in urinary tract

infection. E. coli is an aerobic, Gram-negative bacterium and is resident flora in

the GIT. When gaining access into the urine tract (which is sterile), E. coli causes

infection. Women are particularly vulnerable due to a short urethra and close

proximity between the urethra and anus.Mechanical obstruction of the urinary

tract, such as with renal calculi or an enlarged prostate and introduction of

urinary catheters and bladder can also increase the likelihood of developing a

urinary tract infection.

Any factor that reduces urinary flow or causes obstruction, which results in

urinary stasis or reduces urine volume through dehydration and inadequate fluid

intake, increases the risk of developing kidney stones. Low urinary flow is the

most common abnormality, and most important factor to correct with kidney

stones. It is important for health practitioners to concentrate on interventions for

correcting low urinary volume in an effort to prevent recurrent stone disease.

Contributing Factors of Nephrolithiasis

Sex. Males tend to have a three times higher incidence of kidney stones than

females. Women typically excrete more citrate and less calcium than men, which

may partially explain the higher incidence of stone disease in men

7

Ethnic Background. Stones are rare in Native Americans, Africans, American

Blacks, and Israelis

Family History. Patients with a family history of stone formation may produce

excess amounts of a mucoprotein in the kidney or bladder allowing crystallites to

be deposited and trapped forming calculi or stones. Twenty-five percent of stone-

formers have a family history of urolithiasis. Familial etiologies include absorptive

hypercalciuria, cystinuria, renal tubular acidosis, and primary hyperoxaluria

Medical History. Past medical history may provide vital information about the

underlying etiology of a stone's formation. A positive medical history of skeletal

fracture and peptic ulcer disease suggests a diagnosis of primary

hyperparathyroidism. Intestinal disease, which may include chronic diarrheal

states, ileal disease, or prior intestinal resection, may be a predisposition to

enteric hyperoxaluria or hypocitraturia. This may result in calcium oxalate

nephrolithiasis because of dehydration and chemical imbalances. Irritable bowel

disease or intestinal surgery may prevent the normal absorption of fat from the

intestines and alter the manner in which the intestines process calcium or

oxalate. This may also lead to calculi or stone formation. Patients with gout may

form either uric acid stones or calcium oxalate stones. Patients with a history of

urinary tract infections (UTI) may be prone to infection nephrolithiasis caused by

urea-splitting bacteria. Cystinuria is a homozygous recessive disease leading to

8

stone formation. Renal tubular acidosis is a familial disorder that causes kidney

stones in most patients who have this disorder.

Dietary Habits. Fluid restriction or dehydration may cause kidney stone

formation. Dietary intake that is high in sodium, oxalate, fat, protein, sugar,

unrefined carbohydrates, and ascorbic acid (vitamin C) has been linked to stone

formation. Low intake of citrus fruits can result in hypocitraturia, which may

increase an individual's risk for developing stones.

Environmental Factors. Fluid intake consisting of drinking water high in minerals

may contribute to kidney stone development. Another contributing factor may be

related to geographical variables such as tropical climates. Stone formation is

greater in mountainous, high-desert areas that are found in the United States,

British Isles, Scandinavia, Mediterranean, Northern India, Pakistan, Northern

Australia, Central Europe, Malayan Peninsula, and China. Affluent societies have

a higher rate of small upper tract stones whereas large infection stones occur

more commonly in developing countries Bladder stones are more common in

underserved countries and are likely related to dietary habits and malnutrition

Medications. Medications such as ephedrine, guaifenesin, thiazide, indinavir, and

allopurinol may be contributory factors in the development of calculi.

9

Occupations. Occupations in which fluid intake is limited or restricted or those

associated with fluid loss may be at greater risk for stone development as a

result of decreased urinary volume.

Pathogenesis

For ages nephrolithiasis has been a widespread disease and clinical statistics

prove that its morbidity index is still increasing, thus it becomes a social problem.

