Download Ameilia Hernandez Situation: 48 yo female admitted complaining of

Ameilia Hernandez
Situation: 48 yo female admitted complaining of sporatic pain x 1 week in L flank region with a sudden
onset accompanied by nausea and vomiting. She has had a purposeful weight loss of 30 lbs. consuming
high energy protein drinks.
Background:
UTI's in past states about 1-2 per year. HTN GERD
Social History: Divorced. She has 3 children all alive and well. She works at a local bank as a teller. She
admits to ethanol consumption of mild to moderate nature.
Assessment: Allergic to PCN, Sulfa full code
Head: Normocephalic, normal hair distribution, face symmetrical, appears anxious no edema
Neuro: A&Ox4, PERRLA, +EOM’s
Thorax: AP: Transverse 1:2, breathing non labored, lungs CTA, HR reg no murmurs S1 S2
Abdomen, rounded, but non distended, no prominent venous pattern, no masses or pulsations noted, +
guarding unable to palpate due to pain
UE & LE: WNL
Vitals: T 90 degree F, BP 162/92, P 96, RR 24 O 2 sat 98% RA
Diagnostics:
CBC: RBC 4.9, HGB 14gm/dL, HCT 42%, PLT 325,000 WBC 15,000 Neutrophils 69% bands 18%, lymph
10% Mono , eos 2%, baso 1%
UA: + protein, wbc, rbc, leukocyte esterase, nitrates
KUB suggestive of L ureterlithiasis
chest xray negative
IVP+ for L ureteral lithiasis with L hydronephrosis
1. Highlight all abnormal data pertaining to this patient’s condition on your
worksheet.
2. What risk factors does Ms. Hernandez have?
TABLE 46-11 RISK FACTORS FOR THE DEVELOPMENT OF URINARY TRACT CALCULI
Metabolic: Abnormalities that result in increased urine levels of calcium, oxaluric acid, uric acid,
or citric acid
Climate: Warm climates that cause increased fluid loss, low urine volume, and increased solute
concentration in urine
Diet: Large intake of dietary proteins that increases uric acid excretion
Excessive amounts of tea or fruit juices that elevate urinary oxalate level.
Large intake of calcium and oxalate
Low fluid intake that increases urinary concentration
Genetic Factors Family history of stone formation, cystinuria, gout, or renal acidosis
Lifestyle: Sedentary occupation, immobility
3. Define the difference between and ategrade IVP and a retrograde IVP
Antegrade: Evaluates upper urinary tract when there is allergy to contrast media or decreased
renal function and when abnormalities prevent passage of a ureteral catheter. Contrast media
may be injected percutaneously into renal pelvis or via a nephrostomy tube that is already in
place when determining tube function or ureteral integrity after trauma or surgery.*
Nursing Interventions: Explain procedure and prepare patient as for IVP.
Watch for signs of complications (e.g., hematuria, infection, hematoma).
Retrograde pyelogram: X-ray of urinary tract taken after injection of contrast material into
kidneys. It may be done if an IVP does not visualize the urinary tract or if patient is allergic to
contrast media or has decreased renal function. A cystoscope is inserted and ureteral catheters
are inserted through it into renal pelvis. Contrast media is injected through catheters.*
Nursing Interventions: Prepare patient as for IVP. Inform patient that pain may be experienced
from distention of pelvis and discomfort from cystoscope. Inform patient that anesthesia may be
given for procedure.
Mrs. Hernandez is diagnosed L ureteral lithiasis with L nephrosis
Recommendation
IV 0.9% NS to run at 250 mL/hr x 4 hours then decrease to 125mL/hr
Regular Diet as tolerated
MS 10 mg IM every 4 hours PRN pain
Acetmoniophen 650 mg PO for fever > 101F
Lovastatin 10 mg PO every evening
Aspirin 81 mg PO every evening
I/O strain all urine
Schedule extracorporeal shock-wave lithotripsy (ESWL)
Consult cardiology for cardiac clearance for possible OR tomorrow
4. What is the purpose of straining the urine?
Id the composition of the stome
5. What is the priority nursing intervention for a patient with this condition?
1st:Treating the symptoms of pain, infection, or obstruction as indicated for the individual patient.
At frequent intervals, opioids are typically required for relief of renal colic pain.
Many stones pass spontaneously.
However, stones larger than 4 mm are unlikely to pass through the ureter, and the patient may
require insertion of a ureteral stent to prevent obstruction from passage of stone fragments.
2nd:Evaluate the cause of the stone formation and the prevention of further development of
stones. Information to be obtained from the patient includes family history of stone formation,
geographic residence, nutritional assessment including the intake of vitamins A and D, activity
pattern (active or sedentary), history of periods of prolonged illness with immobilization or
dehydration, and any history of disease or surgery involving the GI or genitourinary tract.
6. Discuss what ESWL is.
In extracorporeal shock-wave lithotripsy (ESWL), a noninvasive procedure, the patient is
anesthetized (spinal or general) and placed in a water bath. Anesthesia is required to ensure that
the patient's position is maintained during the procedure. Fluoroscopy or ultrasound is used to
focus the lithotripter on the affected kidney, and a high-voltage spark generator produces highenergy acoustic shock waves that shatter the stone without damaging the surrounding tissues.
The stone is broken into fine sand and excreted within the urine
7. Discuss potential complications of this procedure.
Complications are rare but they include hemorrhage, sepsis, and abscess formation.
