Prepared by: Rekha Sharma

The main (specific) objectives of this case study are as follows:

To provide holistic nursing care to the patient using the nursing process. To gain through knowledge about one specific disease, its pathology and management. Apply nursing theories while giving comprehensive care to patient.

To explain about disease its prognosis and apply in planning nursing actions. To communicate effectively to the patient and his family. To perform skill to reduce pain and discomfort for family. To collaborate with the client, families and health team members in the discharge planning and follow up care of patient from hospital to the community

At the end of this session, participants will be able to explain about nephrolithiasis in terms of its clinical presentation, diagnosis, treatment and nursing management.

 To

share the knowledge on specific subject matter confidently. exchange knowledge gain from case study with teacher and friends and get feedback. get confidence to face the mass.

To

To

Name Age Sex Address Occupation Marital status Religion Educational level

: Choklal Subedi : 37 years : Male :Sukranagar-7,chitwan : Foreign worker (lab our) : Married : Hindu : 10+2 passed in Education

Date of admission Date of discharge Provisional diagnosis

:067-02-08 :067-02-16 :Rt.Nephrolithiasis with grade III Hydronephrosis

Final diagnosis

:Rt. Pyelolithotomy with DJ Stenting Attending physician :Dr. Chandra Prakash Information obtained from: Sita Subedi( wife)

Pain in the right loin on and off since 3 months

Patient was apparently well 3 months back. Then he had a sudden onset of pain in the right loin .He visited doctor and took some medications for 5 days. However the pain did not subside and he started having burning micturation, then he again visited the doctor and did some investigations (IVU,Urine test)and kidney stone was ruled out. And then lithotripsy was done in Korea on April 15.

Alleviating / aggravating factors: Heavy work aggravates and rest relives the symptoms.

No history of any chronic illness No history of any UTIs and renal stone No history of any drug allergy and long term use of any medications No history of hospitalization and operation

Type of family: Joint family Total no of family member: 8 Medical history of family member: In the family his father has diabetes since 5 years. No any other chronic diseases and history of any renal stone among other members of the family. Health status of other family members is good. Good relation among family members. Has 5 room well ventilated and separate kitchen. Environmental sanitation well maintained.

He is a non smoker and non alcohol user. No history of any food allergy. He is a nonvegetarian is very much fond of meat and milk products. He has a poor water drinking habit. He takes bath daily and sleeps for about 6-7 hours in 24 hours period. He has regular bowel habit.

Patient including his family members has a complete belief in modern science and visit doctor and hospital during health problems.

General inspection Level of conscious - Alert Gait - Balance Facial expression- Anxious Nutritional status - Well nourished General build - Average Hygiene - Well maintained

Measurement Height 165 cm Weight 63kg BMI- 23.14 Temperature 98.2 F Pulse 80/min Respiration 20/min Blood pressure 120/84 mm of Hg

Head to toe physical examination : During head to toe examination , tenderness on deep palpation over costovertebral [CVA] angle. No any other abnormal findings detected.

Kidney stones are solid concretions or calculi (crystal aggregations) formed in the kidneys from dissolved urinary minerals. Nephrolithiasis refers to the condition of having kidney stones. Urolithiasis refers to the condition of having calculi in the urinary tract (which also includes the kidneys), which may form or pass into the urinary bladder. Ureterolithiasis is the condition of having a calculus in the ureter, the tube connecting the kidneys and the bladder.

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. Kidney stones are sometimes called renal calculi. One in every 20 people develops a kidney stone at some point in their life.

A kidney stone is a hard, crystalline mineral material formed within the kidney or urinary tract. The condition of having kidney stones is termed nephrolithiasis

Within the United States, about 1015% of adults will be diagnosed with a kidney stone. The incidence rate increases to 2025% in the Middle East, because of increased risk of dehydration in hot climate.

Kidney stones affect 240,000 to 720,000 people in the US each year and account for 7 to 10 of every 1000 hospital admissions. Renal calculi are 2.5 times more common in men and women and in persons between the ages of 20 and 50. In CMCTH in 3 month period account 13 patients were diagonsed renal stone among 755 hospital admitted patients .

Calcium: Calcium is the most common substance and found in up to 90% of stones. Calcium stones are usually composed of calcium phosphate or calcium oxalates. They may range from very small particle to giant stag horn calculi, which may fill the entire pelvis and extend up into the calyces . The peak onset is during a persons 20s and these stones affect primarily males.

Oxalate: The second most frequent stone is oxalate, which is relatively insoluble in urine. Its solubility is affected by changes in the pH. The mechanism of oxalate availability is unclear but may be closely related to diet. The disease is most common in areas where cereals are a major dietary component and least common in dairy farming regions.

