ACKNOWLEDGEMENT

This case study report has been prepared during my clinical practice in Chitwan School of Teaching Hospital. It is the practical requirements of the post basic bachelor nursing curriculum. I got myself completely involved in the care and management of the patient during the period. However the work would not be having accomplished successfully with my efforts alone, without the guidance and support of a number of people in the endeavor. I have a great pleasure to express my gratitude to the CSMS, school of nursing for providing this kind of course of study and present them in systematic way. I would like to express my indebtedness to campus chief, co-ordinator and all respected teachers. My special thanks go to all clinical supervisors Madam Kalpana Sharma, Madam Saraj Gurung for providing theoretical knowledge, supervision and suggestion as well as managing time and place during my practice. I am equally thanking full to my colleagues, senior as well as juniors and also thankful to my patient and his family for providing the necessary information so kindly and co-operatively. Also I would like to bestow thanks to Nursing Director and all the staff of CSMS for their kind helps. Lastly, I am thankful to all helping hands that encouraged and supported directly or indirectly to give case study report in final shape.

Thanks. Rekha Sharma (Parajuli) BN 1st year Hospital major group CSMS

CONTENTS
S.N. 1 2 3 4 5 6 A B C D E F G H I J K L M N A p p l i ca t i o n of n ur si ng t h e o r y. B a c kgr o u n d O b j e ct i ve s of t he c ase s t ud y R a t i on a l f or t he s el ect i o n o f ca s e H i s t or y t a ki n g a n d p hys i c a l e x a mi n a t i o n . D e ve l o p me n t a l t a s ks a n d c r i si s NEPHROLITHIASIS In t r o d u c t i o n a bo u t di s e a se D e f i ni t i o n E p i d e mi o l o gy T yp e s of c al c ul i P a t h o ph ys i o l o gy E t i ol o gy a n d r i s k f ac t o r C l i ni c al ma n i f es t at i on D i a gn o s t i c e va l ua t i o n F i n d i n gs o f t h e i n ve s t i ga t i o ns M e d i c al ma n a ge me n t S u r gi c a l ma n a ge me n t D r u gs p r o f i l e N u r s i n g ma n a ge me n t TOPICS PAGE NO.

O 7 8 9 10 11 12 13 14 15 16 17

N u r s i n g c ar e pl a n C o mp l i c a t i o n D a i l y p r o gr e ss n ot e . D i ve r s i o na l t h er a p y. H e a l t h e d uc at i o n gi ven d u r i n g h o s p i t al i za t i o n . D i s c h ar ge t ea c hi n g a n d p l an n i n g D i s c h ar ge me d i c i n e P r o gn o s i s F o l l o w -u p c a r e a n d ho me vi s i t L e a r ni n g f r o m c a s e s t u d y C o n c l us i o n R e f e r e n ce s

BACKGROUND
A c c o r di n g t o t h e c ur r i c ul u m, w e a r e mo b i l i ze d t o M e di c al / S ur gi c a l w a r d a s t h e p ar t of h o sp i t a l ma j o r pr a ct i c u m f o r f o u r w ee ks . W e a r e r e s p on s i b l e t o p e r f o r m o n e M ed i ca l / S u r gi c al ca s e s t ud y d u r i n g t he p er i od o f mo b i l i za t i o n . W e a r e p r o vi d ed t h e o p p o r t u n i t y t o i mp l e me n t o u r t h eo r et i c al kn o w l e d ge i n t h e r ea l si t ua t i o n . W e c a n a ss e ss t h e n o r ma l d e ve l o p me n t al t a s k a n d s i t u a t i o n a l cr i si s d ur i n g i l l n e ss i n t he s u r gi c al w a r d . T h r o u gh t h i s w e c a n al so c o mp a r e t he n o r ma l de ve l o p me n t a l t a s k w i t h t h e i l l p at i e nt .

OBJECTIVES OF CASE STUDY

A t t he e nd o f 5 ( f i ve ) w e e ks p e r i o d i n me d i c al / s u r gi ca l wa r d i n C h i t w a n M e di c al C o l l a ge , T e a c hi n g H os p i t a l , I w i l l b e a b l e t o p r o vi d e c o mp r e h en si ve c a r e t o pa t i e nt t h r o u gh c a se st u d y. T h e ma i n ( s pe ci f i c) o bj e ct i ve s o f t hi s c a se st u d y ar e as f o l l o w s: The main (specific) objectives of this case study are as follows: 1 . T o pr o vi d e ho l i st i c nu r s i n g c a r e t o t h e pa t i e nt u si n g t h e n ur si n g p r o c es s . 2 . T o ga i n t h r ou gh kn o w l e d ge a b o ut on e s pe c i f i c di s e as e , i t s pat h o l o gy a n d ma n a ge me n t . 3. A p p l y n u r si n g t h e or i e s w h i l e gi vi n g c o mp r e h e ns i ve c ar e t o pa t i e n t .

4 . T o e x p l a i n a b o ut di s ea s e i t s p r o gn o si s an d a p p l y i n pl a nn i n g n u r s i n g a c t i o ns . 5 . T o c o m mu n i c a t e e f f ec t i ve l y t o t h e p a t i e nt a n d h i s f a mi l y. 6 . T o ob s er ve a n d c o -r e l a t e t h e de ve l o p me n t mi l e s t o ne t o t h e c h i l d. 7 . T o di st i n gu i s h t h e c op i n g me c h a n i s ms b e t w e e n c hi l d a n d ab o u t p e r s on . 8 . T o pe r f o r m s ki l l t o r ed u c e pa i n a n d di s c o mf o r t f or f a mi l y. 9 . T o c ol l a b o r a t e w i t h t h e c l i e nt , f a mi l i e s a n d he a l t h t e a m me mb e r s i n t h e d i s c ha r ge p l an n i n g a n d f ol l o w u p c ar e o f p a t i e nt f r o m h o s p i t a l t o t he c o m mu n i t y.

RATIONAL FOR SELECTION OF THE CASE

N e p h r ol i t h i a si s is one of t he c o m mo n proble m in Nepal. It i s mo r e c o m m o n i n a d ul t h oo d . It i s o n e o f t he i n t e r e s t ed c a s e s a mo n g d i f f e r e n t c a se s . It i nc i d e nc e i s i n cr e as i n g d a y b y d a y. T h e r i s k f a c t or s of n e p h r ol i t hi a si s a r e pr e ve n t a bl e . M os t o f t h e m a r e d u e t o i m mo b i l i t y a n d s e d e nt ar y l i f e s t yl e w h i c h i n c r e a se st a si s, d e h yd r a t i o n w hi c h l e a ds t o s u p er s a t ur at i o n, hi gh mi n e r al c on t ai n i n d r i n ki n g w a t er , a d i e t h i gh i n p ur i ne s , o x a l at es , ca l c i u m s up p l e me n t s a n d a ni m a l pr ot e i n s . S o , w e c a n mi n i mi ze n e p h r ol i t hi a si s b y i mp r o vi n g o u r l i f es t yl e. W e c a n gi ve h e a l t h e d u c a t i o n t o r e d u ce r i s k.

