UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION

Salinas Drive, Lahug, Cebu City

COLLEGE OF NURSING

In Partial Fulfilment of the

Requirements of the Subject
NCM 103L

Submitted to:
Ms. Ivy C. Villaceran, RN, MAN

Submitted by:
RLE Group 2
Bacatan, Kayra Marie Means, Jhean Alphonsine
Calipara, Crystal Natividad, Trisha Noby
Cortez, Felbert Charles Pomarejo, Vaughn Chadwick
Gamallo, Chayryl Tito, Venus de Salve
Golis, Marc Daniel Valera, Lornalyn
Masayon, Merjuly Vendiola, Khoreine Leigh
 CONTENT

I. Introduction

II. General Information or Patient’s Profile

III. Pertinent Nursing Health History

History of Present Illness

Developmental Task
Genogram
Gordon’s Functional Health Pattern
Physical Assessment
Diagnostics and Laboratory Exams
IV. Anatomy and Physiology

V. Pathophysiology

VI. Summary of Significant Findings

VII. Nursing Care Management: Nursing Care Plans

VIII. Drug Studies

IX. Discharge Plan

X. Health Teaching Plan

XI. Bibliography

2|Urolithiasis
 INTRODUCTION

Urolithiasis is the process of forming stones in the kidney, bladder, and/or

urethra (urinary tract). Kidney stones are a common cause of blood in the urine
and pain in the abdomen, flank, or groin. Kidney stones occur in 1 in 20 people at
some time in their life.

Urinary Calculi (Urolithiasis) are calcifications in the urinary system.

Commonly called stones, calculi form primarily in the kidney(nephrolithiasis), but
they can form in or migrate to the lower urinary system. They are typically
asymptomatic until they pass into the lower urinary tract. Stones are usually
managed by a urologist. Primarily bladder calculi are rare and usually develop
from a history of urinary stasis from obstruction or chronic infection.

Types of Calculi:

Diseases associated with stone formation:

• Hyperparathyroidism • Crohn’s disease,
• renal tubular acidosis • malabsorptive conditions
(partial/complete) • sarcoidosis
• jejunoileal bypass • Hyperthyroidism

Medication associated with stone formation:

• calcium supplements • ascorbic acid in mega doses (> 4
• vitamin D supplements g/day),
• Acetazolamide • Sulphonamides

Anatomical abnormalities associated with stone formation:

•tubular ectasia (medullary sponge •ureteral stricture
kidney) •vesico-ureteral reflux
•pelvo-ureteral junction obstruction •horseshoe kidney
•calix cyst •ureterocele

3|Urolithiasis
EPIDEMIOLOGY
Kidney stone disease is a crystal concretion formed usually within the
kidneys. It is an increasing urological disorder of human health, affecting about
12% of the world population. It has been associated with an increased risk of end-
stage renal failure.
Urolithiasis is one of the major diseases of the urinary tract and is a major
source of morbidity. Stone formation is one of the painful urologic disorders that
occur in approximately 12% of the global population and its re-occurrence rate
in males is 70-81% and 47-60% in female. It is assessed that at least 10% of the
population in industrialized part of the world are suffering with the problem of
urinary stone formation. The occurrence of the renal calculi is less in the southern
part when compared with other parts. The rate of occurrence is three times higher
in men than women, because of enhancing capacity of testosterone and
inhibiting capacity of estrogen in stone formation. More common in Caucasians
and Asians. A higher prevalence of stone disease is found in hot, arid, or dry
climates such as the mountains, desert, or tropical areas.
[Source:https://www.hindawi.com/journals/au/2018/3068365/; Kidney Stone
Disease: An Update on Current Concepts - Tilahun Alelign and Beyene Petros]

In the Philippines, where many people have elevated uric acid level in their
blood, the incidence of kidney urate stones is also relatively higher compared to
those in other countries. Aside from preventing gouty arthritis in your joints, of
keeping your blood uric acid level at a normal level. The DOH has since estimated
an increase in the number of kidney disease cases between 10 to 15 percent a
year. Kidney problems, however, consistently rank among the top 10 causes of
morbidity (7th) and mortality (8th), according to the Philippine Statistics Authority.

We. the 2nd group of level III students chose this case - client who is
diagnosed with Hydronephrosis secondary to Urolithiasis as the topic for our
Nursing Care Audit because we would want to know, learn and share how
Urolithiasis develops? What can trigger the disease to occur? This also helps the
student nurses in determining how to cater to the biological, psychosocial,
physiological and spiritual needs of clients having renal stones. Through this case
presentation and case study, it will also benefit the listeners and readers as this
case study provides a bird’s eye view of the background of people who are
diagnosed with Urolithiasis. It will also aid the listeners and readers in the future
when they encounter situations or clients who have renal stones and on how to
handle these clients in a therapeutic manner.

