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.


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.


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.


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.


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



8 PM 37 83 31 150/110

140/80


12 NN 36.5 76 20 130/90110/70


4 AM 36.8 88 19 140/100

120/90


4 PM 36.4 81 19 130/90

120/70



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

PELVIOLITHIASIS

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