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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

4Y1-7 (Group 7A)

Our Lady of Fatima University

Valenzuela City Campus

Mrs. Elisa Lasanas, RN, MAN

Clinical Instructor

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Nursing Management II

Nursing Management of a Patient with Calyceal Calculi

Mr. D. B. A, a 30 year-old male, married Filipino from Pussian Alcala

Cagayan, had a chief complaint of left flank pain. One year prior to

admission patient DBA has positive occasional flank pain associated w/

dysuria, hematuria and passage of stone. No consult was done and no

medication taken. One month prior to admission of flank pain, the patient

consulted to a private physician and was given Ciprofloxacin 500g/tab, BID

×7 days w/c provided temporary relief. Two weeks prior to admission KUB-

UTZ was requested, revealing an inferior Calyceal Calculi, causing mild

superior calicetasia. Other, medications were also given K+ Citrate, 1TAB

TID and Sambong capsule, 1tap TID. One day prior to admission, due to

resistance of flank pain, patient was subsequently referred to Armed

Forces of the Philippines Medical Center where further medical evaluations

were done. Hence, admission was made.

In understanding the formation of calyceal calculi, we shall know

that kidney is important part of the body. Their function is to remove

waste and toxic substances from the blood and passing out the liquid

called urine. The journey of urine starts from the kidney to the bladder

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through ureter then exit to urethra. If there is more waste material in the

urine, these substances form crystals and then finally calyceal calculi.

The stone may develop usually because of the super-concentrated

urine. The other cause that can form the stone is if the output of a given

chemical waste products are increased. For instance, the calcium stones

may occur when there is too much supplement of the calcium and urine is

full of calcium. This also depends on the capacity of absorbing the calcium

from the intestines. Some people may have overactive parathyroid glands

called hyperparathyroidism which results in calcium being leached out of

the bones and getting collected in the urine.

The other chemical compounds that can form the calculi include uric

acid and the cystine, an amino acid. The calcium gets combined with

either phosphate or oxalate. Any type of obstruction to the flow of the

urine can also increase the chances for stone formation. Kidney stones

associated with infections are known as “infectious stones”.

The age group which is affected the most begins after 40 year and

continues up to 70 year. The person with one stone is likely to develop

more stones.

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Nursing Management

III

Pathophysiology

In understanding the formation of the calyceal stone, we must be

able to know first the anatomy and physiology of the urinary system. The

glomeruli of the kidneys filter about 1% (10 g) of the total body calcium

each day. Only the ultrafilterable calcium crosses the glomerular

basement membrane. The ultrafilterable calcium is the free or ionized

calcium (47%) plus a small amount (6%) which is complexed to

phosphates and citrates. Of the filtered calcium, 98% is reabsorbed by the

renal tubules. The proximal tubules are responsible for 65%, the ascending

loop of Henle for 20-25% and the distal tubules for 10%. The calcium in

the tubular fluid is nearly all ionized. Calyceal stones are found in the

funnel shaped area called the calyx between the kidney and the ureter.

The pathogenesis of calyceal stones is mainly explained with

different factors. These factors are the following (1)Deficiency of citrate,

magnesium, nephrocalcin, uropontin which is responsible to prevent

crystallization in the urine (2) Fluid volume deficiency (dehydrated patient)

incline stones to occur more often (3) Infection, urinary stasis, periods of

immobility causes slow renal drainage and alters calcium metabolism (4)

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Increase calcium concentrations in blood and urine promote precipitation

of calcium (5)Neurogenic bladder, foreign bodies, recurrent UTI’s lead to

infection stones (6) inflammatory bowel disease causes increase

absorption of too much oxalate. All of these factors lead to formation of

stones. When calculi are already formed, it causes trauma to the urinary

tract & irritate the cellular lining. Thus, it makes the patient feel flank pain

(Myers, Neighbors et al, 2006). The calyceal stones may destroy the

nephrons causing excruciating pain and discomfort. Moreover, Calyceal

calculi development blocks the flow of urine causing obstruction.

Obstruction may distend the renal pelvis and proximal ureter causing

hematuria, renal colic, and nausea and vomiting. In addition, obstruction

Increase hydrostatic pressure and causes urinary retention

As for the possible risk factors, calyceal calculi are much more

common in men than in women. Men generally have a larger muscle mass

than women. Hence they have more of the daily breakdown and rebuilding

of tissue that result in metabolic waste. And an increase in metabolic

waste predisposes people to stone formation (Curhan, Gary C., 2003).

