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m General:
At the end of our 1-2 hours case
presentation we will be able to know about
nephrolithiasis, its cause, treatment, and
preventive measures. With this, we hope we
will be able to know how to care patients
having this kind of condition.
pecific:
Within 1-2 hours case presentation we
should be able to:
m Define what nephrolithiasis is.
m Discuss the normal anatomy and physiology
related to this condition.
m Trace the pathophysiology of the said
condition.
m Formulate an appropriate nursing care plan
for this disease.
m Discuss the different drugs to be used in this
disease.
m Discuss the different diagnostic exams and
laboratory results.
m Provide desired health teaching related to
patient¶s condition.
m Formulate a prognosis with regards to
patient¶s condition.
The condition of having kidney stones is
termed nephrolithiasis. Having stones at any
location in the urinary tract is referred to as
urolithiasis, and the term ureterolithiasis is
used to refer to stones located in the ureters.
A kidney stone is a hard, crystalline mineral
material formed within the kidney or urinary
tract. Kidney stones are a common cause of
blood in the urine (hematuria) and often
severe pain in the abdomen, flank, or groin.
m Kidney stones are sometimes called renal
calculi. Kidney stones form when there is a
decrease in urine volume and/or an excess
of stone-forming substances in the urine.
The most common type of kidney stone
contains calcium in combination with either
oxalate or phosphate. Other chemical
compounds that can form stones in the
urinary tract include uric acid and the amino
acid cystine.
m Dehydration from reduced fluid intake or
strenuous exercise without adequate fluid
replacement increases the risk of kidney
stones. Obstruction to the flow of urine can
also lead to stone formation. In this regard,
climate may be a risk factor for kidney stone
development, since residents of hot and dry
areas are more likely to become dehydrated
and susceptible to stone formation. Kidney
stones can also result from infection in the
urinary tract; these are known as struvite or
infection stones.
m There are some types of calculi: the
calcium, oxalate, struvite, uric acid, cystine,
and xanthine. Despite the type of stone
that forms, the potential damage is
essentially the same: (1) pain, spasm, or
colic from peristalsis movements of the
ureter contracting on the stone; (2)
obstruction with the possible
hydronephrosis or hydroureter; (3) tissue
trauma with secondary hemorrhage; and
(4) infection
m Anyone may develop a kidney stone, but
people with certain diseases and
conditions or those who are taking certain
medications are more susceptible to their
development. Most urinary stones develop
in people 20-49 years of age, and those
who are prone to multiple attacks of kidney
stones usually develop their first stones
during the second or third decade of life. A
small number of pregnant women develop
kidney stones, and there is some evidence
that pregnancy-related changes may
increase the risk of stone formation.
m Factors that may contribute to stone
formation during pregnancy include a
slowing of the passage of urine due to
increased progesterone levels and
diminished fluid intake due to a decreasing
bladder capacity from the enlarging uterus.
Healthy pregnant women also have a mild
increase in their urinary calcium excretion.
m ric acid kidney stones are more
common in people with chronically
elevated uric acid levels in their blood. A
small number of pregnant women
develop kidney stones, and there is
some evidence that pregnancy-related
changes may increase the risk of stone
formation. Factors that may contribute to
stone formation during pregnancy
include a slowing of the passage of urine
due to increased progesterone levels
and diminished fluid intake due to a
decreasing bladder capacity from the
enlarging uterus. Healthy pregnant
women also have a mild increase in their
urinary calcium excretion.
m There are some kidney stones may not
produce symptoms (known as "silent"
stones), people who have kidney stones
often report the sudden onset of
excruciating, cramping pain in their low back
and/or side, groin, or abdomen. Changes in
body position do not relieve this pain. The
abdominal, groin, and/or back pain typically
waxes and wanes in severity, characteristic
of colicky pain (the pain is sometimes
referred to as renal colic).
m It may be so severe that it is often
accompanied by nausea and vomiting.
Kidney stones also characteristically cause
blood in the urine. If infection is present in
the urinary tract along with the stones, there
may be fever and chills. ometimes,
symptoms such as difficulty urinating, urinary
urgency, penile pain, or testicular pain may
occur due to kidney stones.
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 NURSING ASSESSMENT
(ADULT)
GENERAL INFORMATION:

