Vicente Sotto Memorial Medical Center B. Rodriguez St.

, Cebu City

Nursing Service Division Training Office

A CASE REPORT ON PATIENT M.A., 43 YEARS OLD, DIAGNOSED WITH URETEROLITHIASIS PROXIMAL THIRD, RIGHT S/P LAPAROSCOPIC URETEROLITHIASIS UTILIZING VIRGINIA HENDERSONS HUMANE HOLISTIC CARE THEORY

Submitted by: Chyzyz Y. Semblante

Ward VI: Female, Pediatric Surgical Ward

April 15, 2011 July 15, 2011

CHAPTER I INTRODUCTION M.A., 43 years old, female, married, residing in Buaya, Lapu-Lapu City, Cebu, was admitted for the first time at Vicente Sotto Memorial Medical Center (VSMMC) last May 1, 2011 for the complaints of sudden sharp pain in the costovertebral area radiating to the hypogastric region, right with a pain scale of 7/10. Patient arrived to the hospital conscious, responsive, coherent and with ease in respiration via private vehicle accompanied by her husband and personnel from Lapu-Lapu City Hall. She was admitted under the services of Dr. Victor Cabrera, Jr. under the Department of Urology and Dr. Aponesto under the Department of General Surgery with a hospital number of 240377 and a case number of 128757. Rationale Establishing good and trustful nurse-client relationship aids in data collection pertaining to the clients perception, practices, and management of health. More intensive data can be gathered the moment the researchers have earned the clients trust and support thus opening obtaining clear and precise data for a comprehensive case study. Factors such as coherence, responsiveness, and patient cooperation contributed much in acquiring health history. The case was selected for the reason that primary data can be obtained in a manner by which the client has no difficulty in recalling past events and shows interest in offering her time to answer questions that supply information in areas that need to be assessed. Incidence of kidney stones, or urolithiasis, is on the rise worldwide, with highest growth projected in Asia and other geographical regions with hot, dry climates. Adding to this trend is a global rise in the incidence of diseases linked to an elevated risk of urolithiasis such as obesity, hypertension and diabetes. Furthermore the lifestyle today has greatly increased the risk of developing ureterolithiasis but due to the lack of sufficient knowledge of the disease, actions towards lifestyle modification which is one of the single most effective method of prevention and cure of ureterolithiasis are compromised. It is also one of the poor habits of Filipinos to seek medical consult for any disease when they are unable to bear the pain and are closer to severe complications already. The mere existence of these data may not mean anything to most of the Filipinos nowadays that are at a greater risk of acquiring ureterolithiasis but the researcher who have chosen to conduct this case study know better than to neglect it. The researcher, has conducted this study to increase our knowledge in ureterolithiasis especially on how vast it can affect other organ functioning. Furthermore, the researcher would like to analyze the active problems of patient M.A. which may be an underlying result of her ureterolithiaisis. The researcher chose this case because of its wide recognition and its increased number of

occurrence in the area. Likewise, pursuing this study would help the patient in terms of managing her disease; future researchers and other members of the health care team to consider the efficiency and effectivity of the intervention done in order to manage the disease. In the process of learning and practicing, all the members of the health care team seek to inculcate the right attitude within themselves as they care for the patient. Overview of the Disease Urinary Calculi Urinary calculi (urolithiasis) are calcifications in the urinary system. Commonly called stones, calculi form primarily in the kidney (nephrolithiasis), but they can form in or migrate to the lower urinary system. Ureterolithiasis can be used to describe the condition of having stones in the ureter. Types of Calculi Calcium. Calcium is the most common substance and is found in up to 90% of stones. Calcium stones are usually composed of calcium phosphate or calcium oxalate. They may range from very small particles, often called sand or gravel, to giant staghorn calculi, which may fill the entire renal pelvis and extend up into the calyces. Oxalate. The second most frequent stone is oxalate, which is relatively insoluble in urine. Its solubility is affected only slightly by changes in the urinary pH. The mechanism of oxalate availability is unclear but may be closely related to diet. The disease is most common in areas where cereals are a major dietary component and least common in dairy farming regions. Struvite. Struvite stones, also called triple phosphate, are composed of carbonate apatite and magnesium ammonium phosphate. Their cause is certain bacteria, usually Proteus, which contain enzyme urease. This enzyme splits urea into two ammonia molecules, which increases urine pH. Uric Acid. Uric acid stones are caused by increased urate excretion, fluid depletion, and a low urinary pH. Hyperuricuria is the result of either increased uric acid production or the administration of uricosuric agents. Cystine. Cystinuria is the result of a congenital metabolic error inherited as an autosomal recessive disorder. Cystine stones typically appearf during childhood and adolescence; development in adults is very rare. Xanthine. Xanthine stones occur as a result of a rare hereditary condition in which there is a xanthine oxidase deficiency. This crystal precipitates readily in urine. Etiology

The two primary causative factors are (1) urinary stasis and (2) supersaturation of urine with poorly soluble crystalloids. Infection, foreign bodies, failure to empty the bladder completely, metabolic disorders, and obstruction in the urinary tract contribute to the formation of calculi as well. Inhibitor substances, such as citrate and magnesium, appear to keep particles from aggregating and forming crystals; a lack of inhibitors increases risk of stone development. Not only does the deficiency of inhibitors predispose the client to calculi, but there are many anti-inhibitors in the urine, such as aluminum, iron, and silicone. Certain medications may induce calculus formation, such as acetazolamide, absorbable alkalis (e.g., calcium carbonate and sodium bicarbonate), and aluminum hydroxide. Massive doses of Vitamin C increases urinary oxalate levels. Risk Factors - Immobility and a sedentary lifestyle, which increases stasis - Dehydration, which leads to supersaturation - Metabolic disturbances that result in an increase in calcium or other ions in the urine - Previous history of urinary calculi - Living in stone belt areas - High mineral content in drinking water - A diet high in purines, oxalates, calcium supplements, animal proteins - UTIs - Prolonged indwelling catheterization - Neurogenic bladder - History of female genital mutilation Clinical Manifestations Clinical features vary with size, location and etiology of calculi. - Pain: sharp, severe, sudden onset caused by movement of the calculus and consequent irritation. Depending on the site of the stone, this pain may be either renal or ureteral colic. Renal colic originates deep in the lumbar region and radiates around the site and down toward the testicle in male and the bladder in female. Ureteral colic radiates toward the genitalia and thigh. - Nausea and vomiting - Grunting respirations, elevated blood pressure and pulse - Diaphoresis and anxiety - Fever and chills - Hematuria: gross or microscopic - Urinary frequency, hesitancy and dysuria - Abdominal distention - Pyuria - Oliguria and anuria

Diagnosis The diagnosis of bladder stone includes urine analysis, ultrasound, x rays or cystoscopy (inserting a small thin camera into the urethra and viewing the bladder). In the past a study called the intravenous pyelogram was frequently used to assess the presence of kidney stones. This test involves injecting a dye which is passed slowly into the urinary system. X ray images are then obtained every few minutes to determine if there is any obstruction to the dye as it is excreted into the bladder. Today, Intravenous Pyelogram has been replaced at most rural health centers by Ct scans. CT scans are more sensitive and can identify very small stones not seen by other tests. Medical Management Conservative or medical management is appropriate if there is no obstruction, if the pain can be managed, if the client can be hydrated with oral fluids, and if the stone is less than 5mm. Increase fluids. Increasing fluid intake facilitates passage of small stones and prevents the development of new ones. Encourage clients to increase fluids to 3 to 4 L daily, unless contraindicated, to ensure urine output of 2.5 to 3 L daily. Reduce pain. The client usually requires treatment with opioids and antispasmodic agents. Opioids such as morphine sulfate are given intravenously or intramuscularly to control moderate to severe pain. Nonsteroidal anti-inflammatory drugs may also be effective. Antispasmodic agents, such as oxybutinin chloride (Ditropan), are very effective for relieving and controlling colic pain associated with spasm of the ureter. Prevent stone recurrence. Diet modifications and medications may be required to prevent further calculus formation in clients who return with repeated stones.

Surgical Management About 20% of stones require additional treatment with shock wave lithotripsy or endourologic or surgical procedures. Open surgery is used only for small percentage of clients who cannot be successfully treated with lithotripsy or endourologic procedures. Endourologic Procedures Depending on the position of the calculus, cystoscopy may be done. Small stones may be removed transurethrally with a cystoscope, ureteroscope, or ureterorenoscope. Additionally, 1 or 2 ureteral catheters or stents may be inserted past the stone. At times, a continuous chemical irrigation may be used to

dissolve uric acid, struvite, and cystine stones. Larger stones may be crushed with an instrument called a lithotrite (stone crusher) to facilitate removal. Lithotripsy Laser Lithotripsy: Lasers are used together with a uereroscope to remove or loosen impacted stones. Extracorporeal Shock Wave Lithotripsy: ESWL is the use of sound waves applied externally to break up stones in the kidney or uereter. The client may be strapped to a frame in a water bath or secured on a table, depending on the type of lithotripsy equipment used. The client is offered conscious sedation or general anesthesia. The procedure lasts 30-50 minutes with administration of 500 to 1500 shock waves. Percutaneous Lithotripsy: Involves the insertion of a guide percutaneously (throught the skin) under fluoroscopy near the area of the stone. An ultrasonic wave is aimed at the stone to break it into fragments. Open Surgical Procedures Ureterolithotomy: is the surgical removal of a stone from the ureter through a flank incision for higher stones or an abdominal incision for lower ones. A Penrose drain and ureteral catheter are usually placed postoperatively for healing and drainage of urine. Cystolithotomy: removal of bladder calculi through a suprapubic incision, is used only when stones cannot be crushed or removed transurethrally. Pyelolithotomy: a stone is removed from the renal pelvis. Nephrolithotomy: a stone is removed from the renal calyx.