Likewise, men generally eat more meat than women do (Curhan, Gary C.,

2003). Aside from that, if one or both of your parents made stones, there

is a greater chance that you will make stones (Rodman & Sosa).

Furthermore, fat malabsorption can lead to an increased net oxalate

absorption and, finally, to increased urinary oxalate (Seidman & Jones)

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Nursing Management

IV

History

According to the patient during the interview, he was admitted in the

hospital for the second time. First time he was admitted was when he had

an appendectomy operation. He got no allergies to either food or drugs.

Aside from that, the patient told that his father have hypertension.

Familial medical history suggests that his mother had the same renal

problem. The family is a nuclear type. They are residing in Cagayan. He

has a wife and it is eight months pregnant. Their religion is Roman

Catholic.

Furthermore, the patient is not allergic to any kind of food.

According to his personal history, he is the eldest among them. He said

that he’s a non-smoker but an occasional alcoholic beverage drinker. He

prefers salty foods because for him it seems tastier than any other type of

food. He normally drinks about 3000 liters of water; however there are

times during their duty that he wasn't able to drink due to scarcity of the

resources.

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Nursing Management V

Nursing Physical Assessment

Mr. DBA was conscious and coherent at the time of assessment. The

patient’s temperature was 36.2 °C, respiratory rate was 22 cpm, pulse

rate of 80bpm and blood pressure of 130/80 mmHg. The client has a

medium body frame. He can stand and sit properly. He is well – groomed

upon assessment, he has no body odor. No deformity noted.

He has a good eye contact. Pupils are black, round and equal in size.

Sclera is white bulbar conjunctiva is clear, palpebral conjunctiva is pink

and lacrimal apparatus is moist. Eyebrows are thin and symmetrical.

However, there are presence of eyebags .

According to the patient, there is tenderness at his left flank area

before. The patient’s skin was warm to touch. Prior to admission, the

patient experienced left flank pain.

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According to Myers, pain often comes in waves. It has been said that

kidney stone pain is the worst pain that a man can experience. It radiates

towards the thigh and genitals.

Laboratory tests were done to find out some abnormalities on Mr.

DBA. Urinalysis showed that the urine was yellow & slightly turbid with 3P

Gravity: 1.610, microscopic analysis showed increased level of WBC. KUB

Ultrasound was the diagnostic tool used to the patient. It showed that both

kidneys are within the normal limits in size and configuration. Renal

Outlines are smooth and intact. Cortical echoes are homogenous.

However, there are several mid and inferior calyceal calculi noted in the

left causing mild superior caliectesia. The size range to 0.5 to 0.9 cm

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Nursing Management

VI

Related Treatment

The patient had different medications being taken. The medications

that were given are the following: Rowatinex, 3 times a day before meal,

an anti-urolithic drug. It promotes diuresis and relaxes urinary tract spasm,

thus assisting the passage of stones. Liquid intake should be encouraged

during the therapy. Likewise, Irbesartan is also prescribed, 1 tab OD, for

hypertension, it decreases excess water and salt in the body. It may take

with or without food, drink plenty of water to prevent dehydration. On the

other hand, Celecoxib is being ordered to relieve pain as necessary. And

Ural sachet, a gastric alkanizer, used to relieve the symptoms

of infections in the urinary system or excessive gastric acid. This

medication is to be taken 3 times a day. Ural works to reduce the burning

sensation when passing urine and the discomfort experienced. It works to

increase the pH in the urinary and gastric system, therefore making your

urine less acidic.

In order to remove the stone that was located on mid and inferior

calyces in left kidney, medical procedure was performed to the patient.

And the intervention done was Extracorporeal Shockwave Lithotripsy

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(ESWL) therapy, a non-invasive alternative treatment. This procedure is

the most convenient way to remove the stones from the patient. The

successive shock wave pressure pulses result in direct shearing forces,

attempts to break up the stone with minimal collateral damage by using

an externally-applied, focused, high-intensity acoustic pulse.

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Nursing Management VII

Nursing Care Plan

The diagnosis for the patient was Sleep Deprivation related to

frequent urinary urgency as manifested by presence of eyebags and

frequent yawning upon the interview.

The plan for the patient is that after 2 hours of nursing intervention,

the client will be able to verbalized the causative/contributing factors of

his sleep deprivation,know the importance of enough sleep in our body

and understand proper sleep inducing techniques (Doenges and Murr,

2010).