4|Urolithiasis
 PATIENT’S PROFILE:

Name: C., F.
Age: 53 years old
Sex: Female
Civil Status: Married
Occupation: Housewife
Nationality: Filipino
Religion: Roman Catholic
Address: San Jose, Purok 5, Cebu City
Name of Hospital: North General Hospital
Date of Admission: September 28, 2018
Time of Admission: 12:55PM
Ward and Bed No.: Ward 2-A, Room 233
Case No.: 18-2681
Physician: Dr. I. E. M.D. & Dr. K. E. M.D.
Chief Complaint: Left Flank Pain, hematuria, dysuria, headache
Admitting Diagnosis/Impression: Left Pelvocaliectasia 2 ͦ Left Urolithiasis

5|Urolithiasis
 PERTINENT NURSING HEALTH HISTORY

CHIEF COMPLAINT

Left flank pain rated as 7/10, from a scale of 0-10, 10 being the highest;
hematuria, dysuria, accompanied by headaches.
HISTORY OF PAST ILLNESS
Upon assessment, patient stated that she has had previous hospitalizations
associated with her current condition. In the year 2014, patient was diagnosed
with multiple calculus in her left kidney. Treatment included insertion of a ureteral
stent. In the year 2015, she was admitted for reinsertion of ureteral stent due to
the same condition. She was confined in multiple hospitals including NGH. The
patient stated that she also felt pain in her left flank, pain when urinating and
frequency. The patient added that she has had recurrence of urinary tract
infections.
HISTORY OF PRESENT ILLNESS
3 days PTA, patient had onset of dysuria, urinary frequency and pain on the
left side of her back. The pain was usually stimulated when she paced her walking
and lifting heavy objects but is sometimes relieved by rest. She claims that she
had cloudy, tea colored urine and it burned a little when she urinates. The night
before admission, the patient had an onset of pain at her left flank area radiating
to her left leg rated as 7/10, from a scale of 0-10, 10 being the highest and there
was presence of blood in her urine. The patient stated that she was tolerating the
pain but decided to seek consult and was advised for admission.
SOCIAL AND ENVIRONMENTAL HISTORY
The patient lives with 2 of her sons, aged 21 and 27; and her husband aged
58. They all live in a secluded, private compound at San Jose, Purok 5, Cebu City.
At the age of 18 she began to smoke 5 sticks per day to the point where she
reached smoking 2 packs per day then stopped when her first son was born and
added that she drinks beer occasionally for socialization purposes. She is fond of
eating high salt and high sugar foods with a bottle of acidic beverages. Almost
6|Urolithiasis
every day, she eats junk foods, soft drinks and loves to eat in fast food restaurants
like Jollibee, KFC, and McDonald’s. The client is a housewife, and is a high school
graduate. She is friendly and loves to mingle with others. Due to her kindness,
generosity, and friendly attitude, she is loved by many and is always visited by her
neighbors, friends, and relatives in their house and they used to have snacks. Their
house is sited along the street and was surrounded by mango trees. She loves to
eat mango with “bagoong”.
FAMILY HISTORY:
The patient’s father died because of stroke and hypertension. The mother
was deceased with a history of kidney stones and hypertension. She has 3 siblings,
with her being the second eldest. The patient stated that her eldest brother is
hypertensive and her younger sister has asthma. According to her, their relatives
from the mother side have the same illness also and some relatives passed away
with the same health problem.
Maternal: Paternal:
Asthma HPN
Kidney stone Chronic Smoker
HPN
OBSTETRIC HEALTH HISTORY
The patients’ menarche happened when she was 12 years old. Her menstrual
duration lasted for 3-5 days and has regular days with lighter menstrual flow on
the first day and become gradually heavier towards the end of menses
consuming 3-4 pads in a day. According to the patient, when she had her first
pregnancy at 26 years old, and her second child when she was 32 years old. She
was healthy with both of her pregnancies and she had complete prenatal check-
ups and was taking her vitamins daily. She gave birth via Normal Spontaneous
Vaginal Delivery with both of her children. She entered the menopausal stage at
51 years old.

Gravida- 2, Para- 2 Term - 2, Abortion- 0, Live birth- 2

7|Urolithiasis
 DEVELOPMENTAL TASK

Generativity vs. Stagnation

Existential Question: Can I make my life count?
Basic Virtue: Care
Important Event/s: Work, parenthood

Generativity refers to "making your mark" on the world through caring for
others as well as creating and accomplishing things that make the world a better
place.

Stagnation refers to the failure to find a way to contribute. These individuals

may feel disconnected or uninvolved with their community and with society as a
whole.

