Case Formatted

8/3/2019 Case Formatted

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I. INTRODUCTION

Kidneys that are failing have scars. Irreversible scars. Once a kidney is damaged you

cannot get that kidney function back. Kidneys do much more than filter urine. They get

rid of the toxins in our blood that we build up in our body such as CO2. They help

produce red blood cells so we can have oxygen flow through our body. If it wasn't for our

kidneys the rest of the organs in our body would die from being poisoned. This is just the

icing on the cake.

The kidneys are an essential part of the body's urinary system. Each kidney is

composed of about one million microscopic "filtering packets" called glomeruli. The

glomeruli remove uremic waste products from the blood. Each glomerulus connects to a

long tube, called the tubule. Urine made by the glomerulus moves down the tubule.Together, the glomerulus and the tubule form a unit called a nephron. Each nephron

connects to progressively larger tubular branches, until it reaches a large collection area

called the calyx. The calices form the funnel-shaped portion of the upper ureter (renal

pelvis). Urine moves from the renal pelvis to the ureters, the large tubes that connect the

kidney to the bladder.

The kidneys produce three important hormones: erythropoietin (EPO), which triggers

the production of red blood cells in bones; renin, which regulates blood pressure; and

vitamin D, which helps regulate the body's metabolism of calcium necessary for healthy

bones.

Chronic kidney failure is not caused by an obstruction. Acute renal failure can be

caused by a kidney stone blocking the ureter into the bladder. That can be reversed by

surgery or lithotripsy. Chronic Renal Failure is usually caused by an underlying disease

such as diabetes, hypertension, PKD, or autoimmune diseases to name a few.

Kidney tumors form when cells overgrow within a kidney. Usually, older cells die and

are replaced by new cells. When this process goes awry, the old cells don't die off, and

new cells grow when they are not needed, creating a tumor. When a kidney tumor is

benign, it is not cancerous and it does not spread to other body parts. However, tumors

can sometimes impair organ function, so they may be removed surgically.

Much more serious is a malignant kidney tumor, which is cancerous and can spread

to other areas in a person's body. This type of kidney tumor is potentially life threatening.

Renal cell carcinoma, transitional cell carcinoma, and Wilms' tumor are the most

frequently diagnosed cancerous kidney tumors. In adults, renal cell carcinoma develops

most frequently. Children are more likely to develop Wilms' tumor cancer


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Incidence and Prevalence of Kidney Cancer

According to the National Cancer Institute, the highest incidence of kidney

cancer occurs in the United States, Canada, Northern Europe, Australia, and New

Zealand. The lowest incidence is found in Thailand, China, and the Philippines.

In the United States, kidney cancer accounts for approximately 3% of all adult cancers.

According to the American Cancer Society, about 32,000 new cases are diagnosed and

about 12,000 people die from the disease annually. Kidney cancer occurs most often in

people between the ages of 50 and 70, and affects men almost twice as often as

women.

Smokers develop renal cell carcinoma about twice as often as nonsmokers and

develop cancer of the renal pelvis about 4 times as often. Not smoking is the most

effective way to prevent kidney cancer and it is estimated that the elimination of smokingwould reduce the rate of renal pelvis cancer by one-half and the rate of renal cell

carcinoma by one-third.
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II. OBJECTIVES

a. General Objective

After this case presentation, the students will be able to gain knowledge regarding

the general health and disease condition of a patient with Nephrolithiasis. its disease

process, possible complications, and treatment plan, medical and nursing interventions.

b. Specific Objectives

At the end of this case presentation, the students will be able to:

Skills

Accurately present a thorough general assessment of the client which includes

physical assessment and family history taking. Discuss the responsibility of the nurse in caring patient with Nephrolithiasis.

Develop a good communication skills toward patient, folks as well as to other

members of the health team.

Perform nursing procedures effectively and correctly to attain his optimum level of

wellness.

Knowledge

Know what Nephrolithiasis is, causes and its risk factors.

Review the anatomy and physiology of the organ affected.

Effectively identify signs and symptoms exhibited by a patient with Nephrolithiasis.

Understand the pathophysiology of the disease.

Describe the important of pharmacological treatments and giving details about

their actions.

Efficiently make appropriate nursing diagnosis in line with the clients medical

condition and skillfully formulate nursing care plans for the problems identified.

Attitude

Promote therapeutic interpersonal relationships through demonstration of positive

attitude to the client.

Understands patient feelings towards his condition.

