57592160 caase-study-chy-tambok

Vicente Sotto Memorial Medical Center
B. Rodriguez St., Cebu City
Nursing Service Division
Training Office
A CASE REPORT
ON
PATIENT M.A., 43 YEARS OLD, DIAGNOSED WITH URETEROLITHIASIS
PROXIMAL THIRD, RIGHT S/P LAPAROSCOPIC URETEROLITHIASIS
UTILIZING VIRGINIA HENDERSON’S HUMANE HOLISTIC CARE THEORY
Submitted by:
Chyzyz Y. Semblante
Ward VI: Female, Pediatric Surgical Ward
April 15, 2011 – July 15, 2011

CHAPTER I
INTRODUCTION
M.A., 43 years old, female, married, residing in Buaya, Lapu-Lapu City, Cebu,
was admitted for the first time at Vicente Sotto Memorial Medical Center
(VSMMC) last May 1, 2011 for the complaints of sudden sharp pain in the
costovertebral area radiating to the hypogastric region, right with a pain scale of
7/10. Patient arrived to the hospital conscious, responsive, coherent and with
ease in respiration via private vehicle accompanied by her husband and
personnel from Lapu-Lapu City Hall. She was admitted under the services of Dr.
Victor Cabrera, Jr. under the Department of Urology and Dr. Aponesto under the
Department of General Surgery with a hospital number of 240377 and a case
number of 128757.
Rationale
Establishing good and trustful nurse-client relationship aids in data collection
pertaining to the client’s perception, practices, and management of health. More
intensive data can be gathered the moment the researchers have earned the
client’s trust and support thus opening obtaining clear and precise data for a
comprehensive case study. Factors such as coherence, responsiveness, and
patient cooperation contributed much in acquiring health history. The case was
selected for the reason that primary data can be obtained in a manner by which
the client has no difficulty in recalling past events and shows interest in offering
her time to answer questions that supply information in areas that need to be
assessed.
Incidence of kidney stones, or urolithiasis, is on the rise worldwide, with highest
growth projected in Asia and other geographical regions with hot, dry climates.
Adding to this trend is a global rise in the incidence of diseases linked to an
elevated risk of urolithiasis such as obesity, hypertension and diabetes.
Furthermore the lifestyle today has greatly increased the risk of developing
ureterolithiasis but due to the lack of sufficient knowledge of the disease, actions
towards lifestyle modification which is one of the single most effective method of
prevention and cure of ureterolithiasis are compromised. It is also one of the poor
habits of Filipinos to seek medical consult for any disease when they are unable
to bear the pain and are closer to severe complications already.
The mere existence of these data may not mean anything to most of the Filipinos
nowadays that are at a greater risk of acquiring ureterolithiasis but the researcher
who have chosen to conduct this case study know better than to neglect it. The
researcher, has conducted this study to increase our knowledge in
ureterolithiasis especially on how vast it can affect other organ functioning.
Furthermore, the researcher would like to analyze the active problems of patient
M.A. which may be an underlying result of her ureterolithiaisis. The researcher
chose this case because of its wide recognition and its increased number of

occurrence in the area. Likewise, pursuing this study would help the patient in
terms of managing her disease; future researchers and other members of the
health care team to consider the efficiency and effectivity of the intervention done
in order to manage the disease. In the process of learning and practicing, all the
members of the health care team seek to inculcate the right attitude within
themselves as they care for the patient.
Overview of the Disease
Urinary Calculi
Urinary calculi (urolithiasis) are calcifications in the urinary system. Commonly
called stones, calculi form primarily in the kidney (nephrolithiasis), but they can
form in or migrate to the lower urinary system. Ureterolithiasis can be used to
describe the condition of having stones in the ureter.
Types of Calculi
Calcium. Calcium is the most common substance and is found in up to 90% of
stones. Calcium stones are usually composed of calcium phosphate or calcium
oxalate. They may range from very small particles, often called “sand” or “gravel,”
to giant staghorn calculi, which may fill the entire renal pelvis and extend up into
the calyces.
Oxalate. The second most frequent stone is oxalate, which is relatively insoluble
in urine. Its solubility is affected only slightly by changes in the urinary pH. The
mechanism of oxalate availability is unclear but may be closely related to diet.
The disease is most common in areas where cereals are a major dietary
component and least common in dairy farming regions.
Struvite. Struvite stones, also called triple phosphate, are composed of
carbonate apatite and magnesium ammonium phosphate. Their cause is certain
bacteria, usually Proteus, which contain enzyme urease. This enzyme splits urea
into two ammonia molecules, which increases urine pH.
Uric Acid. Uric acid stones are caused by increased urate excretion, fluid
depletion, and a low urinary pH. Hyperuricuria is the result of either increased
uric acid production or the administration of uricosuric agents.
Cystine. Cystinuria is the result of a congenital metabolic error inherited as an
autosomal recessive disorder. Cystine stones typically appearf during childhood
and adolescence; development in adults is very rare.
Xanthine. Xanthine stones occur as a result of a rare hereditary condition in
which there is a xanthine oxidase deficiency. This crystal precipitates readily in
urine.
Etiology

