CASE STUDY ON BILATERAL NEPHROLITHIASIS RLE GROUP 2

OBJECTIVES

GENERAL OBJECTIVE After this case study, We will be able to develop our knowledge, skills and attitude in managing and dealing patients with Bilateral Nephroliathiasis. SPECIFIC OBJECTIVES KNOWLEDGE To be able to know our responsibilities such as promoting health, prevent further injury or illness, as well as restoration of health according to the extent of our knowledge and skills. To have knowledge about Bilateral Nephrolithiasis. To familiarize ourselves the different treatments and medications of the disease. To learn the pathophysiology, anatomy and physiology, signs and symptoms, its prevention and those who are at risk of the disease.

SKILLS To know how to deal and handle patients who are suffering from Bilateral Nephrolithiasis. To provide nursing care in patients with Bilateral Nephrolithiasis. ATTITUDE To be able to understand the patient's feeling towards his condition. Empathize with the patients.

INTRODUCTION

 Nephrolithiasis, the process of forming a kidney stone, a stone in the kidney (or lower down in the 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. The development of the stones is related to decreased urine volume or increased excretion of stone-forming components such as calcium, oxalate, urate, cystine, xanthine, and phosphate. The stones form in the urine collecting area (the pelvis) of the kidney and may range in size from tiny to staghorn stones the size of the renal pelvis itself. The process of stone formation nephrolithiasis, is also called urolithiasis. "Nephrolithiasis" is derived from the Greek nephros- (kidney) lithos (stone) = kidney stone "Urolithiasis" is from the French word "urine" which, in turn, stems from the Latin "urina" and the Greek "ouron" meaning urine = urine stone. The stones themselves are also called renal caluli. The word "calculus" (plural: calculi) is the Latin word for pebble.

 Mortality/Morbidity The morbidity of renal calculi is primarily due to obstruction with its associated pain, although non obstructing calculi can still produce considerable discomfort. Conversely, patients with obstructing calculi may be asymptomatic, which is the usual scenario in patients who experiences loss of renal function due to chronic untreated obstruction. Stone-induced hematuria is frightening to the patient but is rarely dangerous by itself.

Factors Race Renal calculi are far more common in Asians and whites than in Native Americans, Africans, African Americans, and some natives of the Mediterranean region. Although some differences may be attributable to geography (stones are more common in hot and dry areas) and diet. Heredity also appears to be a factor. This is suggested by the finding that, in regions with both white and nonwhite populations, stone disease is much more common in whites. Sex In general, urolithiasis is more common in males (male-tofemale ratio of 3:1).Stones due to discrete metabolic/hormonal defects (eg, cystinuria, hyperparathyroidism) and stone disease in children are equally prevalent between the sexes. Stones due to infection are more common in women than in men.

 Age Most renal calculi develop in persons aged 2049 years. Patients in whom multiple recurrent stones form usually develop their first stones while in their second or third decade of life.

VITAL INFORMATION

A. Patients Data Name: Age: Sex: Address: Civil status: Religion: Nationality: Occupation: Date and Time Admitted: Ward: Chief Complaint: Admitting Diagnosis: Mrs. C.D. 80 y.o Female Capagao Panitan, Capiz Married Roman Catholic Filipino Housewife Sept. 8,2010 8:10 am IHM, Room Bilateral flank pain Obstructive Neuropathy secondary to Bilateral Nephrolithiasis; renal cyst. Dr. R.B Dr. R.J Dr. J.A

Attending Physician(s):

HISTORY

History of Present Illness Before admission. Pt. was already diagnosed with Bilateral Nephrolithiasis and renal cyst. Right kidney stones were monitored every 3 mos. and were maintained on acalka and sambong. I week pta.pt. had onset of bilateral flank pain with patient tolerated at home but the pain progressed which prompted admission. Pt. was admitted on Sept. 8, 2010 8:10 am at St. Anthony College Hospital, IHM ward with the chief compliant of Bilateral Flank Pain under the service of Dr. RB, Dr. RJ and JA. (+) wt. loss (+) bowel changes (+) low back pain (+) dyspnea (+) cough

Past Medical History Last Feb. 2009 pt. was admitted at doctors hospital, Iloilo for the operation of her eyes. She has hypertension, bilateral nephrolithiases and right renal cyst. Family History Mrs. C.D. and her husband both have history of Hypertension in the family.

GENOGRAM

Retired Bus Driver

Mr. D 80y/o

Mrs. CD 80 y/o

Mr. E. 58 y/o

Mrs. M 54 y/o

Mrs. R 50 y/o

OFW

Employee

Businesswo man

Legend
Male

Female

Patient Hypertension Pneumonia

Occupation

PHYSICAL ASSESSMENT

General Appraisal: Body structure: Average Movement: Immobile Speech: Coherent and can t speak clearly. Level of Consciousness: Lethargic Vital Signs: Temp: 36.3 AR: 62 Pulse: 60 RR: 25 BP: 130/80

Body Parts

Method of Assessment

Findings

Interpretation

Skin

Inspection Skin is normal in color, warm and moist.

