Our Lady of Fatima UniversityResearch and Development Center i Nursing Management Nursing Management of a Patient with Calyceal Calculi A Case Study by Alojado, Christine Mae B. Cueva, Paulyn Dalisay, Inah Joy 4Y1-8 (Group 8A) Our Lady of Fatima University Valenzuela City Campus Mrs. Elisa Lasanas, RN, MAN Clinical Instructor C O L L E G E O F N U R SI N G He was rushed to nearby hospital and KUB & ultrasound was done revealing pelvicaliocyceal left secondary to ureteropelvic junction calculus. 1 month prior to his admission. 6 months prior to his admission. which afforded temporary relief. described as colicky. B. Hence. had a chief complaint of left flank pain. the above symptoms persisted. D. he was noted with occasional flank pain on his left side. a 30 year-old male. He was diagnosed with left nephrolithiasis since 2005 and was given sodium citrate (Rowatinex) and potassium citrate three times a day as his medication. He didn’t have any consultations and his previous medications were continued. radiating to the left leg. He was then referred to Armed Forces of the Philippines Medical Center where further medical evaluations were done.Our Lady of Fatima University Research and Development Center ii Nursing Management II Nursing Management of a Patient with Calyceal Calculi Mr. He was apparently well and was lost to follow up. A. admission was made. C O L L E G E O F N U R SI N G . and associated with some passage of sandy urine. married Filipino from Leyte. diet.” This pain is caused by the spasmodic contraction of an obstructed ureter. we will discuss what ureterolithiasis is all about.Our Lady of Fatima University Research and Development Center iii To fully understand the case of the patient. This may be either as nephrolithiasis (kidney stones) or ureterolithiasis (ureter stones). chronic urinary tract infection. renal disease & gout (a disease of increased uric acid production or decreased excretion) (Myers. or both. calcium phosphate. spasmodic flank pain often described as “the worst pain I’ve had in my entire life. but some precipitating factors include dehydration. Urinary colic is an extreme. 2005). and immobility or prolonged bed rest leading to release of calcium from the bones. Typical symptoms of kidney stones are hematuria and renal or urinary colic. Calculus/calculi are precipitates of mineral salts ordinarily dissolved in urine. According to Timby (2005). urolithiasis refers to a condition of stones (calculus/calculi) that forms in the urinary tract. Renal calculi or kidney stones are composed of calcium oxalate. Cause of stone formation is unknown. metabolism. C O L L E G E O F N U R SI N G . And some possible causes are obstruction to urine flow. It’s more common in males than females and commonly occurs between ages thirty to fifty (Timby. Obstruction of the ureter by the kidney stones causes a renal colic attack which is why intense pain is felt in groin and back.Our Lady of Fatima University Research and Development Center iv Ureterolithiasis is a kidney stone specifically found in the ureter (the long tube that travels from your kidney to your bladder). Ureteral stones are usually small. C O L L E G E O F N U R SI N G . 2005). some may be no larger than a grain of sand. The functional units of the kidney are called nephrons. we must first recall the anatomy & physiology of the renal system.The Renal System is consists of the kidneys. urinary bladder and the urethra. hormones and metabolized drugs.Our Lady of Fatima University Research and Development Center v Nursing Management III Pathophysiology To fully understand the pathophysiology of ureterolithiasis. potassium and phosphates. ureters. These components work together to maintain ion balance for optimal function and eliminate unnecessary material from plasma (Amerling & Levin. Urine normally consists of 95% water. calcium. . Each nephron contains a glomerulus. the nitrogenous waste products of protein which are urea. Each kidney has more than 1 million nephrons. Bowman’s capsule and tubule system. C O L L E G E O F N U R SI N G The glomerulus is the filtering system of the nephron. 2001). uric acid and creatinine. the excessive electrolytes sodium. a semipermeable and allows water and soluble waste to pass through and be eliminated as urine. g calcium oxalate & calcium phosphate) precipitate. together with calcium phosphate. This normally results to fluid loss & loss of bicarbonate which may lead to metabolic acidosis. 