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ACKNOWLEDGEMENT First, we would like to thank God for giving us the strength and knowledge, wisdom and perseverance

to finish this study. We would like to express our deepest gratitude to all the people who gave us the possibility to complete this study, And to all or parents, for their financial and emotional support.

We would also recognize Mrs. Maria Celeste M. Miranda, RN, our RLE clinical instructor for giving us enough time to prepare and finish this study.

Our group would also like to acknowledge our Nursing Care Management lecturer, Mrs. Syrilla Joan Domingo-Valdez II, in developing our knowledge in order to go through this study. The staff nurses of St. Cabrini Medical Center, for helping and guiding us all throughout our clinical duty. Above all, we extend our deepest gratitude to our Dean Ritchie Villasanta. We thank her for continuously developing activities that are very helpful for us, nursing students. The school curriculum is very beneficial to us as our institution is developing responsible and excellent health care practitioners.

INTRODUCTION Kidney stones are painful urinary disorders that start as salt/chemical crystals which precipitate out from urine. Under normal circumstances, the urine contains substances that prevent crystallization but for patients with this condition, these inhibitory substances are ineffective. Tiny crystals will pass out along with the urinary flow without causing problems. At least 1% of people will pass a kidney stone during their lifetime, producing some of the most severe pain possible.

Urolithiasis (urinary tract calculi or stones) and nephrolithiasis (kidney calculi or stones) are well-documented common occurrences in the general population of the United States. The etiology of this disorder is mutifactorial and is strongly related to dietary lifestyle habits or practices. Proper management of calculi that occur along the urinary tract includes investigation into causative factors in an effort to prevent recurrences. Urinary calculi or stones are the most common cause of acute ureteral obstruction. Approximately 1 in 1,000 adults in the United States are hospitalized annually for treatment of urinary tract stones, resulting in medical costs of approximately $2 billion per year


PURPOSE OF THE STUDY Our study would primarily benefit the nursing students in our institution. This paper would serve as their resource material if they are conducting research related to ours. It would also help the next generation of student nurses in proposing projects that would combat health issues in their course. They can borrow our paper and study it as they develop projects for their subordinates. The fact that our study is accurate, it would serve as an important basis and tool. The private and public hospitals can also use our paper as they come up with health missions. They could analyze our data gathered; determine health cases, what health concern to focus to and what actions to be developed to fight health problems. Our paper would also help the professors in our institution. They could have this as their material in imparting learning to their students

Related Literature The literature reflects the incidence of kidney (renal) stone formation to be greater among white males than black males and three times greater in males than females. Although kidney stone disease is one-fourth to one-third more prevalent in adult white males, black males demonstrate a higher incidence of stones associated with urinary tract infections caused by urea-splitting bacteria. Kidney stones are most prevalent between the ages of 20 to 40, and a substantial number of patients report onset of the disease prior to the age of 20. The lifetime risk for kidney stone formation in the adult white male approaches 20% and approximately 5% to 10% for women. The recurrence rate for kidney stones is approximately 15% in year 1 and as high as 50% within 5 years of the initial stone.

Anatomy and Physiology of the Urinary Tract The urinary tract is made up of the kidneys, two ureters, the bladder, and urethra. The major components are the kidneys, a pair of bean-shaped organs located below the ribs near the middle of one's back. The kidneys comprise a complex filtration system made up of individual nephrons that work together to remove waste products from the blood, which are eliminated from the body in the form of urine. The kidneys also function to maintain a stable balance of salts and other substances in the blood, as well as to produce a hormone erythropoietin, which triggers the production of red blood cells in the bone marrow.

The ureters are tube-like structures that transport the urine from the kidneys to the bladder where the urine is stored. Muscles called sphincters tighten around the urethra to prevent urine from leaking out. There are two sphincters: the internal is not controlled consciously, while the external sphincter is under voluntary control. The bladder is elastic and expands as it fills with urine. When the bladder reaches a certain capacity, which differs for each individual, the brain sends impulses to the internal sphincter to relax and other impulses to a muscle called the detrusor to contract and expel the urine out the urethra. This process is under the voluntary control of the individual, who can hold the urine until social circumstances allow for urination. (Loss of this control is urinary incontinence.)