Establish rapport and therapeutic communication in order to gain information

about the patient which includes the medical and family health history,

expectations of his condition to him gather significant data from the patients

chart and to his family and etc.; and for the betterment of nursing care.


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III. ANATOMY AND PHYSIOLOGY

Urinary System is a group of organs in the body concerned with filtering out excess fluid

and other substances from the bloodstream

COMPOSED OF:

KIDNEY - A pair of purplish-brown organs located below the ribs toward the

middle of the back. Each kidney is about 4 or 5 inches long-about the size of a

fist.

URETER - the ureters are muscular ducts that propel urine from the kidneys to

the urinary bladder.

BLADDER - The urinary bladder is the organ that collects urine excreted by

the kidneys prior to disposal by urination. It is a hollow muscular, and distensible

(or elastic) organ, and sits on the pelvic floor.

URETHRA - is a tube which connects the urinary bladder to the outside of the

body. The urethra has an excretory function in both sexes to pass urine to the

outside, and also a reproductive function in the male, as a passage

for semen during sexual activity.

Kidney

The kidneys are two bean-shaped organs, each measuring the size of your fist. These

organs function as 24-hour cleaning machines for your blood.

Each Kidney is enclosed in a transparent membrane called the renal capsule which

helps to protect them against infections and trauma. The kidney is divided into two main

areas a light outer area called the renal cortex , and a darker inner area called the renal


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medulla . Within the medulla there are 8 or more cone-shaped sections known as renal

pyramids . The areas between the pyramids are called renal columns .

The most basic structures of the kidneys, are nephrons . Inside each kidney there are

about one million of these microscopic structures. They are responsible for filtering theblood and removing waste products.

Functions of Kidney:

Remove waste products from the blood.

Remove extra fluid.

Adjust level of minerals and other chemicals.

Produce hormones.


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IV. TEXTBOOK DISCUSSION

A nephrectomy is asurgical procedure for the removal

of a kidney or section of a kidney.

Nephrectomy may involve

removing a small portion of the

kidney or the entire organ and

surrounding tissues. In partial

nephrectomy, only the diseased or

infected portion of the kidney is

removed. Radical nephrectomy

involves removing the entire kidney, a section of the tube leading to the bladder (ureter),

the gland that sits atop the kidney (adrenal gland), and the fatty tissue surrounding the

kidney. A simple nephrectomy performed for living donor transplant purposes requires

removal of the kidney and a section of the attached ureter.

Purposes

It is performed on patients with severe kidney damage from disease, injury, or

congenital conditions. These include cancer of the kidney (renal cell carcinoma);

polycystic kidney disease (a disease in which cysts, or sac-like structures, displace

healthy kidney tissue); and serious kidney infections. It is also used to remove a healthy

kidney from a donor for the purposes of kidney transplantation

Types of Nephrectomy

Open nephrectomy

In a traditional, open nephrectomy, the kidney donor is administered general

anesthesia and a 610 in (15.225.4 cm) incision through several layers of muscle is

made on the side or front of the abdomen. The blood vessels connecting the kidney to

the donor are cut and clamped, and the ureter is also cut between the bladder and

kidney and clamped. Depending on the type of nephrectomy procedure being performed,

the ureter, adrenal gland, and/or surrounding tissue may also be cut. The kidney is

removed and the vessels and ureter are then tied off and the incision is sutured (sewn

up). The surgical procedure can take up to three hours, depending on the type of

nephrectomy being performed.


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Laparoscopic nephrectomy

Laparoscopic nephrectomy is a form of minimally invasive surgery that utilizes

instruments on long, narrow rods to view, cut, and remove the kidney. The surgeon

views the kidney and surrounding tissue with a flexible videoscope. The videoscopeand surgical instruments are maneuvered through four small incisions in the abdomen,

and carbon dioxide is pumped into the abdominal cavity to inflate it and improve

visualization of the kidney. Once the kidney is isolated, it is secured in a bag and pulled

through a fifth incision, approximately 3 in (7.6 cm) wide, in the front of the abdominal

wall below the navel. Although this surgical technique takes slightly longer than a

traditional nephrectomy, preliminary studies have shown that it promotes a faster

recovery time, shorter hospital stays, and less post-operative pain.

