Republic of the Philippines

Tarlac State University

COLLEGE OF NURSING
Lucinda Campus
Brgy. Ungot, Tarlac City Philippines 2300

Nephrolithiasis
Presented by:
Agcaoili, Claire P.
Baluyut, Donna C.
Bautista, Karen L.
Brojan, May Daisyree C.
Bugayong, Emmanuel Dominic Raymond M.
Caampued, John Matley M.
Calendas, Arcelene Joy E.
Capiendo, Mc Jim Emmanuel I.
Cas Alyssa Daphne L.
Catap, Stephanie Jill L.
BSN 3A-A1

Presented to:
Jonathan Cura, R.N.,C.R.N.
Instructor

August 13, 2010

 TABLE OF CONTENTS

I. Introduction …………………………………………………………….. 3
Objectives ………………………………………………………………. 5
II. Nursing Process ………………………………………………………… 7
A. Assessment ………………………………………………………….. 7
1. Personal Data ……………………………………………………. 7
a. Demographic Data …………………………………………… 7
b. Environmental Status ………………………………………... 7
c. Lifestyle ……………………………………………………….. 8
2. Family History of Health and Illness ………………………….. 9
3. History of Past Illness ………………………………………….. 10
4. History of Present Illness ………………………………………. 10
5. 13 Areas of Assessment ……………………….……………….. 11
6. Diagnostic and Laboratory Procedures ……………………….. 29
7. Anatomy and Physiology ……………………………………….. 33
8. Pathophysiology ………………………………………………….. 37
a. Book Based ……………………………………………………. 37
b. Client Based …………………………………………………... 38
B. Planning ……………………………………………………………... 39
Nursing Care Plans ……………………………………………... 39
C. Implementation 45
IV Fluids............................................................................................ 45
Drug Studies……………………………………………………….
Diet....................................................................................................
SOAPIE............................................................................................
III. Conclusion ……………………………………………………………… 49
IV. Recommendations ……………………………………………………….. 51

INTRODUCTION
Nephrolithiasis refers to the condition of having kidney stones. The stones are
solid concretions or calculi (crystal aggregation) form in the kidneys from dissolved
urinary minerals. The stones are solid and are common in premature infants.
(www.wikipedia.com)
About 5% of women and 10% of men will have at least one episode by age 70.
Kidney stones affect about 2 out of every 1000 people. Recurrence is common, and the
risk of the recurrence is greater if 2 or more episodes of kidney stones occur.
(www.wikipedia.com)
Some type of stones tends to run in the families. Some types may be associated
with other conditions such as bowel disease, iliac bypass for obesity, or renal tubule
defects. A personal or family history of stones is associated with increase of stone
formation. (www.wikipedia.com)
For the Filipinos who are fond of eating salty foods and fatty foods, also cigarette
smoker and alcohol drinker were at risk for having this condition.
In the United States, 23, 685 of its population have the incidence of
Nephrolithiasis. (http://kidney.niddk.nih.gov/kudisease/pubs/kustats/) Nephritis, nephritic
syndrome, kidney stone and nephrosis has the number of 11,056 or 3.6% over 100,000
populations in the Philippines. (http://www.doh.gov.ph/kp/statistics/lading motality as of
2008).
a. Importance of the case study

This study is significant to the nursing education of broadening the knowledge of

the students’ skills, knowledge and attitude of the nursing practice. It supplies extensive
analysis about the condition selected through research and actual observation as it serves
as and guidance in developing learned skills in the assessment and management of
Nephrolithiasis.

Through this study, the researcher will be able to familiarize the different medical
approaches toward ongoing curative phase and the holistic approach in assessing
patient’s health will be delivered for proper intervention to be given.
For the researcher to have a baseline information about nephrolithiasis,
management and clinical interventions.
b. Reasons of choosing the case study:

The researcher choose this study to learn the detailed process of the disease
nephrolithiasis associated with it’s prevention and treatment and somehow, help the client
and his family to promote and restore support and wellness by providing proper nursing
intervention. And for the researcher to have further understanding on the disease.
 c. Objectives:

c.1 General objective:

To have a better understanding of the course of the disease, its causes, signs and
symptoms, diagnoses & treatment.

c.2 Specific Objectives

Nurse-Centered

1. Assess properly to determine the contributing factors regarding to the client’s

disease and identify any present abnormalities.

a. Personal Data

b. Family history of health & illness

c. History of past illness

d. History of present illness

e. 13 areas of assessment

2. Gather the needed data that can help to understand how and why the disease
occurs.

a. Diagnostic & Laboratory procedures

b. Pathophysiology (book-based and client-based)

3. Develop an individualized plan considering client characteristics or the situation

and setting specific, measurable, attainable, realistic and time-bound plan that reflects
the onset, date of problem identified.

a. Planning (NCP)
 4. Judge the effectiveness of chosen interventions, nursing care and the quality of
care provider.

a. Client daily program in the hospital

5. Learn the actual cause or formation of the disease process.

6. Identify major risk on developing Nephrolithiasis

Client-Centered
1. Discuss the indications and management of the client with Nephrolithiasis

2. Discuss the implications for medications commonly prescribed for clients with
Nephrolithiasis.

3. Describe nursing care for the client with Nephrolithiasis

4. Use the nursing process to provide holistic care for a client with Nephrolithiasis.

5. To comply with the health teachings provided during the hospital confinement.

II. NURSING PROCESS

A. ASSESSMENT

1. Personal Data

1.a) Demographic data

NAME: Mr. V

AGE: 66 y/o
 SEX: Male

CIVIL STATUS: Married

RELIGION: Roman Catholic

POSITION IN THE FAMILY: Father

ADDRESS: Moncada, Tarlca City

DATE OF BIRTH: March 20, 1944

NATIONALITY: Filipino

USUAL SOURCE OF MEDICAL CARE: Phil Health

ADMITTING DIAGNOSIS: Nephrolithiasis

CHIEF COMPLAINT: Flank pain

DATE & TIME OF ADMISSION: July 27, 2010 / 08:04:14 PM

ADMISSION #: 152879

1.b) Environmental Status

Mr. V lives in unfinished house with an existing one bedroom. The

back part of their house is a farm planted with corns and rice grains wherein
they would also have the capacity to plant any trees or any other vegetation
that they can use for other source of food. The drainage is located at 40 m.
distant from their house. Their house is in close proximity to the RHU. Water
pump outside their house which is owned by them is usually their source of
water.