Peak morbidity usually occurs at the age between 30 and 40, that is why many

patients professionally active and creative have to leave their jobs for a long

period. In contrast to earlier years, frequency of the disease occurrence in

females is systematically increasing and nowadays it is only slightly lower from

that in males. Etiology and pathogenesis of the disease is also not entirely

explained. It is generally accepted that urinary stone formation is determined by

multiple factors which affect first of all chemical composition and physical

features of urine. Individual properties of the kidneys and urinary tract and

infections especially with urease producing pathogens as well as environmental

factors are also taken into account. The most favourable circumstances for

nephrolithiasis occurrence is co-existence of all these factors.

Prevalence

10

As much as 10% of the U.S. population will develop a kidney stone in their

lifetime. Upper urinary tract stones (kidney, upper ureter) are more common in

the United States than in the rest of the world. Researchers attribute the

incidence of nephrolithiasis in the United States to a dietary preference of foods

high in animal protein

Clinical Presentation

Symptoms may vary and depend on the location and size of the kidney stones or

calculi within the urinary collecting system. In general, symptoms may include

acute renal or ureteral colic, hematuria (microscopic or gross blood in the urine),

urinary tract infection, or vague abdominal or flank pain. A thorough history and

physical examination, along with selected laboratory and radiologic studies, are

essential to making the correct diagnosis. Small nonobstructing stones or "silent

stones" located in the calyces of the kidney are sometimes found incidentally on

x-rays or may be present with asymptomatic hematuria. Such stones often pass

without causing pain or discomfort.

Kidney Stone Symptoms

Stones in the kidneys can become lodged at the junction of the kidney and ureter

(ureteropelvic junction), resulting in acute ureteral obstruction with severe

intermittent colicky flank pain. Pain can be localized at the costovertebral angle.

Hematuria may be present intermittently or persistently and it may be

microscopic or gross.

11

Kidney Stone Complications

Occasionally, stones can injure the kidneys by causing infection, resulting in

fever, chills, and loss of appetite or urinary obstruction. If a UTI accompanies the

urinary obstruction, pyelonephritis or urosepsis can occur. If stones are bilateral,

they can cause renal scarring and damage, resulting in acute or chronic renal

failure.

Causes of Nephrolithiasis

Low Urine Volume

Low urine output is defined as < 1 liter/day. The typical etiologies of

nephrolithiasis are low fluid intake and reduced urine volume. Other possible

causes of low urine volume include chronic diarrheal syndromes that result in

large fluid loses from the gastrointestinal tract and fluid loss from perspiration, or

evaporation from lungs or exposed tissue. Stone formation may be initiated by a

low urine output, providing a concentrated environment for substances such as

calcium, oxalate, uric acid, and cystine to begin crystallization.

No Pathological Disturbance

In approximately 35% of the stone-forming population, no identifiable risk factors

for stone formation can be found. This group includes individuals with normal

serum calcium and PTH, normal fasting and calcium load response, normal urine

12

volumes, normal pH, calcium, oxalate, uric acid, citrate, and magnesium levels in

the presence of calcium nephrolithiasis.

RELATED DIAGNOSTIC TESTS

Urinalysis:

Color may be yellow, dark brown, bloody. Commonly shows RBCs, WBCs,

crystals (cystine, uric acid, calcium oxalate), casts, minerals, bacteria, pus; pH

may be less than 5 (promotes cystine and uric acid stones) or higher than 7.5

(promotes magnesium, struvite, phosphate, or calcium phosphate stones).

Urine (24-hr): Cr, uric acid, calcium, phosphorus, oxalate, or cystine may be

elevated.

Urine culture: May reveal UTI (Staphylococcus aureus, Proteus, Klebsiella,

Pseudomonas).

Biochemical survey: Elevated levels of magnesium, calcium, uric acid,

phosphates, protein, electrolytes.

Serum and urine BUN/Cr: Abnormal (high in serum/low in urine) secondary to

high obstructive stone in kidney causing ischemia/necrosis.

Serum chloride and bicarbonate levels:

13

Elevation of chloride and decreased levels of bicarbonate suggest developing

renal tubular acidosis.