Struvite: Struvite stones , also called triple phosphate , are composed of carbonate apatite and magnesium ammonium phosphate. Their cause is certain bacteria , usually proteus. Stone formed by these is stag horn calculi . These stone a re difficult to eliminate because the hard stone forms around a nucleus of bacteria, protecting them .Any small fragment left after removal begins the cycle again.

Uric acid: Uric acid stones are caused by increased urate excretion, fluid depletion and a low ph of urine. Hyperuricuria or people with gout develop uric acid stones. A diet high in purine may predispose clients to uric acid stones.

Cystine: Cystinuria is the result of a congenital metabolic error inherited as an autosomal recessive disorder. Cystine stones typically appear during childhood and adolescence, development in adults is rare.

Xanthine: Xanthine stones occurs as a result of a rare hereditary condition in which there is xanthine oxidase deficiency.

Urinary concentrations of substances such as calcium oxalate, calcium phosphate and uric acid increase.

Leads to increased concentration( super saturation) of urine.

Leads to stone formation.

Stone formation is not clearly understood and there are number of theories about their causes.

Theory 1 :- There is a deficiency of substances that normally prevent crystallization in the urine such as citrate, magnesium, nephrocalcin and uropontin. Another theory relates to body fluid volume status of patient. Certain factors favor the formation of stones, including infection, urinary stasis, an periods of immobility, all of which slow renal drainage and alter calcium metabolism. Increased calcium concentration in the blood and urine promote precipitation of calcium and formation of stones. (about 75% of all renal stones are calcium based).

According to book
1. Decrease in urine volume
2. Dehydration from reduced fluid intake or strenuous exercise . 3. Urinary stasis 4. Super saturation of urine with poorly soluble crystalloids. 5. Lack of normal inhibitors such as : citrate and magnesium.

According to patient
- Patient used to do strenuous activity and has a poor water drinking habit.

According to book
6. 6. Diet- high protein and high calcium. 7. Hereditary.

According to patient
- He is fond of meat and milk products.

8. A number of different medical conditions can lead to an increased risk for developing kidney stone. Gout Hypercalciuria Hyperparathyroidism Diabetes Hypertension Inflammatory bowel disease

According to book
9. Certain medications such as acetazolamide, absorbable alkalis(e.g., calcium carbonate and sodium bicarbonate and Crixivan, a drug used to treat HIV infection. 10. Infection

According to patient

11. Foreign bodies

12. Failure to empty the bladder completely

According to book
1. While some kidney stones may not produce symptoms (known as "silent" stones). 2. Colicky pain: sudden onset of excruciating, cramping pain in their loin and/or side, groin, or abdomen.

According to patient

- Patient has characteristic pain in rt. loin

According to book
3. Pain radiates around the sides and down towards the testicle in the males and the bladder in the female. 4. Nausea and vomiting

According to patient

5. Hematuria , Pyuria, Dysuria, Oliguria

6. Post renal azotemia: the blockage of urine flow through a ureter.

According to book
7. Hydronephrosis : the distension and dilation of the renal pelvis and calyces.

According to patient
- Hydronephrosis present

8. Fever and chills (if infection is present)

According to book

According

to patient

1. The diagnosis of kidney stones is - Typical characteristic pain was suspected by the typical pattern of present symptoms . 2. History Taking 3. Physical examination - History taking was done - Physical Examination was done

4. Kidney, ureter and bladder(KUB) 5. Intra venous urogram (IVU) 6. Ultrasound - IVU done: Rt. Nephrolithiasis with grade III Hydronephrosis - USG done: Rt.nephrolithiasis with Rt. moderate Hydronephrosis

According to book
7. Abdominal CT Scan 8. Blood test: Complete Blood Count, blood calcium, urea, creatinine 9. Urine R/E 10. Urine C/S

According to patient

-Blood test done.(CBC, RBS, Urea, Creatinine, Sodium, Potassium)

11. 24 hour urine collection to measure total daily urinary volume, magnesium, sodium, uric acid, calcium, citrate, oxalate and phosphate.

According to book

According to patient
Other investigation carried out in my patient are: a. b. c. d. e. f. g. h. i. BT CT PT with INR RBS HIV HBsAg HCV Chest X-Ray ECG: left ventricular hypertrophy with prolonged QT

Medical management or conservative management Surgical management Nursing management

According to book
Conservative or medical management is appropriate if there is no obstruction, if pain can be managed, if the client can be hydrated with oral fluids and if the stone are less than 5 mm. Reduce pain using: NSAIDs Opoids such as morphine sulphate Anti spasmodic agents such a oxybutynin chloride (Ditropan)

According to patient

Anti emetics for nausea and vomiting

According to book
Increase fluids: Encourage clients to increase fluids to 3 to 4 liters unless contraindicated

According to patient
- Patient was encouraged to drink plenty of fluids 3 to 4 liters per day and at least half of it should be water.

