Hydronephrosis

Presented by : Louie H. Dela Cruz,R.N

Introduction

Hydronephrosis literally "water inside the kidney" refers to distention and dilation of the renal pelvis and calyces, usually caused by obstruction of the free flow of urine from the kidney. This may be a normal variant or it may be due to an underlying illness or medical condition. Untreated, it leads to progressive atrophy of the kidney.

TYPES:

Unilateral- caused by obstruction at the level of the ureter, pelviureteric junction or renal pelvis

Bilateral- caused by obstruction of the level of the bladder or urethra

CAUSES:
Intrinsic: Ureter ( kidney stones, blood clot, stricture or scarring Bladder ( bladder cancer, bladder stones, bladder neck contracture) Urethra ( inability of the bladder to empty, urethral stricture) Extrinsic Cause ( pregnancy, uterine prolapsed, scarring due to radiation therapy, prostate hypertrophy or swelling, prostate cancer Functional cause (Neurologic bladder or the inability of the bladder to function properly, vesicourethral reflux)

I.PATIENTS DATA

Patients Profile: Name: Mr. N.A Address: Daet, Camarines Norte Age: 43 years old Sex: Male Civil Status: Single Birth Date: March 4, 1969 Religion: Mormons Date of Admission: February 24, 2012

 Attending Physician: Dr. J. Ferrer Chief Complaint: Hypogastric pain radiating to back; left, difficulty of urination Pre-operative Diagnosis: Hydronephrosis secondary to Uretero Pelvic Junction Stricture; Left Final Diagnosis: Hydronephrosis secondary to Uretero Pelvic Junction Stricture; Left Contemplated Surgery: Cysto RGP Stenting (Failed 2 times) Operation Performed: Released of Peri-ureteral Adhesions; Intra operative Ureteral Stenting

History of Present Illness :

Last February 2012, Mr. N.A went at Dr. J. Ferrer clinic for consultation following almost 6 months of difficulty urination, pain at hypogastric area radiating at his back. He also complained of having decreased urine output. Upon series of diagnostic exams it was found out in the ultrasounds that he was having increased size kidney. He was then referred to the OLLH where he was scheduled for Cysto RGP stenting. The said procedure was failed twice. After the unsuccessful procedure Dr. J Ferrer decided to refer him to his friend, whom also an Urologist, whom he proposed another surgical procedure which is dismembered Pyeloplasty. On March 3, at exactly 6 am the procedure was started, and it was a successful one.

PAST MEDICAL HISTORY:

According to him last 2009 he was diagnosed with a kidney stone. He was then referred at NKTI by his physician wherein he was confined and undergone a surgical procedure to remove the kidney stone. He also claimed that he is hypertensive for the past few years.

Family History:

Mr. N.A. K has a history of hypertension. His mother was died due to a heart disease and his father was hypertensive and died in the said disease.

REVIEW of SYSTEM

Gastrointestinal Tract: loss of appetite Integumentary: pale and dry skin Cardiovascular: occasional hypertension, fatigue Genito-urinary: Difficulty of Urination, Decreased Urine output

PHYSICAL EXAMINATION:
The client is conscious and alert, relaxed, coherent and appears congruently to the age that he stated. Vital Signs: BP: 140/90 mmHg, PR: 90 bpm, RR: 20 cpm, T: 370C

ANATOMY and PHYSIOLOGY

The Kidney
Located near the vertebral column at the small of the back Left kidney is lying a little higher than the right. Bean-shaped, about 10 cm long and 6.5 cm wide. Each kidney comprises an outer cortex and an inner medulla. -is supplied with oxygenated blood via the renal artery and drained of deoxygenated blood by the renal vein. Functions of the kidney Regulates fluid and electrolyte balance by filtration, secretion and reabsorption. Activates both erythropoietin (for production of red blood cells) and vitamin-D (which regulates calcium metabolism). It also produces renin (in the afferent arteriole) which affects various aspects of water and electrolyte homeostasis. Excretion of Waste Products Autoregulation of blood pressure

Functional anatomy of the kidney

3 major anatomical demarcate functions in the kidney: the cortex the medulla The renal pelvis.

The Nephron
Functional unit of the kidney. Role of Nephron is to make urine by: Filtering blood of small molecules and ions such as water, salt, glucose and other solutes including urea. Large macromolecules like proteins are untouched. Recycling the required quantities of useful solutes which then re-enter the bloodstream. (A process called reabsorption) Allowing surplus or waste molecules/ions to flow from the tubules/ureter as urine.

