A. GENERAL OBJECTIVES:

This case presentation seeks to the student’s knowledge regarding thegeneral health and disease condition of a patient with Nephrolithiasis, it’s disease process, possible complications, treatment plan, medical and nursing interventions.

B. SPECIFIC OIBJECTIVES:The group presenters aim to achieve the following objectives in an hour of case presentation:

1. Accurately present a thorough general assessment of the client which includes physical assessment and family history taking.

2. Effectively identify signs and symptoms exhibited by a patient with Nephrolithiasis.

3. Thoroughly discus, explain and elaborate the nature of the disease process.4. Efficiently provide appropriate and proper nursing diagnosis in line with the

client’s medical condition and skillfully formulate nursing care plans for the problems identified.

5. Appropriately apply nursing interventions necessary for the patient’s condition in reference with the learned theories and concepts of the disease.

I. PERSONAL DATA:

Name: T.R.C.

Age: 62 years old

Religion: Roman Catholic

Address: Sitio Sto. Nino West Cupang Muntinlupa City

Date of Admission: February 22 2010

Date of Discharge: February 27 2010

Chief complain: right flank pain

Final diagnosis: Bilateral Nephrolithiasis

Gouty Arthritis

II. HISTORY OF PRESENT ILLNESS

In 2004, while at work in the store in Muntinlupa, patient TRC noted severe right sided flank pain, with the scale of 5 and is not associated with dysuria, hematuria, fever, chills and pain and swelling of his knees. He started to drink 1 glass of coconut juice every time he feels pain but no relief, just helps him to increase his urination

While in 2005, Patient TRC went back to his province still having flank pain with pain scale of 8 and pain and swelling of his knees. He consulted on a midwife regarding his pain, and was advised to take Diclofenac 1 tab as needed for pain which he took on and off (approximately 3 to 4 times a week) for 1 year which relieved the symptoms.

In 2008, patient, still experiencing intermittent right sided flank pain, with the scale of 8 with undocumented fever, dysuria, and pain with swelling and erythema of knees, lateral and medial malleous, associated with limitation of movement. He also hears thudding sounds during his urination. He returned to Metro Manila and consulted in Alabang Medical Center. Ultrasound of Kidneys Ureters and Bladder (KUB) was done revealing nephrolithiasis on his right kidney. He was then advised by his doctor to undergo removal of the stone, but was postponed due to pain and swelling of knee. No medications were prescribed yet.

Last Feb 14, 2010, the patient again developed severe right sided flank pain with pain scale of 8, radiating to his right leg associated with fever, dysuria, chills noted.

Feb 16, 2010, He consulted again in Alabang Medical Center and urinalysis and CBC was done. Urinalysis shows hematuria. He was sent home with medication of Ciprofloxacin 500mg/tab BID, which provided him a relief from symptoms within 4 days until he again experience the same symptoms.

Feb 18, 2010, He returned to AMC and underwent urinalysis, KUB ultrasound, and CT sonogram. And from there, he was confined in the said institution for 2 days.

During his confinement, Cysto-RGP bilateral was done, and 1 day after the procedure patient developed swelling of knees, ankles, with pain in the scale of 8, with limitation of movement. His doctor referred him to San Juan de Dios Hospital for right urethral stent application in preparation for Extracorporeal Shockwave Lithotripsy (ESWL).

February 22, 2010, noon he was confined in San Juan De Dios Hospital.

February 23, 2010, he underwent Cysto-RGP right DJ stent application.

February 25 Patient is supposed to be transferred for ESWL in Manila Doctor’s Hospital, but was postponed due to his’ arthritis.

His final diagnosis is Bilateral Nephrolithiasis secondary to Gouty Arthritis in SJDEFI(Hospital)

III. HISTORY OF PAST ILLNESS

Unrecalled history of immunizations except for “flu vaccines”. He had measles during his childhood. (Age is unrecalled)

Patient RT has history of arthritis since 2004. 

IV. FAMILY HISTORY

His mother died of Lung Cancer His Father is positive of bronchial asthma

V. PSYCHOSOCIAL HISTORY

Patient RT is married with seven children

In 2005 he worked as fisherman as a source of living

He smokes since he was 20 years old. Consuming 5 rolls of tobacco per day for about 40 years, but claimed to have quit one week prior to admission.

He is also a heavy alcohol drinker with an average of 3 bottles of Lambanog per week. (1 bottle contains 1L of Lambanog)

IX. DISEASE ENTITY:

Definition of the disease

NEPHROLITHIASIS

Kidney stones ( renal colic or ureterolithiasis ) results from stones or renal calculi (from Latinren, renes, "kidney" and calculi, "pebbles"[1]) in the ureter. The stones are solid concretions orcalculi (crystal aggregations) formed in the kidneys from dissolved urinary minerals.