Normal

Nails

Head

Inspection The nail is pale pink in color. No clubbing, Normal no lesions. Good capillary refill. Inspection Head is normocephalic. Hair not evenly Normal distributed, brown in color with visible white hair. No lesions, no dandruff. Inspection The eyelid covers the top portion of the iris. Cornea is clear and without lesion. Conjunctiva is pinkish in color, no inflammation, & no discharge. Sclera is white and no lesion. PERRLA Normal

Eyes

Ears

Inspection

Both ears are symmetric, no signs of Normal inflammation and infection and there is no secretions. Nose bridge is aligned, nostrils are symmetric. No nasal discharge, no lesions. Normal

Nose

Inspection

Mouth

Inspection

Lips are not dry, no lesion. Normal The oral mucosa is pink and moist; gums, pink & moist and tongue is pink, moist and no lesions. The uvula is at the middle. Tonsils are not inflamed, and are pink in color. Neck is symmetric & skin is intact, there is no lesion, no neck masses, and no enlargement. The trachea is at the middle and is aligned. Normal

Neck

Inspection Palpation

Chest Abdomen

Inspection Inspection

The chest-wall is Normal symmetric. Distented abdomen. Urinary Retention It is soft and nontender; no masses noted.

Musculoskeletal: Inspection

No evidence of swelling or Osteoporosis deformity. Immobile. Hypertrophic Degenerative Osteoarthropathy

Genitourinary

Inspection

With urinary catheter.

Normal

TEXTBOOK DISCUSSION

 DEFINITION: The term Nephrolithiasis refers to kidney stone. The most common cause of upper urinary tract obstruction is urinary calculi. Although stones can form in any part of the urinary tract, most develop in kidneys. Urinary stones are the third most common disorder of the urinary tract, exceeded only by UTIs and prostate disorders. Kidney stones are crystalline structures made up of materials that the kidneys normally excrete in the urine.

TYPES OF KIDNEY STONE

TYPES OF STONE CONTRIBUTING FACTORS Calcium(Oxalate and y Hypercalcemia hypercalciura phosphate) Immobilization
y y y y y y y Hyperparathyroidism Vit. D intoxication Diffuse bone disease Milk-alkali syndrome Renal tubular acidosis Hyperxoxaluria Urinary tract infections and y y y

TREATMENT
Treatment of underlying conditions Increased fluid intake Thiazide diuretics

Magnesiun Ammonium phosphate (struvite) Uric Acid (Urate)

y y y

Treatment of urinary tract infections Acidification of the urine Increased fluid intake Increased fluid intake Allopurinol for hyperuricuria Alkalinization of urine Increased fluid intake Alkalinization of urine

y y y

Formed in acid urine with y pH of approximately 5.5 y Gout High- purine diet y Cystinuria disorder of metabolism (inherited y amino acid y

Cystine

CLINICAL MANIFESTATIONS Pain 2 types of pain: Renal Colic- is the term used to describe the colicky pain that accompanies stretching of the collecting system of the ureter. Noncolicky Renal Pian- is caused by stones that produce distentions of the renal calices and renal pelvis.
SIGNS AND SYMPTOMS: SIGNS AND SYMPTOMS OF PATIENT:

y y y y y y y y y y y

Pyelonepritis and UTI Chills Fever Frequency Pain and discomfort Hematuria Pyuria Nausea and vomiting Episode of renal colic Irritation Urinary retention

y Pain and Discomfort y Episode of renal Colic y Urinary Retention

COMPLICATION: Kidney failure Renal failure DIAGNOSIS Urinalysis provides information related to hematuria, infection, the presence of stone forming, crystals, and urine pH. Intravenous pyelography uses an intravenously injected contrast medium that is filtered in the ureters and kidneys. Abdominal ultrasound highly sensitive to hydronephrolithiasis, which may be a manisfestation of ureteral obstruction. Retrograde urography and CT scanning a new imaging technique called nuclear scintigraphy uses biophosphate markers as a means . TREATMENT Antibiotic therapy Increased fluid intake Thiazide diuretics Removing of kidney stones Ureteroscopic removal Percutaneous nephrolithotomy Extracorporeal shockwave lithotripsy

Medical Management

 Percutaneous Nephrolithotomy Percutaneous nephrolithotomy, or PCNL, is a procedure for removing mediumsized or larger renal calculi (kidney stones) from the patient's urinary tract by means of an nephroscope passed into the kidney through a track created in the patient's back. PCNL was first performed in Sweden in 1973 as a less invasive alternative to open surgery on the kidneys. The term "percutaneous" means that the procedure is done through the skin. Nephrolithotomy is a term formed from two Greek words that mean "kidney" and "removing stones by cutting. Purpose The purpose of PCNL is the removal of renal calculi in order to relieve pain, bleeding into or obstruction of the urinary tract, and/or urinary tract infections resulting from blockages. Kidney stones range in size from microscopic groups of crystals to objects as large as golf balls. Most calculi, however, pass through the urinary tract without causing problems. Preparation Most hospitals require patients to have the following tests before a PCNL: a complete physical examination; complete blood count ; an electrocardiogram (EKG); a comprehensive set of metabolic tests; a urine test; and tests that measure the speed of blood clotting.