CBC:

Hb/Hct:

Abnormal if patient is severely dehydrated or polycythemia is present

(encourages precipitation of solids), or patient is anemic (hemorrhage, kidney

dysfunction/failure).

RBCs:

Usually normal.

WBCs:

May be increased, indicating infection/septicemia.

Parathyroid hormone (PTH):

May be increased if kidney failure is present. (PTH stimulates reabsorption of

calcium from bones, increasing circulating serum and urine calcium levels.)

14

KUB x-ray:

Shows presence of calculi and/or anatomical changes in the area of the kidneys

or along the course of the ureter.

IVP:

Provides rapid confirmation of urolithiasis as a cause of abdominal or flank pain.

Shows abnormalities in anatomical structures (distended ureter) and outline of

calculi.

Cystoureteroscopy:

Direct visualization of bladder and ureter may reveal stone and/or obstructive

effects.

CT scan:

Identifies/delineates calculi and other masses; kidney, ureteral, and bladder

distension.

Ultrasound of kidney:

To determine obstructive changes, location of stone; without the risk of failure

induced by contrast medium.

15

Nursing Care Management

Nursing history

Demographic data

Patient’s name: M, RA B.

Age: 21

Birth date: April 16, 1988

Address: Bukal South, Batangas City

Height: 5’1”

Weight: 48kg

Civil status: single

Religion: catholic

Occupation: factory worker

Highest educational

Attainment: high school

Father: R.M.

Mother: M.M.

Rate: 720.00

Room number: 236b

Hospital number: 73553

16

Admission number: 40863

Admission date: May 27, 2009

Admission time: 1:27 pm

Attending physician:Dr. Ronald Miranda

Chief complaint:

Painful urination

History of present illness:

One week prior to admission, the patient started to experience

painful urination. She consulted their office clinic and was given Bactrim. On

Monday, she had blood in the urine. The severity of the pain is 5/10 last week

and turned to 8/10 pain scale. She consulted in this institution and was admitted.

The patient has no allergy in any medicine and food.

History of past illness:

17

The patient had mild hepatitis a when she was young. She’s

complete in immunization and never undergone any surgery.

Lifestyle and health practices:

The patient does’nt has any vices hence not doing any exercise.

She’s working as a factory worker in Calamba.

Nutritional habits:

The patient is eating regular foods most of the time but she’s also

fond of eating junk foods and soft drinks.

Recent sleep:

The patient has different positions in sleeping. Her sleeping time

ranges from 11-12:00 pm and wakes up at 6 in the morning. There’s no

interruption when she sleeps.

Treatment and medication

18

Solution Frequency

D5LR 1L Q8

Paracetamol Tcup IV

For temperature 38.8 Q4

Tazocin Q12

Paracetamol 500mg/tablet

For Temperature 37.8 Q4

Lactated ringers in 5% dextrose

Used for rehydration.

Intravenous paracetamol

Used to revitalize. Intravenous administration is more reliable and

reaches peak concentrations faster compared with oral routes, as proven for

19

paracetamol. Since paracetamol’s side effect profile is considerably superior,

availability of an intravenous form is very useful when other routes are less

feasible.

Paracetamol

Commonly used for the relief of fever, headaches, and other minor

aches and pains, and is a major ingredient in numerous cold and flu

remedies. While generally safe for human use at recommended doses,

acute overdoses of paracetamol can cause potentially fatal liver damage

and, in rare individuals, a normal dose can do the same; the risk is

heightened by alcoholism.

Paracetamol toxicity

Foremost cause of acute liver failure.

Tazocin

Tazocin injection contains two active ingredients, piperacillin which

is a penicillin-type antibiotic, and tazobactam, which is a medicine that prevents

bacteria from inactivating piperacillin. The injection is used to treat infections with

bacteria.

20

Tazocin is given by injection or infusion (drip) into a vein. It is used

to treat severe infections, including those caused by multiple organisms.