The two primary causative factors are (1) urinary stasis and (2) supersaturation
of urine with poorly soluble crystalloids. Infection, foreign bodies, failure to empty
the bladder completely, metabolic disorders, and obstruction in the urinary tract
contribute to the formation of calculi as well.
Inhibitor substances, such as citrate and magnesium, appear to keep particles
from aggregating and forming crystals; a lack of inhibitors increases risk of stone
development. Not only does the deficiency of inhibitors predispose the client to
calculi, but there are many anti-inhibitors in the urine, such as aluminum, iron,
and silicone. Certain medications may induce calculus formation, such as
acetazolamide, absorbable alkalis (e.g., calcium carbonate and sodium
bicarbonate), and aluminum hydroxide. Massive doses of Vitamin C increases
urinary oxalate levels.
Risk Factors
- Immobility and a sedentary lifestyle, which increases stasis
- Dehydration, which leads to supersaturation
- Metabolic disturbances that result in an increase in calcium or other ions
in the urine
- Previous history of urinary calculi
- Living in stone belt areas
- High mineral content in drinking water
- A diet high in purines, oxalates, calcium supplements, animal proteins
- UTIs
- Prolonged indwelling catheterization
- Neurogenic bladder
- History of female genital mutilation
Clinical Manifestations
Clinical features vary with size, location and etiology of calculi.
- Pain: sharp, severe, sudden onset caused by movement of the calculus
and consequent irritation. Depending on the site of the stone, this pain
may be either renal or ureteral colic. Renal colic originates deep in the
lumbar region and radiates around the site and down toward the testicle in
male and the bladder in female. Ureteral colic radiates toward the genitalia
and thigh.
- Nausea and vomiting
- Grunting respirations, elevated blood pressure and pulse
- Diaphoresis and anxiety
- Fever and chills
- Hematuria: gross or microscopic
- Urinary frequency, hesitancy and dysuria
- Abdominal distention
- Pyuria
- Oliguria and anuria

Diagnosis
The diagnosis of bladder stone includes urine analysis, ultrasound, x rays or
cystoscopy (inserting a small thin camera into the urethra and viewing the
bladder). In the past a study called the intravenous pyelogram was frequently
used to assess the presence of kidney stones. This test involves injecting a dye
which is passed slowly into the urinary system. X ray images are then obtained
every few minutes to determine if there is any obstruction to the dye as it is
excreted into the bladder. Today, Intravenous Pyelogram has been replaced at
most rural health centers by Ct scans. CT scans are more sensitive and can
identify very small stones not seen by other tests.
Medical Management
Conservative or medical management is appropriate if there is no obstruction, if
the pain can be managed, if the client can be hydrated with oral fluids, and if the
stone is less than 5mm.
- Increase fluids. Increasing fluid intake facilitates passage of small stones
and prevents the development of new ones. Encourage clients to increase
fluids to 3 to 4 L daily, unless contraindicated, to ensure urine output of 2.5
to 3 L daily.
- Reduce pain. The client usually requires treatment with opioids and
antispasmodic agents. Opioids such as morphine sulfate are given
intravenously or intramuscularly to control moderate to severe pain.
Nonsteroidal anti-inflammatory drugs may also be effective.
Antispasmodic agents, such as oxybutinin chloride (Ditropan), are very
effective for relieving and controlling colic pain associated with spasm of
the ureter.
- Prevent stone recurrence. Diet modifications and medications may be
required to prevent further calculus formation in clients who return with
repeated stones.
Surgical Management
About 20% of stones require additional treatment with shock wave lithotripsy or
endourologic or surgical procedures. Open surgery is used only for small
percentage of clients who cannot be successfully treated with lithotripsy or
endourologic procedures.
Endourologic Procedures
Depending on the position of the calculus, cystoscopy may be done. Small
stones may be removed transurethrally with a cystoscope, ureteroscope, or
ureterorenoscope. Additionally, 1 or 2 ureteral catheters or stents may be
inserted past the stone. At times, a continuous chemical irrigation may be used to

dissolve uric acid, struvite, and cystine stones. Larger stones may be crushed
with an instrument called a lithotrite (stone crusher) to facilitate removal.
Lithotripsy
Laser Lithotripsy: Lasers are used together with a uereroscope to remove or
loosen impacted stones.
Extracorporeal Shock Wave Lithotripsy: ESWL is the use of sound waves
applied externally to break up stones in the kidney or uereter. The client may be
strapped to a frame in a water bath or secured on a table, depending on the type
of lithotripsy equipment used. The client is offered conscious sedation or general
anesthesia. The procedure lasts 30-50 minutes with administration of 500 to
1500 shock waves.
Percutaneous Lithotripsy: Involves the insertion of a guide percutaneously
(throught the skin) under fluoroscopy near the area of the stone. An ultrasonic
wave is aimed at the stone to break it into fragments.
Open Surgical Procedures
Ureterolithotomy: is the surgical removal of a stone from the ureter through a
flank incision for higher stones or an abdominal incision for lower ones. A
Penrose drain and ureteral catheter are usually placed postoperatively for
healing and drainage of urine.
Cystolithotomy: removal of bladder calculi through a suprapubic incision, is
used only when stones cannot be crushed or removed transurethrally.
Pyelolithotomy: a stone is removed from the renal pelvis.
Nephrolithotomy: a stone is removed from the renal calyx.