During middle adulthood between ages 40 to 65 yrs., we establish our

careers, settle down within a relationship, begin our own families and develop a
sense of being a part of the bigger picture. During this time, adults strive to create
or nurture things that will outlast them; often by parenting children or contributing
to positive changes that benefit other people. Contributing to society and doing
things to benefit future generations are important needs at the generativity versus
stagnation stage of development.

We give back to society through raising our children, being productive at

work, and becoming involved in community activities and organizations.

By failing to achieve these objectives, we become stagnant and feel

unproductive. Success in this stage will lead to the virtue of care.
As for our patient, C., F. is successful in passing this stage. During our
assessment of her, she was with her cousin then replaced by her eldest son and
before our shift ended we saw her husband and son taking care of her, feeding
her showing that her family really cares and loves her so much. She added that in
this time of her life, she is really grateful because she has all of her loved ones
beside her. She also added that her family never fails to remind her that they love
her and that they thank her for coming into their lives and for bringing their sons
in this world. Aside from being a caring mother and wife, she is also involved in
community activities and organizations, despite not having finished college, she
has established her career as a mother and a wife, settled down, growing and
nurturing a long-lasting relationship and raising a family. It is apparent that she has
successfully developed the virtue of care and generativity.

8|Urolithiasis
9|Urolithiasis
 GORDON’S FUNCTIONAL HEALTH PATTERNS
FUNCTIONAL HEALTH BEFORE HOSPITALIZATION DURING HOSPITALIZATION
PATTERN
Health Perception and According to the Upon assessment patient
Health Maintenance patient, she said that she still feels pain
experienced onset of on her left flank area with
left flank pain radiatinga pain score of 7/10 with
to her left leg. Patient
10 rated as the highest.
tolerated the pain and Patient feels very
took Advil to relieve thenauseous and weak.
pain. The patient stated Patient also showed
that she normally adjusts guarded behavior and
to her day to day body was self-focused,
changes, aware that especially when the pain
she was already was stimulated. Patient
diagnosed with multiple also added that she
calculi in her kidneys.would have mild to
severe headaches.
Nutrition and As verbalized by the Patient was encouraged
Metabolism patient “wala man koy to increase oral fluids.
pili og pagkaon, The patient continues to
mukaon raman ko ug eat nutritious food for her
bisag unsa.” She only recovery. Patient was
drinks about a couple of advised to increase oral
glasses of water a day, a fluids before her CT scan
cup of coffee every procedure. During our
morning and eats 3x a 8hour shift, patient C., F.
day. Her favorite snack had a total of 800ml of
to nibble on during the fluid intake and 420cc of
day are fish crackers IV fluids.
and green mangoes.
She loves chocolates,
canned sardines, and
seafoods. She mostly
loves to eat at fast food
chain restaurants, like
Jollibee, McDonald’s
and KFC. At night before
going to bed, she drinks
a glass of milk. She
added that she drinks
alcohol especially when
there is an occasion,

10 | U r o l i t h i a s i s
 usually more than 3
glasses of beer. She used
to smoke but stopped at
the time she had her
first-born son.
PACK YEARS:
8x2= 16 pack years
Elimination The patient verbalized Patient hasn’t defecated
that she defecates once since she was admitted,
a day. She urinates and on my 8H shift the
mostly 3-4 times a day. patient urinated 6 times
And her urine is colored with cloudy, tea colored
yellow. urine. Patient also added
that she feels a burning
sensation when urinating.
During our 8H shift,
patients’ total output was
only 950cc.

Activity and Exercise Patient states that she The patient stated that
wakes up early in the she rarely gets to move
morning around 6am to around because she feels
cook for her children l nauseated and weak
and her husband. She most of the time.
does household chores
every day and walks
around the
neighborhood for
exercise.
Cognition and Patient stated that she is Patient is oriented to time,
Perception aware of her condition. place and person.
Patient does not fail to
answer questions
coherently.
Sleep and Rest Patient sleeps around 9- Patient tries to get some
10 pm and wakes up at rest and sleep but is
6am and takes nap sometimes disturbed by
usually after lunch at routine medical
least 1-2 hours during the treatment.
day.
Sexuality and Patient has not been Patient is still admitted.
Reproduction engaging in any sexual
activities for almost a

