Medical-Surgical Nursing 1

A Case Presentation on Nephrolithiasis

I. Patient’s Profile

Name: Mrs. R.D

Age: 57 years old

Sex: Female

Address: 36 Luna Street, Lapaz, Iloilo City

Religion: Roman Catholic

Occupation: Housewife

Attending Physician: Dr. F.M

Date of admission: December 12, 2012

Date of discharge: still on admission during data gathering.

Chief Complaint: Right Flank Pain

Diagnosis: Nephrolithiasis with moderate hydronephrosis and

hydroureter secondary to obstructing proximal ureterolithiasis, right.

Special procedures: Human Albumin Transfussion- 57cc 25%

Operative Procedure: CVP Insertion

II. History of Present Illness

Mrs. RD is apparently well, until in the morning of the day of admission. She started to complain of right flank pain accompanied by terminal dyspnea and urinary frequency. She took mefenamic acid with no relief of symptoms.

In the afternoon there was persistence of symptoms and she had fever and chills, thus sought consult in the hospital and was subsequently admitted.

Mrs. RD stopped taking her maintenance since August 2012.

III. Past Medical History

• Hypertension

-on telmisartan + amlodipine 40/5mg, stopped last August 2012.

• Bilateral Nephrolithiasis

- on potassium citrate, stopped last August 2012.

• 3.1 Previous Hospitalization

-TAHBSOO last 2007 secondary to myoma.

• 3.2 Allergies-none

• 3.3 Habits

-doing all the household chores whenever she is able to.

• 3.4Family History

-Hypertension (paternal side)

• 3.5 Social/Environmental History-

-Non-smoker, Non-alkoholic

IV. Physical Examination

• TPR on Admissiono T- 39.4 °Co P- 122 bpmo R- 22 bpmo BP- 140/80

mmhg

• TPR range during hospital stay.o T- 36 °C to 39.4

°Co P-81 bpm to 122

bpmo R- 19 bpm to 33

bpmo BP-90/60mmhg to

140/80 mmhg.

General Assessment

• Awake, conscious and coherent, dressed in clean and comfortable clothing, conversant with folks. With vital signs upon assessment of:

• T-36.7 °C• CR-118bpm• RR-26bpm• BP-140/80mmhg

• 4.1 Head- normocephalic, symmetrical and smooth. Absence of depressions, masses and scars. Hair is smooth, colored gray and evenly distributed.

• 4.2 Face- oval shaped, absence of pimples, acne and scars. Edema, disproportionate structures and involuntary movements not noted.

• 4.3 Eyes- anicteric, symmetrical, inline with each other, non-protruding and equal palpebral fissures. Pupils are equally round, reactive to light and accomodation.

• 4.4 Nose-located symmetrically on the midline of the face, absence of swelling, lesions, perforations and discharges. With pinkish nasal mucosa.

• 4.5 Ears- aligned with the outer canthus of the eyes, symmetrical and no discharges nor perforations noted.

• 4.6 Mouth- dry lips and oral mucosa. Tongue in midline of the mouth. Tooth decay noted on right canine and frontal teeth. No halitosis noted.

• 4.7 Neck- head is in central position. No deformities, lesions nor limits in range of motion. Lymph nodes are non-palpable.

• 4.8 Chest- symmetrical, no masses, lesions nor retractions noted.

• 4.9 Heart- tachycardic, adynamic precordium.

• 4.10- Abdomen- uniform in color, no scars nor lesions noted. Tenderness noted on hypogastric and epigastric area.

• 4.11Genitalia- not assessed, but patient complains of dysuria and urinary frequency.

• 4.12 Upper extremities- equal in size and length. No deformities, lesions nor scars noted, able to perform full range of motion.

• 4.12 Lower extremities- both legs are edematous ( plus 2 pitting edema), unable to perform full range of motion exercises. Still with full pulses.

Laboratory Results

Laboratory Data

Hematology Result Normal Values

Hemoglobin 103g/L M: 130-180 g/LF: 120-160 g/L

Hematocrit 0.34 vol. fr. M: 0.40-0.54 vol. fr.F: 0.37-0.47 vol. fr.

RBC Count 5.18 x 10/L M: 4.6-6.2 x10/LF: 4.2-5.4 x10/L

WBC Count 19.53 x 10/L 4.5 -11.0 x 10/L

Differential Count Neutrophil Segmenter Stab Lymphocyte

93%85%8%6%

50-70%2-5%20-40%

Platelet Count 72.0 x10/L 150-450 x 10/L

December 12, 2012

Urinalysis Results Normal Values

Color Pale straw Light yellow -amber

Transparency Hazy Clear

Reaction Acidic Acidic

Specific Gravity 1.030 1.005-1.035

Microscopic Findings

Puss cells 50-60 None

RBC 2-4 None

Chemical Tests

Sugar Negative Negative

Albumin Trace negative

December 12, 2012

ABG Results Normal Values

pH 7.41 7.35-7.45

paCO2 28.8 mmhg 35-45 mmhg

pO2 73 mmhg 80-100mmhg

HCO3 18.8 mmol/L 22-26 mmol/L

O2 saturation 95.7% 95-100%

December 12, 2012

Chest PA

Impression :

Atherosclerosis; aortaSubsegmental atelectasis left lung

December 12, 2012

Ultrasound ReportImpressions:•Diffuse fatty liver•Nephrolithiasis, with hydronephrosis and hydroureter•Normal gallbladder, pancreas, spleen, left kidney and urinary bladder.

