I. INTRODUCTION: Nephrolithiasis (kidney stones) is a disease affecting the urinary tract.

Kidney stones are small deposits that build up in the kidneys, made of calcium, phosphate and other components of foods. They are a common cause of blood in urine. Some types of stones tend to run in families. Some types may be associated with other conditions such as bowel disease, ileal bypass for obesity, or renal tubule defects. A personal or family history of stones is associated with increased risk of stone formation. Other risk factors include renal tubular acidosis and resultant nephrocalcinosis. Kidney stone formation may result when the urine becomes overly concentrated with certain substances. These substances in the urine may complex to form small crystals and subsequently stones. Stones may not produce symptoms until they begin to move down the ureter, causing pain. The pain is severe and often starts in the flank region and moves down to the groin. The size of the renal stone will dictate the natural history of this condition. If the stone is less the 5mm in diameter, then it will most likely pass on future urination. If the stone is larger than 5mm, urological procedures may be required to remove the stone. Surgical intervention will be required in any patient whose urinary tract in completely obstructed. This situations represents a surgical emergency. Symptoms of renal stone disease may include:

Pain: unilateral or bilateral flank or back pain. Is is normally severe and colicky (spasm-like) in nature, radiating to the pelvis, groin and/or genitals. Nausea, Vomiting, Urinary frequency/urgency, Haematuria (blood in the urine), Abdominal pain, Dysuria (painful urination), Nocturia (excessive at night), Urinary hesitancy, Fever, Chills and Abnormal urine color or smell.

A number of blood and urine tests will be required to detect the presence of infection and test the function of the kidneys. Urinary tests may also allow the type of stone to be identified, allowing further guidance of therapy. When urinary stones are suspected, a x-ray of the abdomen is also required to detect the stones or any other problem causing a similar set of symptoms. Kidney stones are painful but usually are excreted without causing permanent damage. They tend to recur, especially if the underlying cause is not found and treated.

II. PATIENTS PROFILE: Name: Rodel Garcia Age: 25 years old Sex: Male Civil Status: Married Religion: Roman Catholic Address: Ilocos Norte Occupation: Soldier Current Diagnosis: Nephrolithiasis left II. CHIEF COMPLAINTS: The patient complains of pain at right lower quadrant area radiating to flank right. III. HISTORY OF PRESENT ILLNESS: Patient came in with an ultrasound result of nephrolithiasis left hence, admission. IV. PAST MEDICAL HISTORY: At the year of 2004 she underwent TAHBSO because of ovarian cyst at Veterans Hospital. And in 2007 she was hospitalized because of diabetes. Pt. has no allergies with medications prescribed to her. She has no injuries or accidents incurred. Pt. is hypertensive and diabetic. V. SOCIAL AND ENVIRONMENTAL HISTORY: Mrs. R.M 52 years old mother of 6 children admits that at the age of 18 she began to smoke 5 sticks per day then stopped at year 2009 but started to drink occasionally for socialization purposes. She is fond of eating high salt and high sugar foods with a bottle of acidic beverages. Almost everyday, she eats junk foods, softdrinks and loves to eat in fast food restaurants like jollibee, KFC, and Mcdo. The client is a housewife, and is a high school graduate. She is friendly and loves to mingle with others. Due to her kindness, generosity, and friendly 2

attitude, she is loved by many and is always visited by her neighbors, friends, and relatives in their house and they used to have snacks. Their house is sited along the street and was surrounded by mango trees. She loves to eat mango with fish sauce/ alamang, then loves to take a sip on it. VI. FAMILY HISTORY: The patients father died because of stroke and hypertension. The mother was deceased with a history of diabetes and hypertension. They had nine siblings, two were twins; our patient was the second child. Two of her sisters was also diabetic and most of them were hypertensive. According to her, their relatives from the mother side have the same illness also and some relatives passed away with the same health problem. VII. PHYSICAL EXAMINATION: GENERAL SURVEY Pt is 52 in height and 73kgs in weight, she is overweight. Pt. has a good posture and gait but her movement was quite limited because of discomfort in her inflamed left foot due to accident before admission. She, during our duty, sometimes complains of on and off pain at the RLQ radiating to back rated as 58/10, from a scale of 0-10, 10 being the highest. Appears clean and neat, practices good hygiene. Mrs. R.M is cooperative and coherent. She has an ongoing IVF of D5LRS infusing well at the left hand.

2. HEAD, EYES, EARS, NOSE, THROAT a. HEAD The clients head is symmetrical and no fracture observed with a smooth short black evenly distributed hair without flakes, lesions, masses, tenderness and head lice noted on scalp. Face is symmetrical, no pain and tenderness on the temporomandibular joint upon palpation. b. EYES Eyes are symmetrical with evenly distributed hair in the eyebrows and eyelashes. Eyelids can close properly and no difficulty. No discharges, lesions, redness, swelling noted on both eyes. Sclera appears white and palpebral conjunctiva appears pink in color. Pupils are black and symmetrical, pupil is dilated and reactive to light at 2-3 mm. The client has no known deficits such as color blindness. She was not able to read 3