2006). Normally. dehydration (such as lack of drinking fluids – water) may contribute to the formation of calculi since the urine becomes highly concentrated. foods that contain oxalates are asparagus. . Calcium oxalates on the other hand. comprises 75-80% of calculi formation (Lippincott. the pH of the urine becomes acidic (<6.Our Lady of Fatima University Research and Development Center vi One of the predisposing factors that contribute to the formation of stones is the intake of foods containing purine & oxalate. males tend to have this kind of illness. immobility may contribute to the risk of having calculi (Timby & Smith. men are more likely to have calculi than women (Myers. 2004). Regional enteritis & ulcerative colitis may precipitate further formation of uric acid calculi. In addition to that. C O L L E G E O F N U R SI N G As for the possible risk factors. Aside from that. Neighbors et al. chocolates. As a result. and caffeinated beverages among others.0). According to Lippincott (2004). Due to their lifestyle preferences. diet that is high in purine such as meat. fish & poultry increases the levels of uric acid in the body. Calculi form when substances that are normally dissolved in the urine (e. Neighbors et al. C O L L E G E O F N U R SI N G . 2004). He lacks of taking breaks & does some exercise. he normally sits for longer periods of time.g flank pain) as violent contractions in the ureter (Myers. calcium components tend to collect. According to Timby & Smith. When calculi are already formed. Nausea & vomiting may also accompany a patient with this condition. and may further precipitate the formation of calculi (Lippincott. As a result. 2006). this may result to urine stasis. Just in the case of the patient which is a driver of taxi. Aside from that. This compounds to the pain that the patient feels (e.Our Lady of Fatima University Research and Development Center vii 2005). it causes trauma to the urinary tract & irritate the cellular lining. infection may occur. gross or microscopic hematuria may also be seen to a patient as a result of tearing of tissues while calculi tend to move downward. Our Lady of Fatima University Research and Development Center viii Nursing Management IV History According to the patient during the interview. sardines. he had no previous history revealed of hypertension. He normally drinks water. or worst. but when times that there’s scarcity of water. He was also not allergic to any kind of food. & other salty foods. he would drink buko juice. His condition was the only time that when he sought for medical attention. C O L L E G E O F N U R SI N G . he is the sixth among seven children. Familial medical history suggests that none of his parents have the same medical problems as that of the patient. He said that during combats. or Diabetes Mellitus. asthma. especially in the mountains. the usual foods that he ate include daing. He said that he’s a non-smoker but an occasional alcoholic beverage drinker. According to his personal history. noodles. no fluids at all. sharp.S. . respiratory rate was 20 cpm. Prior to admission. very severe and colicky (intermittent) not improved by changes in position.2 °C. H. Ureteral colic is the term that best describes this instance where that severe. was conscious and coherent at the time of assessment.Our Lady of Fatima University Research and Development Center ix Nursing Management V Nursing Physical Assessment Mr. and into the groin.D. down the flank. There is tenderness at his left flank area. soft. sudden pain radiates towards the thigh and genitals. The patient abdomen was flabby. The patient’s skin was warm to touch. the patient experienced left flank pain. The patient has that desire to void but little urine is passed. no cyanosis and no edema observed. C O L L E G E O F N U R SI N G Brunner & Suddarth (2010) cited that pain associated with kidney stones are usually of sudden onset. radiating from the back. pulse rate of 65 bpm and blood pressure of 110/70 mmHg. The patient’s temperature was 37. This can be also said when there is a decrease in lymphocyte count. H.5 cm. Its impression was pelvocaliectasia left.19. C O L L E G E O F N U R SI N G According to Brunner & Suddarth (2010). segmenters (neutrophil) count increased at 0.54 x109/L. It also showed that the left kidney is more dilated than the right with a cortical thickness of 1.72 & lymphocyte count at 0.Our Lady of Fatima