CHAPTER II
STATEMENT OF OBJECTIVES
General Objectives
This study aims to utilize Virginia Henderson’s Humane Holistic Care Theory in
the care of patient M.A. diagnosed with ureterolithiasis, right to evaluate efficacy
and effectiveness of nursing interventions rendered to patient and to share
knowledge to the patient regarding the promotion, prevention and treatment of
her disease.
Specific Objectives
This study aims to specifically:
- Share information regarding ureterolithiasis it’s etiology, risk factors,
clinical manifestations, management and prevention
- Assess patient’s history using Gordon’s Functional Health Patterns to
identify signs and symptoms of the disease manifested by patient and the
effects of her condition on her activities of daily living
- Review the anatomy and physiology of the involved organs
- Identify actual and risk problems manifested by the patient and implement
nursing interventions under the 3 different roles of a nurse (substitutive,
complementary, and supplementary) using Virginia Henderson’s Humane
Holistic Care Theory
- Determine significant highlights of the patient’s status in her admission in
the Ward
- Impart health teachings regarding the patient’s medications and how to
prevent recurrence of her condition

CHAPTER III
PATIENT’S PROFILE
Client in Context
M.A., 43 years old, female, married, residing in Buaya, Lapu-Lapu City, Cebu,
was admitted for the first time at Vicente Sotto Memorial Medical Center
(VSMMC) last May 1, 2011 for the complaints of sudden sharp pain in the
7/10. Patient arrived to the hospital conscious, responsive, coherent and with
ease in respiration via private vehicle accompanied by her husband and
personnel from Lapu-Lapu City Hall. She was admitted under the services of Dr.
Victor Cabrera, Jr. under the Department of Urology and Dr. Aponesto under the
Department of General Surgery with a hospital number of 240377 and a case
number of 128757.
History of Present Illness:
Six months PTA, patient noted that she had an iced tea colored urine and had an
onset of sudden pain in the costovertebral area radiating to the hypogastric
region, right with a pain scale of 5/10 relieved by limitation of movements. No
other symptoms associated. Patient went to Mactan Doctor’s Hospital Out-patient
Department for consult under the service of Dr. Rey Pino. Interventions done
were ultrasound of the KUB, diet medication: limit intake of calcium, acidic and
oily foods and some unrecalled medications. According to patient, ultrasound
result showed that she had inflamed kidneys. Patient was advised for a follow up
check-up but she didn’t return. Patient claimed that her condition can be
tolerated.
Four months PTA, patient had another onset of sudden sharp pain in the
8/10 and was admitted for four days at Mactan Doctor’s Hospital under Dr.
Barcenas. According to patient, she was diagnosed with inflammation of the
kidneys due to stones and obstruction. Patient was advised to undergo
Laparoscopic Ureterolithotomy. Patient refused since her money was not
enough. Patient was prescribed with Ural one sachet 3 times a day. Other
medications were unrecalled. After discharge, patient claimed that her condition
was fine but pain was still noted.
Patient went to Sacred Heart Hospital for a second opinion under Dr. Velasco for
the same complaints. She was prescribed with Acalka 2 tablets thrice a day;
Rowatinex 2 tablets twice a day; Sambong one glass twice a day; Shi Lin Tong 7
tablets thrice a day. Patient was advised for a check-up every 3 months. Patient
claimed that she felt that the pain was lesser on the flank area, right with a pain
scale of 3/10.

Hours PTA, patient had another onset of sudden sharp pain in the costoverteral
area radiating to the back with a pain scale of 7/10 which prompted this
admission.
Previous Hospitalization:
October 25, 1995 – Patient was admitted at Tojong Maternity Hospital in Looc
Lapu-Lapu City, Cebu due to labor pains. Patient delivered via NSD a live baby
boy. She stayed in the hospital for 2 days. Medications taken were unrecalled.
Patient was discharged with improved condition.
May 8, 2001 – Patient was admitted at Tojong Maternity Hospital in Looc Lapu-
Lapu City, Cebu due to labor pains. Patient delivered via NSD a live baby girl.
She stayed in the hospital for 2 days. Medications taken were unrecalled. Patient
was discharged with improved condition.
January 3, 2011 – Patient was admitted for four days at Mactan Doctor’s Hospital
under Dr. Barcenas due to onset of sudden sharp pain in the costovertebral area
radiating to the hypogastric region, right with a pain scale of 8/10. According to
patient, she was diagnosed with inflammation of the kidneys due to stones and
obstruction. Patient was advised to undergo Laparoscopic Ureterolithotomy.
Patient refused since her money was not enough. Patient was prescribed with
Ural one sachet 3 times a day. Other medications were unrecalled. After
discharge, patient claimed that her condition was fine but pain was still noted.
Past Health History
Patient is non-hypertensive, non-diabetic, non-asthmatic, non-smoker and non-
alcoholic drinker. She has no history of illegal drug abuse. She has no known
food and drug allergies. Patient claims that she has no heredofamilial diseases
both on the paternal and maternal side. Childhood illnesses include mumps and
measles.
GORDON’S FUNCTIONAL HEALTH PATTERNS
I. Health Perception – Health Management Pattern
Patient describes health as, “importante jud” and illness as, “normal lang kay
magkasakit man jud ang tao.” When patient was asked to rate herhealth before
onset of condition, she rated it as 10/10 with 10 as the highest and one as the
lowest and verbalized, “grabe kaayo ko ka energetic.” During the onset of
condition, she rated her health as 4/10 and verbalized, “dili naman gud kaayo ko
maka trabaho tungod sa sakit.” She doesn’t have regular check-ups but after she
was diagnosed she visited Dr. Velasco every month at her clinic in Sacred Heart

