A.

G ENERAL OBJECTIVES:
This case presentation seeks tothe student¶s knowledge regarding the
general health and disease condition of a patient with Nephrolithiasis,it¶s diseaseprocess, possible
complications, treatment plan, medical and nursing interventions.
B.S PECI FICOIBJECTIVES:
The group presenters aim to achieve the following objectives in an hour of case
presentation:
1.Accurately present a thorough general assessment of the client which includes
physical assessment and family history taking.
2. Effectively identify signs and symptoms exhibited by a patient with
Nephrolithiasis.
3.Thoroughly discus, explain and elaborate the nature of the disease process.
4.Efficiently provide appropriate and proper nursing diagnosis in line with theclient¶s medical condition and
skillfully formulate nursing care plans for theproblems identified.
5.Appropriately apply nursing interventions necessary for the patient¶s
condition in reference with the learned theories and concepts of the disease.
I.
PERSONAL DATA:
Name: T.R.C.
Age: 62 years old
Religion: Roman Catholic
Address: Sitio Sto. Nino West Cupang Muntinlupa City
Date ofAdmission: February 22 2010Date of Discharge: February 27 2010Chief complain: right flank
pain
Final diagnosis: Bilateral Nephrolithiasis
GoutyArthritis
II.
HISTORYOF PRESENT ILLNESS
 In 2004, while at work in the store in Muntinlupa, patient TRC noted severe right sided
flank pain, with the scale of 5 and is not associated with dysuria, hematuria, fever, chillsand pain and
swelling of his knees. He started to drink 1 glass of coconut juice every timehe feels pain but no relief, just
helps him to increase his urination
 While in 2005, Patient TRC went back to his province still having flank pain with pain
scale of 8 and pain and swelling of his knees. He consulted on a midwife regarding hispain, and was
advised to take Diclofenac 1 tab as needed for pain which he tookon andoff (approximately 3 to 4 times a
week) for 1 year which relieved the symptoms.
 In 2008, patient, still experiencing intermittent right sided flank pain, with the scale of 8
with undocumented fever, dysuria, and pain with swelling and erythema of knees, lateraland medial
malleous, associated with limitation of movement. He also hears thuddingsounds during his urination. He
returned to Metro Manila and consulted inAlabangMedical Center. Ultrasound of Kidneys Ureters and
Bladder (KUB) was done revealingnephrolithiasis on his right kidney. He was then advised by his doctor
to undergo removalof the stone, but was postponed due to pain and swelling of knee. No medications
wereprescribed yet.
 Last Feb 14, 2010, the patient again developed severe right sided flank pain with pain
scale of 8, radiating to his right leg associated with fever, dysuria, chills noted.
 Feb 16, 2010, He consulted again inAlabang Medical Center and urinalysis and CBC
was done. Urinalysis shows hematuria. He was sent home with medication ofCiprofloxacin 500mg/tab
BID, which provided him a relief from symptoms within 4 daysuntil he again experience the same
symptoms.
 Feb 18, 2010, He returned toAMC and underwent urinalysis, KUB ultrasound, and CT
sonogram.And from there, he was confined in the said institution for 2 days.
 During his confinement, Cysto-RGP bilateral was done, and 1 day after the procedure
patient developed swelling of knees, ankles, with pain in the scale of 8, with limitation ofmovement. His
doctor referred him to San Juan de Dios Hospital for right urethral stentapplication in preparation for
Extracorporeal ShockwaveLithotripsy (ESWL).
 February 22, 2010, noon he was confined in San Juan De Dios Hospital.
 February 23, 2010, he underwent Cysto-RGP right DJ stent application.
 February 25 Patient is supposed to be transferred for ESWL in Manila Doctor¶s Hospital,
but was postponed due to his¶ arthritis.
His final diagnosis is Bilateral Nephrolithiasis secondary to Gouty Arthritis in
SJDEFI(Hospital)
III.
HISTORYOF PAST ILLNESS
Unrecalled history of immunizations except for ³flu vaccines´. He had measles during his
childhood. (Age is unrecalled)
Patient RT has history of arthritis since 2004.
IV.
FAMILYHISTORY
 His mother died ofLung Cancer
 His Father is positive of bronchial asthma

V.
PSYCHOSOCIALHISTORY
 Patient RT is married with seven children
 In 2005 he worked as fisherman as a source of living
 He smokes since he was 20 years old. Consuming 5 rolls of tobacco per day for
about 40 years, but claimed to have quit one week prior to admission.
 He is also a heavy alcohol drinker with an average of 3 bottles ofLambanog per
week. (1 bottle contains 1L ofLambanog)

