CASE STUDY -- Bilateral Nephrolithiasis

CASE STUDY ON BILATERAL

NEPHROLITHIASIS

RLE GROUP 2

OBJECTIVES

GENERAL OBJECTIVE• After this case study, We will be able to develop our knowledge,

skills and attitude in managing and dealing patients with Bilateral Nephroliathiasis.

• SPECIFIC OBJECTIVES • KNOWLEDGE • To be able to know our responsibilities such as promoting

health, prevent further injury or illness, as well as restoration of health according to the extent of our knowledge and skills.

• To have knowledge about Bilateral Nephrolithiasis.• To familiarize ourselves the different treatments and

medications of the disease.• To learn the pathophysiology, anatomy and physiology, signs and

symptoms, its prevention and those who are at risk of the disease.

SKILLS• To know how to deal and handle patients who

are suffering from Bilateral Nephrolithiasis.• To provide nursing care in patients with Bilateral

Nephrolithiasis.ATTITUDE• To be able to understand the patient's feeling

towards his condition.• Empathize with the patients.

INTRODUCTION

• Nephrolithiasis, the process of forming a kidney stone, a stone in the kidney (or lower down in the 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. The development of the stones is related to decreased urine volume or increased excretion of stone-forming components such as calcium, oxalate, urate, cystine, xanthine, and phosphate. The stones form in the urine collecting area (the pelvis) of the kidney and may range in 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 the Latin "urina" and the Greek "ouron" meaning urine = urine stone. The stones themselves are also called renal caluli. The word "calculus" (plural: calculi) is the Latin word for pebble.

• Mortality/Morbidity• The morbidity of renal calculi is primarily due to

obstruction with its associated pain, although non obstructing calculi can still produce considerable discomfort.

• Conversely, patients with obstructing calculi may be asymptomatic, which is the usual scenario in patients who experiences loss of renal function due to chronic untreated obstruction.

• Stone-induced hematuria is frightening to the patient but is rarely dangerous by itself.

Factors• Race• Renal calculi are far more common in Asians and whites than in

Native Americans, Africans, African Americans, and some natives of the Mediterranean region. Although some differences may be attributable to geography (stones are more common in hot and dry areas) and diet. Heredity also appears to be a factor. This is suggested by the finding that, in regions with both white and nonwhite populations, stone disease is much more common in whites.

• Sex• In general, urolithiasis is more common in males (male-to-

female ratio of 3:1).Stones due to discrete metabolic/hormonal defects (eg, cystinuria, hyperparathyroidism) and stone disease in children are equally prevalent between the sexes. Stones due to infection are more common in women than in men.

• Age• Most renal calculi develop in persons aged 20-

49 years. Patients in whom multiple recurrent stones form usually develop their first stones while in their second or third decade of life.

VITAL INFORMATION

A. Patient’s Data

Name: Mrs. C.D.

Age: 80 y.o

Sex: Female

Address: Capagao Panitan, CapizCivil status: Married

Religion: Roman Catholic

Nationality: Filipino

Occupation: Housewife

Date and Time Admitted:Ward:

Sept. 8,2010 8:10 amIHM, Room

Chief Complaint: Bilateral flank pain

Admitting Diagnosis: Obstructive Neuropathy secondary to Bilateral

Nephrolithiasis; renal cyst.

Attending Physician(s): Dr. R.BDr. R.JDr. J.A

HISTORY

History of Present Illness• Before admission. Pt. was already diagnosed with Bilateral

Nephrolithiasis and renal cyst. Right kidney stones were monitored every 3 mos. and were maintained on acalka and sambong.

• I week pta.pt. had onset of bilateral flank pain with patient tolerated at home but the pain progressed which prompted admission.

• Pt. was admitted on Sept. 8, 2010 8:10 am at St. Anthony College Hospital, IHM ward with the chief compliant of Bilateral Flank Pain under the service of Dr. RB, Dr. RJ and JA.

• (+) wt. loss• (+) bowel changes• (+) low back pain• (+) dyspnea• (+) cough

Past Medical History• Last Feb. 2009 pt. was admitted at doctors

hospital, Iloilo for the operation of her eyes. She has hypertension, bilateral nephrolithiases and right renal cyst.

Family History• Mrs. C.D. and her husband both have history of

Hypertension in the family.•

GENOGRAM

Mrs. CD80 y/o

Mrs. CD80 y/o

Mr. D 80y/oMr. D 80y/o

Mr. E.

58 y/o

Mr. E.

58 y/o

Mrs. M 54 y/oMrs. M 54 y/o

Mrs. R50 y/oMrs. R50 y/o

Retired Bus

Driver

Businesswoman

EmployeeOFW

Legend Male Female Patient

Hypertension Pneumonia

Occupation

PHYSICAL ASSESSMENT

General Appraisal:• Body structure: Average• Movement: Immobile• Speech: Coherent and can’t speak clearly.• Level of Consciousness: Lethargic• Vital Signs:• Temp: 36.3• AR: 62• Pulse: 60• RR: 25• BP: 130/80•

Body Parts Method of

Assessment

Findings Interpretation

Skin Inspection Skin is normal in color, warm and

moist.

