ureterolithiasis (2)

COLLEGE OF NURSING

Our Lady of Fatima University Research and Development Center

Nursing Management

Nursing Management of a Patient with Calyceal Calculi

A Case Study by

Alojado, Christine Mae B.

Cueva, Paulyn

Dalisay, Inah Joy

4Y1-8 (Group 8A)

Our Lady of Fatima University

Valenzuela City Campus

Mrs. Elisa Lasanas, RN, MAN

Clinical Instructor

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Nursing Management II

Nursing Management of a Patient with Calyceal Calculi

Mr. D. B. A, a 30 year-old male, married Filipino from Leyte, had a

chief complaint of left flank pain. He was diagnosed with left

nephrolithiasis since 2005 and was given sodium citrate (Rowatinex) and

potassium citrate three times a day as his medication. He was apparently

well and was lost to follow up. 6 months prior to his admission, he was

noted with occasional flank pain on his left side, described as colicky,

radiating to the left leg, and associated with some passage of sandy

urine. He didn’t have any consultations and his previous medications were

continued, which afforded temporary relief. 1 month prior to his admission,

the above symptoms persisted. He was rushed to nearby hospital and KUB

& ultrasound was done revealing pelvicaliocyceal left secondary to

ureteropelvic junction calculus. He was then referred to Armed Forces of

the Philippines Medical Center where further medical evaluations were

done. Hence, admission was made.

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To fully understand the case of the patient, we will discuss what

ureterolithiasis is all about. According to Timby (2005), urolithiasis refers

to a condition of stones (calculus/calculi) that forms in the urinary tract.

Calculus/calculi are precipitates of mineral salts ordinarily dissolved in

urine. This may be either as nephrolithiasis (kidney stones) or

ureterolithiasis (ureter stones).

Renal calculi or kidney stones are composed of calcium oxalate,

calcium phosphate, or both. Typical symptoms of kidney stones are

hematuria and renal or urinary colic. Urinary colic is an extreme,

spasmodic flank pain often described as “the worst pain I’ve had in my

entire life.” This pain is caused by the spasmodic contraction of an

obstructed ureter. Cause of stone formation is unknown, but some

precipitating factors include dehydration, chronic urinary tract infection,

and immobility or prolonged bed rest leading to release of calcium from

the bones. And some possible causes are obstruction to urine flow,

metabolism, diet, renal disease & gout (a disease of increased uric acid

production or decreased excretion) (Myers, 2005).

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Ureterolithiasis is a kidney stone specifically found in the ureter (the

long tube that travels from your kidney to your bladder). Obstruction of

the ureter by the kidney stones causes a renal colic attack which is why

intense pain is felt in groin and back. Ureteral stones are usually small;

some may be no larger than a grain of sand. It’s more common in males

than females and commonly occurs between ages thirty to fifty (Timby,

2005).

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Nursing Management III

Pathophysiology

To fully understand the pathophysiology of ureterolithiasis, we must

first recall the anatomy & physiology of the renal system.The Renal

System is consists of the kidneys, ureters, urinary bladder and the urethra.

The functional units of the kidney are called nephrons. Each kidney has

more than 1 million nephrons. Each nephron contains a glomerulus,

Bowman’s capsule and tubule system. These components work together to

maintain ion balance for optimal function and eliminate unnecessary

material from plasma (Amerling & Levin, 2001).

The glomerulus is the filtering system of the nephron, a semi-

permeable and allows water and soluble waste to pass through and be

eliminated as urine. Urine normally consists of 95% water; the

nitrogenous waste products of protein which are urea, uric acid and

creatinine; the excessive electrolytes sodium, calcium, potassium and

phosphates; hormones and metabolized drugs.

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One of the predisposing factors that contribute to the formation of

stones is the intake of foods containing purine & oxalate. According to

Lippincott (2004), diet that is high in purine such as meat, fish & poultry

increases the levels of uric acid in the body. Regional enteritis & ulcerative

colitis may precipitate further formation of uric acid calculi. This normally

results to fluid loss & loss of bicarbonate which may lead to metabolic

acidosis. As a result, the pH of the urine becomes acidic (<6.0). Calcium

oxalates on the other hand, together with calcium phosphate, comprises

75-80% of calculi formation (Lippincott, 2004). Normally, foods that

contain oxalates are asparagus, chocolates, and caffeinated beverages

among others. Calculi form when substances that are normally dissolved

in the urine (e.g calcium oxalate & calcium phosphate) precipitate. In

addition to that, dehydration (such as lack of drinking fluids – water) may

contribute to the formation of calculi since the urine becomes highly

concentrated.

As for the possible risk factors, men are more likely to have calculi

than women (Myers, Neighbors et al, 2006). Due to their lifestyle

preferences, males tend to have this kind of illness. Aside from that,

immobility may contribute to the risk of having calculi (Timby & Smith,

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2005). Just in the case of the patient which is a driver of taxi, he normally

sits for longer periods of time. He lacks of taking breaks & does some

exercise. According to Timby & Smith, this may result to urine stasis. As a

result, calcium components tend to collect, infection may occur, and may

further precipitate the formation of calculi (Lippincott, 2004).

