I. INTRODUCTION Passage of a urinary stone is the single most common cause of acute ureteral obstruction and affects as many as 12% of the population. The pain may be some of the most severe pain that humans experience, and complications of stone disease may result in severe infection; renal failure; or, in rare cases, death (http://emedicine.medscape.com/article/381993-overview). Semins et al performed a study regarding how increased body mass index (BMI) may affect the risk of kidney stone disease. They found that in patients with a BMI greater than 30 kg/m 2 , there was a significantly increased likelihood of kidney stone formation. Renal calculi occur in 5-12% of the American population, and they are bilateral in 10-15% of patients. The prevalence of urinary lithiasis is as high as 2-3% in the general population. A slightly lower prevalence of urinary stones is found in less developed countries, possibly because of diets lower in protein. Passage of a renal stone is the most common cause of acute ureteral obstruction. When this occurs, pressure in the collecting system and renal blood flow acutely increase, followed by decreased blood flow after 1-2 hours. Hematuria usually occurs. This can be intermittent or persistent and microscopic or gross. However, as many as 10% of patients with acute stones may not have hematuria. Acute ureteral obstruction by stone causes severe, colicky (intermittent) 1
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Transcript
I. INTRODUCTION
Passage of a urinary stone is the single most common cause of acute ureteral
obstruction and affects as many as 12% of the population. The pain may be some of
the most severe pain that humans experience, and complications of stone disease
may result in severe infection; renal failure; or, in rare cases, death
(http://emedicine.medscape.com/article/381993-overview). Semins et al performed a
study regarding how increased body mass index (BMI) may affect the risk of kidney
stone disease. They found that in patients with a BMI greater than 30 kg/m2, there
was a significantly increased likelihood of kidney stone formation. Renal calculi
occur in 5-12% of the American population, and they are bilateral in 10-15% of
patients. The prevalence of urinary lithiasis is as high as 2-3% in the general
population. A slightly lower prevalence of urinary stones is found in less developed
countries, possibly because of diets lower in protein.
Passage of a renal stone is the most common cause of acute ureteral
obstruction. When this occurs, pressure in the collecting system and renal blood flow
acutely increase, followed by decreased blood flow after 1-2 hours. Hematuria
usually occurs. This can be intermittent or persistent and microscopic or gross.
However, as many as 10% of patients with acute stones may not have hematuria.
Acute ureteral obstruction by stone causes severe, colicky (intermittent) flank pain
that can radiate throughout the groin, testicles, back, or periumbilical region. Some
patients with renal calculi may have no symptoms at all. Stones smaller than 4 mm
pass spontaneously in approximately 80% of patients. Stones that are 4-6 mm pass
in approximately 50% of patients, whereas stones larger than 8 mm pass in only
approximately 20% of patients. Occasionally, recurrent infection may result in
pyelonephritis or abscess. Stones can cause renal scarring, damage, or even renal
failure if they are bilateral. In 10% of patients, stones recur within 1 year. This
percentage increases to 50% within 10 years.
Urinary stones occur more often in white populations than in black
populations. They are also more prevalent in highly developed countries, possibly as
a result of a higher protein diet. Males are at a greater risk than females, with a
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male-to-female ratio of 3:1 (except for struvite stones and in black populations).
Stones are uncommon but not unknown in children. The peak age for development
is in persons aged 40-60 years.
This case presentation pertains to a case of patient NQ, a 64-year old female
who was admitted at NMMC last december,11 2010. The patient was diagnosed
with Nonfunctioning kidney secondary to urolithiasis and nephrolithiasis. As you read
the next pages, you will fully understand what it is.
A.GENERAL OBJECTIVES
At the end of 1 hour of case presentation, we will be able to present the
necessary and significant information regarding the nature of the patient’s
condition. In line with this, we will be able to utilize and enhance our knowledge
regarding Benign Positional Vertigo in addition to gaining a thorough
understanding of the patient’s condition. We also aim to integrate the different
skills and procedures gained from our Medical Surgical in the implementation of
the applicable nursing interventions and to correlate the clinical manifestations of
the patient related to the disease process, laboratory results used to diagnose
this condition, and to develop a sense of empathy to the family of the
aforementioned patient. Lastly we will be able to listen to the Clinical Instructor’s
feedback about the case presentation to enhance nursing knowledge, skills and
attitude.
B.SPECIFIC OBJECTIVES
At the end of 45 minutes case presentation, we will be able to:
1. Briefly give an introduction about the patient’s general condition.
2. Discuss thoroughly the assessment done to the patient.
3. Discuss the signs and symptoms of the patient who has Benign Positional
Vertigo.
4. Briefly review the anatomy and physiology of the bodily systems involved in
the disease condition.
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5. Discuss thoroughly the pathophysiology of the disease, identifying correctly
the predisposing and precipitating factors and correlating the manifestations
of the patient with the disease process.
6. Interpret correctly the laboratory results obtained.
7. Present the different drugs administered, their actions and contraindications
to the patient.
8. Formulate a holistic nursing care plan based on the assessment and data
gathered of the care delivered to the patient.
9. Present nursing management and necessary interventions appropriate for the
patient who has Benign Positional Vertigo.
10.Present a realistic and attainable discharge plan appropriate for the patient’s
fast recovery and continuity of care.
11.Clarify and answer questions from the clinical instructor related to the
patient’s condition.
12. Manifest open-mindedness to the constructive criticisms of the clinical
instructor and accept necessary feedbacks as learning experiences regarding
the presentation.
C. SCOPE AND LIMITATION
The primary focus of this case presentation is the identified diagnosis of
the patient’s condition which is Nonfunctioning kidney secondary to urolithiasis
and nephrolithiasis . The normal anatomy and physiology of the said condition
and the major systems affected by the disease condition are all included so as to
find out the abnormalities that can be observed in the disease process. Also,
included in this case presentation, are the nursing care plans formulated based
on the identified nursing diagnoses.
Information and data relevant to the study of the patient’s condition were
taken starting from December 14,2010 and continued up to December 16,2010
through daily follow up assessments. The patient was cared for by members of
the group only on December 15,2010 and December 16,2010. However, we
limit the case presentation only to the identified abnormalities as assessed by the
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student nurses. Further complications of the patient’s condition, if any, are not
included. The actual management are given so as to show how the patient’s
condition altered the usual treatment outline for cases of Nonfunctioning kidney
secondary to urolithiasis and nephrolithiasis. We also limit our nursing
management recordings to the actual observed response of the patient in relation
to the nursing interventions given during the two days duty.
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II. NURSING ASSESSMENT
A. Assessment tool
(1st assessment)
I. GENERAL INFORMATION
Name: NQ Age: 64 yrs old
Birthday: Nov. 6, 1946 Civil status: Married
Sex: Female Religion: Roman Catholic
Occupation: housewife
Address: San Pedro, Initao
Informant: AQ, and the patient herself Relation: daughter
Admission Date: 12/11/2010 Time: 1:00PM
Chief Complaint: operation in Kidney – Right Kidney
Attending Physician: DR. M.
Final Diagnosis: Non-fixing Right kidney secondary to obstructing distal
ureterolithiasis with nephrolithiasis.
Vital Signs:
HR: 81bpm RR: 21cpm T: 36.5oC BP: 140/90mmHg
Weight: 54kg HT: 5’2’’ft
II. ACTIVITY/REST
Subjective:
Usual activities/hobbies:
Before admission:“gapanilhig ko sa balay ako pud gapanglaba”
(“I used to sweep and wash clothes @ home”)
After admission:”naa raku diri sa katre ga higda”
(‘I’m just here in the bed lying”)
Leisure time activities: “manilhig ko sa balay, mananaw TV”
(“Sweeping the floor and watching TV”)
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Limitations Imposed by Condition: “sa karon, ani lang di pa kayo makalihok bag-o
pang opera”
(“For now, my actions and movements are limited because I’m newly operated”)
Number of hrs of sleep: “taas iyang tulog kng walay gabation”
(“She sleeps long if and only she is in good feeling-well rested”)
Naps: 2hrs
Aids: “ wala man pud’’ (none).
Difficulty in sleeping: “ayha ra kung naai bation” (“only if she feels unease”)
Feeling on awakening: “okay ra – reklamo siya di siya kadungog sa amo inig mata
niya” (its ok she can’t she always exclaimed that she can’t hear us when she’s already
awake”)
Objective
Observed response to activity:
Cardiovascular: increased heart rate upon walking to CR
Respiratory: increased RR (25) upon walking to CR
Mental status: cooperative
Posture: slightly stooped
LOM: patient wasn’t able to reach the CR due to increased pain
Tremors: no tremors noted
III. CIRCULATION
Subjective
History of hypertension: “usahay mutaas pero wala jud ni siya gi highblood sauna”
(“her blood pressure shoots up sometimes but she was never been in a high blood
state before”)
Heart Trouble: “wala” (none)
Ankle/leg edema: “wala” (none)
Slow healing: “wala” (none)
Claudication: “wala” (none)
cough/hemoptysis: “oo. Gahi siya. Yellow, pero walay dugo”
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(“Yes, she have cough with yellow phlegm but there’s no blood on it”)
Extremities numbness: “wala” (none)
Tingling: “dili man pud” (no)
Change in frequency/amount in urine: “sauna kay mga ika-lima ikaw unom na siya
mangihi karon kay mga ika-duha ikaw tulo nalang”
(“2-3 times a day( usual of 5-6 times a day)”)
Others/comments:
He SO verbalized, “gahawoy lang iyang tiil panalagsa”
Objective
BP:
R lying: 140/90 mmHg L lying: 140/ 90 mmHg
R sitting: 140/80 mmHg L sitting: 140/80 mmHg
R standing: 140/80 mmHg L standing: 140/80 mmHg
Pulse pressure: 50mmHg
Heart rate/sounds: 85bpm
Rhythm: regular
Pulse:
Carotid: 84bpm Radial: 83bpm Popliteal: 83bpm
Temporal: 83bpm Femoral: 82bpm Dorsal pedis: 80bpm
Vascular bruit: no bruit heard
Breath sounds: crackles Jugular vein distention: none
Extremities:
Temperature: warm to touch Color: light brown
Capillary refill: refills in less than 2 seconds
Homan’s sign: (-)
Varicosities: prominent on both legs
Color of nail beds: pinkish
Lips: dry, pale lips Mucous membranes: dry, pale
Sclera: white, anicteric.
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IV. EGO INTEGRITY
Subjective
Reports of stress factors: “daghan gyud, sa ubo niya karon, gusto na pud niya
mugawas”
(”there are lots of it but one would her cough and she also want to go home already”)
Ways of Handling Stress: “mamahala nalang” (“we just let things be”)
Financial concerns: “daku gyud” (“we really does have”)
Relationship status: “Okey man ang relasyon”
(“We do have good relationship inside the family”)
Lifestyle: “sa balay ra. Makalakaw man gali, usahay ra.”
(“I’m always inside the house I seldom go outside”)
Recent changes: “Karon, cgeg lakaw – pa check-up”
(“Now, we always go for check-ups”)
Feelings of Helplessness: “ wala man” (none)
Hopelessness: “ wala pud” (none)
Powerlessness: “dili pud” (none)
Others/comments:
“Positibo mana siya mag hunahuha” (she usually thinks in a positive manner)
Objective
Emotional status
Calm: (+) anxious :(-) withdrawn :(-) fearful: (-)
Angry: (-) irritable: (-) Euphoric: (-)
Observed physiologic response: patient was calm and cooperative during
assessment
V. ELIMINATION
Subjective
Usual bowel pattern: Before admission: 2 times a day
During admission: 4-5 times a week
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Character of stool: “wala ko kabantay sa karon kay malibang raman siyag iyaha ra
gyud” (“I haven’t seen her feces coz she usually defecate all by herself”)
Last BM: 12/10/2010 Laxative use: “wala man” (none)
History of bleeding: “wala man pud sukad” (“she never been”)
Hemorrhoids: “wala man tingale, wala mi kabalo” (“we don’t know”)
Constipation: “ah, dili pud” (“ah, no”)
Diarrhea:” usahay mu tukar, pero wala karon”
(“Sometime she does have but now she don’t have”)
Usual voiding pattern: Before admission: 5-6x a day
During admission: 2-3x a day
After admission: 4-6x a day
Incontinence: “wala man” (none)
Urgency: “wala pud” (none)
Retention: “wala” (none)
Frequency: ““sauna kay mga ika-lima ikaw unom na siya mangihi karon kay mga ika-
duha ikaw tulo nalang” “2-3 times a day( usual of 5-6 times a day)”
Pain/burning/difficulty in voiding: “Saunsa katung pinaka una na na-admit na siya.