magazines or newspaper at a distance of 36 cm without using reading glass. c. EARS Auricles are symmetrical and the same color as facial skin, has a clean external auditory canal without lesions or discomfort noted. She can hear at a distance of about 2 feet by repeating what we said as requested her to do so. And using the watch tick test she was able to hear ticking and hearing is intact. d. NOSE External nose color is same as facial skin, symmetrical nares, moist pink mucosal wall without discharges and lesions noted. Has a patent nasal cavities and no masses noted. Can differentiate odors since when asked to close her eyes and discriminate orange and coffee, she was able to distinguish the odors of the two. e. THROAT The throat was not edematous and no lesions observed. 3. RESPIRATORY SYSTEM Mrs. R.M has clear breath sounds, no adventitious sound heard upon auscultation with a respiratory rate of 20 bpm which is within normal range. She is not suffering from any form of respiratory disress. 4. CARDIOVASCULAR SYSTEM The patients blood pressure ranges from 140/60 up to 160/100 mmHg at the left arm while on lying position. Extremities are warm to touch and peripheral pulses are present, regular and palpable but weak at the radial. Apical pulse is 62 bpm which is within normal. 5. GASTROINTESTINAL SYSTEM The abdomen is globular in shape; non distended, soft, no direct and rebound tenderness. Tympanic sound is heard upon percussion over the bladder. 6. GENITO-URINARY SYSTEM The client eliminates at comfort room. His urine output ranges from 100-1000ml, amber in color for 12hrs and has bowel movement one to two times a day. No bladder distention upon assessment at the hypogastric region. 7. MASCULO- SKELETAL SYSTEM

The client is not in complete bed rest without bathroom privileges and needs minimum assistance in moving and performing ADL because of inflamed left foot. Client is able to perform flexion, extension, abduction and adduction independently. No other deformities observed. 8. INTEGUMENTARY SYSTEM The client has a pink palpebral conjunctiva. Skin is moist and warm to touch. No lesion, cracks, signs of inflammation and bruises noted. The client has a short, smooth well comb black hair. No dandruff and parasites observed. Nails are clean and well trimmed. 9. NERVOUS SYSTEM Orientation of three areas (time, place and date) was not limited because the client was able to communicate well. Can communicate well by verbalization, understands simple to complex instruction, able to write and read. It is evident that intellectual development is appropriate on his age.

VIII. DIAGNOSTIC:

DATE March 7, 2010

DIAGNOSTIC PROCEDURE KUB

DESCRIPTION X rays are a form of radiation that can penetrate the body and produce an image on an x-ray film. Another name for x ray is radiograph. Consist of two views, the frontal view (referred to as posterioranterior or PA) and the lateral (side) view. It is preferred that the patient stand for this exam, particularly when studying collection of fluid in the lungs.

PURPOSE Used to evaluate organs and structures within the chest for symptoms of diseases. Chest x-ray include views of the lungs, heart, small portion of the GIT, thyroid gland and the bones of the chest area

RESULT Hazy opacities are seen on the right middle lobe Heart is not enlarged Pulmonary vascularity is within normal. Visualized osseous structures are unremarkable.

IMPRESSION Pneumonitis, right middle lobe

DATE March 11, 2010

DIAGNOSTIC PROCEDURE CBC

DESCRIPTION Is a series of test used to evaluate the composition and concentration of the cellular components of blood.

PURPOSE As a preoperative test to ensure both adequate oxygen carrying capacity and hemostasis

NORMAL WBC= 5.010.0

RESULT 10.2x10^9/L

Granulocyte s= 2.0-7.0 Granulocyte s (%)=50.070.0 MCV= 82.095.0 MCH=27.031.0

7.2x10^9/L 70.5% 96.8 fL 31.9 pq

IMPRESSION White blood cells help fight infection. It also help produce, transport and distribute antibodies to build the bodys immune system. A high count indicates not a specific disease by itself but indicates infection, systemic illness, inflammation, allergy and leukemia, too much of mental stress also increases the count of the white blood cells in the body. Also, once the count of white blood cell is on the higher side, the risk of cardiovascular mortality also increases. When the number is high, it indicates an infection or inflammation somewhere in the urinary tract. When the number is high, it indicates an infection or inflammation somewhere in the urinary tract. Increased with B12 and Folate deficiency; decreased with iron deficiency and thalassemia Mirrors MCV results

DATE March 13,, 2010

DIAGNOSTIC PROCEDURE ECG

DESCRIPTION A test that checks for problems with the electrical activity of your heart.

PURPOSE An electrocardiogram is done to know if:

RESULT PR= .18 QRS=.06

The heart's electrical activity. The cause of unexplained chest pain The cause of symptoms of heart disease How well medicines are working and whether they are causing side effects PURPOSE The troponin test is used to help diagnose a heart attack, to detect and evaluate mild to severe heart injury, and to distinguish chest pain that may be due to other causes.

INTERPRETATION Normal ( 0.12-0.20 sec) Duration should not exceed 0.10 second. A widened complex indicates ventricular enlargement

QT=.34

DATE March 13,, 2010

DIAGNOSTIC PROCEDURE Troponin I

DESCRIPTION Troponin tests are primarily ordered for people who have chest pain to see if they have had a heart attack or other damage to their heart. Either a troponin I or a troponin T test can be performed; usually a laboratory will offer one test or the other.

