Case Study Group 2

BULACAN STATE UNIVERSITYCOLLEGE OF NURSING

S.Y. 2013-2014

A CASE STUDY OF 62 YEARS OLD FEMALE WITH UTEROLITHIASIS

SUBMITTED BY: SUBMITTED TO:GROUP 2 BSN 3-D Maria Ongleo, RN, MSN

LEADER: Lorenzo, Hannah Gail M. CLINICAL INSTRUCTORMEMBER: Dela Cruz, Mary Grace C.

Federis, Nerissa Joy E.Flores, Marjelene G.Junio, Ma. Jaecelyn S.Llano, Ma. Joanna MarieLumba, Jeffrey C.Maluyo, SarahMasangcay, MilcahMasangkay, KriselleMontales, Michelle D.Pascual, Rotche M.

I. Introduction

This is a case of Mrs. A.V.A, 62 years old client from Poblacion, Plaridel, Bulacan, she was admitted at Bulacan Medical Center last April 29,2013 at 8:37 AM with a chief complaint of abdominal pain on lower right quadrant and dysuria.

Ureterolithiasis is when kidney stones, or calculus / calculi are formed in the ureters. Ureters are the ducts that move urine along from the kidneys to the urinary bladder, also called cloaca. With ureterolithiasis 75 to 85 percent of kidney stones or calculi are calcium stones. About half of caluli are composed of both oxalate and calcium phosophate. Ureterolithiasis can cause a painful condition called a renal colic attack in which either one or both of the ureters become blocked by kidney stones. Renal colic is often described as the strongest pain a person has ever felt. The pain from such an attack usually starts in the loin and travels through the urinary tract to the genitals as the stones are passed from the body. Major symptoms include decreased urine production, Vitamin A or C deficiency, excruciating pain radiating from side, back to groin or abdomen and Fever, night chills / sweats. There are several possible reasons for the formation of the kidney stones that cause ureterolithiasis, though it is not always possible for a doctor to find a cause. Diet can play a role in the growth of stones, though it is not commonly believed to cause their formation. A family or personal history with kidney stones, metabolic disorders, and cystic kidney disease are all believed to play a role in the development of kidney stones.

The diagnostic procedure done with our client. The patient’s medications were given.

According to NIH statistics, kidney stones cause about 500,000 people to visit emergency rooms annually. Additionally, 2.5 million people who have less severe symptoms are treated for kidney stones yearly. The prevalence of kidney stones was 8.8%. Among men, the prevalence of stones was 10.6%, compared with 7.1 women. Kidney stones were more common among obese than normal-weight individuals (11.2% compared with 6.1%). Black, non-Hispanic and Hispanic individuals were less likely to report a history of stone disease than were white, non-Hispanic individuals (black, non-Hispanic: odds ratio [OR]: 0.37; Hispanic: OR: 0.60). Obesity and diabetes were strongly associated with a history of kidney stones in multivariable models. The cross-sectional survey design limits causal inference regarding potential risk factors for kidney stones.

We chose this case because we are aiming to gain more knowledge and explain all the necessary information about Ureterolithiasis. In addition, our group will learn the needed action for this type of disease in hospital setting aside from the knowledge acquired in Nursing Education. And this study also aims to be a reference for future studies and researches of other nursing students.

II. Objectives

General Objective:

To be able to acquire knowledge regarding the patient’s disease condition by determining causative factors and providing appropriate intervention to improve patient’s condition and prevent possible complication of the disease.

Specific Objectives:

To formulate appropriate nursing intervention by prioritizing patient’s problem related to the disease condition to provide effective nursing care. To impart knowledge to patient and significant others about the disease and its possible complications. To determine functional health status of the patient with Ureterolithiasis.

Client – Centered

Knowledge: To provide client education and involve in implementing therapeutic regimen to promote understanding compliance. To be more aware about the underlying causes of the disease. To provide knowledge about general health problems related to her disease.

Skills: To help the patient in motivating her to continue the health care provided by the health care worker. To conduct physical assessment and interpret it in order to give the care the patient needed. To be able to take care of herself even outside the hospital.

Attitudes: To raise level of awareness of the patient on health problems that she may encounter. To facilitate patient in taking necessary actions to solve and prevent the identified problems on her own. To support and encourage the client and her family to ask questions so that information could be clarified.

Student – Centered

Knowledge: To gain knowledge about pharmacologic therapy given to the client with Ureterolithiasis. To evaluate outcomes after implementation of nursing care to determine what nursing actions needs to be modified or improve. To identify and become familiar with the different diagnostic procedure applicable to our client’s disease.

Skills: To be able to develop an individualize nursing care plan for the client with Ureterolithiasis and carry out appropriate interventions. To collect and organize relevant information concerning the client’s current health status through careful observation and skillful assessment. To describe the special nursing needs of patients with Ureterolithiasis.

Attitude: To establish appropriate behavior such as honest, reliable, courteous, and open minded. To develop our nursing responsibilities in dealing with the client. To be able to take care of oneself even outside the hospital.

