BULACAN STATE UNIVERSITY COLLEGE OF NURSING S.Y.

2013-2014

A CASE STUDY OF 62 YEARS OLD FEMALE WITH UTEROLITHIASIS

SUBMITTED BY: GROUP 2 BSN 3-D LEADER: Lorenzo, Hannah Gail M. MEMBER: Dela Cruz, Mary Grace C.
Federis, Nerissa Joy E. Flores, Marjelene G. Junio, Ma. Jaecelyn S. Llano, Ma. Joanna Marie Lumba, Jeffrey C. Maluyo, Sarah Masangcay, Milcah Masangkay, Kriselle Montales, Michelle D. Pascual, Rotche M.

SUBMITTED TO: Maria Ongleo, RN, MSN CLINICAL INSTRUCTOR

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 patients 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 patients disease condition by determining causative factors and providing appr opriate intervention to improve patients condition and prevent possible complication of the disease. Specific Objectives: To formulate appropriate nursing intervention by prioritizing patients 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 clients 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 clients 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. Patients 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 patients 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 doesnt 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 didnt 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 doesnt have any illness at all.

?
LEGEND:
- male - female L.D Lung Disease V.A Vehicular Accident D.M Diabetes Mellitus C.A Cardiac Arrest H.I Head Injury A/W Alive and Well Art Arthritis Asth Asthma Ure - Ureterolithiasis -deceased -deceased
Mr. P.V. C.A.

?
Mrs. M.V. 83y/o H.I.

Mr. P.V. L.D.

Mr.R,V, ?

Mr. N.V. ?

Mr. E.V, V.A

Mrs. G.V. Arth.

Mrs. L.V. Asth.

Mrs. C.V. A/W

Mr. R.V. Art. D.M.

Mrs. A.V. Ure.

Mrs. N.V. A/W

IV. Gordons 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 She stated that she will always follow doctors order for her to regain her hospital last February. She stated that she dont have bad habits like smoking tone. and drinking alcohol. She stated that she always attend Medical Mission and always have her monthly checkup. She follows doctors 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. 2. NUTRITIONAL METABOLIC PATTERN

Prior to Hospitalization

During Hospitalization

The client stated that she prefer vegetables more than meats. She consumes The doctor orders her to have a D5LR 1L as preparation for her operation. 1000-1200 ml of water a day. She is wearing dentures. She weighs 43 kg and April 28,2013 April 29,2013 April 30,2013 her height is 153 cm. Her BMI is 18.5 which is underweight.
Breakfast 1 cup of Rice 2 pcs of sardines 250ml of water of Bangus 1 cup of Rice 250 mL of water 1 plate of Pancit 250 ml ofwater NPO

Lunch

Dinner

1 cup of rice NPO 1 serving of ampalaya 250 ml of water of Bangus 1 serving of NPO 1 cup of rice Sinigang na 250 ml of water baboy 1 cup of rice

250 ml of water

3. ELIMINATION PATTERN

Prior Hospitalization

During Hospitalization

According to the client the client defecates once a day and urinates 3 According to the client the client defecates once a day and urinates 3 times a day times a day with discomfort upon urination. without discomfort upon urination due to medication taken. Characteristic Color Stool Semi-solid Odor Frequency Discomfort Characteristic Yellow foul 1 time odor yellow no 4 times a day Urine Regular urination foul odor Perspiration: Often perspire due to hot weather. No discomfort Pain felt on the lower abdomen Stool Semi-solid Color Yellow Odor Frequency Discomfort No discomfort No discomfort foul 1 time odor yellow no 4 times a day Urine Regular urination foul odor Perspiration: Often perspire due to hot weather.

4.