A modified laparoscopic technique called hand-assisted laparoscopic nephrectomy may

also be used to remove the kidney. In the hand-assisted surgery, a small incision of 35

in (7.612.7 cm) is made in the patient's abdomen. The incision allows the surgeon to

place his hand in the abdominal cavity using a special surgical glove that also maintains

a seal for the inflation of the abdominal cavity with carbon dioxide. This technique gives

the surgeon the benefit of using his hands to feel the kidney and related structures. The

kidney is then removed by hand through the incision instead of with a bag.

Diagnosis/Preparation

Prior to surgery, blood samples will be taken from the patient to type and

crossmatch in case transfusion is required during surgery. A catheter will also be

inserted into the patient's bladder. The surgical procedure will be described to the

patient, along with the possible risks.

Aftercare

Nephrectomy patients may experience considerable discomfort in the area of the

incision. Patients may also experience numbness, caused by severed nerves, near or on

the incision. Pain relievers are administered following the surgical procedure and during

the recovery period on an as-needed basis. Although deep breathing and coughing may

be painful due to the proximity of the incision to the diaphragm, breathing exercises are

encouraged to prevent pneumonia. Patients should not drive an automobile for aminimum of two weeks.
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Risks

Possible complications of a nephrectomy procedure include infection, bleeding

(hemorrhage), and post-operative pneumonia. There is also the risk of kidney failure in a

patient with impaired function or disease in the remaining kidney.

RENAL ABSCESS

A renal or kidney abscess is a pus -filled hole in a kidney that forms when the

tissues of that kidney begin to break down due to a bacterial infection. It is a rare

disease, but if it is not treated, it may be fatal. If a kidney abscess occurs, it is typically

the result of a severe kidney infection or a urinary tract infection that was left untreated.

Some people are more prone to kidney abscesses than others. For example,

people plagued by kidney stones are often susceptible to the condition. In addition,

people with kidney inflammation and urinary tract infections may suffer from the disease

if they are not promptly treated. Individuals with abscesses in their skin due to the abuse

of intravenous drugs or other health issues may also be at risk for kidney abscesses.

Signs and Symptoms

Symptoms Manifested by patient Fever Chills Kidney tenderness Abdominal spasm /

abdominal

pain

Back pain Blood in urine Pus in urine Weight loss

Cause

Medical conditions involving some type of pathogen, such as a virus or bacteria.

Any condition affecting the kidneys.
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Medical conditions affecting the abdominal region.

Medical conditions affecting urination, urinary organs or the urinary system.

DIagnostic Procedures

On ultrasound the abscess can appear similar to a cyst, but with some internal

echoes or wall irregularity; as a solid mass, and mimic a renal neoplasm; or the echo

pattern of an abscess may be indistinguishable from adjacent renal parenchyma. On CT,

the abscess appears as a heterogeneous low-attenuation mass. There is often an

irregular, enhancing wall. Wall enhancement is secondary to hyperaemia or granulation

tissue formation. A bulge in the renal cortex is typically present, if the abscess is

peripheral. Inflammatory changes are seen in the adjacent fat. On contrast-

enhanced MRI, a liquefied portion of the abscess and enhancing wall are suggestive of

the diagnosis. The preferred treatment is image-guided percutaneous drainage, often

performed under CT guidance.

NEPHROLITHIASIS

Nephrolithiasis specifically refers to calculi in the kidneys, but this article

discusses both renal calculi (see the first image below) and ureteral calculi

(ureterolithiasis; see the second image below). Ureteral calculi almost always originate in

the kidneys, although they may continue to grow once they lodge in the ureter.

Although nephrolithiasis is not a common cause of renal failure, certain problems,

such as preexisting azotemia and solitary functional kidneys, clearly present a higher risk

of additional renal damage. Other high-risk factors include diabetes, struvite and/or

staghorn calculi, and various hereditary diseases such as primary hyperoxaluria, Dent

disease, cystinuria, and polycystic kidney disease. Spinal cord injuries and similar

functional or anatomical urological anomalies also predispose patients with kidney

stones to an increased risk of renal failure.

Recurrent obstruction, especially when associated with infection and tubular

epithelial or renal interstitial cell damage from microcrystals, may activate the fibrogenic

cascade, which is mainly responsible for the actual loss of functional renal parenchyma.

Etiology

A low fluid intake, with a subsequent low volume of urine production, produces

high concentrations of stone-forming solutes in the urine. This is an important, if not the

most important, environmental factor in kidney stone formation. The exact nature of the

tubular damage or dysfunction that leads to stone formation has not been characterized.