11 | U r o l i t h i a s i s

Self-perception and Self-
concept
Roles and Relationship
Stress Tolerance and
Coping
12 | U r o l i t h i a s i s
6months. Patient had
her last menstruation at
the age of 51.
Patient always thought Patient still remains
that everything was positive with everything
going to be okay and despite her condition but
most of the time still worries because of the
tolerates her pain thought that she has
because she doesn’t been hospitalized
want her family to worry. multiple times because of
the same reason. Patient
also stated that
everybody goes through
this point in their lives and
if God decides it is time to
leave this world, then its
time.
Patient plays the role of Patient plays the same
a mother to her children, role. She added that she
a wife to her husband is very thankful to have
and a sister to her
her family around in this
siblings. Patient stated
that she has a very close time of need.
relationship with her
family, friends and
neighbors.
She describes how much
affection she gives to
her family and friends,
especially her husband.
She states that she and
her husband seldom
have fights. Which is
normal, she added.
Patient copes up with Patient sleeps most of the
stress by watching tv or time and sometimes turns
movies or sharing on the tv when she’s
problems to her bored.
husband. And just
mainly by doing
household chores. She
releases stress sometimes
by hanging around with
 her friends in the
neighborhood, singing
on the karaoke and
drinking beer.
Sometimes they go out
on dates with her
husband and reminisce
on their younger years.
Values and Belief According to the The patient does not
patient, her family goes have time to go to
to church on Sundays. church for she is still in the
She added that nothing hospital but prays on her
is impossible with God. room. She believes that
with trust and faith in the
Lord, she and her family
will be able to get
through this.

13 | U r o l i t h i a s i s
 PHYSICAL ASSESSMENT

GENERAL SURVEY: Received patient C., F. at ward 2A- Room No. 233,
awake, conscious, and responsive with vital signs of: T- 36.0 ͦC, P- 70 bpm, R- 18
cpm, Bp- 90/60 mmhg, with IVF: D5LR 40 gtts/min - infusing well. With a pain score
of 7/10, rated 10 as the highest.
O – abrupt onset that started 3 days PTA
L – Left Flank Pain radiated to LLQ of abdomen and groin
D – variable, 3-5 minutes
C – extreme pain, colicky, associated with nausea and vomiting
A – upon heavy lifting, swift movements
R – relieved by resting, sitting, often sleeping, drinking water
T –Ibuprofen for pain relief
Pt is 4’11” in height and 53kgs in weight. Pt. has a good posture and gait
but her movement was quite limited because of her being nauseous and having
a headache. Patient showed signs of diminished alertness, guarded behavior,
irritability, facial grimace and narrowed focus. Appears clean and neat, practices
good hygiene.

NORMAL FINDINGS ABNORMAL INTERPRETATION

FINDINGS
SKIN, HAIR, AND Skin tones w/o Skin was dry and Patient may be
NAILS unusual prominent flaky. dehydrated as
discoloration. Nails With fine grey evidenced by
are intact & free hairs noted upon urinary
from lesions. inspection. frequency and
Hair is black, long Nails were a little was advised to
and hangs freely. bit long. increase oral
CRT: <2 seconds fluids.
HEAD AND NECK Head is symmetric in
shape still & upright.
Neck is symmetric
with head centered
& w/o bulging
masses.
Nodes: Small,
mobile, nontender
nodes
Thyroid: Small,
smooth, lateral
lobes palpable on
either side.

14 | U r o l i t h i a s i s
 MOUTH AND NOSE Lips were free from Lips were dry -Dehydrated
lesions. upon inspection.
Nose is the same
color as the rest of
the face.
Nasal structure is
symmetric.
No discharges were
observed upon
inspection.
EYES AND EARS Sclera appears She was not able -Decreased
white and palpebral to read visual acuity
conjunctiva magazines or may be due to
appears pink in newspaper at a aging process
color. Pupils are distance of 36
black and cm without using
symmetrical, pupil is reading glass.
dilated and reactive Dark sunken
to light at 2-3 mm. eyes.
The client has no
known deficits such
as color blindness.
Auricles are
symmetrical and the
same color as facial
skin, has a clean
external auditory
canal without
lesions or discomfort
noted. She can hear
at a distance of
about 2 feet by
repeating what we
said as requested
her to do so.
THROAT The throat was not
edematous and no
lesions observed.
BREAST Skin color I uniform Striae was noted -Stretch marks
in color. There were upon inspection. were from
striae on both Breasts have lost birthing
client’s breasts. its form. processes and

15 | U r o l i t h i a s i s
 Client has one breastfeeding
distinct mole on the history.
Left side of her -Breasts are not
Breast. There were their usual
no discharges upon shape and
inspection. Upon form because
palpation, there of BF and
were no masses aging process.
noted and both
breasts were
nontender.
THORACIC & Respiration is regular
LUNGS in depth, chest,
expansion is equal,
both scapulars is
symmetrical & not
protruding. equal
expiratory and
inspiratory phases
Remainder of chest:
Vesicular breath
sounds heard.
CARDIOVASCULAR Normal Heart rate,
rhythm, and heart
sounds upon
auscultation. Pt. has
normal pulse rate-
70 bpm with a Bp-
90/60. Patient was
not hypertensive
upon assessment.
ABDOMEN Stretch marks noted Slightly distended - due to
upon inspection. localized to the increased fluid
Presence of normal left side when in the urinary
bowel sounds: 9/min inspected. Upon tract.
upon auscultation. palpation:
No abdominal tenderness noted
masses noted. at LLQ.
Abdominal girth:
36inches.
GENITOURINARY Skin uniform in color. Hematuria -due to
Even distribution of Dysuria increased
hair. No discharges.

