Published on March 1, 2014
Medical-Surgical Nursing 1 A Case Presentation on Nephrolithiasis
I. Patient’s Profile Name: Age: Sex: Address: Religion: Occupation: Attending Physician: Date of admission: Date of discharge: Mrs. R.D 57 years old Female 36 Luna Street, Lapaz, Iloilo City Roman Catholic Housewife Dr. F.M December 12, 2012 still on admission during data gathering.
Chief Complaint: Right Flank Pain Diagnosis: Nephrolithiasis with moderate hydronephrosis and hydroureter secondary to obstructing proximal ureterolithiasis, right. Special procedures: Human Albumin Transfussion57cc 25% Operative Procedure: CVP Insertion
II. History of Present Illness Mrs. RD is apparently well, until in the morning of the day of admission. She started to complain of right flank pain accompanied by terminal dyspnea and urinary frequency. She took mefenamic acid with no relief of symptoms. In the afternoon there was persistence of symptoms and she had fever and chills, thus sought consult in the hospital and was subsequently admitted. Mrs. RD stopped taking her maintenance since August 2012.
III. Past Medical History • Hypertension -on telmisartan + amlodipine 40/5mg, stopped last August 2012. • Bilateral Nephrolithiasis - on potassium citrate, stopped last August 2012.
• 3.1 Previous Hospitalization -TAHBSOO last 2007 secondary to myoma. • 3.2 Allergies-none • 3.3 Habits -doing all the household chores whenever she is able to. • 3.4Family History -Hypertension (paternal side) • 3.5 Social/Environmental History-Non-smoker, Non-alkoholic
IV. Physical Examination • TPR on Admission o o o o T- 39.4 °C P- 122 bpm R- 22 bpm BP- 140/80 mmhg • TPR range during hospital stay. o T- 36 °C to 39.4 °C o P-81 bpm to 122 bpm o R- 19 bpm to 33 bpm o BP-90/60mmhg to 140/80 mmhg.
General Assessment • Awake, conscious and coherent, dressed in clean and comfortable clothing, conversant with folks. With vital signs upon assessment of: • T-36.7 °C • CR-118bpm • RR-26bpm • BP-140/80mmhg
• 4.1 Head- normocephalic, symmetrical and smooth. Absence of depressions, masses and scars. Hair is smooth, colored gray and evenly distributed. • 4.2 Face- oval shaped, absence of pimples, acne and scars. Edema, disproportionate structures and involuntary movements not noted. • 4.3 Eyes- anicteric, symmetrical, inline with each other, non-protruding and equal palpebral fissures. Pupils are equally round, reactive to light and accomodation.
• 4.4 Nose-located symmetrically on the midline of the face, absence of swelling, lesions, perforations and discharges. With pinkish nasal mucosa. • 4.5 Ears- aligned with the outer canthus of the eyes, symmetrical and no discharges nor perforations noted. • 4.6 Mouth- dry lips and oral mucosa. Tongue in midline of the mouth. Tooth decay noted on right canine and frontal teeth. No halitosis noted.
• 4.7 Neck- head is in central position. No deformities, lesions nor limits in range of motion. Lymph nodes are non-palpable. • 4.8 Chest- symmetrical, no masses, lesions nor retractions noted. • 4.9 Heart- tachycardic, adynamic precordium. • 4.10- Abdomen- uniform in color, no scars nor lesions noted. Tenderness noted on hypogastric and epigastric area.
• 4.11Genitalia- not assessed, but patient complains of dysuria and urinary frequency. • 4.12 Upper extremities- equal in size and length. No deformities, lesions nor scars noted, able to perform full range of motion. • 4.12 Lower extremities- both legs are edematous ( plus 2 pitting edema), unable to perform full range of motion exercises. Still with full pulses.
Laboratory Data December 12, 2012 Hematology Result Normal Values Hemoglobin 103g/L M: 130-180 g/L F: 120-160 g/L Hematocrit 0.34 vol. fr. M: 0.40-0.54 vol. fr. F: 0.37-0.47 vol. fr. RBC Count 5.18 x 10/L M: 4.6-6.2 x10/L F: 4.2-5.4 x10/L WBC Count 19.53 x 10/L 4.5 -11.0 x 10/L Differential Count Neutrophil Segmenter Stab Lymphocyte 93% 85% 8% 6% 50-70% 2-5% 20-40% Platelet Count 72.0 x10/L 150-450 x 10/L
December 12, 2012 Urinalysis Results Normal Values Color Pale straw Light yellow -amber Transparency Hazy Clear Reaction Acidic Acidic Specific Gravity 1.030 1.005-1.035 Puss cells 50-60 None RBC 2-4 None Sugar Negative Negative Albumin Trace negative Microscopic Findings Chemical Tests
December 12, 2012 ABG Results Normal Values pH 7.41 7.35-7.45 paCO2 28.8 mmhg 35-45 mmhg pO2 73 mmhg 80-100mmhg HCO3 18.8 mmol/L 22-26 mmol/L O2 saturation 95.7% 95-100%
December 12, 2012 Chest PA Impression : Atherosclerosis; aorta Subsegmental atelectasis left lung
Decemberv13, 2012 Ultrasound Report Impressions: •Diffuse fatty liver •Nephrolithiasis, with hydronephrosis and hydroureter •Normal gallbladder, pancreas, spleen, left kidney and urinary bladder.