RESULT negative

IMPRESSION Normally, cardiac troponin levels are so low that they cannot be measured. Even slight elevations may indicate some degree of damage to the heart. When a patient has significantly elevated troponin concentrations, then it is likely that the patient has had a heart attack or some other form of damage to the heart 9

DATE March 22, 2010

DIAGNOSTIC PROCEDURE Creatinine

DESCRIPTION PURPOSE RESULT Test is used to assess This test 88.4 umol/L kidney function. measures how effectively your kidneys are filtering small molecules

NORMAL Normal: 44.2150.28 umol/L

IMPRESSION Increased creatinine levels in the blood suggest diseases or conditions that affect kidney function. These can include: Low blood levels of creatinine are not common, but they are also not usually a cause for concern. They can be seen with conditions that result in decreased muscle mass. IMPRESSION

DATE

DIAGNOSTIC PROCEDURE

DESCRIPTION

PURPOSE

RESULT

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March 23, 2010

Ultrasound of A kind of Identify Kidneys, ultrasound suspected Urinary Bladder scan of the problems in the abdomen and urinary system, pelvis such as a kidney stone or blockage in the intestine

Right kidney: 10.60x5.07 cm Cortical thickness: 2.18 Left kidney: 9.63x4.88cm Cortical thickness: 1.37 Both kidneys are normal in size with smooth borders and homogenous parenchymal echopattern. The right cental renal echocomplex is slightly separated. Both cortical thickness are within normal. Multiple hyperechoic foci are seen at the right interpolar area with the largest measuring 2.3cm. Perinephric regions are unremarkable.

Multiple nephrolithiasis with mild hydronephrosis. Right kidney sonographically normal left kidney and urinary bladder.

DATE April 3, 2010

DIAGNOSTIC PROCEDURE Urinalysis

DESCRIPTION Urinalysis is a test that evaluates a sample of your urine. Urinalysis is used to detect and assess a wide range of disorders, including urinary tract infection, kidney disorders and diabetes.

PURPOSE They detect the byproducts of normal and abnormal metabolism, cells, cellular fragments, and bacteria in urine.

RESULT Color Yellow

Ph Specific gravity

6.0 1.03

Sugar

+1

IMPRESSION Normal urine is straw yellow to amber in color. Abnormal colors include bright yellow, brown, black (gray), red, and green. These pigments may result from medications, dietary sources, or diseases. pH level indicates the amount of acid in urine. Abnormal pH levels may indicate a kidney or urinary tract disorder. normally 5 to 7 Specific gravity shows how concentrated particles are in your urine. Higher than normal concentration often is a result of dehydration, rather than another underlying medical condition. But, it may indicate a kidney disorder. normally 1.003 to 1.030 normally the amount of sugar (glucose) in urine is too low to be

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Appeara nce

Pus cells RBC

detected. Any detection of sugar on this test usually calls for follow-up testing for diabetes. Slightly Normal urine is transparent. Turbid (cloudy) urine may be caused turbid by either normal or abnormal processes. Normal conditions giving rise to turbid urine include precipitation of crystals, mucus, or vaginal discharge. Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria. 1-3 Normal (Normal value for pus cells in urine is 0-5/hpf) 4-6 Red blood cells (erythrocytes) may be a sign of kidney disorders, blood disorders or another underlying medical condition, such as bladder cancer.

DATE April 11., 2010

DIAGNOSTIC PROCEDURE Urinalysis

DESCRIPTION Urinalysis is a test that evaluates a sample of your urine. Urinalysis is used to detect and assess a wide range of disorders, including urinary tract infection, kidney disorders and diabetes.

PURPOSE RESULT They detect the Color Light byproducts of yellow normal and abnormal metabolism, Appear Slightly cells, cellular ance turbid fragments, and bacteria in urine. pH 5.0

IMPRESSION Normal urine is straw yellow to amber in color. Abnormal colors include bright yellow, brown, black (gray), red, and green. These pigments may result from medications, dietary sources, or diseases. Normal urine is transparent. Turbid (cloudy) urine may be caused by either normal or abnormal processes. Normal conditions giving rise to turbid urine include precipitation of crystals, mucus, or vaginal discharge. Abnormal causes of turbidity include the presence of blood cells, yeast, and bacteria. pH level indicates the amount of acid in urine. Abnormal pH levels may indicate a kidney or urinary tract disorder. normally 5

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RBC Protein

1-15 Trace

Pus 1-2 Specific 1.005 gravity

Sugar

Negativ e

to 7 Red blood cells (erythrocytes) may be a sign of kidney disorders, blood disorders or another underlying medical condition, such as bladder cancer. Increase in protein usually aren't a cause for concern. Larger amounts of protein in the urine may indicate a kidney problem. Normal (Normal value for pus cells in urine is 0-5/hpf) Specific gravity shows how concentrated particles are in your urine. Higher than normal concentration often is a result of dehydration, rather than another underlying medical condition. But, it may indicate a kidney disorder. normally 1.003 to 1.030 Normally the amount of sugar (glucose) in urine is too low to be detected. Any detection of sugar on this test usually calls for follow-up testing for diabetes.

DATE April 14, 2010

DIAGNOSTIC PROCEDURE SGPT

DESCRIPTION PURPOSE Is found in serum and in typically used to various bodily tissues, but is detect liver injury most commonly associated with the liver.