16 | U r o l i t h i a s i s
 There was no Urinary pressure in the
presence of Frequency urinary tract
inflammation Color: Cloudy, -Fluid reflux in
around patient’s Tea- colored the kidneys
genital area. Amount: 70cc/hr
LABS:
U/A
+cast
+RBC
+Protein
+Cloudy, Tea
colored urine
+WBC
+Specific
gravity
MUSCULOSKELETAL Skin warm, pulses movement was -due to
palpable, full range quite limited headache and
of motion. because of her pain
Patient is able to being nauseous
stand on heels & and having a
toes. Movements headache.
coordinated and Balance was
rhythmic, arms impaired.
swings in opposition
stride length
appropriate.
Pt. had good
posture and gait
NEUROLOGICAL Patient was awake,
responsive, and
coherent.
She was oriented to
time, place and
person.
GCS:
E: 4
V: 5
M: 6

17 | U r o l i t h i a s i s
 DIAGNOSTIC
AND
LABORATORIES

18 | U r o l i t h i a s i s
 North General Hospital
LABORATORY DEPARTMENT
Talamban, Cebu City

Patient Name: C., F. Physician: Dr. I. E.

Age: 53 Sex: F Room: 233 Priority: ROUTINE
Fluid: SERUM Misc:
ID: 092818-11 Misc:

Test Result Normal Range

POTASSIUM 3.8 mmol/L 3.6 – 5.0

UREA NITROGEN 9. mg/dL 8. - 23.
CREATININE L .6 mg/dL .7 – 1.5
BUN H 23mg/dL 7 - 20 mg/dL

INTERPRETATION:
Low creatinine levels can be caused by: A muscle disease, such as
muscular dystrophy. Poor liver function interferes with creatine production, which
can cause low creatinine.
High BUN levels mean your kidneys aren't working well. But elevated blood
urea nitrogen can also be due to: Urinary tract obstruction; Congestive heart
failure or recent heart attack; Gastrointestinal bleeding; Dehydration; Certain
medications, such as some antibiotics; A high-protein diet.

Test Date: Sept 28, 2018

19 | U r o l i t h i a s i s
 X – RAY FINDINGS: September 28, 2018

Examination: Kidney, Ureters and Urinary Bladder

Physician: Dr. I. Esplanada

Findings:
RR: 10.82 x 4:14cm; 1.38 cortex
LR: 11:13 x 5.36 cm; 1.63 cortex

The kidneys are normal in size, shape and position. The center echo
complexes are intact. The renal cortices are unremarkable. No masses seen. The
left pelvocalyses are dilated. There is a 1.2 cm calculus seen at left uretero – pelvic
junction. The right pelvocalyses and ureters are not dilated. The urinary bladder is
smooth in mucosal outline with non – thickened walls. No calculinor mass seen.

Remarks:

Left Pelvocaliectasia 2º to an obstructing calculus at the left uretero pelvic

junction. Unremarkable right kidney and urinary bladder.

20 | U r o l i t h i a s i s
21 | U r o l i t h i a s i s
 URINALYSIS: September 28, 2018

URINALYSIS RESULT REFERENCE INTERPRETATION

RANGE
Color: Cloudy, Tea Yellow Turbid (cloudy) urine
Colored Urine may be caused by
either normal or
abnormal processes.
Normal conditions
giving rise to turbid urine
include precipitation of
crystals, mucus, or
vaginal discharge.
Ph: 7.2pH 5.0 – 8.0 pH level indicates the
amount of acid in urine.
Abnormal pH levels
may indicate a kidney
or urinary tract disorder.
normally 5 to 7.
Specific gravity 1.030 1.005 – 1.030 Can indicate mild
dehydration above
1.010. The higher the
number the more
dehydrated you may
be.
PROTEIN 2+ Negative Normally, the kidneys
filter urine from the
blood but retain
protein. Presence of
Protein in the urine may
be because of acute
inflammation or kidney
stone disease.
Glucose Negative Negative Any detection of sugar
on this test usually calls
for follow-up testing for
diabetes
Blood 3+ Negative Presence of RBCs
(erythrocytes) may be a
sign of kidney disorders,
blood disorders or
another underlying
medical condition,