Naadmit siya kay naglisud ug ihi. Sakit man gyud daw ug naa puy dugo maihi.”
(Before when she was admitted due to difficulty in urination as well as pain and
bleeding during urination)
History of Kidney/bladder disease: “Sauna lge. Naadmit na tungod naa daw bato sa
iyang kidney” (Before she was admitted due a calculi in the kidney)
Others/Comments: The patient had also the hobby of holding her urine. She has
verbalized this to her significant other. The patient still sees blood during urination
maybe because of the recent surgery.
Objective
Abdomen:
Tender: non tender Soft/Firm: soft
Palpable Mass: none Size/Girth: 32cm
Bowel sounds: 25 bowel sounds/min
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Bladder palpable: not palpable Distended: not distended
Others/comments: The client complained for a lower abdominal pain before
whenever she ambulates. “Sauna kanang mu reklamo na siya nga sakit daw iyang
tiyan”
VI. FOOD/FLUID
Subjective
Usual diet (type): “mahilig mana siya ug parat, parehas sa guinamos ug bulad, mga
karne, ug ga inom mga softdrinks”
(“She loves to eat salty foods such as guinamos, sun fried fish, meat and softdrinks”)
Number of meals/day: “katlo sa isa ka adlaw” (“3x a day”)
Last meal/intake: “katong paniudto” (“lunch meal”).
Loss of Appetite: “wala man pud, mokaon rana siyag iyah ra”
(“Nope, she usually eat by herself ”)
Nausea/Vomiting: “adto rang inig human sa operasyon, kalipungon, kasukaon”
(“That was only during after the operation to her”)
Dentures: ”wala” (none)
Allergies/Food intolerance: “wala” (none)
Heartburn/Indigestion: “wala man sad” (none)
Swallowing problems:” “walay problema sa iyang pagtulon” (“no problem at all”)
Weight: Usual: 55kg changes: loss of 1 kg @ present 54 kg
Diuretic use: ”wala” (none)
Others/Comments: The patient had weight loss of I kg after the admission. The
patient also verbalized that she eats meat more frequently.
Objective
Current weight: 54 kg Ht: 5’2’’
Bodies build: endomorph
Skin turgor: decreased in elasticity
Mucous membranes: dry, pale
Hernia/Masses: (-)
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Edema:
General: (-) Dependent: (-)
Periorbital: (-) Ascites: (-)
Thyroid Enlarged :(-) Halitosis: (-)
Condition of teeth/gums: “gamay raman iya pangag “
(“She has only little tooth decay”)
Appearance of tongue: dry, pale
Others/comments: decrease elasticity of the skin is due to aging
VII. HYGIENE
Subjective
ADL (Independent/Dependent)
Mobility: independent
Feeding: independent
Hygiene: independent
Dressing: independent
Toileting: independent
Other: “makabuhat man siya ug mga inana pero hawiran lang lage kay tigulang na
baya” (“she can do all of those stuffs but because she’s old already we used to assist
her minimally”)
Equipment/Presence of devices required: none
Assistance provide by: relatives/ family
Others/comments: still needs minimal assistance, needs attended due to age
Objective:
General appearance: client is neat, slightly kept with oily scalp and hair
Clothing/manner of Dress: appropriate for the occasion and place. Neat and clean
Body odor: slight body odor noted
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Condition of scalp: oily scalp
Presence of vermin: none
Others/Comments: patient used to asked daughter to wipe her body
VIII. NEUROSENSORY
Subjective
Fainting spells/dizziness: “kalipungon siya inig tusok sa tambal”
(“She feels dizzy when given medication”).
Headache: “wala man pud” (none) Location: N/A Frequency: N/A
Tingling/numbness/weakness location: “wala man sad” (none)
Seizure: ’’takig ra kanang hilantan siyag mayo” (“only if she’s very hot”)
Aura: “wala sad” (none)
How controlled: N/A
Eyes Vision loss R: (-) L: (-)
Glaucoma: “wala mi kahibalo’’ (none) Cataract: “wala” (none)
Sense of smell: “okey raman walay problema” (it’s ok no problem with it)
Epitasis: “wala” (none)
Comment: patient exclaimed-“hawuy ang pamati.”
Objective:
Mental status
Orientation/Disoriented: Oriented
Time: aware of time
Place: answers correctly when asked
Person: answers correctly when asked
Alert: alert Drowsy: not
Lethargy: not Stuporous: not Comatose: not
Cooperative: not combative: not
Affect: appropriate Delusion: none Hallucinations: none
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Memory:
Recent: able to remember recent events
Remote: able to remember remote events but has trouble in recalling exact dates
Speech pattern: congruent, clear without slur
Congruence: congruent
Glasses: reading glasses only.
Contacts: none
Hearing aids: none
Pupil size/reaction: R: 2mm L: 2mm
Facial droop: no facial droop observed
Swallowing: no problem on swallowing
Handgrip/release R: weak grasp L: weak grasp
Posturing: slightly stooped DTR: +2
Paralysis: none
Others/Comments: express ideas and feelings concisely
IX. PAIN/COMFORT
Subjective:
Onset: motukar raman ang sakit“ (“the pain is just any time it’s sudden“)
Duration:“mga 15-30 minutes“
Location: “sa akong likod dapit” (“@ the back part”)
Frequency: “mutukar rajud ug iyaha” (“it just so painful”)
Intensity: 8 of the pain scale 1-10 and 10 as the highest and 1 as the lowest
Quality: “sakit jud siya na mangluya na ko” (“the pain makes me almost powerless”)
Description of pain (check all that apply)
Shooting () Stabbing () Gnawing ( )
Sharp () Dull () Aching ( )
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Numb () Thrumbing() Radiating ()
Burning () unbearable ()
Precipitating Factors: “ musakit ra jud siya ug iya” (“the pain is just sudden”)
Aggravating Factors: “mutukar ramana siya”
(“It just start aching in no particular time”)
How relieved: “magtumar ug pain reliever” (“take pain reliever”)
Associated Symptoms: “hilantan, takigan, init ang tiyan”
(“Fever and my stomach feel warm”)
Objective
Grimacing () Being irritable () Maoning ()
Sitting rigidly () Sighing () Moving very slowly ( )
Limping () Clenching teeth ()
Moving in a guarded/protective manner ( ) Requesting help while walking ( )
Lying down during the day () Avoiding physical actions ( )
Other/Comments: Patient states that his condition really affected his ADL especially
those things and works that needs a lot of efforts.
X .RESPIRATION
Subjective
Dyspnea related to: “kanang takigan siya. Hangson dayon inig human”
Cough/sputum of: “gahi nga ubo” (“prolonged cough”)
History of: Bronchitis (-)
Asthma (-) Emphysema (-)
Recurrent pneumonia (-) TB (-)
Exposure to noxious fumes (-)
Smoker: “dili man” Packs: N/A Brand:N/A
Use of respiratory aids: “wala sad” (none)
Oxygen: “wala” (none)
Others/comments: paient is non smoker but patient is experiencing cough right now.
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Objective:
RR:
Depth: shallow breathing
Symmetry: symmetrical
Use of accessory muscle: none
Nasal flaring: none
Fremitus: none
Breath sounds: crackles
Cyanosis: (-)
Clubbing of fingers: (-)
Sputum Characteristics: yellowish phlegm
Restlessness: (-)
Other/Comments: patient was observed to have a productive cough
XI. SAFETY
Subjective:
Allergies/sensitivity: ”wala man siyay allergy” (“she don’t have allergy”)
Reaction: N/A
History of STD(date/type): “wala pud” (none)
Blood trans/number: “after opera ra duha ka bag” (“2 bags after the operation”)
When: 12/12/2010
History of accidental injuries: “wala sad” (none)
Fractures/dislocations: “wala man pud” (none)
Arthritis/unstable joints:“ tukar2x lang gyud ...haplas(efficascent sahay pao de arco)“
(sometimes and usually we applied efficascent or pao de arco to relieved such“)
Back problems: “wala” (none)
Changes in moles: “wala may pag bag-o” (none)
Enlarged nodes: “wala sad” (none)
Prosthesis: “ wala, makalakaw raman siya” (“none,she walk by herself”)
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Ambulatory devices: ‘wala” (none)
Expression of Ideation of violence (self/others): The patient expresses no ideation
of violence against self and others.
Objective
Temp: warm to touch
Diaphoresis: none
Skin integrity: dry skin noted with surgical wound @ the right lower quadrant of the
abdomen (@ mcburney’s point) with sutures intact with minimal serous blood
discharges.
Scars: none
Rashes: none
Lacerations: none
Ulcerations: none
Ecchymosis: none
Blisters: none
Burns (degree/%): none
Drainage (note location): none
General Strength: slightly weak due to pain on operative side
Muscle tone: decreased muscle tone
Gait: steady
Paresthesia/paralysis: none
Others/Comments: patients wound are intact with surgical dressing
XII. SEXUALITY
Sexually active: no
Sexual concerns/difficulties: “naa siyempre karon” (“ofcourse, there is”)
Recent change in frequency or interest: “wala na karon kay tigulang na”
(“Now, none since she’s old already”)
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Female:
Subjective
Age of menarch: 16 yrs old
Length of cycle: “kada bulan” (“twice a month”)
LMP: “wala natiman.an” (“forgotten”)
Menopause: menopause
Vaginal discharge: “wala” (none)
Bleeding between periods: “wala”(none)
Pregnancy HX: 4x been pregnant
Episiotomy: “normal mi tanan”
Lochia: none
Complication of pregnancy: “wala” (none)
Surgeries: mattress-tumor sa mattress (dugay nah)
Hormonal therapy/calcium use: “wala” (none)
Practice SBE: “wala” (none)
Discharges: “wala “ (none)
Last PAP smear: “wala man mi nag pacheckup”
(“We never been to some check-ups”)
Method of birth control: “wala sila ana” (“they don’t practice such”)
Others/Comments: Patient has not undergone any examination on his genitals
Objective
Breast examination:
Vaginal warts/lesions: none
XIII. SOCIAL INTERACTIONS
Subjective
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Marital status: “Minyo ko” (Married)
Yrs in relationship: “43 years”
Living with: ”with apo and family” (“with grandchildren and family”)
Concerns/stresses : “sa kwarta jud karon” (“money matters”)
Extended family: “oo” (yes)
Other support person: “anak” (“children”)
Role within family structure: mother
Report of problems related to illness/condition: “dili na kayo makatabang sa balay
tungod aning sakit ni mama “(“she’s unable to help us with the household chores
because of her present condition”)
Others/comments: The main concern of the patient is about money matters and her
present condition.
XIV. Teaching/ Learning
Subjective
Dominant language (specify): “bisaya” (“visayan”)
Literate:” oo” (yes)
Educational Level: Elementary Graduate
Health beliefs/ practices: “wala man kau”(none in particular)
Famlilial risk factors:
Diabetes: none
TB: none
Heart Disease: none
Stroke: none
High BP: none
Epilepsy: none
Kidney Disease: renal failure(Paternal side).
Cancer: none
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Mental Illness: none
Use of alcohol: “panalagsa. Kung naai party” (“sometimes, and when there is a party”)
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Facial pain scale: with a pain scale of 3/5 with 5 as the highest
Crackles heard on both lung fields upon auscultation.Body uild:
EndomorphBMI:
Slowed movement, slightly weak
Slow pace:Walks with assistanceAvoiding physical actions and moving in protective manner
Slightly weak handgrip
Dry pale lips and mucous membranes
Condition of scalp: oily
V/s of:BP=140/90 mmHgRR=21cpm
Surgical wound @
the right lower
quadrant of the
abdomen (@
mcburney’s point)
with sutures intact
with minimal serous
blood discharges.
Pain: gnawing and achingIntensity: 8 of the
pain scale 1-10 and
10 as the highest
and 1 as the lowest
IVF: D5LR 1 L @ 30 gtts/min infusing well @ right handDate ordered:12/12/201000
(2nd assessment)
l. GENERAL INFORMATION
Name: NQ Age: 64 yrs old
Birthday: Nov. 6, 1946 Civil status: Married
Sex: Female Religion: Roman Catholic
Occupation: housewife
Address: San Pedro, Initao
Informant: AQ, and the patient herself Relation: daughter
Admission Date: 12/11/2010 Time: 1:00PM
Chief Complaint: operation in Kidney – Right Kidney
Attending Physician: DR. M.
Final Diagnosis: Non-fixing Right kidney secondary to obstructing distal
ureterolithiasis with nephrolithiasis.