Normal

Nails Inspection The nail is pale pink in color. No clubbing, no lesions.Good capillary refill.

Normal

Head Inspection Head is normocephalic. Hair not evenly distributed, brown in color with visible white hair. No lesions, no dandruff.

Normal

Eyes Inspection The eyelid covers the top portion of the iris.Cornea is clear and without lesion.Conjunctiva is pinkish in color, no inflammation, & no discharge.Sclera is white and no lesion.PERRLA

Normal

Ears Inspection Both ears are symmetric, no signs of inflammation and infection and there is no secretions.

Normal

Nose Inspection Nose bridge is aligned, nostrils are symmetric.No nasal discharge, no lesions.

Normal

Mouth Inspection Lips are not dry, no lesion.The oral mucosa is pink and moist; gums, pink & moist and tongue is pink, moist and no lesions. The uvula is at the middle.Tonsils are not inflamed, and are pink in color.

Normal

Neck Inspection

Palpation

Neck is symmetric & skin is intact, there is no lesion, no neck masses, and no enlargement. The trachea is at the middle and is aligned.

Normal

Chest Inspection The chest-wall is symmetric.

Normal

Abdomen Inspection

Flabby abdomen.It is soft and nontender; no masses noted.

Urinary Retention

Musculoskeletal: Inspection

No evidence of swelling or deformity. Immobile.

Osteoporosis

Hypertrophic Degenerative Osteoarthropathy

Genitourinary Inspection

With urinary catheter. Normal

TEXTBOOK DISCUSSION

• DEFINITION:• The term Nephrolithiasis refers to kidney stone. The most common

cause of upper urinary tract obstruction is urinary calculi. Although stones can form in any part of the urinary tract, most develop in kidneys. Urinary stones are the third most common disorder of the urinary tract, exceeded only by UTIs and prostate disorders.

• Kidney stones are crystalline structures made up of materials that the kidneys normally excrete in the urine.

TYPES OF KIDNEY STONETYPES OF STONE CONTRIBUTING

FACTORSTREATMENT

Calcium(Oxalate and phosphate)

Hypercalcemia and hypercalciura Immobilization

Hyperparathyroidism Vit. D intoxication Diffuse bone disease Milk-alkali syndrome Renal tubular acidosis Hyperxoxaluria

Treatment of underlying conditions

Increased fluid intake Thiazide diuretics

Magnesiun Ammonium phosphate (struvite)

Urinary tract infections Treatment of urinary tract infections

Acidification of the urine Increased fluid intake

Uric Acid (Urate) Formed in acid urine with pH of approximately 5.5

Gout High- purine diet

Increased fluid intake Allopurinol for

hyperuricuria Alkalinization of urine

Cystine Cystinuria (inherited disorder of amino acid metabolism

Increased fluid intake Alkalinization of urine

CLINICAL MANIFESTATIONS• Pain • 2 types of pain: • Renal Colic- is the term used to describe the colicky pain that accompanies

stretching of the collecting system of the ureter. • Noncolicky Renal Pian- is caused by stones that produce distentions of the renal

calices and renal pelvis.

SIGNS AND SYMPTOMS: SIGNS AND SYMPTOMS OF PATIENT:

Pyelonepritis and UTI Chills Fever Frequency Pain and discomfort Hematuria Pyuria Nausea and vomiting Episode of renal colic Irritation Urinary retention

Pain and Discomfort Episode of renal Colic Urinary Retention

COMPLICATION:• Kidney failure • Renal failureDIAGNOSIS • Urinalysis – provides information related to hematuria, infection, the presence of

stone forming, crystals, and urine pH.• Intravenous pyelography – uses an intravenously injected contrast medium that

is filtered in the ureters and kidneys.• Abdominal ultrasound – highly sensitive to hydronephrolithiasis, which may be a

manisfestation of ureteral obstruction.• Retrograde urography and CT scanning – a new imaging technique called nuclear

scintigraphy uses biophosphate markers as a means .TREATMENT• Antibiotic therapy• Increased fluid intake• Thiazide diuretics• Removing of kidney stones• Ureteroscopic removal• Percutaneous nephrolithotomy• Extracorporeal shockwave lithotripsy

Medical Manageme

nt

• Percutaneous Nephrolithotomy• Percutaneous nephrolithotomy, or PCNL, is a procedure for removing medium-

sized or larger renal calculi (kidney stones) from the patient's urinary tract by means of an nephroscope passed into the kidney through a track created in the patient's back. PCNL was first performed in Sweden in 1973 as a less invasive alternative to open surgery on the kidneys. The term "percutaneous" means that the procedure is done through the skin. Nephrolithotomy is a term formed from two Greek words that mean "kidney" and "removing stones by cutting.“

PurposeThe purpose of PCNL is the removal of renal calculi in order to relieve pain, bleeding into or obstruction of the urinary tract, and/or urinary tract infections resulting from blockages. Kidney stones range in size from microscopic groups of crystals to objects as large as golf balls. Most calculi, however, pass through the urinary tract without causing problems.