1.c) Lifestyle
 The patient’s main habits at home are doing household chores such
as cleaning the surroundings, washing dishes and clothes. When he’s not yet
married, he often drinks alcoholic beverages such as beer, redhorse and gin.
He stated that 4x a week, he and his friends were having alcohol drinking
session. He consumes approximately 5 bottles of gin or 10 bottles of beer and
red horse every time they will have session. They often starts at 7pm and
ended at 11 pm and goes home to sleep when he’s already drunk and wakes
up in the morning at 4 to do some household chores. He is also a cigarette
smoker, usually consumes two packs per day which is equivalent to forty
sticks. But, when he got married he gradually lessen his take of alcohol and
cigarette, from five bottles to two bottles of gin, from ten bottles to four
bottles of beer and redhorse, from two packs to one pack of cigarette per day
until the day that he is not drinking alcohol and smoking cigarette anymore.
He also loves salty and fatty food( example: sinigang na baboy na maraming
taba or piritong baboy chicharon). He cannot eat foods without having
“sawsawan” such as bagoong, alamang and patis. His main form of exercise
is walking, doing household chores and planting; he is also fond of listening to
radio when he is at rest.
 2. Family History of Health and Illness

Paternal Maternal

N/A N/A N/A N/A

N/A N/A

66 64 62 59 57 56 55 53
Nephro A&W A&W A&W A&W A&W A&W A&W A&W

Schematic Diagram Legends:

 -Deceased Male

-Living Male

-Deceased Female

-Living Female

N/A- Not Applicable

Nephro- Nephrolithiasis
-pertains to patient
3. History of past illness

The client experienced having chicken pox and sore eyes during his childhood
years and verbalized that he was unable to complete his immunization. The client
doesn’t have allergies to drugs, animals, insects, or any other environmental agents.
He claims that whenever he gets sick he used OTC drugs such as paracetamol
(biogesic and neozep).

4. History of present illness

Mr. V felt the pain at first time on March 2010. He stated that he was just planting
rice at that time and felt the pain on the lower quadrant on the abdomen radiating to
back with a pain scale of four over ten. He just took a rest and the pain is relieved
according to him. The pain occurs two times a week. The pain continued until April
and he had ultrasound showing that there is a left renal cyst and medications were
given.

On June, the pain got worst but he can still tolerate and relieved by rest. He can
do planting anymore due to pain but he can still do light activity such as washing
dishes, and sweeping the floor.

One week prior to admission, he can no longer tolerate the pain. He had just lied
on bed and tried to overcome the pain.

Few hours prior to admission, the patient was unable to walk and straighten up his
body due to pain and already needs assistance.
5. 13 Areas of Assessment

1. Social Status

Mr. V 66 years old married and is the eldest among eight siblings of the family,
currently he is residing in Moncada, Tarlac. He works as a farmer at the back of their
house. The patient verbalized that he and his family usually communicate with one
another during mealtime. Every misunderstanding throughout the family is being settled
immediately. Mr. V claimed that after his work he use to have bonding moments with his
friends. Often times they tend to drink alcoholic beverages and consumed up to two
bottles each. During the interview the patient always thinks about his health condition
and when will be the operation. You can see on his face the worry he feels. Although, he
is ill and experiencing pain, he still doing his best to cooperate during the interview. He
used to talk to the other patients inside the ward.

NORMS:
Family members perform roles. Good communication within the family must be
maintained to obtain a healthy relationship with one another. Social support is a
perception tat one has emotional and tangible resources to call on when needed,
perceived social support is being followed by the family to express the love of the family.
Financial aspect is one of the normal constraints in the family. (Nursing Fundamentals by
Rick Daniel; Community Health Nursing in the Philippines)
Analysis/interpretation:
Mr. V has a good and harmonious relationship with the people around him.

2. Mental Status

General appearance and Behavior

The patient was well-groomed. He entertained every questions asked and
answered willingly. He listened attentively and was cooperative. Patient manifested facial
expression and affect in response to various topics of the conversation.

Level of consciousness
The patient is responsive during the interaction yet as time goes by he is
becoming less attentive and loss his focus on the interview. He was unable to maintain
eye contact during the interview.

Orientation
The patient was oriented regarding his condition and his stay in the hospital. He
was able to state the right time, right place and date of the interview.

Speech
The patient can speak Filipino and Ilocano. He conversed mostly in Tagalog and
was able to express himself well. His speech was understandable and no speech defect
was noted.

Intellectual Functioning
Mr. V was able to understand the questioned ask to him. The researchers did not
have a hard time explaining anything to him. His memory is good because he did not
have difficulty in recalling past events in his life including his check up. He was able to
recall his activities since this morning.
NORMS:
Mental status is the degree of comprehensive shown by a person in intellectual,
emotional, psychological, and personality functioning.(Mosby’s Pocket Dictionary of
Medicine, Nursing, and Health Professions).

Analysis/interpretation:
The patient responded accordingly to the situation and can be considered as
mentally healthy.