Vital Signs:
HR: 75bpm RR: 19cpm T: 36.3oC BP: 150/100mmHg
Weight: 54kg HT: 5’2’’ft
II. ACTIVITY/REST
Subjective:
Usual activities/hobbies: “naa ra man ko sa balay gapanlimpyo” (“I’m just inside the
house cleaning” as verbalized by the patient)
Leisure time activities: “manilhig ko sa balay, manan-aw TV”
(“Sweeping the floor and watching TV”)
Limitations Imposed by Condition: “medyo sakit pa japon e lihok-lihok lage,kai bag-o
bag-o pa sad ning samad mag duha pa ka adlaw karon”.
(“It’s still painful when you suddenly move since the wound is still fresh the wound is for
two days now”)
Number of hrs of sleep: “kung mag ngot-ngot na iyang samad dili siya ka tulog ug
tarong bali mga 6-7 hours iya tulog”.
(“If the wound aches her sleep is interrupted”)
Naps: 2hrs
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Aids: “unlan para makatarong ug tulog” (“Pillow for her to sleep well”)
Difficulty in sleeping: “kanang magsakit ang samad” (“if the wound aches”)
Feeling on awakening: “mag mata-mata lang kong nay bation”
(“Feels awake when something feels not good”)
Objective
Observed response to activity:
Cardiovascular: increased heart rate upon walking to CR
Respiratory: increased RR (22) upon walking to CR
Mental status: pleasant and friendly
Posture: slightly stooped
LOM: patient was able to reach the CR with SOs assistance
Tremors: no tremors noted
III. CIRCULATION
Subjective
History of hypertension: “dili mani siya high blood”
(“She’s not in high blood pressure”)
Heart Trouble: “wala” (none)
Ankle/leg edema: “wala” (none)
Slow healing: “wala” (none)
Claudication: “wala” (none)
Cough/hemoptysis: “gahi lage na iya ubo tapos ga yellow ang plemas”
(“She has a cough with yellowish plegm”)
Extremities numbness: “wala” (none)
Tingling: “dili man pud” (no, it doesn’t)
Change in frequency/amount in urine: “sauna kay mga ika-lima ikaw unom na siya
mangihi karon kay mga ika-duha ikaw tulo nalang”
(“2-3 times a day( usual of 5-6 times a day)”)
Others/comments:
AQ verbalized, “gahawoy lang iyang tiil panalagsa”
21
Objective
BP:
R lying: 150/90mmHg L lying: 150/90mmHg
R sitting: 140/100 mmHg L sitting: 140/100mmHg
R standing: 150/90mmHg L standing: 150/90mmHg
Pulse pressure: 50 mmHg
Heart rate/sounds: 75bpm / no unusual sound noted
Rhythm: regular
Pulse:
Carotid: 83bpm Radial: 75bpm Popliteal: 81bpm
Temporal: 80 bpm Femoral: not assessed Dorsal pedis: 78bpm
Vascular bruit: no bruit heard
Breath sounds: crackles
Jugular vein distention: none
Extremities:
Temperature: warm to touch
Color: light brown
Capillary refill: refills in less than 2 seconds
Homan’s sign: (-)
Varicosities: prominent on both legs
Color of nail beds: pinkish
Lips: dry, pale lips
Mucous membranes: dry, pale
Sclera: white,clear
IV. EGO INTEGRITY
Subjective
Reports of stress factors: “kaning iya ubo karun sab” (“this cough she had right now”)
Ways of Handling Stress: “mamahala nalang” (“we just let it be”)
Financial concerns: daku gyud,problema jud sa kuarta kay kapos man”
(“We do have a big problem about money matters”)
22
Relationship status: “maayo man akong relasyon saku mga anak ug akong asawa
wla may bikil sab”
(“My relationship with my children and my husband is in harmony and in good terms”)
Lifestyle: “sa balay ra. Makalakaw man gali, usahay ra”
(“I’m always inside the house I seldom go outside”)
Recent changes: “Karon, cgeg lakaw – pa check-up”
(“Now, we always go for check-ups”)
Feelings of Helplessness: “wala man” (none)
Hopelessness: “wala pud” (none)
Powerlessness: “dili pud” (none)
Others/comments: Patient stressed the negative impact brought by his condition that
led her not to do her usual works at home.
Objective
Emotional status
Calm: (+) anxious :(-)
Withdrawn :(-) fearful :(-)
Angry :(-) irritable :(-)
Euphoric: (-)
Observed physiologic response: patient was calm and cooperative during
assessment
Others/comments: The patient was emotionally calm as well as cooperative whenever
assessed.
V. ELIMINATION
Subjective
Usual bowel pattern: Before admission: 2 times a day
During admission: 4-5 times a week
Character of stool; Formed, solid, yellow-brown
Last BM: 12/11/2010 Laxative use: “wala man” (none)
History of bleeding: “Sa pagpangihi lang” (“only urination”)
Hemorrhoids: “wala man tingale, wala mi kabalo”(“None I guess, we don’t know”)
23
Constipation: “ah, dili pud” (“none”)
Diarrhea: “usahay mu tukar, pero wala karon”
(“Sometime she does have but now she don’t have”)
Usual voiding pattern: Before admission: 5-6x a day
During admission: 2-3x a day
After admission: 4-6x a day
Incontinence: “wala man” (none)
Urgency: “wala pud” (none)
Retention: “wala” (none)
Frequency: “wala” (none)
Frequency: ““sauna kay mga ika-lima ikaw unom na siya mangihi karon kay mga ika-
duha ikaw tulo nalang” “2-3 times a day( usual of 5-6 times a day)”
Pain/burning/difficulty in voiding: “Saunsa katung pinaka una na na-admit na siya.
Naadmit siya kay naglisud ug ihi. Sakit man gyud daw ug naa puy dugo maihi.”
(Before when she was admitted due to difficulty in urination as well as pain and
bleeding during urination)
History of Kidney/bladder disease: “Sauna lge. Naadmit na tungod naa daw bato sa
iyang kidney” (Before she was admitted due a calculi in the kidney)
Others/Comments: The patient had also the hobby of holding her urine. She has
verbalized this to her significant other. The patient still sees blood during urination
maybe because of the recent surgery.
Objective
Abdomen:
Tender: non tender Soft/Firm: soft
Palpable Mass: none Size/Girth: 32 inches
Bowel sounds: 25 bowel sounds/min
Bladder palpable: not Distended: not distended
Others/comments: The client did not complain any tenderness upon assessment. .
“Sauna kanang mu reklamo na siya nga sakit daw iyang tiyan”
24
VI. FOOD/FLUID
Subjective
Usual diet (type): “karon kay depende sa ihatag pero sinabaw gyud na permi”
(“It depends on what the dietician gives but usually a soup”)
Number of meals/day: 3x a day
Last meal/intake: lunch meal
Loss of Appetite: “ok raman iya kaon” (“She eats well”)
Nausea/Vomiting: “wla man” (none)
Dentures: ‘wala” (none)
Allergies/Food intolerance: “wala” (none)
Heartburn/Indigestion: “wala man sad” (none)
Swallowing problems: “walay problema sa iyang pagtulon” (none)
Weight: Usual: 55 kg changes: loss of 1 kg @ present 54 kg
Diuretic use:”wala” (none)
Others/Comments: The patient had weight loss of I kg after the after the admission.
The patient doesn’t have any problem with eating.
Objective
Current weight: 54 kg Ht: 5’2’’ft
Body builds: endomorph
Skin turgor: decreased in elasticity
Mucous membranes: dry, pale
Hernia/Masses: (-)
Edema:
General :(-) Dependent: (-)
Periorbital:(-) Ascites:(-)
Thyroid Enlarged: (-) Halitosis: (-)
Condition of teeth/gums: “pangag iyang bangkil2x na ngipon”
(“She lost her incisors”)
Appearance of tongue: dry, pale
Others/comments: decrease elasticity of the skin is due to aging
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VII. HYGIENE
Subjective
ADL (Independent/Dependent)
Mobility: independent
Feeding: independent
Hygiene: independent
Dressing: independent
Toileting: independent
Other: “kaya man niya mag buhat ug ginagmay na lihok pero e assist lage nimu pa sad
gamay” (”She is able to do things on her on but of course she still needs minimal
assistance”)
Equipment/Presence of devices required: none
Assistance provide by: relatives/ family
Others/comments:
Objective:
General appearance: client is neat, well dressed with surgical wound @ the right
lower quadrant of the abdomen (@ mcburney’s point) with sutures intact with minimal
serous blood discharges.
Clothing/manner of Dress: appropriate for the occasion and place. Neat and clean
Body odor: slight body odor noted
Condition of scalp: oily scalp
Presence of vermin: none
Others/Comments: Patient states that he takes half baths every night before sleeping
and brushes his teeth ones a day.
VIII. NEUROSENSORY
Subjective
Fainting spells/dizziness: “kana lang dili siya makatarong ug tulog”
(“Only if she is not well rested @ night”)
26
Headache: “ wala man pud” (none) Location: “wala”(none) Frequency: “wala” (none)
Tingling/numbness/weakness location: “wala man sad” (none)
Seizure: “kung nay hilanat “ (“only if there is a fever”)
Aura: “wala sad” (none)
Eyes Vision loss R: (-) L: (-)
Glaucoma: “wala” (none) Cataract: “wala” (none)
Sense of smell: “ok lng” (“just ok”) Epistaxis: “wala” (none)
Comment: no unusualities observed
Objective:
Mental status
Orientation/Disoriented: Oriented
Time: aware of time
Place: answers correctly when asked
Person: answers correctly when asked
Alert: _____ Drowsy: _____
Lethargy: _____ Stuporous: ____ Comatose: _____
Cooperative: ____ Combative: ____
Affect: appropriate Delusion: none Hallucinations: none
Memory:
Recent: able to remember recent events
Remote: able to remember remote events but has trouble in recalling exact dates
Speech pattern: spontaneous, clear
Congruence: congruent
Glasses: reading glasses only.
Contacts: none
Hearing aids: none
Pupil size/reaction: R: 2mm L: 2mm
Facial droop: no facial droop observed
Handgrip/release R: strong grasp L: strong grasp
27
Posturing: slightly stooped DTR: +2
Paralysis: none
Others/Comments: express ideas and feelings concisely
IX. PAIN/COMFORT
Subjective:
Onset: „motukar raman ang sakit“
(the pain is just any time it’s sudden“)
Duration:“mga 15-30 minutes“
Location: “sa kaning gi operahan na samad”
(“@ the surgical wound area”- @ right lower quadrant)
Frequency: “kanang makalitan ug tandog” (“When touched or moved unintentionally”)
Intensity: 8 of the pain scale 1-10 and 10 as the highest and 1 as the lowest
Quality: “ngot-ngot siya”
Description of pain (check all that apply)
Shooting () Stabbing () Gnawing ( )
Sharp () Dull () Aching ( )
numb () Thrumbing() Radiating ()
Burning () unbearable ()
Precipitating Factors: “musakit lang”
Aggravating Factors: “kana matandugan ug dili matagaan ug meds” (“if accidentally
touched and if no meds given for pain”)
How relieved: “tambal” (medication)
Associated Symptoms: “hilantan,manginit “ (“Fever and I feel warm”)
Objective
Grimacing () Being irritable () Maoning ()
Sitting rigidly () Sighing () Moving very slowly ( )
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Limping () Clenching teeth ()
Moving in a guarded/protective manner () Requesting help while walking ()
Lying down during the day () Avoiding physical actions ( )
Other/Comments: Patient states that his condition really affected his ADL especially
those things and works that needs a lot of efforts.
X .RESPIRATION
Subjective
Dyspnea related to: “kanang takigan siya. Hangson dayon inig human
Cough/sputum of: “ga ubo taz nay plemas”
(“She has cough with green to yellowish plegm”)
History of: Bronchitis (-)
Asthma (-) Emphysema (-)
Recurrent pneumonia (-)TB (-)
Exposure to noxious fumes (-)
Smoker: “dili man” (no)
Packs: N/A
Brand:N/A
Use of respiratory aids: “wala sad” (none)
Oxygen: “wala” (none)
Others/comments: patient is non smoker. Patient has a productive cough.
Objective:
RR: 19cpm
Depth: shallow breathing Symmetry: symmetrical
Use of accessory muscle: none Nasal flaring: none
Fremitus: none Breath sounds: crackles
Cyanosis: (-)
Clubbing of fingers: (-)
Sputum Characteristics: yellowish phlegm
Restlessness: (-)
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Other/Comments: patient was observed to have a productive cough
XI. SAFETY
Subjective:
Allergies/sensitivity: “wala man siyay allergy” (“she don’t have allergy”)
Reaction: N/A
History of STD (date/type): “wala pud” (none)
Blood trans/number: 2 bags after the operation
When:
History of accidental injuries: “wala sad” (none)
Fractures/dislocations: “wala man pud” (none)
Arthritis/unstable joints: ou,naa tukar2x lng“ (‘she experience such sometime“)
Back problems: “wala” (none)
Changes in moles: “wala” (none)
Enlarged nodes: “wala sad” (none)
Prosthesis: “wala, makalakaw raman siya” (“None, she can walk without such”)
Ambulatory devices: “wala” (none)
Expression of Ideation of violence (self/others): The patient expresses no ideation
of violence against self and others.