CHAPTER II STATEMENT OF OBJECTIVES General Objectives This study aims to utilize Virginia Hendersons Humane Holistic Care Theory in the care of patient M.A. diagnosed with ureterolithiasis, right to evaluate efficacy and effectiveness of nursing interventions rendered to patient and to share knowledge to the patient regarding the promotion, prevention and treatment of her disease. Specific Objectives This study aims to specifically: - Share information regarding ureterolithiasis its etiology, risk factors, clinical manifestations, management and prevention - Assess patients history using Gordons Functional Health Patterns to identify signs and symptoms of the disease manifested by patient and the effects of her condition on her activities of daily living - Review the anatomy and physiology of the involved organs - Identify actual and risk problems manifested by the patient and implement nursing interventions under the 3 different roles of a nurse (substitutive, complementary, and supplementary) using Virginia Hendersons Humane Holistic Care Theory - Determine significant highlights of the patients status in her admission in the Ward - Impart health teachings regarding the patients medications and how to prevent recurrence of her condition

CHAPTER III PATIENTS PROFILE Client in Context M.A., 43 years old, female, married, residing in Buaya, Lapu-Lapu City, Cebu, was admitted for the first time at Vicente Sotto Memorial Medical Center (VSMMC) last May 1, 2011 for the complaints of sudden sharp pain in the costovertebral area radiating to the hypogastric region, right with a pain scale of 7/10. Patient arrived to the hospital conscious, responsive, coherent and with ease in respiration via private vehicle accompanied by her husband and personnel from Lapu-Lapu City Hall. She was admitted under the services of Dr. Victor Cabrera, Jr. under the Department of Urology and Dr. Aponesto under the Department of General Surgery with a hospital number of 240377 and a case number of 128757. History of Present Illness: Six months PTA, patient noted that she had an iced tea colored urine and had an onset of sudden pain in the costovertebral area radiating to the hypogastric region, right with a pain scale of 5/10 relieved by limitation of movements. No other symptoms associated. Patient went to Mactan Doctors Hospital Out-patient Department for consult under the service of Dr. Rey Pino. Interventions done were ultrasound of the KUB, diet medication: limit intake of calcium, acidic and oily foods and some unrecalled medications. According to patient, ultrasound result showed that she had inflamed kidneys. Patient was advised for a follow up check-up but she didnt return. Patient claimed that her condition can be tolerated. Four months PTA, patient had another onset of sudden sharp pain in the costovertebral area radiating to the hypogastric region, right with a pain scale of 8/10 and was admitted for four days at Mactan Doctors Hospital under Dr. Barcenas. According to patient, she was diagnosed with inflammation of the kidneys due to stones and obstruction. Patient was advised to undergo Laparoscopic Ureterolithotomy. Patient refused since her money was not enough. Patient was prescribed with Ural one sachet 3 times a day. Other medications were unrecalled. After discharge, patient claimed that her condition was fine but pain was still noted. Patient went to Sacred Heart Hospital for a second opinion under Dr. Velasco for the same complaints. She was prescribed with Acalka 2 tablets thrice a day; Rowatinex 2 tablets twice a day; Sambong one glass twice a day; Shi Lin Tong 7 tablets thrice a day. Patient was advised for a check-up every 3 months. Patient claimed that she felt that the pain was lesser on the flank area, right with a pain scale of 3/10.

Hours PTA, patient had another onset of sudden sharp pain in the costoverteral area radiating to the back with a pain scale of 7/10 which prompted this admission. Previous Hospitalization: October 25, 1995 Patient was admitted at Tojong Maternity Hospital in Looc Lapu-Lapu City, Cebu due to labor pains. Patient delivered via NSD a live baby boy. She stayed in the hospital for 2 days. Medications taken were unrecalled. Patient was discharged with improved condition. May 8, 2001 Patient was admitted at Tojong Maternity Hospital in Looc LapuLapu City, Cebu due to labor pains. Patient delivered via NSD a live baby girl. She stayed in the hospital for 2 days. Medications taken were unrecalled. Patient was discharged with improved condition. January 3, 2011 Patient was admitted for four days at Mactan Doctors Hospital under Dr. Barcenas due to onset of sudden sharp pain in the costovertebral area radiating to the hypogastric region, right with a pain scale of 8/10. According to patient, she was diagnosed with inflammation of the kidneys due to stones and obstruction. Patient was advised to undergo Laparoscopic Ureterolithotomy. Patient refused since her money was not enough. Patient was prescribed with Ural one sachet 3 times a day. Other medications were unrecalled. After discharge, patient claimed that her condition was fine but pain was still noted. Past Health History Patient is non-hypertensive, non-diabetic, non-asthmatic, non-smoker and nonalcoholic drinker. She has no history of illegal drug abuse. She has no known food and drug allergies. Patient claims that she has no heredofamilial diseases both on the paternal and maternal side. Childhood illnesses include mumps and measles.

GORDONS FUNCTIONAL HEALTH PATTERNS I. Health Perception Health Management Pattern Patient describes health as, importante jud and illness as, normal lang kay magkasakit man jud ang tao. When patient was asked to rate herhealth before onset of condition, she rated it as 10/10 with 10 as the highest and one as the lowest and verbalized, grabe kaayo ko ka energetic. During the onset of condition, she rated her health as 4/10 and verbalized, dili naman gud kaayo ko maka trabaho tungod sa sakit. She doesnt have regular check-ups but after she was diagnosed she visited Dr. Velasco every month at her clinic in Sacred Heart

Hospital. Patient cant recall if she was given any inmmunizations and verbalized, sa bukid man gud ko nagdako murag wala man siguro ko na bakunahan. But, patient claims that she was given complete Tetanus Toxoid shots during her pregnanacy. Patient practices self medication only when she has fever and takes Saridon 1 tab/day. Patient is non-compliant with her medications and verbalized, wala na nako palita ang Acalka kay mahal. Instead, patient only bought the herbal medications prescribed, Sambong one glass twice a day and Shilintong 7 tablets thrice a day. Patient does not practice BSE since she does not know how to perform the procedure. II. Nutritional Metabolic Pattern Height: 51 Weight (before admission): 67 kgs. Weight (during admission): 56 kgs. Ideal Body Weight: 54.94kgs. Body Mass Index: 23.3 (Normal) Clients Diet Breakfast Lunch Dinner Snacks 24 Hour Recall Usual Diet (8am) 1 cup rice, 1 serving (8am) 1 cup rice, 1 serving of of fried fish, 1 glass of water fish tinola, 1 cup of coffee or luy-a powder (1pm) 1 cup rice, 1 serving (12pm) 1-2 cups rice, 1 serving of ground pork, 1 glass of of vegetables, 1 glass of water water (7pm) 1 cup rice, 1 serving (7pm) 1-2 cups of rice, 1 serving of pork humba, atchara, 1 of grilled fish, 1 glass of water glass of water (3pm) sweet (10am and 4pm) sweet potatoes/banana, 1 glass of potatoes/banana/bread, 1 glass water water

Her food preferences are grilled fish and vegetable soup. Food storage, source and preparation are done by the patient. She doesnt have any food intolerance. She doesnt take any Vitamins and Supplements. Before onset of condition, her fluid intake was 5-6 glasses/day. She also drinks 3 cups of 3 in 1 coffee in a day and rarely drinks carbonated beverages. After the diagnosis, her fluid intake was 3L/day. She drinks coffee from (sinugbang mais na ginaling) twice a day. During hospitalization, patients recommended diet was DAT. Her fluid intake was 2L/day. Patient does not have any regular dental check-ups. Dental regimen is tooth brushing. She has one upper molar tooth missing and 2 lower molar teeth missing. Patient has no difficulty chewing or swallowing.

III. Elimination Pattern Before hospitalization, patient defecates once a day usually early in the morning, stool color is yellowish brown and well formed. Patient claims that she never experienced constipation. Patient does not use any laxatives and enema. According to patient, when she experiences diarrhea she takes Diatabs one capsule as needed. During hospitalization, patient claims that there were no changes in bowel elimination. Before onset of condition, patient voids twice a day with 140ml/episode. Color of urine is yellow. Patient claims that she has not experienced nocturia, pain upon urination, hematuria, UTI and hemorrhoids. After patient was diagnosed, she voids 12 times a day with 140-150mL/episode. Color of urine is light yellow-clear. Patient claims that she still experiences nocturia but has not experienced pain upon urination, hematuria, UTI and hemorrhoids. During hospitalization, patient voids 12 times a day with 140-150mL/episode. Color of urine is light yellow-clear. Patient claims that she still experiences nocturia but has not experienced pain upon urination, hematuria, UTI and hemorrhoids. Post-operatively, she had an FBC attached to urobag with output of 60-100mL/hour. IV. Activity Exercise Pattern Patient is a housewife. On her typical day, she wakes up at 4:30am and then she cooks breakfast, cleans the house and takes a bath. Around 5am, she opens their sari-sari store. At 7am, she eats her breakfast and stays at their store to attend to their customers. She eats lunch at 12 noon and resumes her activities at the sari-sari store. Around 6pm, she cooks dinner and then resumes her activities at their sari-sari store. At 7pm, she eats her dinner and resumes her activities at the store. Around 9pm, she closes their sari-sari store and then she watches TV. Around 10pm, she sleeps. Patient does not need assistance with her ADLs. Patient does not have any regular exercise, as verbalized, wala jud koy exercise kay naa raman ko pirmi mag bantay sa tindahan namo. Her recreational activities are watching TV, listening to radio dramas and spending time with her family. According to patient after the onset of condition, she has difficulties lifting up heavy objects, doing the laundry and walking fast because of the pain she experiences on her right flank area. During hospitalization, patient claims that there were no changes in her activity exercise pattern. V. Sleep Rest Pattern Before hospitalization, patient usually sleeps around 10pm and wakes up at 4:30am. She usually had a sleeping duration of 6 hours. Patient claims that she

doesnt use any sleeping aids and verbalized, makatulog rajud ko dayon inig higda nako sa katre. She does not take any drugs or sedatives to facilitate sleep. She usually prays before sleeping. Patient uses two pillows and a blanket when sleeping. She doesnt have any difficulties falling asleep. During the onset of condition, patient experiences nocturia and quality of sleep is not straight. When asked if she feels well rested upon waking up, patient verbalized, maayo raman gihapon akong katog bisan pag mag-mata mata ko para mangihi. During hospitalization patient sleeps around 7pm and wakes up around 4am. Patient verbalized, sayo ko makatulog diri kay laay man kaayo wala tay laing lingaw matulog ra. Patient takes nap at around 2pm with the duration of half an hour. Patient still experiences nocturia and quality of sleep is not straight but claims that she feels well rested upon waking up. VI. Sexuality Reproductive Pattern Patient had her menarche at the age of 12. Last menstrual period was April 25, 2011. Patient has regular menstrual cycles with moderate flow lasting for 4-5 days and sometimes experiences dysmenorrhea. She usually consumes 2 pads of sanitary napkins in a day. She cant recall her first sexual contact but shares that it was with her husband. Patient has no history of STD. She shared that her husband uses condom. Before onset of condition, patient engages in coitus with husband twice a month but during the onset of condition their sexual activities stopped because of the pain she feels in her right flank area. Patient claims that her condition has affected her sexual activities and verbalized, wala najud, zero jud ta anang dapita tungod kay sakit man akong may hawak dapit. Patients obstetrical score is G2P2002. Patient does not perform BSE and does not have any Pap smear and mammogram check-ups. VII. Cognitive Perceptual Pattern

Patient is oriented to time, place, people and has an intact sensory status. Her highest educational attainment is graduating high school. She can speak English, Tagalog and English. When asked if she understands her illness, she verbalized, O mu maning sakit ang ubos sa akong likod kay ni hubag man akong kidneys kay tungod sa bato. Patient was able to recall recent events and past event that happened. Patient has an intact judgment, when asked if VSMMC will caught fire what would she do, patient verbalized, mudagan jud ko ug mayo para makagawas sa hospital. Patient uses eyeglasses with a grade of 150/100. She does not use hearing aids and has no problems with her sense of taste, smell, and tactile sensations.