5 parts of the nephron:

1. The glomerulus 2. The proximal convoluted tubule 3. The loop of Henle 4. The distal convoluted tubule 5. The collecting system

Pathophysiology
CAUSE

Reflux of urine in the kidney

Increased pressure within the structure of the kidney

Stretching and Dilation of the structure of the kidney

Decline in Renal blood flow and GFR

S/Sx Intense pain in the flank area Nausea and Vomiting Dysuria Decreased Urine Output Hypertension

Renal Impairment

Laboratory Results

COMPLETE BLOOD COUNT

Result Hematocrit Hemoglobin Erythrocyte no; WBC Lymphocyte Neutrophil Eosinophil monocyte Platelet count 0.43 141 5.01 6.9 0.38 .57 0.02 0.03 321 Normal level 0.40- 0.50 140-170 g/l 5.5-8.5x106 5-10x103 .20-0.35 .40-.60 .02-0.6 .02-.06 150-450x103 Viral infection Implication

NURSING CARE PLAN

Subjective: kinakabahan ako sa gagawing operasyon sa akin as verbalized

Objective data: Afebrile Anxious Irritable With poor eye contact BP:140/90mmHg

 Assessment: Anxiety (mild) related to perceived threat to self secondary to upcoming surgical procedure. Planning: After the nursing intervention the pt. will describe a reduction in the level of anxiety experienced.

Intervention:
ACTION
V/S taken and recorded

RATIONALE
to have baseline data

Maintained a calm quiet -the pt. feeling of stability increases environment while interacting with in calm and nonthreatening the pt. atmosphere. Used simple language and brief statements when inter acting the PT. about self care measures or about surgical procedures. -when experiencing moderate to severe anxiety PTs may be unable to comprehend anything more than simple and brief instructions.

Intervention:
ACTION Encouraged relaxation technique and diversional activities
Encouraged expression of feelings Encouraged family closeness and unity in praying to god: keep and strengthen the faith to him.

RATIONALE -to relax and prevent PT from being overwhelmed

-enhances trust and therapeutic relationships. -spiritual support can stimulate PTs to regain or strengthen his connection with inner selves, his loved ones. -meeting spiritual needs enhances PTs wellness -praying is one of relieving worries and heavy burdens.

Evaluation:
After the nursing intervention the client anxiety lessened as evidenced by calm and relaxed appearance, smiling while telling stories.

NURSING CARE PLAN

Subjective: Ang sakit ng inoperahan sa akin as verbalized. Objective: Afebrile With pain; P/s 6/10 With slight facial grimace upon movement With slight irritability; noted

NURSING CARE PLAN

Assessment: Acute pain related to presence of surgical incision. Planning: After the nursing intervention the PT will report control or relieve of pain.

Intervention:
ACTION
V/S taken and recorded

RATIONALE
to have baseline data

Obtained client assessment of pain -assessment of the pain experience its severity, location, precipitating is the first step in planning pain or relieving factor management strategies. Other methods such as descriptive scales can be used to identify extent of pain Encouraged non-pharmacological relief of pain such as. Guided imagery Distraction activities -the use of a mental picture or an imagined event involves use of the five senses to distract oneself from painful stimuli.

Intervention:
ACTION
Relaxation exercises, breathing exercises

RATIONALE
-techniques are used to bring about a state of physical and mental awareness and tranquility. The goal of these is to reduce tension, subsequently reducing pain.

Provided comfort measures such -To provide non-pharmacological as repositioning pain management Provided rest periods to -pain may be come exaggerated as facilitate comfort, rest and sleep the result of fatigue

Intervention:
ACTION
Administered medication as prescribed (Nalbuphine Hcl 5mg I.M)

RATIONALE
-opiod agonist-antagonist analgesic -acts as an agonist at specific opiod receptors in the CNS to produce analgesia

Evaluation: Patient verbalized reduction of s evidenced by P/s of 2/10

NURSING CARE PLAN

Subjective: Mainit ang pakiramdam ko ngayon as verbalized Objective: Febrile, temp:38.9 C Warm to touch Flushed skin BP:140/90mmHg

 Assessment: hyperthermia related to tissue trauma secondary to post surgical procedure Planning: to decrease /maintain core temperature within normal range

Intervention:
ACTION
V/S taken and recorded

RATIONALE
to have baseline data

Assessment: hyperthermia related to tissue trauma secondary to post surgical procedure Planning: to decrease /maintain core temperature within normal range

Intervention:
RATIONALE
to have baseline data

ACTION
V/S taken and recorded