It i n t e r f er es n o t o nl y p a t i e n t s l i f e b u t al s o a l l t h e f a mi l y me mb e r s j o b. S o , p a t i e nt a n d h i s f a mi l y me mb e r s h o ul d kn o w a b o u t t he c as e . I s e l e ct t h i s ca se f o r c as e st u d y t o go t o d e p t h a n d kn o w t h e p a t h o p h ys i ol o gy o f n e p h r ol i t hi a si s a n d a l s o t o ga i n kn ow l e d ge a b o u t h o w t o ma n a ge n e p h r o l i t h i as i s at h o sp i t al s e t t i n g, h o w i t ef f ec t o n p at i e n t s h e al t h a nd hi s da i l y r ou t i ne , h o w t o mi n i mi ze r i s k f a ct o r o f mo r b i d i t y a n d mo r t a l i t y, t o kn o w a b o u t pa t i e nt s f a mi l y e n vi r o n me n t , s u p p o r t i n g s ys t e m a n d e c o n o mi c s t at u s a nd i t s e f f e ct i n p a t i e nt s c o n di t i o n .

A f t er ga i n i n g kn o w l e d ge a b o u t n e p hr o l i t h i a s i s, I c a n s h a r e m y k n o w l e d ge w i t h m y p a t i e n t a n d hi s f a mi l y. T h i s c an h e l ps t o p r e ve nt f r o m c o mp l i c a t i o n a nd p r o vi d e s s u p p or t s t o t h e p at i en t an d f a mi l y.

HISTORY TAKING
1. BIO -DATA Name : Choklal Subedi Age : 37 years Sex : Male Address : Sukranagar-7,chitwan Occupation : Foreign worker (lab our) Marital status : Married Religion : Hindu Educational level : 10+2 passed in Education I. P NO : 20543 Ward : Male Surgical Ward Bed NO :7 Date of admission :067-02-08 Date of discharge :067-02-16 Provisional diagnosis :Rt.Nephrolithiasis with grade III Hydronephrosis Final diagnosis :Rt. Pyelolithotomy with DJ Stenting Attending physician :Dr. Chandra Prakash Information obtained from : Sita Subedi ( wife)

2. CHIEF COMPLAIN Pain in the right loin on and off since 3 months

3. HISTORY OF PRESENT ILLNESS 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. But still there was no relief in pain so he came to CMC for further treatment. Description of symptoms: Onset: sudden Characteristics: sudden onset of colicky pain in the rt. loin, non progressive but increase with exertion Duration: 3 months Prior history of similar problem: no Aggravating/ alleviating factors: Heavy work aggravates and rest relives the symptoms.

History of contact: 85 days earlier in Korea in a hospital Treatment: lithotripsy done on April 15

4. PAST HEALTH HISTORY History of any chronic illness (in client): no Any other health problem: no History of any UTIs and renal stone: no History of any drug allergy and long term use of any medications: no Previous hospitalization: no History of any operation: no

5. FAMILY HISTORY 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 of the patient among family members.

FAMILY TREE

INDEX
Female Male Patient

6. PERSONAL HISTORY Smoking: Non smoker Alcohol: Non alcoholic Personal care habit: Takes bath daily Rest and sleep habit: Sleeps for 6-7 hours in 24 hours Recreational habit: Watch news in TV and read newspaper

Elimination habit: Has a regular bowel and bladder. Dietary habit: He is a non-vegetarian. No of meals taken in a day: 2 times a day but has a poor water drinking habit (drinks only 2 glasses of water in a day) Food likes: Meat and milk products Food dislikes: No any food dislikes Food allergy: No any food allergy

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

8. HOME ENVIRONMENT

Total number of family members: 8

Number of rooms in home: 5

Kitchen: Separate kitchen

Type of fuel used: Gas

Source of drinking water: Tube well

Type of toilet used: Water sealed

Type of drainage system: Closed drainage

PHYSICAL EXAMINATION
I General Inspection Level of conscious - Alert Gait Balance Facial expression - Anxious Nutritional status well nourished General build - Average Hygiene Well maintained( good hygiene)

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

III.EXAMINATION OF HEAD, FACE AND NECK Inspect head for Color and texture of hair: black and silky hair Cleanliness: clean Pediculosis: no pediculosis Abrasions/injuries/others: no

Inspect eyes for Swelling of eyelids: no Discharge: no Colour of sclera/ conjunctiva: white and transparent Corneal lens opacity: transparent lens, no opacity present. Pupil size and reaction to light: 3 mm and both eyes equally reactive to light. Eyes movement: both eyes move together while following the object. Vision problem: no any vision problem

Inspect ears for Appearance: symmetrical Location: the top of the pinna crosses the eye- occiput line Pain and discharge: no pain and discharge Wax/ redness of external auditory canal: no redness, wax present. Hearing problem: no any hearing problem

Inspect for nose Discharge: no discharge Blockage: no blockage Bleeding: no bleeding Septal defect: not present

Inspect for mouth Colour of lips / mucus membrane: pink, moist Sore/ crack/ bleeding/ pain of gums: not present Dental caries/ missing of teeth/ dentures/ bridges: no dental caries, dentures and bridges

Sores/ cracks on lips: no sore and crack on lips Enlargement of tonsils: no enlargement of tonsil Oral hygiene: good

Inspect for neck Enlarged lymph node: not palpable Enlarged thyroid gland: not enlarged Enlarged neck veins: not enlarged

IV. EXAMINATION OF CHEST Inspect chest for Shape and symmetry of the chest: symmetrical shape and the lateral diameter is wider than the anteroposterior diameter Chest movement: even expansion of the chest Difficulty in breathing: no difficulty in breathing Palpate chest for Tenderness: no tenderness Depression along the ribs: no depression along ribs

Chest percussion Deep resonant sound over the lungs.

Auscultate the chest for Breathing sound(front and back): Breathing sound heard in all areas of the lungs. Abnormal sounds: no rales, ronchi, wheezing sound present Heart sound(4 areas): Lub & dub sound present in 4 areas and no heart murmur

V. EXAMINATION OF ABDOMEN Inspect abdomen for Size: normal Shape: round and uniform shape Scars: no scars Enlarged veins: no visible blood vessels present

Auscultate for bowel sound Bowel sound present in all areas.

Abdominal percussion Scattered areas of tympany and dullness No tenderness

Palpate abdomen for Enlarged liver: not palpable Enlarged spleen: not palpable Enlarged kidney: not palpable Tenderness: present over costo-vertebral angle Masses: not present

VI. EXAMINTION OF LIMBS Inspect/ palpate limbs for Joint mobility/ tenderness/ redness/ swelling/ temperature: able to move joints freely and no tenderness, redness, swelling and normal temperature

Texture and elasticity of skin: smooth skin and skin quickly comes back to its previous state when pulled and released quickly ( elastic skin) Colour of nails: pink

Palpate axillae/ groin for Enlarged lymph nodes: not present

VII. EXAMINATION OF BACK Inspect the back for Position of spine: spine is in the midline Condition of skin/prone to bed sore: normal and not prone to bed sore

VIII. EXAMINATION OF MALE GENITALIA Inspect the genitalia for Sores: no sores Discharge: no discharge from the urethra Swelling and redness of scortum: no swelling and redness Hygiene: clean

Palpate the scortum for Lump: no lump Size of testes: testes are equal in size Tenderness: no tenderness

DEVELOPMENTAL TASKS AND CRISIS

My patients age is 37 years. Therefore he belongs to young adulthood. Young adulthood starts at the age of 21 to 39 years. Childhood and adolescents are the period of growing up; adulthood is the time for settle down. The growth of body system is completed; it is a period of gaining some rewards and facing challenges and crisis. During adulthood, individuals increasingly move away from their families or remain single. Young adults are active and must adapt new experiences and newly acquired independence. This is a time of continuing transitions when individuals may reassess their life goals. Physical characteristics of young adults begin changes in reproductive and physical abilities that signify the beginning of another stage in life. The young adult is expected to enter new roles of responsibility at work, at home, and in society and to develop values, attitudes and interests on keeping with these roles. According to Gilligan (1993), women struggle with the issues of care and responsibility, and in turn their relationships progress towards a maturity of interdependence. As a progress towards adulthood, the moral rights without interfering in the rights of others to how to lead a moral life, which includes obligations to themselves and their families and people in general. Young adults being quite active, experience severe illness less commonly than older age groups and often post pond seeking health care. The developmental crisis of young adult is intimacy versus isolation according to Erik Erickson. This means that the young adult attempts to establish close relationship with other persons, sexual or otherwise; failure to resolve this stage successfully can lead to feelings of social and emotional isolation. The developmental tasks of the young adult as compared to my patient are as follows:

According to book
1. 2. 3. 4. 5. The young adults achieve independence from parental control. They begin to develop strong friendships and intimate relationship outside the family. They establish personal set of values. They develop a sense of personal identity. They prepare for life work and develop the capacity for intimacy.

