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Assessment 2: Case study essay

School of Nursing and Midwifery, Edith Cowan University

NUM2306 Adult Health Care 1

Dr Amanda Graf

October 11th, 2021

1319 words
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Assessment 2: Case study essay

Introduction

Obstruction to the bladder, ureters and/or kidney can cause Acute Kidney Injury (AKI),

and if not treated, can lead to renal failure (Goldfrap, 2016). AKI decreases the functioning

abilities of the kidney and the body’s homeostasis, due to the decline in Glomerular Filtration

Rate (GFR) (Craft et al., 2019). Kidney stones, also known as renal calculi, are a known cause of

postrenal AKI and cause of urinary obstruction (Nevo et al., 2019). In Australia, 10% of the

population will experience a kidney stone (Thia & Saluja, 2021). Annually 12,000 hospital

admissions are due to renal calculi, noting that 75-90% of incidences pass spontaneously without

surgical attention (Cunningham et al., 2016). Key risk factors include poor diet, dehydration,

hypercalciuria, PH imbalances, humid climates, and presence of supersaturation in urine

(Srivastava et al., 2019). This case study is focussed on patient Sally Jones, a 56-year-old lady,

who has a 6mm stone in her right ureter. The pathophysiology of renal calculi and the clinical

manifestations that Sally presents will be discussed, along with recommended nursing

management and medical interventions that would be put in place for Sally.

Pathophysiology

Acute Kidney Injury (AKI), previously known as acute kidney failure, is classified by the

location of the obstruction/trauma (Goldfrap, 2016). The three classifications are prerenal,

intrarenal and postrenal (Craft & Gordon, 2020). Kidney stones are an example of postrenal AKI

(Zeimba & Matlaga, 2015), and are characterised by their mineral composition (Shadman &

Bastani,2017). Evidence states there are four types of renal calculi, the most being calcium

stones, accounting for up to 75% of calculi incidences (Solo et al., 2017). The less common are

uric acid stones, struvite stones (Also known as ‘infection stones’, caused by UTIs) and cystine
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calculi, which are traced to genetic or secondary to a metabolic disorder (Shadman & Bastani,

2017). Moreover, precipitation of these minerals forms small hard crystals due to decrease of

urine volume, supersaturation of urine or change in the PH levels (Srivastava et al., 2019). A

stone may continue to grow once attached to the urothelium, due to additional organic matter

forming around the nidus (Craft et al., 2019). Renal calculi are generally asymptomatic until they

enter the ureter (Solo et al., 2017).

Sally may have had an UTI first, that has led to a struvite stone. By consideration of the

urinalysis (UA), which displays blood, nitrates, proteins, and a cloudy appearance which is a

diagnosis of infection in the bladder (Trimarchi, young & Lombi, 2015). The common symptoms

of acute pyelonephritis (caused by a UTI and struvite stone) are fever, chills, cloudy urine,

voiding and flank pain, which are all clinical manifestations Sally is experiencing and secondary

to kidney stones (Grasso & Goldfrap, 2014). The right sided flank pain that Sally is experiencing

is called renal colic, this occurs due to the stone passage causing spasming and contracting of the

smooth muscle in the ureter (Cunningham et al., 2016). Additionally, the obstruction due to the

calculus in the ureter, initiates the release of prostaglandins and the inflammatory response

(Afshar et al., 2015). Prostaglandins generate vasodilation that increases urinary flow, intra-

ureteral pressure, oedema, vascular permeability and uretic spasming and hyperperistalsis

(Afshar et al., 2015). Moreover, prostaglandins are what causes Sally to feel continuous pain and

nausea (Steinberg & Chang, 2016). The presence of haematuria and higher than normal serum

creatinine and BUN levels indicate AKI and the decline in kidneys function and glomerular

filtration rate (GFR) (Craft et al., 2020). The decline in the GFR means retention of waste

products such as creatine and BUN that are otherwise excreted in a normal functioning kidney

(Jennette et al., 2015). Moreover, this will also signal the brain centres that the renal BP has
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decreased, which will initiate a negative feedback response increasing Sally’s heart rate

(108bpm), BP (124/87), and respiratory rate (22) to compensate and work to restore the

homeostasis (Craft et al., 2019). Immediate medical attention is needed to relieve pain and

smooth muscle spasming in the ureter (Thia & Saluja, 2021).

