Care of a client with:

HYDRONEPHROSIS
Secondary to:
UROLITHIASIS
BY: GROUP 2,
Level II & III
INTRODUCTION
 UROLITHIASIS
 Hydronephrosis: dilation of the renal pelvis and calyces.
 Urolithiasis is the process of forming stones in the kidneys, ureters, bladder,
and/or urethra (urinary tract). Kidney stones are a common cause of
blood in the urine and pain in the abdomen, flank, or groin. Kidney stones
occur in 1 in 20 people at some time in their life.
 Urinary Calculi (Urolithiasis) are calcifications in the urinary system.
Commonly called stones, calculi form primarily in the
kidney(nephrolithiasis), but they can form in or migrate to the lower
urinary system. They are typically asymptomatic until they pass into the
lower urinary tract.
 The pain with kidney stones is usually of sudden onset, very severe and
colicky (intermittent), not improved by changes in position, radiating from
the back, down the flank, and
into the groin. Nausea and vomiting are common.
Factors leading to kidney stones include recent reduction in
fluid intake, increased exercise with dehydration, diet and
lifestyle, infections, genetics, gender, age, medications that
cause hyperuricemia (high uric acid) and a history of gout.
Treatment includes relief of pain, hydration and, if there is
concurrent urinary infection, antibiotics. The majority of
stones pass spontaneously within 48 hours. However, some
stones may not. There are several factors which influence the
ability to pass a stone. These include the size of the person,
prior stone passage, prostate enlargement, pregnancy, and
the size of the stone. A 4 mm stone has an 80% chance of
passage while a 5 mm stone has a 20% chance.
Types of Calculi:
 Ingestion of excessive amounts of purines, oxalates,
calcium, phosphate, and other elements often results in
excessive excretion of these components in urine. A low
fluid intake, with a subsequent low volume of urine
production, produces high concentrations of stone-
forming solutes in the urine. This is an important
environmental factor in stone formation.
Diseases associated with stone formation:
Hyperparathyroidism
Renal tubular acidosis (partial/complete)
Crohn’s disease,
Sarcoidosis
Hyperthyroidism
 Anatomical Medication
abnormalities associated associated with
with stone formation: stone formation:
pelvo-ureteral junction calcium supplements
obstruction vitamin D
calix cyst supplements
ureteral stricture
ascorbic acid in
vesico-ureteral reflux
mega doses (> 4
horseshoe kidney
g/day),
Sulphonamides
 EPIDEMIOLOGY
 Kidney stone disease is a crystal concretion formed usually within the
kidneys. It is an increasing urological disorder of human health,
affecting about 12% of the world population. It has been associated
with an increased risk of end-stage renal failure.
 Urolithiasis is one of the major diseases of the urinary tract and is a
major source of morbidity.
 Stone formation is one of the painful urologic disorders that occur in
approximately 12% of the global population and its re-occurrence
rate in males is 70-81% and 47-60% in female.
 It is assessed that at least 10% of the population in industrialized part
of the world are suffering with the problem of urinary stone formation.
 The occurrence of the renal calculi is less in the southern part
when compared with other parts.
 More common in Caucasians and Asians.
 A higher prevalence of stone disease is found in hot, arid, or
dry climates such as the mountains, desert, or tropical areas.
 However, genetic factors and dietary influences may
outweigh the effects of geography.
 High stone prevalence included the United States, the British
Isles, Scandinavian and Mediterranean countries, northern
India and Pakistan, northern Australia, Central Europe, portions
of the Malay peninsula, and China
 In the Philippines, where many people have elevated uric acid level in
their blood, the incidence of kidney urate stones is also relatively
higher compared to those in other countries.
 According to the DOH, Kidney problems, consistently rank among the
top 10 causes of morbidity (7th) and mortality (8th), according to the
Philippine Statistics Authority.
 Based on the Philippine Renal Disease Registry, there are over 28,000
Filipinos undergoing dialysis. Of the over 28,000 Filipino patients
undergoing dialysis, only about 300 to 500 kidney transplantations are
performed annually and with an estimated 2,500 cases in 15 hospitals,
many are left waiting. In fact, one patient dies each week while
waiting for a suitable organ.
 We, the 2nd group of Level II and Level III students chose this case
– a client who is diagnosed with Hydronephrosis secondary to
Urolithiasis as the topic for our Nursing Care Audit because we
would want to know, learn and share how Urolithiasis develops?