Major health problems of young adults Accidents related to the following activities may cause injury or death: Driving a vehicle Occupational Recreational

Social problems: Drug abuse Suicidal attitude( poison, burns or hanging) AIDS, STI

According to patient
1. 2. 3. 4. 5. Achieved independence from parental control. Developed strong friendship and intimate relationship outside the family. Established personal set of values. Has a sense of personal identity. Is prepared for life work and developed the capacity for intimacy.

Health problem My patient has no any other significant health problem except Nephrolithiasis.

NEPHROLITHIASIS

INTRODUCTION
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.

DEFINATION
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

EPIDEMIOLOGY
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.

TYPES OF CALCULI
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 are 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 occur as a result of a rare hereditary condition in which there is xanthine oxidase deficiency.

PATHOPHYSIOLOGY

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, any 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).

ETIOLOGY
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. 6. Diet- high protein and high calcium. 7. Hereditary. 8. A number of different medical conditions can lead to an increased risk for developing kidney stone. - Gout

9.

Hypercalciuria Hyperparathyroidism Diabetes Hypertension Inflammatory bowel disease

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 11. Foreign bodies 12. Failure to empty the bladder completely

According to patient 1. Patient used to do strenuous activity and has a poor water drinking habit. 2. He is fond of meat and milk products.

CLINICAL MANIFESTATIONS
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.

3. Pain radiates around the sides and down towards the testicle in the males and the bladder in the female. 4. Nausea and vomiting 5. Hematuria , Pyuria, Dysuria, Oliguria 6. Post renal azotemia: the blockage of urine flow through a ureter. 7. Hydronephrosis : the distension and dilation of the renal pelvis and calyces. 8. Fever and chills (if infection is present)

According to patient 1. Patient has characteristic pain in rt. loin 2. Hydronephrosis present

DIAGNOSTIC EVALUATION
According to book 1. The diagnosis of kidney stones is suspected by the typical pattern of symptoms. 2. 3. History Taking Physical examination

4. Kidney, ureter and bladder(KUB) 5. Intra venous urogram (IVU) 6. Ultrasound

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

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

According to patient 1. Typical characteristic pain was present 2. History taking was done 3. Physical Examination was done 4. IVU was done 5. USG was done 6. Blood test done were(CBC, RBS, Urea, Creatinine, Sodium, Potassium) 7. Other investigation carried out in my patient are: a. BT b. CT c. PT with INR d. HIV e. HBsAg f. HCV

g. VDRL/RPR h. Chest X-Ray i. ECG

Findings of the investigations:

Radiology
IVU: It shows Rt. Nephrolithiasis with grade III Hydronephrosis. USG: It shows Rt.nephrolithiasis with Rt. moderate Hydronephrosis Chest X-Ray: Normal

Hematology
Complete Blood Count: HB% - 12.7gm/dl TLC - 7500mm3 DLC - Neutrophils : 66% - Lymphocytes: 30% - Monocytes : 02% - Eosinophils : 02% Platelet count - 1,49,000/cmm Blood grouping - O positive

Biochemistry
RBS - 82.0mg/dl Urea - 24.0mg/dl Creatinine -1.2mg/dl Sodium -144.0meq/l Potassium - 4.5meq/l

Coagulation Assay
BT - 3.0 CT - 11.00 PT/Control - 13.5 INR - 0.94

Serology

HIV -Non reactive HBsAg - Non reactive HCV antibody - Non reactive VDRL/RPR - Non reactive

Others
ECG - Left ventricular hypertrophy with repolarization abnormality. Prolonged QT

MANAGEMENT
Medical management or conservative management Surgical management

MEDICAL 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 as oxybutynin chloride (Ditropan) Anti emetics for nausea and vomiting Increase fluids: Encourage clients to increase fluids to 3 to 4 liters unless contraindicated 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. 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 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 Patient was encouraged to drink plenty of fluids 3 to 4 liters per day and at least half of it should be water.

SURGICAL MANAGEMENT
According to book About 20% of stones require additional treatment with shock wave lithotripsy or endourologic or surgical procedures. 1. Endourologic Procedures: Endourologic methods of stone removal may be used to extract renal calculi that cannot be removed by other procedures. Percutaneous Nephrolithotomy: The word percutaneous refers to a procedure done through the skin. Nephro refers to the kidneys, and lithotomy means removing stones through cutting. Percutaneous nephrolithotomy, also known as nephrolithotripsy, therefore, is a surgical procedure that involves making a small incision in the skin through which a nephroscope is introduced through a percutaneous route into the renal parenchyma. Depending on the size of stone, it may be extracted with forceps or by a stone retrieval basket that is formed in the kidney. It is often recommended in the treatment of kidney stones, which are of medium or larger size, and those which are already causing obstruction in the flow of urine. The presence of staghorn calculi, a kidney stone associated with frequent kidney infections, may also need percutaneous nephrolithotomy.

2. Lithotripsy Laser Lithotripsy: A newer treatment for calculi is laser lithotripsy. Lasers are used together with ureteroscope to remove or loosen impacted stones. Constant water irrigation of the ureter is required to dissipate the heat. Extracorporeal Shock Wave Lithotripsy(ESWL): ESWL is a noninvasive procedure used to break up stones in the calyx of the kidney. In ESWL, high energy amplitude of pressure, or shockwave, is generated by the abrupt release of energy and transmitted through water and soft tissue. When the shock wave encounters a substance of different intensity (a renal stone), a compression wave causes the surface of the stone to fragment. during the procedure the client is usually offered conscious sedation or general anesthesia. The procedure lasts for 30 to 50 mins with administration of 500 to 1500 shock waves. After ESWL the stone fragments may bunch up causing obstruction so a double j stent is commonly placed before ESWL for larger stones more than 6mm. the fragments may be passed for up to 3 months after the procedure.

Percutaneous Lithotripsy: Percutaneous lithotripsy involves the insertion of a guide percutaneously (through the skin) under fluoroscopy near the area of the stone. An ultrasonic wave is aimed at the stone to break it into fragments.

3. Double -J stents:

A ureteral stent, sometimes as well called ureteric stent, is a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney. The length of the stents used in adult patients varies between 24 to 30 cm. Additionally stents come in differing diameters or gauges, to fit different size ureters. The stent is usually inserted with the aid of a cystoscope. One or both ends of the stent may be coiled to prevent it from moving out of place, this is called a JJ stent, double J stent or pig-tail stent.

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

4. Open Surgical Procedures:

If the stone is too large or if endourologic and lithotripsy procedures fails to remove the stone an open surgical procedure is performed which includes:

Pyelolithotomy: It is a surgical procedure to make an incision through the side and back to get to and open the kidney to remove a calculus from the renal pelvis of the kidney. A calculus is also sometimes called a "stone", this would be surgery to open the kidney to remove a kidney stone that is too large to pass through the urinary system and cannot be treated with lithotripsy (a non-surgical method, often ultrasonic, to break the stone into tiny, even sand-like, pieces so the pieces can be passed through the urinary system), or that cannot be treated with other less-invasive surgical procedures.