Use with caution in

- Decreased kidney function

- Kidney failure

- History of allergies

- Low sodium diet

- Low blood potassium levels (hypokalaemia)

Not to be used in

- Allergy to penicillin or cephalosporin type antibiotics

- Allergy to beta-lactamase inhibitors

This medicine should not be used if you are allergic to one or any of its

ingredients. Please inform your doctor or pharmacist if you have previously

experienced such an allergy. If you feel you have experienced an allergic

reaction, stop using this medicine and inform your doctor or pharmacist

immediately.

21

Side effects

Medicines and their possible side effects can affect individual people in different

ways. The following are some of the side effects that are known to be associated

with this medicine. Because a side effect is stated here, it does not mean that all

people using this medicine will experience that or any side effect.

- Diarrhea

- Nausea and vomiting

- Rash

- Overgrowth of the yeast Candida, which may cause infection such as thrush

- Disturbances in the normal numbers of blood cells in the blood

- Headache

- Difficulty sleeping (insomnia)

- Low blood pressure (hypotension)

- Inflammation of the wall of a vein with a blood clot forming in the affected

segment of vein (thrombophlebitis)

- Constipation

- Indigestion

- Sore mouth

- Skin reactions such as itching, hives, flushing, eczema

- Severe allergic skin rashes

- Fever (pyrexia)

- Reactions at injection site

22

- Liver or kidney disorders

- Fatigue

- Muscle pain and weakness

- Hallucinations

Abstract:

Each time we are permitted to take our journey with the patient and their

family, we treat it as an honor they have bestowed upon us. We have the

opportunity to provide care to clients and to communicate to them by and by.

As we entered at our patient’s room which is room number 236, we

greeted her and then we gave our best smiles to her. The patient that was

assigned to us seems to be very kind, she is very accommodating and has

showed willingness in participation in the interview. She is M, RA B., a 21 years

old girl. Her birthday is April 16, 1988 came from Bukal South, Batangas City.

She’s single, a catholic and a Filipino. Her highest educational attainment is High

school that’s why she’s working as a factory worker at First Philippine Industrial

Park located at Sto. Tomas, Batangas.

23

She was admitted on May 27, 2009 at exactly 01:27pm. One week prior to

admission, the patient started to experience painful urination. She consulted their

office clinic and was given Bactrim. On Monday, she had blood in the urine. The

severity of the pain is 5/10 last week and turned to 8/10 pain scale. She

consulted in this institution and was admitted. The patient has no allergy in any

medicine and food. About her past illness, the patient had mild hepatitis A when

she was young. She’s complete in immunization and never undergone any

surgery. The patient does’nt has any vices hence not doing any exercise. The

patient is eating on time but fond of eating junk foods and soft drinks. The patient

has different positions in sleeping. Her sleeping time ranges from 11-12:00 pm

and wakes up at 6 in the morning. There’s no interruption when she sleeps.

Due to the diagnosis, which is Urinary Tract Infection, the Doctor

prescribed her to take medications such as D5LR 1L, Paracetamol Tcup IV,

Tazocin, and Paracetamol 500mg/tablet.

24

Nursing Process

Assessment Nursing

Diagnosis

Planning Nursing

Intervention

Rationale Expected

Outcome

Subjective;

:“Masakit

angpagihi ko” as

verbalized by the

patient

Acute pain related

to biological

factors such as

trauma or activity

of disease

process

Short term:

At the end of the

shift, the patients

may relief pain

and discomfort.

Use

antispasmo

dic drugs

Encourage

patient to

To relieve

irritability

and pain

To provide

adequate

The Patient will

experience relief

pain

25

Objective:

>Facialgrimace.

>Restlessness.

>V/S taken

asfollows:T:

37.3P: 82R:

19BP: 120/90

Long term;

Upon the patient

discharge, the

patient may

increase

knowledge of

preventive

measure and

treatment

modalities and

absence of

complication.

drink liberal

amount of

fluid

Instruct the

patient to

avoid

urinary

tract

irritant.

Teach

patient to

cleanse

hydration to

patients at

risk for

hydration

To reduce

concentrati

on of

pathogens

of the

Vaginal

The Patient will

understand UTI”s

and their

treatment.

26

around

perineum

and

urethral

meatus

after bowel

movement

with front to

back

motion

opening.