3. Emotional Status

During the interview Mr. V is uncomfortable at times when he was experiencing

pain and not able to concentrate. His wife is with home to address his needs and to
provide support. He expresses his opinions and emotions as the researchers go along the
conversation.

NORMS:

It is normal for an individual to react on the stimuli she perceives and feels.
(Health Assessment and Physical Examination, Estes 2006)

Analysis/Interpretation:

The patient’s mood was influenced by the present condition and the environment.

4. Sensory Perception

In the assessment of sensory perception, examination of vision, hearing, smell,

taste and touch were included.
Vision

In the examination of the eyes, extra ocular muscle movements of both eyes were
examined first. To test this, the Six Fields of Gaze was used as the assessment method.
Standing two feet in front of the patient, a pen was used for the patient to follow from
superior, inferior, left, and right oblique angles. Both eyes of the patient symmetrically
followed the pen is moved to the different locations. For the test of papillary constriction
a penlight was used, light was introduced from the front to the lateral side of one and then
repeated the same procedure to the eye. Both pupils constricted as light was directed to
them. The patient was unable to read newspapers showed to him.

NORMS:
For the test of the Cardinal Fields of Gaze, the extra ocular muscle movements are
being assessed. Normally, both eyes of the patients should move smoothly and
symmetrically in each of the six fields of gaze. Pupils should constrict briskly to direct
and consensual light and to accommodation, reading is possible at a distance of 14inches
for the assessment of near vision. (Health Assessment and Physical Examination, Estes
2006)

Analysis/Interpretation

The patient’s, extra ocular muscle movements and papillary response are still
within normal but the client has a blurred vision.

Hearing

For the auditory assessment, the voice-whisper test was used. Standing two feet
between the patients other ear, words and phrases were whispered and allowed the patient
to repeat the words and phrases that were whispered. The procedure was then repeated to
other ear. The patient was not able to repeat the words being used.
NORMS:

For the auditory accuracy, the patient should be able to repeat words whispered
from a distanced of two feet. (Health Assessment and Physical Examination, Estes 2006).

Analysis/Interpretation:

The patient’s auditory accuracy

Smell

In assessing the sense of smell of the patient, she was instructed to close her eyes
and let her smell things like orange fruit and alcohol which is present on their table. She
was then instructed to recognize and name the different materials. The client was able to
recognize the scent of the things being asked him to smell.

NORMS:

Olfactory receptor cell are located in the upper parts if the nasal cavity, the
superior nasal conchae, and on parts of the nasal septum and are covered by hair like cilia
that project into the cavity. The chemical component of odors binds with the receptors,
causing nerve impulses to be transmitted to the olfactory cortex located in the base of the
fontal lobe. (Health Assessment and Physical Examination, Estes 2006).

Analysis/Interpretation:

It denotes that the patient’s olfactory function transmits impulses to the frontal
lobe properly.
Taste

For the assessment of the sense of taste, the patient was again instructed to close
his eyes and let her taste things like sugar and coffee which are present on their table then
enabling him to name them. The patient named all things that he tasted.

NORMS:

Four qualities of taste are found in the taste buds distributed over the surface of
the tongue: bitter is located at the base, sour along the sides, and salty and sweet near the
tip. (Health Assessment and Physical Examination, Estes 2006).

Analysis/Interpretation:

Her taste buds that help transmit taste sensations are functioning well.

Tactile

In the examination of the touch sensation of the patient was again instructed to
close his eyes and let him feel things like spoon soaked from hot water and pinched his
on the forearm to assess pain sensation. The patient responded to the different sensation
and expressed what he felt. He verbalized that the spoon soaked from the hot water was
hot and the pinch was painful.

NORMS:

The skin contains receptors for pain, touch, pressure and temperature. These
receptors originate in the dermis and terminate as either that are encapsulated and found
predominantly in the fingertips and lips. Sensory signals that help determine precise
locations on the skin are transmitted along rapid sensory pathways, and less distinct
signals such as pressure or poorly localized touch are sent via slower sensory pathways.
(Health Assessment and Physical Examination, Estes 2006).

Analysis/Interpretation:

The patient’s sensory transmission functions well.

5. Motor Stability

The patient is able to ambulate from her bed. He was slouched and weak in
appearance. The lower limb was not able to bear full body weight during standing and
ambulation. The head and neck turn toward the included direction, followed by the rest of
the body. He was not able to transfer easily from various positions.

Assessment for the Range of Motion of the patient was done through instructions
assistance which includes the ability of the patient to bend her shoulder farther apart. He
can also move her shoulder medially (toward the midline of the body), and laterally
(away the midline of the body) as well as rotating her shoulder medially and laterally. He
can bend her elbows closer and farther apart or rotate it laterally to face upward and
medially to face downward. Extension and flexion of his wrist can be done, and
extending it beyond the neutral position.

The patient can also flex and extend her knees and do dorsiflexion (flexing the
foot at the ankle so that the toes moves toward the chest) or plantar flexion (moving the
foot at the ankle so that the toes move away from the chest) of her ankles and feet, or
titling her foot inward and outward and moving it toward away the midline of the body.
The patient shows active movement against gravity.
Norms:

Range of Motion standards are follows:

Walking is limited in one smooth, rhythmic fashion as the heel strikes the floor
body weight is then shifted to the bail of the foot, and then elevates off the floor before
the nest step forward.

The normal ROM for the shoulder is forward flexion, abduction, adduction,
internal and external rotation. The normal ROM for the elbows is extensions, supination,
pronation, and flexion. The normal ROM of the wrist is extension, hyperextension, and
flexion

The normal ROM for the knees is flexion, extension in some cases,
hyperextension is possible.

The normal ROM for the ankles and feet is dorsiflexion, plantar flexion,
inversion, abduction, and adduction. (Health Assessment and Physical Examination,
Estes 2006).