December 13, 2012 Results Normal Values FBS (Fasting Blood Sugar) 9.55 mmol/L 4.1-5.9 mmol/L Uric Acid 497.54 umol/L 155-357 umol/L. December 14,2012 Result HbA1C Normal Value 7.5% 4.8-6.0%
December 14, 2012 Miscellaneous Report Prothrombin Time Normal Values % Activity: 80% 70-10% Patient: 14.8 seconds 11.6-16.0 seconds INR: 1.15
December 16, 2012 Blood Chemistry Results Normal Values Albumin 22.55 g/L 34-50g/L BUN 13.14 mmol/L 2.5- 6.40 mmol/L Creatinine 155.59 umol/L 53-88umol/L Sodium 140.28 mmol/L 136-146 mmol/L Potassium 3.39 mmol/L 3.5- 5.1 mmol/L
December 16, 2012 ABG Results Normal Values pH 7.38 7.35-7.45 paCO2 31 mmhg 35-45 mmhg pO2 80 mmhg 80-100mmhg HCO3 18.3 mmol/L 22-26 mmol/L O2 saturation 95% 95-100% FULLY COMPENSATED METABOLIC ACIDOCIS WITH ADEQUATE OXYGENATION
• Paracetamol 500mg/tab 1 tab q6h PRN for fever >/= t. 37.8°C. • Telmisartan + amlodipine40mg/5mg/tab OD • Clonidine (catapress) 75mcg/tab 1 tab SL q6h for BP >/=150/90 • Omeprazole 40 mg OD
• Kalium durole TID x 9 doses. • Midazolam 2g slow IVTT on route to OR • Dopamine 400mcg in 250cc D5W • Furosemide 20mg IV with precautions
Precipitating Factors -excesive intake of calcium/hyperclcemia -decreased intake of water. Nephrolithiasis Predisposing Factors -male -family history of renal disease Saturation of urine Decreased urinary flow May produce excess amounts of mucoprotein in the bladder Allowing crystallites to be deposited and trapped forming calculi or stones Urine (upon voiding) moves tiny stones to the ureter Large stones tiny stones
Large stones Tiny stones Blocks the ureter Becomes nidus for bacteria Causes spasm Decreased urine output Injures the wall of the ureter UTI Increased WBC count Painful urination Blood combines with urine/hematuria Decreased hgb count Makes urine turbidity cloudy
VII. Nursing Diagnosis and Care Plans Nursing Diagnosis according to priority of care: • Acute pain related to ureteral contractions secondary to stones in the kidney. • Hyperthermia related to infection process. • Fluid volume excess related to compromised regulatory mechanism.
• Altered urinary elimination related to mechanical obstruction. • Altered nutrition less than body requirements related to nausea and vomiting. • Risk for decreased cardiac output related to severe acidosis. • Risk for infection related to invasive procedures. (Urinary catheter, CVP insertion.)
• Risk for injury related to decreased RBC production. • Risk for impaired skin integrity related to edema. ( 2+) • Knowledge deficit regarding condition related to information misinterpretation
Updates on Nephrolithiasis
Home remedies from herbal teas and grocery foods dissolve kidney stones and reverse renal failure October 31, 2012 by: JB Bardot • • • • • • Lemonade Apple cider vinegar Cranberry juice Parsley and dandelion Marshmallow root buchu
• lemonade • Apple cider vinegar
• Cranberry juice • Parsleys and dandelion
• Marshmallow roor • Buchu
Fresh Insight on Effective Drug Treatments for Kidney Stones New research by scientists at Washington University School of Medicine in St. Louis shows evidence to explain why some people are more prone to develop kidney stones than others
When claudin-14 is idled, the kidney's filtering system works like it's supposed to. Essential minerals in the blood like calcium and magnesium pass through the kidneys and are reabsorbed back into the blood, where they are transported to cells to carry out basic functions of life. But when people eat a diet high in calcium or salt and don't drink enough water, the small RNA molecules release their hold on claudin 14. An increase in the gene's activity prevents calcium from re-entering the blood, the study shows.
Calcification Inhibitors in CKD and Dialysis Patients
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