Preparation• Most hospitals require patients to have the following tests before a PCNL: a

complete physical examination; complete blood count ; an electrocardiogram (EKG); a comprehensive set of metabolic tests; a urine test; and tests that measure the speed of blood clotting.

Aspirin and arthritis medications should be discontinued seven to 10 days before a PCNL because they thin the blood and affect clotting time. Some surgeons ask patients to take a laxative the day before surgery to minimize the risk of constipation during the first few days of recovery.

• The patient is asked to drink only clear fluids (chicken or beef broth, clear fruit juices, or water) for 24 hours prior to surgery, with nothing by mouth after midnight before the procedure.

Aftercare• A standard PCNL usually requires hospitalization for five to six days after

the procedure. The urologist may order additional imaging studies to determine whether any fragments of stones are still present. These can be removed with a nephroscope if necessary. The nephrostomy tube is then removed and the incision covered with a bandage. The patient will be given instructions for changing the bandage at home.The patient is given fluids intravenously for one to two days after surgery. Later, he or she is encouraged to drink large quantities of fluid in order to produce about 2 qt (1.2 l) of urine per day. Some blood in the urine is normal for several days after PCNL. Blood and urine samples may be taken for laboratory analysis of specific risk factors for calculus formation.

Risks• There are a number of risks associated with PCNL:• Inability to make a large enough track to insert the nephroscope. In this case, the

procedure will be converted to open kidney surgery.• Bleeding. Bleeding may result from injury to blood vessels within the kidney as well

as from blood vessels in the area of the incision.• Infection.• Fever. Running a slight temperature (101.5°F; 38.5°C) is common for one or two

days after the procedure. A high fever or a fever lasting longer than two days may indicate infection, however, and should be reported to the doctor at once.

• Fluid accumulation in the area around the incision. This complication usually results from irrigation of the affected area of the kidney during the procedure.

• Formation of an arteriovenous fistula . An arteriovenous fistula is a connection between an artery and a vein in which blood flows directly from the artery into the vein.

• Need for retreatment. In general, PCNL has a higher success rate of stone removal than extracorporeal shock wave lithotripsy (ESWL), which is described below. PCNL is considered particularly effective for removing stones larger than 1 in (0.5 cm); staghorn calculi; and stones that have remained in the body longer than four weeks. Retreatment is occasionally necessary, however, in cases involving very large stones.

• Injury to surrounding organs. In rare cases, PCNL has resulted in damage to the spleen, liver, lung, pancreas, or gallbladder.

Ureteroscopic Removal• A ureteral stent is a thin, flexible tube threaded into the ureter to help urine drain

from the kidney to the bladder or to an external collection system.Purpose• Urine is normally carried from the kidneys to the bladder via a pair of long, narrow

tubes called ureters (each kidney is connected to one ureter). A ureter may become obstructed as a result of a number of conditions including kidney stones, tumors, blood clots, postsurgical swelling, or infection. A ureteral stent is placed in the ureter to restore the flow of urine to the bladder.

• Ureteral stents may be used in patients with active kidney infection or with diseased bladders (e.g., as a result of cancer or radiation therapy). Alternatively, ureteral stents may be used during or after urinary tract surgical procedures to provide a mold around which healing can occur, to divert the urinary flow away from areas of leakage, to manipulate kidney stones or prevent stone migration prior to treatment, or to make the ureters more easily identifiable during difficult surgical procedures. The stent may remain in place on a short-term (days to weeks) or long-term (weeks to months) basis.

Diagnosis/Preparation• A number of different technologies aid in the diagnosis of ureteral obstruction. These

include:

• the interior of the bladder)• ultrasonography (an imaging technique that uses high-frequency sounds waves to

visualize structures inside the body)• computed tomography (an imaging technique that uses x rays to produce two-

dimensional cross-sections on a viewing screen)• pyelography (x rays taken of the urinary tract after a contrast dye has been injected

into a vein or into the kidney, ureter, or bladder)

• Prior to ureteral stenting, the procedure should be thoroughly explained by a medical professional. No food or drink is permitted after midnight the night before surgery. The patient wears a hospital gown during the procedure. If the stent insertion is performed with the aid of a cystoscope, the patient will assume a position that is typically used in a gynecological exam (lying on the back, with the legs flexed and supported by stirrups).