Scale

0 No muscular contraction

1 Barely flicker of contraction

2 Active movement with gravity removed

3 Active movement against gravity

4 Active movement against gravity and

some resistance

5 Active movement against full resistance

with no fatigue

Scale for Muscle Strength

Analysis/Interpretation:

Mr. V was able to ambulate. Both lower limbs were able to bear full body weight.
Normal muscle strength allows for complete voluntary range of joint motion against both
gravity and moderate to full resistance. Muscle strength is equal bilaterally. There are no
observed involuntary muscle movements.

6. Body Temperature

Table 1.1 Body Temperature

Date Temperature
July 28, 2010: 11-3 shift 36. 8 degree celcius
July 29, 2010: 11-7 shift 36.9 degree Celcius
7-3shift 36. 6 degree celcius
July 30, 2010: 6:00am 36.0 degree Celcius
8:00am 36.5 degree Celcius
10:00am 36.5 degree Celcius
2:00pm 36.2 degree celcius

Norms:
The temperature per axilla is 35.0 degress to 36.8 degress Celcius. (Health
Assessment by Leasia Monahan, 2002)

Analysis/Interpretation:
Mr. V’s body temperature taken per axilla is within normal limits. There is
uniformity in temperature of her body upon palpation.

7. Respiratory Status
The following listed below were the recorded respiratory rates as per assessment:

Table 1.2 Respiratory Rate

Date Respiratory Rate

July 28, 2010: 11-3 shift 23cpm
 July 29, 2010: 11-7 shift 21cpm
7-3shift 25cpm
July 30, 2010 6:00am 20cpm
8:00am 25cpm
10:00am 23cpm
2:00pm 23cpm

Norms:
Based on the Health Assessment and Physical Examination Third Edition (Mary
Ellen Zator Estes, 2006), the normal respiratory rate for adult is 12- 20 breaths per
minute, normal respiration are regular and even in rhythm, depth of inspiration is not
exaggerated and effortless with the thorax rises and falls in unison in the respiratory
cycle.

Analysis/Interpretation:
It shows that there is slight elevation on the respiration, since. He has irregular
rhythm.

8. Circulatory Status
Upon assessment of the blanch test results in prompt returning of pinkish color of
the nail beds for two seconds. The patient’s skin turgor after pinching turns to its normal
position.
The force of the arterial pulse can be classified as in three point scale:
3+--------------fall, bounding
2+--------------normal
1+--------------weak, thready
0----------------absent

Table 1.3 Pulse Rate and Blood Pressure

Date Pulse rate Blood Pressure

July 28, 2010: 11-3 shift 71 bpm 100/70 mmHg
July 29, 2010: 11-7 shift 68bpm 100/80 mmHg
7-3shift 87 bpm 120/80 mmHg
July 30, 2010: 6:00am 81 bpm 120/80 mmHg
 8:00am 101 bpm 120/80 mmHg
10:00am 90 120/80 mmHg
2:00pm 90 120/70 mmHg

Laboratory reports dated July 27, 2010 reported RBC as 4.16 T/L and Hgb 122
g/L.

Norms:
The normal pulse rate ranges from 60-100 beats per minute and the rhythm is
normal due to it is regular with equal bilateral strength upon bounding. The normal blood
pressure is within the 120 to 140 systolic pressure and 80-90 diastolic pressure. (Health
Assessment and Physical Examination Third Edition, Mary Ellen Zator Estes, 2006). The
normal value of hemoglobin is 120 to 180g/L* and the RBC has the standard value from
4.20 to 6.30 T/L*. *Normal Values of the laboratory results are based on the normal values used in
TPH.

Analysis/Interpretation:
The pulse from the scale given above, it falls under to the 2+ which is normal.
There is an occurrence of increases in the blood pressure of the patient. The laboratory
findings of hemoglobin and RBC are below normal range.

9. Nutritional Status
According to Mr. V, he eats three times a day. He usually eats vegetables, fish
and fatty foods such as chicharon. The patient verbalized that he cannot eat foods without
soy sauce and fish sauce
.In terms of fluid intake, the client stated that he consumes at an average of 4-6
glasses of water per day, distributed at around 3 glasses in the morning, 4 at noon and 3
glasses at evening before and during hospitalization.

Her Body Mass Index is computed as follows:

 BMI=weight in kg
Height (m) ²
BMI = 48 kg
(1.68) ²
= 17.02
Norms:
Normal eating pattern is at on the minimum of 3 times per day, depending upon
metabolic need and demands. Fluid intake is on the average of 8 to 10 glasses per day.
Normal BMI range:
<18.5……………………………...underweight
18.5 – 24.9………………………..healthy
25.0 – 29.9………………………..overweight
30≥………………………………..obesity
(Physical Assessment and Health Examination IV Edition by: Carolyn Javis)

Analysis/Interpretation:
There are no remarkable deviations in the client’s eating pattern, frequency, and
attitude. Her BMI is within normal limit as compared to the normal value which is 18.5 to
24.9 thus making her healthy.

10. Elimination Pattern

Bowel Habits: Mr. V was not able to defecate for three days (from July 27- July
30, 2010).
Bladder Habits: He voids 3-4 times a day with dark yellow urine in small amount
(500cc for 24 hrs) and with pain during urination.

Norms:
 Normal bowel movement is 1 to 3 times a day and voiding at 1200 to 1500ml/day.
(Health Assessment and Physical Examination Third Edition, Mary Ellen Zator Estes,
2006).

Analysis/Interpretation:
Mr. V has abnormal bowel elimination for three consecutive days. His urine
output is not within normal range. There is presence of difficulty in urination.

11. Reproductive Status

Mr. V claims that his first coitus happened when he was 27 years old. He also
claims that he does not use condoms or other contraceptives with her wife. He has 9
children.