VIII.

Role Relationship Pattern

Genogram Paternal Side Maternal Side

Unrecalled

P LEGEND: - Male - Female P D - Patient - Dead

Patient has been married to her husband for 15 years. Patient described their relationship as harmonious and verbalized, mag-away pud mi usahay pero natural raman jud na basta minyo mo. According to the patient, she has many roles in the family; she is incharge of their budget; the harmonizer and the disciplinarian. Patient has 2 kids which are both in school so she sees to it that she can attend to the needs of her children. Patient claims that she has a good relationship with her friends. She also shared that she is very contented and happy with the relationship she has built with her family and friends. During hospitalization, her husband took care of her since her children cant visit the ward and she also had a few visits from her friends. According to patient, she misses her children because shes not used to being away from them.

IX. Self Perception Self Concept Pattern: When asked to describe herself, patient gladly shared that she is God-fearing, simple, hardworking and independent. When I asked her husband to describe the patient, he shared that his wife is very caring, loving, strong and most of all very generous and verbalized, mu bitaw na na inlove jud ko niya. She also shared that raising her two children is the greatest accomplishment in her life. She verbalized, bahala nag pobre mi basta malipayon lang ang among pagpuyo ug maayo lang ang lawas, ok najud ko ana. Patient claims that she is satisfied with her life. According to patient, her illness did not affect her body image because she can still do things by herself. X. Coping Stress Tolerance Pattern Patient defined stress as problems that everyone faces. She verbalized, kanang ma stress ta kung naa tay mga problema kay mag sige man ta ug huna-huna ana. Patient claims that she is little bit stressed because shes hospitalized esp. with the bills that they have to pay. Patient verbalized that, ma stress pud ko day basta magpa badlong akong mga anak. According to patient, when she has problems she usually talks to the people involved. Her family and friends are her support system whenever she has problems. She relieves her stress through her recreational activities such as watching TV, listening to radio dramas, relaxing and seeking God through prayers and novenas. XI. Value Belief Pattern Patient is a Christian. She is an active member of the Christian Alliance Fellowship. She attends mass every Wednesdays and Sundays and also joins novenas. Patient strongly believes in God and shared that He is the source of her strength. Patient prays everyday esp. at night before she sleeps. Her current condition has not affected how she practices her faith in anyway. Environmental History Patient has been living in Buaya Lapu-Lapu City for 15 years. It is a one- storey house made with mixed materials. It has 2 bedrooms, 4 doors and 5 windows. They have distinct and separate spaces for their kitchen, dining, living and flush source of water is from a deep well. Garbage disposal is through burning since the garbage truck cant reach their place. There are 5 people living in the house. They dont own a pet. The house is accessible to the public market, church, Barangay hall and transportation vehicles. Distance from the main road is approximately 5 minutes, from the nearest grocery store 10 minutes, from the nearest drug store is 5 minutes, from the health center is 15 minutes when walking and from the hospital 15 25 minutes, from the church 15 minutes and from the fire station 30 minutes when travelling. Patient describes the neighborhood as congested but with a peaceful and orderly situation.

CHAPTER IV PATHOPHYSIOLOGY Anatomy and Physiology

The Urinary System Kidney The kidneys are small, dark, red organs, with a kidney bean shape, which lie against the dorsal wall in a retroperitoneal position in the superior lumbar region. The kidneys extend from the T12 to L3 vertebra thus they receive protection from the lower part of the rib cage. Because it is crowded by the liver, the right kidney is positioned slightly lower than the left. An adult kidney is about 12cm (5in) long, 6cm (2.5in) wide, and 3cm (1in) thick, about the size of a large bar of soap. It is convex laterally and has a medial indentation called the hilus, where the ureters, the renal blood vessels and nerves, enter or exit the kidney. Atop each kidney is an adrenal gland, which is part of the endocrine system and is distinctly separate organ functionally. A fibrous, transparent renal capsule encloses each kidney. In a living person, a fatty mass, the adipose capsule, surrounds each kidney and helps hold it in place against the muscles of the trunk wall. Coronally sectioned, the outer region, which is light in color, is the renal cortex. Deep to the cortex is a darker reddish-brown area, the renal medulla. The medulla has many triangular regions with a striped appearance, the medullary pyramids. The broader base of each pyramid faces toward the cortex; its tip, the apex, points toward the inner region of the kidney. The pyramids are separated by extensions of cortex-like tissue, the renal columns. Medial to the hilus is a flat, basinlike cavity, the renal pelvis. This is continuous with the ureter leaving the hilus. Extensions of the pelvis, calyces, form cup-shaped areas that enclose the tips of the pyramids. The calyces collect urine, which continuously drains from the tips of the pyramids into the renal pelvis. Urine then flows from the pelvis into the ureter, which transports it to the bladder for temporary storage. Blood Supply Approximately, one quarter of the total blood supply of the body passes through the kidneys each minute. The arterial supply of each kidney is the renal artery.

As the renal artery approaches the hilus, it divides into segmental arteries. Once inside the pelvis, the segmental arteries break up into lobar arteries, each of which gives off several branches called interlobar arteries, which travel through the renal columns to reach the cortex. At the medulla-cortex junction, interlobar arteries give off the arcuate arteries, which curve over the medullary pyramids. Small interlobular arteries then branch off the arcuate arteries and run outward to supply the cortex tissue. Venous blood draining from the kidney flows through veins that trace the pathway of the arterial supply but in a reverse direction interlobular veins to arcuate veins to interlobar veins to the renal vein, which emerges from the kidney hilus. Nephrons Nephrons are the structural and functional unit of the kidneys and are responsible fro forming urine product. Each nephron consists of two main structures: a glomerulus which is a knot of capillaries and a renal tubule. The closed end of the renal tubule is enlarged and cup-shaped and completely surrounds the glomerulus. This portion of the renal tubule is called the glomerular or bowmans capsule. The inner layer of the capsule is made up of highly modified octopuslike cells called podocytes. Podocytes have long branching processes called pedicels that intertwine with one another and cling to the glomerulus. Because openings, the so-called filtration slits, exist between their extensions, the podocytes from a porous or holey, membrane around the glomerulus. The rest of the tubule is about 3cm (1.25in) long. As it extends from the glomerular capsule, it coils and twists (PCT, Proximal Convoluted Tubule) before forming a hairpin loop (Loop of Henle) and then again becomes coiled and twisted (DCT, Distal Convoluted Tubule) before entering a collecting tubule called the collecting duct. Most nephrons are called cortical nephrons because they are located almost entirely within the cortex. In a few cases, the nephrons are called juxtamedullary nephrons because they are situated close to the cortexmedulla junction, and the loops of Henle dip deep into the medulla. The collecting ducts, each of which receives urine from many nephrons, run downward through the medullary pyramids, giving them their striped appearance. They deliver the final urine product into the calyces and renal pelvis. The glomerulus is both fed and drained by arterioles. The afferent arteriole, which arises from an interlobar artery, is the feeder vessel and the efferent arteriole receives blood that has passed through the glomerulus. Both arterioles have high resistance and the afferent arteriole has a larger diameter than the efferent. Blood pressure in the glomerulus is extraordinarily high. This extremely high pressure forces fluid and solutes (smaller than proteins) out of the blood into the glomerular capsule. Most of this filtrate (99%) is eventually reclaimed by the renal tubule cells and returned to the blood in the peritubular capillary beds. The second capillary bed, the peritubular capillaries arises from the efferent arteriole that drains the glomerulus. Unlike the high pressure glomerulus, these capillaries are low pressure, porous vessels that are adapted for absorption instead of filtration.