PATIENT¶S NAME: Patient X RELIGION: Roman catholic

AGE: 70 yrs.old OCCUPATION: None
SEX: Female STATUS: Married
ADDRESS: P-3 , Tudela , Misamis Occidental NATIONALITY: Filipino
BIRTHPLACE: Tudela , Misamis Occidental DATE ADMITTED:01/16/10
BIRTHDAY: 11/23/39 TIME ADMITTED: 5:59 pm
CHIEF COMPLAINT: on and off fever, abdominal pain ROOM/BED #: Old FW
DIAGNOSIS: Nephrolithiasis
PHYSICIAN: Dr. Leonida Bodiongan
 PRESENT ILLNESS REACTIONS TO AND EXPECTATION TO
HOSPITALIZATION

Patient X, a 70 yrs.old, married was admitted last Jan. 16, Eulanda felt worried about the hospitalization because of
2010 @ around 5:59 pm, accompanied by her husband with the expenses at the hospital if she would stay longer.
a chief complaint of on and off fever and abdominal pain.

PREVIOUS ILLNESS REACTION ABOUT TREATMENT AND DIAGNOSTIC

PROCEDURES

Patient was hospitalized last May 2010 because she was Patient expected to have a better condition after treatment.
suffering from fever with the same diagnosis. She wanted to know about the result after all the procedure
done to her. She cooperate well whatever procedure made/
done for she will be cured early.
 Nursing History Clinical Inspection On-going Appraisal Other Sources Laboratory
Normal Patterns of Observation on First Day of Observation on 2nd Day of Exam Results
Functioning Duty Duty
(Before Admission)

RESPIRATION: Patient has nonproductive HEMATOLOGY:

Pt. always experience cough cough, and experienced Total WBC -9.6x10^9/L
and sometimes shortness of shortness of breath Total RBC ± 4.45x10^12/L
breath. sometimes. Hemoglobin -13.1g/L
She does not do any (+) edema on her left lower Hematocrit -38.9%
breathing exercise at home. leg MCV ± 85.7fL
She sneezed sometimes Her vital signs is in normal MCH ± 28.9pg
because of any range with: MCHC ± 33.7g/dL
environmental problems, like Temp.- 37 C Platelet Count ± 468x10^9/L
too much heat. Pulse ± 94 bpm Differential Count:
CIRCULATION: RR. ± 20 cpm Neutrophil ± 53.0%
Pt. has poor circulation, B/P ± 130/70 mmHg Lymphocyte- 30.5%
never has pounding of heart Eosinophil ± 23%
nor skips beats. Basophil ± 0.3%
Presence of swollen or
edematous on her left lower
leg.
 Nursing History
FOOD & FLUID INTAKE:
Pt. usually eats 3x a day and
often has snacks morning @
10:00 am and in afternoon.
She usually eats rice with egg,
fish and milk as her breakfast.
Snacks usually a hotcake or
banana cue & juices or coke for
her beverage.
ELIMINATION:
Pt. void once or twice a day and
usually urinates 3-4 times a day.
Not using of enemas, laxatives or
suppositories.
REST & SLEEP:
Pt. usually slept @ around 8:00
pm and wake up 5:30 am.
Days before her admission, she
can¶t sleep well because of the
pain she felt.
She can¶t sleep if it¶s noisy and
she sleep with dim-light and with
her 2 pillows and blanket. She
can¶t sleep also in warm room.
She can take a nap during
afternoon.
Clinical Inspection On-going Appraisal Other Sources
Pt. has good appetite even if she No allergies of any food.
has an illness. URINALYSIS:
With PLR 1L @ 20 gtts/min & Macroscopic:
D5LR 1L @ 20 gtts/min. Color ± straw Appearance-clear
DIET ± diet as tolerated Glucose- negative
Protein ±positive
pH ± 6.0
Specific Gravity ± 1.065
Microscopic:
WBC/hpf ± loaded
Pt. urinates 5-10 times a day and RBC/hpf ± to numerous to count
defecates once a day. Epithelial Cells ± few
She is taking diuretics. Bacteria - moderate
No enemas, laxatives or
suppositories used.
Pt. has still a problem of sleeping
because of the surrounding is
noisy and warm.
She often goes to CR
and urinate.
Not taking any sedatives.
 EXERCISES:
Walking was her source of exercise, usually morning
and in the afternoon. Also in doing the household
chores.
PAIN/DISCOMFORT
Pt. experienced flank pain on her right side and fever
but she just only take paracetamol and pain reliever
just to relieve the pain.
REGULATORY MECHANISM:
Pt. has a history of fever and experienced chills.
Walking to the toilet is part of her exercise and she
just sit on her bed or in the chair.
She felt discomfort about her present illness which
she can¶t sleep normally because of the pain she felt
and staying in one position because she cant turn
right side laterally because of the pain.
Vital signs is in normal range:
B/P ± 130/70
Temp. ± 37 C
She is in good level of consciousness.
 PERSONAL HYGIENE:
Pt. usually takes a bath twice a
day.
She uses shampoo and bath soap
upon bathing.
Brushes her teeth 3x a day.
COMMUNICATION & SPECIAL
SENSES:
Pt. can understand well, speak well She is approachable, she smile
and heard well.
She can understand and speak
English and tagalong.
COPING W/ STRESS
When she¶s facing stressful
situations, she just stays @ home.
Sought advices from her family and talking to the other pt. and watchers
friends.
She doesn¶t take her bath in the
hospital since admission, but she
changes her clothes every now and
then and when she felt hot, she uses
alcohol and water with face towel in
cleaning herself.
Still she brushes her teeth after
meal.
With clean nails and pallor skin
noted.
often and very friendly.
No signs of mannerism, no hearing
aid worn, she can speak clearly and
uses cellphone.
She just lying on bed and
sometimes sits on the chair and
in the ward.
RELIGIOUS LIFE: She has no religious medal worn, but she brings
She was baptized as a Roman Catholic and Bible with her.
believes God above all. She often went to church She often talks to the other pt. and read bible.
every Sunday and attended Sunday mass.