Aftercare• Stents must be periodically replaced to prevent fractures within the catheter wall

or build-up of encrustation. Stent replacement is recommended approximately every six months; more often in patients who form stones

Risks• Complications associated with ureteral stenting include:• bleeding (usually minor and easily treated, but occasionally requiring transfusion)• catheter migration or dislodgement (may require readjustment)• coiling of the stent within the ureter (may cause lower abdominal pain or flank pain

on urination, urinary frequency, or blood in the urine)• introduction or worsening of infection• penetration of adjacent organs (e.g., bowel, gallbladder, or lungs)

Extracorporeal shockwave lithotripsy• Lithotripsy is the use of high-energy shock waves to fragment and disintegrate

kidney stones. The shock wave, created by using a high-voltage spark or an electromagnetic impulse outside of the body, is focused on the stone. The shock wave shatters the stone, allowing the fragments to pass through the urinary system. Since the shock wave is generated outside the body, the procedure is termed extracorporeal shock wave lithotripsy (ESWL). The name is derived from the roots of two Greek words, litho , meaning stone, and trip , meaning to break.

Purpose• ESWL is used when a kidney stone is too large to pass on its own, or when a stone

becomes stuck in a ureter (a tube that carries urine from the kidney to the bladder) and will not pass. Kidney stones are extremely painful and can cause serious medical complications if not removed.

Diagnosis/Preparation• ESWL should not be considered for persons with severe skeletal deformities,

people weighing more than 300 lb (136 kg), individuals with abdominal aortic aneurysms, or persons with uncontrollable bleeding disorders. Women who are pregnant should not be treated with ESWL. Individuals with cardiac pacemakers should be evaluated by a cardiologist familiar with ESWL. The cardiologist should be present during the ESWL procedure in the event the pacemaker needs to be overridden.

Prior to the lithotripsy procedure, a complete physical examination is performed, followed by tests to determine the number, location, and size of the stone or stones. A test called an intravenous pyelogram (IVP) is used to locate the stones, which involves injecting a dye into a vein in the arm. This dye, which shows up on x ray, travels through the bloodstream and is excreted by the kidneys. The dye then flows down the ureters and into the bladder. The dye surrounds the stones. In this manner, x rays are used to evaluate the stones and the anatomy of the urinary system. Blood tests are performed to determine if any potential bleeding problems exist. For women of childbearing age, a pregnancy test is done to make sure they are not pregnant. Older persons have an EKG test to make sure that no potential heart problems exist. Some individuals may have a stent placed prior to the lithotripsy procedure. A stent is a plastic tube placed in the ureter that allows the passage of gravel and urine after the ESWL procedure is completed.

The process of lithotripsy generally takes about one hour. During that time, up to 8,000 individual shock waves are administered. Depending on a person's pain tolerance, there may be some discomfort during the treatment. Analgesics may be administered to relieve this pain.

Aftercare• Most persons pass blood in their urine after the ESWL procedure. This is normal

and should clear after several days to a week. Lots of fluids should be taken to encourage the flushing of any gravel remaining in the urinary system. Treated persons should follow up with a urologist in about two weeks to make sure that everything is progressing as planned. If a stent has been inserted, it is normally removed at this time.

Risks• Abdominal pain is fairly common after ESWL, but it is usually not a cause for worry.

However, persistent or severe abdominal pain may imply an unexpected internal injury. Occasionally, stones may not be completely fragmented during the first ESWL treatment and further lithotripsy procedures may be required.

• Some people are allergic to the dye material used during an IVP, so it cannot be used. For these people, focused sound waves, called ultrasound, can be used to identify where the stones are located.

PATHOPHYSIOLOGYNEPHROLOTHIASIS/

RENAL CALCULI

PREDISPOSING FACTORS

AGE ( 20-25 Y.O)Gender (more common in male)Race(common in whites)Genetic

3 MAJOR THEORIESSaturation TheoryMatrix TheoryInhibitor

PRECIPITATING FACTORS1.Metabolic Abnormalities2. Climate3. Diet4. Lifestyle (sedentary occupation, immobility)

STONE FORMATION Types:Calcium (oxalate and phosphate)Magnesium ammonium phosphate (struvite)Uric acid (urate)cystine Urinary stasis Fever, Chills, Nausea, and vomiting

Obstruction by stone

Severe pain, hematuria, hydronephrosis, anuria from bilateral obstruction, ad abdominal distention

Calculi/stone traveling down the ureter

Hematuria, obstruction and severe pain

DEATH

Acute Renal Failure

Laboratory Results

Ultrasound KUB

September 8 2010Interpretation:

Urinary retention, 153.7 ml (66%)

Nephrolithiasis, right kidney with regression in size and numbers

Nephrolithisasis, left kidney with regression

Renal cyst, right kidney, increasing in size

Radiology (x-ray)

September 8, 2010

Thoracolumbar APL

Interpretation:

Osteoporosis

Hypertropic degenerative osteoarthropathy, lumbar spine

Compression fracture, L2

September 8, 2010

Result Normal Values

Urea 8.45 mmol/L 2.50 – 6.10 mmol/L Renal failure

Creatinine 200.3 mmol/L 62 – 106 Renal disease that has seriously damaged 50% or more of the nephrons, acromegaly.

