Introduction

Renal stones are formed within the kidneys, and this is called nephrolithiasis. Urolithiasis is a condition
that occurs when these stones exit the renal pelvis and move into the remainder of the urinary
collecting system, which includes the ureters, bladder, and urethra. The symptoms of kidney stone are
related to their location whether it is in the kidney, ureter, or urinary bladder (S.B.N. Kumar, et. al.,
2012). Initially, stone formation does not cause any symptom. Later, signs and symptoms of the stone
disease consist of renal colic (intense cramping pain), flank pain (pain in the back side), hematuria
(bloody urine), obstructive uropathy (urinary tract disease), urinary tract infections, blockage of urine
flow, and hydronephrosis (dilation of the kidney).

Globally, kidney stone disease prevalence and recurrence rates are increasing (T. Knoll, 2010), with
limited options of effective drugs. Urolithiasis affects about 12% of the world population at some stage
in their lifetime (C.K. Chauhan, et. al., 2008). It affects all ages, sexes, and races (O.W. Moe, et. al., 2010)
but occurs more frequently in men than in women within the age of 20–49 years (V.O. Edvardsson, et.
al., 2013).

Common risk factors for stone formation include poor oral fluid intake, high animal-derived protein
intake, high oxalate intake (found in foods such as beans, beer, berries, coffee, chocolate, some nuts,
some teas, soda, spinach, potatoes), and high salt intake (M.J. Chung, 2017). Oral hydration is
recommended at a rate that produces approximately 2.5 L of urine per day, and acceptable choices for
fluids include water, coffee, tea, beer, and low sugar fruit juices except for tomato (high sodium
content), grapefruit, and cranberry (high oxalate content). Consumption of citrate helps to prevent
stone formation as it inhibits crystal aggregation by forming complexes with calcium salts within the
urine. Low calcium intake has been shown to increase the risk of kidney stone formation, contrary to
common belief. Decreased oral calcium intake will reduce calcium levels within the GI tract, which
would otherwise be available to bind to oxalate. This, in turn, will increase oxalate absorption and
excretion, increasing the risk of stone formation. Vitamin C intake and fish oil have also been shown to
increase the risk of calcium stones.

Occlusion of the renal system can follow resulting in nephrolithiasis and eventually kidney failure. The
following case describes a patient in which urolithiasis resulted in occlusion of the renal system and
nephrolithiasis. This case was significant because it paved a way into a deeper extent in knowing the
whole picture of its disease process which is mostly experienced by male adults than of women.
Moreover, it also enriches my practice and awareness in handling these kinds of cases as it needs
constant monitoring towards the patient's condition.
NURSING HEALTH HISTORY

Nursing health history is a tool used by nurses to gather important and relevant information that would
help in the patient’s care. It does not only record the client’s problems but describes the client as a
whole and in relation to social and physical environment and other important components that affects
client’s perceptions towards health. The gathered information obtains knowledge of client’s problems
and needs within the context of the particular client’s life that will support therapy and care.

The student had chosen a case in relation to the Care of Clients with Medical Surgical Problem for the
Individual Case Study, all of the information gathered in this report are obtained through a thorough
interview from the patient and the data gathered are limited only from the information gathered
through the said interview. To maintain confidentiality, the student used a pseudonym, Patient B.

Patient Demographic Profile

Patient B, is a 72 year old male, living in Cabadbaran City. He was born on February 14, 1950 and was a
Christian- Seventh Day Adventist by faith. Patient’s current weight is 50 kg and is 172.5 cm tall. Patient B,
lives at Purok 1, Punt Puting, Cabadbaran City and was living with his wife. Patient works as a driver
sometimes if his son lets him use the motorized tricycle.

Patient Health History

Patient B, has no history of a family comorbidities. However, patient mentioned that he has arthritis.
According to the patient, he have undergone a surgery (year wasn’t mentioned) due to a vehicular
accident where he had an open reduction internal fixation (ORIF). He is also currently taking his
maintenance medication, such Rifampicin 150mg + Isoniazid 75mg (Anti-Tuberculosis) in which he
started taking last November 2021.

History upon Admission

About a month PTA noted difficulty urination with scanty urination which became intolerable thus
advised for consultation. Patient B was then instructed for work up CT stonogram. According to Patient
B, he had started experiencing the intolerable symptoms of ureterolithiasis three days prior to his
admission where he experienced pain that radiates to the lower abdomen and groin. Patient also said
that he experienced urinating in small amounts. He was then admitted at Manuel J. Santos Hospital in
Butuan City, last March 28, 2022 at 8:30PM.
PHYSICAL ASSESSMENT

PHYSICAL ASSESSMENT Physical assessment is an organized systemic process of using the techniques of inspection, palpation, percussion, and
auscultation in collecting objective data based upon a health history and head-to-toe or general systems examination. A physical assessment
should be adjusted to the patient, based on his needs. It can be a complete physical assessment, an assessment of a body system, or an
assessment of a body part. Nursing assessment do sometimes contribute to the identification of a medical diagnosis, the unique focus of a
nursing assessment is on the patient's responses to actual or potential problems.