III. Nursing Health History

A. Patient’s Profile

Name: Mrs. A.V.A.

Address: Poblacion, Plaridel, Bulacan

Birthday: May 24, 1951

Age: 62 years old

Sex: Female

Civil Status: Married

Religion: Roman Catholic

Nationality: Filipino

Date of Admission: April 29, 2013

Diagnosis: Ureterolithiasis ®

Date Obtained: April 30, 2013 then followed up after operation last May 2, 2013.

B. Reason for Visit

“ Matindi na yung nararamdaman niyang sakit sa tiyan nya kaya dinala na namin siya sa ospital. Alam na rin kasi namin na may sakit siya sa bato kaya dinala na namin kasi baka malala na.” as verbalized by the patient’s daughter.

C. Present Health History

Prior to admission, the client is having abdominal pain on right lower quadrant. So the Family decided to rushed the client at Bulacan Medical Center and admitted at the same time on April 29,2013. She has been diagnosed to have Ureterolithiasis.

D. Past Health History

The client already has been admitted last February 19, 2013 at Bulacan Medical Center with diagnosis of having Diarrhea with vomiting and Herpes Zoster. She doesn’t have any vaccine administered.

E. Family Health Illness History (GENOGRAM)

According to our client her mother died because of head injury. While bathing, her mother slips off and her head hit the floor. Her dad died due to a cardiac arrest. Five of her siblings died with different cases and diseases. Her eldest brother died because of lung cancer, second and third also died but our client didn’t recognize the reason. Her fourth brother died because of a vehicular accident, while her sixth sister died with asthma. Her fifth brother was still alive but has arthritis, while her eight brother has Diabetes Mellitus. Lastly, her seventh and tenth sister doesn’t have any illness at all.

Mr. P.V.L.D.

Mr. E.V,V.A

Mr. N.V.?

Mr.R,V,?

Mrs. G.V.Arth. Mr. R.V.

Art.D.M.

Mrs. N.V.A/W

Mrs. A.V.Ure.

Mrs. C.V.A/W

Mrs. L.V.Asth.

Mr. P.V.C.A.

Mrs. M.V.83y/oH.I.

??? ?

LEGEND: - male -deceased - female -deceased

L.D – Lung DiseaseV.A – Vehicular AccidentD.M – Diabetes MellitusC.A – Cardiac ArrestH.I – Head InjuryA/W – Alive and WellArt – ArthritisAsth – AsthmaUre - Ureterolithiasis

IV. Gordon’s Functional Health Pattern

1. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN

Prior to Hospitalization During Hospitalization

According to client, she has a urinary tract infection and was admitted to the hospital last February. She stated that she don’t have bad habits like smoking and drinking alcohol. She stated that she always attend “Medical Mission” and always have her monthly checkup. She follows doctor’s prescription. She used to take over-the-counter drugs whenever she feels sick. She also add that performing activities of daily living for her is considered as her exercise.

She stated that she will always follow doctor’s order for her to regain her tone.

2. NUTRITIONAL METABOLIC PATTERN


The client stated that she prefer vegetables more than meats. She consumes 1000-1200 ml of water a day. She is wearing dentures. She weighs 43 kg and her height is 153 cm. Her BMI is 18.5 which is underweight.

The doctor orders her to have a D5LR 1L as preparation for her operation.

April 28,2013 April 29,2013 April 30,2013Breakfast 1 cup of Rice

2 pcs of sardines250ml of water

1 plate of Pancit250 ml ofwater

NPO

Lunch ¼ of Bangus1 cup of Rice250 mL of water

1 cup of rice1 serving of ampalaya250 ml of water

NPO

Dinner ¼ of Bangus1 cup of rice250 ml of water

1 serving of Sinigang na baboy1 cup of rice250 ml of water

NPO

3. ELIMINATION PATTERN

Prior Hospitalization During Hospitalization

According to the client the client defecates once a day and urinates 3 times a day with discomfort upon urination.

According to the client the client defecates once a day and urinates 3 times a day without discomfort upon urination due to medication taken.

4. ACTIVITY/EXERCISE PATTERN


Characteristic

Color Odor Frequency Discomfort

Stool Semi-solid Yellow foul odor

1 time No discomfort

Urine Regular urination

yellow no foul odor

4 times a day Pain felt on the lower abdomen

Perspiration: Often perspire due to hot weather.

Characteristic Color Odor Frequency Discomfort

Stool Semi-solid Yellow foul odor

1 time No discomfort

Urine Regular urination

yellow no foul odor

4 times a day No discomfort

Perspiration: Often perspire due to hot weather.

Requires assistance from her son.

Feeding =3 toileting =3 grooming =3 Bathing = 3 dressing =3 bed mobility =3LEGEND:0- Full Self Care1- requires use of equipment or device2- requires assistance or supervision from other person3- requires assistance or supervision from other person/ device4 dependent and does not participate

Requires assistance from her son.