When calculi are already formed, it causes trauma to the urinary

tract & irritate the cellular lining. This compounds to the pain that the

patient feels (e.g flank pain) as violent contractions in the ureter (Myers,

Neighbors et al, 2006). Aside from that, gross or microscopic hematuria

may also be seen to a patient as a result of tearing of tissues while calculi

tend to move downward. Nausea & vomiting may also accompany a

patient with this condition.

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Nursing Management IV

History

According to the patient during the interview, he had no previous

history revealed of hypertension, asthma, or Diabetes Mellitus. He was

also not allergic to any kind of food. His condition was the only time that

when he sought for medical attention. Familial medical history suggests

that none of his parents have the same medical problems as that of the

patient. According to his personal history, he is the sixth among seven

children. He said that he’s a non-smoker but an occasional alcoholic

beverage drinker. He said that during combats, the usual foods that he ate

include daing, sardines, noodles, & other salty foods. He normally drinks

water, but when times that there’s scarcity of water, especially in the

mountains, he would drink buko juice, or worst, no fluids at all.

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Nursing Management V

Nursing Physical Assessment

Mr. H.D.S. was conscious and coherent at the time of assessment.

The patient’s temperature was 37.2 °C, respiratory rate was 20 cpm, pulse

rate of 65 bpm and blood pressure of 110/70 mmHg. The patient abdomen

was flabby, soft, no cyanosis and no edema observed. There is tenderness

at his left flank area. The patient’s skin was warm to touch. Prior to

admission, the patient experienced left flank pain.

Brunner & Suddarth (2010) cited that pain associated with kidney

stones are usually of sudden onset, very severe and colicky (intermittent)

not improved by changes in position, radiating from the back, down the

flank, and into the groin. Ureteral colic is the term that best describes this

instance where that severe, sharp, sudden pain radiates towards the thigh

and genitals. The patient has that desire to void but little urine is passed,

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and often times, blood can be seen due to the abrasive action of the

stone.

There were laboratory tests done to find out some abnormalities on

Mr. H.D.S. Urinalysis showed that the urine was yellow & slightly turbid,

microscopic analysis showed RBC level 5-8/HPF, pus cells of 8-10 & pH

level of 8. CBC was also done to determine abnormalities on the blood. It

showed that the WBC count was increased, at 12.54 x109/L, segmenters

(neutrophil) count increased at 0.72 & lymphocyte count at 0.19. KUB

Ultrasound was the diagnostic tool used to the patient. It showed a 1.7 cm

shadowing high intensity echo seen in the ureteropelvic junction. Its

impression was pelvocaliectasia left, possibly secondary to ureteropelvic

junction calculus/calculi. It also showed that the left kidney is more dilated

than the right with a cortical thickness of 1.5 cm.

According to Brunner & Suddarth (2010), an increased in WBC and

segmenters count in the blood would indicate that there is an infection

happening to the patient. This can be also said when there is a decrease in

lymphocyte count. White blood cells primarily the body from being

infected while the segmenters (neutrophils) are the first line of body’s

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defense against acute infection. The same can be said on the amount of

RBC & in the urinary analysis. Since there is a marked increase of RBC in

the urine, which is normally at around 1-5 per high-power field (hpf), this

indicates that there is bleeding caused by the renal calculi. And since

there is already infection occurring in the system, pus will be seen as a

result of that.

KUB or Kidney, Ureter & Bladder Study, is an X-ray study of the

abdomen. It was performed in order to determine the size, shape, &

position of the kidneys & to reveal urinary system abnormalities (Brunner

& Suddarth, 2010). In this case, the patient’s kidneys were the ones that

was determined since there was marked dilation on the left kidney

compared to that of the right kidney.

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Nursing Management VI

Related Treatment

The patient had different medications taken to relieve symptomatic

& aggravating factors of his illness. One of the medications given to the

patient was omeprazole, an anti-ulcerative drug. It was given to the

patient in order to prevent getting gastric ulcers due to medications

(Lippincott, 2010). That can be also said about the other drug that was

given, which was pantoprazole, another anti-ulcerative drug. Hyoscine

butylbromide (Buscopan) & metoclopramide HCl (Reglan), antiemetic

drugs, were also provided for the patient. These were given in order to

avoid nausea & vomiting (Lippincott, 2010). Several pain reliving drugs

were given to the patient to provide comfort and avoid pain. Paracetamol

& Etoricoxib (Arcoxia), non-steroidal anti-inflammatory drugs, were

provided to relieve acute pain to the patient whereas morphine was given

for severe pain.