Norms:
Based on Sigmund Freud’s psychosexual development the genital stage is where
sexual desires reemerge due to physiological changes, fluctuating hormone levels, and
changing social relationship (Pediatric Nursing; Thomson Edition 2003).

Analysis/Interpretation:
The patient’s early engagement to sexual activities is normal, since his
reproductive organs are not yet fully develop.

12. State or Physical Rest and Sleep

The patient had stated that during his hospitalization, he experienced sleep
difficulties. His hours of sleep only range three to four hours a day. He claimed that his
sleep difficulties were primarily due to the pain on the abdomen and the different
interactions to check his medical conditions.

Norms:
 Based from Daniels (2004) Fundamentals of Nursing, 8- 10 hours of sleep is
needed to have an adequate rest and an environment that is conducive to health is
necessary to provide comfort to an individual.

Analysis/Interpretation:

The client has an abnormal state of sleep and rest. Pain was the primary factor of
sleep deprivation during these days.

13. State of Skin Appendages

Upon inspection, the client’s skin is light brown and there is a presence of palmar
pallor. Texture is described as cold clammy and a presence of mild sweating, grade 3
pitting edema was found in both hands and feet and skin turgor returns promptly after
pinching. Sclerae are anicteric. Nails are intact with no swelling on eponychium and are
pale in color. In abdominal area, skin is uniform similar as in the body, and his abdomen
show signs of tenderness.

Norms:
The normal generalized color for dark-skinned individuals is light to dark brown
to olive with milder colored palms, soles, nail beds and lips. Texture is described as
smooth, soft, warm, and dry to touch. Pinched skin to test for skin turgor should return
immediately after. There should also be no swelling, pitting or edema present when
pressed firmly for 5 to 10 seconds over tibia or ankle.
Nails are present per distal phalanx, are in pink color, round and with a 160
degree nail base. It is also hard, immobile and firm in texture. Evidence of Pallor is seen
in patients who had abortion due to blood loss. (Health Assessment and Physical
Examination Third Edition, Mary Ellen Zator Estes, 2006).

Analysis/Interpretation:
Palmar pallor is present due to ineffectrive peripheral tissue perfussion and a
grade 3 pitting edema was noted in both hands and feet.
6. Diagnostic and Laboratory Procedures
Diagnostic/laboratory Date ordered and date Indication/s or Results Normal values Analysis and
procedures result/s Purpose/s ( units used in interpretation of results
the hospital)
Hematology Results 07-27-10 Indicates the total All results are within the
number of blood normal range.
cells as well as the
hemoglobin,
hematocrit and
RBC indices.

1. White Blood cells

a.Lymphocytes 8.6 G/L 4.1-10.9 G/L
b. Monocytes 13.2% 10.0-58.5% L
c. Eosinophils 4.16 T/L 4.20-6.30 T/L

2. Red blood cells

a. Hematocrit 0.371 L/L 0.370-0.510
L/L
b. Hemoglobin 122 G/L 120-180 G/L

3. Platelets 393 G/L 140-440 G/L

 Diagnostic/laboratory Date Indication/s or Purpose/s Results Analysis and
procedures ordered and interpretation of results
date result/s
Ultrasound 04-10-10 To visualize of the upper There is a cyst in the lateral cortex Left renal cyst with
abdominal area for any measuring 1.6 cm with two reflective structures
stones or calculi formed in reflective structures within both with no shadowing.
the kidney. measuring 0.3 cm without shadows.
7. Anatomy and physiology

The kidney participates in whole-body homeostasis, regulating acid-base

balance, electrolyteconcentrations, extracellular fluid volume, and regulation
of blood pressure. The kidney accomplishes these homeostatic functions both
independently and in concert with other organs, particularly those of
the endocrine system. Various endocrine hormones coordinate these endocrine
functions; these include renin, angiotensin II, aldosterone, antidiuretic hormone,
andatrial natriuretic peptide, among others.

Many of the kidney's functions are accomplished by relatively simple

mechanisms of filtration, reabsorption, and secretion, which take place in
the nephron. Filtration, which takes place at the renal corpuscle, is the process by
which cells and large proteins are filtered from the blood to make an ultrafiltrate
that will eventually become urine. The kidney generates 180 liters of filtrate a
day, while reabsorbing a large percentage, allowing for only the generation of
approximately 2 liters of urine. Reabsorption is the transport of molecules from
this ultrafiltrate and into the blood. Secretion is the reverse process, in which
molecules are transported in the opposite direction, from the blood into the urine.
8. Pathophysiology

Book Based
Client Based
B. Planning
Assessment
S>”Masakit kapag umuihi ako”
O>Rated pain as 6/10, with 10
being the highest
>Weak in appearance
>With muscle guarding
behavior on RLQ upon
movement that last for 5 secs.
>Complains of pain upon
palpation on RLQ of abdomen
>Facial grimace
>Prefers to position self in
side lying
>Irritability and restlessness
Diagnosis:
Acute pain r/t presence of
obstruction of cyst within the
Left kidney
Scientific Explanation:
A cyst obstruct the Unpleasant
sensory and emotional
experience feeling caused by
renal cyst that is obstructed
within the urinary system
resulting to sudden and severe
abdominal or flank pain.
Planning
Within 2-4 hrs. of appropriate
nursing intervention the patient
will be able to verbalize relief
of pain from a scale of 6/10 to
4/10.
Interventions Expected Outcome
> Apply hot compress at the After 2-4 hours of proper
flank area. nursing intervention the
R: to reduce pain and provide patient’s pain scale will
comfort. decrease from p/s of 6/10 to
4/10.
> Assist patient in a
comfortable position regularly.
R: to promote feeling of
comfort.
> Encourage deep breathing
exercise.
R: to reduce muscle tension.
> Provide diversional activities
such as talking to relatives.
R: to divert attention from pain.
> Encourage or assist with
frequent ambulation as
indicated.
R: to facilitate passage of stone
to renal system.
> Provide therapeutic touch
such as gentle rubbing of back.
R: to promote comfort.