Nephrolithotomy: A nephrolithotomy is a surgical procedure that removes kidney stones from the renal calyx. Nephrolithotomy is performed to relieve a patients pain or to remove blockages caused by kidney stones. The surgery is usually performed on patients who have kidney stones that are larger than 1 inch (2 cm) in diameter, that block the flow of urine. Patients undergoing nephrolithotomy receive general, regional, or spinal anesthesia before the procedure begins. First, the kidney stones location must be determined, and then a small incision is made in the patients lower back. A needle is passed through the incision into the kidney and a guide wire is passed through the needle. A tube is then passed over the guide wire, and the stone is removed through the tube.

Nephrectomy: It is a surgical procedure where kidney is removed. Rarely, a partial or total nephrectomy is necessary because of extensive kidney damage, over- whelming renal infection, or abnormal renal parenchyma, which can be responsible for stone formation.

According to patient

1. Lithotripsy was done 37 days before but it failed to treat the condition. 2. DJ stent was kept in my patient to facilitate passage of small stone from kidney to bladder without causing obstruction and also to treat hydronephrosis. 3. Pyelolithotomy was done in my patient Surgical procedure performed was Rt. Pyelolithotomy with DJ stenting.

DRUGS USED IN MY PATIENT

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)

In surgery ward 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)

DRUG PROFILE
Inj. Dextrose (5%) : Dextrose injections are used as a source of calories and water for hydration. There are various preparation of dextrose, among them 5% dextrose is isotonic solution and is used for calories & water replacements and dextrose solution concentration higher than 5% (i.e. 10%, 25%, 50%) are hypertonic and used to provide adequate calories in a minimal volume of water. 25% & 50% dextrose injection are frequently used in adults and children to restore blood glucose concentration in hypoglycemic state. 500 ml of 5% dextrose contain 250 gm glucose & provide 1000 Kcal energy. Preparation: Injection Dextrose, usual strength (5%), other strength (10%, 25%, 50%). Indication: Condition where fluid replacement necessary, prevention & treatment of hypoglycemia. Adverse Effect: Venous irritation & thrombophlebitis may occur with hypertonic glucose injection, risk of infection at the site of injections. Nursing Consideration: - Patients electrolyte level and acid base balance should monitor and periodically record on patients chart with prolonged therapy. - Used in caution in patients with overt or known sub-clinical diabetes mellitus or with carbohydrate intolerance. - Hypertonic dextrose solutions are contraindicated in patients with anuria, intraspinal or intracranial hemorrhage & in patient with delirium tremens if such patients are already dehydrated.

Inj. Normal Saline (NS): (Sodium Chloride) Sodium chloride solution is closely approximate the composition of the extra cellular fluid of the body. so, it is also known as isotonic solution & physiological saline. It contain 0.9% (9gm or 150 mmol each Na+ and Cl- per litre) sodium chloride which is same as the osmotic pressure of the body. It dose not haemolyse erythrocytes so usually go after blood transfusion.

Sodium chloride solutions are used as a source of sodium chloride and water for hydration so it is used to treat deficiencies of sodium & chloride caused by excessive diuresis or excessive salt restriction, management of metabolic alkalosis, dehydration etc. Hypertonic (3% or 5%) sodium chloride injection is used in management of severe sodium chloride depletion when rapid electrolyte restoration is essential.

Contraindication: Fluid retention, hypernatremia.

Adverse effects:
Sodium accumulation & pulmonary edema can occur with very large volume (doses), facial flushing, phlebitis, fever. Nursing Consideration: - Use sodium chloride cautiously in patients with cirrhosis, CHF, hypertension, or renal impairment. - Dont administer sodium and chloride preserved with benzyl alcohol to neonates. - Administer hypertonic solutions (3% or 5%) through a large vein at a rate not exceeding 100 ml/hr. Avoid infiltration. - Dilute vials containing 2.5 to 4.0 mEq/ml (concentrated NaCl) with D5W or D10W before administration. - Assess the IV site for extravasation. - Assess the patient for signs and symptoms of hypernatremia (edema, hypertension, and weight gain) and hyponatremia (dry mucous membranes, muscle cramps, nausea and vomiting).

Tab Alprax (Alprazolam): Category: Anxiolytic/Benzodiazepines Mechanism of action: Benzodiazepines bind to specific sites on the GABA receptors and increase GABA levels. Science GABA is an inhibitory neurotransmitter; it has claming effect on the central nervous system, thus reducing anxiety.

Indication: Anxiety states, Psychosomatic disorders, Status epilepticus, Insomnia due to anxiety, Premenstrual syndrome. Contraindications: Hypersensivity to benzodiazepines., Acute alcohol intoxication with depressed vital signs, Acute angle glaucoma, Concurrent use of intra-conazole or keto-conazole, Myasthenia Gravis, Severe COPD.

Doses and route: For adults: 0.25-0.5mg/day TDS or BD. And maximum dose can exceed up to 1omg/day.Frequent:- Ataxia; light headedness; transient, mild somnolence; slurred speech (particularly in elderly or debilitated patients) Occasional:- Confusion, depression, blurred vision, constipation, diarrhea, dry mouth, headache, nausea. Rare:- Behavioral problems: such as, anger; impaired memory; paradoxical reactions such as insomnia, nervousness, or irritability. Nursing considerations: 1. Baseline Assessment Assess the patient for motor responses, such as agitation, tension, and trembling, and autonomic response, such as cold, clammy hands and diaphoresis. Lifespan Considerations: Alprazolam crosses the placenta and is distributed in breast milk.Chronic use of alprazolam during pregnancy may produce withdrawal symptoms in the patient and CNS depression in the neonate. The safety and efficacy of Alprazolam have not been established in children.

2. Precaution: Use alprazolam cautiously in patients with impaired renal or hepatic function. Administration and Handling: PO -Give alprazolam to regard without food.Crush tablets as needed. PO (Extended-Released) -Administer once a day

-Swallow tablets whole. Do not break, chew, or crush tablets. 3. Intervention and Evaluation: Expect to perform blood tests periodically to assess hepatic and renal function in patients receiving long-term therapy. Assess the patient for paradoxical CNS reaction, particularly early in therapy. Evaluate the patient for the desired therapeutic response, including a calm facial expression and decreased insomnia and restlessness.

4. Patient Teaching: Caution the patient not to stop take alprazolam abruptly after long term therapy. Inform the patient that drowsiness usually disappears with continued therapy. Instruct the patient to change positions slowlyfrom recumbent, to sitting, before standingto prevent dizziness. Caution the patient to avoid tasks that require mental alertness or motor skills until his or her response to the drug has been established.eg:-driving. Advise the patient not to take other medications, including OTC drugs, without consulting the physician. Urge the patient to avoid alcohol during therapy.

Aciloc (Ranitidine Hydrochloride): Category: H2 receptor antagonist. Mechanism of action:

It blocks histamine H2 receptor in the stomach and prevents histamine-mediated gastric acid secretion. It has no anticholinergic action. Acid secretion in response to pentagastrin, bethanechol and food is also inhibited.

Indications and doses: - Duodenal ulcers, benign gastric ulcers, gastroesophageal reflux disease. PO Adults, Elderly: 150mg twice a day or 300 mg at bedtime. Maintenance: 150mg at bed time. Children: 2-4mg/kg/day in divided doses twice a day. Maximum: 300mg/day. - Erosive esophagitis PO Adults, Elderly: 150mg 4 times a day. Maintenance: 150mg 2 times per day or 300 mg at bedtime.