Aspirin and arthritis medications should be discontinued seven to 10 days before a PCNL because they thin the blood and affect clotting time. Some surgeons ask patients to take a laxative the day before surgery to minimize the risk of constipation during the first few days of recovery. The patient is asked to drink only clear fluids (chicken or beef broth, clear fruit juices, or water) for 24 hours prior to surgery, with nothing by mouth after midnight before the procedure. Aftercare A standard PCNL usually requires hospitalization for five to six days after the procedure. The urologist may order additional imaging studies to determine whether any fragments of stones are still present. These can be removed with a nephroscope if necessary. The nephrostomy tube is then removed and the incision covered with a bandage. The patient will be given instructions for changing the bandage at home. The patient is given fluids intravenously for one to two days after surgery. Later, he or she is encouraged to drink large quantities of fluid in order to produce about 2 qt (1.2 l) of urine per day. Some blood in the urine is normal for several days after PCNL. Blood and urine samples may be taken for laboratory analysis of specific risk factors for calculus formation.

Risks There are a number of risks associated with PCNL: Inability to make a large enough track to insert the nephroscope. In this case, the procedure will be converted to open kidney surgery. Bleeding. Bleeding may result from injury to blood vessels within the kidney as well as from blood vessels in the area of the incision. Infection. Fever. Running a slight temperature (101.5F; 38.5C) is common for one or two days after the procedure. A high fever or a fever lasting longer than two days may indicate infection, however, and should be reported to the doctor at once. Fluid accumulation in the area around the incision. This complication usually results from irrigation of the affected area of the kidney during the procedure. Formation of an arteriovenous fistula . An arteriovenous fistula is a connection between an artery and a vein in which blood flows directly from the artery into the vein. Need for retreatment. In general, PCNL has a higher success rate of stone removal than extracorporeal shock wave lithotripsy (ESWL), which is described below. PCNL is considered particularly effective for removing stones larger than 1 in (0.5 cm); staghorn calculi; and stones that have remained in the body longer than four weeks. Retreatment is occasionally necessary, however, in cases involving very large stones.

 Injury to surrounding organs. In rare cases, PCNL has resulted in damage to the spleen, liver, lung, pancreas, or gallbladder. Ureteroscopic Removal A ureteral stent is a thin, flexible tube threaded into the ureter to help urine drain from the kidney to the bladder or to an external collection system. Purpose Urine is normally carried from the kidneys to the bladder via a pair of long, narrow tubes called ureters (each kidney is connected to one ureter). A ureter may become obstructed as a result of a number of conditions including kidney stones, tumors, blood clots, postsurgical swelling, or infection. A ureteral stent is placed in the ureter to restore the flow of urine to the bladder. Ureteral stents may be used in patients with active kidney infection or with diseased bladders (e.g., as a result of cancer or radiation therapy). Alternatively, ureteral stents may be used during or after urinary tract surgical procedures to provide a mold around which healing can occur, to divert the urinary flow away from areas of leakage, to manipulate kidney stones or prevent stone migration prior to treatment, or to make the ureters more easily identifiable during difficult surgical procedures. The stent may remain in place on a short-term (days to weeks) or long-term (weeks to months) basis. Diagnosis/Preparation A number of different technologies aid in the diagnosis of ureteral obstruction. These include:

 the interior of the bladder) ultrasonography (an imaging technique that uses high-frequency sounds waves to visualize structures inside the body) computed tomography (an imaging technique that uses x rays to produce twodimensional cross-sections on a viewing screen) pyelography (x rays taken of the urinary tract after a contrast dye has been injected into a vein or into the kidney, ureter, or bladder)

 Prior to ureteral stenting, the procedure should be thoroughly explained by a medical professional. No food or drink is permitted after midnight the night before surgery. The patient wears a hospital gown during the procedure. If the stent insertion is performed with the aid of a cystoscope, the patient will assume a position that is typically used in a gynecological exam (lying on the back, with the legs flexed and supported by stirrups). Aftercare Stents must be periodically replaced to prevent fractures within the catheter wall or build-up of encrustation. Stent replacement is recommended approximately every six months; more often in patients who form stones Risks Complications associated with ureteral stenting include: bleeding (usually minor and easily treated, but occasionally requiring transfusion) catheter migration or dislodgement (may require readjustment) coiling of the stent within the ureter (may cause lower abdominal pain or flank pain on urination, urinary frequency, or blood in the urine) introduction or worsening of infection penetration of adjacent organs (e.g., bowel, gallbladder, or lungs)