Assessment
S>”hindi ako gaanong umiihi,
mga 2-3 beses lang kada araw”
O>150cc urine collected for 8
hours
>with a yellow to brownish
colored urine
> no crystals or blood
observed
> goes to comfort room twice
per shift
Diagnosis:
Impaired urinary elimination
related to decreased renal
perfusion secondary to
Planning
Within 6 hours of appropriate
nursing intervention the patient
will be able to have a urine
output of 30-50 cc per hour or
void in normal amounts and
usual pattern.
> Administer medication as
prescribed by the physician.
R: to maintain acceptable level
of pain.
Interventions Expected Outcome
> Monitor intake and output After 6 hours of appropriate
and characteristic of urine nursing intervention the patient
R: provide information about will be able to have a normal
the kidney function and urine output and void in a
presence of complication. normal amounts as evidenced
by 30-50cc level per hour.
> Encourage increase fluid
intake.
R: to increase hydration to
flushed bacteria.
> Investigate reports of bladder
fullness or palpate suprapubic
distension.
R: the urinary retention may
develop causing tissue
nephrolithiasis
Scientific Explanation:
Obstruction of the urinary
stones(calculi) in the urinary
tract causes urinary retention.
Over distension of the bladder
causes poor contractivity of the
detrusor muscle, further
imparting urination. And
urinary retention causes
overflow voiding or
incontinence.
Assessment
S>”Paano ba nagkakaroon ng
bato”
O>Asking questions about his
health problem
>Requested for a list of
contraindicated foods
>Unfamiliar with the things
that contributes to his health
problem like eating salty foods
Diagnosis:
Knowledge deficit r/t lack of
information regarding current
health condition.
Scientific Explanation:
Planning
Within 2 hrs. of proper nursing
intervention, the patient will be
able to verbalize understanding
of his disease process and
potential complications.
distension and potentiates risk
of infection.
> Document any stone expelled
and send laboratory for
analysis.
R: retrieval of calculi allows
identification of type of stones
and influences choice of
therapy.
Interventions Expected Outcome
>review disease process and After 2 hrs. of proper using
future expectations intervention, the patient is able
R: provides knowledge base to verbalized understanding of
from on which patient can his disease process and
make and formed choices potential complication
>encourage patient to notice
dry mouth and excessive
diaphoresis and to increase
fluid intake whether or not
feeling thirsty
R: increased fluid
losses/dehydration require
additional intake beyond usual
daily needs
>encourage patient to eat
* low purine diet (example:
Lack of cognitive information
or psychomotor skills required
for health promotion, recovery
and maintenance.
lean meat, legumes)
R: decreases oral intake of uric
acid precursors that leads to
formation of uric acid calculi.
*low calcium diet (limited
milk, cheese, green leafy
vegetables)
R: reduces calcium oxalate
stone formation
*low oxalate diet (restrict
chocolate, caffeine)
R: reduce calcium oxalate
stone formation
>discuss medication regimen
R: drugs will be given to
acidify or alkalize urine
 Assessment Planning Interventions Expected Outcome
S>tatlong araw na akong di Within 2-4 hrs of proper >Monitor intake and output After 2-4 hrs. of proper nursing
nakakapagbawas” nursing intervention, the >Auscultate for bowel sounds intervention, the patient will
O>weak in appearance patient will demonstrate >Instruct client to increase demonstrate behaviors to
>restless behaviors to relieved fluid intake from 4-6 glasses 6- relieved constipation as
>irritable constipation 8 glasses per day evidenced by feeling of
>abdominal tenderness >instruct client to eat foods that relieved and urge to defecate
>discomfort are high in fiber such as
oranges, pineapple
>Encourage client to increase
mobility or exercise such as
Diagnosis: walking
Constipation r/t insufficient >Administer laxative
physical activity medications (Dulcolax)

Scientific Explanation:
Decrease in normal frequency
of defecation accompanied by
difficult or incomplete passage
of stool and passage of
excessively hard, dry stool.
 Assessment
S > “parang puputok na ang
pantog ko.”
O> bladder distension
> small frequent voiding
> urine output of 150cc
within 8 hrs
Diagnosis:
Chronic urinary retention
related to pain felt during
urination secondary to
obstruction of the urinary tract.
Scientific Explanation:
Urine retention occurs because
the cl;ient experiences pain
during urination, he is unable
to excrete all the urine in his
bladder.
Planning
Within 4-8 hrs of proper
nursing interventions the
patient will be able to void in
sufficient amounts with no
palpable bladder distention
Interventions Expected Outcome
>evaluate hydration status After 4-8 hrs, of proper nursing
>pour warm water over interventions, the patient will
perineum to stimulate reflex be able to void in sufficient
arc amounts (260 cc in 8 hrs.) with
>encouraged client to report no palpable bladder status
problems immediately
>measure amount of voided
residual
>determine frequency of
voiding
>encourage patient to use
valsalva maneuver if
appropriate
 Assessment
S > “Hinang-hina ako”
O> grade 3 pitting edema on of
hands and feet
> intake of six glasses of
water a day
> 500cc urine output in 24
hours.
> increase respiratory rate
25cpm.
Diagnosis:
Fluid volume excess r/t to
compromise renal function.
Scientific Explanation:
Due to impairment of the renal
function fluid retention occur
that lead to excessive fluid in
the body.
Planning
Within the 8 hours shift of
proper nursing intervention the
patient will stabilize fluid
volume as evidence by balance
intake/ output.
Interventions Expected Outcome
>Note intake and output. After 8 hours shift of proper
R: to have a baseline data of nursing intervention the patient
fluid intake and output. will stabilize fluid volume as
evidence by balance intake/
> Review intake of sodium and output.
protein.
R: to know if foods taken
aggravate the condition.
> Note pattern and amount of
urination.
R: to have a measurement of
fluid output.
> Observe skin and mucus
membrane.
R: to assess for decubitus or
ulceration.
> Restrict sodium fluid intake
as indicated.
R: to avoid further fluid
retention.
>Assist patient when changing
position.
R: to reduce pressure tissue
pressure.
C. IMPLEMENTATION
1. Medical Management
i. IVF
Medical Management/Treatment
PLRS
Date ordered General Description Indication/s or Purpose/s Client’s reaction to
treatment
July 27, 2010 Isotonic fluid. These For replacement of acute Client shows no adverse
solutions provide extracellular fluid loses reactions
sources of water and without disturbing normal
electrolytes. Their electrolyte relationships
electrolyte content
resembles that of the
principle ionic
constituents of
normal plasma.