Nephrolithiasis

Nephrolithiasis, the process of forming a kidney stone, a stone in the kidney (or lower down in the urinary tract). Kidney stones are a common cause of blood in the urine and pain in the abdomen, flank, or groin. Kidney stones occur in 1 in 20 people at some time in their life.

The development of the stones is related to decreased urine volume or increased excretion of stone-forming components such as calcium, oxalate, urate, cystine, xanthine, and phosphate. The stones form in the urine collecting area (the pelvis) of the kidney and may range in size from tiny to staghorn stones the size of the renal pelvis itself.

The process of stone formation, nephrolithiasis, is also called urolithiasis. "Nephrolithiasis" is derived from the Greek nephros- (kidney) lithos (stone) = kidney stone "Urolithiasis" is from the French word "urine" which, in turn, stems from the Latin "urina" and the Greek "ouron" meaning urine = urine stone. The stones themselves are also called renal caluli. The word "calculus" (plural: calculi) is the Latin word for pebble.

Kidney stones typically leave the body by passage in the urine stream, and many stones are formed and passed without causing symptoms. If stones grow to sufficient size before passage on the order of at least 2-3—millimeters they can cause obstruction of the ureter. The resulting

obstruction causes dilation or stretching of the upper ureter and renal pelvis (the part of the kidney where the urine collects before entering the ureter) as well as muscle spasm of the ureter, trying to move the stone. This leads to pain, most commonly felt in the flank, lower abdomen and groin (a condition called renal colic). Renal colic can be associated with nausea and vomiting. There can be blood in the urine, visible with the naked eye or under the microscope (macroscopic ormicroscopic hematuria) due to damage to the lining of the urinary tract.

There are several types of kidney stones based on the type of crystals of which they consist. The majority are calcium oxalate stones, followed by calcium phosphate stones. More rarely, struvitestones are produced by urea-splitting bacteria in people with urinary tract infections, and people with certain metabolic abnormalities may produce uric acid stones or cystine stones.

Who gets Nephrolithiasis?

Sex

In general, urolithiasis is more common in males (male-to-female ratio of 3:1).

Stones due to discrete metabolic/hormonal defects (eg, cystinuria, hyperparathyroidism)

and stone disease in children are equally prevalent between the sexes.

Stones due to infection (struvite calculi) are more common in women than in men.

Age

Most urinary calculi develop in persons aged 20-49 years.

Patients in whom multiple recurrent stones form usually develop their first stones while

in their second or third decade of life.

An initial stone attack after age 50 years is relatively uncommon.

Risk factors:

Immobility and a sedentary lifestyle which increases stasis

Dehydration which leads to supersaturation

Metabolic disturbances that result in an increase in calcium or other ions in the urine

Previous history of urinary calculi

High mineral content in drinking water

Diet high in purines, oxalates, calcium supplements, animal proteins

UTIs

Prolonged indwelling catheterization

Neurogenic bladder

Types of renal calculus:

1. Calcium calculi – It occur more often in men than in women, and usually appear between

ages 20 - 30. They are likely to come back. Calcium can combine with other substances, such as

oxalate (the most common substance), phosphate, or carbonate to form the stone. Oxalate is

present in certain foods. Diseases of the small intestine increase the risk of forming calcium

oxalate stones. Evidences reveal that consumption of low-calcium diets is actually associated

with a higher overall risk for the development of kidney stones. This is perhaps related to the role

of calcium in binding ingested oxalate in the gastrointestinal tract. As the amount of calcium

intake decreases, the amount of oxalate available for absorption into the bloodstream increases;

this oxalate is then excreted in greater amounts into the urine by the kidneys. In the urine, oxalate

is a very strong promoter of calcium oxalate precipitation, about 15 times stronger than calcium.

2. Cystine stones - are due to cystinuria, an inherited (genetic) disorder of the transport of an amino acid (a building block of protein) called cystine that results in an excess of cystine in the urine (cystinuria) and the formation of cystine stones. Cystinuria is the most common defect in the transport of an amino acid. Although cystine is not the only overly excreted amino acid in cystinuria, it is the least soluble of all naturally occurring amino acids. Cystine tends to precipitate out of urine and form stones (calculi) in the urinary tract. Small stones are passed in the urine. However, big stones remain in the kidney (nephrolithiasis) impairing the outflow of urine while medium-size stones make their way from the kidney into the ureter and lodge there further blocking the flow of urine (urinary obstruction).