Extracorporeal shockwave lithotripsy Lithotripsy is the use of high-energy shock waves to fragment and disintegrate kidney stones. The shock wave, created by using a high-voltage spark or an electromagnetic impulse outside of the body, is focused on the stone. The shock wave shatters the stone, allowing the fragments to pass through the urinary system. Since the shock wave is generated outside the body, the procedure is termed extracorporeal shock wave lithotripsy (ESWL). The name is derived from the roots of two Greek words, litho , meaning stone, and trip , meaning to break. Purpose ESWL is used when a kidney stone is too large to pass on its own, or when a stone becomes stuck in a ureter (a tube that carries urine from the kidney to the bladder) and will not pass. Kidney stones are extremely painful and can cause serious medical complications if not removed. Diagnosis/Preparation ESWL should not be considered for persons with severe skeletal deformities, people weighing more than 300 lb (136 kg), individuals with abdominal aortic aneurysms, or persons with uncontrollable bleeding disorders. Women who are pregnant should not be treated with ESWL. Individuals with cardiac pacemakers should be evaluated by a cardiologist familiar with ESWL. The cardiologist should be present during the ESWL procedure in the event the pacemaker needs to be overridden.

Prior to the lithotripsy procedure, a complete physical examination is performed, followed by tests to determine the number, location, and size of the stone or stones. A test called an intravenous pyelogram (IVP) is used to locate the stones, which involves injecting a dye into a vein in the arm. This dye, which shows up on x ray, travels through the bloodstream and is excreted by the kidneys. The dye then flows down the ureters and into the bladder. The dye surrounds the stones. In this manner, x rays are used to evaluate the stones and the anatomy of the urinary system. Blood tests are performed to determine if any potential bleeding problems exist. For women of childbearing age, a pregnancy test is done to make sure they are not pregnant. Older persons have an EKG test to make sure that no potential heart problems exist. Some individuals may have a stent placed prior to the lithotripsy procedure. A stent is a plastic tube placed in the ureter that allows the passage of gravel and urine after the ESWL procedure is completed. The process of lithotripsy generally takes about one hour. During that time, up to 8,000 individual shock waves are administered. Depending on a person's pain tolerance, there may be some discomfort during the treatment. Analgesics may be administered to relieve this pain.

Aftercare Most persons pass blood in their urine after the ESWL procedure. This is normal and should clear after several days to a week. Lots of fluids should be taken to encourage the flushing of any gravel remaining in the urinary system. Treated persons should follow up with a urologist in about two weeks to make sure that everything is progressing as planned. If a stent has been inserted, it is normally removed at this time. Risks Abdominal pain is fairly common after ESWL, but it is usually not a cause for worry. However, persistent or severe abdominal pain may imply an unexpected internal injury. Occasionally, stones may not be completely fragmented during the first ESWL treatment and further lithotripsy procedures may be required. Some people are allergic to the dye material used during an IVP, so it cannot be used. For these people, focused sound waves, called ultrasound, can be used to identify where the stones are located.

PATHOPHYSIOLOGY NEPHROLOTHIASIS/R ENAL CALCULI

PREDISPOSING FACTORS AGE ( 20-25 Y.O) Gender (more common in male) Race(common in whites) Genetic

3 MAJOR THEORIES Saturation Theory Matrix Theory Inhibitor

PRECIPITATING FACTORS 1.Metabolic Abnormalities 2. Climate 3. Diet 4. Lifestyle (sedentary occupation, immobility)

STONE FORMATION

Types: Calcium (oxalate and phosphate) Magnesium ammonium phosphate (struvite) Uric acid (urate) cystine Fever, Chills, Nausea, and vomiting Severe pain, hematuria, hydronephrosis, anuria from bilateral obstruction, ad abdominal distention

Urinary stasis

Obstruction by stone

Calculi/stone traveling down the ureter

Hematuria, obstruction and severe pain

Acute Renal Failure

DEATH

Laboratory Results

Ultrasound KUB September 8 2010 Interpretation: Urinary retention, 153.7 ml (66%) Nephrolithiasis, right kidney with regression in size and numbers Nephrolithisasis, left kidney with regression Renal cyst, right kidney, increasing in size Radiology (x-ray) September 8, 2010 Thoracolumbar APL Interpretation: Osteoporosis Hypertropic degenerative osteoarthropathy, lumbar spine Compression fracture, L2

September 8, 2010 Result Urea Creatinine 8.45 mmol/L 200.3 mmol/L Normal Values 2.50 6.10 mmol/L 62 106 Renal failure Renal disease that has seriously damaged 50% or more of the nephrons, acromegaly. Dehydration, Impaired renal function Liver disease