ACTIVITY/EXERCISE PATTERN Prior to Hospitalization Requires assistance from her son. During Hospitalization Requires assistance from her son. Feeding =2 Bathing =2 toileting = 2 dressing = 2 grooming = 2 bed mobility = 2

Feeding =3 toileting =3 grooming =3 Bathing = 3 dressing =3 bed mobility =3 LEGEND: 0- Full Self Care 1- requires use of equipment or device 2- requires assistance or supervision from other person 3- requires assistance or supervision from other person/ device 4 dependent and does not participate

LEGEND: 0- Full Self Care 1- requires use of equipment or device 2- requires assistance or supervision from other person 3- requires assistance or supervision from other person/ device 4 dependent and does not participate

5. SLEEP/REST PATTERN

Prior to Hospitalization

During Hospitalization

The client stated that she has an adequate sleep, she always sleep 9 She has an inadequate sleep. She sleeps at 10pm and woke up at 12pm and go hours a day from 9pm to 6am. back to sleep from 10am-1pm.

6. COGNITIVE PERCEPTUAL PATTERN Prior to Hospitalization During Hospitalization

The clients vision is 450.400. She is wearing eyeglasses. Cooperative and The clients vision is 450/400. She is wearing eyeglasses. Cooperative and coherent. 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 the most painful.

7. SELF PERCEPTION PATTERN Prior to Hospitalization During Hospitalization

She stated that she has thin body because of stress. Believed that she needs the She stated that she has thin body because of stress. Believed that she need the operation for her to be well and didnt feel any fear. operation for her to be well and didnt feel any fear.

8. ROLE RELATIONSHIP PATTERN Prior to Hospitalization During Hospitalization

She stated that she is separated with her husband for 12 years and is now She is always visited by her children. 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.

9. COPING-STRESS TOLERANCE PATTER Prior to Hospitalization During Hospitalization

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

10. VALUE-BELIEF PATTERN Prior to Hospitalization 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 Godseeking person, she stated that when she felt hopeless she just pray and believes that everything will be alright. During Hospitalization 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 Godseeking person, she stated that when she felt hopeless she just pray and believes that everything will be alright. And she believes in God thats why she doesnt feel any fear regarding her operation.

V. Growth and Development

Theories Stages Justification

According to our patient, she engages sexual activity with her husband only. Since they were Genital Stage: post puberty Freuds Stage Of Energy is directed toward full sexual maturity separated, she dont do that to other. Our patient is fully independent. She can make decision Psychosexual Development and function and development of skill needed to on her own. cope with the environment. The Formal Operational Stage (20 to Adulthood) During this time, people develop the ability to think about abstract concepts. Skills such as logical thought, deductive reasoning, and systematic planning also emerge during this stage.

Jean Piagets Stage Of Cognitive Development

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

Our patient passes this stage. She was very active in their community. She used to help in Erik Ericksons Stage Of Adulthood ( 25 to 65 years old) Generativity vs, stagnation their Barangay Health. She was very friendly and easy to mingle with. Psychososial Development Those 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. Kohlbergs Stage of Moral Level 3: Post Conventional Morality Development Stage 5 Social Contract and Individual Rights At 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

Non-Modifiable

Due to low water intake and metabolic disturbances

Decreased fluid volume

Increase urine concentration

Formation of sediments in the urinary tract

Formation of stone in the kidney that travel to the ureter

Scarring of the smooth muscles

Inflammatory process

Irritation and injury to the urinary tract

Release of prostaglandin Accumulation of urine in the ureter

Irritation of the nerves

Hydroureter Pain (pelvic and area of the abdomen) Decrease urine flow

Anxiety

Increase respiration

Diaphoresis

VIII. Physical Assessment VITAL SIGNS: PR = 68 bpm RR = 28 cpm

BP = 120/80 mmHg Temp. = 3 .4 C

PARTS TO BE ASSESSED

TECHNIQUE

NORMAL FINDINGS General appearance

ACTUAL FINDINGS

REMARKS

1. Body built in relation to clients age, lifestyle & health 2. Clients posture & gait, standing, sitting & walking 3. Clients overall hygiene & grooming 4. Body & breath odor 5. Signs of distress in posture or facial expression 6. Obvious signs of health or illness

Inspection

Proportionate and varies with lifestyle

He has a proportionate (endomorph) body built which is appropriate with her lifestyle n/a

Normal

Inspection

Relax, erect posture, coordinated body movements Neat No body odor or minor body odor relative No distress noted

n/a

Inspection

He is neat and clean.