Urine is normally "sterile," meaning that it usually contains no bacteria. The body accomplishes this through several methods. First, the two sphincter muscles that

prevent urine leaking from the bladder to the urethra, also prevent the bacteria that normally colonize the skin from ascending through the meatus (the opening in the urethra) into the bladder. Second, the length of the urethra makes it difficult for bacteria to get to the bladder. The fact that women have a much shorter urethra than men accounts for the fivefold increase of UTIs among women compared to men. Finally, if bacteria do make it to the bladder, the body is equipped with valves where the ureters empty into the bladder, a region known as the trigone. These valves prevent the "reflux" of urine, and any bacteria present, back up into the kidneys. Further, the bladder almost completely empties when urination occurs, so that any bacteria present should be excreted as well. Nevertheless, despite all these defense mechanisms, infections sometimes occur.

Pathophysiology of Nephrolithiasis Escherichia coli is the most common microorganism implicated in urinary tract infection. E. coli is an aerobic, Gram-negative bacterium and is resident flora in the GIT. When gaining access into the urine tract (which is sterile), E. coli causes infection. Women are particularly vulnerable due to a short urethra and close proximity between the urethra and anus.Mechanical obstruction of the urinary tract, such as with renal calculi or an enlarged prostate and introduction of urinary catheters and bladder can also increase the likelihood of developing a urinary tract infection. Any factor that reduces urinary flow or causes obstruction, which results in urinary stasis or reduces urine volume through dehydration and inadequate fluid intake, increases the risk of developing kidney stones. Low urinary flow is the most common abnormality, and most important factor to correct with kidney stones. It is important for health practitioners to concentrate on interventions for correcting low urinary volume in an effort to prevent recurrent stone disease. Contributing Factors of Nephrolithiasis Sex. Males tend to have a three times higher incidence of kidney stones than females. Women typically excrete more citrate and less calcium than men, which may partially explain the higher incidence of stone disease in men

Ethnic Background. Stones are rare in Native Americans, Africans, American Blacks, and Israelis

Family History. Patients with a family history of stone formation may produce excess amounts of a mucoprotein in the kidney or bladder allowing crystallites to be deposited and trapped forming calculi or stones. Twenty-five percent of stoneformers have a family history of urolithiasis. Familial etiologies include absorptive hypercalciuria, cystinuria, renal tubular acidosis, and primary hyperoxaluria

Medical History. Past medical history may provide vital information about the underlying etiology of a stone's formation. A positive medical history of skeletal fracture and peptic ulcer disease suggests a diagnosis of primary

hyperparathyroidism. Intestinal disease, which may include chronic diarrheal states, ileal disease, or prior intestinal resection, may be a predisposition to enteric hyperoxaluria or hypocitraturia. This may result in calcium oxalate nephrolithiasis because of dehydration and chemical imbalances. Irritable bowel disease or intestinal surgery may prevent the normal absorption of fat from the intestines and alter the manner in which the intestines process calcium or oxalate. This may also lead to calculi or stone formation. Patients with gout may form either uric acid stones or calcium oxalate stones. Patients with a history of urinary tract infections (UTI) may be prone to infection nephrolithiasis caused by urea-splitting bacteria. Cystinuria is a homozygous recessive disease leading to

stone formation. Renal tubular acidosis is a familial disorder that causes kidney stones in most patients who have this disorder.

Dietary Habits. Fluid restriction or dehydration may cause kidney stone formation. Dietary intake that is high in sodium, oxalate, fat, protein, sugar, unrefined carbohydrates, and ascorbic acid (vitamin C) has been linked to stone formation. Low intake of citrus fruits can result in hypocitraturia, which may increase an individual's risk for developing stones.