Postoperatively, the patient usually complains of moderate to severe colicky pain. The first few
times that the patient urinates, the urine is bright red. As the bleeding subsides, the urine
becomes dark red or turns a smoky color. Antibiotics are usually administered for 2 weeks to
reduce the risk of infection.
Hematuria is common after lithotripsy procedures. A self-retaining ureteral stent is often placed
after the procedure to facilitate passage of sand (shattered stone) and prevent sand buildup
within the ureter, which might lead to obstruction. The stent is typically removed within 2 weeks
following lithotripsy. If a stone is large or positioned in the mid or distal ureter, additional
treatment, such as surgery, may be necessary.
8. Does a consent need to be signed? If yes, why?
Yes, invasive
Mrs. Hernandez voids and a stone is found and sent to the lab for analysis and was found to be
a purine calculi.
Mrs. Hernandez returns to her room after the procedure with a ureterostomy after an
unsuccessful attempt to dissolve the stone. She will go to surgery in 2 days.
9. Devise a plan of care for Mrs Hernandez who is recovering from ESWL and has a
ureterostomy tube in place.
The ureteral catheter is placed through the ureters into the renal pelvis. The catheter is inserted either (1)
by being threaded up the urethra and bladder to the ureters under cystoscopic observation or (2) by
surgical insertion through the abdominal wall into the ureters. The ureteral catheter is used after surgery
to splint the ureters and to prevent them from being obstructed by edema. Record the urine volume from
the ureteral catheter separately from other urinary catheters. The patient is usually kept on bed rest
while a ureteral catheter is in place until specific orders indicate that ambulation is permissible. The selfretaining ureteral catheter is often inserted after a lithotripsy procedure has been done or when ureteral
obstruction from adjacent tumors or fibrosis threatens renal function. The double-J ureteral catheter is
frequently used and allows the patient to ambulate. One end coils up in the kidney pelvis, while the other
coils in the bladder.
Check the placement of the ureteral catheter frequently, and avoid tension on the catheter. The
catheter drains urine from the renal pelvis, which has a capacity of 3 to 5 mL. If the volume of
urine in the renal pelvis increases, tissue damage to the pelvis will result from pressure.
Therefore do not clamp the ureteral catheter. If the physician orders irrigation of the ureteral
catheter, strict aseptic technique is required. If output is decreased, the physician should be
notified immediately. Drainage should be checked often (at least every 1 or 2 hours). It is normal
for some urine to drain around the ureteral catheter into the bladder. Accurate recording of urine
output from both the ureters and the urethral catheter is essential. Sometimes a ureteral
catheter may be used as a stent and is not expected to drain. It is important to check with the
physician as to the type of catheter and what to expect.
10. Discuss the dietary changes she will need to make to avoid this complication in the
future.
Depending on the type of calculi, modify the diet to decrease foods that are high in the substance
that is the cause of the calculi. Listed below are foods that are moderate or high in purine,
calcium, or oxalate content.
Purine *
High: Sardines, herring, mussels, liver, kidney, goose, venison, meat soups, sweetbreads
Moderate: Chicken, salmon, crab, veal, mutton, bacon, pork, beef, ham
Calcium
High: Milk, cheese, ice cream, yogurt, sauces containing milk; all beans (except green beans),
lentils; fish with fine bones (e.g., sardines, kippers, herring, salmon); dried fruits, nuts; Ovaltine,
chocolate, cocoa
Oxalate
High: Dark roughage, spinach, rhubarb, asparagus, cabbage, tomatoes, beets, nuts, celery,
parsley, runner beans; chocolate, cocoa, instant coffee, Ovaltine, tea; Worcestershire sauce
11. Compare and contrast the different diets and the types of stones they form (chart).
Depending on the type of calculi, modify the diet to decrease foods that are
high in the substance that is the cause of the calculi. Listed below are foods
that are moderate or high in purine, calcium, or oxalate content.
Purine *
High: Sardines, herring, mussels, liver, kidney, goose, venison, meat soups,
sweetbreads
Moderate: Chicken, salmon, crab, veal, mutton, bacon, pork, beef, ham
Calcium
High: Milk, cheese, ice cream, yogurt, sauces containing milk; all beans
(except green beans), lentils; fish with fine bones (e.g., sardines, kippers,
herring, salmon); dried fruits, nuts; Ovaltine, chocolate, cocoa
Oxalate
High: Dark roughage, spinach, rhubarb, asparagus, cabbage, tomatoes, beets,
nuts, celery, parsley, runner beans; chocolate, cocoa, instant coffee, Ovaltine,
tea; Worcestershire sauce
To manage an obstructing stone, have the patient drink adequate fluids to avoid dehydration.
Forcing excessive fluids is not advised as this has not proved effective to facilitate
spontaneous “passage” (excretion) of stones via the urine. Forcing fluids may also increase the
pain associated with this episode or precipitate development of renal colic.
After an episode of urolithiasis, a high fluid intake (approximately 3000 mL/day) is recommended to
produce a urine output of at least 2 L/day. High urine output prevents supersaturation of minerals (i.e.,
dilutes the concentration of urine) and promotes excretion of the minerals within the urine, thus
preventing stone formation. Increasing the fluid intake is particularly important for patients at risk for
dehydration, including those who (1) are active in sports, (2) live in a dry climate, (3) perform physical
exercise, (4) have a family history of stone formation, and/or (5) work outside or in an occupation that
requires a great deal of physical activity. Water is the preferred fluid. Consumption of colas, coffee, and
tea should be limited because high intake of these beverages tends to increase rather than diminish the
risk of recurring urinary calculi.33