Implement dietary changes: Calcium stone are advised to restrict protein and sodium in their diet. Uric acid stones are advised to have low- purine diet which involves limiting cheese, wine, bony fish and organs meat.

According to book
Cystine stones a low protein diet is advised and fluid intake is increased to alkalinized the urine. Oxalate stones intake of food containing oxalate like spinach, strawberries, chocolate, tea, peanuts cabbage, apple , beer, cola etc are limited

According to patient

According to book
Administer medications: For hypercalciuria: a thiazide diuretics Calcium oxalates stones: Vitamin B6, magnesium oxide Uric acid stones: allopurinol Xanthine stones: sodium bicarbonate Cystine stones: tiopronin (thiola)

According to patient

According to book
About 20% of stones requires additional treatment with shock wave lithotripsy or endourologic or surgical procedures. 1. Endourologic Procedures: a. Percutaneous Nephrolithotomy b. Lithotripsy Laser Lithotripsy Extracorporeal Shock Wave Lithotripsy Percutaneous Lithotripsy

According to patient

- Lithotripsy was done 37 days before

According to book
c. Double -J stents

According to patient
- DJ stent was kept in my patient to facilitate passage of small stone from kidney to bladder without causing obstruction. -Pyelolithotomy was done in my patient

2. a. b. c.

Open Surgical Procedures: Pyelolithotomy Nephrolithotomy Nephrectomy

Abdominal X-ray showing a double J stent to relieve colics from kidney stones

In pre operative period Tab. Alprax 0.5mg p/o H.S In post operative period Inj.NS II pint & inj. 5%Dex IV pint I/V over 24 hours( for 1 day then IVF NS II pint over 24 hours for 1 day) Inj. Cipro 200mg I/V B.D ( for 2 days) Inj. Ranitidine 50mg I/V T.D.S ( for 1 day) Inj. Nemadol 50mg + Inj. Stagon 25mg I/M T.D.S (for 1 day then sos)

Tab. R-loc 150mg p/o B.D (continued) Cap. Opidol 100mg p/o T.D.S (for 5 days) Tab. Cicin 500mg p/o B.D ( for 4 days)

1. Recurrence of stones 2. Urinary tract infection 3. Kidney damage, scarring 4. Decrease or loss of function of the affected kidney.

Preventive strategies include dietary modifications and sometimes also taking drugs with the goal of reducing excretory load on the kidneys: Drinking enough water to make 3 to 4 liters of urine per day. A diet low in protein, nitrogen and sodium intake. Restriction of oxalate-rich foods, such as chocolate, nuts, soybeans, plus maintenance of an adequate intake of dietary calcium. There is equivocal evidence that calcium supplements increase the risk of stone formation, though calcium citrate appears to carry the lowest, if any, risk. Taking drugs such as thiazides, potassium citrate, magnesium citrate and allopurinol, depending on the cause of stone formation as prescribed by the doctor to prevent stone formation.

Some fruit juices, such as orange, blackcurrant, and cranberry, may be useful for lowering the risk factors for specific types of stones. Orange juice may help prevent calcium oxalate stone formation, black currant may help prevent uric acid stones, and cranberry may help with UTIcaused stones. Limit intake of caffeinated beverages, such as coffee. Avoidance of cola beverages. Avoiding large doses of vitamin C.

Assessment findings Pain in incision site Verbalization of fear Demonstrate queries regarding stone formation Risk for chest infection Risk for wound infection

Goal: Relief of pain and discomfort within 2 hours. Nursing interventions: a. Assessed level of pain (provides baseline for later evaluation
of pain relief strategies)
b. c.

Administered analgesics as prescribed (promotes pain

relief)

Applied massage to areas with muscular aches

(promotes relaxation and relief of muscle pain and discomfort

d. Splint incision with hands or pillows during movement (minimizes tension on incision and provides
sense of support to the patient)

e. Assist and encourage early ambulation

(promotes resumption of muscle active exercise and increases peristalsis movement)

Evaluation: Reports relief of pain and Discomfort after 2 hours.

Goal: Reduction of fear and anxiety Nursing Intervention: a. Assess patients anxiety and fear before surgery if possible (provides a baseline for post operative
assessment)
b.