RESULT 20.5 u/l

NORMAL Normal: 5-35u/l

HgbA1c

Is a form of hemoglobin used primarily to identify the

Monitoring the HbA1c in type-1

7.8%

4.8%-6.9%

IMPRESSION elevated levels of SGPT often suggest the existence of other medical problems such as viral hepatitis, congestive heart failure, liver damage, bile duct problems, infectious mononucleosis, or myopathy. In poorly controlled diabetes, its 8.0% or above,

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average plasma glucose concentration over prolonged periods of time. It is formed in a non-enzymatic pathway by hemoglobin's normal exposure to high plasma levels of glucose.

diabetic patients may improve treatment

and in well controlled patients it's less than 7.0%

IX. MEDICAL DIAGNOSIS: Nephrolithiasis right, HPN, DM 2, Obese

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X. COMPREHENSIVE PATHOPHYSIOLOGY:

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XI. TREATMENT and MANAGEMENT: A.) Drug study TRADE AND GENERIC NAME Trade Name: Zydol Generic name: Tramadol CLASSIFICATION Pharmacologic class: Opioid agonist Therapeutic class: Analgesic MECHANISM OF ACTION Inhibits reuptake of serotonin and norepinephrine in CNS SIDE EFFECTS CNS: dizziness, headache, drowsiness, anxiety, confusion EENT: visual disturbances GI: nausea, constipation abdominal pain, dyspepsia, flatulence, dry mouth GU: urinary retention and frequency, proteinuria, menopausal symptoms Skin: pruritus, sweating Other: physical or psychological drug dependence, drug tolerance NURSING INTERVENTIONS Patient monitoring Assess patients response to drug 30 minutes after administration. Monitor respiratory status.Withhold drug and contact prescriber if respirations become shallow or slower than12 bpm. Monitor for physical and psychological drug dependence. Report signs to prescriber. Patient teaching Tell patient drug works best when taken before pain becomes severe. Inform patient (and significant other as appropriate) that drug may cause respiratory depression if used with alcohol. Recommend abstinence. Tell patient drug interacts with many common OTC 17

drugs and herbal remedies. Instruct him to consult prescriber before taking these products.

TRADE AND GENERIC NAME Trade Name: Rocephin Generic name: Ceftriaxone

CLASSIFICATION Pharmacologic class: Thirdgeneration Cephalosporin Therapeutic class: Anti-infective

MECHANISM OF ACTION Interferes with bacterial cell-wall synthesis and division by binding to cell wall, causing cell to die.

SIDE EFFECTS CNS: headache, confusion, hemiparesis, CV: hypotension GI: nausea, abdominal cramps Hematologic: lymphocytosis, eosinophilia, bleeding tendency, hemolytic anemia Musculoskeletal: arthralgia Skin: urticaria Other: pain at I.M. injection site

NURSING INTERVENTIONS Patient monitoring Monitor coagulation studies. Assess CBC and kidney function test results. Be aware that crosssensitivity to penicillins and cephalosporins may occur. Patient teaching Instruct patient to report persistent diarrhea, bruising, or bleeding. Caution patient not to use herbs unless prescriber approves.

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TRADE AND GENERIC NAME Trade Name: Toradol Generic name: ketorolac tromethamine

CLASSIFICATION Pharmacologic class: Nonsteroidal anti-inflammatory drug (NSAID) Therapeutic class: Analgesic, antipyretic, anti-inflammatory

MECHANISM OF ACTION Interferes with prostaglandin biosynthesis by inhibiting cyclooxygenase pathway of arachidonic acid metabolism; also acts as potent inhibitor of platelet aggregation

SIDE EFFECTS CNS: drowsiness, headache, dizziness CV: hypertension EENT: tinnitus GI: nausea, vomiting, diarrhea, constipation, flatulence, dyspepsia, epigastric pain, stomatitis Hematologic: thrombocytopenia Skin: rash, diaphoresis Other: excessive thirst, injection site pain

NURSING INTERVENTIONS Patient monitoring Check I.M. injection site for hematoma and bleeding. Monitor fluid intake and output. Patient teaching Inform patient that drug is meant only for short-term pain management. Advise patient to minimize GI upset by eating small, frequent servings of healthy foods. Instruct patient to avoid aspirin products and herbs during therapy. Caution female patient not to take drug if she is breastfeeding. especially those related to the drugs, tests, and herbs mentioned above.

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TRADE AND GENERIC NAME Trade Name: Januvia Generic name: sitagliptin phosphate

CLASSIFICATION Pharmacologic class: Dipeptidyl peptidase 4 (DPP-4) inhibitor Therapeutic class: Hypoglycemic

MECHANISM OF ACTION Inhibits DPP-4 and slows inactivation of incretin hormones, helping to regulate glucose homeostasis through increased insulin release and decreased glucagon levels

SIDE EFFECTS CNS: headache EENT: nasopharyngitis GI: abdominal pain, nausea Respiratory: upper respiratory tract infection Other: hypersensitivity reactions

NURSING INTERVENTIONS Patient monitoring Monitor blood glucose and hemoglobin levels periodically during therapy. Monitor patient for signs and symptoms of hypersensitivity reactions and immediately stop drug and institute emergency measures if such reactions occur. Check for diabetes signs and symptoms and disease progression routinely during therapy. Patient teaching Instruct patient to take drug with or without food. Teach patient about signs and symptoms of hypoglycemia (such as blurred vision, sweating, excessive hunger, drowsiness, and fast 20

heart rate). Teach patient about signs and symptoms of hypersensitivity reactions and to immediately contact prescriber if these occur. Instruct patient to routinely monitor blood glucose levels at home.

