Case study on Urolithiasis

1. SRN NOORHAZAMIN HAMID
NURSING EDUCATION SERVICES

2. At the end of this session, you
will be able to :
 State the definition of urolithiasis.
 List the etiology of urolithiasis.
 Identify the pathophysiology of
urolithiasis.
 State the sign & symptom of
urinary tract stone.

3. LEARNING OBJECTIVES cont.
 Identify the complication of urinary
tract stone.
 Understand regarding treatment of
urinary tract stone.
 Identify the nursing intervention &
appreciate the nursing care for
urinary tract stone patient.

5. PATIENT’S PROFILE
 MR. T
 MALE
 44 YEARS OLD
 TRAINER

6. PATIENT’S PROFILE
 WHEEL CHAIR
 ANXIOUS
 ALLERGICS - NIL
 D.O.A 4/6/14 @ 2100 Hr

7. Mr T was admitted to
5XX-1 with complaint
of right loin to groin
pain X 1/7 under Dr N.

9. PATIENT’S PROFILE
 MEDICAL HISTORY
 HPT
 SURGICAL HISTORY
 NIL
 FAMILY MED HISTORY
 HPT (Both parents)

10. CURRENT MEDICATION
 Tab Amlodipine 1/1 Daily

12. VITAL SIGN
 TEMPERATURE : 37.2˚C
 BLOOD PRESSURE : 160/95mmHg
 PULSE : 70 bpm
 RESPIRATION : 21 bpm
 PAIN SCORE : 2
Weight : 71kg

13. ACTIVITY DAILY LIVING
 Anxious and asking many questions.
 Bowel movement alternate day
 Constipation (on high fiber diet)

14. PHYSICAL EXAMINATION

15. S/B Dr N in A&E
 Light breakfast at 6am CM then fast
 Ural 1/1 TDS
 Norgesic 1/1 TDS
 IV Dynastat 40mg BD
 IV Pethidine 25mg STAT & repeat
another 25mg IV if pain not relief in 15
minutes

16. Continue….
 IM Pethidine 75mg 6 hourly PRN
 IM Maxalon 10mg 6 hourly PRN
 For right URS / lithotripsy CM
 ECG
 OT / Anaest / Consent

30. Stone Types
• Calcium stones (60-80%)
–Most primarily calcium oxalate
– Less often, calcium phosphate
• Struvite (magnesium ammonium phosphate)
(10-15%)
• Uric acid (if pure, then radiolucent) (5-10%)
• Cystine (1%)
• Other (indiavir, triamterene, etc) (1%)

38. ↓ fluid volume / substance that prevent
crystallization (citrate, magnesium,
nephrocalcin / uropontin)
Supersaturated urine
↑ urinary concentration of calcium oxalate
/ calcium phosphate / uric acid
Crystallization of urine
Stone formation

40. SIGN & SYMPTOMS
• Pain in abdomen, flank or groin
(sudden onset, very severe and
intermittent colic)
• Haematuria
• Decreased urine volume
• Nausea and vomiting

41. CLINICAL MANIFESTATIONS
• Manifestations depend on the
presence of obstruction,
infection, and edema. Symptoms
range from mild to
excruciating pain and
discomfort.

42. Ureteral Colic (Stones Lodged in
Ureter)
• Acute, excruciating, colicky, wavelike pain,
radiating down the thigh to the genitalia
• Frequent desire to void, but little urine
passed; usually contains blood because of the
abrasive action of the stone (known as
ureteral colic)

43. Stones in Renal Pelvis
• Intense, deep ache in costovertebral region
• Hematuria and pyuria
• Pain that radiates anteriorly and downward
toward bladder in female and toward testes in
male
• Acute pain, nausea, vomiting, costovertebral
area tenderness (renal colic)
• Abdominal discomfort, diarrhea

44. Stones Lodged in Bladder
• Symptoms of irritation associated with urinary
tract infection and hematuria
• Urinary retention, if stone obstructs bladder
neck
• Possible urosepsis if infection is present with
stone

46. RISK FACTORS
• Reduction of fluid intake
• Recurrent UTI
• Hyperuricemia-caused medication
• Inflammatory bowel syndrome
• History of gout
• Poor micturation habit
• Male

48. COMPLICATION
• Pyelonephritis
• Urosepsis
• Chronic renal failure

51. SURGICAL PROFILE
• Lymphocyte
- 17.7% (20-45%)
• Glucose
- 6.8 (3.9 – 6.1mmol/L)
• Potassium
- 3.3 (3.5 – 5.5mmol/L)

52. URINE FEME
• Bacteria
- Occasional (Nil)

53. CTU
• Right VUJ stone ~5mm with
obstructive hydronephrosis

57. DRUGS
INWARD
DATE
ORDERED
DATE
OFF
IV Pethidine 25mg STAT &
rpt another 25mg if pain
not relief after 15 min
4/6/14 4/6/14
IM Pethidine 75mg
6hourly PRN
4/6/14 6/6/14
IM Maxalon 10mg
6hourly PRN
4/6/14 6/6/14
IV Dynastat 40mg BD 4/6/14 6/6/14

58. DRUGS
INWARD
DATE
ORDERED
DATE
OFF
Ural 1/1 TDS 4/6/14 6/6/14
Norgesic 1/1 TDS 4/6/14 6/6/14
IV Sulperazone 1gm BD 5/6/14 6/6/14
Tab Prednisolone 10mg
BD
5/6/14 6/6/14
Tab Hytrin 2mg ON 5/6/14 6/6/14

67. NURSING DIAGNOSIS
 Alteration in comfort :
pain related to obstructive
ureteric stone.

68. NURSING DIAGNOSIS
 Alteration in emotional
status anxiety related to
surgical management and
treatment.

69. NURSING DIAGNOSIS
 Knowledge deficit
related to management of
blood pressure control.

70. NURSING DIAGNOSIS
 Potential infection
related to intravenous
cannulation.

72. NURSING DIAGNOSIS
 Potential bleeding
related to surgical
intervention.

73. NURSING DIAGNOSIS
 Potential infection
related to surgical
intervention.

75. DRINK :
• Drink 2.5 – 3 litres H₂O per day
(neutral pH)
• Take 2 glasses of water at bedtime
to prevent urine concentration at
night
• Avoid excessive intake of milk or
alkaline drink

76. DIET :
• Minimize protein intake (60g/day) to
decrease urinary excretion of calcium &
uric acid
• Minimize sodium (3-4g/day) because
sodium competes with calcium for
reabsorption in kidneys
• Avoid oxalate-containing food (spinach,
strawberry, tea, peanut & wheat bran)

77. EXERCISE :
• Regular exercise
• Avoid strenuous activity leading to
sudden increase body temperature
that lead to excessive sweating &
dehydration

78. URINARY TRACT INFECTION :
• Maintain personal hygiene
• Seek treatment immediately at 1st
sign & symptom of UTI