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M Age: 52 years old Sex: Female Civil Status: Married Religion: Roman Catholic Address: Cabaruan, Umingan Pangasinan Occupation: Housewife Current Diagnosis: Nephrolithiasis right II. CHIEF COMPLAINTS: The patient complains of on and off right lower quadrant pain radiating to back rated as 7/10, from a scale of 0-10, 10 being the highest. III. HISTORY OF PRESENT ILLNESS: 3 years PTA, patient complains of on and off pain. She has no consultation and medication except that she uses herbal medicine such as sambong, lagundi and ampalaya. 1 month PTA, she felt pain at RLQ that causes her not able to sleep well. She decided to consult private clinic and at Poly Medic Hospital located in their place, same results were found then she was referred to Revosa Lab, located in their place also, and was advised to take potassium citrate 10 meq tablet 2x a day and sambong (tablet) 2x a day . In Revosa, they confirmed that she has multiple kidney stones at the right kidney. She was then referred to Baguio General Hospital for further medical intervention and for removable of these stones. She claims that she had tea colored urine and was once associated with a crystal like stone, rough in texture. Also, she complains of on and off pain at the RLQ radiating to back rated as 7/10, from a scale of 0-10, 10 being the highest but she did not suffer from difficulty of urination. The pain is usually stimulated when she’s doing basic carpentry in their house but is relieved sometimes by rest and walking exercise. Her potassium citrate and sambong were continued upon admission to BGH.
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 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 patient’s 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 5’2” 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 5-8/10, 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 client’s 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 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 patient’s 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 1001000ml, 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.
DATE March 7, 2010
DIAGNOSTIC PROCEDURE Chest PA
DESCRIPTION PURPOSE X rays are a form of Used to evaluate radiation that can organs and penetrate the body and structures within produce an image on an the chest for x-ray film. Another symptoms of name for x ray is diseases. Chest xradiograph. ray include views Consist of two views, of the lungs, heart, the frontal view small portion of the (referred to as GIT, thyroid gland posterioranterior or and the bones of the PA) and the lateral chest area (side) view. It is preferred that the patient stand for this exam, particularly when studying collection of fluid in the lungs.
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
Granulocytes = 2.0-7.0 Granulocytes (%)=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 body’s 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 QT=.34
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
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.
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
DATE March 22, 2010
DIAGNOSTIC PROCEDURE Creatinine
DESCRIPTION PURPOSE RESULT Test is used to assess This test measures 88.4 umol/L kidney function. 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 • Multiple nephrolithiasis with mild hydronephrosis. • Right kidney sonographically normal left kidney and urinary bladder.
DATE March 23, 2010
DIAGNOSTIC PROCEDURE Ultrasound of Kidneys, Urinary Bladder
DESCRIPTION A kind of ultrasound scan of the abdomen and pelvis
PURPOSE Identify suspected problems in the urinary system, such as a kidney stone or blockage in the intestine
RESULT • 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.
DATE April 3, 2010
DIAGNOSTIC PROCEDURE DESCRIPTION Urinalysis 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
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 6.0 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 1.03 Specific gravity shows how concentrated particles are in your urine. gravity 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 Sugar +1 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. Appearan Slightly Normal urine is transparent. Turbid (cloudy) urine may be caused by ce turbid 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. Pus cells 1-3 Normal (Normal value for pus cells in urine is 0-5/hpf) RBC 4-6 Red blood cells (erythrocytes) may be a sign of kidney disorders, blood disorders or another underlying medical condition, such as bladder cancer.
DIAGNOSTIC DATE PROCEDURE DESCRIPTION April Urinalysis Urinalysis is a test that 11., 2010 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 Appeara Slightly metabolism, cells, nce turbid cellular fragments, and bacteria in urine. pH 5.0 RBC Protein Pus Specific gravity 1-15 Trace 1-2 1.005
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 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 various typically used to bodily tissues, but is most detect liver injury commonly associated with the liver.
RESULT 20.5 u/l
NORMAL Normal: 5-35u/l
Is a form of hemoglobin used primarily to identify the 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.
Monitoring the HbA1c in type-1 diabetic patients may improve treatment
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, and in well controlled patients it's less than 7.0%
IX. MEDICAL DIAGNOSIS: Nephrolithiasis right, HPN, DM 2, Obese
X. COMPREHENSIVE PATHOPHYSIOLOGY:
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 patient’s 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 drugs and herbal remedies. Instruct him to consult prescriber before taking these products. 15
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 cross-sensitivity 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.
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.
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 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. 18
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 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. ● 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 in brain.
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 lightheadedness caused by sudden blood pressure decrease.