University Research and Development Center x and often times. at 12. pus cells of 8-10 & pH level of 8. It showed a 1. There were laboratory tests done to find out some abnormalities on Mr. possibly secondary to ureteropelvic junction calculus/calculi. blood can be seen due to the abrasive action of the stone. White blood cells primarily the body from being infected while the segmenters (neutrophils) are the first line of body’s .7 cm shadowing high intensity echo seen in the ureteropelvic junction.D. KUB Ultrasound was the diagnostic tool used to the patient.S. an increased in WBC and segmenters count in the blood would indicate that there is an infection happening to the patient. microscopic analysis showed RBC level 5-8/HPF. CBC was also done to determine abnormalities on the blood. Urinalysis showed that the urine was yellow & slightly turbid. It showed that the WBC count was increased. It was performed in order to determine the size. pus will be seen as a result of that. & position of the kidneys & to reveal urinary system abnormalities (Brunner & Suddarth. 2010). KUB or Kidney. which is normally at around 1-5 per high-power field (hpf).Our Lady of Fatima University Research and Development Center xi defense against acute infection. the patient’s kidneys were the ones that was determined since there was marked dilation on the left kidney compared to that of the right kidney. shape. C O L L E G E O F N U R SI N G . In this case. Ureter & Bladder Study. And since there is already infection occurring in the system. The same can be said on the amount of RBC & in the urinary analysis. Since there is a marked increase of RBC in the urine. this indicates that there is bleeding caused by the renal calculi. is an X-ray study of the abdomen. were C O L L E G E O F N U R SI N G provided to relieve acute pain to the patient whereas morphine was given for severe pain. another anti-ulcerative drug. Paracetamol & Etoricoxib (Arcoxia). It was given to the patient in order to prevent getting gastric ulcers due to medications (Lippincott. Several pain reliving drugs were given to the patient to provide comfort and avoid pain. That can be also said about the other drug that was given. These were given in order to avoid nausea & vomiting (Lippincott. were also provided for the patient. 2010).Our Lady of Fatima University Research and Development Center xii Nursing Management VI Related Treatment The patient had different medications taken to relieve symptomatic & aggravating factors of his illness. Hyoscine butylbromide (Buscopan) & metoclopramide HCl (Reglan). an anti-ulcerative drug. . One of the medications given to the patient was omeprazole. 2010). non-steroidal anti-inflammatory drugs. which was pantoprazole. antiemetic drugs. Our Lady of Fatima University Research and Development Center xiii In order to remove the stone that was located on the left ureter. surgical intervention was performed to the patient. it was the more convenient way to remove the stones from the patient. C O L L E G E O F N U R SI N G . a non-invasive alternative treatment. is very expensive. And the procedure done was ureterolithotomy. Actually. 2010). Since Extracorporeal Shockwave Lithotripsy (ESWL) therapy. this surgical procedure is only done to 1 to 2% of patients (Brunner & Suddarth. 2010). C O L L E G E O F N U R SI N G The main nursing intervention to the patient is to provide adequate information. the patient will be able to explain & identify different ways to avoid the recurrence of stone formation (Brunner & Suddarth.Our Lady of Fatima University Research and Development Center xiv Nursing Management VII Nursing Care Plan The diagnosis for the patient was Deficient knowledge regarding prevention of recurrence of ureteral stones as manifested by the client frequently asking questions. & document teaching regarding the following: The patient must be taught about dietary limitations he must take such as low uric acid (e.g. . The plan for the patient is that after 2 hours of nursing intervention. reinforcing as necessary. meats. legumes) & low oxalates (chocolates. g. If this happens. Depending on their composition. potassium citrate) as recommended by the physician is essential. C O L L E G E O F N U R SI N G . pain. he should go for a follow-up check-up. maintaining the urine pH by taking medications (e. Observe for signs & symptoms of the following: hematuria. oliguria is also important since the incidence of