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Most research on the etiology and prevention of urinary tract stone disease has

been directed toward the role of elevated urinary levels of calcium, oxalate, and uric acid

in stone formation, as well as reduced urinary citrate levels.

Hypercalciuria is the most common metabolic abnormality. Some cases of hypercalciuria are related to increased intestinal absorption of calcium (associated with

excess dietary calcium and/or overactive calcium absorption mechanisms), some are

related to excess resorption of calcium from bone (ie, hyperparathyroidism), and some

are related to an inability of the renal tubules to properly reclaim calcium in the

glomerular filtrate (renal-leak hypercalciuria).

Magnesium and especially citrate are important inhibitors of stone formation in the

urinary tract. Decreased levels of these in the urine predispose to stone formation.

The following are the 4 main chemical types of renal calculi, which together are

associated with more than 20 underlying etiologies:

Calcium stones-

Calcium stones account for 75% of renal calculi. Recent data suggest that a low-

protein, low-salt diet may be preferable to a low-calcium diet in hypercalciuricstone formers for preventing stone recurrences. [4]Epidemiological studies have

shown that the incidence of stone disease is inversely related to the magnitude of

dietary calcium intake in first-time stone formers.

Struvite (magnesium ammonium phosphate) stones

Struvite stones account for 15% of renal calculi. They are associated with chronic

urinary tract infection (UTI) with gram-negative rods capable of splitting urea into

ammonium, which combines with phosphate and magnesium. Usual organismsinclude Proteus, Pseudomonas, and Klebsiella species. Escherichia coli

is not

capable of splitting urea and, therefore, is not associated with struvite stones.

Urine pH is typically greater than 7.

Uric acid stones

Uric acid stones account for 6% of renal calculi. These are associated with urine

pH less than 5.5, high purine intake (eg, organ meats, legumes, fish, meat

extracts, gravies), or malignancy (ie, rapid cell turnover). Approximately 25% of

patients with uric acid stone have gout.

Cystine stones
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Cystine stones account for 2% of renal calculi. They arise because of an intrinsic

metabolic defect resulting in failure of renal tubular reabsorption of cystine,

ornithine, lysine, and arginine. Urine becomes supersaturated with cystine, with

resultant crystal deposition.

Imaging studies

Calcium-containing stones are relatively radiodense , and they can often be

detected by a traditional radiograph of the abdomen that includes the kidneys, ureters,

and bladder .Some 60% of all renal stones are radiopaque. In general, calcium

phosphate stones have the greatest density, followed by calcium oxalate and

magnesium ammonium phosphate stones. Cystine calculi are only faintly radiodense,

while uric acid stones are usually entirely radiolucent.

A noncontrast helical CT scan with 5 millimeters (0.20 in) sections is the

diagnostic modality of choice in the radiographic evaluation of suspected

nephrolithiasis. All stones are detectable on CT scans except very rare stones composed

of certain drug residues in the urine, such as from indinavir .

An intravenous pyelogram (IVP) may be performed to help confirm the diagnosis

of urolithiasis. The IVP involves intravenous injection of a contrast agent followed by a

KUB film. Uroliths present in the kidneys, ureters or bladder may be better defined by the

use of this contrast agent. Stones can also be detected by a retrograde pyelogram ,

where a similar contrast agent is injected directly into the distal ostium of the ureter

(where the ureter terminates as it enters the bladder).

Ultrasound imaging of the kidneys can sometimes be useful as it gives details

about the presence of hydronephrosis, suggesting the stone is blocking the outflow of

urine. Radiolucent stones, which do not appear on CT scans, may show up on

ultrasound imaging studies. Other advantages of renal ultrasonography include its low

cost and absence of radiation exposure . Ultrasound imaging is useful for detecting

stones in situations where x-rays or CT scans are discouraged, such as in children or

pregnant women. Despite these advantages, renal ultrasonography is not currently

considered a substitute for noncontrast helical CT scan in the initial diagnostic evaluation

of urolithiasis. The main reason for this is that compared with CT, renal ultrasonography

more often fails to detect small stones (especially ureteral stones) as well as other

serious disorders that could be causing the symptoms.