B. IV Fluids COMPONENT N 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. CLASSIFICATIO EFFECTS/ USES SIGNIFICANCE
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 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 Objective Intervention Rationale 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
Nephrolithiasis: The process of forming a kidney stone, a stone in STO: After 2 to 4 hours the kidney (or lower down in the of nursing interventions urinary tract). the patient will verbalize relief of pain from a scale of 8/10 to 3-5/10 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 stoneforming 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
Dx: >observed non verbal cues of >observation may/may pain not be congruent with verbal reports or may be an indicator of present complaint when client is unable to verbalize >assessed level of pain >to rule out worsening noting its characteristics, of underlying location, quality, intensity, condition/development and precipitating factors of complication >assessed for referred pain >to help determine possibility of underlying condition or organ dysfunction requiring treatment Tx: >applied hot compress to >to reduce pain and flank area promote comfort >provided comfort measure like backrub measures, quiet environment and calm activities >ambulated patient as much as possible >to promote non pharmacological pain management >to facilitate passage of stone through the
were obtained from the kidney 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/script/ 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 3–4 l/day within cardiac tolerance.
urinary system >to maintain 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.
ACTUAL PROBLEM 3: Impaired urinary ilimination r/t decreased renal perfusion secondary to nephrolithisis
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 impairing urination. And urinary retention causes overflow voiding or incontinence.
GOAL/OBJECTIVE After 8 hours of nursing intervention the patient will be able to have a urine output of 25-30cc/hour or void in normal amounts and usual pattern.
INTERVENTION independent -monitored i&o and characteristics of urine.
EVALUATION Goal met since after 8 hours of nursing intervention the patient was able to have a urine output of 25-30cc/hour or void in normal amounts and usual pattern.
-determined patient’s 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. -obtained urine for culture and sensitivities. Edx:
-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 certain electrolytes indicate presence/degree of kidney dysfunction. - determines presence of uti, which may be causing/ complicating symptoms.
ACTUAL PROBLEM 3: Knowledge deficit related to lack of information to present condition as evidenced by questions and statement of misconceptions
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 didn’t know up until she was diagnosed, Therefore she doesn’t 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.
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
-provides knowledge base from which patient can make informed choices. -flushes renal system, -stressed importance of decreasing opportunity increased fluid intake, for urinary stasis and e.g., 3–4l/day or as much stone formation. as 6–8 l/day. -increased fluid losses/ -encourage patient to dehydration require notice dry mouth and additional intake beyond excessive usual daily needs. diuresis/diaphoresis and to increase fluid intake whether or not feeling thirsty. -diet depends on the type -review dietary regimen, of stone. understanding as individually reason for restrictions appropriate: provides opportunity for patient to make informed choices, increases cooperation with regimen, and may prevent recurrence. -decreases oral intake of *low-purine diet, uric acid precursors. e.g.,limited lean meat, legumes, whole grains, alcohol -reduces risk of calcium *low-calcium diet, stone formation. e.g., limited milk, cheese, green leafy vegetables, yogurt; -reduces calcium oxalate *low-oxalate diet, stone formation. e.g., restrict chocolate, caffeine-containing beverages, spinach. -drugs will be given to -discuss medication acidify or alkalize urine, regimen; avoidance of depending on underlying otc drugs, and reading cause of stone all product/food formation. ingestion of
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 >to maintain normal hydration and prevent 29 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 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
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 self-administering any over the counter medication
POTENTIAL PROBLEM 2:
Risk for infection related to stasis of urine secondary to nephrolithiasis
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 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 patient’s normal range, moist mucous membranes, and good skin turgor.
Intervention independent -monitor i&o. document incidence and note characteristics and frequency of vomiting and diarrhea, as well as accompanying or precipitating events. -increase fluid intake to 3–4 l/day within cardiac tolerance. -monitor vital signs. evaluate pulses, capillary refill, skin turgor, and mucous membranes.
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. -easily digested foods decrease gi activity/irritation and help maintain fluid and nutritional balance. -reduces nausea/ vomiting.
Evaluation Goal met if after 2-3 days of nursing interventions and after pt’s operation the patient will be able to maintain adequate fluid balance as evidenced by vital signs and weight within patient’s normal range, moist mucous membranes, and good skin turgor.
-weigh daily. collaborative -monitor hb/hct, electrolytes. -administer iv fluids.
-provide appropriate diet, clear liquids, bland foods as tolerated. -administer medications as indicated: antiemetics, e.g.,
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-thecounter medications or herbal remedies — without first talking with your doctor.
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 O’Connell Smeltzer c.) Understanding Pathophysiology by Sue E. Huether and Kathryn L. McCance (2nd edition) d.) Nurse’s 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
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. XV. Nursing Diagnosis Discharge Plan List of References
XIV. Conclusions and Recommendations XVI. Appendices
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 Ma’am, 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: Ms. Cindy joy Go Clinical Instructor
Ms. Petelyn Pangket Clinical Coordinator Level III
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