Feeding =2 toileting = 2 grooming = 2 Bathing =2 dressing = 2 bed mobility = 2

5. SLEEP/REST PATTERN


The client stated that she has an adequate sleep, she always sleep 9 hours a day from 9pm to 6am.

She has an inadequate sleep. She sleeps at 10pm and woke up at 12pm and go back to sleep from 10am-1pm.

6. COGNITIVE PERCEPTUAL PATTERN


The client’s vision is 450.400. She is wearing eyeglasses. Cooperative and coherent.

The client’s vision is 450/400. She is wearing eyeglasses. Cooperative and coherent. Can understand and answer the questions clearly. She stated that she felt pain on her lower abdomen with a pain scale of 5 over 10 as 10 being the highest or

LEGEND:0- Full Self Care1- requires use of equipment or device2- requires assistance or supervision from other person3- requires assistance or supervision from other person/ device4 dependent and does not participate

the most painful.

7. SELF PERCEPTION PATTERN


She stated that she has thin body because of stress. Believed that she needs the operation for her to be well and didn’t feel any fear.

She stated that she has thin body because of stress. Believed that she need the operation for her to be well and didn’t feel any fear.

8. ROLE RELATIONSHIP PATTERN


She stated that she is separated with her husband for 12 years and is now leaving with her 4 children. She just stay at home and do household chores, she no longer do heavy works because she have children that will support her. Has a good relationship with her children.

She is always visited by her children.

9. COPING-STRESS TOLERANCE PATTER


Since she is separate to her husband she talks to her children about the problems. When she felt like hopeless she seeks God and prays.

Since she is separate to her husband she talks to her children about the problems. When she felt like hopeless she seeks God and prays.

10. VALUE-BELIEF PATTERN


She always attends Sunday masses, but sometimes when joint pain attacks she failed to attend. But if so, she watched the live mass on television. She is a God-seeking person, she stated that when she felt hopeless she just pray and believes that everything will be alright.

She always attends Sunday masses, but sometimes when joint pain attacks she failed to attend. But if so, she watched the live mass on television. She is a God-seeking person, she stated that when she felt hopeless she just pray and believes that everything will be alright. And she believes in God that’s why she doesn’t feel any fear regarding her operation.

V. Growth and Development

Theories Stages Justification

Freud’s Stage Of Psychosexual Development

Genital Stage: post pubertyEnergy is directed toward full sexual maturity and function and development of skill needed to cope with the environment.

According to our patient, she engages sexual activity with her husband only. Since they were separated, she don’t do that to other. Our patient is fully independent. She can make decision on her own.

Jean Piaget’s Stage Of Cognitive Development

The Formal Operational Stage (20 to Adulthood)During this time, people develop the ability to think about abstract concepts. Skills such

The client thinks rationally and logically. She is able to solve problem with her family by communicating to them and vice versa.

as logical thought, deductive reasoning, and systematic planning also emerge during this stage.

Erik Erickson’s Stage Of Psychososial Development

Adulthood ( 25 to 65 years old)Generativity vs, stagnationThose who are successful during this phase will feel that they are contributing to the world by being active in their home and community. Those who fail attain this skills will feel unproductive in the world.

Our patient passes this stage. She was very active in their community. She used to help in their Barangay Health. She was very friendly and easy to mingle with.

Kohlberg’s Stage of Moral Development

Level 3: Post Conventional MoralityStage 5 – Social Contract and Individual RightsAt this stage, people begin to account for differing values, opinions and beliefs of other people. Rules of law are important for maintaining a society, but members of the society should agree upon these standards.

The patient understand the different roles of the society and can distinguish what is right or wrong based on internalized rules of conscience rather than the social law. She follows rules according to her willingness. According to her, she will follow all the orders of the doctor that will help make her condition better.

VI. Anatomy and Physiology

Anatomy and Physiology

The urinary system which is also called excretory system. Is the organ system that produces stores,and eliminates urine . In humans it includes two kidneys ,two ureters ,urinary bladder and the urethra.

The kidneys are bean-shaped organs which lie in the abdomen .the kidneys receive their blood supply of 1.25 L/M (25% of the cardiac output) it concentrates urine ,plays a crucial role in regulating electrolytes and maintains acid based homeostasis . The kidney excretes and reabsorbs electrolytes (eg.calcium , potassium, and sodium) .Ureter is the passageway where urine flow to the urethra and stored in the bladder.

Urinary bladder ,it swells into a round shape when it is full and gets smaller when empty . it can hold 300 ml of urine comfortably for two to five hours . and the sphincters regulate the flow of urine from the bladder.

Urethra is the endpoint of the urinary system .typically the urethra in humans is colonized by bacteria below the external urethral sphincter . the urethra emerges from the end of the penis in males and between the clitoris and vagina in females.