Hospital. Patient can’t recall if she was given any inmmunizations and verbalized,
“sa bukid man gud ko nagdako murag wala man siguro ko na bakunahan.” But,
patient claims that she was given complete Tetanus Toxoid shots during her
pregnanacy. Patient practices self medication only when she has fever and takes
Saridon 1 tab/day. Patient is non-compliant with her medications and verbalized,
“wala na nako palita ang Acalka kay mahal.” Instead, patient only bought the
herbal medications prescribed, Sambong one glass twice a day and Shilintong 7
tablets thrice a day. Patient does not practice BSE since she does not know how
to perform the procedure.
II. Nutritional Metabolic Pattern
Height: 5’1”
Weight (before admission): 67 kgs.
Weight (during admission): 56 kgs.
Ideal Body Weight: 54.94kgs.
Body Mass Index: 23.3 (Normal)
Client’s Diet 24 – Hour Recall Usual Diet
Breakfast (8am) 1 cup rice, 1 serving
of fried fish, 1 glass of water
(8am) 1 cup rice, 1 serving of
fish tinola, 1 cup of coffee or
luy-a powder
Lunch (1pm) 1 cup rice, 1 serving
of ground pork, 1 glass of
water
(12pm) 1-2 cups rice, 1 serving
of vegetables, 1 glass of water
Dinner (7pm) 1 cup rice, 1 serving
of pork humba, atchara, 1
glass of water
(7pm) 1-2 cups of rice, 1 serving
of grilled fish, 1 glass of water
Snacks (3pm) sweet
potatoes/banana, 1 glass of
water
(10am and 4pm) sweet
potatoes/banana/bread, 1 glass
water
Her food preferences are grilled fish and vegetable soup. Food storage, source
and preparation are done by the patient. She doesn’t have any food intolerance.
She doesn’t take any Vitamins and Supplements. Before onset of condition, her
fluid intake was 5-6 glasses/day. She also drinks 3 cups of 3 in 1 coffee in a day
and rarely drinks carbonated beverages. After the diagnosis, her fluid intake was
3L/day. She drinks coffee from (sinugbang mais na ginaling) twice a day. During
hospitalization, patient’s recommended diet was DAT. Her fluid intake was
2L/day.
Patient does not have any regular dental check-ups. Dental regimen is tooth
brushing. She has one upper molar tooth missing and 2 lower molar teeth
missing. Patient has no difficulty chewing or swallowing.

III. Elimination Pattern
Before hospitalization, patient defecates once a day usually early in the morning,
stool color is yellowish – brown and well formed. Patient claims that she never
experienced constipation. Patient does not use any laxatives and enema.
According to patient, when she experiences diarrhea she takes Diatabs one
capsule as needed. During hospitalization, patient claims that there were no
changes in bowel elimination.
Before onset of condition, patient voids twice a day with 140ml/episode. Color of
urine is yellow. Patient claims that she has not experienced nocturia, pain upon
urination, hematuria, UTI and hemorrhoids.
After patient was diagnosed, she voids 12 times a day with 140-150mL/episode.
Color of urine is light yellow-clear. Patient claims that she still experiences
nocturia but has not experienced pain upon urination, hematuria, UTI and
hemorrhoids.
During hospitalization, patient voids 12 times a day with 140-150mL/episode.
Color of urine is light yellow-clear. Patient claims that she still experiences
nocturia but has not experienced pain upon urination, hematuria, UTI and
hemorrhoids. Post-operatively, she had an FBC attached to urobag with output of
60-100mL/hour.
IV. Activity – Exercise Pattern
Patient is a housewife. On her typical day, she wakes up at 4:30am and then she
cooks breakfast, cleans the house and takes a bath. Around 5am, she opens
their sari-sari store. At 7am, she eats her breakfast and stays at their store to
attend to their customers. She eats lunch at 12 noon and resumes her activities
at the sari-sari store. Around 6pm, she cooks dinner and then resumes her
activities at their sari-sari store. At 7pm, she eats her dinner and resumes her
activities at the store. Around 9pm, she closes their sari-sari store and then she
watches TV. Around 10pm, she sleeps. Patient does not need assistance with
her ADL’s. Patient does not have any regular exercise, as verbalized, “wala jud
koy exercise kay naa raman ko pirmi mag bantay sa tindahan namo.” Her
recreational activities are watching TV, listening to radio dramas and spending
time with her family. According to patient after the onset of condition, she has
difficulties lifting up heavy objects, doing the laundry and walking fast because of
the pain she experiences on her right flank area. During hospitalization, patient
claims that there were no changes in her activity exercise pattern.
V. Sleep – Rest Pattern
Before hospitalization, patient usually sleeps around 10pm and wakes up at
4:30am. She usually had a sleeping duration of 6 hours. Patient claims that she