22 | U r o l i t h i a s i s
 such as bladder
cancer.
WBC 1+ Negative Presence of WBCS in
the urine can indicate
infection or
inflammation.
Casts 1 RBC cast/hpf None Casts are the result of
solidification of material
(protein) in the lumen of
the kidney tubules,
more specifically in the
nephron; kidney
disease exists; the
presence of casts
indicates kidney (renal)
disease

23 | U r o l i t h i a s i s
 ANATOMY AND PHYSIOLOGY
The Urinary System

The urinary system is also called excretory system or the genitourinary system
(GUS) is the organ system that produces, stores, and eliminates urine in humans.
The organs of the urinary system include the kidneys, renal pelvis, ureters, bladder
and urethra.

The body takes nutrients from food and converts them to energy. After the
body has taken the food components that it needs, waste products are left
behind in the bowel and in the blood.

The kidney and urinary systems help the body to eliminate liquid waste
called urea, and to keep chemicals, such as potassium and sodium, and water
in balance.

Humans produce about 1.5 liters of urine over 24 hours, although this
amount may vary according to circumstances. Because the rate of filtration at
the kidney is proportional to the glomerular filtration rate, which is in turn related
to the blood flow through the kidney, changes in body fluid status can affect
kidney function. Hormones exogenous and endogenous to the kidney alter the
amount of blood flowing through the glomerulus. Some medications interfere
directly or indirectly with urine production. Diuretics achieve this by altering the

24 | U r o l i t h i a s i s
amount of absorbed or excreted electrolytes or osmolytes, which causes a
diuresis.

In humans and other related organisms, the urinary bladder is a hollow

muscular organ shaped like a balloon, located in the anterior pelvis. The bladder
stores urine. The maximum that it can hold is one liter. It swells into a round shape
when it is full and gets smaller when empty. In the absence of bladder disease, it
can hold up to 300 ml of urine comfortably for two to five hours. The epithelial
tissue associated with the bladder is called transitional epithelium. Normally the
bladder is sterile.

Sphincters (circular muscles) regulate the flow of urine from the bladder.
The bladder itself has a muscular layer (detrusor muscle) that, when contracted,
increases pressure on the bladder and creates urinary flow.

Urination is a conscious process, generally initiated by stretch receptors in

the bladder wall which signal to the brain that the bladder is full. This is felt as an
urge to urinate. When urination is initiated, the sphincter relaxes and the detrusor
muscle contracts, producing urinary flow. The endpoint of the urinary system is the
urethra. Typically, the urethra in humans is colonized by commensal bacteria
below the external urethral sphincter. The urethra emerges from the end of the
penis in males and between the clitoris and the vagina in females.

(Frontal section of the kidney)

25 | U r o l i t h i a s i s
 The kidneys are a pair of brownish-red structures; bean-shaped, and each
measure about 11 cm long, 5 cm wide, and 3 cm thick, which is about the size of
a clenched fist. An adult kidney weighs 120 to 170 g (about 4.5 oz).

FUNCTIONS OF THE KIDNEY:

1. Excretion. Nearly 21% of the blood pumped out of the heart each minute is
routed to the kidneys. There, some of the plasma is filtered and separated from
the blood cells. Large molecules, such as proteins, remain in the blood, whereas
smaller molecules and ions enter the filtered fluid. As the fluid flows through the
kidneys, it is slowly modified until it is converted into urine. This conversion requires
the reabsorption of most of the fluid volume back into the blood, along with useful
molecules and ions. The resulting fluid contains metabolic wastes, toxic molecules,
and excess ions. Additional waste products are secreted into the fluid, eventually
forming urine.

2. Regulation of blood volume and pressure. The kidneys play a major role in
controlling the extracellular fluid volume in the body by producing either a large
volume of dilute urine or a small volume of concentrated urine, depending on the
hydration level of the body. Consequently, the kidneys regulate blood volume
and hence blood pressure.

3. Regulation of blood solute concentrations. The kidneys help regulates the

concentration of primarily the major ions—Na+, Cl−, K+, Ca2+, HCO3 −, and HPO4
2−; they also regulate other solute concentration, such as urea.

4. Regulation of extracellular fluid pH. The kidneys secrete variable amounts of H+

to help regulate the extracellular fluid acidity.

5. Stimulation of red blood cell synthesis. The kidneys secrete the hormone
erythropoietin, which stimulates the synthesis of red blood cells in red bone
marrow.

6. Activation of vitamin D. The kidneys play an important role in controlling blood

levels of Ca2+ by activating vitamin D.