What can trigger the disease to occur? This also helps the student
nurses in determining how to cater to the biological, psychosocial,
physiological and spiritual needs of clients having renal stones.
Through this case presentation and case study, it will also benefit the
listeners and readers as this case study provides a bird’s eye view of
the background of people who are diagnosed with Urolithiasis. It will
also aid the listeners and readers in the future when they encounter
situations or clients who have renal stones and on how to handle
these clients in a therapeutic manner.
 CASE PRESENTATION:
Patient C.,F. was a 53 year old married female, was admitted to the
Medical Surgical Ward at North General Hospital from the Out-Patient’s
Department. Upon arrival, patients chief complaint was left flank pain,
haematuria and dysuria. Patient reported a history of Nephrolithiasis
back in 2014 and had a Ureteral stent procedure. By 2015, there was
recurrence of multiple calculi and had re-insertion of Ureteral stent. The
patient stated that she had similar symptoms with her past illness. The
patient also added that she has had previous UTI’s before.
Admitting V/S:
T: 36.6
P: 85bpm
R: 21cpm
BP: 120/90mmhg
SpO2: 95%
 3 days PTA, patient had onset of dysuria, urinary frequency and
pain on the left side of her back. She claims that she had cloudy, tea
colored urine and it burned a little when she urinated. The night
before admission, the patient had an onset of pain at her left flank
area radiating to her left leg rated as 7/10, from a scale of 0-10, 10
being the highest and there was presence of blood in her urine.
Upon assessment, patient was conscious, coherent and afebrile.
Lungs were symmetrical ; normal breath and heart sounds were
heard upon auscultation. Normal bowel sounds were heard in all
quadrants. Abdominal assessment of patients’ abdomen included a
bit of distended appearance and upon palpation abdomen was
tender. KUB UTZ revealed a 1.2 cm calculus seen at left uretero –
pelvic junction.
Remarks:
Left Pelvocaliectasia 2º to an obstructing calculus at the left uretero
pelvic junction.
 PATIENT’S PROFILE:
Name: C., F.
Age: 53 years old
Sex: Female
Civil Status: Married
Occupation: Housewife
Nationality: Filipino
Religion: Roman Catholic
Address: San Jose, Purok 5, Cebu
City
Name of Hospital: North General
Hospital
Date of Admission: September 28,
2018
Time of Admission: 12:55PM
Ward and Bed No.: Ward 2-A, Room
233
Case No.: 18-2681
Physician: Dr. I. Esplanada M.D. &
Dr. K. Eugenio M.D.
Chief Complaint: Left Flank Pain,
hematuria and dysuria
Admitting Diagnosis/Impression:
Left Pelvocaliectasia 2 ͦ Left
Urolithiasis
PERTINENT NURSING
HEALTH HISTORY
CHIEF COMPLAINT
 Left flank pain rated as 7/10, from a scale of 0-10, 10 being the
highest; hematuria and dysuria.
HISTORY OF PAST ILLNESS
 Upon assessment, patient stated that she has had previous
hospitalizations associated with her current condition. In the year
2014, patient was diagnosed with multiple calculus in her left
kidney. Treatment included insertion of a ureteral stent. In the year
2015, she was admitted for reinsertion of ureteral stent due to the
same condition. She was confined in multiple hospitals including
NGH. The patient stated that she also felt pain in her left flank,
pain when urinating and frequency. The patient added that she
has had recurrence of urinary tract infections.
HISTORY OF PRESENT ILLNESS
 3 days PTA, patient had onset of dysuria, urinary frequency
and pain on the left side of her back. The pain was usually
stimulated when she paced her walking and lifting heavy
objects but is sometimes relieved by rest. She claims that she
had cloudy, tea colored urine and it burned a little when she
urinates. The night before admission, the patient had an onset
of pain at her left flank area radiating to her left leg rated as
7/10, from a scale of 0-10, 10 being the highest and there was
presence of blood in her urine. The patient stated that she was
tolerating the pain but decided to seek consult and was
advised for admission.
SOCIAL AND ENVIRONMENTAL HISTORY
 The patient lives with 2 of her sons, aged 21 and 27; and her
husband aged 58. They all live in a secluded, private
compound at San Jose, Purok 5, Cebu City. At the age of 18
she began to smoke 5 sticks per day then stopped when her
first son was born and added that she drinks beer
occasionally for socialization purposes. She is fond of eating
high salt and high sugar foods with a bottle of acidic
beverages. Almost every day, she eats junk foods, soft drinks
and loves to eat in fast food restaurants like Jollibee, KFC, and
McDonald's. The client is a housewife, and is a high school
graduate. She is friendly and loves to mingle with others. Due
to her kindness, generosity, and friendly attitude, she is loved
by many and is always visited by her neighbors, friends, and
relatives in their house and they used to have snacks. Their
house is sited along the street and was surrounded by mango
trees. She loves to eat mango with “bagoong”.