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In order to remove the stone that was located on the left ureter,

surgical intervention was performed to the patient. And the procedure

done was ureterolithotomy. Actually, this surgical procedure is only done

to 1 to 2% of patients (Brunner & Suddarth, 2010). Since Extracorporeal

Shockwave Lithotripsy (ESWL) therapy, a non-invasive alternative

treatment, is very expensive, it was the more convenient way to remove

the stones from the patient.

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Nursing Management VII

Nursing Care Plan

The diagnosis for the patient was Deficient knowledge regarding

prevention of recurrence of ureteral stones as manifested by the client

frequently asking questions. The plan for the patient is that after 2 hours

of nursing intervention, the patient will be able to explain & identify

different ways to avoid the recurrence of stone formation (Brunner &

Suddarth, 2010).

The main nursing intervention to the patient is to provide adequate

information, reinforcing as necessary, & document teaching regarding the

following:

The patient must be taught about dietary limitations he must take

such as low uric acid (e.g. meats, legumes) & low oxalates (chocolates,

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caffeinated drinks). This is done so that limiting foods rich in calculus-

forming substances may inhibit recurrence of calculi.

Another aspect of providing information is to practice regular activity

movements such as exercise. Activity decreases urine stasis & risk of

calculi recurrence.

The need for adequate fluid intake is so much important for a

patient with this disorder. As much as 10-12 glasses (>2000 ml/day) of

water is need to help flush calculus fragments & helps prevent stone

fragments from recurring.

As for medical or collaborative intervention, maintaining the urine

pH by taking medications (e.g. potassium citrate) as recommended by the

physician is essential. Depending on their composition, calculus may form

in either acid or alkaline urine. The goal is to maintain the desired levels of

urine pH.

Observe for signs & symptoms of the following: hematuria, pain,

oliguria is also important since the incidence of recurrence of calculi is

high. If this happens, he should go for a follow-up check-up.

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In order to evaluate the patient’s understanding of this plan, the

patient was able to explain & identify different ways to avoid the

recurrence of stone formation.

Nursing Management VIII

Recommendations

There are precautions in which the patient may consider in his diet.

The patient must eat just enough amount of protein. Excess intake of

protein would lead to the accumulation of waste products like urea,

creatinine and uric acid in the blood. Consumption of white meat (chicken,

fish and eggs) is better than the intake of red meat (pork and beef). Avoid

concentrated foods like organ meats and processed foods.

Phosphorus level in the blood increases as kidney function declines,

therefore, it is important to avoid foods high in this nutrient, such as:

excess intake of milk, cheese and other dairy products, legumes like beans

and mongo beans, chocolate and cocoa, & nuts.

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Restricting salty foods and condiments (bagoong, dried fish, salted

egg, chips, soy sauce, fish sauce, vetsin, broth cubes) is also included

since it could precipitate uric acid increase due to purine.

Water therapy is essential during his recovery. One needs to start

drinking a lot of fluids. While any fluids can be consumed, water is

considered to be the ideal solution. If you tend to form stones, you should

try to drink enough liquids throughout the day to produce at least 2 quarts

of urine in every 24-hour period.

There are no restrictions in physical activities, for as long as the

patient practices proper voiding habits.

There are also medications and treatment which includes relief of

pain, hydration and antibiotics that the patient should take.

Home medications include the following: ofloxacin (Floxin), an

antibiotic. It should be given with plenty of fluids. Potassium citrate

(Acalka), an antiurolithic, must also be given which inhibits urine

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crystallization, treatment of patients with renal lithiasis, and

hypocitraturia, chronic formers of calcium oxalate, uric acid lithiasis. The

tablet must not be masticated or diluted. It is recommended that the

patients in treatment with Acalka follow a diet without salt and increase

the intake of fluids. Releaf tablet (sambong supplement) can be included

as it contains powdered leaves of the sambong plant. It helps to dilute

stones in the urinary tract and act as a diuretic. Tramadol is recommended

if the patient feels moderate to moderately severe pain.

There are also warning signs which are stated in the discharge plan

like fever and Hematuria more than 3 days that needs immediate

consultation. A follow-up visit in the hospital after 2 weeks is important to

determine whether the treatment was effective or not.

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Nursing Management IX

References

Books:

1. Myers, Jeffrey W., Neighbors, Marianne, Tannehill-Jones, Ruth (2002);

Principles of Pathophysiology and Emergency Medical Care,

Thomson Learning Inc., Clifton Park, NY

2. Smeltzer, Suzanne, et al (2010); Brunner & Suddarth’s Textbook of

Medical-Surgical Nursing, Wolters Kluwer Health/Lippincott Williams

& Wilkins, Philadelphia, PA

3. Timby, Barbara Kuhn, Smith, Nancy Ellen (2005); Essentials of

Nursing: Care of Adults and Children By; Lippincott, Williams &

Wilkins, Philadelphia, PA.

4. Pathophysiology: A 2-in-1 Reference for Nurses (2004); by Lippincott

Williams & Wilkins Philadelphia, PA.

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ureterolithiasis (2)

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