doesn’t use any sleeping aids and verbalized, “makatulog rajud ko dayon inig
higda nako sa katre.” She does not take any drugs or sedatives to facilitate
sleep. She usually prays before sleeping. Patient uses two pillows and a blanket
when sleeping. She doesn’t have any difficulties falling asleep. During the onset
of condition, patient experiences nocturia and quality of sleep is not straight.
When asked if she feels well rested upon waking up, patient verbalized, “maayo
raman gihapon akong katog bisan pag mag-mata mata ko para mangihi.”
During hospitalization patient sleeps around 7pm and wakes up around 4am.
Patient verbalized, “sayo ko makatulog diri kay laay man kaayo wala tay laing
lingaw matulog ra.” Patient takes nap at around 2pm with the duration of half an
hour. Patient still experiences nocturia and quality of sleep is not straight but
claims that she feels well rested upon waking up.
VI. Sexuality – Reproductive Pattern
Patient had her menarche at the age of 12. Last menstrual period was April 25,
2011. Patient has regular menstrual cycles with moderate flow lasting for 4-5
days and sometimes experiences dysmenorrhea. She usually consumes 2 pads
of sanitary napkins in a day. She can’t recall her first sexual contact but shares
that it was with her husband. Patient has no history of STD. She shared that her
husband uses condom. Before onset of condition, patient engages in coitus with
husband twice a month but during the onset of condition their sexual activities
stopped because of the pain she feels in her right flank area. Patient claims that
her condition has affected her sexual activities and verbalized, “wala najud, zero
jud ta anang dapita tungod kay sakit man akong may hawak dapit.” Patient’s
obstetrical score is G2P2002. Patient does not perform BSE and does not have any
Pap smear and mammogram check-ups.
VII. Cognitive – Perceptual Pattern
Patient is oriented to time, place, people and has an intact sensory status. Her
highest educational attainment is graduating high school. She can speak English,
Tagalog and English. When asked if she understands her illness, she verbalized,
“O mu maning sakit ang ubos sa akong likod kay ni hubag man akong kidneys
kay tungod sa bato.” Patient was able to recall recent events and past event that
happened. Patient has an intact judgment, when asked if VSMMC will caught
fire what would she do, patient verbalized, “mudagan jud ko ug mayo para
makagawas sa hospital.” Patient uses eyeglasses with a grade of 150/100. She
does not use hearing aids and has no problems with her sense of taste, smell,
and tactile sensations.

VIII. Role – Relationship Pattern
Genogram
Paternal Side Maternal Side
LEGEND:
- Male
- Female
P - Patient
D - Dead
Patient has been married to her husband for 15 years. Patient described their
relationship as harmonious and verbalized, “mag-away pud mi usahay pero
natural raman jud na basta minyo mo.” According to the patient, she has many
roles in the family; she is incharge of their budget; the harmonizer and the
disciplinarian. Patient has 2 kids which are both in school so she sees to it that
she can attend to the needs of her children. Patient claims that she has a good
relationship with her friends. She also shared that she is very contented and
happy with the relationship she has built with her family and friends.
During hospitalization, her husband took care of her since her children can’t visit
the ward and she also had a few visits from her friends. According to patient, she
misses her children because she’s not used to being away from them.
D D D D
D D
Unrecalled
P

IX. Self Perception – Self Concept Pattern:
When asked to describe herself, patient gladly shared that she is God-fearing,
simple, hardworking and independent. When I asked her husband to describe the
patient, he shared that his wife is very caring, loving, strong and most of all very
generous and verbalized, “mu bitaw na na inlove jud ko niya.” She also shared
that raising her two children is the greatest accomplishment in her life. She
verbalized, “bahala nag pobre mi basta malipayon lang ang among pagpuyo ug
maayo lang ang lawas, ok najud ko ana.” Patient claims that she is satisfied with
her life. According to patient, her illness did not affect her body image because
she can still do things by herself.
X. Coping – Stress Tolerance Pattern
Patient defined stress as problems that everyone faces. She verbalized, “kanang
ma stress ta kung naa tay mga problema kay mag sige man ta ug huna-huna
ana.” Patient claims that she is little bit stressed because she’s hospitalized esp.
with the bills that they have to pay. Patient verbalized that, “ma stress pud ko day
basta magpa badlong akong mga anak.” According to patient, when she has
problems she usually talks to the people involved. Her family and friends are her
support system whenever she has problems. She relieves her stress through her
recreational activities such as watching TV, listening to radio dramas, relaxing
and seeking God through prayers and novenas.
XI. Value – Belief Pattern
Patient is a Christian. She is an active member of the Christian Alliance
Fellowship. She attends mass every Wednesdays and Sundays and also joins
novenas. Patient strongly believes in God and shared that He is the source of her
strength. Patient prays everyday esp. at night before she sleeps. Her current
condition has not affected how she practices her faith in anyway.
Environmental History
Patient has been living in Buaya Lapu-Lapu City for 15 years. It is a one- storey
house made with mixed materials. It has 2 bedrooms, 4 doors and 5 windows.
They have distinct and separate spaces for their kitchen, dining, living and flush
source of water is from a deep well. Garbage disposal is through burning since
the garbage truck can’t reach their place. There are 5 people living in the house.
They don’t own a pet. The house is accessible to the public market, church,
Barangay hall and transportation vehicles. Distance from the main road is
approximately 5 minutes, from the nearest grocery store 10 minutes, from the
nearest drug store is 5 minutes, from the health center is 15 minutes when
walking and from the hospital 15 – 25 minutes, from the church 15 minutes and
from the fire station 30 minutes when travelling. Patient describes the
neighborhood as congested but with a peaceful and orderly situation.