SOCIAL/OCCUPATIONAL LIFE: She uses celphone and make a call to some of her
Pt. lived in their house with her family. relatives.
Sometimes she will spent nights to her sister¶s
house in Maningcol.
She have 6 children.

RECREATIONAL /DIVERSION:
Pt. usually watched TV and listening news on radio She usually calls the attention of the nurse on duty if
during past time and taking good care of her problem arises in her condition.
grandchildren.

HEALTH SUPERVISION:
Pt. goes to the hospital for check up or for
hospitalization when she can¶t bear it anymore and
goes to the health center for her minor cases.
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 Severe pain
Release of Inc. Pulse
Scarring/
Chemical Nerves becomes
Inflammation
Mediators irritated thus Inc. Resp. Rate
Modifiable Factor
Types of Calculi The smooth muscles (prostaglandin) eliciting (pain) Anxiety
becomes irritated Diaphoresis
Inc. BP
Diet
Calcium Uretral colic ʹradiates
Nausea/ Inflammatory Process Renal Colic Pain ʹ towards the genetalia
UTI, Prolonged Struvite Vomiting Originates deep in the and thigh
indwelling catheter lumbar regions and
Visceral pain ʹmediated
Dec. radiates around the
by the autonomic nervous
side and down toward
Lifestyle sedentary intestinal system via celiac ganglia
Uric acid the testicle (male) and
lifestyle increase stasis motility which causes
bladder of the female

Paralytic
ileus

Urinary Stasis
Formation of
and Kidney
kidney stones Inc. Fluid Volume Inc. Blood volume Inc. Blood Pressure
Supersaturation becomes
Non modifiable Factor obstructed
Hydronephrosis ʹdistention of renal pelvis
and calices caused by obstruction of normal
Sex (Male) urine flow Decrease Urine Frequency of
Capacity urination
Xanthine
Age (30 and 50 have Hydroureter
three times risk of Stones in the
calculi) Ureters Size of the bladder
Cystine
Uretral Colic will be compromised
Oxalate
Stones in the Stones scar the bladder Hematuria ʹblood in the urine
Living in stone-belt area Bladder causing it to (p

) (͞clink͟ against the toilet)