Normal

Inspection

no body odor

normal

Inspection

No distress noted

Normal

Inspection

Healthy appearance

Sign of Illness

Deviation from normal

PARTS TO BE ASSESSED 7. Clients attitude . Clients affect/mood; appropriateness of the clients response 9. Quantity of speech, quality & organization 10. Relevance & organization of thoughts

TECHNIQUE Inspection

NORMAL FINDINGS Cooperative

ACTUAL FINDINGS Cooperative

REMARKS Normal

Inspection

Appropriate to the situation

Appropriate to the situation

Normal

Inspection

Understandable, moderate pace; exhibits thought association Logical sequence; makes sense; has sense of reality. SKIN

Understandable, moderate pace; exhibits thought association She has a sense of reality

Normal

Inspection

Normal

1. Skin moisture 2. Skin Texture 3. Skin turgor

Inspection Inspection Inspection and palpation

moisture in skin fold and axillae smooth Springs back Hair and Nails

There is moisture in skin fold and axillae smooth moves back easily

Normal Normal Normal

1. Fingernails plate shape to determine its curvature & angle 2. Fingernail & toenail bed

Inspection

Convex curvature, angle of nail plate about 160 degrees. Highly vascular and pink in light skinned clients; dark-

Convex and has less than 180 degree Pinkish in color

Normal

Inspection

Normal

PARTS TO BE ASSESSED color

TECHNIQUE

NORMAL FINDINGS skinned clients may have brown or black pigmentation in longitudinal streaks.

ACTUAL FINDINGS

REMARKS

3. Tissues surroundings nails 4. Fingernail & toenail texture 5. Blanch test of capillary refill

Inspection Palpation

Intact epidermis. Smooth texture. Prompt return of pink or usual color (generally less than 4 seconds.)

She has an intact epidermis with no hangnails Smooth nail texture The color return to the original color in 2 seconds

Normal Normal

Palpation

Normal

1. Evenness of growth over the scalp 2. Hair thickness & thinness 3. Presence of infections or infestations 4. Texture & oiliness over the scalp

Inspection Palpation Inspection

Evenly distributed hair. Thick/thin hair. Not present.

Her hair is well distributed She has a thick white hair Not present.

Normal Normal Normal

Palpation

Silky, resilient hair. SKULL

Silky, resilient hair.

Normal

1. Size, shape & symmetry

Palpation

Rounded (normocephalic and symmetrical, with frontal,

Head is symmetrically

Normal

parietal, and occipital prominences); smooth skull contour. 2. Nodules or masses & depressions Palpation Smooth, uniform consistency; absence of nodules or masses. FACE Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds. Symmetrical facial movements. EYEBROWS & EYELASHES Hair evenly distributed; skin intact. Eyebrows asymmetrically aligned equal movement. Eyelashes curl slightly outward.

rounded.

No mass or nodules noted;

Normal

1. Facial features

Inspection

Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds. Facial movements are symmetrical

Normal

2. Symmetry of the facial movements

Inspection

Normal

1. Evenness of distribution & direction of curl

Inspection

Eyebrows and eyelashes are both evenly distributed, symmetrical aligned. Eyelashes curl slightly outward.

Normal

EYELIDS 1. Surface characteristics & Inspection and Palpation Skin intact, no discharge, no discoloration. Lids close Eyelids skin are intact, no noted discharge, and no noted Normal

ability to blink

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. CONJUNCTIVA

discoloration. Lids close symmetrically. Client exhibited 18 involuntary blinks per minute.

1. Bulbar conjunctivas color, texture & presence of lesions 2. Palpebral conjunctivas color, texture & presence of lesions

Inspection

Transparent; capillaries sometimes evident.

