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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.