Environmental Factors. Fluid intake consisting of drinking water high in minerals may contribute to kidney stone development. Another contributing factor may be related to geographical variables such as tropical climates. Stone formation is greater in mountainous, high-desert areas that are found in the United States, British Isles, Scandinavia, Mediterranean, Northern India, Pakistan, Northern Australia, Central Europe, Malayan Peninsula, and China. Affluent societies have a higher rate of small upper tract stones whereas large infection stones occur more commonly in developing countries Bladder stones are more common in underserved countries and are likely related to dietary habits and malnutrition Medications. Medications such as ephedrine, guaifenesin, thiazide, indinavir, and allopurinol may be contributory factors in the development of calculi.

Occupations. Occupations in which fluid intake is limited or restricted or those associated with fluid loss may be at greater risk for stone development as a result of decreased urinary volume.

Pathogenesis For ages nephrolithiasis has been a widespread disease and clinical statistics prove that its morbidity index is still increasing, thus it becomes a social problem. Peak morbidity usually occurs at the age between 30 and 40, that is why many patients professionally active and creative have to leave their jobs for a long period. In contrast to earlier years, frequency of the disease occurrence in females is systematically increasing and nowadays it is only slightly lower from that in males. Etiology and pathogenesis of the disease is also not entirely explained. It is generally accepted that urinary stone formation is determined by multiple factors which affect first of all chemical composition and physical features of urine. Individual properties of the kidneys and urinary tract and infections especially with urease producing pathogens as well as environmental factors are also taken into account. The most favourable circumstances for nephrolithiasis occurrence is co-existence of all these factors.


Prevalence As much as 10% of the U.S. population will develop a kidney stone in their lifetime. Upper urinary tract stones (kidney, upper ureter) are more common in the United States than in the rest of the world. Researchers attribute the incidence of nephrolithiasis in the United States to a dietary preference of foods high in animal protein Clinical Presentation Symptoms may vary and depend on the location and size of the kidney stones or calculi within the urinary collecting system. In general, symptoms may include acute renal or ureteral colic, hematuria (microscopic or gross blood in the urine), urinary tract infection, or vague abdominal or flank pain. A thorough history and physical examination, along with selected laboratory and radiologic studies, are essential to making the correct diagnosis. Small nonobstructing stones or "silent stones" located in the calyces of the kidney are sometimes found incidentally on x-rays or may be present with asymptomatic hematuria. Such stones often pass without causing pain or discomfort. Kidney Stone Symptoms Stones in the kidneys can become lodged at the junction of the kidney and ureter (ureteropelvic junction), resulting in acute ureteral obstruction with severe intermittent colicky flank pain. Pain can be localized at the costovertebral angle.


Hematuria may be present intermittently or persistently and it may be microscopic or gross. Kidney Stone Complications Occasionally, stones can injure the kidneys by causing infection, resulting in fever, chills, and loss of appetite or urinary obstruction. If a UTI accompanies the urinary obstruction, pyelonephritis or urosepsis can occur. If stones are bilateral, they can cause renal scarring and damage, resulting in acute or chronic renal failure. Causes of Nephrolithiasis Low Urine Volume Low urine output is defined as < 1 liter/day. The typical etiologies of nephrolithiasis are low fluid intake and reduced urine volume. Other possible causes of low urine volume include chronic diarrheal syndromes that result in large fluid loses from the gastrointestinal tract and fluid loss from perspiration, or evaporation from lungs or exposed tissue. Stone formation may be initiated by a low urine output, providing a concentrated environment for substances such as calcium, oxalate, uric acid, and cystine to begin crystallization. No Pathological Disturbance In approximately 35% of the stone-forming population, no identifiable risk factors for stone formation can be found. This group includes individuals with normal


serum calcium and PTH, normal fasting and calcium load response, normal urine volumes, normal pH, calcium, oxalate, uric acid, citrate, and magnesium levels in the presence of calcium nephrolithiasis.