Sodium Potassium

126 mmol/L 2.93 mmol/L

137 145 mmol/L 3.50 5.10 mmol/L Radiology (x-ray) September 9, 2010

Chest AP Interpretation: Atheromatous and tortuous aorta

September 19, 2010 Result Calcium Albumin 1.82 mmol/l 22.7 g/L Normal Values LO 2.10 2.55 mmol/L LO 35 50 g/L Significance Osteoporosis Kidney dysfunction

Cross Matching Result Slip September 19, 2010 Blood Type Serial no. Cross Matching Note o Rh Positive 018634 Compatible Screened @ PNSG 250cc, PRBC

Urinalysis September 20,2010 Microscopic Result Color Transparency Reaction Sp. Gravity Protein Glucose RBC/hpf WBC/hpf Pale Yellow Slightly Hazy pH 6.0 1.010 Negative Negative 2 0-3 Normal Values Straw Clear 4.5-8 1.010 1.025 Negative Negative 0-2 0-5 Stool Physical exam Color Consistency Occult Blood No OVA of intestinal parasite found on direct smear Dark Brown Soft Positive Significance Alcohol, large fluid intake Infection WNL WNL WNL WNL WNL WNL

September 21, 2010 Test Sodium Result 104 mmol/L Normal Value 136 145 mmol/L Significance Dehydration, Impaired renal function

September 22, 2010 Test Sodium Result 125.1 mmol/l Normal Value 136 145 mmol/L Significance Dehydration, Impaired renal function

Chemistry Test SGPT Result 73 U/L September 22, 2010 Normal Value 730 U/L Significance Cirrhosis Muscle inflammation Obesity Hepatitis

September 22, 2010

Test Sodium Potassium Creatinine Result 118.5 mmol/L 1.94 mmol/L 121 mmol/L Normal Value 136 145 mmol/L 3.50 5.10 53 - 115 Significance Dehydration, Impaired renal function Due to diuretics or kidney problem Renal disease that has seriously damaged 50% or more of the nephrons, acromegaly.

Other Result September 22,2010 Examination desired H Pylori determination Result: Negative (TV: 0.05) Interpretation: TV negative < 0.75 TV equivocal > = 0.75 & < 1.00 TV positive > 1.00

Hematology September 22,2010 Result Hematocrit 0.33 vol (fr) Normal Values 0.36 0.45 vol (fr) Significance Anemia, hemodilution, or massive blood loss Anemia, hemodilution, or massive blood loss Anemia, hemodilution, or massive blood loss WNL

Hemoglobin

110 gms/L

123 153 gms/L

Red cell Count

3.85 x 10^12/L

4.5-5.1 x 10^12/L

White Cell Count Differential Count Segmenters Eosinophils Lymphocytes Monocytes Prothrombin time

7.9 x 10^9/L

4.5-11x10^/L

0.83 0.03 0.13 0.01 15.9 seconds

50 65 % 1-4% 25 30% 2-5% 10-16 seconds

Infection WNL Infection Infection WNL

Test Init(September 23, 2010) Fluid: Serum Test Result Normal Value Significance

Potassium

LO 3.34 mmol/L

3.50 5.10mmol/L

Due to diuretics or kidney problem

Peripheral Blood Smear September 23,2010 Result Hct Hgb WBC ct. RBC ct. Segmenters Eosinophils Lymphocytes Monocytes Platelet count MCV MCH MCHC Bands 0.24 L/L 81 g/L 7.4 x 10 ^ /L 2.86 x 10 ^ /L 84% 2% 12% 1% 214 x 10^ /L 84 fl 28.3 pg 336 g/L 0% Normal Values 0.36 0.45 L/L 123 153 g/L Significance Anemia, hemodilution, or massive blood loss Anemia, hemodilution, or massive blood loss

4.5 11 x 10^ /L WNL 4.5 5.1 x 10^ / L anemia 36-66% Infection 2-3% 24-44% 4-6% 150 450 x 10^ /L 80 96 fl 27-31 pg 320-360 g/L 5-11% WNL Infection Infection WNL WNL WNL WNL

September 24, 2010 Test Result Normal Value Significance

Sodium

129.1 mmol/L

136 145 mmol/L

Dehydration, Impaired renal function

DRUG STUDY

Generic (Brand) Name Trimetazadine (Vastarel MR)

Drug class Anti-Anginal Drugs

Indications Long treatment of coronary insufficiency Angina pectoris

Mechanism of actions Acts by directly counteracting all the major metabolic disorders occurring within the ischemic cell Calcium channel blocker that inhibits calcium ion influx across cardiac amd smooth muscle cells, decreasing myocardial contractility and oxygen demand

Adverse reaction Headache, dizziness Nausea, constipation Somnolence

Nursing responsibilities y Monitor blood pressure and heart rate when starting therapy and during dosage adjustment. Administer drug with or after meals.

Generic (Brand) Name Rowatinex (Borneol, Camphene, Pinene) y

Drug class

Indications

Mechanism of actions

Adverse reaction

Nursing responsibilities Liquid intake should be increased during therapy. Administer drug with or after meals.