Sodium 126 mmol/L 137 – 145 mmol/L Dehydration, Impaired renal function

Potassium 2.93 mmol/L 3.50 – 5.10 mmol/L Liver disease

Radiology (x-ray)

September 9, 2010

Chest AP

Interpretation:

Atheromatous and tortuous aorta

September 19, 2010

Result Normal Values Significance

Calcium 1.82 mmol/l LO 2.10 – 2.55 mmol/L

Osteoporosis

Albumin 22.7 g/L LO 35 – 50 g/L Kidney dysfunction

Cross Matching Result Slip

September 19, 2010

Blood Type “o” Rh Positive

Serial no. 018634

Cross Matching Compatible

Note Screened @ PNSG 250cc, PRBC

Urinalysis

September 20,2010

Microscopic


Color Pale Yellow Straw Alcohol, large fluid intakeTransparency Slightly Hazy Clear Infection Reaction pH 6.0 4.5-8 WNLSp. Gravity 1.010 1.010 – 1.025 WNLProtein Negative Negative WNLGlucose Negative Negative WNLRBC/hpf 2 0-2 WNLWBC/hpf 0-3 0-5 WNL

Stool

Physical exam

Color Dark Brown

Consistency Soft

Occult Blood Positive

“ No OVA of intestinal parasite found on direct smear”

September 21, 2010

Test Result Normal Value Significance

Sodium 104 mmol/L 136 – 145 mmol/L Dehydration, Impaired renal function

September 22, 2010


Sodium 125.1 mmol/l 136 – 145 mmol/L Dehydration, Impaired renal function

Chemistry

September 22, 2010

Test Result Normal Value SignificanceSGPT 73 U/L 7–30 U/L Cirrhosis

Muscle inflammationObesity Hepatitis

September 22, 2010


Sodium 118.5 mmol/L 136 – 145 mmol/L Dehydration, Impaired renal function

Potassium 1.94 mmol/L 3.50 – 5.10 Due to diuretics or kidney problem

Creatinine 121 mmol/L 53 - 115 Renal disease that has seriously damaged 50% or more of the nephrons, acromegaly.

Other Result

September 22,2010

Examination desired H Pylori determinationResult: Negative (TV: 0.05)

Interpretation:

TV negative < 0.75

TV equivocal > = 0.75 & < 1.00

TV positive > 1.00

Hematology

September 22,2010


Hematocrit 0.33 vol (fr) 0.36 – 0.45 vol (fr) Anemia, hemodilution, or massive blood loss

Hemoglobin 110 gms/L 123 – 153 gms/L Anemia, hemodilution, or massive blood loss

Red cell Count 3.85 x 10^12/L 4.5-5.1 x 10^12/L Anemia, hemodilution, or massive blood loss

White Cell Count 7.9 x 10^9/L 4.5-11x10^/L WNL

Differential Count

Segmenters 0.83 50 – 65 % Infection

Eosinophils 0.03 1-4% WNL

Lymphocytes 0.13 25 – 30% Infection

Monocytes 0.01 2-5% Infection

Prothrombin time 15.9 seconds 10-16 seconds WNL

Test Init(September 23, 2010)

Fluid: Serum


Potassium LO 3.34 mmol/L 3.50 – 5.10mmol/L Due to diuretics or kidney problem

Peripheral Blood Smear

September 23,2010


Hct 0.24 L/L 0.36 – 0.45 L/L Anemia, hemodilution, or massive blood loss

Hgb 81 g/L 123 – 153 g/L Anemia, hemodilution, or massive blood loss

WBC ct. 7.4 x 10 ^ /L 4.5 – 11 x 10^ /L WNL

RBC ct. 2.86 x 10 ^ /L 4.5 – 5.1 x 10^ / L anemia

Segmenters 84% 36-66% Infection

Eosinophils 2% 2-3% WNL

Lymphocytes 12% 24-44% Infection

Monocytes 1% 4-6% Infection

Platelet count 214 x 10^ /L 150 – 450 x 10^ /L

WNL

MCV 84 fl 80 – 96 fl WNL

MCH 28.3 pg 27-31 pg WNL

MCHC 336 g/L 320-360 g/L WNL

Bands 0% 5-11%

September 24, 2010


Sodium 129.1 mmol/L 136 – 145 mmol/L Dehydration, Impaired renal function

DRUG STUDY

Generic (Brand) Name

Drug class Indications Mechanism of actions

Adverse reaction

Nursing responsibilities

Trimetazadine (Vastarel MR)

Anti-Anginal Drugs

Long treatment of coronary insufficiencyAngina pectoris

Acts by directlycounteracting all the major metabolic disorders occurringwithin the ischemic cellCalcium channel blocker that inhibits calcium ion influx across cardiac amd smooth muscle cells, decreasing myocardial contractility and oxygen demand

Headache, dizzinessNausea, constipation Somnolence

Monitor blood pressure and heart rate when starting therapy and during dosage adjustment.