Laboratory examination
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microscopic examination of the urine, which may show red blood cells ,

bacteria, leukocytes , urinary casts and crystals;

urine culture to identify any infecting organisms present in the urinary tract

and sensitivity to determine the susceptibility of these organisms to specific

antibiotics;

complete blood count (CBC), looking for neutrophilia (increased neutrophil

granulocyte count) suggestive of bacterial infection, as seen in the setting of struvite

stones;

renal function tests to look for abnormally high blood calcium blood levels

(hypercalcemia );

24 hour urine collection to measure total daily urinary volume, magnesium,

sodium, uric acid, calcium, citrate, oxalate and phosphate ;

collection of stones (by urinating through a Stone Screen kidney stone collection

cup or a simple tea strainer ) is useful. Chemical analysis of collected stones can

establish their composition, which in turn can help to guide future preventive and

therapeutic management

Prevention

Dietary measures

Increasing fluid intake of citrate -rich fluids (especially citrate-rich fluids such

as lemonade and orange juice ), with the objective of increasing urine output to more

than 2 liters per day

Attempt to maintain a calcium (Ca) intake of 1000 1200 mg per day

Limiting sodium (Na) intake to less than 2300 mg per day

Limiting vitamin C intake to less than 1000 mg per day

Limiting animal protein intake to no more than 2 meals daily, with less than 170

230 gram per day (A positive association between animal protein consumption and

recurrence of kidney stones has been shown in men, but not yet in women.)

Limiting consumption of foods containing high amounts of oxalate (such

as spinach , strawberries , nuts , rhubarb , wheat germ , dark chocolate , cocoa ,

brewed tea )

Urine alkalinization

The mainstay for medical management of uric acid stones is alkalinization

(increasing the pH) of the urine. Uric acid stones are among the few types
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amenable to dissolution therapy, referred to as chemolysis . Chemolysis is usually

achieved through the use of oral medications, although in some cases

intravenous agents or even instillation of certain irrigating agents directly onto the

stone can be performed, using antegrade nephrostomy or retrograde

ureteral catheters . Acetazolamide (Diamox ) is a medication that alkalinizes the

urine. In addition to acetazolamide or as an alternative, certain dietary

supplements are available that produce a similar alkalinization of the urine. These

include sodium bicarbonate , potassium citrate , magnesium citrate , and Bicitra (a

combination of citric acid monohydrate and sodium citrate dihydrate). Aside from

alkalinization of the urine, these supplements have the added advantage of

increasing the urinary citrate level, which helps to reduce the aggregation of

calcium oxalate stones.

Increasing the urine pH to around 6.5 provides optimal conditions for dissolution

of uric acid stones. Increasing the urine pH to a value higher than 7.0 increases

the risk of calcium phosphate stone formation. Testing the urine periodically

with nitrazine paper can help to ensure that the urine pH remains in this optimal

range. Using this approach, stone dissolution rate can be expected to be around

10 millimeters (0.39 in) of stone radius per month

Diuretics

One of the recognized medical therapies for prevention of stones is

the thiazide and thiazide-like diuretics , such as chlorthalidone or indapamide .

These drugs inhibit the formation of calcium-containing stones by reducing urinary

calcium excretion. Sodium restriction is necessary for clinical effect of thiazides,

as sodium excess promotes calcium excretion. Thiazides work best for renal leak

hypercalciuria (high urine calcium levels), a condition in which high urinary

calcium levels are caused by a primary kidney defect. Thiazides are useful for

treating absorptive hypercalciuria, a condition in which high urinary calcium is a

result of excess absorption from the gastrointestinal tract.

Allopurinol

For people with hyperuricosuria and calcium stones, allopurinol is one of the fewtreatments that has been shown to reduce kidney stone recurrences. Allopurinol

interferes with the production of uric acid in the liver . The drug is also used in

people with gout or hyperuricemia (high serum uric acid levels). Dosage is

adjusted to maintain a reduced urinary excretion of uric acid. Serum uric acid level
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at or below 6 milligrams/100 milliliters) is often a therapeutic goal. Hyperuricemia

(high serum uric acid levels) is not necessary for the formation of uric acid stones;

hyperuricosuria can occur in the presence of normal or even low serum uric acid .

Some practitioners advocate adding allopurinol only in people in whom

hyperuricosuria and hyperuricemia persists despite the use of a urine alkalinizing

agent such as sodium bicarbonate or potassium citrate

Management

Medical

Analgesia

Management of pain often requires intravenous administration of NSAIDs or

opioids. Orally-administered medications are often effective for less severe discomfort.

Intravenous acetaminophen also appears to be effective.