PNSS July 29, 2010 Isotonic fluid is used Replacement & Client shows no adverse
frequently in maintenance of fluid and reactions
intravenous drips for electrolytes.
patients who can’t
take fluids orally
and have developed
or are in danger of
developing
dehydration or
hypovolemic.
D5W July 30, 2010 Hypotonic fluid that Used to supply water and Client shows no adverse
provides free water calories to the body. reactions
for intravenous
KVO. Provides a
modest sugar source
for cellular
 metabolism

NURSING RESPONSIBILITIES

Before:
 Check the doctor’s order at the client’s chart. Ensure proper identification.
 Assess the client’s history for allergic reaction to medication.
 Perform hand hygiene and wear clean gloves.
 Inform the client about the procedure.
During:
 Maintain aseptic technique.
After:
 Check the doctor’s order for the flow rate.
 Inform the client not to elevate his hands to prevent back flow of blood.
 Assess the condition of the vein and signs of infection.
ii. Drugs
Name of Drug Date Route of Mechanism of Indication, Client’s
Ordered/ administration & action Purpose response to
Date taken Dosage & Frequency medicine
or given of administration with actual
side effect
GENERIC NAME: July 28, 2010 1g IVP q12˚ Inhibits synthesis Single No side
Ceftriaxone of bacterial cell preoperative doses effects noted
BRAND NAME: wall, causing cell may decrease the
Rocephin death. incidence of post
CLASSIFICATIONS: operative
> 3rd generation Cephalosphorin infections.
> Antibiotic

NURSING RESPONSIBILITIES:

 Explain to the patient and family on what is the effect of drug and its action.
 Assess patient’s infection before therapy.
 Before giving first dose, do sensitivity test
 Before giving the first dose, ask patient about previous reaction to Cephalosporin or Penicillin.
 Assess CBC and kidney function results
 Name of Drug Date Route of Mechanism of Indication, Client’s response
Ordered/ administration & action Purpose to medicine with
Date taken Dosage & Frequency actual side effect
or given of administration
GENERIC NAME: July 28, 30 mg IVP q6˚ Anti- Short term  No
Ketorolac Tromethamine 2010 inflammatory and management of adverse
BRAND NAME: analgesic pain reaction
Toradol activity; inhibits noted
CLASSIFICATIONS: prostaglandin and
NSAID, Analgesic leukotriene
synthesis.

NURSING RESPONSIBILITIES:

 Explain to the patient and family on what is the effect of drug and its action.
 Assess patient’s infection before therapy.
 Monitor fluid intake and output.
 Check for any side effects that may occur.
 Name of Drug Date Ordered/ Route of administration Mechanism of Indication, Client’s
Date taken or & Dosage & Frequency action Purpose response to
given of administration medicine with
actual side
effect
GENERIC NAME: July 30, 2010 1 tab OD PO Has a known Short term relief No adverse
Bisacodyl tendency to cause of constipation. reaction noted
BRAND NAME: potassium
Dulcolax depletion.
CLASSIFICATIONS: Stimulates mucus
Laxatives secretion and
synthesis
contributes to the
laxative action of
and the part of the
potassium
secretion is due to
mucus release.

NURSING RESPONSIBILITIES:

 Explain to the patient and family on what is the effect of drug and its action.
 Assess patient’s infection before therapy.
 Monitor fluid intake and output.
 Check for any side effects that may occur.
iii. Diet

Type of Diet Date ordered General description Indication/s, Specic foods taken Client’s response
Purpose/s and/or reaction to
the diet
Full Diet July 27, 2010 Is a diet which is The full liquid diet Vegetables fruits, No allergic
July 28, 2010 intermediate between the is often used as a breads reaction noted
clear liquid and mechanical step between a
soft diet in characteristics. clear liquid diet
and a regular diet
A normal diet limited to soft
,
Soft Diet July 29, 2010 easily digestible foods. It is commonly Banana, soup No allergic
recommended for reaction noted
people who have
GI disturbances or
Nutritionally adequate diet acute infections
differs from the normal diet and those unable to
in having reduced fiber tolerate a normal
content soft consistency diet.
bland flavor.
Low salt, July 29, 2010 Fruits, vegetables No allergic
low fat A diet containing limited reaction noted
amounts of fat and
consisting chiefly of easily
digestible foods of high
carbohydrate content
3. Nursing Management (SOAPIER)

S>”Masakit kapag umuihi ako”

