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

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 smoking would reduce the rate of renal pelvis cancer by one-half and the rate of renal cell carcinoma by one-third.

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.

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

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 the blood 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.

IV. TEXTBOOK DISCUSSION

nephrectomy

is

surgical 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.

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 videoscope and 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 a minimum of two weeks.

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.

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 contrastenhanced 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.

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 stonesCalcium stones account for 75% of renal calculi. Recent data suggest that a lowprotein, low-salt diet may be preferable to a low-calcium diet in hypercalciuric stone 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 organisms include Proteus, Pseudomonas, and Klebsiellaspecies. 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

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 acontrast 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

microscopic examination of the urine, which may show red blood cells, urine culture to identify any infecting organisms present in the urinary tract

bacteria, leukocytes, urinary casts and crystals;

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 24 hour urine collection to measure total daily urinary volume, magnesium, collection of stones (by urinating through a Stone Screen kidney stone collection

(hypercalcemia);

sodium, uric acid, calcium, citrate, oxalate andphosphate;

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

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 few treatments that has been shown to reduce kidney stone recurrences. Allopurinol interferes with the production of uric acid in theliver. 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

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 cause fragmentation 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.

V. VITAL INFORMATION Name Sex Age Mrs. I.C. Female 44 yrs old

Address Date and time admitted

Cuartero Capiz November 11,2011 10:00am

Chief complaint Ward Diet Room Religion Admitting diagnosis Final diagnosis Operation Performed Surgeon Attending physician

Flank pain Blessed Rendu ward Soft diet 105 Roman Catholic Acute Pyelonephritis Renal abscess, Pelvic lithothiasis r/o Renal Tumor Nephrectomy Right Dr. P. A Dr. A. B 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.

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. She was rushed to St. Anthony College Hospital. She then undergo Nephrectomy.

VII. CLINICAL INSPECTION

A. Upon Admission

Vital Signs

Temperature Cardiac Rate Pulse Rate Respiration Rate Blood Pressure

37.8oc 90bpm 88 bpm 26 bpm 160/80

During Care Vital Signs Temperature Respiration Cardiac Rate Pulse Rate Blood Pressure
B.

4:00pm 36.50C 26 bpm 88 bpm 86 bpm 140/100 mmHg

6:00pm 36.80C 24 bpm 89 bpm 87bpm 150/80 mmHg

10:00pm 36.90C 20 bpm 86 bpm 84 bpm 130/90 mmHg

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

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 Skin Methods of Assessment Inspection Findings Brown in color generally uniformed. Palpation Hot, flushed skin. T= 38.1 C This is due to invasion of pathogens leading to infection. Poor skin turgor, wrinkled. This is due to physiologic changes associated with aging. Smooth and firm, with an even surface. Hair Inspection Black colored hair Has a thin hair, silky and resilient. No infections and infestations. Has a variable amount of body Nails Inspection hair. Convex curvature, angle is about 160 degrees. NORMAL NORMAL Interpretation

Palpation

Nails do not promptly return to usual color upon

There is slow capillary

performing Blanch test. Capillary refill = 4 seconds.

nail bed refill because of poor arterial circulatio n. NORMAL

Skull and Face

Inspection

Normocephalic and symmetric with frontal, parietal and occipital prominences.

Palpation

Symmetric facial movements. Smooth skull contour. Absence of nodules and masses. Eyebrows are symmetrically aligned to the pinna of the ears.

Eyes

Inspection

Red conjunctiva. No discharge and discoloration. Pupils are equally rounded and reactive to light and accommodation.

Due to increase in RBC production.

Ears

Inspection

Pupil size: 3mm Auricles are aligned to the outer canthus of the eye.

NORMAL

Pinna recoils after

it is folded. Nose and Sinuses Inspection No discharges. Symmetric No discharges and nasal flaring. Nasal septum is intact and in midline. Palpation Not tender maxillary and frontal sinuses. Mouth and Oropharynx Inspection Neck Inspection Lips are dry and crack Present gag reflex. The ovula rises upon talking. Muscles equal in size; head centered. Coordinated, smooth movements with no discomfort. Palpation Breasts and Axillae Inspection No palpable lymph nodes. The trachea is in the midline. Breasts are even with the chest wall. Palpation Respiratory Inspection Nipples are everted. No discharges. No masses and palpable lymph. NORMAL NORMAL NORMAL NORMAL

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. This may due to the presence of secretions in the lungs.

Cardiovascular System Auscultation

23 - 26 breaths per minute. (+) 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

Flat, measured 74 cm in diameter. Penrose Drain No tenderness. Relaxed abdomen with smooth, consistent tension. Surgical Procedure

Auscultation

Audible hypoactive bowel sounds.

This is due to decrease peristalsis

associated with decrease activity. Genitor-urinary System Inspection Scant amount of hair. Penile skin intact. She has a foley catheter attached to urobag with a moderate amount of urine output draining yellow Muscoloskeletal System Inspection colored urine. Symmetric muscles. NORMAL 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.

VIII.

LABORATORY AND DIAGNOSTIC DATA November 11, 2011 Impression: Bibasal Pneumonia

CHEST X-RAY (PA View)

X-RAY (KUB)

November 11, 2011 Impression: Pelvic Lithiasis Right Kidney

Examination

Result

Normal Values

Significance of

Abnormal Result DATE: Novemeber 10, 2011 Blood Chemistry (Creatinine) 119 umol/L 53-115 mmol/L

Increased 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 Result

DATE: Novemeber 11, 2011 Blood Chemistry Cholesterol 5.7 mmol/L 0 5.2 mmol/L

High 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. High levels of cholesterol

Cholesterol Risk Factor

5.4 mmol/L

0 -4 mmol/L

risk factor indicates an increase risk for coronary heart disease.

Predisposing Factor Age Gender Lifestyle

Precipitating Factor Low fluid intake and excessive intake of protein, salt and oxalate Hypertension

Uric acid, ammonia phosphate and calcium oxalate stone material deposition on proximal renal tubule

IX. PATHOPHYSIOLOGY

Super saturation of urine by stone formingconstituents

Allowing crystallites to be deposited and trapped forming calculi or stones

Nephrocalcinosis on proximaltubule Super saturation of urine by stone forming constituents Randalls plaque

Urinary Tract Infection caused by urea

Increase production of WBC

Progression of stones inLoop of Henle

Accumulation of stones & increasing in size

Stones formation <5mm in kidneys

Stone descended in renal pelvis

Deposited and Trapped theUreter

Pelvic Lithiasis

X. MEDICAL MANAGEMENT

XI. NURSING MANAGEMENT

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 2cap 5. 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 physical conditioning 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

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 respiratory infections, 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.