Expulsion therapy

The use of medications to speed the spontaneous passage of ureteral calculi is referred

to as medical expulsive therapy.Several agents including alpha adrenergic

blockers (such as tamsulosin ) and calcium channel blockers (such as nifedipine ) have

been found to be effective. A combination of tamsulosin and a corticosteroid may be

better than tamsulosin alone.These treatments also appears to be a useful adjunct to

lithotripsy.

Surgical

Extracorporeal shock wave lithotripsy

Extracorporeal shock wave lithotripsy (ESWL) involves the use of a lithotriptor machine

to deliver externally-applied, focused, high-intensity pulses of ultrasonic energy to causefragmentation of a stone over a period of around 3060 minutes.

Ureteroscopic surgery

Ureteroscopy has become increasingly popular as flexible and

rigid fiberoptic ureteroscopes have become smaller. One ureteroscopic technique

involves the placement of a ureteral stent (a small tube extending from the bladder, up

the ureter and into the kidney) to provide immediate relief of an obstructed kidney.

More invasive operations

Percutaneous nephrolithotomy or, rarely, anatrophic nephrolithotomy is the treatment of

choice for large or complicated stones (such as calyceal staghorn calculi) or stones that

cannot be extracted using less invasive procedures.
http://en.wikipedia.org/wiki/Hypouricemiahttp://en.wikipedia.org/wiki/Tamsulosinhttp://en.wikipedia.org/wiki/Nifedipinehttp://en.wikipedia.org/wiki/Ureteroscopyhttp://en.wikipedia.org/wiki/Optical_fiberhttp://en.wikipedia.org/wiki/Lithotomyhttp://en.wikipedia.org/wiki/Hypouricemiahttp://en.wikipedia.org/wiki/Tamsulosinhttp://en.wikipedia.org/wiki/Nifedipinehttp://en.wikipedia.org/wiki/Ureteroscopyhttp://en.wikipedia.org/wiki/Optical_fiberhttp://en.wikipedia.org/wiki/Lithotomy


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V. VITAL INFORMATION

Name Mrs. I.C.

Sex Female

Age 44 yrs old


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Address Cuartero Capiz

Date and time

admitted

November 11,2011

10:00am

Chief

complaint

Flank pain

Ward Blessed Rendu ward

Diet Soft diet

Room 105

Religion Roman Catholic

Admitting

diagnosis

Acute Pyelonephritis

Final

diagnosis

Renal abscess, Pelvic lithothiasis r/o Renal

Tumor Operation

Performed

Nephrectomy Right

Surgeon Dr. P. ADr. A. B

Attending

physician Dr. R.H.

VI. CLINICAL ASSESSMENT

A. Past Medical History

Mrs. I.M. is a known hypertensive. Shes currently taking Atorvastatin (Lipitor) as

her maintenance for the past 3 years now.

Mrs. I.M. was known to be allergic to seafoods. She has not experienced any

serious illness aside from common colds, cough and fever.


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B. Family History

The mother of Mrs. I.M. was asthmatic. Her father also as hypertension and died

because of stroke.

Nursing History

3 months prior to admission, Mrs. I.M. was admitted at St. Anthony College

Hospital because of UTI. She had undergone several test and it was found out in

the ultrasound that she has urinary stone. She was given Sambong as a remedy.

Two months after her follow up checkup it was found out that the stone

progresses. One week prior to admission, she experienced severe flank pain. Shewas rushed to St. Anthony College Hospital. She then undergo Nephrectomy.

VII. CLINICAL INSPECTION

A. Vital Signs

Upon Admission

Temperature 37.8 ocCardiac Rate 90bpm

Pulse Rate 88 bpmRespiration Rate 26 bpmBlood Pressure 160/80

During Care

Vital Signs 4:00pm 6:00pm 10:00pmTemperature 36.5 0C 36.8 0C 36.9 0CRespiration 26 bpm 24 bpm 20 bpm

Cardiac Rate 88 bpm 89 bpm 86 bpmPulse Rate 86 bpm 87bpm 84 bpm

Blood Pressure 140/100 mmHg 150/80 mmHg 130/90 mmHg

B.Physical Assessment (Cephalocaudal)

General Appearance

She was lying on bed with present IVF of PNSS IL x 60cc/hr. regulated as drops per

minute, with foley catheter attached to urobag. She had the urge to void while the tubing is


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clamped. She is healthy, tall and well-nourished, with a well-groomed appearance. She

appears restless but cooperative and is able to follow instructions.