Children: 4-10 mg/kg/day in 2 divided doses. Maximum: 600mg/day. - Hypersecretory conditions

PO Adults, Elderly: 150mg twice a day. May increase up to 6gm/day. Contraindications: History of acute porphyria. Side effects: Headache, occasionally diarrhoea, dizziness, rarely hepatitis, thrombocytopaenia, leucopaenia, hypersensitivity reactions, confusion, gynaecomastia, impotence, somnolence, vertigo, hallucinations, anaphylaxis, rarely constipation. Nursing consideration: 1. Base Line assessment: Blood chemistry test results including BUN, Serum Alkaline Phosphate, bilirubin, creatinine, AST (SGOT), and ALT (SGPT) levels to assess hepatic and renal function Life span considerations:Expect to obtain the elderly are more likely to experience confusion, especially those with hepatic or renal impairment. 2. Precaution Administration and handling:
PO -Give ranitidine without regards to the meals. -Do not administer within 1 hour of magnesium or aluminium containing antacids because they decrease ranitidine by 33%. -Give 2 hours after ketoconazole administration -If patient is taking a single daily dose, advise him to take it at bed time. -Tell patient to swallow oral form whole with water; dont chew IV -Solutions normally appear clear and are colourless to yellow : slight darkening does not affect potency. -For IV push, dilute each 50mg with 20ml 0.9% NaCl or D5W.Administer IV push over minimum of 5 minutes to prevent arrhythmias and hypotension. IM -Give IM in large muscles mass such as the gluteus maximus. -Urge the patient to avoid alcohol and tell the patient that smoking decreases the effectiveness of ranitidine. -Instruct the patient that transient itching or burning may occur with IV administration. -Instruct the patient to inform the doctor if headache occur within the ranitidine therapy.

-Instruct patient to take drug as directed, even a aspirin, both of which may cause GI distress, after pain subsides, to ensure proper healing. 3. Intervention and evaluation:

Monitor the patients serum alkaline phosphate, bilirubin, AST and Alt levels.

Assess the elderly patients mental status.

4 Patient Teaching: Tell the patient that smoking decreases the effectiveness of ranitidine. Warn the patient that transient itching or burning may occur with IV administration. Instruct the patient to inform the doctor if headache occur within the ranitidine therapy. Urge the patient to avoid alcohol and aspirin, both of which may cause GI distress, during ranitidine therapy. Instruct patient to take drug as directed, even after pain subsides, to ensure proper healing.

Tramadol (Tramadol Hydrochloride): Category: Non- Narcotic Analgesics Mechanism of action: An analgesic that binds to mu-opioid receptors and inhibits reuptake of nor epinephrine and serotonin. Reduces the intensity of pain stimuli reaching sensory nerve endings. Indication and doses: Moderate to severe pain. PO Adults, Elderly: 50-100mg; 4-6hrly Maximum: 400mg/day for patients 75 yr and younger; 300mg/day for patients older than 70yrs. Dosage in renal impairment. For patient with creatinine clearance of less than 30ml/min, increase dosing intervals to q12h. Maximum: 200mg/day.

Dosage in hepatic impairment Dosage is decreased to 50mg q12h.

Contraindications: Acute alcohol intoxication; concurrent use of centrally acting analgesics, hypnotics or psychotrophic drugs, suicidal patients, head injuries, raised intracranial pressure, severe renal impairment, lactation. Side effects: Frequent (25%-15%) Dizziness or vertigo, nausea, constipation, headache, somnolence.

Occasional (10%-5%) Vomitting, pruritus, CNS stimulation (such as nervousness, anxiety, agitation, tremor, euphoria, mood swings, and hallucinations), asthenia,diaphoresis, dyspepsia, dry mouth, diarrhea. Rare (less than 5%) Malise Vasodilation, anorexia, flatulence, rash, blurred vision, urine retention or urinary frequency, menopausal symptoms.

Serious Reactions: Overdose results in respiratory depression and seizures. It may have a prolonged duration of action and cumulative effect in patients with hepatic or renal impairment.

Nursing Consideration: 1. Baseline assessment: Assess the duration, location, and type of pain. Determine the patients medication history, especially the use of carbamazepine, CNS depression, and MAOIs. Review the patients medical history, especially for seizures. Obtain a CBC and liver and renal function studies. 2. Precautions: Use tramadol extremely cautiously in patients with acute alcoholism, advanced cirrhosis, anoxia, CNS depression, epilepsy, respiratory depression, or shock.

Use the drug cautiously in patients with acute abdominal conditions, hepatic or renal impairment, increased intracranial pressure, opioid dependence, or sensitivity to opioids.

3. Intervention and evaluation: Monitor the patients blood pressure and pulse rate. Assist the patient with ambulation if he or she experiences dizziness or vertigo Offer the patient cola and dry crackers to relieve nausea and sips of tepid water to relieve dry mouth. Assess the patients pattern of daily bowel activity and stool consistency. Palpate the patients bladder for urine retention. Assess the patient for clinical improvement, and record the onset of pain relief. 4. Patient Teaching: Caution the patient that tramadol use may cause dependence Urge the patient to avoid alcohol and OTC drugs such as analgesics and sedatives during tramadol therapy. Inform the patient about the side effects of tramadol. Instruct the patient to notify the physician about chest pain, difficulty in breathing, excessive sedation, muscle weakness, palpitations, seizures, severe constipation, or tremors.

Phenargan (Promethazine Hydrochloride): Category: Anti-emetic, Anti-histamine & sedative- hypnotic Mechanism of action: A promethazine, that acts as an anti-emetic, anti-histamine, and sedative-hypnotic. As antiemetic, diminishes vestibular stimulation, depresses labyrinthine function, and act on the chemoreceptor trigger zone (CTZ) by blocking dopamine receptors in the CTZ.. As a sedative-hypnotic, produces CNS depression by decreasing stimulation to brain stem reticular formation. Indication and Dosage: Allergic symptoms PO Adults, Elderly: 6.25-12.5mg, three times a day plus 25 mg at bed time. Children: 0.1mg/kg/dose (maximum: 12.5mg), 3 times a day plus 0.5 mg/kg/dose (maximum: 25mg) at bed time.

IM, IV Adults, Elderly: 25mg. May repeat in 2hr. Motion sickness PO Adults, Elderly: 25mg 30-60 min before departure; may repeat in 8-12 hr, then every morning on rising and before evening meal. Children: 0.5 mg/kg 30-60min before departure; may repeat in 8-12 hr, then every morning on rising and before evening meal. Prevention of nausea and vomiting PO, IV, IM, Rectal Adults, Elderly: 12.5-25mg q4-6h as needed. Children: 0.25-1mg/kg q4-6h as needed. Pre-operative and post operative sedation; adjunct to analgesics IV, IM Adults, Elderly: 25-50mg/dose Children: 12.5-25mg/dose. Sedative PO, IV, IM, Rectal Adults, Elderly: 25-50mg/dose. May repeat q4-6h as needed. Children: 0.5-1mg/kg/dose q6h as needed. Maximum: 50mg/dose.

Contraindication: Angle-closure Glaucoma GI or GU obstruction Severe CNS depression or coma. Side Effects: Expected: Somnolence, Disorientation; in elderly, hypotension, confusion, syncope. Frequent: Dry mouth, nose, or throat,; urine retention,; thickening of bronchial secretions. Occasional: Epigastric distress, flushing, visual disturbances, hearing disturbances, wheezing, paresthesia, diaphoresis, chills. Rare: Dizziness, urticaria, photosensitivity, nightmares.