VII. Pathophysiology

Modifiable

Due to low water intake and metabolic disturbances

Non-Modifiable

Decreased fluid volume

Irritation and injury to the urinary tract

Accumulation of urine in the ureter

Hydroureter

Decrease urine flow

Inflammatory process

Pain (pelvic and area of the abdomen)

Irritation of the nerves

Release of prostaglandin

Anxiety

DiaphoresisIncrease respiration

VIII. Physical Assessment

VITAL SIGNS: PR = 68 bpm BP = 120/80 mmHgRR = 28 cpm Temp. = 38.4 Q C

PARTS TO BE ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS

General appearance

1. Body built in relation to client’s age, lifestyle & health

InspectionProportionate and varies with

lifestyle

He has a proportionate (endomorph) body built which

is appropriate with her lifestyle

Normal

2. Client’s posture & gait, standing, sitting & walking

InspectionRelax, erect posture,

coordinated body movementsn/a n/a

3. Client’s overall hygiene & grooming

Inspection Neat He is neat and clean. Normal

4. Body & breath odor InspectionNo body odor or minor body

odor relative no body odor normal

5. Signs of distress in posture or facial expression

Inspection No distress noted No distress noted Normal

6. Obvious signs of health or illness

Inspection Healthy appearance Sign of Illness Deviation from normal


7. Client’s attitude Inspection Cooperative Cooperative Normal

8. Client’s affect/mood; appropriateness of the clients response

Inspection Appropriate to the situation Appropriate to the situation Normal

9. Quantity of speech, quality & organization

InspectionUnderstandable, moderate

pace; exhibits thought association

Understandable, moderate pace; exhibits thought

associationNormal

10. Relevance & organization of thoughts

InspectionLogical sequence; makes

sense; has sense of reality.She has a sense of reality Normal

SKIN

1. Skin moisture Inspectionmoisture in skin fold and

axillaeThere is moisture in skin fold

and axillaeNormal

2. Skin Texture Inspection smooth smooth Normal

3. Skin turgor Inspection and palpation Springs back moves back easily Normal

Hair and Nails

1. Fingernails plate shape to determine its curvature & angle

InspectionConvex curvature, angle of

nail plate about 160 degrees.Convex and has less than 180

degreeNormal

2. Fingernail & toenail bed color

Inspection Highly vascular and pink in light skinned clients; dark-

Pinkish in color Normal


skinned clients may have brown or black pigmentation

in longitudinal streaks.

3. Tissues surroundings nails Inspection Intact epidermis.She has an intact epidermis

with no hangnailsNormal

4. Fingernail & toenail texture Palpation Smooth texture. Smooth nail texture Normal

5. Blanch test of capillary refill

PalpationPrompt return of pink or usual

color (generally less than 4 seconds.)

The color return to the original color in 2 seconds

Normal

1. Evenness of growth over the scalp

Inspection Evenly distributed hair. Her hair is well distributed Normal

2. Hair thickness & thinness Palpation Thick/thin hair. She has a thick white hair Normal

3. Presence of infections or infestations

Inspection Not present. Not present. Normal

4. Texture & oiliness over the scalp

Palpation Silky, resilient hair. Silky, resilient hair. Normal

SKULL

1. Size, shape & symmetry Palpation Rounded (normocephalic and symmetrical, with frontal,

Head is symmetrically Normal

parietal, and occipital prominences); smooth skull

contour.rounded.

2. Nodules or masses & depressions

PalpationSmooth, uniform consistency; absence of nodules or masses.

No mass or nodules noted; Normal

FACE

1. Facial features Inspection

Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial

folds.

Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial

folds.

Normal

2. Symmetry of the facial movements

InspectionSymmetrical facial

movements.Facial movements are

symmetricalNormal

EYEBROWS & EYELASHES

1. Evenness of distribution & direction of curl

Inspection

Hair evenly distributed; skin intact. Eyebrows

asymmetrically aligned equal movement. Eyelashes curl

slightly outward.

Eyebrows and eyelashes are both evenly distributed,

symmetrical aligned. Eyelashes curl slightly

outward.

Normal

CORNEA

1.Clarity & color Inspection Transparent, shiny and smooth; Details of iris are visible. Deviation from Normal

EYELIDS

1. Surface characteristics & ability to blink

Inspection and Palpation

Skin intact, no discharge, no discoloration. Lids close

symmetrically approximately 15-20 involuntary blinks per minute; bilateral blinking.

When lids open, no open, no visible sclera above corneas, and upper and lower borders

of cornea are slightly covered.

Eyelids skin are intact, no noted discharge, and no noted

discoloration. Lids close symmetrically. Client

exhibited 18 involuntary blinks per minute.

Normal

CONJUNCTIVA

1. Bulbar conjunctivas color, texture & presence of lesions

InspectionTransparent; capillaries

sometimes evident.

Transparent, capillaries evident, no discharge was

noted.Normal

2. Palpebral conjunctivas color, texture & presence of lesions

InspectionShiny, smooth, pink or red in

color.Shiny, smooth and red in

color. Normal

SCLERA

1. Color & clarity InspectionSclera appears white

(yellowish in dark- skinned clients).

Sclera appears white Normal

details of the iris are visible. In older people, a thin grayish white

ring around the margin, called arcussenilis, may be evident.