LOCATION OF THE KIDNEYS:

The kidneys are retroperitoneal and are located on each side of the
vertebral column near the psoas major muscles. They extend from the lower
portion of the rib cage at the level of the last thoracic (T12) vertebra to the third
lumbar (L3) vertebra. The liver is superior to the right kidney, causing the right
kidney to be slightly lower than the left.

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EXTERNAL ANATOMY OF THE KIDNEYS:
Each kidney is surrounded by an outer layer of connective tissue, called the
renal capsule. Surrounding the outside of the capsule is a thick layer of adipose
tissue, which cushions and protects the kidneys.

A thin layer of connective tissue, the renal fascia, surrounds the adipose
tissue and helps anchor the kidneys to the abdominal wall. More adipose tissue
surrounds the renal fascia.

The hilum is a small area on the concave, medial side of the kidney that is
continuous with an adipose and connective tissue-filled cavity of the kidney,
called the renal sinus.

The hilum is where structures enter and exit the kidney, then pass through the renal
sinus. These structures help the kidney perform its functions. The hilum structures
are the renal artery and nerves, which enter the kidney and the renal vein and
ureter, which exit the kidney.

LAYERS OF THE KIDNEYS:

Renal Cortex

The renal cortex is the outer smooth, continuous layer of the kidney. The
process of ultra-filtration of blood is carried out in the renal cortex which is also
known as high pressure filtration.

Renal cortex is the external, outermost part of kidney and the filtration process is
termed so, as this filtration can only be completed when the blood coming into
the kidney through the renal artery is already carrying high pressure.

The cortex contains the:

 glomeruli
 proximal and distal tubules,
 cortical collecting ducts and their adjacent peritubular capillaries.

Medulla

The medulla resembles conical pyramids whose bases project into the
cortex. These projections are called medullary rays. Between the renal pyramids
and their medullary rays, there are extensions of cortical tissue toward the
medulla, called renal columns.

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The pyramids are situated with the base facing the concave surface of the kidney
and the apex facing the hilum, or pelvis. Each kidney contains approximately 8
to 18 pyramids.

The renal pyramids are a collection of tubes and ducts that transport fluid
throughout the kidney and modify it into urine. Once urine is formed, ducts in the
renal pyramids transport it toward the renal sinus. The tips of the pyramids, the
renal papillae, point toward the renal sinus.

In the renal sinus, another set of tubes collects the urine for movement to the
bladder. When urine leaves a renal papilla, it empties into a small, funnel-shaped
chamber surrounding the tip of the papilla called a minor calyx (4 to 13 minor
calices or calyx). Urine from several minor calyces are emptied into a larger,
funnel-shaped chamber called a major calyx (2 to 3 major calices/calyx) that
open directly into the renal pelvis.

Renal Pelvis

The hilum, or pelvis, is the concave portion of the kidney through which the
renal artery enters and the renal vein exits. It is a single, enlarged, funnel-shaped
chamber where the urine is emptied from the major calyces. The renal pelvis is
embedded in and surrounded by the renal sinus.

At the hilum, it narrows significantly, forming the small-diameter tube called the
ureter. Urine moves from the renal pelvis into the ureter for transport to the
bladder.

The renal artery (arising from the abdominal aorta) divides into smaller and smaller
vessels, eventually forming the afferent arteriole. The afferent arteriole branches
to form the glomerulus, which is the capillary bed responsible for glomerular
filtration. Blood leaves the glomerulus through the efferent arteriole and flows
back to the inferior vena cava through a network of capillaries and veins.

NEPHRONS:

Each kidney contains about 1.3 million nephrons, the histological and functional
units of the kidney. Nephrons usually measure about 50–55 mm in length. Each
kidney is capable of providing adequate renal function if the opposite kidney is
damaged or becomes nonfunctional.

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The nephron consists of separate segments that are distributed throughout the
cortex and medulla, namely:
 a glomerulus containing afferent and efferent arterioles,
 Bowman’s capsule, (filters the blood)
 proximal tubule, (returns filtered substances to the blood)
 loop of Henle, (helps conserve water and solutes)
 distal tubule, (rids the blood of additional wastes)
 and collecting ducts

Collecting ducts converge into papillae, which empty into the minor calices,
which drain into three major calices that open directly into the renal pelvis.

Nephrons are structurally divided into two types:

 cortical
 juxtamedullary.

Cortical nephrons are found in the cortex of the kidney, and juxtamedullary
nephrons sit adjacent to the medulla. The juxtamedullary nephrons are
distinguished by their long loops of Henle and the vasa recta, long capillary loops
that dip into the medulla of the kidney.

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PATHOPHYSIOLOGY

Urinary stone formation is a result of different mechanisms. Whereas

exceeding supersaturation (i.e., free stone formation) is the cause of uric acid or
cystine calculi, infection stones result from bacterial metabolism.