Objective
Temp: warm to touch Diaphoresis: none
Skin integrity: dry skin noted with surgical wound @ the right lower quadrant of the
abdomen (@ mcburney’s point) with sutures intact with minimal serous blood
discharges.
Scars: none
Rashes: no rashes noted
Lacerations: none Ulcerations: none
Ecchymosis: none Blisters: none
Burns (degree/%): none Drainage (note location): none
General Strength: slightly weak due to pain on operative side
30
Muscle tone: decreased muscle tone
Gait: steady
Paresthesia/paralysis: none
Others/Comments: Patient appears weak and the decrease muscle tone is due to
aging.
XII. SEXUALITY
Subjective
Sexually active: no
Sexual concerns/difficulties: “naa siyempre karon”
(“ofcourse she does have right now”)
Recent change in frequency or interest: “wala na karon kay tigulang na”
(“Now, none since she’s old already”)
Female:
Subjective
Age of menarche: 16 yrs.old
Length of cycle: per month
LMP: “wala natiman.an” (“Forgotten already”)
Menopause: menopause
Vaginal discharge: “puti-puti nalang ginagmay” (“white tiny discharges”)
Bleeding between periods: “wala mi kabalo” (“we don’t know”)
Pregnancy HX: 4x been pregnant
Episiotomy: “normal mi tanan” (“we are all delivered normally”)
Lochia: none
Complication of pregnancy: “wala” (none)
Surgeries: “mattress-tumor sa mattress (dugay nah)”
Hormonal therapy/calcium use: “wala” (none)
Practice SBE: “wala” (none)
Discharges: “wala” (none)
Last PAP smear: “wala man mi nag pacheckup”
31
(“we never been to some check-ups”)
Method of birth control: “wala sila ana” (“they don’t practice such”)
Others/Comments: Patient has not undergone any examination on his genitals
Objective
Breast examination: “wala” (none)
Vaginal warts/lesions: none
XIII. SOCIAL INTERACTIONS
Subjective
Marital status: “Minyo ko” (Married)
Yrs in relationship: “43 years”
Living with: “with apo and family” (“with grandchildren and family”)
Concerns/stresses: “sa kwarta jud karon” (“for now, it would be money matters”)
Extended family: “oo” (“yes”)
Other support person: “anak” (“children”)
Role within family structure: mother
Report of problems related to illness/condition: “dili na kayo makatabang sa balay
tungod aning sakit ni mama” (“she’s unable to help us with the household chores
because of her present condition”)
Others/comments: The main concern of the patient is about money matters and her
present condition.
XIV. Teaching/ Learning
Subjective
Dominant language (specify): “bisaya” (“visayan”)
Literate: “oo” (“yes”)
Educational Level: Elementary Graduate
Health beliefs/ practices: “wala” (none)
Familial risk factors:
Diabetes: none
32
TB: none
Heart Disease: none
Stroke: none
High BP: none
Epilepsy: none
Kidney Disease: renal failure(Paternal side).
Cancer: none
Mental Illness: none
Use of alcohol: “panalagsa. Kung naai party” (“sometimes, and when there is a party”)
Others/comments: drink alcohol of about 1-2 glasses.
XV - Body Map
(Illustrate in the body map how your patient looks like, e.g. tubes inserted, bruises, surgical incisions, physical abnormalities, affected areas. Mark with a small “X” where it is located or draw it on the body map and then label it in the space provide.)
33
Slightly stooped
Productive cough w/ yellowish phlegm
Skin turgur: decreased elasticity
Dry and pale mucous membranes
Breath sound: crackles
Weak grasp
Shallow breathing
Moving slowly and avoiding physical actions
Oily scalp
Slight body odor noted
IVF: D5LR 1 L @ 30 gtts/min infusing well @ right handDate ordered:12/12/201000
surgical wound @
the right lower
quadrant of the
abdomen (@
mcburney’s point)
with sutures intact
with minimal
serous blood
discharges.
Pain: gnawing and achingIntensity: 8 of the
pain scale 1-10
and 10 as the
highest and 1 as
the lowest
B. History Present illness:
5 months: prior to admission patient had sudden onset of right flank pain radiating to the right upper quadrant as well as pain in urination. Patient was admitted to a local hospital in Initao and admitted which in ultrasound revealed nephrolithiasis.
3 months: prior to admission patient was again admitted in a local hospital in Initao because of blood in urination and was initially diagnosed to have Ureterolithiasis and was referred to this institution.
2 months: prior to admission patient consulted in this institution(NMMC). Patient’s kidneys were examined and the results was: Nonfunctioning kidneys secondary ureterolithiasis with nephrolithiasis.
2 weeks: prior to admission, patient’s s.o. said: gahi iyang kilid gihilantan siya ug gitakigan. gidala namo siya sa ospital sa initao para magpa check up pero nag ingon ang nurse “balik pagka huwebes kai nay private doctor from CDO “. Pagbalik namo pagpa.check-up, gi UTZ siya. 3 days after mi nagpa.UTZ, ingon ang doctor nga naa daw stone sa right niya nga kidney. Gi-adto dayon mi sa Mercury Hospital sa Iligan, pagtan-aw sa result, ingon ang doctor nga kelangan daw operahan kai dako daw pud ang bato.
10 days: prior to admission, pt’s urine was tested and revealed nephritis and infection. Patient’s blood was also tested and revealed nephritis and hemoconcentration.
5 days: prior to admission the complained for pain felt “ Ga inum siya ug tambal para mawala ra. Ginadaladala raman gud na niya” as verbalized by SO.
1 day: prior to admission the patient consulted the local hospital for the schedule of the surgery due to the pain that the patient felt. The pain got worst but can still tolerate and relieved by rest. The patient can still do light activity.
2-3 hours: prior to admission the patient was unable to walk straighten up his body due to pain and already needs assistance.
34
C. Laboratory Results
Radiographic ReportPatient: NQPlate no. 2010-11-1619Tentative Diagnosis: HydronephrosisDate Examined: October 28, 2010Parts Examined: Kidneys Requested by: Dr. EFindings:
IV UROGRAMScout film shows a non-obstructive gastrointestinal gas pattern/ Psoas shadows are distinct. An ovoid Calcific density measuring 3.2 x 2.1 cms in the Right hemiabdomen between L2 & L3 and another irregular Calcific Density seen measuring 1.1 x 0.7 cms in the Right iliac wing. The visualized osseous structures are unremarkable. Serial films following intravenous administration of contrast opacification of the left Pelvocalyceal System which exhibits no dilatation, but filling defect. The ureter likewise opacifice and runs a normal course with normal caliber. There is no nephrogram effect noted on the Right Kidney. There is also opacification of the right pelvocalyceal system and ureter even in delayed 24-hour study. The bladder adequately distends which shows an remarkable mucosal pattern with filling defect .Post void study shows a uncomplete emptying of the bladder.Impression:
o Nonfunctioning kidneys secondary ureterolithiasis with nephrolithiasis.
o Normal functioning Left Kidneys.
Radiographic ReportPatient: NQPlate no. 2010-11-1619Tentative Diagnosis: HydronephrosisDate: Nov. 17, 2010Parts Examined: ChestRequested by: Dr. BFindings:
Chest – PA, upright viewo There is no evidence of active parenchymal infiltrates.
o Heart is not enlarged
o Aorta, Trachea, Diaphragm and Sulci are unremarkable.
Impression:No radiographic abnormality in chest.
35
St. Ignatius Urine AnalysisDate: 12/1/2010 11:06AM
Normal values
Interpretation
MacroscopicColor Straw Yellow-amber NormalTransparency Turbid Clear to
slightly turbidNormal
pH 4.0 4.8-8.0 Acidic: indicates accumulation of solutes in the urine in relation to the calculi formation.
Specific Gravity 1.010 1.005-1.030 NormalChemicalProtein Trace Negative Indicates nephritisSugar Negative Negative NormalMicroscopic- CellPUS cells Loaded/HPF Few Indicates InfectionRBC 1-3/HPF 0-2/HPF NormalMicroscopic- EpitheliumSquamous Few None or few NormalBacteria Moderate None Indicates Infection
St. IgnatiusClinical ChemistryDate: 12/1/2010
Result Normal Values InterpretationRBS 106.5 80-140 NormalCreatinine 1.0 0.5-1.3 NormalBUN 29.0 10-30 NormalSodium 157.0 135-145 Nephritis,
hemoconcentrationPotassium 4.1 3.5-5.0 Normal
Ultrasound KUB December 1, 2010 Interpretation:Urinary retention, 153.7 ml (66%)Nephrolithiasis, right kidney with regression in size and numbersNephrolithisasis, left kidney with regression
36
St. IgnatiusHematology ReportDate: 12/1/2010
Patient value Normal values InterpretationTotal WBC 5.9 5-10 NormalTotal RBC 4.10 3.69-5.9 NormalHemoglobin 10.6 11.7-14.0 Decrease Hemoglobin
indicates anemia and nutritional deficiency
Hematocrit 32.9 34.10-44 Decrease hematocrit indicates anemia
MCV 80.2 70-97 NormalMCH 25.9 26.1-33.3 Decrease in microcytic
anemiaMCHC 32.2 32-35 NormalRDW-CV 14.3 11-16 NormalDifferential countNeutrophils 54.5 55-62 An overwhelming
infection can deplete the bone marrow of neutrophils and produce neutropenia.
Lymphocytes 28.4 20-40 NormalMonocytes 11.5 4-10 Increased levels are
seen in tissue breakdown or chronic infections.
Eosinophils 5.4 1-6 NormalBasophils 0.2 0-1 NormalPlatelet 252 150-390 Normal
Blood Transfusion Release FormBlood Group: ARh (+)12/13/2010Packed RBC = 2 unitsDonor’s Blood Bag No.
Segment no.
Blood Group
Rh Group Crossmatched Result
Date Expiry
Status
2K10-12-7912
69847600 A (+) Compatible 1-16-10 Taken
2K10-12-7882
48456913 A (+) Compatible 1-16-10 Taken
37
Hematology ReportDate: 12/14/2010 11:43 AM
Patient value Normal values InterpretationTotal WBC 8.4 5-10 NormalTotal RBC 4.14 3.69-5.9 NormalHemoglobin 10.5 12-16 Decreased Hemoglobin
indicates anemia and nutritional deficiency
Hematocrit 32.6 35-47 Decreased hematocrit indicates anemia
MCV 78.7 84-96 Decreased in microcytic anemia
MCH 25.4 28-33 Decreased in microcytic anemia
MCHC 32.2 33-35 Decreased in severe hypochromic anemia
RDW-CV 15.0 12-17 NormalPDW 8.2 9-16MPV 8 8-12 NormalDifferential countNeutrophils 14.6 17.4-48.2 An overwhelming
infection can deplete the bone marrow of neutrophils and produce neutropenia.
Lymphocytes 72.7 43.4-76.2 NormalMonocytes 11.7 4.5-10.5 Increased levels are
seen in tissue breakdown or chronic infections.
Eosinophils 1.0 1-3 NormalBasophils 0.0 0-2 NormalBands/ StabsPlatelet 234 150-400 Normal
III. ANATOMY AND PHYSIOLOGY
38
The kidneys are organs with several functions. They are seen in many types
of animals, including vertebrates and some invertebrates. They are an essential part of
the urinary system and also serve homeostatic functions such as the regulation
of electrolytes, maintenance ofacid-base balance, and regulation of blood pressure.
They serve the body as a natural filter of the blood, and remove wastes which are
diverted to the urinary bladder. In producing urine, the kidneys excrete wastes such
as urea and ammonium; the kidneys also are responsible for the reabsorption
of water, glucose, and amino acids. The kidneys also
produce hormonesincluding calcitriol, renin, and erythropoietin.
Located at the rear of the abdominal cavity in the retroperitoneum, the kidneys receive
blood from the paired renal arteries, and drain into the paired renal veins. Each kidney
excretes urine into a ureter, itself a paired structure that empties into the urinary
bladder.
Renal physiology is the study of kidney function, while nephrology is the medical
specialty concerned with kidney diseases. Diseases of the kidney are diverse, but
individuals with kidney disease frequently display characteristic clinical features.