RELATED DIAGNOSTIC TESTS Urinalysis: Color may be yellow, dark brown, bloody. Commonly shows RBCs, WBCs, crystals (cystine, uric acid, calcium oxalate), casts, minerals, bacteria, pus; pH may be less than 5 (promotes cystine and uric acid stones) or higher than 7.5 (promotes magnesium, struvite, phosphate, or calcium phosphate stones). Urine (24-hr): Cr, uric acid, calcium, phosphorus, oxalate, or cystine may be elevated. Urine culture: May reveal UTI (Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas). Biochemical survey: Elevated levels of magnesium, calcium, uric acid, phosphates, protein, electrolytes. Serum and urine BUN/Cr: Abnormal (high in serum/low in urine) secondary to high obstructive stone in kidney causing ischemia/necrosis. Serum chloride and bicarbonate levels:


Elevation of chloride and decreased levels of bicarbonate suggest developing renal tubular acidosis.

CBC: Hb/Hct: Abnormal if patient is severely dehydrated or polycythemia is present (encourages precipitation of solids), or patient is anemic (hemorrhage, kidney dysfunction/failure). RBCs: Usually normal. WBCs: May be increased, indicating infection/septicemia. Parathyroid hormone (PTH): May be increased if kidney failure is present. (PTH stimulates reabsorption of calcium from bones, increasing circulating serum and urine calcium levels.)


KUB x-ray: Shows presence of calculi and/or anatomical changes in the area of the kidneys or along the course of the ureter. IVP: Provides rapid confirmation of urolithiasis as a cause of abdominal or flank pain. Shows abnormalities in anatomical structures (distended ureter) and outline of calculi. Cystoureteroscopy: Direct visualization of bladder and ureter may reveal stone and/or obstructive effects. CT scan: Identifies/delineates calculi and other masses; kidney, ureteral, and bladder distension. Ultrasound of kidney: To determine obstructive changes, location of stone; without the risk of failure induced by contrast medium.


Nursing Care Management Nursing history

Demographic data Patients name: M, RA B. Age: Birth date: Address: Height: Weight: Civil status: Religion: Occupation: Highest educational Attainment: Father: Mother: Rate: Room number: Hospital number: high school R.M. M.M. 720.00 236b 73553 16 21 April 16, 1988 Bukal South, Batangas City 51 48kg single catholic factory worker

Admission number: 40863 Admission date: Admission time: May 27, 2009 1:27 pm

Attending physician:Dr. Ronald Miranda

Chief complaint: Painful urination

History of present illness: One week prior to admission, the patient started to experience painful urination. She consulted their office clinic and was given Bactrim. On Monday, she had blood in the urine. The severity of the pain is 5/10 last week and turned to 8/10 pain scale. She consulted in this institution and was admitted. The patient has no allergy in any medicine and food.

History of past illness: 17

The patient had mild hepatitis a when she was young. Shes complete in immunization and never undergone any surgery.

Lifestyle and health practices: The patient doesnt has any vices hence not doing any exercise. Shes working as a factory worker in Calamba.

Nutritional habits: The patient is eating regular foods most of the time but shes also fond of eating junk foods and soft drinks. Recent sleep: The patient has different positions in sleeping. Her sleeping time ranges from 11-12:00 pm and wakes up at 6 in the morning. Theres no interruption when she sleeps.

Treatment and medication


Solution D5LR 1L Paracetamol Tcup IV For temperature 38.8

Frequency Q8


Tazocin Paracetamol 500mg/tablet For Temperature 37.8



Lactated ringers in 5% dextrose Used for rehydration.

Intravenous paracetamol Used to revitalize. Intravenous administration is more reliable and reaches peak concentrations faster compared with oral routes, as proven for


paracetamol. Since paracetamols side effect profile is considerably superior, availability of an intravenous form is very useful when other routes are less feasible.

Paracetamol Commonly used for the relief of fever, headaches, and other minor aches and pains, and is a major ingredient in numerous cold and flu remedies. While generally safe for human use at recommended doses, acute overdoses of paracetamol can cause potentially fatal liver damage and, in rare individuals, a normal dose can do the same; the risk is heightened by alcoholism.