Transparent, shiny and smooth. But she has visual of 450/400

IRIS

1. Shape & color Inspection Flat and roundFlat and round and uniform in

color.Normal

PUPILS

1. Color, shape & symmetry of size

InspectionBlack in color; equal in size;

normally 3-7 mm in diameter; round, smooth border.

Firm and equal pupils Normal


EAR’S AURICLE

1. Color & symmetry of size &position

Inspection

Color same as facial skin, symmetrical, auricle aligned with outer canthus of eye, about 10cm from vertical.

Color is same with facial skin, symmetrical with each other,

auricle aligned with outer canthus of eye, about 10 cm

vertical

Normal

2. Texture & elasticity & areas of tenderness

Palpation Mobile, firm and not tender, pinna recoils after it is

Both pinna recoils after being folded. Mobile, firm and not

Normal


folded. tender.

EXTERNAL EAR CANAL

1. Cerumen, skin lesions, pus & blood

Inspection

Distal third contains hair follicles and glands. Dry

cerumen in various shades of brown

No noted pus, blood and odor. Minimal cerumen noted. Distal

third contains hair follicles.Normal

HEARING ACUITY TEST

1. Client’s response to normal voice tones

Inspection Normal voice tones audibleClient responds to normal

voice tonesNormal

NOSE

1. Shape, size or color & flaring or discharge from the nares

Inspection

Symmetric and straight

No discharge or flaring

Uniform color

No discharge and/or flaring noted. Symmetrical on both sides. Also uniform in color.

Normal

2. Presence of redness, swelling, growths & discharge or nares using the flashlight

Inspection

Mucosa pink

Clear, watery discharge

No lesions.

Mucosa are intact and pinkish; minimal moist noted inside; no

swelling or nodules found.Normal

3. Position of nasal septum InspectionNasal septum intact and in

midline, intactNasal septum is intact and in

midlineNormal


4. Test patency of both nasal septum

InspectionAir moves freely as the

client breathes through the nares

Air moves freely as the client breathes through each nares

Normal

5. Tenderness, masses & displacement of bone & cartilage

Palpation Not tender; no lesionsNo tenderness, no lesions noted. No displacement of

bone & cartilage.Normal

LIPS

1. Symmetry of contour color & texture

Inspection and Palpation

Uniform pink color

Soft, moist, smooth texture

Symmetry of contour

Ability to purse lips

Uniform pink color

Soft, moist, smooth texture

Symmetry of contour

Has the ability to purse lips

Normal

TEETH

1. Inspect for color, number & condition & presence of

denturesInspection

32 adult teeth

Smooth, white, shiny tooth enamel

Still has denture. Deviation from Normal

GUMS

1. Color & condition Inspection Pink gums (bluish or dark patches in dark-skinned

clients)

Pink gums (bluish or dark patches in dark-skinned

clients)

Normal

Moist, firm texture to gums Moist, firm texture to gums

TONGUE/FLOOR OF THE MOUTH

1. Color & texture of the mouth floor & frenulum

Inspection and PalpationSmooth tongue base with

prominent veinsSmooth tongue base with

prominent veinsNormal

2. Position, color & texture, movement & base of the

tongueInspection and Palpation

Central in position

Pink in color (some brown pigmentation on tongue borders in darj-skinned

clients); moist; slightly rough; thin white coating

Smooth, lateral margins, no lesions

Raised papillae (taste buds)

Moves freely, no tenderness

Central in position

Pink in color (some brown pigmentation on tongue borders in darj-skinned

clients); moist; slightly rough; thin white coating

Smooth, lateral margins, no lesions

Raised papillae (taste buds)

Moves freely, no tenderness

Normal

ABDOMEN

1. Skin integrity Inspection

Unblemished skin, uniform in color, silver white striae

(stretch marks) or surgical scars.

Uniform in color. Normal

2. Abdominal contour InspectionFlat, rounded (convex) or

scaphoid(concave)Convex in shape.