Nursing Consideration: 1. Baseline assessment: Assess the patient for dehydration, including dry mucous membranes, longitudinal furrows in the tongue, and poor skin turger, before and regularly during therapy when promethazine is used as an antiemetic. Expect to discontinue the drug 4 days before antigen skin testing.

2. Precautions: Use promethazine cautiously in patients with asthma, history of seizures, cardiovascular disease, hepatic impairment, peptic ulcer disease, sleep apnea, possible Reyes syndrome, BPH, pregnancy & lactation. 3. Intervention and evaluation: Give promethazine without regard to food. Assess the blood pressure and pulse rate if the patients receives the parenteral form of promethazine. Avoid giving subcutaneously or give deep I/M because significant tissue necrosis may occur. Assist the patient with ambulation if he or she experiences drowsiness or lightheadedness. 4. Patient Teaching: Inform the patient that drowsiness and dry mouth are expected side effects of drug. Tell the patient that drinking coffee or tea may help reduce drowsiness and sipping tepid water and chewing sugarless gum may relieve dry mouth. Warn the patient to avoid performing tasks that require mental alertness or motor skills until his or her response to the drug has been established. Instruct the patient to notify the physician if he or she experience visual disturbance. Urge the patient to avoid alcohol and other CNS depressants during promethazine therapy. Extra pyramidal reaction may appear early in drug therapy so should be observed the symptoms carefully and inform to doctor. \ Cipro (Ciprofloxacin) Category: Fluroquinolone Antimcrobial Mechanism of action: Bactericidal by inhibition of DNA supercoiling in the bacteria . One of the most active fluroquinolones, its spectrum includes gram- negative aerobic bacteria including Enterobacteriaceae, Haemophilus, Neisseriae, and Pseudomonas aeruginosa. It is also active in vitro, against many Gram-positive aerobic pathogens including penicillinase-producing, and methicillin-resistance staphylococci. Indication and dosage: Oral UTI: Adult = 250-500mg b.i.d PROSTATITIS AND COMPLICATED UTI: Adult = 500mg 12 hourly

LOWER RESPIRATORY TRACT INFECTIONS: Adult = 250-500mg 12 hourly. Sometimes 750mg 12 hourly may be given GYANECOLOGICAL INFECTIONS AND BACTERIAL DIARRHOEA: Adult = 500mg 12 hourly SKIN AND SOFT TISSUE, BONE AND JOINT INFECTIONS: Adult = 500-750mg 12 hourly GONORRHOEA: Adult = 250-500mg single dose SURGICAL PROPHYLAXIS: Adult = 750mg 60-90 mins before procedure. Intravenous UTI: Adult = 100mg b.i.d by slow infusion RTI AND OTHER INFECTIONS: Adult = 200-400mg b.i.d by slow infusion over 60 mins GONORRHOEA: Adult = 100mg slow infusion as single dose.

Contraindication: Children below 12 yrs and adolescents, except where benefit clearly exceeds risk. Lactation and hypersens. Special precaution: Epilepsy, severe renal dysfunction, history of convulsive disorders. Patients should be well hydrated. G-6PD defects and pregnancy. Adverse reaction: GI disturbances, dizziness, headache, tremor, confusion, convulsions. Rashes, blurred vision, joint pain. Judgement and dexterity may be impaired. Transient inceases in serum creatinine. Haematological, hepatic and renal disturbances. Vasculitis, pseudomembranous colitis, trachycardia. Nursing considerations: Donot give any product containing magnesium or calcium, iron or aluminium with this product or with in 2 hours of product. Photosensitivity may occur so patient should avoid sunlight or use sunscreen to prevent burn. If dizziness occurs, to ambulate, perform activities with assistance. To complete full course of product therapy not to double or miss dose. Teach patient and family to contact prescriber if adverse reactions occurs or if inflammation or pain in tendon occurs. Increase in fluid 2-3 liters/ day to avoid crystallization in kidney. To use frequent rinsing of mouth , sugarless candy or gum for dry mouth.

NURSING MANAGEMENT
Nursing management of patient with kidney stones. 1. Frequent doses of analgesics were administered to relieve severe pain while stones pass to ureter. 2. Patient was encouraged to ambulate and fluid intake was increased to 3-4 liters/day. 3. Encouraged to take orange juices to acidify urine. Surgery was planned for my patient so, preoperative and postoperative nursing cares were given: Preoperative nursing care Patient was explained about the operative procedure. Emotional and psychological support was given because the patient was anxious, not only about the surgery but also about the post operative renal function and possible recurrence of the disease. Preoperative teaching was given to ensure a positive surgical experience for the patient, which includes deep breathing and coughing exercise, ambulation, pain control, positioning and turning etc. To reduce preoperative anxiety and fear tab.alprax 0.5mg p/o was given at bedtime a day before surgery. Patient was kept on NPO from midnight. Skin preparation was done on morning of surgery. Vitals signs were checked and recorded. An informed consent was taken from the patient family members and patient as well. All the necessary arrangements were made including collecting all the laboratory reports and arranging of the blood. Patient was advised to wear a hospital gown and was shifted to OT on a stretcher with all the documents.

Postoperative nursing care Patient was received from the OT, was kept on comfortable position and ABC was maintained. Vital signs were monitored regularly and skin color was also noted.

 Analgesics were administered as prescribed to reduce pain.

IV fluids were administered frequently (4 hourly) to treat intra operative fluid loss. Surgical incision and drainage tubes were observed frequently to detect unexpected blood loss. Accurate record of drainage from the drain tubes was maintained and its color and consistency was also monitored. Intake and output was strictly maintained. Antibiotics were administered as ordered. Any signs of infection such as chills, fever etc was watched for. Patient was ambulated from the 1st postoperative day. Dressing of the wound was done with aseptic technique. Drainage tubes and Foley were checked frequently for their patency. Patient was encouraged for deep breathing and coughing exercise. Patient was started with sips from the 1st postoperative day and then to liquid-soft-normal diet from the 2nd postoperative day.

THEORY APPLIED DURING NURSING CARE

I applied the OREMS GENERAL THEORY OF NURSING while giving nursing care to my patient Mr. Choklal Subedi. According to Orems, Nursing is the provision of self care which is therapeutic is sustaining life and health in recovering from disease of injury or coping with their effects. Orem has developed her general theory of nursing in three related parts. They are: Self care theory Self care deficit theory Nursing system

Self care theory:

Self care comprises those activities performed independently by an individual to promote and maintain personal well- being throughout life. Each person possesses the ability and responsibility to care for themselves and dependants. Self care is the practice of activities that individuals personality initiates and performs on their own behalf to maintain life healthy and wellbeing. Care is related to man, environment, culture and value daily living.

In my patient: I encouraged my patient for self care in the day of hospitalization. I encouraged him to do his daily routine activities by himself such as brushing teeth, washing hands, bathing and eating. I encouraged him for his daily activities and exercises gradually.

Self care deficit theory:

Self care deficit is a relation between the human properties of therapeutic self care demand and self care agency in which constituents develop self care capabilities within the self care agency are not operable or not adequate for knowing and meeting some or all components of the existent or projected therapeutic self care demand. The theory of self care deficit is the core of general theory of nursing because it delineates when nursing is needed. Nursing may be provided if the care abilities are less than those required for meeting the current self care demand but a future deficit relationship can be foreseen because of predictable decrease in care abilities, qualitative or quantitative increases in the care demand or both.