FAMILY HISTORY:
 The patient’s father died because of stroke and hypertension.
The mother was deceased with a history of kidney stones and
hypertension. She has 3 siblings, with her being the second
eldest. The patient stated that her eldest brother is hypertensive
and her younger sister has asthma. According to her, their
relatives from the mother side have the same illness also and
some relatives passed away with the same health problem.
Maternal: Paternal:
Asthma HPN
Kidney stone Chronic Smoker
HPN
OBSTETRIC HEALTH HISTORY
 The patients’ menarche happened when she was 11 years old.
Her menstrual duration lasted for 3-5 days and has regular days
with lighter menstrual flow on the first day and become gradually
heavier towards the end of menses consuming 3-4 pads in a day.
According to the patient, when she had her first pregnancy at 26
years old, and her second child when she was 32 years old. She
was healthy with both of her pregnancies and she had complete
prenatal check-ups and was taking her vitamins daily. She gave
birth via Normal Spontaneous Vaginal Delivery with both of her
children. She entered the menopausal stage at 51 years old.
Gravida- 2, Para- 2 Term - 2, Abortion- 0, Live birth- 2
Generativity refers to "making your mark" on the
world through caring for others as well as creating
and accomplishing things that make the world a
better place.
Stagnation refers to the failure to find a way to
contribute. These individuals may feel
disconnected or uninvolved with their community
and with society as a whole.
During middle adulthood between ages 40 to 65 yrs., we
establish our careers, settle down within a relationship,
begin our own families and develop a sense of being a
part of the bigger picture. During this time, adults strive
to create or nurture things that will outlast them; often by
parenting children or contributing to positive changes
that benefit other people. Contributing to society and
doing things to benefit future generations are important
needs at the generativity versus stagnation stage of
development.
 As for our patient, C., F. is successful in passing this stage. During
our assessment of her, she was with her cousin then replaced by her
eldest son and before our shift ended we saw her husband and son
taking care of her, feeding her showing that her family really cares
and loves her so much. She added that in this time of her life, she is
really grateful because she has all of her loved ones beside her. She
also added that her family never fails to remind her that they love
her and that they thank her for coming into their lives and for
bringing their sons in this world. Aside from being a caring mother
and wife, she is also involved in community activities and
organizations, despite not having finished college, she has
established her career as a mother and a wife, settled down,
growing and nurturing a long-lasting relationship and raising a family.
It is apparent that she has successfully developed the virtue of care
and generativity.
GENOGRAM
 GORDON’S
FUNCTIONAL HEALTH
PATTERN
 PHYSICAL
ASSESSMENT
GENERAL SURVEY: Received patient C., F. at ward 2A-
Room No. 233, awake, conscious, and responsive with
vital signs of: T- 36.0 ͦC, P- 70 bpm, R- 18 cpm, Bp- 90/60
mmhg, pain score 5/10, with IVF: D5LR 40 gtts/min -
infusing well.
Pt is 4’11” in height and 53kgs in weight. Pt. has a good
posture and gait but her movement was quite limited
because of her being nauseous and having a
headache. Patient shows signs of diminished alertness.
Appears clean and neat, practices good hygiene.
e

CRT: <2secs
DIAGNOSTIC TESTS
AND
EXAMINATIONS
 SUMMARY OF
SIGNIFICANT FINDINGS
 ANATOMY
AND
PHYSIOLOGY
 The urinary system is also called excretory system or the
genitourinary system (GUS) is the organ system that
produces, stores, and eliminates urine in humans. The organs
of the urinary system include the kidneys, renal pelvis, ureters,
bladder and urethra.
 The body takes nutrients from food and converts them to
energy. After the body has taken the food components that
it needs, waste products are left behind in the bowel and in
the blood.
 The kidney and urinary systems help the body to eliminate
liquid waste called urea, and to keep chemicals, such as
potassium and sodium, and water in balance.
 Humans produce about 1.5 liters of urine over 24 hours,
although this amount may vary according to circumstances.