Paracetamol toxicity Foremost cause of acute liver failure.

Tazocin Tazocin injection contains two active ingredients, piperacillin which is a penicillin-type antibiotic, and tazobactam, which is a medicine that prevents bacteria from inactivating piperacillin. The injection is used to treat infections with bacteria.


Tazocin is given by injection or infusion (drip) into a vein. It is used to treat severe infections, including those caused by multiple organisms.

Use with caution in Decreased Kidney History Low of sodium kidney failure allergies diet function

- Low blood potassium levels (hypokalaemia) Not to be used in Allergy to penicillin or cephalosporin type antibiotics

- Allergy to beta-lactamase inhibitors This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor or pharmacist if you have previously experienced such an allergy. If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately.




Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Because a side effect is stated here, it does not mean that all people using this medicine will experience that or any side effect. Nausea and Diarrhea vomiting Rash

- Overgrowth of the yeast Candida, which may cause infection such as thrush - Disturbances in the normal numbers of blood cells in the blood Low Difficulty blood sleeping pressure Headache (insomnia) (hypotension)

- Inflammation of the wall of a vein with a blood clot forming in the affected segment Reactions Skin reactions Severe such as Sore itching, allergic Fever at injection hives, flushing, skin of vein (thrombophlebitis) Constipation Indigestion mouth eczema rashes (pyrexia) site





disorders Fatigue





- Hallucinations


Each time we are permitted to take our journey with the patient and their family, we treat it as an honor they have bestowed upon us. We have the opportunity to provide care to clients and to communicate to them by and by.

As we entered at our patients room which is room number 236, we greeted her and then we gave our best smiles to her. The patient that was assigned to us seems to be very kind, she is very accommodating and has showed willingness in participation in the interview. She is M, RA B., a 21 years old girl. Her birthday is April 16, 1988 came from Bukal South, Batangas City. Shes single, a catholic and a Filipino. Her highest educational attainment is High school thats why shes working as a factory worker at First Philippine Industrial Park located at Sto. Tomas, Batangas.


She was admitted on May 27, 2009 at exactly 01:27pm. One week prior to admission, the patient started to experience painful urination. She consulted their office clinic and was given Bactrim. On Monday, she had blood in the urine. The severity of the pain is 5/10 last week and turned to 8/10 pain scale. She consulted in this institution and was admitted. The patient has no allergy in any medicine and food. About her past illness, the patient had mild hepatitis A when she was young. Shes complete in immunization and never undergone any surgery. The patient doesnt has any vices hence not doing any exercise. The patient is eating on time but fond of eating junk foods and soft drinks. The patient has different positions in sleeping. Her sleeping time ranges from 11-12:00 pm and wakes up at 6 in the morning. Theres no interruption when she sleeps.

Due to the diagnosis, which is Urinary Tract Infection, the Doctor prescribed her to take medications such as D5LR 1L, Paracetamol Tcup IV, Tazocin, and Paracetamol 500mg/tablet.


Nursing Process Assessment Nursing Diagnosis Subjective; :Masakit Acute pain related Short term: to biological At the end of the such as shift, the patients relief pain Planning Nursing Intervention Use antispasmo dic drugs To Rationale Expected Outcome relieve The Patient will relief

irritability and pain

experience pain

angpagihi ko as factors

verbalized by the trauma or activity may patient of process Objective:

disease and discomfort. Encourage patient to To provide adequate hydration to patients at risk for

drink liberal Long term; >Facialgrimace. Upon the patient >Restlessness. discharge, the amount fluid of



patient >V/S asfollows:T: 37.3P: 19BP: 120/90 82R: taken increase knowledge preventive measure treatment modalities absence complication.