Inspection to inspect, carefully look, listen, and smell to distinguish normal from abnormal findings. It is important to deliberately practice the
skill and learn to recognize all the possible pieces of data that can be gathered through inspection alone.

Palpation involves using the sense of touch to gather information. Through touch you make judgements about expected and unexpected
findings of the skin or underlying tissue, muscle, and bones.

Percussion involves tapping the skin with the fingertips to vibrate the underlying tissues and organs. The vibration travels through the body
tissues, and the character of the resulting sound reflects the density of the underlying tissue. The denser the tissue, the quieter is the sound. By
knowing how various densities influence sound, it is possible to locate organs or masses, map their edges, and determine their size.

Auscultation involves listening to sounds the body makes to detect variations from normal. Some sounds such as speech and coughing can be
herd without additional equipment, but stethoscope is necessary to hear internal body sounds.

Patient was assessed last April 5, 2022

Materials used:

 Tape measure
 Ruler
 Thermometer
 BP apparatus
 Wrist watch
 Penlight
 Pulse Oximeter
 LEGEND:

BLACK – NORMAL

RED - ABNORMAL

GENERAL SURVEY

ASSESSMENT OBSERVATIONS
Body build Ectomorph
Posture Erect during sitting and walking
Hygiene and grooming Untrimmed and unkempt finger nails
Attitude Cooperative
Affect/mood Patient is alert during interview session
Quality and quantity of speech Patient was able to speak and respond well to questions.
Relevance of thoughts The patient responds accordingly and responses correlate to the
questions asked.

VITAL STATISTICS

ASSESSMENT MEASUREMENTS INTERPRETATIONS

Height 172.5 cm
Weight 50 kg
BMI 16.8 Underweght

VITAL SIGNS

DATE INITIAL VITAL SIGNS LATEST VITAL SIGNS

Temperature Pulse Respiration Blood Temperature Pulse Rate Respiration Blood SpO𝟐
Rate Rate Pressure Rate Pressure
April 5, 2022 36 ℃ 83 bpm 22 bpm 120/80mmH 35.6 ℃ 82 bpm 20 bpm 120/90mmH 97%
g g
April 6, 2022 37.1 ℃ 78 bpm 22 bpm 130/80mmH 36.6 ℃ 78 bpm 22 bpm 130/80mmH 97%
 g g

BODY PART INSPECTION PALPATION PERCUSSION AUSCULTATION

SKIN Skin color is uniform Skin is dry. Skin turgor N/A N/A
thorough out the body. returns within 2 seconds
after pinching and no
edema noted.
HAIR Hair is grey, baldness Hair is dry. N/A N/A
noted. No pediculosis or
dandruff noted. Heart
shape hairline noted.
NAILS Finger nails are Nails are smooth and firm. N/A N/A
untrimmed and unkempt. During the capillary refill it
Nail plate are attach to returns within 2 seconds
the nail bed. to blanched nail beds
when pressure is
released.
SKULL Head is rounded, No nodules palpated N/A N/A
normocephalic and
symmetrical.
EYES Eyelashes are curled out No pain felt in the lacrimal N/A N/A
and symmetric. Eyebrows gland and nasolacrimal
are symmetrical in sac.
movement. Pupils are
black, equal in size and
constrict to light. Cornea
is transparent and shiny
Sclera and conjunctiva are
clear and free of
discharges, lesions and
redness.
EARS Auricles are same in color No nodules and palpated N/A N/A
 as facial skin and recoils
back The outer canthus of
eyes is aligned in the top
pinna and having a 10
degree angle. No cerumen
noted on both ear.
NOSE Nose in midline in face,
septum is midline and
intact.
MOUTH AND THROAT Lips are dry, no lesions
present. No dental caries
seen. Buccal mucosa is
pink and no lesions. Uvula
is in midline. Tongue is in
midline, pink and no
lesions. Palates are pink
and no lesions present.
NECK No bulging masses seen.
Coordinated muscle
movements and no
discomfort if neck is move
from side to side. Jugular
vein is not visible.
CHEST & LUNGS Symmetric in shape.
The chest expands
symmetrically during
breathing.
HEART AND CENTRAL No visible veins present.
VESSELS No visible pulsation seen
on the pericardium
ABDOMEN Umbilicus is midline. No
visible pulsation and
vascular pattern seen
over the ears and in the
mastoid process
No tenderness palpated N/A N/A
over the sinuses.
Not able to assessed N/A N/A
because patient is
uncomfortable in the
procedure.
No nodules and lymph N/A N/A
nodes noted. Trachea is in
midline
No masses or nodules No adventitious sounds
noted For tactile fremitus, heard.
bilateral vibrations/ sound
waves is felt
N/A N/A No bruit auscultated No
heart murmurs heard
Bowel sounds are heard
at a rate of 10 clicks per
minute.
No bruit heard over
 abdominal aorta. No
friction hub over liver and
spleen is present
GENITALIA Was not able to assess Was not able to assess N/A N/A
because patient is because patient is
uncomfortable uncomfortable
ANUS Was not able to assess Was not able to assess N/A N/A
because patient is because patient is
uncomfortable uncomfortable
BACK AND EXTREMITIES Erect posture during No edema or tenderness N/A N/A
sitting and standing palpated over extremities.
Extremities are
symmetrical in size. Arms
and legs doesn’t show full
ROM without assistance.
Anatomy and Physiology

Anatomy is the study of the structure and relationship between body parts, while physiology is the study
of the function of body parts and the body as a whole. This section intends to identify and explain parts
and areas of the body that is affected by the disease and to initially provide insight as to where areas
contain deviation to preliminary understand the pathophysiology of the disease which will be further
explained and mapped out in the next section.

