NATIONAL UNIVERSITY-BAGUIO #57 Bokawkan Road, Baguio City COLLEGE OF NURSING

A Case Analysis Presented to the Faculty of College of Nursing National University-Baguio

In Partial Fulfillment of the Requirements in Related NCM-104 (Benguet General Hospital- SURGERY WARD)

Submitted to: Mrs. Imelda Payas Class Advisor

Submitted by: MERCADO, Sean Derick C. BSN IV-A February 13, 2012

I. PATIENTS PROFILE
Patients Name: Patient X Age: 61 years old Gender: Male Birth date: 06/06/1950 Birth place: Pangasinan Civil Status: Married Nationality: Filipino Religion: Jehovas Witnesses Address: Manaog, Matulong, Pangasinan Ward/Bed: Surgery, male ward, SO8-3 Date & Time of Admission: 1/17/12 @ 12:30 PM Chief Complaints: Left Lumbar Pain Admitting Diagnosis: Ureterolithiasis Left, Obstructive Uropathy

II.

DEVELOPMENTAL TASK
According to Erik Ericksons developmental theory, Mr. X a 61 year old, belongs to middle age group. The developmental task is to establish a sense of generativity through which people extend their concerns from just themselves and their family to the community and the world. In Havighursts developmental theory, a 61 year old, is under middle adulthood. The developmental task are fulfilling civic and social responsibilities, maintaining an economic standard of living, assisting adolescent children to become responsible happy adults, relating to ones partner, adjusting to physiological changes and adjusting to aging parents. In relation to the patient (Mr. X) , he was able to accomplish the tasks.

III. HEALTH HISTORY (PAST & PRESENT ILLNESS)

A. PAST ILLNESS Patient has no history of previous hospitalization and operation. B. PRESENT ILLNESS Lumbar pain of more than one year duration, persistent temporarily relieved by intake of medicines, but pain is unbearable and so patient went to Benguet General Hospital and is diagnosed of having ureterolithiasis, hence, admission.

PRE-OPERATIVE DIAGNOSIS: Obstructive Uropathy left 20 to distal 3rd Ureterolithiasis OPERATION DONE: Nephroureterectomy with bladder cuff excision left with pyonephros. POST OPERATIVE DIAGNOSIS: Obstructive uropathy left 20 to distal 3rd ureterolithiasis with distal 3rd tumor. C. FAMILY HISTORY OF ILLNESS (-) HPN, (-) DM, D. SOCIAL & ENVIRONMENTAL HISTORY According to the patient, he was a non- smoker and non- alcoholic beverage drinker.

IV. PATHOPHYSIOLOGY PAIN

URINARY STASIS & SUPERSATURATION OF URINE WITH POORLY SOLUBLE CRYSTALLOIDS FORMATION OF CRYSTALS GROWTH CONTINUES BY AGGREGATION TO FORM LARGER PARTICLES PARTICLES TRAVEL DOWN THE URINARY TRACT PARTICLES ARE TRAPPED AT SOME NARROW POINT URIC CRYSTAL FORMATION OCCURS OBSTRUCTION OF URINARY TRACT SEVERE PAIN, NAUSEA & VOMITING, PALLOR, ELEVATED BP & PULSE NEPHROURETERECTOMY

MODERATE INCISIONAL PAIN RELATED TO TISSUE TRAUMA 20 SURGICAL PROCEDURE

MONITOR VITAL SIGNS, POSITIONED IN SUPINE,

INSTRUCTED ON PROPER DEEP BREATHING & COUGHING EXERCISES,

V.

MEDICAL TREATMENT & MANAGEMENT INCLUDING PROCEDURE & ITS IMPLICATION TO NURSING