Transparent, capillaries evident, no discharge was noted. Shiny, smooth and red in color.

Normal

Inspection

Shiny, smooth, pink or red in color. SCLERA Sclera appears white (yellowish in dark- skinned clients). CORNEA Transparent, shiny and smooth; details of the iris are visible. In older people, a thin grayish white ring around the margin, called

Normal

1. Color & clarity

Inspection

Sclera appears white

Normal

1.Clarity & color

Inspection

Details of iris are visible. Transparent, shiny and smooth. But she has visual of 450/400

Deviation from Normal

arcussenilis, may be evident. IRIS 1. Shape & color Inspection Flat and round PUPILS 1. Color, shape & symmetry of size Black in color; equal in size; normally 3-7 mm in diameter; round, smooth border. Flat and round and uniform in color. Normal

Inspection

Firm and equal pupils

Normal

PARTS TO BE ASSESSED

TECHNIQUE

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

ACTUAL FINDINGS

REMARKS

1. Color & symmetry of size &position

Inspection

Color is same with facial skin, symmetrical with each other, auricle aligned with outer canthus of eye, about 10 cm vertical Both pinna recoils after being folded. Mobile, firm and not tender.

Normal

2. Texture & elasticity & areas of tenderness

Palpation

Mobile, firm and not tender, pinna recoils after it is folded.

Normal

EXTERNAL EAR CANAL Distal third contains hair follicles and glands. Dry cerumen in various shades of brown HEARING ACUITY TEST 1. Clients response to normal voice tones Inspection Normal voice tones audible NOSE 1. Shape, size or color & flaring or discharge from the nares Symmetric and straight Inspection No discharge or flaring Uniform color Mucosa pink Inspection Clear, watery discharge No lesions. Inspection Nasal septum intact and in midline, intact Air moves freely as the client breathes through the nares No discharge and/or flaring noted. Symmetrical on both sides. Also uniform in color. Client responds to normal voice tones Normal No noted pus, blood and odor. Minimal cerumen noted. Distal third contains hair follicles.

1. Cerumen, skin lesions, pus & blood

Inspection

Normal

Normal

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

Mucosa are intact and pinkish; minimal moist noted inside; no swelling or nodules found. Nasal septum is intact and in midline Air moves freely as the client breathes through each nares

Normal

3. Position of nasal septum

Normal

4. Test patency of both nasal septum

Inspection

Normal

5. Tenderness, masses displacement of bone cartilage

& &

Palpation

Not tender; no lesions

No tenderness, no lesions noted. No displacement of bone & cartilage.

Normal

LIPS TEETH Uniform pink color 1. Inspect for color, number & 1. Symmetry of contour color condition & presence of & texture dentures adultsmooth teeth texture Soft,32 moist, Inspection and Palpation Inspection Smooth, white, shiny tooth Symmetry of contour enamel Ability to purse lips GUMS Pink gums (bluish or dark patches in dark-skinned clients) Moist, firm texture to gums Uniform pink color Soft, moist, smooth texture Still has denture. Symmetry of contour Has the ability to purse lips Pink gums (bluish or dark patches in dark-skinned clients) Moist, firm texture to gums Normal Deviation from Normal

1. Color & condition

Inspection

Normal

TONGUE/FLOOR OF THE MOUTH 1. Color & texture of the mouth floor & frenulum Inspection and Palpation Smooth tongue base with prominent veins 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) Smooth tongue base with prominent veins 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) Normal

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

Inspection and Palpation

Normal

Moves freely, no tenderness

Moves freely, no tenderness

ABDOMEN Unblemished skin, uniform in color, silver white striae (stretch marks) or surgical scars. Flat, rounded (convex) or scaphoid(concave) Audible bowel sounds

1. Skin integrity

Inspection

Uniform in color.

Normal

Normal Convex in shape.