Genito Urinary Antiseptics Disinfectant s

For the treatment of urinary tract spasm and inflammation associated with urolithiasis. Assists in the dissolution and expulsion of stones in the renal system.

ROWATINEX No side effects y promotes a have been diuresis and reported relaxes urinary tract spasm, thus assisting the passage of y stones. The therapeutic effect of the balanced combination of terpenes reduces urinary tract inflammation, stimulating renal blood flow through the kidneys and increasing the output of less concentrated urine.

Generic Drug class (Brand) Name Domperid y Antie one(Motili metic um) y Dopa mener gic blocki ng agent

Indications

Mechanism of actions

Adverse reaction Dizziness Headache Insomia Drowsiness Belching Abdominal distention Irritability Twitching

Delayed gastric emptying of functional origin with gastroesophageal reflux/or dyspepsia. Control of nausea and vomiting of central or local origin. As antiemetic in patients receiving cytostatic and radiation therapy. Facilitates radiological examination of the upper GI tract.

Domperidone is related to its peripheral dopamine receptor blocking properties. Emesis induced by apomorphine, hydergine, morphine or levodopa, through th estimulation of the chemoreceptor trigger zone can be block by domperidone. There is indirect evidence that emesis is also inhibited at the gastric level, since domperidone also inhibits emesis induced by oral levodopa, and local gastric wall concentrations following oral domperidone are much greater than those of the plasma and other organs. Domperidone doesnot readily cross the blood brain barrier and therefore is not expected to have central effects.

Nursing responsibilit ies y Take this drug before meal. y Monitor patient I and O

Generic (Brand) Name Felodipine y y

Drug class

Indications

Mechanism of actions Inhibits the transport of calcium into myocardial and smooth muscle cells resulting in inhibitions of excitation contraction and subsequent contraction.

Adverse reaction Peripheral y edema Headache,dizin ess

Nursing responsibilities Monitor bp and pulses before theraphy, during doasage titration and peridiacally throughout theraphy. Administer drug with or after meals.

Anti Management anginal of Anti hypertension. hypertensi ve Calcium channel blockers

Generic Drug class (Brand) Name Omeprazole Proton pump inhibitor

Mechanism of Indication actions Inhibits acid pump and binds to hydrogen potassium adenosine triphosphatas e on secretory surface of gastric parietal cells block formation of gastric acid Short term treatment of active duodenal ulcer. First line therapy in treatment of heartburn or symptoms of GERD.

Adverse reaction y y y y y y y y y y y

Nursing responsibilities Give drug 30 mins. Before meals Explain the importance of taking drug exactly as prescribed Warn the pt not to crush or chew the drug

Headache y Dizziness Diarrhea Abdominal y pain Nausea Vomiting Constipati on y Flatulence Back pain Cough Rash

Generic (Brand) Name Sambong

Drug class

Indications

Nursing responsibilities

Antiurothiliasis Vitamin supplement

Used to aid the treatment of kidney disorders it helps disposing excess water and sodium in the body

Advice patient to increase fluid intake.

Generic (Brand) Name Drug class

Mechanism of action

Indications

Adverse reaction

Nursing responsibilities Use cautiously in patients with active upper GI problems Give drug with 6 to 8 ounces of water at least 30 min first food or drink of the day to facilitates delivery to the stomach.

Alendronate Metabolic Suppresses Cholecalciferol Bisphosphonat osteoclast es activity in newly formed re absorption surfaces, which reduces bone turnover. Bone formation exceeds re absorption at remodeling sites, leading to progressive gains on bone mass.

Treatment of osteoporosis of post menopausal women.

Headache y Abdominal apin, nausea, dyaspepsia, muscu skelatal pain. y gastritis

Generic (Brand) Name Rebapimide (Mucosta)

Drug Class Mechanism of Action antacids, antireflux and antiulceran ts agents used for mucosal protection, healing of gastro duodenal ulcers, and treatment of gastritis. It works by enhancing mucosal defense, scavenging free radicals, and temporarily activating genes encoding cyclooxygenas e.

Indications

Adverse Effect Nausea and vomiting Heartbur n Diarrhea Jaundice Rash Belching Abdomin al pain

Contraindic Nursing ations Responsibilit ies Patient with y a history of hypersensit ivity to any y ingredient of this drug. y Take this drug with food. Monitor pt food intake. Advise pt not to eat food that can irritate the stomach.

Gastric ulcers. Treatment of gastric mucosal lesions (erosion, bleeding, redness & edema) in acute gastritis & acute exacerbation of chronic gastritis.

y y y y y y

Generic (Brand) Name

Drug Class

Mechanism of Action A food additive, y potassium citrate is used to regulate acidity. Medicinally, it may be used to control kidney stones derived y from either uric acid or cystine. y

Indications

Adverse Effect

Contraindica Nursing Responsibilities tions Renal y function impairment with oliguria, azotemia, untreated Addisons disease, severe myocardial damage, or certain situation when pt are y on sodiumrestricted diet Do not crush, chew,break or suck on extended-release tablet. Swallow the tablet. Breaking or crushing the pill may cause too much of the drug to be released at one time. Sucking on a potassium tablet can irritate your mouth or throat. Avoid lying down for atleast 30 mins after taking the drug, take this drug with meal or snack or within 30 mins after meal. Inform pt not to stop taking this drug without the information of the doctor, if the pt stop taking this drug his/her condition might worse.