Common clinical conditions involving the kidney include the nephritic and nephrotic
syndromes, renal cysts, acute kidney injury, chronic kidney disease, urinary tract
infection, nephrolithiasis, and urinary tract obstruction. Various cancers of the kidney
exist; the most common adult renal cancer isrenal cell carcinoma. Cancers, cysts, and
some other renal conditions can be managed with removal of the kidney,
or nephrectomy. When renal function, measured by glomerular filtration rate, is
persistently poor, dialysis and kidney transplantation may be treatment options.
Although they are not severely harmful, kidney stones can be a pain and a nuisance.
The removal of kidney stones includes sound wave treatment, which breaks up the
stones into smaller pieces which are then passed through the urinary tract. One
common symptom of kidney stones is a sharp pain in the medial/lateral segments of the
lower back.
Location
In humans, the kidneys are located in the abdominal cavity, and lie in a retroperitoneal
position. There are two, one on each side of the spine. The asymmetry within the
abdominal cavity caused by the liver typically results in the right kidney being slightly
39
lower than the left, and left kidney being located slightly more medial than the right. The
left kidney is approximately at the vertebral level T12 to L3, and the right slightly lower.
The right kidney sits just below thediaphragm and posterior to the liver, the left below
the diaphragm and posterior to the spleen. Resting on top of each kidney is an adrenal
gland. The upper (cranial) parts of the kidneys are partially protected by the eleventh
and twelfth ribs, and each whole kidney and adrenal gland are surrounded by two layers
of fat (the perirenal and pararenal fat) and the renal fascia. Each adult kidney weighs
between 125 and 170 grams in males and between 115 and 155 grams in females. The
left kidney is typically slightly larger than the right.
Structure
The kidney has a bean-shaped structure, each kidney has concave and convex
surfaces. The concave surface, the renal hilum, is the point at which the renal
artery enters the organ, and therenal vein and ureter leave. The kidney is surrounded by
tough fibrous tissue, the renal capsule, which is itself surrounded by perinephric
fat, renal fascia (of Gerota) and paranephric fat. The anterior (front) border of these
tissues is theperitoneum, while the posterior (rear) border is thetransversalis fascia.
The superior border of the right kidney is adjacent to the liver; and the spleen, for the
left border. Therefore, both move down on inhalation.
The kidney is approximately 11–14 cm in length, 6 cm wide and 4 cm thick.
The substance, or parenchyma, of the kidney is divided into two major structures:
superficial is the renal cortex and deep is the renal medulla. Grossly, these structures
take the shape of 8 to 18 cone-shaped renal lobes, each containing renal cortex
surrounding a portion of medulla called a renal pyramid (of Malpighi). Between the renal
pyramids are projections of cortex called renal columns (of Bertin). Nephrons, the urine-
producing functional structures of the kidney, span the cortex and medulla. The initial
filtering portion of a nephron is the renal corpuscle, located in the cortex, which is
followed by a renal tubule that passes from the cortex deep into the medullary pyramids.
Part of the renal cortex, a medullary ray is a collection of renal tubules that drain into a
single collecting duct.
The tip, or papilla, of each pyramid empties urine into a minor calyx, minor calyces
empty into major calyces, and major calyces empty into the renal pelvis, which becomes
the ureter.
40
Blood supply
receive blood from the renal arteries, left and right, which branch directly from
theabdominal aorta. Despite their relatively small size, the kidneys receive
approximately 20% of thecardiac output.
Each renal artery branches into segmental arteries, dividing further into interlobar
arteries which penetrate the renal capsule and extend through the renal columns
between the renal pyramids. The interlobar arteries then supply blood to the arcuate
arteries that run through the boundary of the cortex and the medulla. Each arcuate
artery supplies several interlobular arteries that feed into the afferent arterioles that
supply the glomeruli.
The interstitum (or interstitium) is the functional space in the kidney beneath the
individual filters (glomeruli) which are rich in blood vessels. The interstitum absorbs fluid
recovered from urine. Various conditions can lead to scarring and congestion of this
area, which can cause kidney dysfunction and failure.
After filtration occurs the blood moves through a small network of venules that converge
into interlobular veins. As with the arteriole distribution the veins follow the same
pattern, the interlobular provide blood to the arcuate veins then back to the interlobar
veins which come to form the renal vein exiting the kidney for transfusion for blood.
Histology
Innervation
The kidney and nervous system communicate via the renal plexus, whose fibers course
along the renal arteries to reach the kidney. Input from the sympathetic nervous
system triggers vasoconstriction in the kidney, thereby reducing renal blood flow. The
kidney is not thought to receive input from the parasympathetic nervous system.
Sensory input from the kidney travels to the T10-11 levels of the spinal cord and is
sensed in the corresponding dermatome. Thus, pain in the flank region may be referred
from the kidney.
Functions
The kidney participates in whole-body homeostasis, regulating acid-base
balance, electrolyteconcentrations, extracellular fluid volume, and regulation of blood
41
pressure. The kidney accomplishes these homeostatic functions both independently
and in concert with other organs, particularly those of the endocrine system. Various
endocrine hormones coordinate these endocrine functions; these
include renin, angiotensin II, aldosterone, antidiuretic hormone, andatrial natriuretic
peptide, among others.
Many of the kidney's functions are accomplished by relatively simple mechanisms of
filtration, reabsorption, and secretion, which take place in the nephron. Filtration, which
takes place at the renal corpuscle, is the process by which cells and large proteins are
filtered from the blood to make an ultrafiltrate that will eventually become urine. The
kidney generates 180 liters of filtrate a day, while reabsorbing a large percentage,
allowing for only the generation of approximately 2 liters of urine. Reabsorption is the
transport of molecules from this ultrafiltrate and into the blood. Secretion is the reverse
process, in which molecules are transported in the opposite direction, from the blood
into the urine.
Excretion of wastes
The kidneys excrete a variety of waste products produced by metabolism. These
include the nitrogenous wastes urea, from proteincatabolism, and uric acid, from nucleic
acid metabolism.
Acid-base homeostasis
Two organ systems, the kidneys and lungs, maintain acid-base homeostasis, which is
the maintenance of pH around a relatively stable value. The kidneys contribute to acid-
base homeostasis by regulating bicarbonate (HCO3-) concentration. The kidneys have
two important roles in the maintaining of the acid-base balance: to reabsorb bicarbonate
from and to excrete hydrogen ions into urine
Osmolality regulation
Any significant rise in plasma osmolality is detected by the hypothalamus, which
communicates directly with the posterior pituitary gland. An increase in osmolality
causes the gland to secrete antidiuretic hormone (ADH), resulting in water reabsorption
by the kidney and an increase in urine concentration. The two factors work together to
return the plasma osmolality to its normal levels.
ADH binds to principal cells in the collecting duct that translocate aquaporins to the
membrane allowing water to leave the normally impermeable membrane and be
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reabsorbed into the body by the vasa recta, thus increasing the plasma volume of the
body.
There are two systems that create a hyperosmotic medulla and thus increase the body
plasma volume: Urea recycling and the 'single effect.'
Urea is usually excreted as a waste product from the kidneys. However, when plasma
blood volume is low and ADH is released the aquaporins that are opened are also
permeable to urea. This allows urea to leave the collecting duct into the medulla
creating a hyperosmotic solution that 'attracts' water. Urea can then re-enter the
nephron and be excreted or recycled again depending on whether ADH is still present
or not.
The 'Single effect' describes the fact that the ascending thick limb of the loop of Henle is
not permeable to water but is permeable to NaCl. This means that a countercurrent
system is created whereby the medulla becomes increasingly concentrated setting up
an osmotic gradient for water to follow should the aquaporins of the collecting duct be
opened by ADH.
Blood pressure regulation
Long-term regulation of blood pressure predominantly depends upon the kidney. This
primarily occurs through maintenance of theextracellular fluid compartment, the size of
which depends on the plasma sodium concentration. Although the kidney cannot
directly sense blood pressure, changes in the delivery of sodium and chloride to the
distal part of the nephron alter the kidney's secretion of the enzymerenin. When the
extracellular fluid compartment is expanded and blood pressure is high, the delivery of
these ions is increased and renin secretion is decreased. Similarly, when the
extracellular fluid compartment is contracted and blood pressure is low, sodium and
chloride delivery is decreased and renin secretion is increased in response.
Renin is the first in a series of important chemical messengers that comprise the renin-
angiotensin system. Changes in renin ultimately alter the output of this system,
principally the hormones angiotensin II and aldosterone. Each hormone acts via multiple
mechanisms, but both increase the kidney's absorption of sodium chloride, thereby
expanding the extracellular fluid compartment and raising blood pressure. When renin
levels are elevated, the concentrations of angiotensin II and aldosterone increase,
leading to increased sodium chloride reabsorption, expansion of the extracellular fluid
43
compartment, and an increase in blood pressure. Conversely, when renin levels are
low, angiotensin II and aldosterone levels decrease, contracting the extracellular fluid
compartment, and decreasing blood pressure.
Hormone secretion
The kidneys secrete a variety of hormones, including erythropoietin, calcitriol,
and renin. Erythropoietin is released in response to hypoxia(low levels of oxygen at
tissue level) in the renal circulation. It stimulates erythropoiesis (production of red blood
cells) in the bone marrow.Calcitriol, the activated form of vitamin D, promotes intestinal
absorption of calcium and the renal reabsorption of phosphate. Part of the renin-
angiotensin-aldosterone system, renin is an enzyme involved in the regulation
of aldosterone levels.
Kidney StonesA kidney stone is a solid piece of material that forms in the kidney out of substances in the urine. Normally, urine contains chemicals that prevent or inhibit the crystals from forming. However, these inhibitors do not seem to work for everyone. Calcium (Oxalate or Phosphate)The most common kidney stone type contains calcium in combination with either oxalate or phosphate. These are called calcium oxalate stones or calcium phosphate kidney stones, respectively. Calcium is a normal part of a healthy diet and makes up important parts of the body, such as bones and muscles. Calcium that is not used by the bones and muscles goes to the kidneys. In most people, the kidneys flush out the extra calcium in the urine. However, when calcium stays in the kidneys, it joins with other waste products to form a calcium kidney stone. StruviteA struvite stone, also known as an infection stone, may form after there is an infection in the urinary system. This type of kidney stone contains the mineral magnesium and the waste product ammonia. Uric AcidA uric acid stone may form when there is too much acid in the urine. If you tend to form uric acid stones, you may need to cut back on the amount of meat that you eat.
CystineCystine is one of the building blocks that make up muscles, nerves, and other parts of the body. Although cystine stones are rare, they may form when there is too much cystine buildup in the urine. The disease that causes this kidney stone type runs in families.
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IV. PATHOPHYSIOLOGYA. Narrative Pathophysiology
The urinary calculi (Urolithiasis) are calcifications in the urinary system. There are two primary causative factors related to the formation of these stones such as urinary stasis and supersaturation of urine with poor soluble crystalloids. There are also 2 primary predisposing factors that are related to the case such as age and family history. Age is one factor because it is most common in adults age 40 and older, though kidney stones may occur at any age Family history is another predisposing factor because there is an increase of the disease associated in her paternal side. On the other side the precipitating factors are diet, low intake of water, lifestyle, metabolic disturbances, and urinary stasis. Diet is a factor because increase intake of purines, oxidates, calcium supplements and animal proteins can increase occurrence of the disease process. Low intake of water can increase solute concentration occurs because of fluid depletion or an increased solute load. This increased concentration leads to precipitation of crystals, such as calcium, uric acid, and phosphate. Another factor would be metabolic disturbances. It is because it influences the solubility of certain crystals, with some crystal types precipitating readily in acid urine and some in alkaline urine. Abnormal pH levels occur in renal tubular acidosis with the administration of carbonic anhydrase inhibitors, in the presence of urea-splitting bacteria, and in severe, chronic diarrhea. The last precipitating factor would be urine stasis. Stasis of urine from the bladder neck obstruction, continent urinary diversion, and immobilization increases the risk for development of stones because the crystals in unmoving urine precipitate more readily. It all starts with the uric acid, ammonia phosphate, and calcium oxalate stone material deposition on proximal renal tubule. There would then be supersaturation of urine by stone forming constituents and nephrocalcinosis on the proximal tubule. Due to the supersaturation of urine there would then be nidation of crystals of foreign bodies from the supersaturated urine. On the other side, Due to the nephrocalcinosis on the proximal tubule the patient then manifested the Randall’s plaque in relation to the low back flank pain. The stones then progress to the loop of henle and there would be more stones accumulating and would be increasing in size. An increase in stone would then attract itself to the blood vessel wall surface and would finally erode. The process progresses with the stone formation in the kidneys. Due to certain factors such as low intake of water and improper diet, the stone increases its size. Stone matrix progresses due to the mucoproteins that bind to the mass of the stone that forms multiple urinary calculus. On the other hand, due to the stone formation in the kidneys the stones that were accumulated would then descend from the kidneys to the ureter. Growth of these stones continues by aggregation to form larger particles. One of these particles may travel down the urinary tract until it is trapped at some narrow point where for stone formation occurs. It then increases the increases the pressure in the ureter that would then be severely stretched and would then loose its ability to undergo peristaltic contractions. Due to the urethral walls looses its ability to undergo contractions the urethral walls would then bleed and hematuria would again be manifested by the patient. There would also be slowed passage of urine due to the loosed contractions. Due to the bleeding of the urethral walls there would then be invasion and infection of urea splitting bacteria that had increased the production of white blood cells and was manifested with pyuria and fever. The continuous bleeding would result to the scarring
45
of the urethral walls and would then again increase the stasis of urine in the ureters. The increased stasis would then accumulate the urine substances and nucleation occurs, in which crystals are formed from super saturated urine. Due to these occurrences there would then be stone formation in the bladder and ureters that is manifested with decreased urine output. The process then proceeds with the destruction of normal function of the kidney. One the function of our kidneys is blood formation, due to the destruction of the normal functioning of the kidneys there would then be a decrease in production of erythropoietin. Due to this anemia occurs due to the decrease production of red blood cells including oxygen carrying components called hemoglobin.