The two primary causative factors are (1) urinary stasis and (2)
supersaturation of urine with poorly soluble crystalloids. Increased solute
concentration occurs because of fluid depletion or an increased solute load. This
increased concentration leads to the precipitation of crystals, such as calcium,
uric acid, and phosphate. Urinary pH influences the solubility of certain crystals,
with some crystal types precipitating readily on acid urine and some in alkaline
urine. Inhibitor substances, such as citrate and magnesium, appear to keep
particles form aggregating and forming crystals; a lack of inhibitors increases risk
of stones development. Not only does deficiency of inhibitors but there are
maybe “anti-inhibitors” in the urine, such as aluminum, iron and silicone.
Medication such as acetazolamide, absorbable alkalis (calcium carbonate and
sodium bicarbonate), and aluminum hydroxide; and massive doses of vitamin C
increases urinary oxalate levels.
The kidney stone formation in the three broad conceptual categories requires:
 Excessive concentration of solutes in excess of their solubility in the urine.
 Imbalance of modifiers (promoters and inhibitors) and crystallization in the
urine.
 Epithelial abnormalities that allow attachment and subsequent growth of
these crystals in to stone
 Above the factors act in concert and eventuating in the formation of the
kidney stones

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Sign and symptoms:
 Pain- pain is the key symptom of the disease, which is usually resulted from
an obstruction of a large rough calculi that occlude the opening to the
ureters and increase the frequency and force of peristaltic contractions.
This is usually felt on the costovertebral angle to the flank, to the suprapubic
area going to the external genitalia.
 Nausea and Vomiting- usually accompanied by severe pain.
 Fever- as a result of inflammatory processes
 Hematuria- in the event that the stones abrade a ureter
 Pyuria- resulted from pus formation due to tissue necrosis
 Anuria- rarely happens but due to total occlusion of the passage to the
ureters.

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 Nursing Care Management
•Encourage client to increase fluid intake
•Encourage client to schedule micturition
•Monitor intake of fluid amount and urinary output.
•Medicate for pain as prescribed.
•Continue antibiotic therapy as prescribed.
•Correct diet to include reduced protein and calcium
content.

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35 | U r o l i t h i a s i s
 NURSING
CARE
PLAN

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 DRUG
STUDY

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 DISCHARGE PLAN
Medication

*orient patient about the name of the drug, the exact dosage,
frequency, and the route of administration

*instruct the client to follow the instruction when administering

medication

*explain to client the side effects and adverse reactions of the drug
she takes by explaining its manifestation
*advise client not to skip the medication that the doctor ordered
Exercise/Environment
*encourage client to have enough rest

* encourage client to have a clean and healthy environment to

promote fast recovery

* encourage client to maintain a clean and healthy environment to

prevent further
Treatment
*oriented client about the importance of sleep and rest

* instructed the client to have enough rest and avoid strenuous

activities
* obtaining laboratory test
* instructed client to seek medical care if there is any abnormalities or
severe pain or reoccurrences of previous symptoms felt
Health teaching
*After the planned surgery, provide all necessary post-op care
*Care of the surgical site if there is
*Relieved pain and discomfort
*Maintain fluid intake for dehydration
*Observations, signs and symptoms/ OPD referral
*Instructed patient to come back for follow up checkup on the date
ordered

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 * Encouraged to report, with the help of any family members, any
present signs and symptoms
Diet and nutrition

*Advise patient to continue her multivitamins. Also, to eat nutritious

food High in protein

*Tell patient the importance of a well-balanced diet and drink plenty

of fluids
Spirituality
*Provide spiritual and emotional support.

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52 | U r o l i t h i a s i s
 BIBLIOGRAPHY
 Brunner & Suddhart’s textbook of medical-surgical nursing 12th edition and
nurseslabs.com
 Lippincott and Williams, Medical Surgical Nursing 10th Edition
 NANDA, 12th Edition
 Nurses Drug Handbook, 2011
 https://tabletwise.com/schachreter-may2016
 https://www.ncbi.nlm.nih.gov/books/NBK420/
 https://nurseslabs.com/4-urolithiasis-nursing-care-plans/4/
 https://www.rxlist.com/zinacef-drug.htm#medguide
 http://www.phytopharmajournal.com/V2issue3010.pdf
 https://www.hopkinsmedicine.org/healthlibrary/conditions/kidney_and_uri
nary_system_disorders/anatomy_of_the_urinary_system_85,p01468
 https://www.scribd.com/doc/11972074/Urolithiasis-case-report
 https://www.kidney.org/atoz/content/know-your-kidney-numbers-two-
simple-tests

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