Urine Formation Urine formation is a result of three processes: filtration, reabsorption, and secretion. Filtration is a nonselective, passive process. The filtrate that is formed is essentially blood plasma without blood proteins. Both blood proteins and blood cells are normally too large to pass through the filtration membrane. As long as the systemic blood pressure is normal, filtrate will be formed. Besides wastes and excess ions that must be removed from the blood, the filtrate contain many useful substances (including water, glucose, amino acids, and ions) which must be reclaimed from the filtrate and returned to the blood. Tubular reabsorption begins as soon as the filtrate enters the proximal convoluted tubule. The tubule cells take up needed substances from the filtrate and then pass them out their posterior aspect into the extracellular space, from which they are absorbed into peritubular capillary. Tubular secretion is essentially reabsorption in reverse. Some substances such as hydrogen and potassium ions and creatinine, move from the blood of the peritubular capillaries through the tubule cells or from the tubule cells themselves into the filtrate to be eliminated in urine. Ureters The ureters are slender tubes each 25 to 30cm (10 to 12in) long and 6mm (1/4 in) in diameter. Each ureter runs behind the peritoneum from the hilus of a kidney to the posterior aspect of the bladder. The superior end of each ureter is continuous with the pelvis of the kidney. Essentially, the ureters are passageways that carry urine from the kidneys to the bladder. Once urine has entered the bladder, it is prevented from flowing back into the ureters by small valvelike folds of bladder mucosa that flap over the ureter openings. Urinary Bladder The urinary bladder is a smooth, collapsible, muscular sac that stores urine temporarily. It is located retroperitoreally in the pelvis just posterior to the pubic symphysis. If the anterior of the bladder is scanned, three openings are seen the two ureter openings and the single opening of the urethra, which drains the bladder. The smooth triangular region of the bladder of the base outlined by these three openings is called the trigone. The trigone is important clinically because infections tend to persist in this region. The bladder wall contains three layers of smooth muscle, collectively called the detrussor muscle and its mucosa is a special type of epithelium, transitional epithelium. As urine accumulates, the bladder expands and rises in the abdominal cavity. Its muscular wall stretches and the transitional epithelial layer thins allowing the bladder to store more urine without substantially increasing its internal pressure. When the bladder is really distended, or stretched by urine, it becomes firm and pear-shaped and may be felt just above the pubic symphysis. Although urine is formed continuously by the kidneys, it is usually stored in the bladder until its release is convenient. Urethra The urethra is a thin walled tube that carries urine by peristalsis from the bladder to the outside of the body. At the bladder-urethra junction, a thickening of the

smooth muscle forms the internal urethral sphincter, an involuntary sphincter that keeps the urethra closed when urine is not being passed. A second sphincter, the external urethral sphincter, is fashioned by skeletal muscle as the urethra passes through the pelvic floor. This sphincter is voluntarily controlled. The length and relative function of the urethra differ in two sexes. In females it is about 3 to 4cm (1 in) long and its external orifice lies anteriorly to the vaginal opening. Its function is to conduct urine to the body exterior. RAA mechanism (Renin Angiotensin Aldosterone) Three conditions that will signal the start of the RAA mechanism: a decrease in sodium, decrease blood pressure, and a decrease in blood volume. This will then lead to a decrease in renal perfusion. The juxtaglomerular apparatus in the kidneys will then release Renin in the blood which will stimulate the liver to convert Angiotensinogen into Angiotensin I. In the lungs, an enzyme called angiotensin converting enzyme will convert Angiotensin I to Angiotensin II. Angiotensin II is a potent vasoconstrictor causing an increase in peripheral resistance. Angiotensin II will also increase aldosterone levels, increasing sodium reabsorption and water retention. These events result to an increase in sodium, blood volume and blood pressure.

CHAPTER V COURSE IN THE WARD Physical Examination Date Performed: May 9, 2010 - 11:30AM General Appearance: examined patient sitting on bed awake, conscious, responsive, coherent, with ease in respiration, without IVF, and with the ff V/S: BP = 110/80mmHg, PR = 70bpm, RR = 20cpm, T = 37.3oC/axilla SKIN: brown complexion, pinched-up skin returns immediately to original position, no pigmentation, dry and warm to touch, no lesions, no rashes, smooth and moist skin, no tenderness, no edema, no jaundice, no cyanosis, able to sense light touch and pain HEAD AND HAIR : normocephalic, smooth and firm scalp, long, straight, shiny, black, evenly distributed hair, no dandruff, no masses, no lice infestation, no tenderness upon palpation, no lesions, symmetrical facial features, (-)Chvosteks sign (no facial muscle spasms when tapped), no circumoral tingling EYES: symmetrical in shape and size, eyebrows and eyelashes are black equally distributed, pinkish palpebral conjunctivae, clear bulbar conjunctivae, anicteric sclerae, brown iris, no abnormal discharges, no lesions, (+) Corneal reflex, full peripheral vision, (+) Pupils Equally Round and Reactive to Light and Accommodation, (+) Cardinal gazes, can read nameplate at 1 ft distance, cannot read small newspaper print 14 inches from the eyes. EARS: symmetrical, pinna is positioned in line with outer canthus of the eye, skin color is consistent with the facial skin color, smooth skin, minimal cerumen, no nodules, pinna is non tender upon palpation, recoils after being folded, no inflammation, no lesions, can hear and repeat whispered words at 3 ft distance, able to hear and follow instructions NOSE and SINUSES: symmetrical and proportional to other facial features, nasal septum is straight, at midline and perforated, nares are patent, no nasal flaring, no congestion, no discharges or bleeding noted, clear maxillary and frontal sinuses upon transillumination test, no tenderness upon palpation, no swelling, no lesions MOUTH and TONSILS: no halitosis, pinkish symmetrical lips neither cracked nor dry, no lesions, pinkish tongue with rough texture, and is soft and at midline, uvula in midline with no swelling, no tonsil swelling, smooth, soft, pinkish buccal mucosa with no lesion or ulcerations, pinkish and moist gums with no ulcerations, no dentures but has orthodontic appliance, 33 slightly yellowish teeth, (+) gag reflex, able to speak

NECK and LYMPH NODES: symmetrical, able to rotate, flex, and hyperextend neck, no neck vein engorgement, no lesions, non tender, non palpable cervical lymph nodes, no signs of infection such as inflammation, redness, and warmth THORAX and LUNGS: equal chest expansion, no lesions, non tender, no masses, no adventitious breath sounds heard upon auscultation, equal tactile fremitus, muffled egophony, bronchophony, whispered pectoriloquy, resonance upon percussion. CARDIAC and PERIPHERAL CIRCULATION: distinct s1 and s2 heart sounds upon auscultation, no murmurs, no chest pain, heart rate at 70 bpm with regular rhythm, +3 palpable peripheral pulses left hand, +2 peripheral pulses right hand , CRT < 2 seconds on upper and lower extremities, Pulse Strength 0 - Absent +1 - Weak, thready, difficult to palpate, obliterated with pressure +2 - Diminished pulse, cant be obliterated +3 - Easy to palpate, full pulse, cant be obliterated +4 - Strong bounding pulse BREASTS AND AXILLAE: Round with right breast slightly lager than left breast, pendulous, dark brown areola, round, oval, everted nipple, no abnormal discharges noted, no masses upon palpation, non palpable axillary lymph nodes ABDOMEN: flat, no lesions, no scars, normoactive borborygmous sounds auscultated at right lower quadrant, no palpable masses, no rebound tenderness, umbilicus at midline, (-) fluid wave test, (+) kidney punch, no organomegaly GENITOURINARY: grossly female, pinkish labia majora and labia minora as verbalized, no abnormal discharges, no lesion, no masses, no swelling, no pain upon urination, no itching, no rashes, urine output: 1,200ml per shift RECTUM: no rashes, no hemorrhoids, no abnormal discharges, no itchiness EXTREMITIES: Erect posture, no malformations, steady, smooth and coordinated gait, bilateral, firm and developed muscles, no bony deformities, symmetrical, clean, firm and short fingernails and toenails, smooth, hard, and pinkish nail beds, pinkish palm and soles, no edema in both hands and feet, full ROM on both upper and lower extremities, strong grip on both hands, no nail clubbing, no ingrown toenails, no swelling, no lesions, no scars on both upper and lower extremities, no carpopedal spasms on hands and feet, (-)Trousseaus sign.

Muscle Strength R L 5/5 5/5 5/5 5/5

SCALE FOR GRADING MUSCLE STRENGTH 5 Full ROM against gravity, full resistance 4 Full ROM against gravity, some resistance 3 Full ROM with gravity 2 Full ROM with gravity eliminated (passive motion) 1 Slight Reaction 0 No Reaction NEUROLOGIC ASSESSMENT: MENTAL/ CEREBRAL: awake, conscious, responsive, coherent, oriented to time, place and person, speech not slurred, tense less, appropriately dressed, and is well groomed. She performs daily hygiene such as taking a bath, changing clothes, brushing of teeth, and washing of hands before and after eating and going to the bathroom without assistance. She is able to speak English, Filipino, and Visayan dialect. She is able to smile and frown, and able to recall long term memories like year of menarche and birthdays, and short term memories like what she ate that day and the day before (as confirmed by SO), does not have short attention span, and when asked what she would do if the hospital caught fire, she simply stated that she would run outside the hospital. SENSORY: Able to identify things such as cotton when touched to face, (+) Graphesthesia (letter J and L), (+) Stereognosis (with pen), (+) Kinesthesia (up and down), (+) 2 point discrimination. She is able to differentiate between sharp(pencil tip) from blunt(pencil eraser), able to feel light touch and pain when pinched on both upper and lower extremities, can feel vibratory sensation. MOTOR/CEREBELLAR: Able to perform finger - nose test, thumb opposition test, can button and unbutton shirt smoothly, no significant swaying on Romberg test CRANIAL NERVE TESTING: CN 1 (Olfactory): able to identify smell of banana CN 2 (Optic): can read name plate of the nurse trainee at 1 ft distance, cannot read small newspaper print at 14 inches away from eyes CN 3 (Occulomotor): can lift eye lids, can look up and down, + PERRLA CN 4 (Trochlear): can look side to side, + PERRLA

CN 5: (Trigeminal): S: can feel sharp and dull objects on both sides of face; M: intact facial expression at both side of face, can masticate, can clench teeth CN 6 (Abducens): (+) Cardinal gaze, (+) PERRLA CN 7 (Facial): S: able to identify taste (anterior 2/3 of the tongue sweet, sour and salty) when eyes are closed, M: able to smile and frown, raise eyebrows symmetrically, can puff out cheeks CN 8 (Auditory): able to hear whispered words at 3 ft distance CN 9 (Glossopharygneal): (+) gag reflex, able to identify taste (posterior 1/3 of the tongue - bitter), able to swallow CN10 (Vagus): (+) Gag reflex, bilateral and symmetrical rise of soft palate and uvula upon saying ah, able to swallow and cough and talk CN 11 (Accessory): able to shrug shoulder against resistance CN12 (Hypoglossal): able to protrude tongue at midline and move it from side to side and up and down DEEP TENDON REFLEXES (+2) biceps reflex, (+2) triceps reflex, (+2) brachioradialis reflex, (+2) patellar reflex, (+2) Achilles Reflex bilaterally SCALE FOR GRADING REFLEX RESPONSES: 0 No Reflex Response +1 Minimal Activity +2 Normal Response +3 More Active than Normal +4 Maximal Activity (Hyperactive) Date Performed: May 10, 2010 - 1:00PM General Appearance: examined patient sitting on bed awake, conscious, responsive, coherent, with ease in respiration, with IVF 1 PNSS 1L regulated @ 20gtts/min infusing well at right hand, and with the ff V/S: BP = 110/80mmHg, PR = 76bpm, RR = 20cpm, T = 36.8oC/axilla Significant Findings: EYES: cannot read small newspaper print 14 inches from the eyes MOUTH AND TONSILS: no dentures but has orthodontic appliance, 33 slightly yellowish teeth CARDIAC and PERIPHERAL CIRCULATION: +2 peripheral pulse right hand Pulse Strength 0 - Absent +1 - Weak, thready, difficult to palpate, obliterated with pressure +2 - Diminished pulse, cant be obliterated