Body Parts Methods of

Assessment

Findings Interpretation

Skin Inspection

Palpation

Brown in color

generally

uniformed.

Hot, flushed skin.

T= 38.1 C

Poor skin turgor,

wrinkled.

Smooth and firm,

with an even

surface.

This is due to

invasion of

pathogens

leading toinfection.

This is due to

physiologic

changes

associated

with aging.

NORMAL

Hair Inspection

Black colored hair

Has a thin hair,

silky and resilient.

No infections andinfestations.

Has a variable

amount of body

hair.

NORMAL

Nails Inspection

Palpation

Convex curvature,

angle is about

160 degrees.

Nails do not

promptly return to

usual color upon

There is

slow

capillary


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performing Blanch

test. Capillary refill

= 4 seconds.

nail bed

refill

because

of poor

arterial

circulatio

n.Skull and Face Inspection

Palpation

Normocephalic

and symmetric

with frontal,

parietal and

occipitalprominences.

Symmetric facial

movements.

Smooth skull

contour.

Absence of

nodules and

masses.

NORMAL

Eyes Inspection Eyebrows are

symmetrically

aligned to the

pinna of the ears.

Red conjunctiva.

No discharge anddiscoloration.

Pupils are equally

rounded and

reactive to light

and

accommodation.

Pupil size: 3mm

Due to

increase in

RBCproduction.

Ears Inspection Auricles are

aligned to the

outer canthus of

the eye.

Pinna recoils after

NORMAL


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it is folded.

No discharges.Nose and Sinuses Inspection

Palpation

Symmetric

No discharges

and nasal flaring.

Nasal septum is

intact and in

midline.

Not tender

maxillary and

frontal sinuses.

NORMAL

Mouth and

Oropharynx

Inspection

Lips are dry and

crack

Present gag

reflex.

The ovula rises

upon talking.

NORMAL

Neck Inspection

Palpation

Muscles equal insize; head

centered.

Coordinated,

smooth

movements with

no discomfort.

No palpable

lymph nodes.

The trachea is in

the midline.

NORMAL

Breasts and Axillae Inspection

Palpation

Breasts are even

with the chest

wall.

Nipples are

everted.

No discharges.

No masses and

palpable lymph.

NORMAL

Respiratory Inspection


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System

Auscultation

Spine vertically

aligned.

Chest wall intact;

no tenderness, no

masses.

Use of accessory

muscles in

breathing.

(+) non-productive

cough.

Crackles noted

upon auscultation

both on the lower

lung field.

23 - 26 breaths

per minute.

This may

due to the

presence of secretions in

the lungs.

Cardiovascular

System

Auscultation (+) Chest pain.

(+) weak

peripheral pulses. Cardiac rate of

90-103 beats per

minute.

Blood pressure of

160/90 mmHg.

Jugular vein is not

distended.

Gastrointestinal

System

Inspection

Palpation

Auscultation

Flat, measured 74

cm in diameter.

Penrose Drain

No tenderness.

Relaxed abdomen

with smooth,

consistenttension.

Audible

hypoactive bowel

sounds.

Surgical

Procedure

This is due to

decrease

peristalsis


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associated

with decrease

activity.

Genitor-urinarySystem

Inspection Scant amount of hair.

Penile skin intact.

She has a foley

catheter attached

to urobag with a

moderate amount

of urine outputdraining yellow

colored urine.

NORMAL

Muscoloskeletal

System

Inspection Symmetric

muscles.

NORMAL

General Appraisal:

Speech:

She could speak in Aklanon, Filipino and understands English. She

could speak clearly with a moderate tone of voice.

Hearing:

She has a good hearing acuity.

Mental Status:

She has a stable mental status. She is cooperative to directions but

he is irritable. She is alert to time, place, and person.

Emotional Status:

She is irritable. She shows a positive attitude, and fights the pressure

of her illness. There are times she gets bored lying all the time on

bed.


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VIII. LABORATORY AND DIAGNOSTIC DATA

CHEST X-RAY (PA View) November 11, 2011

Impression:

Bibasal Pneumonia

X-RAY (KUB) November 11, 2011

Impression:

Pelvic Lithiasis Right Kidney

Examination Result Normal Values Significance of


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Abnormal ResultDATE: Novemeber 10, 2011

Blood Chemistry

(Creatinine)

119 umol/L 53-115 mmol/LIncreased creatinine

levels in the blood

suggest diseases or

conditions that affect

kidney function. Such as

infection, and altered

kidney function.