TRADE AND GENERIC NAME Trade Name: Fortamet Generic name: metformin hydrochloride

CLASSIFICATION Pharmacologic class: Biguanide Therapeutic class: Hypoglycemic

MECHANISM OF ACTION Increases insulin sensitivity by decreasing glucose production and absorption in liver and intestines and enhancing glucose uptake and utilization

SIDE EFFECTS GI: diarrhea, nausea, abdominal bloating Metabolic: lactic acidosis Other: unpleasant metallic taste, decreased vitamin B12 level

NURSING INTERVENTIONS Patient monitoring Monitor blood glucose level closely. Monitor kidney and liver function tests. Watch for signs and symptoms of lactic acidosis. Stop drug if acidosis occurs. To aid differential diagnosis, check electrolyte, ketone, glucose, blood pH, lactate, and metformin blood levels. Patient teaching Teach patient about diabetes and importance of 21

proper diet, exercise, weight control, and blood glucose monitoring. Inform patient that drug may cause diarrhea, nausea, and upset stomach. Advise him to take it with meals to reduce these effects, and tell him that adverse effects often subside over time.

TRADE AND GENERIC NAME Trade Name: Micardis Generic name: Telmisartan

CLASSIFICATION Pharmacologic class: Angiotensin II receptor antagonist Therapeutic class: Antihypertensive

MECHANISM OF ACTION Inhibits vasoconstricting effects and blocks aldosteroneproducing effects of angiotensin II at various receptor sites, including vascular smooth muscle and adrenal glands

SIDE EFFECTS CNS: dizziness, headache, fatigue CV: chest pain, peripheral edema, hypertension EENT: sinusitis, pharyngitis GI: nausea, vomiting,dyspepsia, abdominal pain Musculoskeletal: myalgia, back and leg pain Other: pain, flu or flulike symptoms

NURSING INTERVENTIONS Patient monitoring Watch for signs and symptoms of hypotension. Patient teaching Tell patient to take 1 hour before or 2 hours after meals. Caution patient not to remove tablet from blister pack until just before taking. Advise patient to report swelling or chest pain. Teach patient to measure blood pressure regularly and report significant changes. 22

 As appropriate, review all other significant adverse reactions and interactions, especially those related to the drugs, tests, and foods mentioned above.

TRADE AND GENERIC NAME Trade Name: Catapres Generic name: Clonidine

CLASSIFICATION Pharmacologic class: Centrally acting Sympatholytic Therapeutic class: Antihypertensive

MECHANISM OF ACTION Stimulates alphaadrenergic receptors in CNS, decreasing sympathetic outflow, inhibiting vasoconstriction, and ultimately reducing blood pressure. Also prevents transmission of pain impulses by inhibiting pain pathway signals

SIDE EFFECTS CNS: drowsiness, dizziness CV: hypotension palpitations GI: nausea, constipation, dry mouth GU: urinary retention, nocturia Metabolic: sodium retention Skin: rash, sweating Other: weight gain

NURSING INTERVENTIONS Patient monitoring Monitor patient for signs and symptoms of adverse cardiovascular reactions. Frequently assess vital signs, especially blood pressure and pulse. Monitor patient for drug tolerance and efficacy. Patient teaching Instruct patient to move slowly when sitting up or standing, to avoid dizziness or light-headedness caused by sudden blood pressure decrease. 23

in brain.

B. IV Fluids COMPONENT N 24 CLASSIFICATIO EFFECTS/ USES SIGNIFICANCE

PNSS

ISOTONIC

o Used to replace fluids in dehydration o Used frequently in intravenous drips (IVs) for patients who cannot take fluids orally and have developed or are in danger of developing dehydration or hypovolemia o Used to replace fluids in dehydration, go with blood transfusions, hyponatremia, and burn victims, it is isotonic,( same osmolarity as our body fluids

o Replacement & maintenance of fluid & electrolytes. o Restores the blood volume rapidly. o The first fluid used when hypovolemia is severe enough to threaten the adequacy of blood circulation and has long been believed to be the safest fluid to give quickly in large volumes.

COMPONENT PLRS

CLASSIFICATION ISOTONIC

EFFECTS/ USES o When administered intravenously, these solutions provide sources of water and electrolytes. Their electrolyte content resembles that of the principal ionic constituents of normal plasma and the solutions therefore are suitable for parenteral replacement of extracellular losses of fluid and electrolytes.

SIGNIFICANCE o For replacement of acute extracellular fluid losses without disturbing normal electrolyte relationships.