Potassium citrate (Urocit-K)

Urinary and system alkanizer

Potassium citrate is used to treat kidney stone condition called renal tubular acidosis. Treatment of chronic metabolic acidosis. Treatment of pt with cystine calculi and uric acid of the urinary tract .

y y y y y y

y y

Nausea and vomiting Stomach pain Dizziness Black/blood y stool Rash Slow/irregu lar heartbeat Mental/moo d changes Trouble breathing hyperkalem ia

Generic (Brand) Name

Drug Class

Mechanism of Action

Indications

Adverse Effect

Contraindicatio ns Contraindicated y in patients with a hypersensitivity to sertraline or any of the inactive ingredients in y ZOLOFT. contraindicated with ANTABUSE y (disulfiram) due to the alcohol content of the concentrate y

Nursing Responsibilities Monitor pt especially when the pt experienced the adverse effect. Always be alert. Take this drug with food. Make sure that the pt is comfortable and free of worries. Advise pt to relax.

Sertraline HCL Antidepressant Serotonin is a (Zolof) neurotransmitter (a chemical messenger) produced by nerve cells in the brain that is used by the nerves to communicate with one another. A nerve releases the serotonin it produces into the space surrounding it. The serotonin either travels across the space and attaches to receptors on the surface of nearby nerves or it attaches to receptors on the surface of the nerve that produced it, to be taken up by the nerve and released again (a process referred to as reuptake).

Treatment of major depressive disorder in adults. treatment of obsessions and compulsions in patients with obsessivecompulsive disorder (OCD) reatment of a major depressive episode treatment of social anxiety disorder, also known as social phobiain adults.

y y y y y y y y y y y y y y

Anxiety Rash ; hives Black/blody stol Chest pain Loss of appetite Nausea and vomiting Trouble sleeping Irregular heartbeat Irritability Memory loss Fainting Fever Hallucination Panic attacks

Nursing Care Plan

Assessment

Nursing Diagnosis

Planning To demonstrate behaviour that shows relief from pain such as decrease in facial grimace, moaning, diaphoresis and lower down pain scale from 6 to 5 within the shift.

S: Naga kinuriit siya kay ga sakit Acute pain related to iya kilid as verbalized by the tissue distension or folks. trauma. O: (+) facial grimace (+) guarding behaviour (+)moaning (+)change in muscle tone (+)diaphoresis BP- 130/80 mmHg RR- 25 bpm Pain scale of 6. Ultrasound KUB reveals: Nephrolithiasis, right kidney with regression in size and numbers. Nephrolithisasis, left kidney with regression. Renal cyst, right kidney, increasing in size.

Intervention

Rationale

Evaluation

Independent: 1. Provide comfort measures, quiet environment and calm activities. 2. Encourage diversional activities such as watching TV, talking to family members or listening to radio.

1. To promote non pharmacological pain management. 2. To divert or distract attention from pain and reduce tension. .

Goal met. As evidenced by patient demonstrates behaviours that show relief from pain, decreased facial grimace, moaning, diaphoresis, and pain scale lowers from 6 to 5.

Assessment Nursing Diagnosis Planning S: Nasakitan kag gamay Impaired urinary elimination 1. To achieve normal lang iya ihi sadto muna gin related to mechanical amount of output within takdan siya catheter as obstruction of urinary flow. 8 hours. verbalized folks. 2. To manage care of O: urinary catheter within -With foley catheter the shift. -Urine output: 500ml/day Ultrasound KUB reveals: Urinary retention, 153.7 ml (66%) Nephrolithiasis, right kidney with regression in size and numbers. Nephrolithisasis, left kidney with regression. Renal cyst, right kidney, increasing in size.

Intervention

Rationale

Evaluation

Independent: 1. Monitor intake and output strictly. 2. Measure urine output and drain catheter regularly every hour.

1. To provide accurate measurement of the exact fluid intake and output. 2. To prevent overflowing of urine and avoid ascending infection.

Goal met. As evidenced by urine output of 300 ml within the shift

Assessment

Nursing Diagnosis

Planning

S: Indi na sya mayad kahulag as verbalized by the folks. O:Bed ridden (+) decreased muscle strength. Radiology reveals:  Osteoporosis  Hypertropic degenerative osteoarthropathy, lumbar spine

Impaired Physical mobility r/t decreased muscle strength and loss of integrity.

Maintain position of function and skin integrity as evidenced by absence of contractures, footdrop and decubitus within the shift.

