pelviolithiasis
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PELVIOLITHIASIS
WHAT IS PELVIOLITHIASIS?
Pelviolithiasis is the presence of stones in the renal pelvis.
The renal pelvis is the enlarged upper end of the ureter, the tube through which the urine flow from the kidney to the urinary bladder.
WHAT IS A KIDNEY STONE?
A kidney stone is a hard, crystalline, mineral formed within the kidney of urinary tract.
It is formed in the body from different compounds, most are calcium oxalate or calcium phosphate however, uric acid, struvite, and cystine are also stone formers
URIC ACID STONES
Uric acid is a waste product of the body excreted through the urine and stool. However, if the kidneys fail to excrete uric acid properly it will remain in the blood and will eventually result to gout or kidney stones.
Uric acid stones are formed because of the excess uric acid in the urine.
INCIDENCE
It is one of the most painful urologic disorder. Each year almost 3 million people suffer from pelvic stones.
CAUSES
Genetic High protein and salt intake, diet rich
in meat, fish, chicken Vitamin B6 deficiency Dehydration Excessive vitamin C intake, Calcium
supplements, and antacids containing calcium
SIGNS AND SYMPTOMS
Flank Pain Hematuria Nausea and vomiting Fever, chills Urinary urgency and difficulty
DIAGNOSTIC TESTS
Laboratory test Urinalysis Blood test
Ultrasound CT scan X-ray
TREATMENT
SURGICAL TREATMENT Pyelolithotomy
-the procedure of choice for stones within the renal pelvis, including stones that demonstrated minimal invasion into calyces and infundibulum.
CONSERVATIVE THERAPY Hydration Diet Lifestyle changes
NURSING MANAGEMENT
Pain Management Increase fluid intake Observe for anuria Observe for signs of infection Strain the urine to detect stones
passing through and save the stones for analysis
Reduce anxiety
Health teaching Explain procedure to patient and family Explain importance of exercise and diet
modification If undergoing flank of abdominal
incision, teach deep breathing exercises and coughing exercise
ANATOMY OF KIDNEY
Functions of kidneys: -Regulate blood volume and
composition -help regulate blood pressure -synthesize glucose -release erythropoietin -participate in vitamin D synthesis -excrete wastes in the urine
Process of Urine:
PATIENT’S PROFILE
Name: Mrs. TabarolAge: 51Sex: FemaleAddress: Iyatan St. Ilaya Del Sur, Paete, Laguna Nationality:FilipinoReligion: CatholicCivil Status: MarriedBirthday: 12/02/1960Date and time of admission: June 27, 2012 (9:15am)Final diagnosis: Pelviolithiasis Principal Operation/ Procedure: Left Pyelolithotomy
HISTORY OF PRESENT ILLNESS During early 2011, Mrs. Tabarol complained of on and
off flank pain radiating to her left trunk, hypertension and hyperacidity. She decided to have a consultation at Pakil Hospital where she was diagnosed of UTI and was admitted for a week. She had undergone an ultrasound which revealed two stones in the renal pelvis at 0.7 and 0.8 cm in size. She was prescribed to take Acalka (potassium citrate) twice or thrice per day for a year, Co-amoxiclav taken 3x per day for a month, ranitidine (Zantax) and omeprazole for her hyperacidity and vitamin B complex. She also used herbal medicine like sambong and had decided to change her eating habits.
After a few months, she complained of hyperacidity that she cannot bear and consulted at a private clinic at Pagsanjan where she was prescribed to take Maalox everytime she experience hyperacidity and heartburn.
Mrs. Tabarol went to Dra. Villanueva for a second opinion regarding the result of her ultrasound and was told that she has to undergo surgery within 2 months to prevent the increase in size of her stones and was then referred to Dr. Chumacera at Laguna Doctor's Hospital. She was then referred by Dr. Chumacera at Laguna Provincial Hospital for surgery.
PAST MEDICAL HISTORY
At 6 years old, she was diagnosed with asthma but did not progress. during her college years, she was accidentally hit by a reversing passenger jeepney on her left breast and ignored it. During early 1980's, she had felt a lump on her left breast and had a left breast biopsy which returned negative. Patient has no known allergies.