(Was not manifested) the disease progresses to a more severe stage. Renal Failure occurs with the increased sympathetic nervous system activity related to dysfunction of autonomic nervous system. There would be an increased activity of renin angiotensin aldosterone system that increases the systemic vascular resistance. It would then also increase the renal absorption of sodium, chloride and water related to a genetic variation in the pathways by which kidneys can handle. There would then be increase in the viscosity of blood as well as increased cardiac workload and would then progress to cardiac failure and finally DEATH.
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V. MEDICAL MANAGEMENT
A. General Management
Ideal Management Actual Management
Intake and Output – to determine
any abnormalities of the function of
the urinary and digestive system.
Vital Signs Monitoring – to monitor
the progress of the patient’s
condition
IV Therapy- for hydration and
replacement of electrolytes to
maintain fluid and electrolyte
balance
Diet as tolerated- for the patient to
get the appropriate amount of
vitamins and minerals needed.
Ranitidine(500mg IVTT q 4 hours
RTC X 24)- treatment for post
surgical ulcer formation
Paracetamol(300mg IVTT q 4
hours RTC X 24) – treatment for
fever
Tramadol (500mg 5/100 IVTT q 6
hours RTC) – Treatment of
moderate or moderately severe
pain felt at the Surgical incision site
Metoclopramide(10mg IVTT stat)-
treatment for post operative
nausea and vomiting
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Diphenylhydramine(50mg 5/100
IVTT PRN)- treatment for allergic
reactions and to prevent motion
sickness
Cefuroxime(750mg IVTT q 8 ANS
(-))- perioperative prophylaxis
Oxygen administration via nasal
cannula- it is given to provide
sufficient oxygen for the body of
the patient.
Blood Transfusion- it is to supply
enough blood for the body due to
blood loss during operation.
Ideal Laboratory Examinations Actual Laboratory Examinations
1. Complete Blood Count
-Include hemoglobin and
hematocrit measurements,
erythrocyte (RBC) count, Leukocyte
(WBC) count, differential white cell
count.
-Basic screening test and one of
the most frequently ordered blood test.
-a common blood test that
evaluates the three major types of
cells in the blood: red blood cells,
white blood cells, and platelets.
-ordered as part of a routine
check-up, or if you are feeling more
tired than usual, seems to have an
1. Complete Blood Count
- Used to determine infection and other diseases. It is used to determine if there are any bleeding problems.
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infection, or has unexplained bruising
or bleeding.
2. Urinalysis
-Ordered to diagnose a number
of medical conditions including
diabetes, urinary tract infections, and
kidney diseases. This is done to detect
any cells, urine crystals, mucus, and
other substances, and to identify any
bacteria or other microorganisms that
might be present.
3. Creatinine levels – to assess for
renal function
2. Urinalysis
-used to determine if there are infections, bleeding and disease.
Ideal Imaging Studies Actual Imaging Studies
1. Chest X-Ray
-used to visualize the lung fields
to check for any scarring or
accumulation of fluid in the lungs.
2. Intravenous Urogram
-The IVU is an x-ray procedure using contrast medium that shows the size,
1.Chest X-Ray
-used to diagnose conditions
affecting the chest, its contents, and
nearby structures.
2. Intravenous Urogram
-used to identify the location and
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placement and function of the parts of the renal tract, which is made up of the kidneys, the ureters (tubes from the kidneys to the bladder) and the bladder.
This test is sometimes used to locate the site and identify the underlying problem when the flow of urine is obstructed. IVU can also show abnormal connections between the urinary tract and the skin or other organs.
3. Ultrasonography of kidney, ureter
and bladder
- high-frequency sound waves
are
transmitted from a transducer to the
kidneys and perirenal structures. The
resulting echoes are displayed on a
monitor as anatomic images. Renal
ultrasonography can be used to detect
abnormalities or clarify those detected
by other tests. It's especially useful in
cases in which excretory urography is
ruled out. Unlike excretory urography,
this test isn't dependent on renal
function and therefore may be useful in
patients with renal failure.
cause of the obstruction of the flow in the urinary tract.
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Ultrasonography of the ureter, bladder,
and gonads also may be used to
evaluate urologic disorders.
Ideal Pharmacotherapy Actual Pharmacotherapy
1.Nonopioid Analgesic
-drugs that have principally analgesic,
antipyretic, and anti-inflammatory
actions. They are milder forms of
analgesics.
2.Thiazide diuretic
-promotes calcium resorption from the
renal tubules, thereby preventing
excess calcium loads in the urine.
3. Vitamin B6(pyridoxine), magnesium
oxide, or cholestyramine.
- for calcium oxalate stones treatment
1.Ranitidine(500mg IVTT q 4 hours RTC
X 24)- treatment for post surgical ulcer
formation
2.Paracetamol(300mg IVTT q 4 hours
RTC X 24) – treatment for fever
3.Tramadol (500mg 5/100 IVTT q 6 hours
RTC) – Treatment of moderate or
moderately severe pain felt at the CTT
insertion site
4.Metoclopramide(10mg IVTT stat)-
treatment for post operative nausea and
vomiting
5.Diphenylhydramine(50mg 5/100 IVTT
PRN)- treatment for allergic reactions and
to prevent motion sickness
6.Cefuroxime(750mg IVTT q 8 ANS (-))-
perioperative prophylaxis.
Ideal Surgical Management Actual Surgical Management
1. Shock Wave Lithotripsy- It may be performed on an outpatient basis, either with intravenous sedation or general anesthesia, and the duration of treatment is usually less than one hour. Recent advances have been made in the
1. Nephrectomy - The surgery done was nephrectomy to remove the whole non functioning right kidney which had kidney stones made up with calcium.
54
understanding of stone fragmentation and the etiology of renal injury which have made SWL more effective and safer. Small variations in the technique with which SWL is applied can affect optimal treatment outcomes. For example, a recent literature review and meta-analysis have found that slowing the rate of SWL delivery to 60 shock waves per minute fragments stones more effectively than treatment at a rate of 120 shock waves per minute.
2. Laser Lithotripsy-can be used to fragment stones in the bladder, ureter or kidney via a laser fiber which is passed through an endoscope [Figure 2]. Typically, a Holmium:YAG laser is used, which operates in the near infra-red area of the electromagnetic spectrum with a wavelength of approximately 2140 nanometers. The Holmium laser is one of the safest intracorporeal lithotripsies available for stone fragmentation. The depth of tissue penetration of the laser light is 0.5 to 1.0 mm, and the laser may be used in patients receiving anti-coagulation medications. Typical fiber diameter sizes for ureteroscopy
55
range from 200-400 microns. The rigidity of the fibers can limit the degree of deflection of the flexible ureteroscope, making the treatment of stones in the lower pole of the kidney especially challenging. The upper limit of stone size that can be efficiently treated with laser lithotripsy is approximately 1.5cm. Laser lithotripsy is usually performed as an outpatient procedure with the patient receiving a general anaesthetic. The operating room time varies based on the stone burden being treated and the surgical approach employed, but typically it lasts one to two hours.
3. Rigid Lithotrites- is a minimally invasive treatment alternative to open surgery for patients with large or complex renal calculi. PNL is performed in the operating room using general anesthesia, with the patient typically in the prone position, although supine PNL has been described. A rigid nephroscope is placed into the collecting system of the kidney via a small incision in the flank. Intracorporeal lithotripsy is then performed by inserting a rigid lithotrite through the endoscope and placing it in contact with the
56
stone. Lithotripters using ultrasonic energy are most commonly utilized during PNL and can efficiently fragment and remove the majority of stone types. Continuous suction irrigation is used to evacuate stone fragments quickly and to maintain clear visibility. However, hard calculi such as cystine and calcium oxalate monohydrate stones are less efficiently fragmented and removed with ultrasonic technology. For these stones, pneumatic lithotripters are often used for fragmentation as these devices readily break stones of any composition. The chief disadvantage of pneumatic lithotripters, however, is their inability to concurrently evacuate stone debris while fragmenting the stone. Rather, manual fragment removal is needed by using stone graspers, which may be a time-consuming process.
4. Nephrectomy -The surgery is performed with the patient under general anesthesia. The surgeon makes an incision in the side of the abdomen to reach the kidney. Depending on circumstances, the incision can also be made midline. The ureter and blood vessels are disconnected, and the kidney is then removed. The
57
surgery can be done as open surgery, with one incision, or as a laparoscopic procedure, with three or four small cuts in the abdominal and flank area.
58
B. Drug Study
RANITIDINE 500mg IVTT q 4 hours RTC x 24Classification: histamine 2 receptor blocking drugIndication Mechanism of action Contraindication Side effects Nursing precaution
Post surgery antacid to prevent ulcer formation
Competitively inhibits gastric acid secretion by blocking the effect of histamine on histamine 2 receptors.
Cirrhosis of the liver, impaired renal or hepatic function
Headache, abdominal pain, constipation, diarrhea, nausea and vomiting
Tell the patient that he may experience side effects brought about by the drug and if such are intolerable he must report them
Oral care if vomiting occurs
Monitor patient continually if giving IV medications
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PARACETAMOL 300mg IVTT q 4 hours RTC X 24Classification: acetaminophen, anti pyretic and analgesicIndication Mechanism of action Contraindication Side effects Nursing precaution
Fever Inhibits prostaglandins in CNS, but lacks anti-inflammatory effects in periphery; reduces fever through direct action on hypothalamic heat regulating center
Renal insufficiency, anemia, liver failure. Clients with pulmonary and cardiac diseases are more susceptible to acetaminophen toxicity
Abdominal pain, confusion, diaphoresis, diarrhea, low BP, malaise, nausea and vomiting
Advise patient to take medication exactly as directed and not to take more than recommended amount.
Avoid alcohol intake.
Caution patient to check the label in the OTC drugs. Advise to avoid taking more than one product containing acetaminophen at a time to prevent toxicity.
Advise patient to consult health care professional if discomfort or fever is not relieved by routine doses of this drug.
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METOCLOPRAMIDE 10mg IVTT statClassification: Anti emeticIndication Mechanism of Action Contraindication Side Effects Nursing Precaution
Treatment for post operative nausea and vomiting when nasogastric tube is undesirable
Blocks dopamine receptors in the chemoreceptor trigger zone of the CNS. Stimulates motility of the upper GI tract and accelerates gastric emptying.
Hypersensitivity; possible GI obstruction or hemorrhage; history of seizure disorder; Parkinson’s disease
Drowsiness, extrapyramidal reactions, restlessness, depression, irritability, diarrhea, dry mouth, Nausea, hypertension, hypotension and arrhythmias.
Dose may be given slowly over 1-2 min. Rapid administration causes transient but intense feeling of anxiety and restlessness followed by drowsiness advise patient to notify health care professional immediately if involuntary movements of eyes, face, or limbs occursadvise patient to avoid concurrent use of alcohol and other CNS depressants while taking this medication May cause drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known.
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DIPHENYLHYDRAMINE 50mg 5/100 IVTT PRNClassification: antihistamine Indication Mechanism of
ActionContraindication Side Effects Nursing Precaution
Relief of allergic symptoms caused by histamine release. Prevention of motion sickness.
Antagonizes the effects of histamine at H21 receptor sites; does not bind to or inactivate histamine. Significant CNS depressant and anti cholinergic properties.