Examination Result Normal Values Significance of

Abnormal ResultDATE: Novemeber 11, 2011

Blood Chemistry

Cholesterol

5.7 mmol/L 0 5.2 mmol/LHigh levels of cholesterol

in the blood may indicate

an increase risk for

coronary heart disease.

LDL 4.2 mmol/L 0 3.9 mmol/L High levels of LDL

indicates a buildup of

cholesterol in the arteries.

Cholesterol Risk

Factor

5.4 mmol/L 0 -4 mmol/L

High levels of cholesterol

risk factor indicates an

increase risk for coronaryheart disease.


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IX. PATHOPHYSIOLOGY

Predisposing FactorAge

GenderLifestyle

Precipitating FactorLow fluid intake andexcessive intake of protein, salt and oxalate

Hypertension

Uric acid, ammonia phosphate andcalcium oxalate stone materialdeposition on proximal renal

tubule

Super saturation of urineby stone

formingconstituents

Allowing crystallites to bedeposited and trapped

forming calculi or stones

Nephrocalcinosis onproximaltubule

Randalls plaque

Increase production of WBC

Progression of stonesinLoop of Henle

Accumulation of stones &increasing in size

Super saturation of urineby stone forming

constituents

Urinary Tract Infectioncaused by urea


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Stones formation


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X. MEDICAL MANAGEMENT

XI. NURSING MANAGEMENT


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XII. DISCHARGE PLANNING

MEDICATIONS

Take the entire course of all prescribed medications, even until feeling well.

Monitor for adverse effects of such drugs, e.g., tachycardia, cardiac

arrhythmias, central nervous system stimulation, and hypertension.

Medications:

1. Sambong 500mg 1tab

2. Fluticasone 5mg 1tab

3. Lipitor 10mg

4. Diflucan 50mg 2cap5. Flagyl

EXCERCISE

Get plenty of rest. Bed rest may help to avoid stress. Adequate rest is

important to maintain progress toward full recovery and to avoid relapse.

Discuss and demonstrate relaxation exercises to reduce stress, tension, and

anxiety. Reemphasize the importance of graded exercise and physicalconditioning programs. Advise to do gradual walking and breathing exercises.

Avoid strenuous activities that may precipitate conditions like, chest pain,

extreme dyspnea or undue fatigue. May have assistance and support if

activities are not tolerated alone.

TREATMENT

Advised patient and family members to seek medical advice if any unusuality

arises.

Instructed to comply with the medications prescribed.

Control your blood pressure by adhering fully to medications, and refraining

from eating foods high in cholesterol.

HOME TEACHINGS

Encourage the guardians to wash patients hands before and after contact with

the patient. The hands come in daily contact with germs that can cause

infection. Washing hands thoroughly and often can help reduce the risk.

Tell guardians to avoid exposing the patient to an environment with too much

pollution (e.g. smoke). Smoking damages ones lungs natural defenses


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against respiratory infections. Encourage the patient to quit from smoking as

well as drinking alcoholic beverages to prevent further complications.

OUT-PATIENT FOLLOW UP

Review with the patient the objectives of treatment and nursing management.

Keep all of follow-up appointments. Consult with the physician at least once a

month for the progress of condition. Emphasized the importance of regular

follow-up check-ups and as instructed by the physician.

Always provide patients safety to prevent injury. Warn patient to stay out of

extremely hot or cold weather and to avoid aggravating bronchial obstruction

and sputum obstruction. Warn patient to avoid persons with respiratoryinfections, and to avoid crowds and areas with poor ventilation.

DIET

Eat nutritious foods such as fruits and vegetables. Avoid eating foods which

can cause the patient to acquire other health problems.

Avoid saturated fat and cholesterol in diet.

Include fruits and vegetables in the diet.Eat fewer foods that are high in salt, like canned and packaged soups, pickles,

and processed meats.

Eat smaller portions and never skip meals. Drink milk every day.

SPIRITUALITY

The most rapid and effective healing takes place when we correct our wrong

beliefs. This does not include that we give new thought to the condition, but

rather new thought to the positive opposite of the unfortunate condition.

Encourage the patient to pray spiritually by giving gratitude and thanks to the

LORD for all the wonderful gifts HE had given to him.

Encouraged to continue to seek Gods guidance and enlightenment.

Encouraged to continue to have a positive outlook in life.

Encouraged to keep faith in God and not to give up easily when hard times

come.

Documents

Case Formatted