IX. DISEASE ENTITY

phrolithiasis
Nephrolithiasis, the process of forming a kidney stone, a stone in the kidney (or lowerdown in
the urinary tract). Kidney stones are a common cause of blood in the urine and pain inthe abdomen, flank,
or groin. Kidney stones occur in 1 in 20 people at some time in their life.
The development of the stones is related to decreased urine volume or increasedexcretion of
stone-forming components such as calcium, oxalate, urate, cystine, xanthine, andphosphate. The stones
form in the urine collecting area (the pelvis) of the kidney and may rangein size from tiny to staghorn
stones the size of the renal pelvis itself.
The process of stone formation, nephrolithiasis, is also called urolithiasis."Nephrolithiasis" is
derived from the Greek nephros- (kidney) lithos (stone) = kidney stone"Urolithiasis" is from the French
word "urine" which, in turn, stems from theLatin "urina" andthe Greek "ouron" meaning urine = urine
stone. The stones themselves are also called renalcaluli. The word "calculus" (plural: calculi) is theLatin
word for pebble.
Kidney stones typically leave the body by passage in the urine stream, and many stones areformed and
passed without causing symptoms.If stones grow to sufficient size before passage onthe order of at least
2-3²millimeters they can cause obstruction of the ureter. The resultingobstruction causes dilation or
stretching of the upper ureter and renal pelvis (the part of thekidney where the urine collects before
entering the ureter) as well as muscle spasm of the ureter,trying to move the stone. This leads to pain,
most commonly felt in the flank, lower abdomenand groin (a
condition
called renal
colic).
Renal
colic
can
be
a
ssociatedwith nausea and vomiting. There can be blood in the urine, visible with the naked eye or
underthe microscope (macroscopic ormicroscopic hematuria) due to damage to the lining of theurinary
tract.
There are several types of kidney stones based on the type of crystals of which they consist. Themajority
are calcium oxalate stones, followed by calcium phosphate stones. Morerarely, struvitestones are
produced by urea-splitting bacteria in people with urinary tractinfections, and people with certain
metabolic abnormalities may produce uric acid stonesor cystine stones.
Who gets Nephrolithiasis?
Sex
y
In general, urolithiasis is more common in males (male-to-female ratio of 3:1).
y
Stones due to discrete metabolic/hormonal defects (eg, cystinuria, hyperparathyroidism)
and stone disease in children are equally prevalent between the sexes.
y
Stones due to infection (struvite calculi) are more common in women than in men.
Agey
Most urinary calculi develop in persons aged 20-49 years.
y
Patients in whom multiple recurrent stones form usually develop their first stones while
in their second or third decade of life.
y
An initial stone attack after age 50 years is relatively uncommon.
Risk factors:
 Immobility and a sedentary lifestyle which increases stasis
 Dehydration which leads to supersaturation
 Metabolic disturbances that result in an increase in calcium or other ions in the urine
 Previous history of urinary calculi
 High mineral content in drinking water
 Diet high in purines, oxalates, calcium supplements, animal proteins
 UTI s
 Prolonged indwelling catheterization
 Neurogenic bladder
Types
of
renal
calculus:
1.Calcium calculi± It occur more often in men than in women, and usually appear betweenages 20 - 30.
They are likely to come back. Calcium can combine with other substances, such asoxalate (the most
common substance), phosphate, or carbonate to form the stone. Oxalate ispresent in certain foods.
Diseases of the small intestine increase the risk of forming calciumoxalate stones. Evidences reveal that
consumption of low-calcium diets is actually associatedwith a higher overall risk for the development of
kidney stones. This is perhaps related to the roleof calcium in binding ingested oxalate in the
gastrointestinal tract.As the amount of calciumintake decreases, the amount of oxalate available for
absorption into the bloodstream increases;this oxalate is then excreted in greater amounts into the urine
by the kidneys.In the urine, oxalateis a very strong promoter of calcium oxalate precipitation, about 15
times stronger than calcium.
2.Cystinest ones - are due to cystinuria, an inherited (genetic) disorder of the transport of anamino acid (a
building block of protein) called cystine that results in an excess of cystine in theurine (cystinuria) and the
formation of cystine stones. Cystinuria is the most common defect inthe transport of an amino
acid.Although cystine is not the only overly excreted amino acid incystinuria, it is the least soluble of all
naturally occurring amino acids. Cystine tends toprecipitate out of urine and form stones (calculi) in the
urinary tract. Small stones are passed inthe urine. However, big stones remain in the kidney
(nephrolithiasis) impairing the outflow ofurine while medium-size stones make their way from the kidney
into the ureter and lodge therefurther blocking the flow of urine (urinary obstruction).
3.Urate stones (uric acid)-About 5±10% of all stones are formed from uric acid Uric acid stonesform in
association with conditions that cause hyperuricosuria with or without high bloodserum uric acid levels
(hyperuricemia); and with acid/base metabolism disorders where the urineis excessively acidic (low pH)
resulting in uric acid precipitation
floor and the bladder.At the junction between the ureter and the bladder, a flaplike fold of
mucous membrane acts as a valve to preventreflux(backflow) of urine up the ureters.
Bladder
The urinary bladder(vesicle) is a hollow, muscular organ that serves as a reservoir for urine andas the
organ of excretion. When empty, it lies behind the symphysis pubis.In men, the bladderliesin front of the
rectum and above the prostate gland, while in women, it lies in front of theuterus and vagina.
The wall of the bladder is made up of four layers:
a) an inner mucous layer
b) a connective tissue layer
c) three layers of smooth muscle fibers, some which of extend lengthwise, some obliquely, and
some more or less circularly, and
d) outer serous layer
The smooth muscle layers are collectively calledd etrusor musc les.It allows the bladder toexpand as it
fills with urine and to contract to release urine to the outside of the body duringvoiding. Thet rigone is the
base of the bladder which is a triangular area marked by the ureteropenings at the posterior corners and
the opening of the urethra at the anterior inferior corner.
The bladder is capable of considerable distention because of rugae(folds) in the mucousmembrane lining
and because of the elasticity of the walls. When full, the dome of the bladdermay extend above the
symphysis pubis; in extreme situations it may extend as high as theumbilicus. Normal bladder capacity is
between 300-600 ml of urine.
Urethra
The urethra extends from the bladder to the urinary meatus(opening).In the adult woman, theurethra lies
directly behind the symphysis pubis, anterior to the vagina, and is between 3-4cm(1.5 in) long. The
urethra serves as passageway for the elimination of urine. The urinarymeatus is located between the labia
minora, in front of the vagina and below the clitoris. Themale urethrea is approximately 20 cm(8 in) long
and serves as a passageway for semen as well asthe urine. The meatus is located at the distal end of the
penis.
In both men and women, the urethra has a mucous membrane lining that is continuous with the
bladder and the ureters. Thus, infection of the urethra can extend through the urinary tract in the
kidneys.
Pelvic f loor
The urethra and rectum pass through the pelvic floor which consists of sheets of muscles andligaments
that provide support to the viscera of the pelvis. The internal sphincter muscle situatedin the proximal
urethra and the bladder neck is composed of smooth muscle under involuntarycontrol.It provides active
tension designed to close the urethral lumen. The external sphinctermuscle is composed of skeletal
muscle under voluntary control, allowing the individual tochoose when urine is eliminated.
Urination
Micturition, voiding or urination all refer to the process of emptying the urinary
bladder. Urine collects in the bladder until pressure stimulates special sensory nerve endings inthe bladder
wall called stretch receptors. This occurs when adult bladder contains between 250and 450ml of urine.
The stretch receptors transmit impulses to the spinal cord, specifically to the
voidingreflex center located at the level of 2nd to 4th sacral vertebrae, causing the internal sphincter
torelax and stimulating the urge to void.If the time and place are appropriate for urination, theconscious
portion of the brain relaxes the external urethral sphincter muscle and urination takesplace.If the time and
place are inappropriate, the micturition reflex usually subsides until thebladder becomes more filled and
the reflex is stimulated again.
Voluntary control of urination is possible only if the nerves supplying the bladderand
urethra, the neural tracts of the cord and brain, and the motor area of the cerebrum are intact.The individual
must be able to sense that the bladder is full.