2. Abdominal contour

Inspection

3. Bowel Sounds

Auscultation

Hyperactive bowel sounds

Normal

IX. Laboratory / Diagnostic Test

A. URINALYSIS
Date: April 16, 2013 TEST Macroscopic Color Transparency Reaction Specific gravity Yellow Slightly turbid 6.0 1.015 Normal Normal Normal Normal RESULT Interpretation

Sugar Protein Microscopic WBC RBC Epithelial cell Mucus threads Amorphous urates Bacteria

(-) +2 10.3 0-2 / HPF few few few few

Normal

Indicates infection Normal Normal Normal Normal Normal

B. Clinical Chemistry Date and time: April 16, 2013 5:01 am Test Result Sodium Ptassium 147.40 4.49

System International Unit mmol/l mmol/l Reference 135-148 3.5-5.30 Result 147.40 4.49

Conventional Unit meq/l meq/l Reference 135-148 3.5-5.30

Interpretation

Hemoconcentration Normal

Clinical Chemistry April 16, 2013 Test FBS Total cholesterol

Result 63.44 225.08

Normal values 70-110 mg/dl Less than 200 mg/dl

Interpretation Normal may indicate kidney problems

Triglycerides HDL VLDL LDL Blood uric acid (F) Creatinine SGPT C. Hematology Date and time: April 15,2013 5:01am Test Prothrombin time Patient control Activity INR PTT Patient Control 36.0 30.0 19.1 14.50 75.92 1.57 Result

83.5 15.83 16.7 193.27 4.8 1.4 15.1

36-165 mg/dl More than 5.5 mg/dl 0-40 mg/dl Less than 150 mg/dl 2.4-5.7 mg/dl 0.50-1.7 mg/dl 0-40 u/l

Normal Normal Normal may indicate kidney problems Normal Normal Normal

Unit secs secs % secs secs

Nomrmal values 10-15 11-16 80-100 0.71-1.55 24-39 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 changes Cholethiasis Pelvocaliectasis, right Pancreas, left kidney, urinary bladder and spleen are unremarkable

X. Patient And His Care Drugs Generic/Brand name/Classification Ordered Taken/ Given

Date Changed

Route of Administration, Dosage, Discontinued Frequency

Mechanism of Action

Clients Response

Nursing Responsibilities

Generic Name: Amlodipine Brand Name: Norvasc Classification: Calcium Channel Blockers

04/30/1 3

04/30/1 3

----

----

OD PO 5mg/tab Inhibits The client transport of experienced calcium into the headache myocardial and and dizziness vascular smooth DURING: muscle cells, Amlodipine may take with result in or without meal. inhibition of Tell the patient that she/he excitationmay experience light contracting headedness or dizziness. coupling and subsequent AFTER: contraction. Monitor vital signs. Systematic Advise the client to report vasodilation signs and symptoms of resulting in chest pain, shortness of decreased breathing, dizziness and blood pressure. altered of vision immediately.

PRIOR: Monitor vital signs. Advise the client to change position slowly to minimize orthostatic hypotension.

Generic/Brand name/Classification Ordered Taken/ Given

Date Changed

Route of Administration, Dosage, Discontinued Frequency

Mechanism of Action

Clients Response

Nursing Responsibilities

Generic Name: Cefuroxime Brand Name: Zinacef Classification: Cephalosporin 2nd Generation

04/30/1 3

04/30/1 3

----

----

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.

Generic/Brand name/Classification Ordered Taken/ Given

Date Changed
Discontinued

Route of Administration, Dosage, Frequency

Mechanism of Action

Clients Response

Nursing Responsibilities

Generic Name: Ketorolac Brand Name: Toradol Classification: Nonsteroidal Antiinflammatory Agents

05/01/1 3

05/02/1 3

----

---doses

Possesses Antiinflammatory, 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 report persistence worsening of pain.

to or

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, 2013 5:00pm 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. 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, thats 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.