FAMILY HISTORY
The patient's mother had a history of hypertension, CVA and goiter while her father was hypotensive. She was the youngest of the five children, two of her siblings has DM, one has stroke and the other has choledocholithiasis.
GORDON’S FUNCTIONAL HEALTH PATTERN
Before Hospitalization During Hospitalization
I. Health perception/Health management
She stated that her perception to health is when there is no feeling of pain or illness, if she having a perspiration and if she normally doing thing well. She verbalized that she is aware and understand her health condition.
She verbalized that she realizes that it is her fault why she is in the hospital. In spite that she already knows her condition, she still continues to take food high in sodium and fats. She promises that she will follow the medication and avoid the foods/ beverages that are bad for her.
II. NutritionaL Pattern/ Metabolic Pattern
The patient stated that she’s having three meals per day. Her usual meals are meat, fish, and vegetables. She loves to eat fatty and salted foods such as peanuts and cornick. She verbalized that she lost her weight about 5 kg. From 64 to 59 kg. She sometimes skipped her breakfast and keeps herself hungry for about two hours. She drinks at least six (6) glasses of water a day which is the same as 1440 ml. a day. She also takes milk during breakfast or before going to sleep. She mentioned that she does not drink coffee and doesn’t drink much soft drink. She also said that she started having loss of appetite because of her hyperacidity.
She stated that she experienced loss of appetite because she was used to in eating salty foods before she was hospitalized. Now she is able to identify the importance of her diet which is to avoid foods high in fats and sodium.
Before Hospitalization During Hospitalization
III. Elimination Pattern Patient verbalizes, at first she is eager in drinking plenty of water so that she may urinate more often since drinking more water makes her urinate more frequent but then she gets tired of doing this that’s why she limited again her fluid intake and sometimes delays the time when she needs to urinate especially at bed time. Her bowel movement is once a day, with black stool. In addition to that, she stated that she doesn’t have any difficulty in defecating.
Patient stated that after the procedure, she did not have bowel movement for two days. She did not complain of any difficulty in urination or urgency. And she observed that the color of her urine is light yellow.
IV. Activity and exercise Pattern Patient verbalizes that she gets easily stress out. She does not have any exercise. The patient’s lifestyle include activity such as eating and doing house chores, being a Brgy.officer ,she is active in participating to any Brgy.activities. She also makes sure to have a quality time with her family.
She stated that she can do her daily activity with some assistance from her husband and other family members.
Before Hospitalization During Hospitalization
V. Sleep/Rest Pattern The patient verbalized that she usually has six (6) hours of sleep every day. She usually go to sleep at eleven (11) in the evening and wakes up five (5) in the morning. There are in between resting period any time every day by taking naps 15-20 minutes.
The patient stated that she needs to sleep most of her free time to recover and restore energy.
VI. COGNITIVE/PERCEPTUAL PATTERN
The patient stated that she’s not having difficulties in understanding and following directions. Her ability to concentrate in work is still intact. She is still able to retain information, and make decisions and solve problems related to work and family. She also said that she uses reading glasses and that she is farsighted. She had her last eye check up on January 2012. The patient did not report any hearing difficulties.
During history taking of the patient, she recalls her personal information without difficulties and with confidence and consistencies. She still uses her reading glasses when she needed to and also has good hearing acuity.
Before Hospitalization During Hospitalization
VII. SELF-PERCEPTION/SELF- CONCEPT PATTERN
The patient described herself as a jolly, positive-thinking person. “Masaya ako kapag nakakatulong ako sa ibang tao.”She said that she sees herself as a hard-working person because she doesn’t want other people to have something bad to say about how she works. She wants her people’s satisfaction.Most of the instances that she loses hope are due to her family problem such as when that time that her daughter got pregnant when she was still in college and when her eldest son got separated from his wife.
Even though she was hospitalized, the patient stated that it is just temporary and after she is well, she can be functional again and resume to her usual role as a wife, a mother, a sibling, and as a barangay kagawad.The patient has a good eye contact and is relaxed while expressing herself.
VIII. ROLE/RELATIONSHIP PATTERN
The patient is living with her husband and one of her sibling. All of her children have now their own families. Both she and her husband have jobs where they get their daily needs.She felt that the people in her barangay accepted her as their kagawad because they cooperate whenever she asks.