Hypersensitivity, acute attacks of asthma; lactation; known alcohol intolerance
Drowsiness, dizziness, headache, blurred vision, hypotension, palpitations, anorexia, dry mouth, constipation, nausea, dysuria, urinary retention, and chest tightening .
May cause drowsiness. Caution patient to avoid driving or any activities which requires alertness until response of drug is known.
Perform oral care since it can cause dry mouth. Frequent oral rinses and candies can decrease dryness.
Advise patient to avoid use of alcohol and other CNS depressants concurrently with this medication.
Instruct patient taking diphenylhydamine in OTC preparation to notify health care professional if symptoms persist after 7 days.
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TRAMADOL 500mg 5/100 IVTT q 6 hours RTCClassification: analgesicIndication Mechanisms of actions Contraindication Side effects Nursing precaution
Moderate to moderate severe pain
Binds to mu opioid receptors. Inhibits re uptake of serotonin and norepinephrine in the CNS
Hypersensitivity; patients who are acutely intoxicated with alcohol, sedatives, hypnotics and centrally acting analgesics; pregnancy and lactation; severe hepatic impairment
Seizures, dizziness, headache, somnolence, anxiety, confusion, euphoria, malaise, nervousness, sleep disorder,constipation, nausea, abdominal pain, dry mouth, dyspepsia, vomiting, and flatulence
May cause dizziness and drowsiness. Caution patient to avoid driving or any activities which requires alertness until response to drug is known.
Advise patient to change positions slowly to minimize orthostatic hypotension.
Caution patient to avoid concurrent use of alcohol and other CNS depressants with this medication.
Encourage patient to turn, cough and breathe deeply every 2 hours to prevent atelectasis.
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CEFUROXIME 750mg IVTT q 8 ANS (-)Classification: anti infective, second generation cephalosporinsIndication Mechanism of action Contraindication Side effects Nursing precaution
Perioperative prophylaxis
Binds to cell wall membrane causing cell death. Bactericidal action to susceptible bacteria.
Hypersensitivity to cephalosporins; serious hypersensitivity to penicillins
Seizures, diarrhea, cramps, nausea, vomiting, rashes, phlebitis at IV site, bleeding and neutropenia
Advise patient to report signs of superinfections( furry overgrowth on the tongue and vaginal itching) and allergies.Instruct patient to notify health care professional if ever fever and diarrhea develop, especially if stool contains blood, pus and mucus. Advise patient not to treat diarrhea without consulting health care profession.
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VI. NURSING CARE PLANNursing Care Plan 1
Cues Diagnosis Planning Interventions Rationale Evaluation
Sujective:
“ Gasakit akong likod ( pointing at the surgical sight)”, as verbalized by the patient
Objective: Pain scale of 8/10 Grimacing Guarding behavior Requesting help while
walking
Acute pain related to surgical incision secondary to surgical procedure
SHORT TERMAfter 3 minutes of nursing interventions the patient will be able to
Report alleviation of pain with a pain scale from 8/10 to 3/10 as evi.denced by absence of grimed face and guarding behavior.
After 30 minutes of nursing interventions the patient will be able to
Demonstrate the use of relaxation skills and diversional activities as indicated such as: deep breathing techniques and imagery technique.
Demonstrate control of pain, feel more relaxed and interact more openly.
1. Instruct bed rest, allowing patient to assume comfortable position
2. Guide and instruct patient in relaxation technique such as deep breathing
3. Provide comfort measures such as therapeutic touch and communication
4. Teach the patient to socialize with family and SNs
5. Provide adequate rest periods
6. Eliminate additional stressors or sources of discomfort by providing quiet and calm environment
7. Assist in position changes
1. To promote rest and reduce fatigue
2. To promote generalized relaxation and to decrease sensation of pain
3. To promote nonpharmacological pain management
4. Diversional activities promote generalized relaxation and to decrease sensation of pain
5. To prevent fatigue6. To promote
nonpharmacological pain management
7. To prevent development of pressure sores
Short term goals were met
Patient was able to report pain was minimized; participate in the plan of care; feel more relaxed and interact more openly.
Patient was able to demonstrate a decrease in pain from 8/10 to 3/10 as evidenced by the absence of grimed face and guarding behavior.
Long term goals that were partially met:
1. Patient was able to report pain was relieved
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LONG TERM
Upon discharge the patient will be able to:
Experience absence of pain on surgical site
66
Nursing Care Plan 2Cues Diagnosis Planning Interventions Rationale Evaluation
Sujective:
Pain: “motukar ra man ang sakit, mga 15-30min”
Location: “sa iyang likud dapit daw”
“sakit jud siya nga mangluya si mama”
Associated s/s: “lantan, takig, gainit ang tiyan”
Itchiness “katol kayo ako samad pero dili nako ginakamot, ginahikap-hikap lang nako sa kilid”
Objective: Pain scale: 8 out of scale
of 1-10 Pain description: sharp Right flank pain noted Surgical incision noted on
right lower back area
Impaired Skin Integrity related to surgical incision
Short Term:Within 16 hours, client will be able to:
1. Verbalize measures in preventing infection correctly.
2. Demonstrate proper wound care and dressing.
3. Demonstrate improved behaviour like diet modification and early mobilization.
4. Verbalize importance of following therapeutic plan.
Independent1. Note changes in skin color,
texture, and turgor. Assess areas of least pigmentation for color changes like sclera, conjunctiva, nailbeds, buccal mucosa, tongue, palms, soles of feet
2. Inspect surrounding skin (of post-operative wound) for erythema, induration, maceration
3. Note odors emitted from site of injury.
4. Inspect skin on a daily basis, describing changes observed including remeasuring the wound.
5. Instruct patient to keep area clean and dry, demonstrating how to dress wounds aseptically, and support the incision ( ex. Splinting when coughing), prevent infection, and stimulate circulation to surrounding areas.
6. Use appropriate barrier dressings, wound coverings, drainage appliances, and skin-protective agents for open/draining wounds
7. Instruct SOs in monitoring for
Assess for abnormalities that may affect patient well-being
Assess for abnormalities that may affect patient well-being
Assess for abnormalities that may affect patient well-being
To monitor progress of wound healing.
Assists body’s natural process of repair
To protect wound and surrounding tissues
Moisture potentiates skin breakdown
After intervention, client was able to:
2. Verbalize and demonstrate proper infection prevention measures and skin care.
3. Demonstrate wound and dressing care properly.
4. Modify diet to increase in oral fluid intake and protein-rich balanced diet.
5. Display clean, non-infected and non-complicated wound.
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moist or wet linens and replace them with clean and dry ones.
8. Reposition patient every 2 hours involving client through client education and on desired positions in conjuction to other activities.
9. Encourage early ambulation
10. Encourage adequate nutritional intake and increase in fluids and protein intake.
11. Discuss importance of early detection on skin changes and complications.
12. Discuss the medical management and preventive care measures to client and SO
13. Reinforce measures in avoiding infection like proper wound care, avoiding moisture in wound site etc.
Dependent:8. Give Cefuroxime 750mg
IVTT q8h ANST (-)RTC per doctor’s order
9. Give Tramadol 500mg 5/100 IVTT q6h RTC per doctor’s order
Enhances understanding and cooperation
Promotes circulation and reduces risks associated with immobility.
To provide positive nitrogen balance to aid in healing and to maintain general good health
To monitor abnormalities and promote cooperation
To promote understanding, commitment to plan of therapy and optimizing outcomes
Reinforce prevention of infection and encourage cooperation
To treat infection For pain relief
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Nursing Care Plan 3
Cues Diagnosis Planning Interventions Rationale EvaluationSubjective:
“takig ra man kanang hilantanon siyag mayo ba”
Dyspnea related to: “ kanang takigan siya”
“hangoson dayun inig human”
Cough:” gahi nga ubo”
Objective: Sputum characteristic:
yellowish plegm
Warm to touch
Risk for infection r/t surgical incision
Short TermWithin 16 hrs duty @ NMMC, client will be able to:
1. Identify risk factors for occurrence of infection correctly.
2. Identify and demonstrate correctly the interventions that prevent/reduce risk of infection.
Long Term1. After 16hours of
duty at NMMC, client will be able to demonstrate lifestyle changes to promote safe environment like proper wound care and dressing, proper hygiene and hand washing, and intake of balanced diet.
INDEPENDENT1. Discuss different risk factors
that may contribute to infection and its prevention measures.
2. Instruct patient to keep area clean and dry, demonstrating how to dress wounds aseptically, and support the incision ( ex. Splinting when coughing), prevent infection, and stimulate circulation to surrounding areas.
3. Use appropriate barrier dressings, wound coverings, drainage appliances, and skin-protective agents for open/draining wounds
4. Demonstrate tepid sponge bath for fever
5. Instruct SOs in monitoring for moist or wet linens and replace them with clean and dry ones.
6. Reposition patient every 2
To broaden client knowledge on risk factors causing infection thus promoting cooperation on prevention measures through self monitoring and change in unhealthy habits
Assists body’s natural process of repair
To protect wound and surrounding tissues
Relieve fever and promote comfort from heat and
Improve circulation Moisture potentiates skin
breakdown
Enhances understanding and cooperation
After nursing interventions, client was able to:
1. Be free of cough, and fever by v/s within ranges of: T=36.5-3C, P=60-100bpm,R=1-20cpm,BP between 90/60mmHg and 140/90mmHg.
2. demonstrate deep breathing and coughing exercises correctly.
3. demonstrate proper hand washing and tepid sponge bath, proper wound and dressing care.
4. Performs early ambulation and frequent
69
hours involving client through client education and on desired positions in conjuction to other activities.
7. Encourage early ambulation
8. Encourage adequate nutritional intake and increase in fluids and protein intake.
9. Discuss importance of early detection of skin changes and complications.
10. reinforce health teachings on keeping wound and dressing clean and dry, proper wound splinting, proper hand washing, frequent change in positions and adequate intake of nutritional foods with increase proteins and fluids
11.Assess and document skin conditions, noting inflammation and drainage.
Promotes circulation and reduces risks associated with immobility.
To provide positive nitrogen balance to aid in healing and to maintain general good health
To monitor abnormalities and promote cooperation and understanding, commitment to plan of therapy and optimizing outcomes
Encourage self-care and reinforce importance of non-pharmacologic intervention on infection prevention
Can be a source of infection and may reveal infection (drainage, inflammation), monitor for early signs of infection and early management and prevention of condition
Informing the client and SO increases self-esteem on
changes in position as tolerated.
5. Performs correct wound splinting.
6. Increase in oral fluid and protein-rich food intake, and intake of balanced diet.
7. Identify risk factors for occurrence of infection correctly.
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12.Note signs and symptoms of sepsis (systemic infection): fever, chills, diaphoresis altered level of consciousness, positive blood cultures. Then instruct client and SO to monitor for s/s of: fever, chills, diaphoresis and altered level of consciousness like confusion.
13.Maintenance of sterile technique in performing invasive procedures.
14.Encouraging deep breathing, coughing exercises, position change.
15.Maintain adequate hydration, void frequently
16.Perform regular perineal care and proper drying
17.Emphasize importance of taking antibiotics as directed (e.x dosage, therapy length)
Dependent:10.Give Paracetamol 300mg
IVTT q4h RTC x 24 per
having role in care and increases cooperation in therapy from gained knowledge on monitoring Signs of systemic infection, knowledge by client and SO aids in improve nursing care and monitoring
To prevent spread of microorganisms, prevention on cross-contamination and defense against nosocomial infection
For mobilization of respiratory secretions.
To avoid UTI
To reduce UTI risk cause by moisture and poor hygiene.
Premature discontinuation of treatment when client begins to feel well may result to infection
To relieve fever
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doctor’s order11.Give Cefuroxime 750mg
IVTT q8h ANST (-)RTC per doctor’s order
To treat infection
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VII. PROGNOSIS
CRITERIA:
Good Poor
A. Response of the patient regarding the presence of the
pain after its management
B. Physiologic response of the body to disease process
C. Relief of symptoms associated with the disease
condition
D. Performance of the daily living of the patient during
confinement (e.g. eating, toileting, dressing, etc.)
E. Compliance of the patient to the medication and/ or
therapy
F. Adequacy of rest periods and sleep
G. Consumption of the patient with nutrition
H. Patient’s significant others’ behaviour regarding the
health teaching given by the health caregiver and the
physician
I. Attitude
J. Duration of Illness
K. Precipitating Factor
L. Nature of Problems
M. Predisposing Factors
N. Family Support
O. Level of Consciousness
CALCULATIONS:
Formula: amount # of (good/poor) x 100 = % (Percentile)
15
Amount of: Percentile
Good = 12 80%
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Poor = 3 20%
INTERPRETATION:
Since, patient is cooperative and its precipitating factors are modifiable, patient’s condition may have a good prognosis. Based on the criteria, 12 out of 15 or 80% accounts for good prognosis,3 out of 15 or 20% accounts for poor prognosis which shows that the patient is compliant to her medications and will have a good recovery.