In my patient: In the 1st and 2nd post operative day, Mr. Choklal Subedi was unable to perform his activities by himself so, I assisted him in morning care, mobilization and also assisted him to be in a comfortable position. I also assisted to change his positions frequently and provided support on deep breathing and coughing exercise.

Nursing system theory:

Nursing system theory refers to a series of action a nurse takes to meet a patients self care needs. It is determined by the patients self care needs. It is composed of three systems:

Wholly compensatory:

Wholly compensatory nursing system is needed when the nurse should be compensating for patients total inability for engaging in self care activities. In this system nurse becomes active and patient is totally inactive. Nurse must ensure that all of his/her needs are meet including elimination, oxygenation, nutrition, hygiene etc. In my patient: After the surgery, my patient was kept in post operative ward and on the OT day, he was unable to engage in any self care activities. So wholly compensatory nursing system was used while giving care in which total patient care was done which includes maintaining hygiene, providing rest and comfort, nutrition, elimination, pain control and easy breathing.

Partially compensatory:

This system exists when both nurse and patient perform care measures or other actions involving manipulative tasks of ambulation. In this system patient and nurse both are active. Patient can perform number of his/her task, but requires other assistance.

In my patient: Besides the OT day, until his 4th post operative day my patient could not perform his activities without assistance so, I assisted him in performing his daily activities including ambulation, dressing, position change, deep breathing and coughing exercise etc.

Supportive educative system:

Supportive educative systems are for situations where the patient is able to perform or can and should learn to perform required measures of externally or internally oriented therapeutic self care. The system exists where the patient requires assistance in decision making, behavior control and acquisition of knowledge and skills. Under this system patient are able to perform self care assistance.

In my patient: During the later days of hospitalization, my patient was conscious, oriented and was able to do his daily activities, but he has lack of knowledge towards exercise, diet, preventive measures and prevention of infection. So health teaching was given as supportive and educative role, which was suitable for him with emphasis on diet, prevention from recurrence of stones, infection prevention and exercise. In this way I applied the Orems theory in caring my patient.

Nursing diagnosis of my patient with application of Orems General Theory of nursing are:

NURSING CARE PLAN

Assessment findings Pain in incision site Verbalization of fear Demonstrate queries regarding stone formation Respiratory system is assessed by auscultation and monitoring for cough, sputum , wheezes etc. Watched for any sign of infection like fever, tachycardia, discharge via wound site.

 Nursing Diagnosis: Acute pain and discomfort related to surgical incision as evidenced by verbalization of pain and facial expression. 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. Administered analgesics as prescribed (promotes pain relief) c. Applied massage to areas with muscular aches (promotes relaxation and relief of muscle pain and discomfort d. Splinted incision with hands or pillows during movement (minimizes tension on incision and provides sense of support to the patient) Assisted and encouraged for early ambulation (promotes resumption of muscle active exercise and increases peristalsis movement)

e.

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

Nursing Diagnosis: Fear and anxiety related to outcome of surgery and alteration in urinary function as evidenced by verbalization and facial expression. Goal: Reduction of fear and anxiety during the period of hospitalization. Nursing Intervention: a. Assessed patients anxiety and fear before surgery if possible (provides a baseline for post operative assessment) b. Assessed patients knowledge about procedure and expected outcome preoperatively (provides a basis for further teaching) c. Encouraged patient to verbalize reactions, feelings and fears (it helps in ultimate resolution of feelings and fears) Encouraged family members esp. the spouse to be with the patient and share feelings (receive mutual support and reduces sense of isolation ) Evaluated 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)

d.

e.

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

 Nursing Diagnosis: Deficient knowledge regarding prevention of recurrence of renal stone as evidenced frequent questioning Goal: Gain knowledge regarding prevention of recurrences of stone within 2 days. Nursing Intervention: a. Increased fluid intake at least 3-4 liters per day (dilutes urine and prevents stone formation) b. Participated in appropriate activities (prolonged immobilization slows renal drainage and alters calcium metabolism) c. Consumed diet prescribed (reduce dietary factors predisposing to stone formation) d. Recognized symptoms (fever, chills, flank pain, haematuria) to be reported to health care provider (understand the sign and symptoms of infection and stone formation and reports immediately) e. Explained the actions and importance of prescribed medications (helps to be in adherence with medication to prevent stone formation) Evaluation: States increased knowledge of health seeking behaviors to prevent recurrences.

Nursing Diagnosis: Risk for pneumonia related to decreased activity and pain.

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.

 Nursing Diagnosis: Risk for infection related to invasive procedure.

Goal: Patient will be prevented from wound infection during his period of hospitalization.

Nursing Intervention: a. Dressing of the wound done following aseptic technique. ( wipe out micro organisms and prevents infection) b. Administered prescribed antibiotics on time. ( it kills micro organisms) c. Advised to change clothes daily n replace dirty ones with clean ones. (prevents infections through dirty clothes) d. Monitored for signs of any infection like fever, redness n swelling of wound etc. ( helps to evaluate infection earlier and manage accordingly) Encouraged to take nutritious diet. ( helps in early wound healing)

e.

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

COMPLICATIONS

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

PREVENTIVE MEASURES

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. Avoid protein intake; usually protein is restricted to 60g/day to decrease urinary excretion of calcium and uric acid stone. 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. During the day, drink fluids (ideally water) every 1-2 hours. Drink two glasses of water at bedtime and an additional glass at each nighttime awakening to prevent urine from becoming too concentrated during the night. 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 beverage and beer. Avoiding large doses of vitamin C. Avoid activities leading to sudden increase in environmental temperatures that may cause excessive sweating and dehydration. Contact your primary health care provider at the first sign of a urinary tract infection.

DAILY PROGRESS NOTE

067-02-08:
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: temperature 98f, Pulse- 84\min, Respiration- 26\min. BP- 110/70mmof Hg. Patient complained of colicky pain in costovertebral region. Pain was none radiating. Stat medicines given. Vitals were monitored regularly. Full information was given regarding surgery. All the required investigations were carried out. Pre-medicine tablet Alprax0.5 Mg P/O given then patient was kept NPO. Patient slept well at night.

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.

067-02-10:
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. Blood was sent for Hb% and hb% was 11.8 gm/dl. 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.

 067-02-11:
Patients general condition was improving. Today was 2nd post op day. Vitals were: temperature:-980 f, pulse:-80/min, respiration:-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, respiration:-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 teaching was 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, respiration:-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, respiration: - 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: temperature:-97.60f, pulse: 82/m, respiration:-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: temperature: - 980f, pulse: - 78/m, respiration: - 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.

DIVERSIONAL THERAPY
Diversions therapy is most important to minimize the stress of family and the patient too. Stress is an unpleasant situation experience of life. Stress remains through the life
Hospital is a very threatening and stressful to everybody especially chronic disease is very stressful. So the diversion therapy is only one thing that will overcome the stress. Diversional therapy should be according to age of patient

Being a nurse, it is our duty and responsibility to help and support them coping with the disease condition and such terrible situation. At that time, I used supportive- educative theory of Orems to solve the problems of family. Along with this, I helped him to cope with the stress by using different types of relaxation techniques, which are as follows:

My patient is 37 years old. He looked stress, mentally and emotionally upset, so I performed some activities such as: Talked with patient about him and his family's member. Suggested and helped in ambulation of patient. Helped and suggested to do self care as possible. Provided informal health teaching regarding diet, hygiene, rest and sleep etc.

In this way, I tried to divert his mind in other things rather than his illness. I found that after the therapy he looked happy and quite familiar. He also followed what I suggested him to do. He and his family member were all very co-operative. I felt grateful to myself that I was successful to reduce anxiety during his period of hospitalization.