Intervention Independent: 1. Reposition regularly. 2. Use side rails for position changes. 3. Support affected body parts using pillows.

Rationale

Evaluation Goal met. As evidenced by patient maintain position of function and skin integrity.

1. To prevent breakage in the skin integrity. 2. To prevent any injury. 3. To maintain position of function and reduce risk of pressure ulcers.

Assessment S: Indi siya ka hala as verbalized by the folks. O: Inability to speak Absence of eye contact.

Nursing Diagnosis Impaired verbal communication related to weakening of muscuskeletal system.

Planning Establish method of communication in which needs can be expressed within the shift.

Intervention Independent: 1. Review history of neurological condition. 2. Establish relationship with the client, listening carefully and attending to clients verbal/nonverbal expression. 3. Maintain eye contact, preferably at clients level. 4. Involve family in plan of care as much possible.

Rationale 1. Neurological condition affect speech such as stroke. 2. Conveys interest and concern. 3. Conveys interest and concern. 4. Enhances participation and commitment to communication with love one.

Evaluation Goal not met. As evidence by patient doesnt establish method of communication in this needs can be expressed within the shift.

Assessment O: With foley catheter.

Nursing Diagnosis Risk for infection r/t invasive procedure.

Planning To prevent any signs of infection within the shift.

Intervention Independent: 1. Monitor urine output hourly and drain urine regularly. 2. Practice hand washing and other infection control practices.

Rationale

Evaluation

Goal met. As evidenced by 1. To prevent the backflow no signs of infection of urine, thus preventing occurred during the shift. ascending infection. 2. Prevents transfer of microorganisms from healthcare providers and healthcare workers.

Assessment O: In TPN Na-104 mmol/L K- 1.94mmol/L Total protein 49.2g/L Albumin 22.7g/L

Nursing Diagnosis Risk for imbalance nutrition less than body requirements related to food intake restriction

Planning Demonstrate behaviours, lifestyle changes to maintain nutritional status within the shift.

Intervention

Rationale

Evaluation Goal met. As evidence by patient demonstrate behaviours, lifestyle changes to maintain nutritional status.

Independent: 1. Ascertain understanding 1. To determine of individual nutritional informational needs of needs. client. 2. Provide diet 2. To provide and meet modifications: total nutritional needs. parenteral infusion. 3. To reveal possible cause 3. Evaluate total daily food of malnutrition/changes intake. Record daily that could be made in calorie intake, patterns clients intake. and times of eating.

Assessment S: Indi siya maayu kahulag as verbalized by the folks. O: (+) body malaise

Nursing Diagnosis Risk for constipation related to immobility.

Planning Demonstrate behaviour or lifestyle changes to prevent developing problems within the shift.

Intervention Independent: 1. Auscultate abdomen for presence, location, and characteristics of bowel sounds. 2. Encourage activity or exercise within limits of individual ability. 3. Ascertain frequency, color, consistency, amount of stools.

Rationale 1. Reflecting bowel activity. 2. To stimulate contractions of the intestines. 3. Provides a baseline for comparison, promotes recognition of changes.

Evaluation Goal not met. As evidence by patient doesnt demonstrate behaviour or lifestyle changes to prevent developing problems within the shift.

Assessment

Nursing Diagnosis

Planning

S: Indi siya kahulag as verbalized by the folks. O: (+) body malaise

Risk for impaired skin integrity related to physical immobility.

Demonstrate behaviours/ techniques to prevent skin breakdown within the shift.

Intervention Independent: 1. Reposition every two hours 2. Keep bedclothes dry and wrinkle-free. 3. Encourage and assess to perform range of motion exercises. 4. Maintain meticulous skin hygiene. 1. 2.

Rationale

Evaluation

3. 4.

Goal met. As evidence by To prevent breakage in the patient demonstrate behaviours/techniques to skin integrity prevent skin breakdown To increase circulation and limit excessive tissue within the shift. pressure To enhance circulation To prevent friction and shear injury.

DISCHARGE PLANNING

Medications Encouraged client to take medications as prescribed by her physician. Teach patient of the different side and adverse effects of the drugs.rse effects of the drugs. Report any unusualities when taking the prescribed drug such as nausea and vomiting or skin allergies. vomiting or skin allergies. Exercise Encourage patient to perform ROM exercises such as hand and leg flexions. Treatment Encouraged the patient to comply with the medication as ordered by her physician. Explain the importance of adhering to her treatment regimen. Home management Provide safety precaution.

Out patient Inform the patient to have follow-up check- up after a week to prevent possible complications and to update the medical team concerning the progress of the patient s condition and to promote continuity of care. Diet Avoid salty foods. Must have green leafy vegetables, and fruits during meal. Must drink plenty of water. Spiritually Encourage to have faith with the Lord. Explains that Lord has a way of curing her physically and emotionally.

UPDATES Mrs. C.D. is still in the hospital at St. Joseph Ward and is still undergoing treatment.

END......