Family of urolithiasis ʹ
Pressure against Heavy feeling during
excessive production of
the bladder neck micturation (voiding)
the mucoprotein
Stones in the
urethra Obstruction Difficulty of urinating
Hereditary (oxalate;
oxaluria, Xanthine,
Pain upon urinating
Cystine) Scarring Pain
especially for men

Urinary Calculi (Kidney Stones/ Urolithiasis)

=


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   #$%$"&"'  $"'%
!" related &( $"&"'&(
͞ ige ko og ihi ± Monitor I & O and *Provides information
to obstruction of "$ "*$
ihi, pero gamay ± characteristics of the about kidney function
the renal pelvis !)!!! !)&!
gamay ra akong urine. and presence of
secondary to " "
ma-ihi͟
complication.
   
  idney stone Encourage increase oral
Achieve normal Achieved the
 formation. fluid intake. *increased hydration
  elimination pattern normal
flushes bacteria, blood,
and participate in Observe for changes in elimination
 and debris and may
measures to mental status, behavior pattern and
facilitate stone passage.
Nocturia 7 times correct for defects. or OC. cooperates to any
*accumulation of uremic treatment done.
Oliguria Be free from any ="!!"
astes & electrolyte
signs of renal Has good urine
Slightly istended Administer medication imbalance can be toxic to
obstruction. outflow.
abdomen as ordered. the CNS
Demonstrate Drinks plenty of
Urine output of behaviors to Diuretics( ydrochlorothi *Used to prevent urinary water.
ml in 24 hours. azide) stasis & decrease calcium
prevent urinary
stone formation
infection.
otassium Citrate
*dissolve/prevent
Percutaneous or open reformation of some
incision stone removal calculi

*to remove stone that is

too large to pass through
the ureters, blocks flow
of urine &is potentially
damaging to kidney
tissue.
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  related #$%$"&"'  *help evaluate site of $"'%$"&"'
to increase force &( obstruction &progress of &("*$
͞akit ipangi-hi͟ Assess pain intensity
of ureteral "$ calculi movement. !)&!"
as verbalized by &characteristics.
contraction or !)!!!
the client. *Complete obstruction of Report pain is relieved
tissue trauma as " Note reports of
ureter can cause and controlled.
 evidenced by increase/persistent
Report pain is perforation &
report of colicky abdominal pain. Feel no pain during
6rimace face upon pain. relieve/control. extravasation of urine into
urination.
urination Provide comfort perineal space.
Appear relaxed
measures.
Frequent Sighing and be free from * to promote
pain. nonpharmaconergic pain
Diaphoresis management.

*Used to prevent urinary

stasis & decrease calcium
stone formation
="!!"
*Narcotic and NSAID
Administer medication
combination is often given
as ordered.
intravenously during acute
Narcotic episodes to quickly
analgesic/NSAID, decrease ureteral colic
and promote
Oral analgesic
muscle/mental relaxation.

*Oral analgesics are

helpful to facilitate stone
passage after acute attack.
=


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 +!"! #$%$"&  $"'%
,&& r/t to
"'&( U to have a baseline $"&"'
͞Nang hupong lage compromise Note intake and
renal function. "$ data of &(
ko͟ as verbalized by output.
!)!! fluid intake and "*
the client. output.
!" Note pattern and $!)&
U to have a
 Stabilize fluid amount of measurement of !"
volume as urination. fluid output.
Venous distention U to assess for stabilized fluid
evidence by
balance Observe skin and decubitus or volume.
6eneralized edema ulceration.
intake/ output. mucus
Absent from
Reports of fatigue, membrane.
edema and any
weaknesses and U to reduce pressure
Assist patient when decubitus
malaise. tissue
changing pressure. ulcers.
BP : 1 /7 mmHg position.
6ain back it͛s
="!!" energy.

Administer
medication as
Uhelp excrete excess
ordered. fluids in the body.
U to avoid further fluid
Diuretics retention.
Restrict sodium fluid
intake
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NAME OF CLASSIFI- DOSAGE, MECHA- INDI- ADVERSE CONTRA- NRSG.
DRUG CATION TIMING, NISM OF CATION REACTION INDICATIO/ CONSIDERATION
AND ACTON CAUTIONS / PATIENT
ROUTE TEACHING

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[ABORATORY
RESU[TS
Ê
-
.