 The kidneys are a pair of brownish-red structures; bean-
shaped, and each measure about 11 cm long, 5 cm wide,
and 3 cm thick, which is about the size of a clenched fist.
An adult kidney weighs 120 to 170 g (about 4.5 oz).
FUNCTIONS OF THE KIDNEY:
Excretion.
Regulation of blood volume and pressure.
Regulation of blood solute concentrations
Regulation of extracellular fluid pH
Stimulation of red blood cell synthesis.
Activation of vitamin D
 LOCATION OF THE KIDNEYS:
The kidneys are retroperitoneal and are located on
each side of the vertebral column near the psoas
major muscles. They extend from the lower portion
of the rib cage at the level of the last thoracic (T12)
vertebra to the third lumbar (L3) vertebra. The liver is
superior to the right kidney, causing the right kidney
to be slightly lower than the left.
 LAYERS OF THE KIDNEYS:
Renal Cortex
 The renal cortex is the outer smooth, continuous layer of the kidney.
The process of ultra-filtration of blood is carried out in the renal
cortex which is also known as high pressure filtration.
Medulla
 The medulla resembles conical pyramids whose bases project into
the cortex. The pyramids are situated with the base facing the
concave surface of the kidney and the apex facing the hilum, or
pelvis. Each kidney contains approximately 8 to 18 pyramids.
 When urine leaves a renal papilla, it empties into a small, funnel-
shaped chamber surrounding the tip of the papilla called a minor
calyx (4 to 13 minor calices or calyx). Urine from several minor
calyces are emptied into a larger, funnel-shaped chamber called
a major calyx (2 to 3 major calices/calyx) that open directly into
the renal pelvis.
Renal Pelvis
The hilum, or pelvis, is the concave portion of the kidney
through which the renal artery enters and the renal vein
exits. It is a single, enlarged, funnel-shaped chamber
where the urine is emptied from the major calyces. The
renal pelvis is embedded in and surrounded by the renal
sinus.
At the hilum, it narrows significantly, forming the small-
diameter tube called the ureter. Urine moves from the
renal pelvis into the ureter for transport to the bladder.
 NEPHRONS:
Each kidney contains about 1.3 medulla, namely:
million nephrons, the histological  a glomerulus containing afferent and
and functional units of the kidney. efferent arterioles,
Nephrons usually measure about  Bowman’s capsule, (filters the blood)
50–55 mm in length. Each kidney is  proximal tubule, (returns filtered substances
capable of providing adequate to the blood)
renal function if the opposite  loop of Henle, (helps conserve water and
kidney is damaged or becomes solutes)

nonfunctional.  distal tubule, (rids the blood of additional

wastes)
The nephron consists of separate  and collecting ducts
segments that are distributed
throughout the cortex and
PATHOPHYSIOLOGY
Nursing Care Management
•Encourage client to increase fluid intake
•Encourage client to schedule micturation
•Monitor intake of fluid amount and urinary output.
•Medicate for pain as prescribed.
•Continue antibiotic therapy as prescribed.
•Correct diet to include reduced protein and calcium content.
NURSING CARE PLANS
1.2cm
DRUG STUDY
DISCHARGE PLAN
 Medication
*orient patient about the name of the drug, the exact dosage,
frequency, and the route of administration
*instruct the client to follow the instruction when administering
medication
*explain to client the side effects and adverse reactions of the drug she
takes by explaining its manifestation
*advise client not to skip the medication that the doctor ordered
 Exercise/Environment
*encourage client to have enough rest
* encourage client to have a clean and healthy environment to
promote fast recovery
* encourage client to maintain a clean and healthy environment to
prevent further
 Treatment
*oriented client about the importance of sleep and rest
*instructed the client to have enough rest and avoid
strenuous activities
* obtaining laboratory test
* instructed client to seek medical care if there is any
abnormalities or severe pain or reoccurrences of previous
symptoms felt
 Health teaching
*After the planned surgery, provide all necessary post-op care
*Care of the surgical site if there is
*Relieved pain and discomfort
*Maintain fluid intake for dehydration
*Observations, signs and symptoms/ OPD referral
*Instructed patient to come back for follow up checkup on
the date ordered
* Encouraged to report, with the help of any family members,
any present signs and symptoms
Diet and nutrition
*Advise patient to continue her multivitamins.
Also, to eat nutritious food High in protein
*Tell patient the importance of a well-balanced
diet and drink plenty of fluids
Spirituality
*Provide spiritual and emotional support.
THANK YOU!!!