CHAPTER IV
PATHOPHYSIOLOGY
Anatomy and Physiology
The Urinary System
Kidney
The kidneys are small, dark, red organs, with a kidney bean shape, which lie
against the dorsal wall in a retroperitoneal position in the superior lumbar region.
The kidneys extend from the T12 to L3 vertebra thus they receive protection from
the lower part of the rib cage. Because it is crowded by the liver, the right kidney
is positioned slightly lower than the left. An adult kidney is about 12cm (5in) long,
6cm (2.5in) wide, and 3cm (1in) thick, about the size of a large bar of soap. It is
convex laterally and has a medial indentation called the hilus, where the ureters,
the renal blood vessels and nerves, enter or exit the kidney. Atop each kidney is
an adrenal gland, which is part of the endocrine system and is distinctly separate
organ functionally. A fibrous, transparent renal capsule encloses each kidney. In
a living person, a fatty mass, the adipose capsule, surrounds each kidney and
helps hold it in place against the muscles of the trunk wall. Coronally sectioned,
the outer region, which is light in color, is the renal cortex. Deep to the cortex is a
darker reddish-brown area, the renal medulla. The medulla has many triangular
regions with a striped appearance, the medullary pyramids. The broader base of
each pyramid faces toward the cortex; its tip, the apex, points toward the inner
region of the kidney. The pyramids are separated by extensions of cortex-like
tissue, the renal columns. Medial to the hilus is a flat, basinlike cavity, the renal
pelvis. This is continuous with the ureter leaving the hilus. Extensions of the
pelvis, calyces, form cup-shaped areas that enclose the tips of the pyramids. The
calyces collect urine, which continuously drains from the tips of the pyramids into
the renal pelvis. Urine then flows from the pelvis into the ureter, which transports
it to the bladder for temporary storage.
Blood Supply
Approximately, one quarter of the total blood supply of the body passes through
the kidneys each minute. The arterial supply of each kidney is the renal artery.

As the renal artery approaches the hilus, it divides into segmental arteries. Once
inside the pelvis, the segmental arteries break up into lobar arteries, each of
which gives off several branches called interlobar arteries, which travel through
the renal columns to reach the cortex. At the medulla-cortex junction, interlobar
arteries give off the arcuate arteries, which curve over the medullary pyramids.
Small interlobular arteries then branch off the arcuate arteries and run outward to
supply the cortex tissue. Venous blood draining from the kidney flows through
veins that trace the pathway of the arterial supply but in a reverse direction –
interlobular veins to arcuate veins to interlobar veins to the renal vein, which
emerges from the kidney hilus.
Nephrons
Nephrons are the structural and functional unit of the kidneys and are
responsible fro forming urine product. Each nephron consists of two main
structures: a glomerulus which is a knot of capillaries and a renal tubule. The
closed end of the renal tubule is enlarged and cup-shaped and completely
surrounds the glomerulus. This portion of the renal tubule is called the glomerular
or bowman’s capsule. The inner layer of the capsule is made up of highly
modified octopuslike cells called podocytes. Podocytes have long branching
processes called pedicels that intertwine with one another and cling to the
glomerulus. Because openings, the so-called filtration slits, exist between their
extensions, the podocytes from a porous or holey, membrane around the
glomerulus. The rest of the tubule is about 3cm (1.25in) long. As it extends from
the glomerular capsule, it coils and twists (PCT, Proximal Convoluted Tubule)
before forming a hairpin loop (Loop of Henle) and then again becomes coiled and
twisted (DCT, Distal Convoluted Tubule) before entering a collecting tubule
called the collecting duct. Most nephrons are called cortical nephrons because
they are located almost entirely within the cortex. In a few cases, the nephrons
are called juxtamedullary nephrons because they are situated close to the cortex-
medulla junction, and the loops of Henle dip deep into the medulla. The collecting
ducts, each of which receives urine from many nephrons, run downward through
the medullary pyramids, giving them their striped appearance. They deliver the
final urine product into the calyces and renal pelvis. The glomerulus is both fed
and drained by arterioles. The afferent arteriole, which arises from an interlobar
artery, is the feeder vessel and the efferent arteriole receives blood that has
passed through the glomerulus. Both arterioles have high resistance and the
afferent arteriole has a larger diameter than the efferent. Blood pressure in the
glomerulus is extraordinarily high. This extremely high pressure forces fluid and
solutes (smaller than proteins) out of the blood into the glomerular capsule. Most
of this filtrate (99%) is eventually reclaimed by the renal tubule cells and returned
to the blood in the peritubular capillary beds. The second capillary bed, the
peritubular capillaries arises from the efferent arteriole that drains the glomerulus.
Unlike the high pressure glomerulus, these capillaries are low pressure, porous
vessels that are adapted for absorption instead of filtration.