VIII. DISCHARGE PLANM- Medication Instruct patient to follow right dose and timing of medication
and not to replace any medication without consultation to physician.
Report any adverse effects and drug/food-drug interactions to the physician.
Instruct patient to follow orders for take home medications upon discharge as prescribed by the physician.
E- Exercise Assist significant others on how to help the patient maintain physical activity, an exercise as well as how to prioritize activities and establish a balance between activities.
Perform exercises and activities tolerated by client.Encourage patient to do active range of motion such as rotating and
flexion of arms and legs.Instruct significant others to be watchful for any risk that may cause
injury to the patient.T- Treatment Perform proper wound care by maintaining aseptic technique to
prevent infection.Keep dressing intact and avoid wound exposure to prevent unwanted
harboring of microorganisms.Strict medication regimen.Discuss drug therapy to the patient and significant others.Instruct patient to keep updated with any follow-up
examinations/therapy/check-ups after discharge.Assure patient and significant others that they will be able to perform
home-based treatment properly. H- Health Teaching Indicate enough bed rest
Explain importance of medication complianceDiscuss to the patient and significant others the indication of the
prescribed medications, outcomes, dosages, contraindications and side effect.
Wash hands before and after performing wound care.O- Out-Patient; Follow-up
Inform the patient about when, where and what time is the next check-up. The next check-up is usually one week after discharge.
Instruct patient and significant others to report to the physician and/or health care personnel when unusualities are noted.
Stress out to the family to seek immediate consultation if adverse reaction of drugs occurs.
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Encourage them to carry out follow up diagnostic regimen.D- Diet Eat meals 3 times a day.
Discuss importance of taking vitamins and minerals.Instruct patient to ensure increase fluid intake at least 8 to 10 glasses
per day.S- Spirituality Encourage her to develop both the trust and faith in God.
Encourage prayers to the client in order for him to express his thoughts, endeavors, and feelings according to her beliefs.
IX. CONCLUSION
The proponents of this case study have gathered all relevant details
regarding the case herein about a 64 year old female diagnosed of
Nonfunctioning kidney secondary to urolithiasis and nephrolithiasis ,
admitted at NMMC. The health team involved in the case provided in conjunction
to the medical treatments, overall nursing management set to alleviate the
client’s condition and support the patient’s over all well being. The necessary
health teachings were also given to the patient and her watcher in order to
alleviate the signs and symptoms of the disease condition.
Implementation of relevant and effective nursing interventions to relieve
signs and symptoms were strictly observed so as to prevent or at least reduce
the risks of complications.
From what the group can surmise however the limitations on the
effectiveness of the provided nursing interventions rest on the grounds of the
presence of irreversible and inalterable factors such as advanced age and
preexisting medical conditions.
With this subsequent information, the persons involved in this study have
realized the significance of this case, its management and its overall impact on
affected clients. In line with this, the proponents worked hand in hand with each
other to help convey what has been researched and planned about the case.
X. RECOMMENDATION
In nursing practice, we recommend student nurses to regularly check and
monitor closely patient’s vital signs especially with patients like NQ that have
advanced age and are diagnosed with other medical conditions which may
75
aggravate the disorder, over all condition of the patient and prompt adherence to
safety precautions considering that the client is at risk for injury. Also follow up
patient’s medication supply for prompt timing of administration.
It is recommended for the healthcare team to:
Participate the client, family, significant others and members of the healthcare
team to establish client-centered goals directed toward promoting and restoring
the clients optimum state of health, preventing illness and providing rehabilitation.
Support client’s and family’s decisions regarding care.
Promote an environment conducive to maintenance or restoration of the client’s
ability to carry out activities of daily living.
Provide for continuity of care in the management of the disorder
Demonstrate caring behaviors in providing nursing care.
Assist other personnel to develop skills in providing nursing care.
Manage an environment that promotes client’s self-esteem, dignity, safety, and
comfort.
Student nurses and other health care providers should read further
number of books regarding Nonfunctioning kidney secondary to
urolithiasis and nephrolithiasis, be updated about the disease and
incorporate it with desired plan of care. This is to prevent patients with
Nonfunctioning kidney secondary to urolithiasis and nephrolithiasis from
developing severe complications, preserve patients’ health and promote
wellness.
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XI. BIBLIOGRAPHY
77
XII. APPENDIXA. Doctors Order
12/13/20106am >to operating room on call12/13/2010 post-op order4pm >to PACU S/P Nephrectomy right under EA-GETA
>monitor V/S q15mins until stable then q1hour>NPO>O2 inhalation @ 5LPM via face mask>IVF: PNSS 1L @ 30gtts/min>IVTTF: PNSS 1L@ 30gtts/min
Piggy back: PRBC 1”U” @ 30gtts/min PRBC 1”U” @ 30gtts/min TWC
>Meds: Cefuroxime 750mg IV q8hours (-)ANSTRanitidine 500mg IV q8hoursMetoclopromide 10g IV PRN for vomitingParacetamol 300mg IV q6 RTC starting tomorrow 6amDiphenhydramine 50mg slow IV push for pruritus
>I & O q1 refer if < 50cc/hr>Morphine precaution, offer if BP <90/60, HR < 50bpm, RR < 12cpm>watch out transfusion reaction>suction secretions PRN>refer accordingly>thank you
5:55PMBP: 130/90 >May transport pt. to wardHR: 110RR: 20O2 Sat: 96%12/14/20107:30 am >pt. CBC now(-) fever >change dressing
>cont. meds>ambulate>D5LR 1L @ 30gtts/min>pls. refer
12/15/20107AM >DAT
>continue IVF and meds>Change dressings>V/S q 4hours>I & O q shift>refer accordingly.
78
B. NURSES NOTES
12/12/10 3-113 pmD> received on bed
>Scheduled for Nephrectomy Right on Dec . 13, 2010 A > Vital signs taken and recorded
>Intake and output measured and recordedDAT >Served and consumed share with fair appetite
>encouraged verbalization of feelings of discomfort>encouraged relaxation technique and deep breathing exercises>adequate rest periods provided>kept watched for any unusualities>needs attended
R >on bed resting>endorsed
12- 12-10 11-711pm D > Received asleep on bed
>Poor eye contact A > Instructed to do deep breathing exercises
>encouraged to verbalize feelingsNPO >instructed and maintined
>for nephrectomy right on 12-13-10 with consent> Morning care done> Hemodialysis started with D5LR regulated at 30gtts/min
R > on bed resting>off to OR on Call
12-13-10 7-3 D > Received on bed
>with D5LR 1L @ 900cc level regulated @ 30gtts/min A >V/S taken and recorded
>visited by Dr.E with orders carried out by NOD> for Nephrectomy Right today with consent signed.
NPO >maintained>still to secure blood for OR use>I&O measured and recorded>kept watched for any unusualities>to OR on call
11:00am> brought to OR per stretcher with above IVF going on12/13/10 7-3 OR notes12:15pm>received from ward per stretcher, awake, conscious and coherent with IVF going on D5LR 1L
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100cc level infusing well on Left arm.>consent signed for nephrectomy>ashered to operating table safely and comfortably in supine position>hooked to monitor with initial V/S of BP:140/70mmHg,PR:90bpm,RR:20cpm,SP O2:100%
12:30 >oxygenation given via face mask>with IVF D5LR 1L consumed and followed up D5LR 1L infusing well.
12:35 >Epidural anesthesia inducted by Dr.L12:40 >general anesthesia inducted by Dr.L
>with IVF D5LR consumed and followed-up with Volvulen 500cc infusing well @ left arm
12:45 >Endotracheal tube inserted>foley catheter French 14 inserted aseptically and attached to urobag draining well.>placed on Left Lateral position with support in placed>final Skin Prep done aseptically>draped accordingly>counting of sponges, instruments and needles done and recorded.
1:25 pm>operation started by Dr.L assisted by Dr.M and Dr.L>bleeding clamped and cauterized
1:45pm>with IVF of Volvulen 500cc consumed and followed-up with PNSS 1Linfusing well on Left arm2:40pm>blood transfusion started @ pts blod type A+ with serial no. 2K10-12-7912 segment
no.648X7600 as side drip.>endorsed to 3-11 shift nurse with complete counting of sponges and instruments
12/13/10 OR notes 3-113:00pm >received on OR table on Left Lateral position ongoing operation in general anesthesia
>with IV fluid of PNSS 1L @ 500cc level regulated @ KVO rate>with side drip of ongoing blood transfusion of 1”U” PRBC with Serial no. 2K10-12-7912 blood type “A” regulated @ 30gtts/min>with endotracheal tube attached to 4LPMO2>with epidural catheter in place>With foley catheter attached to urobag infusing well
80
>initial counting of sponges, sharps, and instruments complete – surgeon informed>suturing done – by layer>operation ended>epidural cath rulled out by Dr.L
4:35 >extubated>post-op wound dressing-applied>post-op care done
4:43 >transported to PACU with same IVF ongoing; with ongoing blood transfusion>with foley catheter>with post-op wound dressing applied>endorsed to PACU NOD with complete documents attached.
3-11 PACU nurses notes
4:40pm >received from OR per stretcher, conscious and coherent, not in respiratory distress, with PNSS
1L @ 10gtts/min @30cc level @ Left arm infusing well.>V/S checked and recorded>BP monitored and recorded>status post nephrectomy Right under general anesthesia>O2 inhalation @ 6L/min, face mask administered>hooked to O2 Sat monitor>with post-op wound dressing dry and intact>kept flat on bed, safely and comfortably>With foley catheter to urobag drainage with Pus>post anesthetic care done
NPO >maintained>with PRBC “U” type “A+” with serial #2k10-12-7912 segment #698Y7660 transported after proper crossmatching and blood typing @ 30gtts/min going on>endorsed to A2F1
OR memo OR surgical safety checklist Sponge count Anesthesia record PACU monitoring
12/14/10 7-37:15amD>received awake from PACU per stretcher accompanied by relatives
81
>with post operative wound @ right flank >with ongoing IVF of D5LR @ KVO rate infusing well >with ongoing blood transfusion of PRBC 1 unit A+ @ 20cc level with serial
#2k10-12-7912 on side drip of IVF
>with foley catheter attached to urobag draining well with yellow colored urine A>ushered to bed safely and comfortably
>vital signs taken>above blood product consumed and followed up with PRBC 1 unit with serial
number 2K10-12 1884 segment #48456913 regulated @ 30gtts/min infusing well >observed for early transfusion reaction
NPO >maintained>kept dry and comfortable>endorsed resting in bed with ongoing blood transfusion
Dec 14, 2010 3-11 shift3:00pmD> Received awake lying on bed with #3 D5LR @ 30gtts/min @ 800 cc
>with postoperative dressing on Right flank clean and dry A >needs attendedClear Liquids> maintained
> turned to sides, back kept dry>kept rested>observed for unusualities>encouraged ambulation
R >well rested
11-711pm D > Received asleep on bed
>with IVF of D5LR I L @ 850 cc level regulated @ 30 gtts/min>with post-op wound
A>instructed to keep post op dressing dry and intact @ all timesClear liquids >liquid in moderate amount with aspiration precaution
>nursing care done>on bed resting>observed
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C. Intake and Output / Vital Signs
DATE TIME BP PR RR TEMP. Intake IVF OutputDec. 11, 2010
11-7 110/80 70 19 38.2
3-11 100/80 80 19 38.5 350 - 40011-7 110/80 75 16 35.8 600 - 400
Dec.12, 2010
7-3 130/90 81 19 36.5 600 - 500
3-11 130/70 76 18 36.5 500 - -11-7 120/80 68 22 36.7 200 - 70
Dec. 13,2010
3-11
8 140/98 72 16 37 NPO
Blood – 20 D-3009 130/80 76 18 36.5 IVF - 600
10 120/70 76 18 36.711-712mn 120/80 80 20 35.7
NPO
Blood - 230 8001 120/90 82 19 37.6 IVF - 150
2 130/80 87 22 37.13 130/90 84 20 37.54 130/90 86 21 36.05 130/80 83 20 36.5
Dec. 14, 2010
7-3
10 120/90 76 20 36.5 240 550 02 110/90 77 18 37.03 150/100 79 20 37.0 450 750 3503-117pm 150/100 80 19 36.511-7
150/90 80 19 36.0 400 650 350140/90 83 20 36.5
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