Liceo de Cagayan-College of Nursing

A Care Study about

Nephrolithiasis

Submitted to:
Mrs. Donna Neri, RN

Submitted by:
Domino, Sheena May
C1

I. Introduction

a. Overview of the Case

 Nephrolithiasis or somtimes called urolithiasis is the process of stone
formation.Nephrolithiasis is a common disease that is estimated to produce medical costs of $2.1
billion per year in the United States. Urinary tract stone disease has been a part of the human
condition for millennia; in fact, bladder and kidney stones have even been found in Egyptian
mummies. Some of the earliest recorded medical texts and figures depict the treatment of urinary
tract stone disease. The incidence of urinary tract stone disease in developed countries is similar
to that in the United States. Stone disease is rare in only a few areas, such as Greenland and the
coastal areas of Japan. In developing countries, bladder calculi are more common than upper
urinary tract calculi; the opposite is true in developed countries. These differences are believed to
be diet-related. Urinary tract calculi are far more common in Asians and whites than in Native
Americans, Africans, African Americans, and some natives of the Mediterranean region. Although
some differences may be attributable to geography (stones are more common in hot and dry
areas) and diet, heredity also appears to be a factor. This is suggested by the finding that, in
regions with both white and nonwhite populations, stone disease is much more common in
whites. In general, urolithiasis is more common in males (male-to-female ratio of 3:1). Most
urinary calculi develop in persons aged 20-49 years. The morbidity of urinary tract calculi is
primarily due to obstruction with its associated pain, although nonobstructing calculi can still
produce considerable discomfort. Conversely, patients with obstructing calculi may be
asymptomatic, which is the usual scenario in patients who experience loss of renal function due
to chronic untreated obstruction. Stone-induced hematuria is frightening to the patient but is rarely
dangerous by itself. The most morbid and potentially dangerous aspect of stone disease is the
combination of urinary tract obstruction and upper urinary tract infection.
Pyelonephritis, pyonephrosis, and urosepsis can ensue. Early recognition and immediate surgical
drainage are necessary in these situations.

My patient was diagnosed to have bilateral nephrolithiasis. Patient X is 19 years

old male with a family history of gouty arthritis which contrIbuted to the formation of calculi. He
was admitted at Polymedic General Hospital. I was able to care for him for about 2 days(16hrs
duty hours)

b. Objective of the Study

c. Scope and Limitation of the Study

II. Health History

a. Profile of the Patient

Name of the Patient: Vallespin, Roger Mark

Sex: Male
Age: 19 years old
Religion: Roman Catholic
Civil Status: Single
Income: N/A
Nationality: Filipino
Date Admitted:
Time:
Hospital: Polymedic General Hospital
Area: Surdical ward
Chief Complaints:
Admitting Diagnosis:
Attending Physician:
Informant:
Temperature:
Pulse Rate:
Respiratory Rate:
BP:
Sensorium:
Pupil:
Eye movement: Spontaneous full
Respiration: Regular normal
Motor response: Spontaneous

b. History of Present Illness

III. Development Data

IV. Medical Management

a. Medical Orders and Rationale

b. Laboratory/ Diagnostic Examinations

V. Pathophysiology with Anatomy and Physiology

a. Anaphysiology
VI. Nursing Assessment

*********NURSING REVIEW CHART*******

Name: Alonte, Gualberto
Vital Signs
Pulse: 86bpm BP: 160/80 mm Hg Temp: 36C Height: 5’4 Weight:
 EENT :

X impaired vision  blind  pain hard of hearing

 reddened  drainage  gums  deaf
 burning  edema  lesion teeth
 No problem

RESP:
 asymmetric  tachypnea
 apnea rales X cough
 barrel chest  bradypnea
 shallow  rhonchi X sputum
 diminished dyspnea
 orthopnea  labored
wheezing X pain  cyanotic
 no problem

CARDIO VASCULAR
 arrhythmia  tachycardia  numbness
 diminished pulses  edema  fatigue
 irregular  bradycardia  murmur
 tingling  absent pulses  pain
X no problem

GASTRO INTESTINAL TRACT

 obese  distention  mass
 dysphagia  rigidity  pain
X no problem

GENITO-URINARY and GYNE

pain  urine color / vaginal bleeding
 hermaturia / discharge  noctoria
X no problem

NEURO
 paralysis  stuporous unsteady  seizures
 lethargic  comatose  vertigo tremors
 confused X vision  grip
 no problem

MUSCULOSKELETAL and SKIN

 appliance  stiffness  itching  petechiae
 hot  drainage  prosthesis swelling
 lesion  poor turgor  cool  deformity
 wound  rash  skin color  flushed
 atrophy  pain  ecchymosis  dry
X no problem
 **********NURSING ASSESSMENT II********