Urine Formation
Urine formation is a result of three processes: filtration, reabsorption, and
secretion. Filtration is a nonselective, passive process. The filtrate that is formed
is essentially blood plasma without blood proteins. Both blood proteins and blood
cells are normally too large to pass through the filtration membrane. As long as
the systemic blood pressure is normal, filtrate will be formed. Besides wastes and
excess ions that must be removed from the blood, the filtrate contain many useful
substances (including water, glucose, amino acids, and ions) which must be
reclaimed from the filtrate and returned to the blood. Tubular reabsorption begins
as soon as the filtrate enters the proximal convoluted tubule. The tubule cells
take up needed substances from the filtrate and then pass them out their
posterior aspect into the extracellular space, from which they are absorbed into
peritubular capillary. Tubular secretion is essentially reabsorption in reverse.
Some substances such as hydrogen and potassium ions and creatinine, move
from the blood of the peritubular capillaries through the tubule cells or from the
tubule cells themselves into the filtrate to be eliminated in urine.
Ureters
The ureters are slender tubes each 25 to 30cm (10 to 12in) long and 6mm (1/4
in) in diameter. Each ureter runs behind the peritoneum from the hilus of a kidney
to the posterior aspect of the bladder. The superior end of each ureter is
continuous with the pelvis of the kidney. Essentially, the ureters are
passageways that carry urine from the kidneys to the bladder. Once urine has
entered the bladder, it is prevented from flowing back into the ureters by small
valvelike folds of bladder mucosa that flap over the ureter openings.
Urinary Bladder
The urinary bladder is a smooth, collapsible, muscular sac that stores urine
temporarily. It is located retroperitoreally in the pelvis just posterior to the pubic
symphysis. If the anterior of the bladder is scanned, three openings are seen –
the two ureter openings and the single opening of the urethra, which drains the
bladder. The smooth triangular region of the bladder of the base outlined by
these three openings is called the trigone. The trigone is important clinically
because infections tend to persist in this region. The bladder wall contains three
layers of smooth muscle, collectively called the detrussor muscle and its mucosa
is a special type of epithelium, transitional epithelium. As urine accumulates, the
bladder expands and rises in the abdominal cavity. Its muscular wall stretches
and the transitional epithelial layer thins allowing the bladder to store more urine
without substantially increasing its internal pressure. When the bladder is really
distended, or stretched by urine, it becomes firm and pear-shaped and may be
felt just above the pubic symphysis. Although urine is formed continuously by the
kidneys, it is usually stored in the bladder until its release is convenient.
Urethra
The urethra is a thin walled tube that carries urine by peristalsis from the bladder
to the outside of the body. At the bladder-urethra junction, a thickening of the

smooth muscle forms the internal urethral sphincter, an involuntary sphincter that
keeps the urethra closed when urine is not being passed. A second sphincter,
the external urethral sphincter, is fashioned by skeletal muscle as the urethra
passes through the pelvic floor. This sphincter is voluntarily controlled. The
length and relative function of the urethra differ in two sexes. In females it is
about 3 to 4cm (1 ½ in) long and its external orifice lies anteriorly to the vaginal
opening. Its function is to conduct urine to the body exterior.
RAA mechanism (Renin Angiotensin Aldosterone)
Three conditions that will signal the start of the RAA mechanism: a decrease in
sodium, decrease blood pressure, and a decrease in blood volume. This will then
lead to a decrease in renal perfusion. The juxtaglomerular apparatus in the
kidneys will then release Renin in the blood which will stimulate the liver to
convert Angiotensinogen into Angiotensin I. In the lungs, an enzyme called
angiotensin converting enzyme will convert Angiotensin I to Angiotensin II.
Angiotensin II is a potent vasoconstrictor causing an increase in peripheral
resistance. Angiotensin II will also increase aldosterone levels, increasing sodium
reabsorption and water retention. These events result to an increase in sodium,
blood volume and blood pressure.

CHAPTER V
COURSE IN THE WARD
Physical Examination
Date Performed: May 9, 2010 - 11:30AM
General Appearance: examined patient sitting on bed awake, conscious,
responsive, coherent, with ease in respiration, without IVF, and with the ff V/S:
BP = 110/80mmHg, PR = 70bpm, RR = 20cpm, T = 37.3o
C/axilla
SKIN: brown complexion, pinched-up skin returns immediately to original
position, no pigmentation, dry and warm to touch, no lesions, no rashes, smooth
and moist skin, no tenderness, no edema, no jaundice, no cyanosis, able to
sense light touch and pain
HEAD AND HAIR : normocephalic, smooth and firm scalp, long, straight, shiny,
black, evenly distributed hair, no dandruff, no masses, no lice infestation, no
tenderness upon palpation, no lesions, symmetrical facial features, (-)Chvostek’s
sign (no facial muscle spasms when tapped), no circumoral tingling
EYES: symmetrical in shape and size, eyebrows and eyelashes are black equally
distributed, pinkish palpebral conjunctivae, clear bulbar conjunctivae, anicteric
sclerae, brown iris, no abnormal discharges, no lesions, (+) Corneal reflex, full
peripheral vision, (+) Pupils Equally Round and Reactive to Light and
Accommodation, (+) Cardinal gazes, can read nameplate at 1 ft distance, cannot
read small newspaper print 14 inches from the eyes.
EARS: symmetrical, pinna is positioned in line with outer canthus of the eye, skin
color is consistent with the facial skin color, smooth skin, minimal cerumen, no
nodules, pinna is non tender upon palpation, recoils after being folded, no
inflammation, no lesions, can hear and repeat whispered words at 3 ft distance,
able to hear and follow instructions
NOSE and SINUSES: symmetrical and proportional to other facial features, nasal
septum is straight, at midline and perforated, nares are patent, no nasal flaring,
no congestion, no discharges or bleeding noted, clear maxillary and frontal
sinuses upon transillumination test, no tenderness upon palpation, no swelling,
no lesions
MOUTH and TONSILS: no halitosis, pinkish symmetrical lips neither cracked nor
dry, no lesions, pinkish tongue with rough texture, and is soft and at midline,
uvula in midline with no swelling, no tonsil swelling, smooth, soft, pinkish buccal
mucosa with no lesion or ulcerations, pinkish and moist gums with no ulcerations,
no dentures but has orthodontic appliance, 33 slightly yellowish teeth, (+) gag
reflex, able to speak