3.Urate stones (uric acid)- About 5–10% of all stones are formed from uric acid Uric acid stones form in association with conditions that cause hyperuricosuria with or without high blood serum uric acid levels (hyperuricemia); and with acid/base metabolism disorders where the urine is excessively acidic (low pH) resulting in uric acid precipitation

4. Struvite stones - also known as infection stones, urease or triple-phosphate stones. About 10–15% of urinary calculi consist of struvite stones. The formation of struvite stones is associated with the presence of urea-splitting bacteria,most commonly Proteus mirabilis (but alsoKlebsiella, Serratia, Providencia species). These organisms are capable of splitting urea

intoammonia, decreasing the acidity of the urine and resulting in favorable conditions for the formation of struvite stones. Struvite stones are always associated with urinary tract infections

Staghorn calculus

renal stone that develops in the pelvicaliceal system, and in advanced cases has a branching configuration which resembles the antlers of a stag. Staghorn calculi are composed of magnesium ammonium phosphate (struvite), which forms in urine that has an abnormally high pH (above 7.2). This high pH usually develops because of recurrent urinary tract infection with microorganisms such as Proteus mirabilis.

Radiographically, struvite stones are of relatively low density, but may have a laminated appearance when combined with calcium salts. Low density struvite stones may not be appreciated on plain radiographs, but can be readily detected by Ultrasound or CT. Intravenous urography or retrograde pyelography may also be used to demonstrate the typical branching appearance of staghorn calculi.

Anatomy and Physiology

HUMAN RENAL SYSTEM

The human renal system is made up of two kidneys, two ureters, the urinary bladder, and the urethra. In addition to the production of urine the renal system has many other functions.

One quarter to one fifth of cardiac output passes through the kidneys at all times. This means that the kidneys filter approximately 1.2 liters of blood every minute. It is therefore not surprising that even slight abnormalities of renal function quickly lead to electrolyte disturbances. If untreated death will occur.

Kidneys

The paired kidneys are situated on either side of the spinal column, behind the peritoneal cavity. The right kidney is slightly lower than the left due to the position of the liver. They are the primary regulators of fluid and acid base-balance in the body. In the average adult, 1,200 ml of blood or about 21% cardiac output passes through the kidneys every minute.

Each nephron has a glomerulus, a tuft of capillaries surrounded by Bowman’s capsule. The endothelium of the glomerular capillaries is porous, allowing fluid and solutes to readily move across the membrane into the capsule. Plasma proteins and blood cells, however, are too large to cross the membrane normally. Glomerular filtrate is similar to the composition of plasma, made up of water, electrolytes, glucose, amino acids and metabolic wastes.

From Bowman’s capsule, the filtrate moves into the tubule of the nephron. In the proximal convoluted tubule, most of the water and electrolytes are reabsorbed. Solutes such as glucose are reabsorbed in the loop of Henle, but in the same area, other substances are secreted into the filtrate, concentrating the urine. In the distal convoluted tubule, additional water and sodium are reabsorbed under the control of hormones such as antidiuretic hormone(ADH) and aldosterone. This controlled reabsorption allows fine regulation of fluid and electrolyte balance in the body. When fluid intake is low or the concentration of the solutes in blood is high, ADH is released from the anterior pituitary, more water is reabsorbed in the distal tubule, and less urine is excreted. By contrast, when fluid intake is high or blood solute concentration is low, ADH is suppressed. Without ADH, the distal tubule becomes impermeable to water, and more urine is excreted. Aldosterone also affects the tubule. When aldosterone is released from the adrenal cortex, sodium and water are reabsorbed in greater quantities, increasing the blood volume and decreasing urinary output.

Blood and Nerve Supply

The kidneys receive their oxygenated blood supply from the renal arteries which come off the abdominal portion of the aorta. Venous blood from the kidneys drains into the renal veins to join the abdominal portion of the inferior vena cava.The hilum of the kidneys is located toward the smaller curvature. The opening in the hilum allows for the entry and exit of blood vessels and nerves. The funnel shaped extension of the kidneys is called the renal pelvis and it connects the kidneys to the two ureters. This structure facilitates the collection of the urine from the kidneys and drainage to the urinary bladder.

The functional parts of the kidneys are divided into two distinct regions. The outer region is reddish brown in color and is called the renal cortex. This is where the nephrons of the kidney are located. The inner layer of the kidney is more pinkish in color and is called the renal medulla. The renal cortex houses the functional units of the kidneys called nephrons. The inner area of the kidneys is supplied by a small blood vessel network called the vasa recta.

Ureters

Once the urine is formed in the kidneys, it moves through the collecting ducts into the calyces of the renal pelvis and from there into the ureters. The ureters are 25 to 30 cm(10-12 in) long in adult and about 1.25 cm(0.5 in) in diameter. The upper end of each ureter is funnel shaped as it enters the kidney. The lower ends of the ureters enter the bladder at the posterior corners of the

Nephron

These are considered as the functional unit of kidney. There are approximately 1 million nephron in each kidney. The kidney however, cannot regenerate new nephron.

floor and the bladder. At the junction between the ureter and the bladder, a flaplike fold of mucous membrane acts as a valve to prevent reflux(backflow) of urine up the ureters.