HEALTH EDUCATION GIVEN DURING HOSPITALIZATION

Each and every person does not know every aspect which is necessary during hospitalization and suffering from illness. Proper and adequate health education provided by nurses during the period of hospitalization can help the patient and family members to cope with the situation and prevent from unexpected damage to the patient. Health teaching can be provided in any aspect which will be beneficial for the patients for early recovery. I provided informal health education to the patient and family members on following topics during the period of hospitalization. Diet: I advise the patient that there are some dietary restrictions that are to be followed. I advised him to take low protein diet. A sodium intake of 2-3 table spoon is recommended but I advised him to reduce intake of table salts and high sodium foods. I also advised not to avoid calcium because low calcium diets are not generally recommended except in hypercalciuria. I also advised him to restrict foods high in purine like mushrooms, organ meats, bony fish, wine etc, foods containing oxalates are also restricted (spinach, chocolates, tea, peanuts, tomato , citrus fruits, green beans etc), limit intake of caffeinated beverages, such as coffee ad avoid cola beverages. I was encouraged him to drink at least 3-4 liters of water per day. Personal hygiene: I gave health education to the patient about the importance of personal hygiene. I advised him to empty the bladder at regular intervals and since urinary tract infection can also cause kidney stone, I also advised him to keep his genitals clean and suggested him to maintain environmental cleanliness avoiding dust, dirt and smoke as well. Rest and exercise: I advised the patient for adequate rest and sleep. I also suggested him to avoid activities leading to sudden increase in environmental temperatures that may cause excessive sweating and dehydration. But a mild form of exercise is required and also encouraged him for frequent turning and movement and avoidance of heavy lifting for minimum 4 weeks. Disease condition: I also provided information about the disease, treatment, prognosis and prevention from stone formation. Medication: I advised the patient to take medicines in time and course of treatment and side effects and importance of medication. Prevention of infection: I advised the patient to follow measures for prevention of infection which includes maintaining hygiene, avoiding holding urine for hours, drinking plenty of fluids, deep breathing and coughing exercises, emptying bladder at regular intervals, sleeping semi fowler position( to prevent infection from DJ stent)etc. Follow up: I also advised the patient for timely follow up and when necessary.

DISCHARGE PLANNING AND TEACHING

The patient needs nursing care not only during hospitalization but also after discharge from the hospital too. So one of the important part of nursing care is discharge teaching. I gave following instruction or teaching on following while discharging patient: Diet and nutrition Adequate fluid intake Personal hygiene Rest and sleep Exercise Wound care Complication Avoid lifting objects exceeding 5 pounds after surgery usually for 4 weeks Prompt and early treatment of UTIs Prevention of infection Prevention of stone formation Follow-up and Removal of DJ stent after 30 days in surgical OPD.

Medications advised on discharge: Tab. R-loc 150mg 1 tab p/o B.D for 5 days.

PROGNOSIS
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.

FOLLOW UP CARE

Follow-up care is important for continuity of care of patient after discharge. From follow-up care, we can know the prognosis of disease. The main objectives of follow-up care are as follows: To assess the health status of the patient. To find out the prognosis of disease To help the child and family to manage their problems related to health. To find out if there is another health problem. To evaluate the knowledge learnt in hospital. To prevent from further complication. To provide health education for promotion and maintenance of optimum health of the patient and family.

Advice of follow-up on discharge: I advised patient to come for follow up after 1 month in surgical OPD or when necessary. I also advised the patient and family members for close monitoring of the patient and report immediately to surgeon if patient: Experiences any sign and symptoms of infection at or around the incision site for e.g. redness, tenderness, swelling, heat or drainage. Experience a fever of 100 0F or more for 2 consecutive days. Develop nausea, vomiting or abdominal pain. Advised patient to maintain adequate dietary intake and avoid foods that cause gastrointestinal irritation. Advised to take medicine regularly.

LEARNING FROM THE CASE STUDY

Case study is the effective method of learning about the related disease in depth and practice. Case study gives the comprehensive study of one selected patient and comparison with book in a real situation.

During my case study of nephrolithiasis, I collected information from different sources such as library, internet and consulted with doctors, seniors of ward, teachers and with my friends. I learned many things from the case study which are as follows:-

About patient: During case study, I was completely involved and attached with my patient. I came to know the emotional status and surgical reaction of the patient about treatment and disease process. I also got to know about the growth and development of the patient and compared it with the normal one. About family and environment: I also got an opportunity to learn general attitude of family and their environment. I also got a chance to know sociocultural, educational and religious and economic status of patient. About nursing care: I got opportunity to learn about the application of nursing theory while caring the patient and use of nursing process. It enhances the scientific method of caring the patient. About diversional therapy and stress management: During case study, I got chance to detect the stressful factors and different therapy to overcome these stress. I got chance to use diversional therapy in practical. About documentation: During this case study, I was involved in documentation which helped me to develop further skills in documentation in a more revised manner. About hospital policy: During case study, I was involved in many sectors of activities like reporting, recording, admission, discharge procedure, investigation. So I got a lot of knowledge about hospital policy. About different treatment techniques used to treat nephrolithiasis.

Finally, I think the case study is one of the ways to develop individual knowledge and attitude.

CONCLUSION

Case study is one of the most important parts of nursing practice. It is a best method of learning. Case Study is concerned with the individualized care which helps to provide holistic nursing care including Physiological, psychological social and cultural traditional beliefs. According to the curriculum of PBBN, I had taken a case nephrolithiasis, named Mr. Choklal Subedi for case study. I collected essential health history from patient and family during the case study. Then thorough physical examination was done and recorded. I revised the normal development process and crisis of elderly adult. I reviewed the collected health history, investigations report, and outcome of physical examination and formulated nursing diagnosis. I applied the Orems theory for the nursing management of the patient. Complete nursing care was provided to the patient by applying nursing process. During the case study, I also studied about disease, its etiology, path physiology, its sign and symptoms, diagnostic procedure, therapeutic as well as nursing management from different books. Patient was admitted on 2067/02/08 at 6 pm with the complain of colicky pain in costovertebral region. I provided different diversional therapy to the patient, as hospital is a stressful environment to the patient. Illness itself is a stressful condition for the patient so I provided some relaxation techniques to the overcome this. He was hospitalized for 8 days and was discharged on 2067/02/16 with oral medicine and advice for follow up after 1 month in Surgery OPD. He went in his home Sukranagar-7,Chitwan after discharge.

REFERENCES:
Basvantthappa, B.T. (2003), Medical- Surgical Nursing , 1st edition, Jaypee brothers medical publisher (p) Ltd, chapter 39, page no. 1219-1224. Black, J.M and Hawks, J.H. (2005), Medical Surgical Nursing, 7th edition, published by Elsevier India Private Limited, Volume 1, chapter 36, page no: 882-890.

Bajracharya K. (1999), Textbook Of Adult Nursing, 1st edition,published by HLMC, TUIOM, Kathmandu, chapter 6, page no.178-206. CIMS (Jan-2005) published by CMPMedica Private Limited, India.

http://en.wikipedia.org/wiki/kidneystone Smeltzer S.C, Bare B.G, Hinkle J.L. and Cheever K.H. (2008), Brunner and Suddarths

Textbook of Medical Surgical Nursing, 11th edition, published by Lippincott Williams and Wilkins, a Wolters Kluwer business, volume 2,chapter 45, page no: 1589-1595.

Tuitui, R. (2006).Pocket Book of Drugs, 3rd edition, Makalu Publication House Wesley L. R. Nursing Theories and Modules, published by Spring House Corporation, Pennsylvania, page no. 1992-1994.