O>Received patient in bed at supine position
>with ongoing PNSS @ R arm regulated at 30 gtts/min
>awake, conscious and coherent
>Rated pain as 6/10, with 10 being the highest
>Weak in appearance
>With muscle guarding behavior on RLQ upon movement that last for 5 secs.
>Complains of pain upon palpation on RLQ of abdomen
>Facial grimace
>Prefers to position self in side lying
>Irritability and restlessness
A> Acute pain r/t presence of obstruction or movement of stones within the urinary
system secondary to nephrolithiasis
P>Within 2-4 hrs. of appropriate nursing intervention the patient will be able to verbalize
relief of pain from a scale of 6/10 to 4/10.
I> Applied hot compress at the flank area.
> Increased fluid intake for atleast 3-4 glasses.
> Assisted patient in a comfortable position regularly.
> Encouraged deep breathing exercise.
> Provided diversional activities such as talking to relatives.
> Encouraged or assist with frequent ambulation as indicated.
> Provided therapeutic touch such as gentle rubbing of back.
> Administered medication as prescribed by the physician.
E> After 2-4 hours of proper nursing intervention the patient’s pain scale decreased from
p/s of 6/10 to 4/10.
S>”hindi ako gaanong umiihi, mga 2-3 beses lang kada araw”
O>Received patient in bed at supine position
>with ongoing PNSS @ R arm regulated at 30 gtts/min
>awake, conscious and coherent
>150cc urine collected for 8 hours
>with a yellow to brownish colored urine
> no crystals or blood observed
> goes to comfort room twice per shift
A>Impaired urinary elimination related to decreased renal perfusion secondary to
nephrolithiasis
P>Within 6 hours of appropriate nursing intervention the patient will be able to have a
urine output of 25-35 cc per hour or void in normal amounts and usual pattern.
I> Monitored intake and output and characteristic of urine
> Encouraged increase fluid intake.
> Investigated reports of bladder fullness or palpate suprapubic distension.
> Documented any stone expelled and send laboratory for analysis.
E> After 6 hours of appropriate nursing intervention the patient had a normal urine output
and void in a normal amounts as evidenced by 25cc level per hour.
S>”Paano ba nagkakaroon ng bato”
O>Received patient in bed at supine position
>with ongoing PNSS @ R arm regulated at 30 gtts/min
>awake, conscious and coherent
>Asking questions about his health problem
>Requested for a list of contraindicated foods
>Unfamiliar with the things that contributes to his health problem like eating salty
foods
A>Knowledge deficit r/t lack of information regarding current health condition.
P>Within 2 hrs. of proper nursing intervention, the patient will be able to verbalize
understanding of his disease process and potential complications.
I>reviewed disease process and future expectations
>stressed the importance of increased fluid intake(3-4 L/day)
>encouraged patient to notice dry mouth and excessive diaphoresis and to increase fluid
intake whether or not feeling thirsty
>encouraged patient to eat
* low purine diet (example: lean meat, legumes)
*low calcium diet (limited milk, cheese, green leafy vegetables)
*low oxalate diet (restrict chocolate, caffeine)
>discussed medication regimen
R>After 2 hrs. of proper using intervention, the patient verbalized understanding of his
disease process and potential complication
S>tatlong araw na akong di nakakapagbawas”
O>Received patient in bed at supine position
>with ongoing PNSS @ R arm regulated at 30 gtts/min
>awake, conscious and coherent
>weak in appearance
>restless
>irritable
>abdominal tenderness
>discomfort
A>Constipation r/t insufficient physical activity
P> Within 2-4 hrs of proper nursing intervention, the patient will demonstrate behaviors
to relieved constipation
I>Monitored intake and output
>Auscultated for bowel sounds
>Instructed client to increase fluid intake from 4-6 glasses 6-8 glasses per day
>instructed client to eat foods that are high in fiber such as oranges, pineapple
>Encouraged client to increase mobility or exercise such as walking
>Administered laxative medications (Dulcolax)
R> After 2-4 hrs. of proper nursing intervention, the patient demonstrated behaviors to
relieved constipation as evidenced by feeling of relieved and urge to defecate
S> “parang puputok na ang pantog ko.”
O>Received patient in bed at supine position
>with ongoing PNSS @ R arm regulated at 30 gtts/min
>awake, conscious and coherent
> bladder distension
> small frequent voiding
> urine output of 150cc within 8 hrs
A>Chronic urinary retention related to pain felt during urination secondary to obstruction
of the urinary tract.
P> Within 4-8 hrs of proper nursing interventions the patient will be able to void in
sufficient amounts with no palpable bladder distention
I>evaluated hydration status
>poured warm water over perineum to stimulate reflex arc
>encouraged client to report problems immediately
>measured amount of voided residual
>determined frequency of voiding
>encouraged patient to use valsalva maneuver if appropriate
R> After 4-8 hrs, of proper nursing interventions, the patient voided in sufficient amounts
(260 cc in 8 hrs.) with no palpable bladder status
III. CONCLUSION
In doing this study, the group had met all the nursing and client objectives that
were formulated. The group was able to practice the skills and observed and applies the
theories and concept that were learned during lecture days. In addition to this, dealing
with a client with Nephrolithiasis gave opportunity to review the different body systems
involved and the possible manifestations that would appear on a client with this kind of
disease process. The group also became familiarized with various tests and diagnosis of
the disease. As student nurses, the group was able to apply the proper nursing
interventions and assessment.
With regards to the client centered objectives, the client acquires
knowledge about the current condition and carries out actions independently.

IV. RECOMMENDATION:
After stone passage or successful medical/surgical treatment, patient should be
evaluated metabolically with serum studies and a 24 hr urine profile to determine whether
any metabolic abnormalities exist that predispose to stone formation. Patients can be
placed on the appropriate medication or alter their diet/lifestyle if needed. Periodic 24 hr
urine monitoring should be performed to assess the efficacy of dietary/ lifestyle changes
and medication. Imaging with non contrast CT scan or KUB should be carried out every
six to twelve months to monitor for recurrence or increased in the size of existing stones.