Assess patients knowledge about procedure and expected outcome preoperatively (provides a
basis for further teaching)

c. Encourage patient to verbalize reactions, feelings and fears (it helps in ultimate resolution o
feelings and fears)

d. Encourage family members esp. the spouse to be with the patient and share feelings
(receive mutual support and reduces sense of isolation )

e. Evaluate the meaning of alterations resulting from surgical procedure for the patient and family (enables understanding of pts reactions and
responses to expected and unexpected results of surgery)

Evaluation: Verbalizes reactions and feelings and reduction of fear and anxiety.

Goal: Gain knowledge regarding prevention of recurrences of stone Nursing Intervention: a. Increase fluid intake at least 3-4 liters per day
(dilutes urine and prevents stone formation)
b.

Participate in appropriate activities (prolonged

c.

immobilization slows renal drainage and alters calcium metabolism) Consume diet prescribed (reduce dietary factors predisposing to stone formation)

d. Recognize symptoms (fever, chills, flank pain, haematuria) to be reported to health care provider (understand the sign and symptoms of e. Explain the actions and importance of prescribed medications (helps to be in adherence
with medication to prevent stone formation)

infection and stone formation and reports immediately)

Evaluation: States increased knowledge of health seeking behaviors to prevent recurrences.

Goal: Patient will be prevented from chest infection during his period of hospital stay. Nursing Intervention: a. Monitored vital signs regularly and chest auscultated for presence of wheezes.( provides
baseline data for evaluation of any chest infection)
b.

Encouraged patient for deep breathing and coughing exercises.( promotes full thoracic
expansion and expel cough)

c.

Encouraged for increased fluid intake.( to liquify

secretions )

d. Encouraged ambulation from the first post operative day. (mobilizes pulmonary secretions) Evaluation: Exhibits no signs of chest infection during hospital stay.

Goal: Patient will be prevented from wound infection during his period of hospitalization. Nursing Intervention: a. Dressing of the wound following aseptic technique . ( wipe out micro organisms and prevents
infection)
b.

Administered prescribed antibiotics on time. ( it

kills micro organisms) dirty clothes)

c.

Advised to change clothes daily n replace dirty ones with clean ones. (prevents infections through

d. Monitored for signs of any infection like fever, redness n swelling of wound etc. ( helps to evaluate
infection earlier and manage accordingly)

e. Encouraged to take nutritious diet. ( helps in early

wound healing)

Evaluation: Patient did not exhibit any signs of infection during his hospital stay.

A new patient was admitted in male surgical ward with diagnosis of Rt. Nephrolithiasis with grade III Hydronephrosis . Patients general condition looks weak and lethargic. Vitals on admission were; temp-98f, Pulse84\min, Resp- 26\min. ,BP- 110/70mmof Hg. Patient complained of colicky pain in costovertebral region. pain was non radiating. Stat medicines given. Vitals were monitored regularly. Full information was given regarding surgery. All the required investigation were carried out. Premedicine tablet Alprax0.5 Mg P/O given then patient was kept NPO. Patient slept well at night.

067-02-08:

067-02-09:

patient looks anxious and worried. Patient was conscious, oriented to time, place and person. He was in NPO. Vitals were: Blood pressure 110/70 mm of Hg, Pulse 80/min, Resp. 24/Min, Temperature 98.4 0F at 9 am. Consent was taken , investigations reports were collected, O.T charge was paid II pint blood was arranged and other necessary pre-op preparations were done. Pre OP and post Op counseling was done. Patient was shifted to OT at 10am.

Patient received from OT at 12:20 PM in post operative ward. Patient was semiconscious. Vitals Blood pressure 124/80 mm of Hg, Pulse 66/Min, Respiration 22/Min, Temperature 98.4 0F. Patient was in NPO till next order. Foley catheter and Rt. Abdominal drain was present. IVF 4 hourly continued.GCS was 15/15. Oxygen saturation was well maintained (100%) without Oxygen inhalation. Intake and output was strictly maintained. Hb% to be sent coming morning. Vitals were monitored regularly. Patient complained of pain and analgesics were given as ordered.

Patient G/C fair. Patient was oriented to time, place and person. Today was 1st Post OP day. His vitals were - Blood pressure 120/80 mm of Hg, Pulse 98/Min, Respiration 20/Min, Temperature 98.20F. Drain was 100ml ,intake was 2575ml and output was 1170ml. IVF continued and he was on NPO. I helped patient in morning care and ambulation . After round drip was maintained for 12 hourly. Bowel sounds were present and sips was allowed and diet was slightly progressed from liquid to soft diet. Patient complained of pain so position maintains and analgesic was given. Health education about breathing and coughing exercise, diet hygiene provided. Patient shifted to male surgical ward at 11:45am.