Administer drug with or after meals.



Adverse reaction


Rowatinex (Borneol, Camphene, Pinene)

Genito Urinary Antiseptics

Disinfectants

For the treatment of urinary tract spasm and inflammation associated with urolithiasis. Assists in the dissolution and expulsion of stones in the renal system.

ROWATINEX promotes a diuresis and relaxes urinary tract spasm, thus assisting the passage of stones. The therapeutic effect of the balanced combination of terpenes reduces urinary tract inflammation, stimulating renal blood flow through the kidneys and increasing the output of less concentrated urine.

No side effects have been reported

Liquid intake should be increased during therapy.



Drug class Indications Mechanism of actions Adverse reaction

Nursing responsibilit

iesDomperidone(Motilium)

Antiemetic

Dopamenergic blocking agent

•Delayed gastric emptying of functional origin with gastroesophageal reflux/or dyspepsia.

•Control of nausea and vomiting of central or local origin.

•As antiemetic in patients receiving cytostatic and radiation therapy.

•Facilitates radiological examination of the upper GI tract.

Domperidone is related to its peripheral dopamine receptor blocking properties. Emesis induced by apomorphine, hydergine, morphine or levodopa, through th estimulation of the chemoreceptor trigger zone can be block by domperidone.There is indirect evidence that emesis is also inhibited at the gastric level, since domperidone also inhibits emesis induced by oral levodopa, and local gastric wall concentrations following oral domperidone are much greater than those of the plasma and other organs. Domperidone doesnot readily cross the blood brain barrier and therefore is not expected to have central effects.

•Dizziness•Headache•Insomia •Drowsiness•Belching•Abdominal distention•Irritability •Twitching

Take this drug before meal.

Monitor patient I and O



Adverse reaction


Felodipine Anti anginal

Anti hypertensive

Calcium channel blockers

Management of hypertension.

Inhibits the transport of calcium into myocardial and smooth muscle cells resulting in inhibitions of excitation contraction and subsequent contraction.

Peripheral edemaHeadache,diziness

Monitor bp and pulses before theraphy, during doasage titration and peridiacally throughout theraphy.



Drug class Mechanism of actions

Indication Adverse reaction


Omeprazole Proton pump inhibitor

Inhibits acid pump and binds to hydrogen potassium adenosine triphosphatase on secretory surface of gastric parietal cells block formation of gastric acid

Short term treatment of active duodenal ulcer.First line therapy in treatment of heartburn or symptoms of GERD.

Headache Dizziness Diarrhea Abdominal

pain Nausea Vomiting Constipati

on Flatulence Back pain Cough Rash

Give drug 30 mins. Before meals

Explain the importance of taking drug exactly as prescribed

Warn the pt not to crush or chew the drug


Drug class Indications Nursing responsibilities

Sambong Anti-urothiliasisVitamin supplement

Used to aid the treatment of kidney disorders it helps disposing excess water and sodium in the body

Advice patient to increase fluid intake.

Generic (Brand) Name Drug class

Mechanism of action

Indications Adverse reaction


Alendronate Cholecalciferol

MetabolicBisphosphonates

Suppresses osteoclast activity in newly formed re absorption surfaces, which reduces bone turnover. Bone formation exceeds re absorption at remodeling sites, leading to progressive gains on bone mass.

Treatment of osteoporosis of post menopausal women.

Headache Abdominal apin, nausea, dyaspepsia, muscu skelatal pain.gastritis

Use cautiously in patients with active upper GI problems

Give drug with 6 to 8 ounces of water at least 30 min first food or drink of the day to facilitates delivery to the stomach.


Drug Class Mechanism of Action

Indications Adverse Effect

Contraindications

Nursing Responsibilit

ies

Rebapimide (Mucosta)

antacids, antireflux and antiulcerants agents

used for mucosal protection, healing of gastro duodenal ulcers, and treatment of gastritis. It works by enhancing mucosal defense, scavenging free radicals, and temporarily activating genes encoding cyclooxygenase.

Gastric ulcers. Treatment of gastric mucosal lesions (erosion, bleeding, redness & edema) in acute gastritis & acute exacerbation of chronic gastritis.

Nausea and vomiting

Heartburn

Diarrhea Jaundice Rash Belching Abdomin

al pain

Patient with a history of hypersensitivity to any ingredient of this drug.

Take this drug with food.

Monitor pt’ food intake.

Advise pt not to eat food that can irritate the stomach.



Indications Adverse Effect Contraindications

Nursing Responsibilities

Potassium citrate (Urocit-K)

Urinary and system alkanizer

A food additive, potassium citrate is used to regulate acidity. Medicinally, it may be used to control kidney stones derived from either uric acid or cystine.