Instruct the patient to




understand UTIs and treatment. their


avoid urinary


tract irritant. To reduce

and of Teach patient cleanse around perineum and urethral meatus to

concentrati on of

pathogens of Vaginal opening. the


after bowel movement with front to back motion


Nutritional Assessment Renal Diet You will be advised to stick to a renal diet if your kidneys have failed meaning that your kidneys are not able to remove the wastes from your body which are usually produced from the foods that you eat and the liquids that you drink.

The main purpose of a renal diet is to control the amount of protein, sodium and phosphorous. Along with this, a renal diet will also help reduce the amount of wastes present in the body thereby helping the kidney work better and avoiding a total renal failure. Renal Diet

In learning about the renal diet, we will focus more on what food is to be avoided because of what they may contain:

Protein: Unless you are on haemodialysis, you should limit the protein in your diet to 0.75g per kilogram of your body weight. Ensure that you are taking in sufficient calories else you will have to increase the intake of protein. The richest sources of protein are meat, fish, cheese, eggs, milk, pulses and nuts.

Sodium: has to be controlled in the diet of renal patients as this helps in maintaining the fluid balance in the body along with avoiding fluid retention and high blood pressure. A high content of sodium is found in table salt,


soups, processed cheese, canned food, junk food and pickles. All of us know that we cannot avoid the normal table salt in our diet completely as food would be completely tasteless and inedible. Fortunately, the quantity of the salt that we use can be controlled with the help of using garlic, mustard and pepper that helps in making the food tastier when very little salt is used. Also, be wary of salt substitutes like Lo-Salt. No doubt these substitutes are low in sodium but they are very high in potassium which makes them equally dangerous in your diet.

Potassium: The intake of potassium should be restricted only if the tests reveal high potassium levels in the blood. The main reason for this is that many healthy foods that form an important part of the diet contain potassium. If you do have to restrict the intake of potassium then avoid leafy vegetables, fruit and fruit juices. Also, potatoes contain a high level of potassium especially if they are fried or baked.

Phosphate: Excess of phosphate in the blood becomes a problem during the 4th and 5th stage of the chronic kidney failure wherein the kidney works at about 20% of its maximum capacity. A high level of phosphate makes the patient itch very badly and has an adverse effect on the arteries too. A good diet in not sufficient to control the level of diets in most cases and additional medications known as phosphate binders too have to be taken along with the food which keep the phosphate in the gut and prevent its absorption into the blood. These medicines have to be taken just before eating or along with food else they will not be effective.


Phosphates are usually associated with proteins and are found in high content in milk, cheese, baking powder, shellfish and wholegrain cereals. It is also found in convenience foods which are added by their manufacturers. With so many limitations on the food that you can consume, it is not uncommon that kidney patients start to lose weight. You have to maintain your weight at a healthy level and here are some food tips that you can use which will fit your diet plan and help you maintain your weight:

All breads, tortillas and cereals except bran breads and cereals can be consumed.

Add a measured quantity of margarine, mayonnaise and vegetable oils like olive oil or canola oil in your diet.

If you are not diabetic, then you can add honey and sugar to add calories. Lastly, remember that you must eat snacks and meals at regular intervals and should not miss any meal.

No matter how much of information you can gather on the internet, it is vital that you consult a dietitian and work out a diet plan for you which will be based on your weight, food habits and renal history. A good diet plan will ensure that you can move forward beyond your kidney failure and lead a healthy and fulfilling life. All it will take is a little self control. All the best!


Sample Renal Diet


1/2 cup cranberry juice 1 egg 2 slices toast 2 teaspoons jelly 2 tablespoons non-milk creamer 1 cup coffee


3 ounces sliced turkey 2 slices bread 1 lettuce leaf 2 teaspoons mayonnaise 1/2 cup cucumber salad 1 tablespoon oil and vinegar dressing 1 medium apple 1 cup lemonade

Evening Meal

3 ounces broiled fish 1/2 cup rice 1/2 cup green beans 1 cup lettuce salad 1 tablespoon oil and vinegar dressing 1 dinner roll 2 teaspoons margarine 1/2 cup canned peaches 1 cup lemon water