+3 - Easy to palpate, full pulse, cant be obliterated +4 - Strong bounding pulse ABDOMEN: (+) kidney punch sign CRANIAL NERVE TESTING: CN 2 (Optic): cannot read small newspaper print at 14 inches away from eyes Date Performed: May 11, 2011 10:00AM (Day 1 S/P Laparoscopic Ureterolithotomy) General Appearance: examined patient sitting on bed awake, conscious, responsive, coherent, with ease in respiration, with IVF 1 PNSS 1L regulated @ 30gtts/min infusing well at right hand, with T-tube draining at lumbosacral area, with FBC attached to urobag, and with the ff V/S: BP = 120/80mmHg, PR = 83bpm, RR = 22cpm, T = 37.2oC/axilla Significant Findings: EYES: pale palpebral conjunctiva, cannot read small newspaper print 14 inches from the eyes MOUTH AND TONSILS: pale, dry lips with sore on the lower lip, no dentures but has orthodontic appliance, 33 slightly yellowish teeth CARDIAC and PERIPHERAL CIRCULATION: +2 peripheral pulse right hand Pulse Strength 0 - Absent +1 - Weak, thready, difficult to palpate, obliterated with pressure +2 - Diminished pulse, cant be obliterated +3 - Easy to palpate, full pulse, cant be obliterated +4 - Strong bounding pulse ABDOMEN: presence of T- tube draining at lumbosacral area GENITOURINARY: presence of FBC attached to urobag EXTREMITIES: IVF attached to right hand, pale nailbeds, palms and soles of feet Muscle Strength R 5/5

L 5/5

4/5 4/5 SCALE FOR GRADING MUSCLE STRENGTH 5 Full ROM against gravity, full resistance 4 Full ROM against gravity, some resistance 3 Full ROM with gravity 2 Full ROM with gravity eliminated (passive motion) 1 Slight Reaction 0 No Reaction CRANIAL NERVE TESTING: CN 2 (Optic): cannot read small newspaper print at 14 inches away from eyes Date Performed: May 12, 2011 10AM General Appearance: examined patient sitting on bed awake, conscious, responsive, coherent, with ease in respiration, with IVF 1 PNSS 1L regulated @ 30gtts/min infusing well at left hand, with T-tube draining at lumbosacral area, and with the ff V/S: BP = 120/80mmHg, PR = 88bpm, RR = 23cpm, T = 36.9oC/axilla Significant Findings: EYES: pale palpebral conjunctiva, cannot read small newspaper print 14 inches from the eyes MOUTH AND TONSILS: pale, dry lips with sore on the lower lip, no dentures but has orthodontic appliance, 33 slightly yellowish teeth CARDIAC and PERIPHERAL CIRCULATION: +2 peripheral pulse right hand Pulse Strength 0 - Absent +1 - Weak, thready, difficult to palpate, obliterated with pressure +2 - Diminished pulse, cant be obliterated +3 - Easy to palpate, full pulse, cant be obliterated +4 - Strong bounding pulse ABDOMEN: presence of T- tube draining at lumbosacral area EXTREMITIES: IVF attached to right hand, pale nailbeds, palms and soles of feet Muscle Strength

R 5/5

L 5/5

4/5 4/5 SCALE FOR GRADING MUSCLE STRENGTH 5 Full ROM against gravity, full resistance 4 Full ROM against gravity, some resistance 3 Full ROM with gravity 2 Full ROM with gravity eliminated (passive motion) 1 Slight Reaction 0 No Reaction CRANIAL NERVE TESTING: CN 2 (Optic): cannot read small newspaper print at 14 inches away from eyes Date Performed: May 13, 2011 10AM General Appearance: examined patient sitting on bed awake, conscious, responsive, coherent, with ease in respiration, with IVF 1 PNSS 1L regulated @ 30gtts/min infusing well at left hand, with T-tube draining at lumbosacral area, and with the ff V/S: BP = 120/80mmHg, PR = 80bpm, RR = 21cpm, T = 37.0oC/axilla Significant Findings: EYES: cannot read small newspaper print 14 inches from the eyes MOUTH AND TONSILS: pale lips with sore on the lower lip, no dentures but has orthodontic appliance, 33 slightly yellowish teeth CARDIAC and PERIPHERAL CIRCULATION: +2 peripheral pulse right hand Pulse Strength 0 - Absent +1 - Weak, thready, difficult to palpate, obliterated with pressure +2 - Diminished pulse, cant be obliterated +3 - Easy to palpate, full pulse, cant be obliterated +4 - Strong bounding pulse ABDOMEN: presence of T- tube draining at lumbosacral area EXTREMITIES: IVF attached to right hand, pale nailbeds, palms and soles of feet

CRANIAL NERVE TESTING: CN 2 (Optic): cannot read small newspaper print at 14 inches away from eyes Laboratory Findings Complete Blood Count Purpose: Blood test that helps in determining certain blood disorders, inflammation, infection and inherited disorders. It evaluates the three major types of cells in blood: red blood cells, white blood cells, and platelets. The CBC is a frequently ordered inpatient and outpatient basic screening and diagnostic test that provide information about the hematologic system and many other systems. It is also used in monitoring routine physical exam and in diagnosis of wide range of conditions and disease of children and adults. Test WBC RBC HGB HCT MCV MCH Platelet Neutrophils Lymphocytes Monocytes Eosinophils Basophils RDW-CV MPV Result (4/15/11) 4.4 3.90 10.9 32.2 82.7 28.0 232 47.1 43.2 7.5 2.0 0.2 16.44 7.0 Reference 4.8 10.8/uL F: 4.2 5.4/uL F: 12 16 g/dL F: 37 47% 27 31 fL 33.0 37.0 pg 130 400/uL 40.0 74.0% 19.0 48.0% 3.4 9.0% 0.00 7.0% 0.0 1.5% 11.5 14.5% 7.2 11.1 fL

Implication: Since patient is going to undergo surgery, the CBC provides valuable information about the blood and to some extent the bone marrow, which is the blood-forming tissue. The CBC is used as a preoperative test to ensure both adequate oxygen carrying capacity and hemostasis. A decrease in the patient's RBC components may be due to her tortuous aorta as shown in her chest x-ray since the aorta is the largest blood vessel in the body. It carries freshly oxygenated blood out of the heart so that it can be distributed to the circulatory system. In most people, the aorta follows a relatively straight path. In people with tortuous aorta, the vessel may be twisted or distorted. This can cause blockages in blood flow, leading to medical complications as a result of poor circulation.

Prothrombin Time Purpose: Prothrombin time (PT) measures the time it takes for the plasma of your blood to clot. Patient (sec) Patient Activity Patient (INR) Control (sec) Control (% activity) Result 12.0 sec 100.0% 0.9 13.4 83.9%

Implications: The result has no significant findings but since the patient needs to undergo surgery, the prothrombin time is used as a preoperative test to ensure that when a person bleeds (by injury or surgery) her body launches a coagulation cascade. Bleeding and Clotting Time (4/15/11) Purpose: This test measures the time taken for blood vessel constriction and platelet plug formation to occur. Bleeding time (Simplate Method) Clotting time (Slide Method) Result 4.5 minutes 3.45 minutes Normal Values 2.3 9.5 minutes 2 6 minutes

Implication: The result has no significant findings but since the patient needs to undergo surgery, the bleeding and clotting time is used as a preoperative test to ensure that she has an effective clotting process to avoid unnecessary blood loss. Blood Chemistry (4/15/11) Purpose: To evaluate fluid electrolyte and acid-base balance and related neuromuscular, renal and adrenal functions FBS Creatinine Result 69.9mg/dL 1.23mg/dL Normal Range 60.0 100.0 0.60 1.50

Implication: No significant findings within normal limits. Electrocardiographic Report (4/15/11)

Purpose: It is a noninvasive routine examination of the electrical activity of the heart that is used to reflect underlying heart conditions. Regular heart movements are controlled by a complex set of electrical impulses that direct the upper and lower heart chambers to contract and relax rhythmically. When these electrical activities are interrupted or misguided, the arrhythmia can be symptoms of heart diseases. Furthermore, the impulses can also show signs of structural or metabolic changes like enlargement or hypoxia of cardiac muscle. Diagnosis: Sinus rhythm within normal limits. Radiology Report Purpose: X-ray is done to demonstrate any cartilage abnormalities, abnormal bone growth, and to demonstrate the location and size of the organs. Chest X-ray PA (4/15/11) Examination Findings: Lung fields are essentially clear. Heart is not enlarged. Pulmonary vascular markings are within normal limits. Tracheal air column is at midline. Aorta is tortuous. Both hemidiaphragm and costophrenic sulci are intact. The visualized osseous are unremarkable. Impression: Essentially clear lung fields; Tortous Aorta X-ray Kidneys, Ureter and Bladder (KUB) (5/2/11) Examination Findings: There is a 2.1 calcific density in the right lumbar region at the level of the L4 vertebrae along the sparse of the ureter. The lumbar spine and pelvis show no significant bony abnormalities. Impression: Consider ureterolithiasis, right. Suggest KUB ultrasound. Drug Study 1. Tramadol Class: Centrally acting opioid analgesic Action: Binds to mu opioid receptors and inhibits the reuptake of norepinephrine and serotonin Indication: Relief of moderate to moderately severe pain Contraindications: Patients hypersensitive to drug or other opioids; in breastfeeding women; and in those with acute intoxication from alcohol, hypnotics, centrally acting analgesics, opioids or psychotropic drugs Side effects: Sedation, dizziness, vertigo, headache, confusion, somnolence, hypotension, nausea, vomiting, urine retention, diaphoresis, rash, respiratory depression Nursing Considerations:

o Monitor patients vital signs. o Assess patients level of pain and then reassess after 30 minutes of drug administration. o Withhold dose and notify prescriber if RR is below 12cpm and if BP is lower than 90/60mmHg. o Monitor patient for drug dependence. o Withdrawal symptoms may occur if drug is stopped abruptly. Reduce dosage gradually. o Advise ambulatory patient to be careful when rising and walking. Patient should have gradual changes in position. o Advise patient to avoid activities that require mental alertness. 2. Ketorolac Class: Nonsteroidal anti-inflammatory drug Action: Inhibits prostaglandin synthesis to produce anti-inflammatory, analgesic, and antipyretic effects Indication: Short term management of moderately severe, acute pain Contraindications: Patients hypersensitive to drug and in those with active peptic ulcer disease, recent GI bleeding or perforation, advanced renal impairment, cerebrovascular bleeding, hemorrhagic diathesis, or incomplete hemostasis, and in those at risk for renal impairment from volume depletion or at risk of bleeding Side effects: drowsiness, sedation, dizziness, headache, edema, hypertension, palpitations, arrythmias, nausea, dyspepsia, GI pain, peptic ulceration, vomiting, decreased platelet adhesion, purpura, prolonged bleeding time, pruritus, rash, pain at injection site Nursing Considerations: o Assess history of peptic ulcer disease or any recent GI bleeding or any risk of bleeding. o Teach patient signs and symptoms of GI bleeding, including blood in vomit, urine or stool. o Monitor patients blood pressure and heart rate. o Advise patient to avoid activities that require mental alertness. 3. Ranitidine Class: H2 receptor antagonist Action: Competitively inhibits action of histamine on the H2 at receptor sites of parietal cells, decreasing gastric acid secretion Indication: Patient is on NPO Contraindications: Patients hypersensitive to drug and in those with acute porphyria Side effects: vertigo, malaise, headache, blurred vision, jaundice, burning and itching at injection site, anaphylaxis Nursing Considerations: o Assess patient for abdominal pain.

o Instruct patient to take without regard to meals because absorption isnt affected by food. o Advise patient to report abdominal pain and blood in stool or emesis. o Urge patient to avoid foods that may increase gastric acid secretion. 4. Ciprofloxacin Class: Fluoroquinolones Action: Inhibits bacterial DNA synthesis, mainly by blocking DNA gyrase; bactericidal Indication: Prophylactic treatment Contraindications: Patients hypersensitive to fluoroquinolones. Side effects: headache, restlessness, tremor, dizziness, thrombophlebitis, crystalluria, edema, nausea, diarrhea, vomiting, abdominal pain, leukopenia, joint or back pain, rash, hypersensitivity reactions Nursing Considerations: o Obtain specimen for culture and sensitivity tests before giving first dose. o Monitor patients intake and output. o Monitor for pain and inflammation on joints. o Advice to take drug as prescribed to prevent growth of resistant organisms. o Monitor for signs and symptoms of superinfection. 5. Celecoxib Class: COX2 inhibitor Action: Inhibit prostaglandin synthesis, impeding cyclooxygenase-2 to produce anti-inflammatory, analgesic and antipyretic effects Indication: Acute pain Contraindications: Patients hypersensitive to drug sulfonamides, aspirin or other NSAIDs; in those with severe hepatic impairment; in the treatment of perioperative pain after coronary artery bypass graft; women in the third trimester of pregnancy; and in those with with history of ulcers or GI bleeding Side effects: dizziness, headache, insomnia, peripheral edema, pharyngitis, abdominal pain, dyspepsia, nausea, back pain, accidental injury Nursing Considerations: o Assess if patient has history of anaphylactic reactions to sulfonamides, aspirin, or other NSAIDs. o Assess if patient has history of ulcers or GI bleeding. o Watch for signs and symptoms of overt and occult bleeding. o Monitor patient for signs and symptoms of fluid retention. o Monitor input and output. o Drug can be given without regard to meals, but food may decrease GI upset. 6. Diphenhydramine

Class: H1 receptor antagonist Action: Competes with histamine for H1 receptor site, prevents but doesnt reverse histamine mediated responses, particularly those of the bronchial tues, GI tract, uterus and blood vessels. Drug provides local anesthesia and suppress cough reflex Indication: Sedation Contraindications: Patients hypersensitive to drug; newborns; premature neonates; breastfeeding women; patients with angle-closure glaucoma; stenosing peptic ulcer; symptomatic prostatic hyperplasia; bladder neck obstruction or pyloroduodenal obstruction; and those having acute asthmatic attack. Side effects: drowsiness, confusion, insomnia, headache, vertigo, sedation, sleepiness, dizziness, palpitations, hypotension, tachycardia, diplopia, blurred vision, nausea, vomiting, dry mouth, urine retention, thromocytopenia, rash Nursing Considerations: o Warn patient not to take this drug with any other products that contain diphenhydramine because it can increase adverse reactions. o Tell patient to take diphenhydramine with food to reduce GI distress. o Warn patient to avoid alcohol and hazardous activities that require alertness. o Inform patient to increase fluid intake. 7. Fleet enema Class: Saline Laxatives Action: Produces an osmotic effect in the small intestines by drawing water into the intestinal lumen Indication: Bowel Preparation pre-operatively Contraindications: Patients on sodium restricted diets and in patients with intestinal obstruction, intestinal perforation, edema, heart failure, megacolon, impaired renal function, or signs and symptoms of appendicitis, or acute surgical abdomen Side effects: Abdominal cramping, fluid and electrolyte disturbance, laxative dependence with long term use Nursing Considerations: o Advise to increase oral fluid intake. o Teach patient about dietary sources of bulk, including bran and other cereals, fresh fruit, and vegetables. o Stress importance of using drug only for a short term therapy.

CHAPTER VI THEORETICAL FRAMEWORK Theoretical Background The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery, or to peaceful death, that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible. Henderson, 1966. She categorized nursing activities into 14 components, based on human needs. She described the nurses role as substitutive (doing for the person), supplementary (helping the person), or complementary (working with the person), with the goal of helping the person become as independent as possible. Physiological 1. Breathe normally. 2. Eat and drink adequately 3. Eliminate body wastes. 4. Move and maintain desirable postures. 5. Sleep and rest 6. Select suitable clothes 7. Maintain body temperature within normal range by adjusting clothing and modifying the environment. 8. Keep the body clean and well groomed and protect the integument. 9. Avoid dangers in the environment and avoid injuring others. 10. Communicate with others in expressing emotions, needs, fears, or opinions. 11. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities. Spiritual 12. Worship according to ones faith Sociological 13. Work in such a way that there is a sense of accomplishment. 14. Play or participate in various forms of recreation.

onceptual Framework
Nursing Roles

Substitutive (Doing for the person)

Complementary (Working with the person)

14 Basic Needs

Supplementary (Helping the person)

G O A L

INDEPENDENCE

Figure 1: Virginia Hendersons Humane Holistic Care Figure 1 shows a framework of Virginia Hendersons Model. There are three components that comprise Virginia Hendersons Humane Holistic Care Theory. Specifically, these are under the theoretical assertions of the Nurse patient relationship. These are: (1) the nurse as a substitute for the patient; (2) the nurse as a helper to the patient; (3) and the nurse as a partner with the patient. These said nursing roles range from very dependent to a quite independent relationship. It is through the implementation of these roles that the client is helped in achieving his goal- independence.

CHAPTER VII NURSING CARE PLAN A. Pre-operative Phase Date: May 9, 2011 1. Chronic Pain Cues: Related to presence of stones in the ureter and inflammatory process secondary to ureterolithiasis as manifested by sudden intermittent sharp pain at the costovertebral area radiating to the hypogastrium, right aggravated by movements and relieved by limiting movements with a pain scale of 7/10; X-ray report of the KUB shows a 2.1cm calcific density in the right lumbar region at the level of L4 vertebrae along the sparse of the ureter. Analysis of the Problem: The most characteristic manifestation of renal or ureteral calculi is a sharp, severe pain of sudden onset caused by movement of the calculus and consequent irritation. Pain may be intermittent, which usually means that the stone has moved. Physician hypothesize that the ureter dilates just proximal to the calculus, which allows urine to pass. Then, as the stone moves into a new obstruction site, the pain returns. Source: Joyce M. Black. Medical Surgical Nursing, page 884, Volume 1. Statement of Care Objectives: Within 1 hour of nursing intervention, the patient will be able to report a decrease in pain scale of 3-5/10 with 10 as the highest and 1 as the lowest. Nursing Actions Rationale Evaluation Independent Functions: Actual Outcome: 1. Monitored vital signs R: Usually altered in the May 9, 2011 every 4 hours. presence of pain After 1 hour of nursing interventions, patients 2. Performed a R: To assess pain is still noted with comprehensive etiology/precipitating a pain scale of 3/10. assessment of pain using contributory factors. OLDCARTS. 3. Accepted clients R: Pain is a subjective description of pain. experience and cannot be felt by others. 4. Observed non-verbal R: Observations may or cues of pain. may not be congruent with verbal reports indicating need for further evaluation.

5. Provided comfort R: To provide measures such as back pharmacologic rub management.

nonpain

6. Encouraged to use R: To assist client to explore relaxation techniques methods for such as deep breathing alleviation/control of pain. exercises. Dependent Functions: 1. Given Celecoxib R: Inhibits prostaglandin 400mg one capsule now. synthesis, impeding cyclooxygenase-2, to produce anti-inflammatory, analgesic and antipyretic effects. 2. Ineffective Health Maintenance Date Identified: May 9, 2011 Cues: Related to insufficient resources such as lack of money to procure maintenance medications secondary low income as manifested by verbalization of, wala nako palita ang Acalka ug Rowatinez kay mahal man. Analysis of the Problem: Many variables influence a persons health status, beliefs, and behaviors or practices. An individual standard of living (reflecting occupation, income, and education) is related to health, morbidity, and mortality. Hygiene, food habits, and the propensity to seek health care advice and follow health regimens vary among high income and low income groups. Source: Kozier et al. Fundamentals of Nursing, 7th edition, pages 176-178. Statement of Patient Care Objectives: Within the course of nursing intervention, patient as well as the SO will be able to understand the importance of being compliant to the therapeutic regimen. They will be able to understand the importance of prevention and be able to verbalize the importance of health and wellness. Nursing Actions Rationale Independent Functions: 1. Assessed patients R: To know patients level of cognitive, ability to comprehend his emotional and physical situation. functioning. 2. Assessed patients R: To determine ability and desire to learn. barriers to learning. Evaluation Actual Outcome: May 9, 2011 After 2 hours of patient, SO and nurse interaction, patient verbalized, mao lagi, kailangan maminaw any sa unsay storya sa doctor kay sila ang mas

nakahibaw. 3. Assessed patients R: To identify if patient health regimen. understands about health and wellness; to know what approach to use in dealing with the patient during health teachings. 4. Assessed patients age R: To identify patients and level of dependency. level of understanding and to identify support persons to whom patient can rely to. 5. Determined level of adaptive behavior, knowledge, and skills about health maintenance, environment and safety. R: Determines beginning point for planning and interventions to assist client in addressing needs.