PARAMETERS RESU[TS NORMA[ VA[UES

Total WBC 9.6 5-1

Total RBC 4.45 3.69-5.1

Hemoglobin 13.1 11.7-14

Hematocrit 38.9 7-97

MCV 85.7 26.1-33.30

MCH 28.9 11-16

MCHC 33.7 14.0-44

PDW.CV 13.7 55-62

Platelet count 468 140-440

Neutrophil 53.0 55-62

[ymphocytes 30.5 20.0-40.0

Eosonophil 13.9 34.10-44

Basophil 23 32-35

Stab cells 0.3 0.00-1.00

BLOOD CHEMISTRY

TEST RESULT NORMAL VALUES

Fasting Blood Sugar 112 100-105mg/dl

Blood Uric Acid 5.48 f-2.6-6.0 m-3.5-7.2mg/dl

Creatinine 1.49 f-0.6-11 m-0.7-13mg/dl

Total Cholesterol 156.3 140-220mg/dl

Blood Nitrogen
 =-/

.

MACROSCOPIC
Odor Straw Waxy
Appearance Clear
6lucose Negative
Protein Negative Threads
Ph 6.0 Amorphous urates
Specific gravity 1.065 Amorphous phosphates
MICROSCOPIC
WBC/hpf [OADED
Epithelial Few crystal
 ULTRASONOGRAPHY
 A follow up ultrasound shows, the left kidney is severely
dilated pelve o calcycael system a lithiasis is noted in the
inferior calm. It measures 29 mm another lithiasis is told in
the pelveo-ureteral junction. It measures 18 mm while the
right is normal a bladder unmemorable.
 Impression
 Serve pelveo caliectaria, left
 Nephrolithiasis left inferior calyx (29 mm)
 Stone pelveo-arfteral junction left (18 mm)
 Right kidney and a bladder no
Name: Burlaos, Eulanda Age:70 Sex: Female

Address: Tudela, Mis. Occ Date: 01-16-2011 Room: female ward

Type of Form: ubutz Accnt no:

Attending Physician: Dr. Ulsound no:

Bodiongan
m Conservative or medical management is
appropriate if there is no obstruction, if the
pain can be managed, if the client can be
hydrated with oral fluids, and if the stone is
under 5 mm. medical management is
directed at relieving the acute manifestation
while facilitating the passage of small
stones. The desired outcomes of medical
management are to:
m Increase fluids ± this is the most effective
management strategy in order to facilitate
passage of the small stones and to prevent
the development of new one. Encourage
client to increase fluids to 3-4 L daily, unless
contraindicated, to ensure a urine output of
2.5-3 L daily. The increased urine volume
resulting from this high fluid intake
decreases the concentration of solutes and
alleviates urinary stasis. Increased fluids
may also decrease pain.
m educe pain ± pain is most severe in 1st
24hrs. In addition to pain control with
increased fluids, the client usually requires
treatment with narcotics and
antispasmodics agents.
m Implement dietary changes ± clients with
oxalate stones should avoid high oxalate
foods, such as tea, tomatoes, instant
coffee, cola drinks and etc. Mega doses of
vitamin C increase oxalate excretion in the
urine and should be avoided. If the stone is
composed of uric acid the client should
follow a low purine diet, which involves
limiting such foods as aged cheese, wine,
bony fish, and organ meats.
m Administer medication ± following recurrent
stone formation, analysis of the stone, or
abnormal metabolic findings, medication
may be required. For hypercalciuric clients, a
thiazide diuretic such as hydrochlorothiazide
will promote calcium resorption from the
renal tubules, thereby preventing excess
calcium loads in the urine. Potassium citrate
is commonly added to thiazide diuretic to
replace potassium as needed.
m Most clients pass the stone naturally from
the ureter and bladder. If the stone does not
move, if it causes obstruction, or x-ray
studies suggest that the calculus is too large
to pass safely to the urethra, more invasive
treatment is necessary. After the acute
phase, medical management is directed
toward preventing recurrence of stone
formation.
 
  

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m 6

m Kidney stones are painful but usually can be
removed from the body without causing
permanent damage. They tend to return,
especially if the cause is not found and treated.
We sincerely apologize

I please?

orry we LOVE you

ir ichzer Vincent

Villamor.