SUBJECTIVE OBJECTIVE

COMMUNICATION: Comments: X Glasses languages

Hearing Loss contact lens hearing aide

X visual changes R L

denied Pupil size : 3mm x speech difficulties

Reaction: PERRLA

OXYGENATION: Comments:

dyspnea Resp. X regular irregular

smoking history

X cough Description :symmetrical

X sputum

denied
CIRCULATION Comments :

X chest pain Heart Rhythm X regular irregular

leg pain Ankle edema: none

numbness of extremities Pulse Car Rad DP Fem

denied R

Comments: all pulse is palpable.

NUTRITION

Diet: Comments: X dentures X none

N V

Character Full Partial With Patient

recent change in weight, appetite

difficulty swallowing Upper

X denied Lower

ELIMINATION: Bowel sounds : present

Usual bowel pattern urinary frequency

Abdominal distention : none
X constipation urgency
Present [] yes [] no
remedy : meds dysuria
Urine*(color consistency, odor):amber
hematuria

Date of last BM: I incontinence

12/3/10 polyuria

diarrhea foley in place

character denied

MGT. OF HEALTH ILLNESS: Briefly describe the patient’s ability to follow

treatments (diet, meds, etc) for chronic problems (if
X alcohol denied present)

(amount, frequency): 1 bottle every day

SBE Last Pap Smear : N/A

 SUBJECTIVE OBJECTIVE

SKIN INTEGRITY: Comments :

dry dry cold pale

itching flushed warm

other moist cyanotic

*
denied rashes, ulcers, decubitus (describe size, location,
drainage) :

ACTIVITY/SAFETY Comments:

convulsion LOC and orientation

dizziness Gait: Walker Cane Other

limited motion steady X unsteady

of joints sensory and motor losses in face or

extremities:
Limitation in ability to
ROM limitations
X ambulate X bathe self

other

denied

Comments:

COMFORT/SLEEP/AWAKE:

X pain ( location, “sakit aku ulo,dyun sakit facial grimaces

frequency, aku dughan kung mag ubo” guarding

remedies) other signs of pain

nocturia side rail release form signed ( 60 + years)

sleep difficulties

denied

COPING:

Occupation : Farmer Observed non-verbal behavior

Members of household : Wife The person and his phone number that can be

Most supportive person: Wife Reached any time : Wife

 Date Date
Diagnostic/Laboratory Date Done IV Fluids/Blood Date Disc.
Oredered Ordered
Exams
12/7/10 PNSS Il @
12/6/10 CBC 12/6/10
10gtts/min

12/6/10 CXR 12/6/10

12/7/10 CT Scan 12/7/10

12/9/19

 “ sakit akung ulo”

 “sakit akung dughan kung mag ubo”

S

 Appears weak

 Slurring of speech noted

 Productive cough noted

O
 BP= 130/80 mmHg

 With ongoing IVF of #3 PNSS Il @ 650cc level regulated at 10gtts/min

 Pain related to inadequate tissue perfusion

A

 After 8hrs. Of nursing intervention the patient will be able to verbalized

minimal headache.
P
  v/s taken and recorded

I  bedside and morning care done

 placed in bed comfortably
 due meds
Instruct givento follow the medication regimen as indicated to promote
the patient
MEDICATION  increase oral fluid intake with strict aspiration precaution
 diversional and thought blocking activities provided
Pharmacological effects. It should be prescribed by the doctor.
 turn to sides every 2 hours

EXERCISE  patient verbalized minimal/ absence of pain

E Instruct the patient to have a ROM exercises daily as tolerated. Which increases
energy level and anxiety of the patient.

Instruct patient to drink plenty of water to lessen secretions.

TREATMENT

Encouraged patient to have a follow-up check up 1 week after discharged. Under

OUTPATIENT
supervision of Dr. Surdilla. This to monitor the condition of the patient.

Encourage patient to eat balance diet. Avoid fatty and salty foods and to quit alcohol
DIET
drinking . Increase fluid intake and nutritious foods.
VIII. Refferals and Follow-up

The patient was referred to Dr. Surdilla. The significant others of the patient was also advised
to refer immediately signs and symptoms of the disease recurrence or worsening. And also the client was
instructed to come back for follow up check up a week after discharged.

IX Prognosis and Evaluation

Criteria Good Prognosis Poor Prognosis

/
A. Onset of Illness
/
B. Duration of illness
/
C. Precipitating Factors
D. Attitude towards taking
/
medications and
treatment
/
E. Financial
/
F. Family Support