Furthermore, after 1 day of nursing intervention, the client should

also be able to establish optimal sleep pattern

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The main nursing intervention to the patient is to provide adequate

sleep by understanding the following:

The patient must be taught about determining presence of physical

or psychological stressors, including recent illness (calyceal calculi). This is

done so that it will provide comparative baseline.

Likewise, it is also important to determine client’s usual patterns and

expectations and ascertain duration of current problem and effect

life/functional ability. This helps identify appropriate options and assists

client understand the importance of achieving enough sleep

Another aspect of promoting sleep is to note factors affecting sleep

such as increased fluid intake during night to determine the underlying

cause of his problem

Moreover, it is also essential to enumerate what are the benefits of

sleep in our health and encourage client to develop plan to restrict

caffeine, alcohol, and other stimulating substances from late/evening

intake. Instead he may drink milk if not contraindicated. This is to

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decrease tension and prepare for rest/sleep and to discuss factors that are

known to disrupt sleep pattern. Caffeine significantly affects visual

vigilance, choice reaction time, repeated acquisition, self-reported fatigue

and sleepiness

The need for observing for physical signs of fatigue (e.g.

restlessness)is also so important for a patient with this disorder. A chronic

sleep-restricted state can cause fatigue and generalized body weakness

In evaluating the patient’s understanding of this plan, the patient

was able to report improvement in sleep pattern as manifested by the

causative/ contributing factors of sleep deprivation and knowing

importance of enough sleep

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Nursing Management

VIII

Recommendations

In the development of an individualized planning for patient DBA

prior to leaving hospital, with the aim of improving patient outcomes, we

have come up with the following guidelines in ensuring the following

management.

First, instructing patient to take prescribed medications regularly

and comply with the treatment regimen prescribed by the physician.

Compliance to appropriate medication and treatment prevents further

complications and promote continuous recovery of optimal health.

Moreover, we should teach patient regarding the names of the drug, its

dosage, time of administration, its contraindication and side effects. The

patient has the right to know his drug’s therapeutic effects as well as its

adverse effects. He also has the right to gain awareness about why is it

given to him. Likewise, we should also educate the patient and the

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significant others about the expected responses of drug to the body, side

effects, adverse effects that may possibly seen into the patient in order

for him to be geared up of enough information that may lead to

immediate medical responses .

Second, we also think that explaining to patient the significance of

regular exercise like walking and stretching is important. Increasingly,

there is evidence that a physical exercise program, integrated into

management plan, has positive benefits for general health, including

weight loss, improved muscle strength, lower level of cholesterol and

blood fats, increased cardiac output and greater physical exercise

capacity. Many of these benefits will also lower risk of heart disease, a risk

which is greater for people with kidney disease than among the general

population. In the case of patient DBA, there are no restrictions in physical

activities, for as long as he practices proper voiding habits.

In addition, home medications are also recommended. It includes

the following: 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. Celecoxib is recommended if the

patient feels moderate to moderately severe pain.

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Next is considering the diet of patient DBA. A mixed balanced diet

with contributions from all food groups, but without excesses of any

kind .Fruit and vegetable intake should be encouraged because of the

beneficial effects of fiber. The alkaline content of a healthy diet also gives

rise to a desirable increase in urinary pH. Furthermore, Animal protein

should not be ingested in excessive amounts, and it is recommended that

animal protein intake is limited to 0.8-1 g/kg body weight. An excessive

consumption of animal protein gives rise to several unfavorable effects on

stone formation, such as hypocitraturia, low pH, hyperoxaluria and

hyperuricosuria. Aside from that, Encouraging client to increase fluid

intake is vital. In patients with an expected low risk of recurrent stone

formation advice on fluid intake and diet may be sufficient to prevent

stone recurrence. The positive effect of such a regimen has been referred

to as the ‘stone clinic effect’

Lastly, warning signs such as fever and Hematuria for more than 3

days may indicate immediate remedial action response. A follow-up visit in

the hospital serves as an evaluation process to note if condition has

progressed to better or worse.

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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. Stamatelou, Kiriaki K.; Francis, Mildred E.; Jones, Camille A; Nyberg

Jr., Leroy M.; Curhan, Gary C. (2003). "Time trends in reported

prevalence of kidney stones in the United States: 1976–1994"

3. Taylor EN; Stampfer MJ; Curhan GC (2004). "Dietary factors and the

risk of incident kidney stones in men: new insights after 14 years of

follow-up."

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4. No More Kidney Stones by John S. Rodman, M.D., R. Ernest Sosa,

M.D., and Cynthia Seidman, M.S., R.D, with Rory Jones.

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