Potassium citrate is used to treat kidney stone condition called renal tubular acidosis.

Treatment of chronic metabolic acidosis.

Treatment of pt with cystine calculi and uric acid of the urinary tract .

Nausea and vomiting

Stomach pain

Dizziness Black/

bloody stool

Rash Slow/

irregular heartbeat

Mental/mood changes

Trouble breathing hyperkalemia

Renal function impairment with oliguria, azotemia, untreated Addison’s disease, severe myocardial damage, or certain situation when pt are on sodium-restricted diet

Do not crush, chew,break or suck on extended-release tablet. Swallow the tablet. Breaking or crushing the pill may cause too much of the drug to be released at one time. Sucking on a potassium tablet can irritate your mouth or throat.

Avoid lying down for atleast 30 mins after taking the drug, take this drug with meal or snack or within 30 mins after meal.

Inform pt not to stop taking this drug without the information of the doctor, if the pt stop taking this drug his/her condition might worse.



Indications Adverse Effect Contraindications

Nursing Responsibilities

Sertraline HCL (Zolof)

Antidepressant Serotonin is a neurotransmitter (a chemical messenger) produced by nerve cells in the brain that is used by the nerves to communicate with one another. A nerve releases the serotonin it produces into the space surrounding it. The serotonin either travels across the space and attaches to receptors on the surface of nearby nerves or it attaches to receptors on the surface of the nerve that produced it, to be taken up by the nerve and released again (a process referred to as re-uptake).

Treatment of major depressive disorder in adults.

treatment of obsessions and compulsions in patients with obsessive-compulsive disorder (OCD)

reatment of a major depressive episode

treatment of social anxiety disorder, also known as social phobiain adults.

Anxiety Rash ; hives Black/blody

stol Chest pain Loss of

appetite Nausea and

vomiting Trouble

sleeping Irregular

heartbeat Irritability Memory loss Fainting Fever Hallucination Panic attacks

Contraindicated in patients with a hypersensitivity to sertraline or any of the inactive ingredients in ZOLOFT.contraindicated with ANTABUSE (disulfiram) due to the alcohol content of the concentrate

Monitor pt especially when the pt experienced the adverse effect. Always be alert.

Take this drug with food.

Make sure that the pt is comfortable and free of worries.

Advise pt to relax.

Nursing Care Plan

Assessment Nursing Diagnosis Planning

S: “Naga kinuriit siya kay ga sakit iya kilid” as verbalized by the folks. O: (+) facial grimace(+) guarding behaviour(+)moaning(+)change in muscle tone(+)diaphoresisBP- 130/80 mmHgRR- 25 bpmPain scale of 6.Ultrasound KUB reveals:Nephrolithiasis, right kidney with regression in size and numbers.Nephrolithisasis, left kidney with regression.Renal cyst, right kidney, increasing in size.

Acute pain related to tissue distension or trauma.

To demonstrate behaviour that shows relief from pain such as decrease in facial grimace, moaning, diaphoresis and lower down pain scale from 6 to 5 within the shift.

Intervention Rationale Evaluation

Independent: 1. Provide comfort

measures, quiet environment and calm activities.

2. Encourage diversional activities such as watching TV, talking to family members or listening to radio.

1. To promote non pharmacological pain management.

2. To divert or distract attention from pain and reduce tension.

.

Goal met.As evidenced by patient demonstrates behaviours that show relief from pain, decreased facial grimace, moaning, diaphoresis, and pain scale lowers from 6 to 5.

Assessment Nursing Diagnosis PlanningS: “Nasakitan kag gamay lang iya ihi sadto muna gin takdan siya catheter” as verbalized folks.O:-With foley catheter-Urine output: 500ml/dayUltrasound KUB reveals:Urinary retention, 153.7 ml (66%)Nephrolithiasis, right kidney with regression in size and numbers.Nephrolithisasis, left kidney with regression.Renal cyst, right kidney, increasing in size.

Impaired urinary elimination related to mechanical obstruction of urinary flow.

1. To achieve normal amount of output within 8 hours.

2. To manage care of urinary catheter within the shift.


Independent:1. Monitor intake and

output strictly.2. Measure urine output

and drain catheter regularly every hour.

1. To provide accurate measurement of the exact fluid intake and output.

2. To prevent overflowing of urine and avoid ascending infection.

Goal met.As evidenced by urine output of 300 ml within the shift


S:“ Indi na sya mayad kahulag” as verbalized by the folks.O:Bed ridden(+) decreased muscle strength.Radiology reveals: Osteoporosis Hypertropic

degenerative osteoarthropathy, lumbar spine

Impaired Physical mobility r/t decreased muscle strength and loss of integrity.

Maintain position of function and skin integrity as evidenced by absence of contractures, footdrop and decubitus within the shift.