Normal

3. Bowel Sounds Auscultation Audible bowel sounds Hyperactive bowel sounds Normal

IX. Laboratory / Diagnostic Test

A. URINALYSIS

Date: April 16, 2013

TEST RESULT InterpretationMacroscopic

Color Yellow NormalTransparency Slightly turbid Normal

Reaction 6.0 NormalSpecific gravity 1.015 Normal

Sugar (-) Normal

Protein +2

Microscopic

WBC 10.3 Indicates infection

RBC 0-2 / HPF Normal

Epithelial cell few Normal

Mucus threads few Normal

Amorphous urates few Normal

Bacteria few Normal

B. Clinical ChemistryDate and time: April 16, 2013 5:01 am

Test System International Conventional Interpretation

Result Unit Reference Result Unit Reference

Sodium 147.40 mmol/l 135-148 147.40 meq/l 135-148 Hemoconcentration

Ptassium 4.49 mmol/l 3.5-5.30 4.49 meq/l 3.5-5.30 Normal

Clinical ChemistryApril 16, 2013

Test Result Normal values Interpretation

FBS 63.44 70-110 mg/dl Normal

Total cholesterol 225.08 Less than 200 mg/dl may indicate kidney problems

Triglycerides 83.5 36-165 mg/dl Normal

HDL 15.83 More than 5.5 mg/dl Normal

VLDL 16.7 0-40 mg/dl Normal

LDL 193.27 Less than 150 mg/dl may indicate kidney problems

Blood uric acid (F) 4.8 2.4-5.7 mg/dl Normal

Creatinine 1.4 0.50-1.7 mg/dl Normal

SGPT 15.1 0-40 u/l Normal

C. Hematology

Date and time: April 15,2013 5:01am

Test Result Unit Nomrmal values

Prothrombin time

Patient 19.1 secs 10-15

control 14.50 secs 11-16

Activity 75.92 % 80-100

INR 1.57 - 0.71-1.55

PTT

Patient 36.0 secs 24-39

Control 30.0 secs 24-39

D. Radiographic Report

Date: April 15, 2013

Follow up examination shows further clearing of the previously seen minimal PTB in the right upper lobe. Residual infiltrates are still seen. The heart is not enlarged. The hemidiaphragms are intact.

E. ECG Report

Impression: Within normal limits

F. Examination: Whole abdomen Ultrasound

Sonographic Report

The liver is increased. The visualized surfaces are smooth. The parenchyma shows inhomogenous echo pattern. No evident mass, calcification or any parenchymal lesion.

The gallbladder is within normal in size and echo pattern. The wall is not dilated with hyperehoic structure seen in the intraluminal measuring 8mm. The common bile duct and intrahepatic ducts are unremarkable.

The pancreas and spleen are normal in suze. The echo pattern is homogenous. No parenchymal lesion in these organs.

Both kidneys are normal in size. There is dilatation of the right pelvocaliectasis.

The urinary bladder wall is not thickened with smooth mucosal outline. No demonstratble mass lesion or lithiasis.

Impression:

Diffuse fatty liver changesCholethiasisPelvocaliectasis, rightPancreas, left kidney, urinary bladder and spleen are unremarkable

X. Patient And His Care Drugs

Generic/Brand name/Classification Date

Route of Administration,

Dosage,Frequency

Mechanism of Action

Client’s Response

Nursing Responsibilities

Ordered Taken/Given

Changed Discontinued

Generic Name:Amlodipine

Brand Name:Norvasc

Classification:Calcium Channel

Blockers

04/30/13

04/30/13

---- ---- OD PO 5mg/tab Inhibits transport of calcium into the myocardial and vascular smooth muscle cells, result in inhibition of excitation-contracting coupling and subsequent contraction.

Systematic vasodilation resulting in decreased blood pressure.

The client experienced

headache and dizziness

PRIOR: Monitor vital signs. Advise the client to change

position slowly to minimize orthostatic hypotension.

DURING: Amlodipine may take with

or without meal. Tell the patient that she/he

may experience light headedness or dizziness.

AFTER: Monitor vital signs. Advise the client to report

signs and symptoms of chest pain, shortness of breathing, dizziness and altered of vision immediately.



Dosage,Frequency

Mechanism of Action

Client’s Response


Ordered Taken/Given

Changed Discontinued

Generic Name:Cefuroxime

Brand Name:Zinacef

Classification:Cephalosporin 2nd

Generation

04/30/13

04/30/13

---- ---- TIV 1.5g:100mcg/ml

Bind to bacterial cell wall membrane causing cell death.

none

PRIOR: Take vital signs. Obtain history to

determine previous use and reactions to penicillins.

DURING: Monitor site frequently for

thrombophlebitis (pain, redness, swelling).

Observe patient for signs and symptoms of anaphylaxis (rash, pruritis, edema).

AFTER: Continuous monitoring of

vital signs. Monitor Input and Ouput.



Dosage,Frequency

Mechanism of Action

Client’s Response


Ordered Taken/ Changed Discontinued

Given

Generic Name:Ketorolac

Brand Name:Toradol

Classification:Nonsteroidal Anti-

inflammatory Agents

05/01/13

05/02/13

---- ---- TIV 30mg q X6̊ 6̊� 4 doses

Possesses Anti-inflammatory, analgesic and antipyretic effects.

Short term management for pain.

The patient feel

drowsiness.

PRIOR: Assess patient pain before

and 1 hour after treatment.

DURING: Monitor for possible

adverse reactions: drowsiness, dizziness, headache, edema and polyuria.

AFTER: Advise the patient to

report persistence or worsening of pain.

Diet

Type of diet Date started General description

Indications/purpose Specific foods taken

Clients response to the diet

Nursing responsibilities

Nothing Per Orem April 29, 20135:00pm up to April 30, 2013

3:00pm

Withhold oral foods and fluids from the patient

NPO is instructed to prevent aspiration usually for those patients who would undergo surgery.

none The client feels hungry and request food to the nurse, but the nurse refused it to do.