The Urinary System and Stones

The urinary filtrate is formed in the glomerulus and passes into the tubules where the volume and
content are altered by reabsorption or secretions. Most solute reabsorption occurs in the proximal
tubules, whereas fine adjustments to urine composition take place in the distal tubule and collecting
ducts. The loop of Henle serves to concentrate urine composed of 95% water, 2.5% urea, 2.5% mixture
of minerals, salts, hormones, and enzymes. In the proximal tubules, glucose, sodium, chloride, and
water are reabsorbed and returned to the blood stream along with essential nutrients such as amino
acids, proteins, bicarbonate, calcium, phosphate, and potassium. In the distal tubule, the salt and acid-
base balance of blood is regulated.

Kidney Stone Compositions

The chemical compositions of urinary stones include crystals and noncrystalline phases or the organic
material (the matrix). The organic matrix of urinary stones consists of macromolecules such as
glycosaminoglycans (GAG’s), lipids, carbohydrates, and proteins. These molecules play a significant role
by promoting or inhibiting the processes of kidney stone development. The main components of the
stone matrix are proteins (64%), nonamino sugars (9.6%), hexosamine as glucosamine (5%), water
(10%), and inorganic ash (10.4%). The matrix acts as a template participating in the assembly of kidney
stones. The matrix of all stones contains phospholipids (8.6%) of the total lipid, which in turn represents
about 10.3% of stone matrix. Cell membrane phospholipids, as part of organic matrix, promote the
formation of calcium oxalate and calcium phosphate stones. Albumin is the major component of the
matrix of all stone types.

Mechanisms of Renal Stone Formation

The pathogenesis of kidney stone or biomineralization is a complex biochemical process which remains
incompletely understood. Renal stone formation is a biological process that involves physicochemical
changes and supersaturation of urine. Supersaturated solution refers to a solution that contains more of
dissolved material than could be dissolved by the solvent under normal circumstances. As a result of
supersaturation, solutes precipitate in urine leads to nucleation and then crystal concretions are formed.
That is, crystallization occurs when the concentration of two ions exceeds their saturation point in the
solution. The transformation of a liquid to a solid phase is influenced by pH and specific concentrations
of excess substances. The level of urinary saturation with respect to the stone-forming constituents like
calcium, phosphorus, uric acid, oxalate, cystine, and low urine volume are risk factors for crystallization.
Thus, crystallization process depends on the thermodynamics (that leads to nucleation) and kinetics
(which comprises the rates of nucleation or crystal growth) of a supersaturated solution. Therefore,
lithiasis can be prevented by avoiding supersaturation.
LABORATORY RESULTS

Laboratory tests check a sample of a person’s blood, urine, or body tissues. A technician or your doctor
analyzes the test samples to see if the results fall within the normal range. The tests use a range because
what is normal differs from person to person (Smith, 2019). In the case of Patient M, he was ordered to
be test for CBC (Complete Blood Count), ultrasound and a urinalysis which results are provided below.

Hematology: Complete blood count

A complete blood count (CBC) is a test that measures the cells that make up the patient’s blood. In the
case of excessive vagina bleeding, CBC is ordered to look for altered count results of test typical of the
later stages of diagnosis. Also, used to help detect a variety of disorders including infections, anemia,
diseases of the immune system.

TESTS RESULT REFERENCE INTERPRETATION

Hemoglobin 74 136-167 Below normal range
Hematocrit 0.22 0.40-0.50 Below normal range
WBC 6.85 5.0-10.0 Within normal range
Segmenters 0.54 0.37-0.72 Within normal range
Lymphocytes 0.28 0.20-0.50 Within normal range
Eosinophil 0.07 0.00-0.06 Slightly above normal range
Monocytes 0.11 0.08-0.14 Within normal range
Basophils 0.00 0.0-0.01 Within normal range
Platelet 453 150-390 Slightly above normal range

Electrolyte Panel

TESTS RESULT REFERENCE INTERPRETATION

Potassium 4.6 3.5-5.3 Within normal range
Sodium 140.0 135-148 Within normal range

Chemistry Section

TESTS RESULT REFERENCE RESULT REFERENCE INTERPRETATION

(c.u.) (s.i.)
Creatinine 2.40 0.90-1.50mg/dl 213.312 80.00-133.00mmol/L Above normal
range
BUN Blood 18.0 8.12-22.97mg/dl 6.426 2.90-8.20mmol/L Within normal
Urea range
Nitrogen