X. TREATMENT & MANAGEMENT

1. SURGICAL MANAGEMENT
February 23,2010
RETROGRADE PYELOGRAPHYAND CYSTOSCOPY
A retrograde pyelogram is a type of x-ray that allows visualization of the bladder, ureters, and
renal pelvis. Generally, this test is performed during a procedure called cystoscopy - evaluationof the
bladder with an endoscope (a long, flexible lighted tube). During a cystoscopy, contrastdye, which helps
enhance the x-ray images, can be introduced into the ureters via a catheter.
Condition thatmay interfere with a retrograde pyelogram.,
y
feces or gas in the bowels
February 26,2010
ARTHROCENTESIS
-Joint aspiration, a procedure whereby a sterile needle and syringe are used
to drain
fluid from a joint..
-
Joint fluid is typically sent for examination to the lab to determine the cause of the joint
swelling, such as infection, gout, and rheumatoid arthritis.
-
Arthrocentesis can be helpful in relieving joint swelling and pain..
EXTRACORPOREAL SHOCKWAVELITHOTRIPSY
Extracorporeal shock wave lithotripsy (ESWL) uses shock waves to break a kidney stone into
small pieces that can more easily travel through the urinary tract and pass from the body.
Complications of ESWL include:
 Pain caused by the passage of stone fragments.
 Urinary tract infection.
DOUBLE JS TENT
Is a thin tube inserted to the ureter to prevent or treat obstruction of the urine flow from the
kidney. Double J Stent have multiple perforations to allow the urine to drain from the kidneydown the
ureter to the bladder. They may be placed to bypass a stone, relieve obstruction, or tokeep the ureter from
swelling shut after a cystoscopicureteroscopic procedure.