XII. NURSING DIAGNOSIS 25

ACTUAL PROBLEM 1: Acute pain related to presence of obstruction or movement of stone within the urinary system secondary to nephrolithiasis Assessment S: nagsakit daytoy ko(pointing her abdominal and flank area) >rated pain as 8 with 10 being the highest O: >w/ guarding behavior noted >complains of pain upon palpation on the RLQ of abdomen >facial mask of pain observed >prefers to position self in side lying A>Acute pain related to presence of obstruction or movement of stone within the urinary system secondary to nephrolithiasis Explanation of the problem Nephrolithiasis: The process of forming a kidney stone, a stone in the kidney (or lower down in the urinary tract). Kidney stones are a common cause of blood in the urine and pain in the abdomen, flank, or groin. Kidney stones occur in 1 in 20 people at some time in their life. The development of the stones is related to decreased urine volume or increased excretion of stone-forming components such as calcium, oxalate, urate, cystine, xanthine, and phosphate. The stones form in the urine collecting area (the pelvis) of the kidney and may range in size from tiny to staghorn stones the size of the renal pelvis itself. The cystine stones (below) compared in size to a quarter were obtained from the kidney Objective STO: After 2 to 4 hours of nursing interventions the patient will verbalize relief of pain from a scale of 8/10 to 3-5/10 Intervention Dx: >observed non verbal cues of pain Rationale >observation may/may not be congruent with verbal reports or may be an indicator of present complaint when client is unable to verbalize >to rule out worsening of underlying condition/development of complication >to help determine possibility of underlying condition or organ dysfunction requiring treatment >to reduce pain and promote comfort >to promote non pharmacological pain management >to facilitate passage of stone through the urinary system >to maintain 26 Evaluation Goal met since After 2-4 hours of nursing interventions the patient was able to report relief of pain from 8/10 to 4/10

>assessed level of pain noting its characteristics, location, quality, intensity, and precipitating factors >assessed for referred pain

Tx: >applied hot compress to flank area >provided comfort measure like backrub measures, quiet environment and calm activities >ambulated patient as much as possible

of a young woman by percutaneous nephrolithotripsy (PNL), a procedure for crushing and removing the dense stubborn stones characteristic of cystinuria. The pain with kidney stones is usually of sudden onset, very severe and colicky (intermittent), not improved by changes in position, radiating from the back, down the flank, and into the groin. Nausea and vomiting are common. Resources: http://www.medterms.com/scri pt/main/art.asp? articlekey=6806

>administered PRN analgesics as ordered Edx: >encouraged use of relaxation techniques such as focused breathing and guided imagery >encourage/assist with frequent ambulation as indicated and increased fluid intake of at least 34 l/day within cardiac tolerance.

acceptable level of pain >promotes relaxation, reduces muscle tension, and enhances coping. >renal colic can be worse in the supine position. vigorous hydration promotes passing of stone, prevents urinary stasis, and aids in prevention of further stone formation >to promote wellness

>discussed impact of pain on lifestyle/independence and ways to maximize level of functioning >explained cause of pain and importance of notifying caregivers of changes in pain occurrence/characteristics

>provides opportunity for timely administration of analgesia and alerts caregivers to possibility of passing of stone/developing complications. sudden cessation of pain usually indicates stone passage. 27

ACTUAL PROBLEM 3:

Impaired urinary ilimination r/t decreased renal perfusion secondary to nephrolithisis

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ASSESSMENT S: di ako masyadong umiihi, dalawa hanggang tatlong beses lng sa isang araw O- 150 cc urine collected for 8 hours -w/ a yellow to brownish colored urine -no crystals or blood observed -goes to comfort room once or twice per shift Ax: Impaired urinary elimination r/t decreased renal perfusion secondary to nephrolithisis

EXPLANATION OF THE PROLEM Excessive amounts of calcium in the urine makes the urine more alkaline and the calcium salts precipitate out as a crystals to form renal calculi (stones ). The stone usually develops in the renal pelvis and pass thru the ureters into the bladder. As the stones pass along the long, narrow, ureters, they causes extreme pain, and bleeding and can sometimes obstruct the urinary tract. Obstruction in the urinary tract causes urinary retention (accumulation of urine in the bladder), bladder distention and urinary incontinence. When urine is not being excreted the bladder gradually becomes distended with urine. The bladder may stretch excessively, eventually inhibiting the urge to void. When bladder distention is considerably, some involuntary urinary dribbling may occur. Over distention of the bladder causes poor contractility of the detrusor muscle, further

GOAL/OBJECTIVE After 8 hours of nursing intervention the patient will be able to have a urine output of 2530cc/hour or void in normal amounts and usual pattern.

INTERVENTION independent -monitored i&o and characteristics of urine.

RATIONALE

EVALUATION Goal met since after 8 hours of nursing intervention the patient was able to have a urine output of 2530cc/hour or void in normal amounts and usual pattern.

-determined patients normal voiding pattern and note variations.

-encouraged increased fluid intake. -strained all urine. Document any stones expelled and send to laboratory for analysis. -investigated reports of bladder fullness; palpate for suprapubic distension. Note decreased urine output, presence of periorbital/dependent edema. -observed for changes in mental status, behavior, or level of consciousness. collaborative -monitored laboratory studies, e.g., electrolytes, bun, cr.

-provides information about kidney function and presence of complications, e.g., infection and hemorrhage. -calculi may cause nerve excitability, which causes sensations of urgent need to void.usually frequency and urgency increase as calculus nears ureterovesical junction. - increased hydration flushes bacteria, blood, and debris and may facilitate stone passage. - retrieval of calculi allows identification of type of stone and influences choice of therapy. - urinary retention may develop, causing tissue distension (bladder/kidney), and potentiates risk of infection, renal failure - accumulation of uremic wastes and electrolyte imbalances can be toxic to the cns.

