Medical-Surgical Nursing 1

A Case Presentation on Nephrolithiasis

I. Patients Profile
Name: Age: Sex: Address: Religion: Occupation: Attending Physician: Date of admission: Date of discharge: Mrs. R.D 57 years old Female 36 Luna Street, Lapaz, Iloilo City Roman Catholic Housewife Dr. F.M December 12, 2012 still on admission during data gathering.

Chief Complaint: Diagnosis:

Right Flank Pain Nephrolithiasis with moderate hydronephrosis and hydroureter secondary to obstructing proximal ureterolithiasis, right. Human Albumin Transfussion57cc 25% CVP Insertion

Special procedures:

Operative Procedure:

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 Admission
o o o o T- 39.4 C P- 122 bpm R- 22 bpm BP- 140/80 mmhg

TPR range during hospital stay.

o T- 36 C to 39.4 C o P-81 bpm to 122 bpm o R- 19 bpm to 33 bpm o 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
December 12, 2012
Hematology Hemoglobin Hematocrit RBC Count WBC Count Differential Count Neutrophil Segmenter Stab Lymphocyte Platelet Count Result 103g/L 0.34 vol. fr. 5.18 x 10/L 19.53 x 10/L 93% 85% 8% 6% 72.0 x10/L Normal Values M: 130-180 g/L F: 120-160 g/L M: 0.40-0.54 vol. fr. F: 0.37-0.47 vol. fr. M: 4.6-6.2 x10/L F: 4.2-5.4 x10/L 4.5 -11.0 x 10/L

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

150-450 x 10/L

December 12, 2012 Urinalysis Color Results Pale straw Normal Values Light yellow -amber

Transparency Reaction
Specific Gravity Microscopic Findings Puss cells RBC Chemical Tests Sugar Albumin

Hazy Acidic
1.030 50-60 2-4 Negative Trace

Clear Acidic
1.005-1.035 None None Negative negative

December 12, 2012 ABG pH paCO2 pO2 HCO3 O2 saturation Results 7.41 28.8 mmhg 73 mmhg 18.8 mmol/L 95.7% Normal Values 7.35-7.45 35-45 mmhg 80-100mmhg 22-26 mmol/L 95-100%

December 12, 2012

Chest PA Impression :

Atherosclerosis; aorta Subsegmental atelectasis left lung

Decemberv13, 2012

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

December 13, 2012 Results FBS (Fasting Blood Sugar) 9.55 mmol/L Normal Values 4.1-5.9 mmol/L

Uric Acid

497.54 umol/L

155-357 umol/L.

December 14,2012 Result HbA1C 7.5% Normal Value 4.8-6.0%

December 14, 2012 Miscellaneous Report Prothrombin Time % Activity: 80% Patient: 14.8 seconds INR: 1.15 Normal Values 70-10% 11.6-16.0 seconds

December 16, 2012

Blood Chemistry Albumin BUN Creatinine Sodium Potassium

Results 22.55 g/L 13.14 mmol/L 155.59 umol/L 140.28 mmol/L 3.39 mmol/L

Normal Values 34-50g/L 2.5- 6.40 mmol/L 53-88umol/L 136-146 mmol/L 3.5- 5.1 mmol/L

December 16, 2012 ABG pH paCO2 pO2 HCO3 O2 saturation Results 7.38 31 mmhg 80 mmhg 18.3 mmol/L 95% Normal Values 7.35-7.45 35-45 mmhg 80-100mmhg 22-26 mmol/L 95-100%

FULLY COMPENSATED METABOLIC ACIDOCIS WITH ADEQUATE OXYGENATION

Drug Study

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

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

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

Nephrolithiasis

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 Makes urine turbidity cloudy

Becomes nidus for bacteria

Causes spasm Decreased urine output

Injures the wall of the ureter

UTI Painful urination Blood combines with urine/hematuria

Increased WBC count

Decreased hgb count

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.