067-02-10:

067-02-11:
Patient general condition improving. Today was 2nd post op day. Vitals were: temp:-980 f, pulse:-80/min, resp:-20/m, BP:-120/80 mm of Hg. Drain was 100 ml ,intake was 2575ml and output was 2750. After round IVF, I/V medications were stopped and I/V cannula was removed. Patient was allowed normal diet. Patient was kept on oral medication. Wound opened and dressing was done .no any redness, soakage and bleeding present. Informal health teaching given on wound care, diet and hygiene. Patient had no any complains of pain and discomfort. Bowel habit returned to normal.

067-02-12:
Patient looks anxious. Vitals were: temp:-980f, pulse:-20/m, resp:-80/m and BP:-120/90 mm of Hg. Drain was 50ml. Patient had concentrated and dark urine so he was advised to take plenty of oral fluids to drink. Patient had no any other complain of pain and discomfort. Informal health given on prevention of infection.

067-02-13:
Patient was alert. It was 4th POD. Drain was 7 ml. patient was taking normal diet. No any complains of patient. Vitals were: temp:- 980f, pulse;-76/m, resp:-20/m and BP:-120/80 mm of Hg. Informal health teaching was given on prevention of recurrent stone.

067-02-14:
Patient was alert and active. It was 5th POD. Drain was 10ml . After round drain was removed and dressing was done. Wound site was healthy. Oral medications were stopped except tab. Aciloc and cicin. Vitals were: temp:97.60f, pulse:- 82/m, resp:- 22/m and BP:110/70 mm of Hg. No any fresh complains.

067-02-15:
Patient was alert. It was 6th POD. Patient was on normal diet. Vitals were: temp:-97.60f, pulse:- 82/m, resp:-22/m and BP:-110/70 mm of Hg. No any fresh complains. Bowel and bladder habit normal. No any fresh complains. Plan for discharge tomorrow. Discharge teaching was given.

067-02-16:
Patient was alert. It was 7th POD. Vitals were: temp:- 980f, pulse:- 78/m, resp:- 20/m and BP:110/70 mm of Hg. Stitches were removed and dressing was done. No any signs of infection. Patient was discharged on tab. Aciloc 150 mg B.D for 5 days. Patient also advised to come for follow up after 1 month in SOPD.

Patient condition was improved .Prognosis of my patient was good. Kidney stones are painful but usually are excreted without causing permanent damage. They tend to recur, especially if the underlying cause is not found and treatment. Stone recurrence is 10% at 1 year, 33% at 5 years, 50% at 10 years .

Personal hygiene Nutritious diet Rest and sleep Disease condition (cause , signs and symptoms, treatment and prevention) Prevention of infection

Fluid intake(3 to 4 liters per day) Implement dietary changes Prevention of recurrent UTIs Medications Rest and sleep Sleeping with upper trunk slightly raised. Exercise

Prevention of stone formation Complications Early detection of infections Avoiding strenuous activities for one month Follow up care

Tab. R-loc 150mg 1 tab p\o B.D x 5 days

The patient was advised for follow up after 1 month in SOPD. He was also advised to come for visit if symptoms like fever, chills, flank pain, haematuria persists. He was also advised to watch for any signs of infection since he was discharged with dj stent .

About patient About family and environment About nursing care About diversional therapy and stress management About hospital policy

My patient MR. Choklal Subedi 37 years\Male admitted in male surgery ward on 067-02-08 at 6 pm with chief complain of flank pain since 3 months which increases on exertion and subsides while taking rest. During admission investigations were carried out which includes USG, IVU, Complete Blood Count etc. through which he was diagnosed with Rt. Sided Nephrolithiasis with grade III Hydronephrosis.

Since patient had done lithotripsy 1 month before he was planned for pyelolithotomy and on 067-02-09 Rt. Pyelolithotomy and DJ stenting was done . Operative findings were; a big stag horn stone and multiple stones about 8 in number and many tiny stones. After operation patient vitals were stable and was shifted in post operative ward for 1 day. On 067-02-10 patient was transferred to surgery ward.

On 067-02-11 patient started to have normal diet, I\V fluid was stopped , patient kept on oral medications, Foley catheter was removed and dressing was done . On 067-02-14 Rt. drain was removed and dressing was done . Patients condition was improved by that time and had no any complains and on 067-02-16 stitches were removed and patient was discharged on tab. Aciloc 150 mg bid for 5 days and to come for follow up after 1 month in SOPD.