Bladder

The urinary bladder(vesicle) is a hollow, muscular organ that serves as a reservoir for urine and as the organ of excretion. When empty, it lies behind the symphysis pubis. In men, the bladder lies in front of the rectum and above the prostate gland, while in women, it lies in front of the uterus and vagina.

The wall of the bladder is made up of four layers:a) an inner mucous layerb) a connective tissue layerc) three layers of smooth muscle fibers, some which of extend lengthwise, some obliquely, and some more or less circularly, and d) outer serous layer

The smooth muscle layers are collectively called detrusor muscles. It allows the bladder to expand as it fills with urine and to contract to release urine to the outside of the body during voiding. The trigone is the base of the bladder which is a triangular area marked by the ureter openings at the posterior corners and the opening of the urethra at the anterior inferior corner.

The bladder is capable of considerable distention because of rugae(folds) in the mucous membrane lining and because of the elasticity of the walls. When full, the dome of the bladder may extend above the symphysis pubis; in extreme situations it may extend as high as the umbilicus. Normal bladder capacity is between 300-600 ml of urine.

Urethra

The urethra extends from the bladder to the urinary meatus(opening). In the adult woman, the urethra lies directly behind the symphysis pubis, anterior to the vagina, and is between 3-4 cm(1.5 in) long. The urethra serves as passageway for the elimination of urine. The urinary meatus is located between the labia minora, in front of the vagina and below the clitoris. The male urethrea is approximately 20 cm(8 in) long and serves as a passageway for semen as well as the urine. The meatus is located at the distal end of the penis.

In both men and women, the urethra has a mucous membrane lining that is continuous with the bladder and the ureters. Thus, infection of the urethra can extend through the urinary tract in the kidneys.

Pelvic floor

The urethra and rectum pass through the pelvic floor which consists of sheets of muscles and ligaments that provide support to the viscera of the pelvis. The internal sphincter muscle situated in the proximal urethra and the bladder neck is composed of smooth muscle under involuntary control. It provides active tension designed to close the urethral lumen. The external sphincter muscle is composed of skeletal muscle under voluntary control, allowing the individual to choose when urine is eliminated.

Urination

Micturition, voiding or urination all refer to the process of emptying the urinary bladder. Urine collects in the bladder until pressure stimulates special sensory nerve endings in the bladder wall called stretch receptors. This occurs when adult bladder contains between 250 and 450ml of urine.

The stretch receptors transmit impulses to the spinal cord, specifically to the voiding reflex center located at the level of 2nd to 4th sacral vertebrae, causing the internal sphincter to relax and stimulating the urge to void. If the time and place are appropriate for urination, the conscious portion of the brain relaxes the external urethral sphincter muscle and urination takes place. If the time and place are inappropriate, the micturition reflex usually subsides until the bladder becomes more filled and the reflex is stimulated again.

Voluntary control of urination is possible only if the nerves supplying the bladder and urethra, the neural tracts of the cord and brain, and the motor area of the cerebrum are intact. The individual must be able to sense that the bladder is full.

X. TREATMENT & MANAGEMENT

1. SURGICAL MANAGEMENT

February 23,2010

RETROGRADE PYELOGRAPHY AND CYSTOSCOPY

A retrograde pyelogram is a type of x-ray that allows visualization of the bladder, ureters, and renal pelvis. Generally, this test is performed during a procedure called cystoscopy - evaluation of the bladder with an endoscope (a long, flexible lighted tube). During a cystoscopy, contrast dye, which helps enhance the x-ray images, can be introduced into the ureters via a catheter.

Condition that may interfere with a retrograde pyelogram.,

feces or gas in the bowels

February 26,2010

ARTHROCENTESIS

- Joint aspiration, a procedure whereby a sterile needle and syringe are used to drain fluid from a joint..

- Joint fluid is typically sent for examination to the lab to determine the cause of the joint swelling, such as infection, gout, and rheumatoid arthritis.

- Arthrocentesis can be helpful in relieving joint swelling and pain..

EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY

Extracorporeal shock wave lithotripsy (ESWL) uses shock waves to break a kidney stone into small pieces that can more easily travel through the urinary tract and pass from the body.

Complications of ESWL include:

Pain caused by the passage of stone fragments. Urinary tract infection.

DOUBLE J STENT

Is a thin tube inserted to the ureter to prevent or treat obstruction of the urine flow from the kidney. Double J Stent have multiple perforations to allow the urine to drain from the kidney down the ureter to the bladder. They may be placed to bypass a stone, relieve obstruction, or to keep the ureter from swelling shut after a cystoscopicureteroscopic procedure.