recurrence of calculi is high. As for medical or collaborative intervention. This is done so that limiting foods rich in calculusforming substances may inhibit recurrence of calculi. Another aspect of providing information is to practice regular activity movements such as exercise. As much as 10-12 glasses (>2000 ml/day) of water is need to help flush calculus fragments & helps prevent stone fragments from recurring. The need for adequate fluid intake is so much important for a patient with this disorder.Our Lady of Fatima University Research and Development Center xv caffeinated drinks). calculus may form in either acid or alkaline urine. Activity decreases urine stasis & risk of calculi recurrence. The goal is to maintain the desired levels of urine pH. creatinine and uric acid in the blood. C O L L E G E O F N U R SI N G Phosphorus level in the blood increases as kidney function declines. it is important to avoid foods high in this nutrient. therefore. fish and eggs) is better than the intake of red meat (pork and beef). chocolate and cocoa. . such as: excess intake of milk. legumes like beans and mongo beans. Avoid concentrated foods like organ meats and processed foods. Excess intake of protein would lead to the accumulation of waste products like urea. Consumption of white meat (chicken. Nursing Management VIII Recommendations There are precautions in which the patient may consider in his diet. the patient was able to explain & identify different ways to avoid the recurrence of stone formation. & nuts. The patient must eat just enough amount of protein. cheese and other dairy products.Our Lady of Fatima University Research and Development Center xvi In order to evaluate the patient’s understanding of this plan. There are no restrictions in physical activities. Potassium citrate (Acalka). Water therapy is essential during his recovery. hydration and antibiotics that the patient should take. If you tend to form stones. One needs to start drinking a lot of fluids. chips. fish sauce. an antibiotic. for as long as the patient practices proper voiding habits. water is considered to be the ideal solution. soy sauce. salted egg. vetsin. C O L L E G E O F N U R SI N G There are also medications and treatment which includes relief of pain. While any fluids can be consumed. you should try to drink enough liquids throughout the day to produce at least 2 quarts of urine in every 24-hour period. broth cubes) is also included since it could precipitate uric acid increase due to purine. an antiurolithic. Home medications include the following: ofloxacin (Floxin). dried fish. must also be given which inhibits urine . It should be given with plenty of fluids.Our Lady of Fatima University Research and Development Center xvii Restricting salty foods and condiments (bagoong. The tablet must not be masticated or diluted. It helps to dilute stones in the urinary tract and act as a diuretic. It is recommended that the patients in treatment with Acalka follow a diet without salt and increase the intake of fluids. C O L L E G E O F N U R SI N G . treatment of patients with renal lithiasis. A follow-up visit in the hospital after 2 weeks is important to determine whether the treatment was effective or not. chronic formers of calcium oxalate. There are also warning signs which are stated in the discharge plan like fever and Hematuria more than 3 days that needs immediate consultation. uric acid lithiasis. Releaf tablet (sambong supplement) can be included as it contains powdered leaves of the sambong plant. Tramadol is recommended if the patient feels moderate to moderately severe pain.Our Lady of Fatima University Research and Development Center xviii crystallization. and hypocitraturia. PA.Our Lady of Fatima University Research and Development Center xix Nursing Management IX References Books: 1. Principles of Pathophysiology and Emergency Medical Care. Neighbors. Nancy Ellen (2005). et al (2010). Marianne. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Ruth (2002). 4. Wolters Kluwer Health/Lippincott Williams & Wilkins. Philadelphia. Jeffrey W. Clifton Park. by Lippincott Williams & Wilkins Philadelphia. Philadelphia. NY 2. Smith. PA 3. Myers. Pathophysiology: A 2-in-1 Reference for Nurses (2004). Timby.. . Williams & Wilkins. PA. Essentials of C O L L E G E O F N U R SI N G Nursing: Care of Adults and Children By.. Suzanne. Lippincott. Barbara Kuhn. Thomson Learning Inc. Smeltzer. Tannehill-Jones.