- elevated bun, cr, and -obtained urine for culture and certain electrolytes sensitivities. indicate presence/degree of kidney dysfunction. - determines presence of

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ACTUAL PROBLEM 3: misconceptions

Knowledge deficit related to lack of information to present condition as evidenced by questions and statement of

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ASSESSMENT S>``kasatnu ba agkakaroon ti bato? O> asks questions about her condition >first time to have this condition in the family >unfamiliar with the things that contributes to her condition like salty foods >requested for a list of contraindicated foods

EXPLANATION OF THE PROLEM Knowledge deficit is a lack of cognitive information or psychomotor skills required for health recovery, maintenance, or health promotion. Teaching may take place in a hospital, ambulatory care, or home setting. The learner may be the patient, a family member, a significant other, or a caregiver unrelated to the patient. Learning may involve any of the three domains: cognitive domain (intellectual activities, problem solving, and others); affective domain (feelings, attitudes, beliefs); and psychomotor domain (physical skills or procedures). In the case of this client, she has kidney stones in which she didnt know up until she was diagnosed, Therefore she doesnt know much about her condition.

OBJECTIVE STO: After 2 hours of nursing intervention patient will verbalize understanding of her disease process and potential complications.

INTERVENTION independent -reviewed disease process and future expectations. -stressed importance of increased fluid intake, e.g., 34l/day or as much as 68 l/day. -encourage patient to notice dry mouth and excessive diuresis/diaphoresis and to increase fluid intake whether or not feeling thirsty. -review dietary regimen, as individually appropriate:

RATIONALE -provides knowledge base from which patient can make informed choices. -flushes renal system, decreasing opportunity for urinary stasis and stone formation. -increased fluid losses/ dehydration require additional intake beyond usual daily needs.

EVALUATION >Goal met since after 2 hours of nursing intervention patient was able to verbalize understanding of her disease process and its potential complications.

A> Knowledge deficit related to lack of information to present condition as evidenced by questions

*low-purine diet, e.g.,limited lean meat, legumes, whole grains, alcohol *low-calcium diet, e.g., limited milk, cheese, green leafy vegetables, yogurt; *low-oxalate diet, e.g., restrict chocolate, caffeinecontaining beverages, spinach. -discuss medication

-diet depends on the type of stone. understanding reason for restrictions provides opportunity for patient to make informed choices, increases cooperation with regimen, and may prevent recurrence. -decreases oral intake of uric acid precursors. -reduces risk of calcium stone formation. -reduces calcium oxalate stone formation. -drugs will be given to

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POTENTIAL PROBLEM 1: Assessment

Risk for infection related to stasis of urine secondary to nephrolithiasis Objectives LTO: After 2-3 days of nursing intervention the patient will be able to understand and identify interventions to prevent and reduce risk of infection Nursing intervention Dx>Monitor and record vital sign especially the temperature Rationales >establishe a baseline for comparison.Changes to baseline data may indicate the presence of infection.Fever usually is the first and only sign of infection >diuretic therapy may result in sudden excessive fluid loss even though edema remains >knowledge of causative factors influences of intervention >to prevent bladder distention and urinary stasis which can contribute to the multiplication of pathogens >reduces risk of ascending urinary tract infection >reduces risk for infection Expected outcome LTO:goal met if after 2-3 days of nursing intervention the patient will take the following measures A. follow appropriate given instruction. B. demonstrate understanding to given measures c.apply given instructions in everyday routine

Explanation of the problem Calculi traumatize the walls of the urinary tract and irrigate the cellular lining, causing pain as violent contraction of the ureter develops to pass the stone along. But the urethral spasm may just as easily hold a stone in place.If a stone totally or partially obstructs the passage urine beyond its location,pressure increases in the area above the stone.The pressure contribute to the pain and urinary stasis promotes secondary to infection The retained urine distend the renal pelvis.Eventually there may be compression of the glomeruli and tiny arterioles that supply to the kidney which result in permanent damage.

O- 150 cc urine collected for 8 hours -w/ a yellow to brownish colored urine -no crystals or blood observed -goes to comfort room once or twice per shift

>monitor intake and output >explore causative factors,review laboratory data and non verbal cues Tx>maintain hydration and voiding schedule

A>Risk for infection related to stasis of urine secondary to nephrolithiasis

>Provide regular urinary catheter and perineal care >maintain sterile technique for all invasive procedure such as IV and urinary

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catheter Edx>encourage to increase intake to at least 3.5 to 4 liter per day. >encourage verbalization of feelings and any significant change to the condition >emphasize necessity of taking antivirals and antibiotics as directed

>to maintain normal hydration and prevent urinary stasis >for immediate access nursing intervention >premature discontinuation of treatment when client begins to feel well may result in return of infection and potentiate drug resistant strains >over the counter medication can contribute to the illness which may result for further complication to the condition

>emphasize consulting with the physician before selfadministering any over the counter medication

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POTENTIAL PROBLEM 2:

Risk for infection related to stasis of urine secondary to nephrolithiasis

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Assessment O-150 cc urine collected for 8 hours -w/ a yellow to brownish colored urine -no crystals or blood observed -goes to comfort room once or twice per shift -scheduled operation is on Monday, April 19 -w/ good skin turgor A> risk for deficient fluid volume r/t post obstructive diuresis

Explanation of the problem Nephrolithiasis, the process of forming a kidney stone, a stone in the kidney (or lower down in the urinary tract). Kidney stones are a common cause of blood in the urine and pain in the abdomen, flank, or groin. One of the management for this would be to surgically remove the stones in the kidney. In that reason, patient may suddenly lose retained fluids that was obstructed before by the stones. The body may not adopt with it immediately thus causing our patient at risk for fluid volume deficit r/t post obstructive dieresis.