27

Nutritional Assessment

Renal Diet

You will be advised to stick to a renal diet if your kidneys have failed meaning

that your kidneys are not able to remove the wastes from your body which are

usually produced from the foods that you eat and the liquids that you drink. 

The main purpose of a renal diet is to control the amount of protein, sodium and

phosphorous. Along with this, a renal diet will also help reduce the amount of

wastes present in the body thereby helping the kidney work better and avoiding a

total renal failure. 

Renal Diet 

In learning about the renal diet, we will focus more on what food is to be avoided

because of what they may contain:

Protein: Unless you are on haemodialysis, you should limit the protein in

your diet to 0.75g per kilogram of your body weight. Ensure that you are

taking in sufficient calories else you will have to increase the intake of

protein. The richest sources of protein are meat, fish, cheese, eggs, milk,

pulses and nuts.

Sodium: has to be controlled in the diet of renal patients as this helps in

maintaining the fluid balance in the body along with avoiding fluid retention

and high blood pressure. A high content of sodium is found in table salt,

28

soups, processed cheese, canned food, junk food and pickles. All of us

know that we cannot avoid the normal table salt in our diet completely as

food would be completely tasteless and inedible. Fortunately, the quantity

of the salt that we use can be controlled with the help of using garlic,

mustard and pepper that helps in making the food tastier when very little

salt is used. Also, be wary of salt substitutes like ‘Lo-Salt’. No doubt these

substitutes are low in sodium but they are very high in potassium which

makes them equally dangerous in your diet.

Potassium: The intake of potassium should be restricted only if the tests

reveal high potassium levels in the blood. The main reason for this is that

many healthy foods that form an important part of the diet contain

potassium. If you do have to restrict the intake of potassium then avoid

leafy vegetables, fruit and fruit juices. Also, potatoes contain a high level

of potassium especially if they are fried or baked.

Phosphate: Excess of phosphate in the blood becomes a problem during

the 4th and 5th stage of the chronic kidney failure wherein the kidney

works at about 20% of its maximum capacity. A high level of phosphate

makes the patient itch very badly and has an adverse effect on the

arteries too. A good diet in not sufficient to control the level of diets in most

cases and additional medications known as phosphate binders too have to

be taken along with the food which keep the phosphate in the gut and

prevent its absorption into the blood. These medicines have to be taken

just before eating or along with food else they will not be effective.

29

Phosphates are usually associated with proteins and are found in high

content in milk, cheese, baking powder, shellfish and wholegrain cereals.

It is also found in convenience foods which are added by their

manufacturers.

With so many limitations on the food that you can consume, it is not uncommon

that kidney patients start to lose weight. You have to maintain your weight at a

healthy level and here are some food tips that you can use which will fit your diet

plan and help you maintain your weight:

All breads, tortillas and cereals except bran breads and cereals can be

consumed.

Add a measured quantity of margarine, mayonnaise and vegetable oils

like olive oil or canola oil in your diet.

If you are not diabetic, then you can add honey and sugar to add calories.

Lastly, remember that you must eat snacks and meals at regular intervals

and should not miss any meal.

No matter how much of information you can gather on the internet, it is vital that

you consult a dietitian and work out a diet plan for you which will be based on

your weight, food habits and renal history. A good diet plan will ensure that you

can move forward beyond your kidney failure and lead a healthy and fulfilling life.

All it will take is a little self control. All the best!

30

Sample Renal Diet

Breakfast

1/2 cup cranberry juice

1 egg

2 slices toast

2 teaspoons jelly

2 tablespoons non-milk creamer

1 cup coffee

Lunch

3 ounces sliced turkey

2 slices bread

1 lettuce leaf

2 teaspoons mayonnaise

1/2 cup cucumber salad

1 tablespoon oil and vinegar dressing

1 medium apple

1 cup lemonade

Evening Meal

3 ounces broiled fish

1/2 cup rice

1/2 cup green beans

1 cup lettuce salad

1 tablespoon oil and vinegar dressing

1 dinner roll

2 teaspoons margarine

1/2 cup canned peaches

1 cup lemon water

31