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A Care Study about Nephrolithiasis Submitted to: Mrs. Donna Neri, RN Submitted by: Domino, Sheena May C1
I. Introduction a. Overview of the Case
such as Greenland and the coastal areas of Japan. in regions with both white and nonwhite populations. This is suggested by the finding that. In developing countries. Early recognition and immediate surgical drainage are necessary in these situations. in fact. which is the usual scenario in patients who experience loss of renal function due to chronic untreated obstruction. Stone disease is rare in only a few areas.Nephrolithiasis is a common disease that is estimated to produce medical costs of $2.1 billion per year in the United States. and urosepsis can ensue. In general. urolithiasis is more common in males (male-to-female ratio of 3:1). The morbidity of urinary tract calculi is primarily due to obstruction with its associated pain. although nonobstructing calculi can still produce considerable discomfort. Some of the earliest recorded medical texts and figures depict the treatment of urinary tract stone disease. Pyelonephritis. heredity also appears to be a factor. African Americans. He was admitted at Polymedic General Hospital. Africans. I was able to care for him for about 2 days(16hrs duty hours) b. Scope and Limitation of the Study . Stone-induced hematuria is frightening to the patient but is rarely dangerous by itself. patients with obstructing calculi may be asymptomatic. The incidence of urinary tract stone disease in developed countries is similar to that in the United States. 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. stone disease is much more common in whites. Most urinary calculi develop in persons aged 20-49 years. bladder calculi are more common than upper urinary tract calculi. The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection. and some natives of the Mediterranean region. Objective of the Study c. These differences are believed to be diet-related. Conversely. Urinary tract calculi are far more common in Asians and whites than in Native Americans. pyonephrosis.Nephrolithiasis or somtimes called urolithiasis is the process of stone formation. Urinary tract stone disease has been a part of the human condition for millennia. the opposite is true in developed countries. Although some differences may be attributable to geography (stones are more common in hot and dry areas) and diet. bladder and kidney stones have even been found in Egyptian mummies.
II. Profile of the Patient Name of the Patient: Vallespin. History of Present Illness III. 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. Development Data . Health History a.
Gualberto Vital Signs Pulse: 86bpm BP: 160/80 mm Hg Temp: 36C Height: 5’4 Weight: . Medical Management a. Nursing Assessment *********NURSING REVIEW CHART******* Name: Alonte. Medical Orders and Rationale b. Pathophysiology with Anatomy and Physiology a. Anaphysiology VI.IV. Laboratory/ Diagnostic Examinations V.
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 COMMUNICATION: Hearing Loss X visual changes denied Comments: X Glasses contact lens R L x speech difficulties OBJECTIVE languages hearing aide Pupil size : 3mm Reaction: PERRLA OXYGENATION: dyspnea smoking history X X cough sputum denied Comments: Resp. X regular irregular Description :symmetrical .
appetite difficulty swallowing X denied Upper Lower ELIMINATION: Usual bowel pattern X constipation remedy : meds urinary frequency urgency dysuria hematuria Date of last BM: 12/3/10 diarrhea character I incontinence polyuria foley in place denied Bowel sounds : present Abdominal distention : none Present  yes  no Urine*(color consistency.CIRCULATION X chest pain leg pain Comments : Heart Rhythm Ankle edema: none Pulse R L Comments: all pulse is palpable. Car Rad DP Fem X regular irregular numbness of extremities denied NUTRITION Diet: N V Full Partial With Patient Comments: X dentures X none Character recent change in weight. frequency): 1 bottle every day SBE Last Pap Smear : N/A . meds. etc) for chronic problems (if present) (amount. odor):amber MGT. OF HEALTH ILLNESS: X alcohol denied Briefly describe the patient’s ability to follow treatments (diet.
drainage) : Cane Other X unsteady sensory and motor losses in face or extremities: ROM limitations frequency. remedies) nocturia sleep difficulties denied COPING: other signs of pain side rail release form signed ( 60 + years) Occupation : Farmer Members of household : Wife Most supportive person: Wife Observed non-verbal behavior The person and his phone number that can be Reached any time : Wife . “sakit aku ulo.SUBJECTIVE SKIN INTEGRITY: dry itching other denied ACTIVITY/SAFETY convulsion dizziness limited motion of joints Limitation in ability to X ambulate other denied Comments: COMFORT/SLEEP/AWAKE: X pain ( location. decubitus (describe size. ulcers.dyun sakit aku dughan kung mag ubo” facial grimaces guarding X bathe self Comments: LOC and orientation Gait: Walker steady * OBJECTIVE Comments : dry flushed moist cold warm cyanotic pale rashes. location.
P . Of nursing intervention the patient will be able to verbalized minimal headache.Date Oredered 12/6/10 12/6/10 12/7/10 Diagnostic/Laboratory Exams CBC CXR CT Scan Date Done Date Ordered 12/7/10 IV Fluids/Blood PNSS Il @ 10gtts/min Date Disc. 12/6/10 12/6/10 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 BP= 130/80 mmHg With ongoing IVF of #3 PNSS Il @ 650cc level regulated at 10gtts/min O A Pain related to inadequate tissue perfusion After 8hrs.
This to monitor the condition of the patient. Avoid fatty and salty foods and to quit alcohol drinking . . Under supervision of Dr. Which increases energy level and anxiety of the patient. turn to sides every 2 hours EXERCISE E patient verbalized minimal/ absence of pain Instruct the patient to have a ROM exercises daily as tolerated. Surdilla. DIET Encourage patient to eat balance diet. OUTPATIENT Encouraged patient to have a follow-up check up 1 week after discharged. Increase fluid intake and nutritious foods. It should be prescribed by the doctor. TREATMENT Instruct patient to drink plenty of water to lessen secretions. v/s taken and recorded bedside and morning care done placed in bed comfortably I MEDICATION due meds givento follow the medication regimen as indicated to promote Instruct the patient increase oral fluid intake with strict aspiration precaution diversional and thought blocking activities provided Pharmacological effects.
Refferals and Follow-up The patient was referred to Dr. Financial F. Precipitating Factors D. Surdilla. Family Support / / / Good Prognosis Poor Prognosis / / / . The significant others of the patient was also advised to refer immediately signs and symptoms of the disease recurrence or worsening. Onset of Illness B. IX Prognosis and Evaluation Criteria A. Duration of illness C.VIII. And also the client was instructed to come back for follow up check up a week after discharged. Attitude towards taking medications and treatment E.
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