Management

Renal calculi require immediate nursing management and medical expulsion therapy

(MET), to relieve Sally of renal colic (Thia et al., 2021). Sally presents to ED with a pain score

of 8 out of 10, which classifies as severe pain (Royal Perth Bentley Group, [RPBG], 2020). The

World Health Organisation Pain management guidelines suggest collecting subjective data, pain

score, and reduce fear (Berman, 2017). The first step is to offer Sally non-pharmalogical

treatment, deep breathing exercises and encouragement of fluid consumption to reduce further

stone formation (Cunningham et al., 2016). The use of intravenous (IV) fluids should be

implemented to work towards urinary dilution, to prevent further stone growth (Ziemba &

Matlaga, 2015).

The second step is dependant on the level of pain andchoosing a medication that will

limit side effects and have the most rapid effect (Royal Perth and Bentley Group [RPBG], 2020).

Evidence suggests that the use of non-steroid anti-inflammatory drugs (NSAIDS), adjuvant

medications (co-analgesics) and alpha blockers, are the most effective relief for renal colic, then

that of opioid medications (Watt et al.,2018). NSAIDs decrease the event of vomiting and

nausea, require less rescue analgesics and work to directly inhibit the inflammation response

initiated by the release of prostaglandins (Cunningham et al., 2016). Alpha-blocker medication,

used alongside NSAIDs will reduce muscle contractions/spasms of the smooth muscle of the

ureter, and decrease the need for surgical intervention (Sahin et al., 2015). The two immediate
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medications that can be to help relieve renal colic and distress for Sally are an NSAIDs

(Diclofenac) and alpha-blocker (Tamsulosin) (Thia & Saluja, 2021).

Medications

There are various non-steroidal anti-inflammatory drugs (NSAIDs), Opioid and adjuvant

medications that can be used to treat renal colic, along with Medical Expulsive Therapy (MET)

(Leonardo & Thiago, 2019) As previously mentioned, immediate pain relief is needed for Sally

and using NSAIDS are most effective and need less rescue than opioids (Watt et al., 2018). The

most used NSAIDs for renal colic is Diclofenac (Asfhar et al., 2015). Diclofenac, like all

NSAIDs works to inhibit the synthesis of prostaglandins, by blocking cyclooxygenase-1 and

cyclooxygenase-2 (COX 1 & 2) (“diclofenac”, n.d). The indications are for tissue inflammation

and pain. It can be administrated orally, topically (local), and intravenously (IV). Side effects can

be dehydration, headache, salt and fluid retention and individuals with asthma may find it

causing bronchospasms and potential exacerbations and GI ulceration or bleeding (“diclofenac”,

n.d). Nursing considerations for this medication are minimal for short-term use but monitoring

for any of the side effects to ensure treatment is withdrawn immediately (“diclofenac”, n.d).

The second medication to elevate pain and induce expulsion of the stone is an alpha

blocker called Tamsulosin hydrochloride (Flomaxtra) (Sahin et al., 2015). This works as an a-

adrenoreceptor antagonist, antagonising/inhibiting the a-adrenergic receptors on the ureters

smooth muscle, by relaxing the smooth muscles of the ureters (“tamsulosin, n.d). The indications

of use are to action relief of benign prostatic hyperplasia (BPH), lower urinary tract symptoms

(LUTS) and for renal stones it can be used for up to four weeks for stone passage (“tamsulosin”,

n.d). It is to be taken orally once daily. Side effects of tamsulosin are hypotension in first dose,

nasal congestion, urinary urgency, headaches, fatigue, and weakness (“tamsulosin”, n.d.).
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Nursing care required from these medications are to be precautious of dizziness that the patient

may manifest. Additionally, the best time to give it would be at bedtime, when standing or

moving around is limited (“tamsulosin”, n.d).

Conclusion

Renal calculi are an example of postrenal acute kidney injury that if managed and treated,

is a reversible condition. The formation and pathophysiology will vary, dependant on stone type,

location, and size. Nursing interventions and management should be focussed on acute pain

relief and stone passage. Pharmalogical treatment is varied and by choosing medications that

require less rescue medications or surgical interventions, offer fast relief to pain and muscle

spasms, are paramount in the nursing considerations when treating kidney stones.
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