According to the patient, her whole family is very caring to her. Her husband is very supportive to her financially and morally, as well as their children who helped much in her hospital bills. The patient added that they were extra caring to her now due to her current condition.
Before Hospitalization During Hospitalization
SEXUALITY REPRODUCTIVE PATTERN
The patient stated that her sexual relationship with her husband is satisfying even though they only do it once a month.She mentioned that she used IUD as a contraceptive for 18 years which started on year 1987.Her menstruation began when she was 12 years of age and her menopause at 49 years old.
The patient stated, “Normal lang na hindi muna naming ginagawa ‘yon mag-asawa, kakaopera ko lang kasi, eh.”
X. COPING/STRESS-TOLERANCE PATTERN
In times of stress, the patient stated that talking with her husband, other family members, and significant others make her feel much better.She denies use of any medications, drugs, alcohol, or tobacco to relax. “Wala akong bisyo”, as the patient added.She also said that praying the rosary helps in calming her mind.
She still does like what she usually does in times of stress before she was hospitalized.
XI. VALUE/BELIEF PATTERN The patient, as a Catholic, goes to church regularly with her husband and/or other family member. She believes that praying is important in life.
Patient’s current health status did not interfere with her faith. She still prays the rosary while in the hospital.
PATHOPHYSIOLOGY
LABORATORY Hematology 06-08-12
Result Ref Value Interpretation
Bleeding Time 2mins 50sec 1-5 mins NORMAL
Clotting Time 4 mins 0 sec 2-6 mins NORMAL
Blood Typing “O”/ Rh typing (+)
Clinical Chemistry 06-08-12Result Normal Values Interpretation
Sodium 144.6 135-155 mEq NORMAL
Potassium 5.39 3.4-5.3 mEq ABNORMAL
Hematology 06-08-12Test Result Ref. Value Interpretation
WBC 8.0 5.0-10.0x109/LRBC 4.77 F 4.2-5.4x1012/L
M 4.5-6.2x1012/LHGB 12.3 13.0-17.0g/dlHCT 0.43 0.39-0.53MCV 91.0 80-100f/LMCH 25.8 27.0-32.0 pg/L LowMCHC 233.0 320-360 g/lRDW 11.8 10.0-16.5%CVPLT 259.0 150-450x103/ulPCT 0.15 0.10-1.00%MPV 5.7 5.0-10.0 fLPDW 18.6 12-18%
Serotology &Immunology 06-08-12 Result Normal Values Interpretation
Hepa B surface Antigen
Reactive Person is infected, it is reactive because patient has infection.
Widal Test 1:20, 1:40,1:80,1:160,1:320
06-20-12 Result Interpretation
HBsAg Reactive Person is infected.
Differential CountAbsolute Count % count Ref Value
Neutrophil 4.4 55.0 50-70%Lymphocyte 3.3 40.7 20-50%Monocyte 0.3 4.3 02-09%Total 8.0 100
Coagulation Factor 06-08-12Examination Patient’s Value Normal Value Interpretation
PTT 41.0 sec 2.7-34 sec NORMALRatio 1.42 0,8-1,2
Control 31.5 sec
Urinalysis 06-20-12Result Normal Values Interpretation
Color YellowTransparency HazySpecific Gravity 1.020 1.0015-1.030Reaction 6.0 ACIDICAlbumin TraceGlucose NegativeRBC 2-4Epith Cells Few FewMucus Thread Few FewBacteria ManyA.Urates ModerateWBC Over 100
Laboratory 06-20-12Thyroid Within range result Ref Result Interpretation
Free T4 (ECLIA) 16.15 12.0-220 pmol/L NORMAL
TSH (ECLIA) 1.200 0.270-4.200 mIU NORMAL
Blood ChemistryExamination S.I. Result Ref. Value Interpretation
FBG 4.9 3.9-5.9 NORMAL
2.5-6.4
BUA
CREA 95 M 62-115 NORMAL
F 53-97
Chemistry 06-25-12 Result Ref Value Interpretation
SGPT/ALT 11.6 4-38 IU/L NORMALSGOT/AST 12.0 0-40 IU/L NORMAL
Diagnostic Imaging Report
Chest XRAY (PA) View:
There are no active lung infiltrates The heart is not enlarged Aorta is tortuous The cp sulci,diaphragm and bony
thorax are unremarkable
Impression: Tortuous Aorta
VITAL SIGNS
06-27-12 Temperature Pulse Respiration Blood Pressure
10:30 36.0 69 23 140/100
1:20PM 36.9 73 20 130/90
4 PM 36.7 76 24 140/100
06-28-12 Temperature
Pulse Respiration Blood Pressure
6 PM 35.7 70 24 150/90
06-29-12 Temperature
Pulse Respiration Blood Pressure
8 PM 37 83 31 150/110
140/80
06-30-12 Temperature Pulse Respiration Blood Pressure
12 NN 36.5 76 20 130/90110/70
07-01-12 Temperature Pulse Respiration Blood Pressure
4 AM 36.8 88 19 140/100
120/90
07-02-12 Temperature Pulse Respiration Blood Pressure
4 PM 36.4 81 19 130/90
120/70
07-03-12 Temperature
Pulse Respiration Blood Pressure
12 AM 36.6 76 22 140/100
DRUG STUDYDRUG CLASSIFICATIO
NUSE ACTION ADVERSE
EFFECTNURSING
CONSIDERATIONS
1. Cefuroxime750mg IV q8
: 3rd generation cephalosporin
UTI, perioperative prophylaxis
Sz (high dose), pseudomembranous colitis, diarrhea, cholelithiasis, rash, urticaria,pruritis, phlebitis, pain at IM site
monitor, HR, BP, temp, sputum, UA, CBC, billirubin, jaundiceUse with caution in pt.s with beta lactam allergy (do not use if hx of anaphlaxis or hives)
2. Omeprazole
40 mg cap OD
Class: proton pump inhibitor
Reduce gastric acid secretion and increases gastric mucus bicarbonate production, creating proactive coating and easing discomfort from excess gastric acid.
Check abd pain, emesis, diarrhea, or constipation, Evaluate IO, watch for elevated liver function test results
DRUG CLASSIFICATION
USE ACTION ADVERSE EFFECT
NURSING CONSIDERATI
ONS3. Ketorolac
30 mg IV q8 x 3 doses
Interferes with prostaglandin biosynthesis by inhibiting cyclooxygenase pathway of arachidonic acid metabolism also act as potent inhibitor of platelet aggregation
monitor adverse reaction, especially prolonged bleeding time and CNS rxn Check IM injection for hematoma and bleeding MIO
4. Amlodipine
5 mg tab OD
Antihypertensive
to control hypertension
decreases intracellular Ca level, inhibits smooth muscle contractions and relaxing coronary and vascular smooth muscles, decreasing peripheral vascular resistance and reducing systolic and diastolic pressure
anxiety,dizziness, fatigue, hypotension, palpitations, abd pain
BP when adjusting dosageTell pt. to take missed dose as soon as remembered and next dose in 24 hoursTake with food to decrease GI upsetRoutinely check BP for possible hypotension
DRUG CLASSIFICATION USE ACTION ADVERSE EFFECT NURSING CONSIDERATIONS
5. Tramadol
100 mg IV q6 x 4 doses
Analgesics Moderate to moderately severe pain
Inhibits reuptake of serotonin and norepinephrine in the CNS.
dizziness, spinning sensation;constipation, upset stomach,headache;drowsiness; or feeling nervous or anxious.
nausea, vomiting, sweating, itching and constipation
Assess type, location, and intensity of pain before and 2-3 hr (peak) after administration.Assess BP & RR before and periodically during administration.Assess bowel function routinely Monitor patient for seizures.Encourage patient to cough and breathe deeply every 2 hr to prevent atelactasis and pneumonia.
DRUG CLASSIFICATION USE ACTION ADVERSE EFFECT NURSING CONSIDERATION
S
6. Celecoxib
400 mg tab BID
NSAID arthritis, pain, menstrual
cramps, and colonic
polyps
blocks the enzyme that makes prostaglandins (cyclooxygenase 2), resulting in lower concentrations of prostaglandins
headache,abdominal pain, dyspepsia, diarrhea, nausea, flatulence, and insomnia.