6. Noted setting where R: To be able to give patient lives. appropriate health teachings or interventions at home setting. 7. Noted patients use of R: To be able to have a professional services and view on what the resources. patients source of income. 8. Discussed with patient and SO beliefs about health and reasons for not following prescribed care plan. R: Determines patients view about current situation and potential for change.

9. Provided anticipatory R: To maintain and guidance. manage effective health practices during periods of wellness and identify ways patient can adapt when progressive illness or long term health problems occur.

10. Evaluated patient and R: To determine patient SOs comprehension on and SOs learning on the the health teachings patients condition. made. Dependent Functions: 1. Discharge instructions R: To inform patient of given by Dr. Aponesto take home medicines and follow up check up. B. Post-operative Phase 1. Acute Pain Date Identified: May 11-12, 2011 Cues: Related to surgical incision on the right lumbar area secondary to S/P Laparoscopic Ureterolithomy Right as manifested by presence of T-tube drain, limitation of movements, verbalization of, sakit siya gamay, aggravated by movements, relieved by pain medications and with a pain scale of 5/10. Analysis of the Problem: Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage. It occurs with many disorders, diagnostic tests, treatments and invasive procedures. Source: Smeltzer and Bare. Medical Surgical Nursing, Volume 1, page 217. All cellular damage caused by thermal, mechanical or chemical stimuli results in the release of excitatory nerutransmitters such as prostaglandins. These pain synthesizing substances surround pain receptors in the extracellular fluid creating the spread of the pain message and causing an inflammatory response. Source: Potter and Perry. Fundamentals of Nursing, 6th ed., page 1230. Statement of Patient Care Objectives: Within 1 hour of nursing interventions, patient will verbalize pain scale of 0-3/10. Nursing Actions Rationale Evaluation Independent Functions: Actual Outcome: 1. Monitored vital signs R: Usually altered in the May 11, 2011 every 4 hours. presence of pain After 1 hour of nursing interventions, patients 2. Performed a R: To assess pain is still noted with comprehensive etiology/precipitating a pain scale of 2/10. assessment of pain using contributory factors. OLDCARTS. May 12, 2011 After 1 hour of nursing 3. Accepted clients R: Pain is a subjective interventions, patients description of pain. experience and cannot be pain is not noted. felt by others.

4. Observed non-verbal R: Observations may or cues of pain. may not be congruent with verbal reports indicating need for further evaluation. 5. Provided comfort R: To provide measures such as back pharmacologic rub management. nonpain

6. Encouraged to use R: To assist client to explore relaxation techniques methods for such as deep breathing alleviation/control of pain. exercises. Dependent Functions: 1. Given Tramadol 50mg IVTT every 6 hours/Tramadol 50mg/tab 1 tab every 6 hours PRN for pain. R: Binds to mu opioid receptors and inhibits the reuptake of norepinephrine and serotonin

2. Impaired Tissue Integrity Date Identified: May 11-13, 2011 Cues: Related to mechanical breakdown of skin secondary to S/P Laparoscopic Ureterolithotomy as manifested by surgical incision and presence of T-tube at lumbar area right Analysis of the Problem: The creation of a surgical wound disrupts the integrity of the skin and its protective function. Source: Smeltzer and Bare. Medical Surgical Nursing, Volume 1, page 487. The skin serves as the primary defense against bacterial invasion. When skin is incised for surgical procedure, this important line of defense is lost. Strict adherence to aseptic technique during surgery and in days following the procedure is necessary to compensate for impaired defense. Source: Adele Pillitteri. Maternal and Child Health Nursing, 4th edition, page 613. Statement of Patient Care Objectives: Within 8 hours of nursing interventions, patients surgical incision with T-tube drain will be free from redness and purulent discharges. Nursing Actions Rationale Evaluation Independent Functions: Actual Outcome: 1. Practiced proper R: To reduce May 11, 2011 handwashing before and transmission of After 8 hours of nursing

after patient contact.

interventions, patients surgical incision was free 2. Noted signs and R: Fever, chills, from signs and symptoms symptoms of infection. diaphoresis, altered level of infection such as of consciousness, and redness and presence of positive blood cultures. purulent discharges. 3. Inspected surgical R: Early reacognition for May 12, 2011 incision and monitored T- signs of infection After 8 hours of nursing tube drain. prevents complication. interventions, patients surgical incision was free 4. Changed T-tube R: Soiled bags potentiate from signs and symptoms drainage bag when skin breakdown and of infection such as necessary. bacterial growth. redness and presence of purulent discharges. R: Reduces accumulation 5. Stressed hygienic of microorganisms May 13, 2011 measures. preventing infection. After 8 hours of nursing interventions, patients 6. Instructed to avoid use R: To promote circulation surgical incision was free of constrictive clothing. for better wound healing. from signs and symptoms of infection such as 7. Instructed to increase R: To prevent redness and presence of fluid intake. dehydration due to purulent discharges. presence of T-tube drain. 8. Encouraged to eat R: To promote tissue foods rich in protein and healing and boost Vitamin C. immune system. Dependent Functions: 1. Given Ciprofloxacin 200mg IVTT every 12 hours/Ciprofloxacin 500mg/tab 1 tab twice a day. R: Inhibits bacterial DNA synthesis, mainly by blocking DNA gyrase; bactericidal

microorganisms

3. Fatigue Date Identified: May 11, 2011 Cues: Related to stress of surgical operation secondary to S/P Laparoscopic Ureterolithotomy as manifested by nonverbal cues of weak presentation, tired and pallor appearance, decrease in performance, muscle strength of 4/5 both in upper and lower extremities, and verbalization of, kapoy jud akong paminaw ron.

Analysis of the Problem: As a common symptom, fatigue is associated with a variety of physical and psychological conditions. Other factors that influence the occurrence of fatigue may include inability to obtain enough rest, stress and anxiety. People with disabilities frequently experience fatigue. Physical weariness maybe caused by discomfort and pain associated with a health problem, and reconditioning associated with prolonged periods of bed. Source: Potter and Perry. Fundamentals of Nursing, 5th edition, page 1254 Statement of Patient Care Objectives: Within 8 hours of nursing interventions, patient will be able to achieve optimal amount of sleep and verbalize decrease of stress and manifest a rested appearance. Nursing Actions Rationale Independent Functions: 1. Noted presence of R: To identify factors contributing to precipitating factors. fatigue such as underlying diseases. 2. Noted reports of R: To identify causative weakness, fatigue, pain factors. and difficulty in accomplishing tasks. 3. Assisted in scheduling R: To improve respiratory a gradual increase in and cardiac conditioning daily activities. thus improving activity tolerance. 4. Planned care with rest R: To promote rest and periods. sleep. 5. Provided an R: To promote relaxation environment comfortable and sleep. for sleep and rest. 6. Encouraged SO to R: Energy conservation assist patient with self in doing activities can care needs. help relieve fatigue. 7. Encouraged to do R: This helps reduce relaxation activities such fatigue and promotes as deep breathing relaxation. exercises and listening to music. Evaluation Actual Outcome: May 11, 2011 After 8 hours of nursing interventions, the patient was able to take naps with a duration of 2 hours, but still looks tired and has weak presentation, muscle strength of 4/5 both in upper and lower extremities, and has verbalized, nakatulog naman ko gamay pero kapoy gihapon ko.

8. Encouraged to eat R: Calories give the body foods high in energy. carbohydrate and calories such as rice, bread and cereals as desired. 4. Partial Self Care Deficit Date Identified: May 11, 2011 Cues: Related to energy deficit, weakness, tiredness and fatigue secondary to S/P Laparoscopic Ureterolithotomy, Right as manifested by assistance in toileting and ambulating and muscle strength of 4/5 both in upper and lower extremities,. Analysis of the Problem: Self care deficits may range from not being able to react with a weak arm to full dependence on others. Clients experiencing weakness, tiredness, pain, discomfort, neuromuscular skeletal impairment may have difficulties in their activities of daily living. Source: Kozier et. al. Fundamentals of Nursing, 7th edition, page 702. Statement of Patient Care Objectives: Within 8 hours of nursing interventions, patient will be able to decrease level of dependency through cooperation in performing ADLs such as toileting and ambulating. Nursing Actions Rationale Independent Functions: 1. 1. Assessed usual R: May be able to level of functioning continue usual activity with necessary adaptations to current condition. Evaluation Actual Outcome: May 11, 2011 After 8 hours of nursing interventions, patient showed cooperation when performing ADLs with little assistance, still 2. Assessed barriers to R: Prepares for increased looks tired and weak. participation in self care independence which and identified enhances self esteem. environmental medications. 3. Collaborated with SO R: Enhances of the patient in caring for coordination and and assisting the patient. continuity of care optimizing outcomes. 4. Arranged patients bed R: To promote comfort linens.