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

XI. Nursing Care Plan Nursing Prioritization DATE IDENTIFIED

MAY 2, 2013

CUES
Subjective: masakit ang tahi ko as verbalized by the client Objective: Pulse rate- 68 bpm Heart rate-27 cpm Blood pressure- 120/80 mmHg Pain scale- 7 out of 10 -facila grimace -guarding behavior -protective gestures

PROBLEM/NURSING DIAGNOSIS
Acute Pain related to surgical procedure as manifested by expressive behaviour

JUSTIFICATION
-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

Impaired Physical Mobility related to surgical procedure

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

-slowed movement

Nursing Care Plan ASSESSMENT NURSING DIAGNOSIS Acute Pain related to surgical procedure as manifested by expressive behaviour PLANNING
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 nonpharmacological methods that provide relief LONG TERM: -after 3 to 4 hours of nursing intervention

INTERVENTION -obtain clients assessment of pain including location,characteristic,ons et, Duration, frequency,quality, Intensity,aggravating factors -provide comfort measures

RATIONALE

EVALUTION

SUBJECTIVE: masakit ang tahi ko as verbalized by the client OBJECTIVE: PR-68 bpm RR-27 cpm BP-120/80 mmHg Pain Scale- 7 out of 10 Observed evidenced of pain: -facial grimace -guarding behavior -protective gestures

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

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 nonpharmaclogical methods that provide relief

-to promote nonpharmacological management -to distruct attention and reduce tension

-instruct/encourage use of -to prevent fatigue relaxation techniques such as focus breathing, music therapy -encourage adequate periods

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

the client will be able to demonstrate use of relaxation skills and diversional activities

ASSESSMENT

NURSING DIAGNOSIS Impaired Skin Integrity related to surgical incision

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: medyo mahapdi ang sugat ko at parang nangangati as verbalized by the client OBJECTIVE: Pulse rate- 68 bpm Heart rate-27 cpm Blood pressure120/80 mmHg -disruption of skin surface -incision at the right inguinal -redness at the site of 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

-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

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

-to prevent infection

-to assist bodys natural process of repair

client will be able to maintain optimal nutrition and physical well being

ASSESSMENT

NURSING DIAGNOSIS Impaired Physical Mobility related to surgical procedure

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE: nahihirapan akong tumayo at kumilos as verbalized by the client Objective: Pulse rate- 68 bpm Heart rate-27 cpm Blood pressure120/80 mmHg -limited range of motion -postural instability -slowed movement

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 intervention The client will be able to demonstrate techniques that in able resumption of activities LONG TERM: -after 2 days of nursing intervention

-istruct client in use of side -for position changes and rails prevent accident -encourage client participation in self care -encourage adequate intake of fluids/ nutritious foods -enhances self concept and sense of independence -promotes 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 intervention The 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 ADLs 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 participate in ADLs and desired activities -after 2 days of nursing intervention the client will be able to maintains or increase strength and function of affected body part XII. SURGICAL MANAGEMENT BRIEF DESCRIPTION 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. INDICATION/ PURPOSES - 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 The client was asleep for the whole operation Monitor the patients 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 After: CLIENTS RESPONSE NURSING RESPONSIBILITIES

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 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

basket, ureteral avulsion, and an obstructing stone are the typical scenarios. At the authors institution, incisional surgery was 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

nurse station if there were signs of severe bleeding.

reconstructive surgery, but the underlying pathology dictates the surgical strategy and technique. XIII. Discharge Planning Medication o Advise the clients caregiver that Medications should be taken regularly as prescribed, on exact dosage, time, & frequency o Report any side effects or adverse effect of the medication Exercise/Environment o Tell the clients caregiver that it is much better to provide the client with a well ventilated room. Treatments o Inform clients 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 Teaching o Teach all about Ureterolithiasis; its signs and symptoms, and how to prevent it. Out Patient o Advise the clients caregiver to report any unusual effect of medication to the client. o Follow scheduled check-up by the Doctor Diet o Drink only clean, mineral or distilled water o Properly prepared bottled milk. Spiritual o 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.As disease. They also learned how to do simple interventions for the clients 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.