ureterolithiasis (2)
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Transcript of 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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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COLLEGE OF NURSING
Our Lady of Fatima University Research and Development Center
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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