Prior:- assess the level of understanding of the patient.- explain the importance of following strictly NPO in terms that the client can understand and then evaluate.During:- strictly monitor clients behavior in following NPO.Post:- instruct the client to continue NPO as prescribed by the Physician.

DAT ( Diet As Tolerated )

May 1, 2013 up to discharge

It is a diet that allows the

patient to eat types/kinds of

foods as long as the client can

tolerate it.

It is instructed following a general liquid diet for better source of good nutrition.

- Lugaw- egg and rice - pinakbet and rice- monggo and rice- sinigang na bangus and rice

Relived hunger Prior:- assess the level of understanding of the patient.- explain that immediate shifting of foods from NPO to General Fluids to DAT without undergoing soft diet can result to constipation, that’s why we need to emphasize eating first soft foods before eating any solid foods.During:- strictly monitor clients behavior in following DAT diet.POST:- advise the client to take soft foods and avoid food rich in fats.

XI. Nursing Care Plan

Nursing Prioritization

DATE IDENTIFIED CUES PROBLEM/NURSING DIAGNOSIS

JUSTIFICATION

MAY 2, 2013 Subjective: “masakit ang tahi ko” as verbalized by the client

Objective:Pulse rate- 68 bpmHeart rate-27 cpm Blood pressure- 120/80 mmHgPain scale- 7 out of 10-facila grimace-guarding behavior-protective gestures

Acute Pain related to surgical procedure as manifested by expressive behaviour

-acute pain because of having a minor surgery we also saw a expressive behavior like facial grimace.

May 2, 2013 Subjective: “medyo mahapdi ang sugat ko at parang nangangati’’ as verbalized by the client

Objective:-disruption of skin surface-incision at the right inguinal-redness at the site of incision

Impaired Skin Integrity related to surgical incision

-we include this prioritization because the skin surface was already disrupted due to surgical incision

May 2, 2013 Subjective:‘’nahihirapan akong tumayo at kumilos’’ as verbalized by the client

Objective:-limited range of motion-postural instability-slowed movement

Impaired Physical Mobility related to surgical procedure

-we include this prioritization because the client tell us about her limited movements.

Nursing Care Plan

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUTION

SUBJECTIVE:‘’masakit ang tahi ko’’ as verbalized by the client

OBJECTIVE:PR-68 bpmRR-27 cpmBP-120/80 mmHgPain Scale- 7 out of 10

Observed evidenced of pain:-facial grimace-guarding behavior-protective gestures

Acute Pain related to surgical procedure as manifested by expressive behaviour

SHORT TERM:-After 1 hour of nursing intervention the client will be able to verbalize that the pain is lessen

-After 1 hour of nursing intervention the client will be able to follow prescribed pharmacological regimen

-after 1 hour of nursing intervention the client will be able to verbalize non-pharmacological methods that provide relief

LONG TERM:-after 3 to 4 hours of nursing intervention the client will be able to demonstrate use of relaxation skills and diversional activities

-obtain client’s assessment of pain including location,characteristic,onset,Duration, frequency,quality,Intensity,aggravating factors

-provide comfort measures

-instruct/encourage use of relaxation techniques such as focus breathing, music therapy

-encourage adequate periods

-to rule out worsening of underlying condition/development of complications

-to promote non-pharmacological management

-to distruct attention and reduce tension

-to prevent fatigue

SHOR TERM:-after 1 hour of nursing intervention the client was able to verbalized that the pain was lessen

-After 1 hour of nursing intervention the client was able to follow prescribed pharmacological regimen

-after 1 hour of nursing intervention the client was able to verbalized non-pharmaclogical methods that provide relief

LONG TERM:-after 3 to 4 hours of nursing intervention the client will be able to demonstrated use of relaxation skills and diversional activities


PLANNING INTERVENTION RATIONALE

EVALUATION

SUBJECTIVE:‘’medyo mahapdi ang sugat ko at parang nangangati’’ as verbalized by the client

OBJECTIVE:Pulse rate- 68 bpmHeart rate-27 cpm Blood pressure- 120/80 mmHg

-disruption of skin surface-incision at the right inguinal-redness at the site of incision

Impaired Skin Integrity related to surgical incision

SHORT TERM:-After 1 hour of nursing intervention the client will be able to verabalize feelings of increased self-esteem and ability To manage situation

-after 1 hour f nursing intervention the client will be able to participate in prevention measures and treatment program

LONG TERM:-After 3 to 4 hours of nursing intervention the client will be able to maintain optimal nutrition and physical well being

-inspect skin on a daily basis, describing wound/lesion characteristics and changes observed

-keep the area clean and dry, carefully dress wounds

-manage incontinence and stimulate circulation

-to monitor progress of healing

-to prevent infection

-to assist body’s natural process of repair

SHORT TERM:-after 1 hour of nursing intervention the client was able to verbalized feelings of increased self-steem and ability to manage situation

- after 1 hour of nursing intervention the client was able to participate in prevention measures and treatment program

LONG TERM:- After 3 to 4 hours of nursing intervention the client was able to maintain optimal nutrition and physical well being


PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:‘’nahihirapan akong tumayo at kumilos’’ as verbalized by the client

Objective:Pulse rate- 68 bpmHeart rate-27 cpm Blood pressure- 120/80 mmHg

-limited range of motion-postural instability-slowed movement

Impaired Physical Mobility related to surgical procedure

SHORT TERM:-after 1 hour of nursing intervention the client will be able to verbalize understanding of situation and individual treatment regimen and safety measures

-after 1 hour of nursing interventionThe client will be able to demonstrate techniques that in able resumption of activities

LONG TERM:-after 2 days of nursing intervention the client will be able to participate in ADL’s and desired activities

-after 2 days of nursing intervention

-istruct client in use of side rails

-encourage client participation in self care

-encourage adequate intake of fluids/ nutritious foods

-for position changes and prevent accident

-enhances self concept and sense of independence

-promote’s well being and maximizes energy production

SHORT TERM:- after 1 hour of nursing intervention the client was able to verbalized understanding of situation and individual treatment regimen and safety measures

- after 1 hour of nursing interventionThe client was able to demonstrated techniques that in able resumption of activities

LONG TERM:-after 2 days of nursing intervention the client will be able to participate in ADL’s and desired activities

-after 2 days of nursing intervention the client was able to maintained or

increased strength and function of affected body part

the client will be able to maintain’s or increase strength and

function of affected body part

XII. SURGICAL MANAGEMENT

BRIEF DESCRIPTION INDICATION/ PURPOSES CLIENT’S RESPONSE NURSING RESPONSIBILITIES

There is a stone in the tubing, in the

ureter, that runs from your kidney to

your bladder.

You have two kidneys, a left

and a right one. They are each about

the size of a fist. They lie deep in your

back on each side of your spine, in

front of the lowest rib on each side.

They make the urine which passes

down the ureter on each side to the

bladder just below your navel.

Stones from the kidney can pass down

the ureter causing pain, blood in the

urine, infection, or can block the

ureter, they do not allow the urine to

drain freely and this will cause

- In general, ureterolithotomy

today becomes necessary only

where ESWL or endoscopic

techniques fail. Usually, these

failures are concomitant with a

complication of previous

therapeutic interventions, in

particular endoscopic

manipulation. Urinary

extravasation, an impacted

ureteral basket, ureteral avulsion,

and an obstructing stone are the

typical scenarios. At the author’s

institution, incisional surgery was

The client was asleep for the

whole operationAfter:

Monitor the patient’s vital signs.

Observe for bleeding on the part

where the suture is.

Always tell to the caregiver of the

patient to keep an eye on the part

where the suture is and report to the

nurse station if there were signs of

severe bleeding.

pressure on the kidney. Often the

stones pass right through by

themselves.

In your case, however, the stone has

stuck in the ureter. It needs to be taken

out with an operation

required in only six of 3,123

patients subjected to a therapeutic

intervention to remove ureteric

stones in a 7-year period. Two

patients had suffered ureteric

avulsion, one patient had a basket

trapped around a stone, in two

patients stones could not be

reached endoscopically, and one

patient, pregnant in the fourth

week of gestation, required rapid

removal of a very large stone

impacted in the lumbar ureter.

Stones can of course also be

trapped above congenital or

acquired ureteric strictures.

Where these require surgical

correction, the stone is removed

at the time of reconstructive

surgery, but the underlying

pathology dictates the surgical

strategy and technique.

XIII. Discharge Planning

Medicationo Advise the client’s caregiver that Medications should be taken regularly as prescribed, on exact dosage, time, & frequencyo Report any side effects or adverse effect of the medication

Exercise/Environmento Tell the client’s caregiver that it is much better to provide the client with a well ventilated room.

Treatmentso Inform client’s caregiver to fully participate in continuous treatment.o Compliance to the medication.o Inform client about the proper cleaning and caring of the wound.

Health Teachingo Teach all about Ureterolithiasis; its signs and symptoms, and how to prevent it.

Out Patiento Advise the client’s caregiver to report any unusual effect of medication to the client.o Follow scheduled check-up by the Doctor

Dieto Drink only clean, mineral or distilled watero Properly prepared bottled milk.

Spiritualo Always believe, pray, trust and have faith to God.

XI. Conclusion

Within the span of 3 days of rendering care to our client baby A.V.A. We are able to identify potential problems of our client and all our Nursing Care Plan met its goals. With the help of health teachings and other interventions, A.V.A and her daughter were able to learn how to recognize signs and symptoms and other risk factors of the condition Mrs. A.V.A’s disease. They also learned how to do simple interventions for the client’s suture after ureterolithotomy. They had also recognized the importance of compliance to treatment regimen in order to manage the condition Mrs. A.V.A.

And at the end of this paper, we the Group 2 of BSN 3D were glad that we acquire the necessary knowledge and important nursing interventions on our chosen case, Ureterolithiasis. We are honored to do this study and are also hoping that this study will be used as one of a source for the future student nurses in their case studies.

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Case Study Group 2

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