Independent:1. Reposition regularly.2. Use side rails for

position changes.3. Support affected body

parts using pillows.

1. To prevent breakage in the skin integrity.

2. To prevent any injury.3. To maintain position of

function and reduce risk of pressure ulcers.

Goal met. As evidenced by patient maintain position of function and skin integrity.

Assessment Nursing Diagnosis PlanningS: “Indi siya ka hala” as verbalized by the folks.O: Inability to speakAbsence of eye contact.

Impaired verbal communication related to weakening of muscuskeletal system.

Establish method of communication in which needs can be expressed within the shift.

Intervention Rationale EvaluationIndependent:1. Review history of

neurological condition.2. Establish relationship with

the client, listening carefully and attending to client’s verbal/nonverbal expression.

3. Maintain eye contact, preferably at client’s level.

4. Involve family in plan of care as much possible.

1. Neurological condition affect speech such as stroke.

2. Conveys interest and concern.

3. Conveys interest and concern.

4. Enhances participation and commitment to communication with love one.

Goal not met. As evidence by patient doesn’t establish method of communication in this needs can be expressed within the shift.


O: With foley catheter. Risk for infection r/t invasive procedure.

To prevent any signs of infection within the shift.


Independent:1. Monitor urine output

hourly and drain urine regularly.

2. Practice hand washing and other infection control practices.

1. To prevent the backflow of urine, thus preventing ascending infection.

2. Prevents transfer of microorganisms from healthcare providers and healthcare workers.

Goal met. As evidenced by no signs of infection occurred during the shift.


O:In TPNNa-104 mmol/LK- 1.94mmol/LTotal protein – 49.2g/LAlbumin – 22.7g/L

Risk for imbalance nutrition less than body requirements related to food intake restriction

Demonstrate behaviours, lifestyle changes to maintain nutritional status within the shift.


Independent:1. Ascertain understanding

of individual nutritional needs.

2. Provide diet modifications: total parenteral infusion.

3. Evaluate total daily food intake. Record daily calorie intake, patterns and times of eating.

1. To determine informational needs of client.

2. To provide and meet nutritional needs.

3. To reveal possible cause of malnutrition/changes that could be made in client’s intake.

Goal met. As evidence by patient demonstrate behaviours, lifestyle changes to maintain nutritional status.


S: “Indi siya maayu kahulag” as verbalized by the folks.O: (+) body malaise

Risk for constipation related to immobility.

Demonstrate behaviour or lifestyle changes to prevent developing problems within the shift.


Independent:1. Auscultate abdomen for

presence, location, and characteristics of bowel sounds.

2. Encourage activity or exercise within limits of individual ability.

3. Ascertain frequency, color, consistency, amount of stools.

1. Reflecting bowel activity.2. To stimulate

contractions of the intestines.

3. Provides a baseline for comparison, promotes recognition of changes.

Goal not met. As evidence by patient doesn’t demonstrate behaviour or lifestyle changes to prevent developing problems within the shift.


S: “Indi siya kahulag” as verbalized by the folks.O:(+) body malaise

Risk for impaired skin integrity related to physical immobility.

Demonstrate behaviours/ techniques to prevent skin breakdown within the shift.


Independent:1. Reposition every two

hours2. Keep bedclothes dry

and wrinkle-free.3. Encourage and assess

to perform range of motion exercises.

4. Maintain meticulous skin hygiene.

1. To prevent breakage in the skin integrity

2. To increase circulation and limit excessive tissue pressure

3. To enhance circulation4. To prevent friction and

shear injury.

Goal met. As evidence by patient demonstrate behaviours/techniques to prevent skin breakdown within the shift.

DISCHARGE PLANNING

Medications• Encouraged client to take medications as prescribed by her physician.• Teach patient of the different side and adverse effects of the drugs.rse

effects of the drugs. • Report any unusualities when taking the prescribed drug such as nausea

and vomiting or skin allergies. • vomiting or skin allergies. Exercise • Encourage patient to perform ROM exercises such as hand and leg

flexions.Treatment• Encouraged the patient to comply with the medication as ordered by

her physician.• Explain the importance of adhering to her treatment regimen.Home management• Provide safety precaution.

Out patient• Inform the patient to have follow-up check- up after a week to prevent

possible complications and to update the medical team concerning the progress of the patient’s condition and to promote continuity of care.

Diet • Avoid salty foods.• Must have green leafy vegetables, and fruits during meal.• Must drink plenty of water.• Spiritually • Encourage to have faith with the Lord.• Explains that Lord has a way of curing her physically and emotionally.

UPDATES• Mrs. C.D. is still in the hospital at St. Joseph Ward and is still

undergoing treatment.

END......

CASE STUDY -- Bilateral Nephrolithiasis

Documents

decreased

complete physical

maintain nutritional

impaired renal

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nursing diagnosis

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generic drug