Decemberv13, 2012

Results Normal Values

FBS (Fasting Blood Sugar)

9.55 mmol/L 4.1-5.9 mmol/L

Uric Acid 497.54 umol/L 155-357 umol/L.

December 13, 2012

Result Normal Value

HbA1C 7.5% 4.8-6.0%

December 14,2012

Miscellaneous Report

Prothrombin Time Normal Values

% Activity: 80% 70-10%

Patient: 14.8 seconds 11.6-16.0 seconds

INR: 1.15

December 14, 2012

Blood Chemistry Results Normal Values

Albumin 22.55 g/L 34-50g/L

BUN 13.14 mmol/L 2.5- 6.40 mmol/L

Creatinine 155.59 umol/L 53-88umol/L

Sodium 140.28 mmol/L 136-146 mmol/L

Potassium 3.39 mmol/L 3.5- 5.1 mmol/L

December 16, 2012

ABG Results Normal Values

pH 7.38 7.35-7.45

paCO2 31 mmhg 35-45 mmhg

pO2 80 mmhg 80-100mmhg

HCO3 18.3 mmol/L 22-26 mmol/L

O2 saturation 95% 95-100%

December 16, 2012

FULLY COMPENSATED METABOLIC ACIDOCIS WITH ADEQUATE OXYGENATION

Drug Study

• Paracetamol 500mg/tab 1 tab q6h PRN for fever >/= t. 37.8°C.

• Telmisartan + amlodipine40mg/5mg/tab OD

• Clonidine (catapress) 75mcg/tab 1 tab SL q6h for BP >/=150/90

• Omeprazole 40 mg OD

• Kalium durole TID x 9 doses.

• Midazolam 2g slow IVTT on route to OR

• Dopamine 400mcg in 250cc D5W

• Furosemide 20mg IV with precautions

Pathophysiology

of

Nephrolithiasis

NephrolithiasisPrecipitating Factors-excesive intake of calcium/hyperclcemia-decreased intake of water.

Predisposing Factors-male-family history of renal disease

Saturation of urine

Decreased urinary flow

May produce excess amounts of mucoprotein in the bladder

Allowing crystallites to be deposited and trapped forming calculi or stones

Urine (upon voiding) moves tiny stones to the ureter

Large stones tiny stones

Large stones Tiny stones

Blocks the ureter

UTI

Becomes nidus for bacteria

Increased WBC count

Decreased urine output

Causes spasmMakes urine

turbidity cloudy

Injures the wall of the ureter

Blood combines with

urine/hematuria

Decreased hgb count

Painful urination

VII. Nursing Diagnosis and Care Plans

Nursing Diagnosis according to priority of care:

• Acute pain related to ureteral contractions secondary to stones in the kidney.

• Hyperthermia related to infection process.

• Fluid volume excess related to compromised regulatory mechanism.

• Altered urinary elimination related to mechanical obstruction.

• Altered nutrition less than body requirements related to nausea and vomiting.

• Risk for decreased cardiac output related to severe acidosis.

• Risk for infection related to invasive procedures. (Urinary catheter, CVP insertion.)

• Risk for injury related to decreased RBC production.

• Risk for impaired skin integrity related to edema. ( 2+)

• Knowledge deficit regarding condition related to information misinterpretation

Updates on

Nephrolithiasis

Home remedies from herbal teas and grocery foods dissolve kidney stones

and reverse renal failure

October 31, 2012 by: JB Bardot • Lemonade• Apple cider vinegar• Cranberry juice• Parsley and dandelion• Marshmallow root• buchu

• lemonade • Apple cider vinegar

• Cranberry juice • Parsleys and dandelion

• Marshmallow roor • Buchu

Fresh Insight on Effective Drug Treatments for Kidney Stones

New research by scientists at Washington University School of Medicine in St. Louis shows evidence to explain why some people are more prone to develop kidney stones than others

When claudin-14 is idled, the kidney's filtering system works like it's supposed to. Essential minerals in the blood like calcium and magnesium pass through the

kidneys and are reabsorbed back into the blood, where they are transported to cells to carry out basic functions

of life. 

But when people eat a diet high in calcium or salt and don't drink enough water, the small RNA molecules

release their hold on claudin 14. An increase in the gene's activity prevents calcium from re-entering the

blood, the study shows.