Objective

Intervention independent -monitor i&o. document incidence and note characteristics and frequency of vomiting and diarrhea, as well as accompanying or precipitating events.

Rationale -comparing actual and anticipated output may aid in evaluating presence/degree of renal stasis/impairment. -documentation may help rule out other abdominal occurrences as a cause for pain or pinpoint calculi. -maintains fluid balance for homeostasis and washing action that may flush the stone(s) out. dehydration and electrolyte imbalance may occur secondary to excessive fluid loss (vomiting and diarrhea). indicators of hydration/circulating volume and need for intervention. -rapid weight gain may be related to water retention. -assesses hydration and effectiveness of/need for interventions. -maintains circulating volume (if oral intake is insufficient), promoting renal function.

Evaluation Goal met if after 2-3 days of nursing interventions and after pts operation the patient will be able to maintain adequate fluid balance as evidenced by vital signs and weight within patients normal range, moist mucous membranes, and good skin turgor.

LTO: After 2-3 days of nursing intervention and after operation the patient will be able to maintain adequate fluid balance as evidenced by vital signs and weight within patients normal range, moist mucous membranes, and good skin turgor. -increase fluid intake to 34 l/day within cardiac tolerance. -monitor vital signs. evaluate pulses, capillary refill, skin turgor, and mucous membranes.

-weigh daily. collaborative -monitor hb/hct, electrolytes. -administer iv fluids.

-provide appropriate diet, clear liquids, bland foods as tolerated.

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XIII. DISCHARGE PLAN: CRITERIA a.DIET HEALTH TEACHING Drink adequate amount of water Eat food low in protein, nitrogen and sodium. Restrict intake of oxalate-rich foods, such as chocolate, nuts, soybeans and spinach plus maintenance of an adequate intake of dietary calcium. Take some fruit juices, such as orange, and cranberry. Orange juice may help prevent calcium oxalate stone formation, and cranberry may help with UTI-caused stones. Limit intake of caffeinated beverages, such as coffee. Avoid cola beverages. Avoid large intake doses of vitamin c Increased mobility if possible Take all your medications as prescribed by your doctor. Keep a list of your medications with you at all times.

b.ACTIVITIES c.MEDICATION

If you have questions or concerns, call your doctor o Do not stop or change the dose of any of your medications without first talking with your doctor. o Do not take any new medications including vitamins, over-the-counter medications or herbal remedies without first talking with your doctor.

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XIV. CONCLUSION AND RECOMMENDATIONS: The case is focused on the importance of precipitating factors that could lead to complicated diseases. The group recommends that during any health teachings, they should

emphasize on the importance of seeking medical advice when feeling not good. With these, complicated diseases should be minimized or prevented as well. Furthermore, the group would like to emphasis to these nurses that proper health teaching to the client with the same situation and those similar needs. Health teachings are very important for the patient and his significant others for them to understand and realize that cooperation is very important in the prevention of disease and improvement of his status. XV. LIST OF REFERENCES 1. Books a.) Pathophysiology by Catherine Paradiso (2nd edition) b.) Medical-Surgical nursing by Suzane C OConnell Smeltzer c.) Understanding Pathophysiology by Sue E. Huether and Kathryn L. McCance (2nd edition) d.) Nurses Pocket Guide by Doenges (11th edition) e.) Drug hand book by Lippincott f.) Anatomy and Physiology by Tortora g.) Anatomy and Physiology by Seeley, et al. h.) Fundamentals of Nursing by Kozier, 2. Websites a. http://www.nlm.nih.gov/medlineplus/ency/article/000077.htm b.http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm? plan=01

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XVI. APPENDICES A) Interview Guide University of the Cordilleras College of Nursing CASE PRESENTATION FORMAT SY 2009-2010 I. General Profile/Information-name, age, sex, marital status occupation, address, religion II. Chief Complaint/s- main complaint of the patient why s/he seek consultation and hence, admitted. III. History of present illness IV. Past medical history V. Social and environmental history VI. Family history VII. VIII. Physical examination Diagnostics

IX. Medical diagnosis- final or principal diagnosis X. Comprehensive Pathophysiology and Management XI. Treatment and Management XII. XIII. XIV. XV. XVI. Nursing Diagnosis Discharge Plan Conclusions and Recommendations List of References Appendices

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B)

Request Letter University of the Cordilleras College of Nursing

Dr. Marian Grace Gascon Dean, College of Nursing Ms. Petelyn Pangket Clinical Coordinator Level III Dear Maam, We the BSN III-6D would like to submit the case of Ms. M with a diagnosis of Nephrolithiasis. This was chosen by the group from the East Surgical ward, BGH last April 15-17, 2010 during the 3-11shift. The group agreed that nephrolithiasis would be a good case. Since we had our duty at BGH we knew that we will cater to a limited number of patients and that we had difficulty in looking for a good case. When we came across this case, we grabbed it because we found it interesting and that this would be a good study. Your approval is highly appreciated. Thank you for your kind consideration.

Sincerely yours, ATTING, Jeri Mae BLANCIA, Jeany CANABE, Jenny Lou DAGUYEN, Katrina DEGAMO, Cielo Cheen ESPERA, Erik John GONZALES, Rowena NASUNGAN, Aliseus SAGUN, Rasi YOCOGAN, Jay Noted by: 40

Ms. Cindy joy Go Clinical Instructor

Ms. Petelyn Pangket Clinical Coordinator Level III

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