5. Assisted patient when R: To prevent pressure turning to sides and in sores and muscle sitting up on bed. weakness from disuse. R: To promote comfort 6. Stressed measures. hygienic

7. Advised patient to R: To avoid orthostatic have gradual changes in hypotension. position. 8. Promoted environment R: To promote relaxation conducive for sleep and and increase energy rest. levels. 5. Risk for Infection Date Identified: May 11-13, 2011 Cues: Related to mechanical break on the skin surgical incision with presence of T-tube drain at lumbar area right secondary to S/P Laparoscopic Ureterolithotomy and presence of peripheral IV line. Analysis of the Problem: The creation of a surgical wound disrupts the integrity of the skin and its protective function. Source: Smeltzer and Bare. Medical Surgical Nursing, Volume 1, page 487. The skin serves as the primary defense against bacterial invasion. When skin is incised for surgical procedure, this important line of defense is lost. Strict adherence to aseptic technique during surgery and in days following the procedure is necessary to compensate for impaired defense. Source: Adele Pillitteri. Maternal and Child Health Nursing, 4th edition, page 613. Statement of Patient Care Objectives: Within 8 hours of nursing interventions, patient will be free from any signs of infection on the incision site with T-tube drain such as redness, purulent discharges and elevated temperature. Nursing Actions Rationale Independent Functions: 1. Assessed incision with R: To monitor signs and the T-tube for redness, symptoms of infection. increased pain and purulent discharges. Evaluation Actual Outcome: May 11, 2011 After 8 hours of nursing interventions, patient was free from any signs of infection such as redness 2. Assessed stability of R: Improperly secured and purulent discharges tube. drains allow access of on incision site with T-

pathogens where tubes tube drain and are placed. 37.2oC/axilla. 3. Performed R: To prevent handwashing before and transmission of after patient contact. microorganisms. 4. Stressed measures. 5. Changed drainage bag necessary. hygienic R: To reduce bacterial growth. T-tube R: Soiled bags when potentiate skin breakdown and bacterial growth.

6. Instructed to avoid use R: To promote circulation of constrictive clothing. for better wound healing. 7. Instructed to increase R: To prevent fluid intake. dehydration due to presence of T-tube drain. 8. Encouraged to eat R: To promote tissue foods rich in protein and healing and boost Vitamin C. immune system. Dependent Functions: 1. Given Ciprofloxacin 200mg IVTT every 12 hours/Ciprofloxacin 500mg/tab 1 tab twice a day. R: Inhibits bacterial DNA synthesis, mainly by blocking DNA gyrase; bactericidal

6. Risk for Impaired Tissue Perfusion: Peripheral Date Identified: May 11, 2011 Cues: Related to prolonged time in the OR: approximately 4 hours of surgery, positioning in the operating room, and blood loss during the surgery secondary to S/P Laparoscopic Ureterolithotomy. Analysis of the Problem: Those who are confined to bed or wheelchair for longer periods of time, triggers vasoconstriction due to pressure which results in decreased blood flow in the skin. In addition, because vasoconstriction of the skin reduces body heat loss, the difference between the core temperature and skin temperature may increase. (http://www1.us.elsevierhealth.com/MERLING/Gulanick/Constructor)

Although vessels that must be cut for surgery are immediately clamped and ligated, some blood loss occurs with surgery. This could lead to ineffective tissue perfusion of all body tissues if the problem is not quickly recognized and corrected. Source: Adele Pillitteri. Maternal and Child Health Nursing, 4th edition, page 568. Statement of Patient Care Objectives: Within 8 hours of nursing interventions, patient maintains optimal tissue perfusion as manifested by strong peripheral pulses, V/S within normal range, CRT < 2 secs on both upper and lower extremities, pink nailbeds, lips and palpebral conjunctiva. Nursing Actions Rationale Independent Functions: 1. Assessed for normal R: These are indicators skin color. Palpated of adequate tissue peripheral pulses. perfusion. 2. Assessed CRT, pallor, R: Indicates capability to pulse rate, cyanosis and provide blood supply to temperature changes of distal tissues. extremities. 3. Monitored vital signs R: To have baseline data. every 4 hours. 4. Elevated head of bed. patients R: To promote venous return and facilitate gravitational blood flow. Evaluation Actual Outcome: May 11, 2011 After 8 hours of nursing interventions, patients vital signs are BP = 120/80mmHg, PR =, + 3 peripheral pulses on left hand and +2 peripheral pulses on right hand, CRT < 2 secs on both lower and upper extremities, pale nailbeds, lips and pink palpebral conjunctiva.

5. Assisted patient when R: Promotes increased turning to sides and in circulation to distal ambulating. tissues. 6. Advised patient not to R: To promote adequate wear constrictive circulation. clothing. 7. Encouraged to sleep R: To decrease oxygen and rest consumption and demand.

CHAPTER VIII DISCHARGE PLAN Date Implemented Time Frame May 13, 2011 Within 15 minutes of nurse patient interaction, nurse will be able to give discharge instructions to patient and SO. Health Teachings Medications - Instructed patient to take medications as advised by the doctor and do not discontinue medications if not indicated. - Instructed patient to take prescribed medication at the right route, right dose, and right frequency at the right time. - Instructed to take the antibiotics for the full course of therapy even when feeling well already. - Advised to keep track with the medications by having a list of it all with their corresponding time and dosage. Environment - Encouraged patient to maintain cleanliness of the house and surroundings. - Encouraged patient to place medicines in a medicine cabinet or in a container away from harmful substances. - Encouraged to keep environment Outcome After 15 minutes of nurse patient interaction, patient verbalized, mubalik ko diri Maam sa akong schedule and paningkamutan nako na masunod tanan imong gistorya nako kay para man pud ni sa akong kaayohan. Salamat kaayo.

conducive for resting. - Encouraged to provide adequate lighting at home. Treatment - Instructed to return on the follow up check up one week after discharge or as instructed by the doctor. - Instructed not to take OTCs without consulting doctor. - Advised not to self medicate as much as possible. - Instructed patient that whenever she has questions, she must not hesitate to ask her doctor. Health Teachings - Instructed patient to avoid calcium rich and highly acidic foods. - Encouraged to have oral fluid intake of at least 1L/day. - Encourage to do regular exercise of at least 30 minutes in a day. Stressed the importance of having proper hygienic measures. - Encouraged to have adequate rest and sleep with at least 8 hours in a day.

- Advised patient that whenever she feels the urgency to void she must do so. - Instructed to watch out for signs and symptoms of infection on surgical site and T-tube drain such as redness, swelling, pain and purulent discharges. - Advised to change T-tube drainage bag as necessary. - Advised to perform handwashing regularly. Observable Signs and Symptoms - Advised to watch out for intermittent sudden sharp pain on lumbosacral radiating to the hypogastrium. - Instructed to watch out for signs of infection such as redness, swelling, purulent discharges and elevated temperature. - Instructed patient to refer all unusualities to the doctor. Diet - Instructed patient to avoid foods that are calcium rich and highly acidic. - Foods to avoid: Cheese, - Avoid alcoholic and

caffeinated beverages. - Encouraged to eat fruits, vegetables, and meat to facilitate tissue healing. Safety, Security and Spirituality - Encouraged to continue faith and belief in God. - Encouraged patient to continue praying everyday and attending mass every Wednesday and Sunday. - Advised to seek medical help to ensure safety with regards to her health condition. - Advised to always seek family support whenever problems arise.

CHAPTER IX CONCLUSION The increasing prevalence rates of acquiring urinary calculi have ushered to create an adequate number of possible interventions to the patients condition. Ureterolithiasis when not managed can lead to devastating effects. Patient has had an operation of Laparoscopic Uretrolithotomy, Right. Total care was given to the patient. The different aspects of health: physical, emotional, and mental were given consideration and priority. Both external and internal environmental stimuli were altered positively as best as possible since these are contributing factors to the adaptation of the patient. These were done through health assessment, plans, interventions and health teachings that were all aimed for the patient. Dependent functions done were giving of medications such as Tramadol, Ketorolac, Ranitidine, Ciprofloxacin, Celecoxib, Diphenhydramine, and Fleet enema; and administration of IVF as ordered. Independent functions done to the patient were vital signs monitoring, providing comfort measures, health teachings, maintaining a therapeutic and secured environment, assisted in her activities of daily living, assessed presence of pain, and preventing and evaluating any signs of infections. On the substitutive role, nurse does morning care to our patient to promote proper hygiene, assist the patient when moving and toileting. And on our complimentary role we help the client in keeping oriented to her environment as much as possible by talking to her of what is happening around her. And on the supplementary role we provided health teachings necessary about the condition to the SO of the client. On the 14 basic needs of the patient, the following interventions were done: Physiological 1. Breathe normally. (Maintaining patent airway by elevating head of bed) 2. Eat and drink adequately (Encouraged patient to eat balanced meals a day and to avoid foods that may trigger crystal formation.) 3. Eliminate body wastes. 4. Move and maintain desirable postures. (Assisting her in attaining the desired position that she wants and that is comfortable to her.) 5. Sleep and rest (Promoted an environment conducive to sleeping and resting.) 6. Select suitable clothes (help in dressing up the patient). 7. Maintain body temperature within normal range by adjusting clothing and modifying the environment. (Placing blanket and assessing body temperature every 4 hours.) 8. Keep the body clean and well groomed and protect the integument. (Assisted in grooming and stressed hygienic measures and in doing

morning care) 9. Avoid dangers in the environment and avoid injuring others. (Encouraged SO to keep watch at all times) 10. Communicate with others in expressing emotions, needs, fears, or opinions. (Talking to the patient about life experiences and establishing rapport.) 11. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities. Spiritual 12. Worship according to ones faith (Encouraged to continue her religious practices even if she is hospitalized.) Sociological 13. Work in such a way that there is a sense of accomplishment. (We also make sure that the interventions done are for the best of the client) 14. Play or participate in various forms of recreation. Since the patient is responsive, coherent and cooperative, the researcher assisted the patient in performing activities that contributes to her recovery in order for her to gain independence as rapidly as possible.

CHAPTER X RECOMMENDATIONS That patients suffering from the same disease should always have proper management as to what are the regimens or procedures that need to be done in order to control the disease or prevent further complications. That all members of the health care team must maintain or if not enhance their capabilities in promoting, preventing, treating and rehabilitating patients suffering from the disease. Also, to always educate the patients about their condition since health education is still the best intervention they can do. Furthermore, they must also recognize the challenges of the disease management and keep abreast of new information. That the future researchers/nurse trainees would do better to indulge in a more advanced assessment and review of the topic in order to come up with a more comprehensive study and to aid other researchers conducting further study of the chronic complications of ureterolithiasis . That the general public should be aware of that implementing lifestyle changes certainly helps in the prevention of lifestyle related diseases. In the great many among people who are at risk, the familiarity of ureterolithiasis to prevent needless possibilities of ureterolithiasis.