Bleeding, ulceration and perforation of the stomach or intestines.
assess patients for any contraindicationsshould be taken with food or milk to lessen the chance of gastric upset.Patients should be taught never to crush, dissolve or chew this medication and to never exceed the prescribed dose as deaths have occurred.
NURSING CARE PLANSASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:“Medyo sumasakit ang tagiliran ko” as verbalized by the patientObjectiveBP: 170/110
Acute pain related to presence of renal calculi as manifested by flank pain
To provide pain relief through independent and dependent nursing actionsTo prevent further recurrence of renal stones
Administer pain medications as prescribedMonitor and evaluate pain level accordinglyEncourage proper positioningIncrease fluid intakeFollow prescribed diet such as low salt, low fat dietProvide quiet and calm environmentInstruct relaxation techniques such as deep breathing exercises, listening to musicProvide non pharmacological pain management such as back rub, change position
To provide immediate pain reliefTo properly plan future actions for pain reliefProper position proved to provide pain reliefConcentrated urine can form renal calculiProper diet can prevent the recurrence of renal calculiLess environmental stimuli can decrease painTo provide comfort
After a series of nursing actions, the patient will verbalized decreased pain, have less recurrence of kidney stones
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONS “Hindi ko alam na mataas ang BP ko, Nalaman ko lang nung nag punta ako sa Ospital ng pakil” as verbalized by the patient.
O
BP:170/110
Deficient Knowledge regarding condition may be related to lack of information as evidence by
After 8 hours of duty the patient will gain enough knowledge regarding her condtion. Was able to
verbalize understanding of disease process and treatment regimen.
Assessed readiness and blocks to learning. Include significant other (SO).
Defined and stated the limits of desired BP. Explain hypertension and its effects.
Assisted patient in identifying modifiable risk factors(obesity,diet high in sodium, saturated fats, and cholesterol, sedentary lifestyle, stressful lifestyle.
Misconceptions and denial of the diagnosis because of long-standing feelings of well-being may interfere with patient/SO willingness to learn about disease, progression, and prognosis.
Provides basis for understanding elevations of B.
These risk factors have been shown to contribute to hypertension and cardiovascular and renal disease.
After 8 hours of nursing interventions the patient gain enough knowledge regarding her condition and able to verbalized understanding regarding the disease process.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Reinforced the importance of adhering to treatment regimen and keeping follow-up appointments.
Instructed and demonstrated technique of BP self-monitoring.
Encouraged patient to established an individual exercise program incorporating aerobic exercise (walking) within patient’s capabilities.
Lack of cooperation is a common reason for failure of antihypertensive therapy.
Monitoring BP at home is reassuring to patient because it provides visual/positive reinforcement for efforts in following the medical regimen and promotes early detection of deleterious changes.
Helping to lower BP, aerobic activity aids in toning the cardiovascular system.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
S> “Dahil mahirap maospital, magastos, iiwasan ko na ang pagkain ng sobrang maaalat at matataba” as verbalized by the patient.O> Good eye contact>able to repeat the instructions given>compliance to health teachings or health instructions given (such as drinking lots of fluid and limiting salty foods)
Readiness for enhanced self-care related to previous hospitalization experience as evidenced by verbalization of disadvantages of being hospitalized
To maintain responsibility for planning and achieving self-care goals/ general well beingTo promote optimum wellness
Assessed for potential barriers (lack of information, catastrophic event, etc) that may affect self-careProvided with accurate/ relevant information regarding current health condition
To enhance participation in self-careSo that she may have discipline regarding her diet
After 8 hours of shift, the pt. gained understanding about her health conditionThe pt. gained eagerness to modify her behavior by stating “iiwas na ako sa maalat at iinom na din ako ng maraming tubig”
DISCHARGE PLANNING
DIET ACTIVITIES MEDICATIONS
advised to drink adequate(6-8 glasses/day) amount of waterencouraged to eat foods with low in sodium and low in fatavoid caffeinated beverages
encouraged exercise atleast 30mins a day if possible
advised to take home medications as prescribed by the doctor.home meds:Cefuroxime 500mg tab 3x/dayCelecoxib 400mg tab 2x/ dayreturn for a follow up check up on June 9, 2012 at 3pm at Laguna Doctor's Hospital
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