NECK and LYMPH NODES: symmetrical, able to rotate, flex, and hyperextend
neck, no neck vein engorgement, no lesions, non tender, non palpable cervical
lymph nodes, no signs of infection such as inflammation, redness, and warmth
THORAX and LUNGS: equal chest expansion, no lesions, non tender, no
masses, no adventitious breath sounds heard upon auscultation, equal tactile
fremitus, muffled egophony, bronchophony, whispered pectoriloquy, resonance
upon percussion.
CARDIAC and PERIPHERAL CIRCULATION: distinct s1 and s2 heart sounds
upon auscultation, no murmurs, no chest pain, heart rate at 70 bpm with regular
rhythm, +3 palpable peripheral pulses left hand, +2 peripheral pulses right hand ,
CRT < 2 seconds on upper and lower extremities,
Pulse Strength
0 - Absent
+1 - Weak, thready, difficult to palpate, obliterated with pressure
+2 - Diminished pulse, can’t be obliterated
+3 - Easy to palpate, full pulse, can’t be obliterated
+4 - Strong bounding pulse
BREASTS AND AXILLAE: Round with right breast slightly lager than left breast,
pendulous, dark brown areola, round, oval, everted nipple, no abnormal
discharges noted, no masses upon palpation, non palpable axillary lymph nodes
ABDOMEN: flat, no lesions, no scars, normoactive borborygmous sounds
auscultated at right lower quadrant, no palpable masses, no rebound tenderness,
umbilicus at midline, (-) fluid wave test, (+) kidney punch, no organomegaly
GENITOURINARY: grossly female, pinkish labia majora and labia minora as
verbalized, no abnormal discharges, no lesion, no masses, no swelling, no pain
upon urination, no itching, no rashes, urine output: 1,200ml per shift
RECTUM: no rashes, no hemorrhoids, no abnormal discharges, no itchiness
EXTREMITIES: Erect posture, no malformations, steady, smooth and
coordinated gait, bilateral, firm and developed muscles, no bony deformities,
symmetrical, clean, firm and short fingernails and toenails, smooth, hard, and
pinkish nail beds, pinkish palm and soles, no edema in both hands and feet, full
ROM on both upper and lower extremities, strong grip on both hands, no nail
clubbing, no ingrown toenails, no swelling, no lesions, no scars on both upper
and lower extremities, no carpopedal spasms on hands and feet, (-)Trousseau’s
sign.

Muscle Strength
R L
5/5 5/5
5/5 5/5
SCALE FOR GRADING MUSCLE STRENGTH
5 – Full ROM against gravity, full resistance
4 – Full ROM against gravity, some resistance
3 – Full ROM with gravity
2 – Full ROM with gravity eliminated
(passive motion)
1 – Slight Reaction
0 – No Reaction
NEUROLOGIC ASSESSMENT:
MENTAL/ CEREBRAL: awake, conscious, responsive, coherent, oriented to
time, place and person, speech not slurred, tense less, appropriately dressed,
and is well groomed. She performs daily hygiene such as taking a bath, changing
clothes, brushing of teeth, and washing of hands before and after eating and
going to the bathroom without assistance. She is able to speak English, Filipino,
and Visayan dialect. She is able to smile and frown, and able to recall long term
memories like year of menarche and birthdays, and short term memories like
what she ate that day and the day before (as confirmed by SO), does not have
short attention span, and when asked what she would do if the hospital caught
fire, she simply stated that she would run outside the hospital.
SENSORY: Able to identify things such as cotton when touched to face, (+)
Graphesthesia (letter J and L), (+) Stereognosis (with pen), (+) Kinesthesia (up
and down), (+) 2 – point discrimination. She is able to differentiate between
sharp(pencil tip) from blunt(pencil eraser), able to feel light touch and pain when
pinched on both upper and lower extremities, can feel vibratory sensation.
MOTOR/CEREBELLAR: Able to perform finger - nose test, thumb opposition
test, can button and unbutton shirt smoothly, no significant swaying on Romberg
test
CRANIAL NERVE TESTING:
CN 1 (Olfactory): able to identify smell of banana
CN 2 (Optic): can read name plate of the nurse trainee at 1 ft distance, cannot
read small newspaper print at 14 inches away from eyes
CN 3 (Occulomotor): can lift eye lids, can look up and down, + PERRLA
CN 4 (Trochlear): can look side to side, + PERRLA

CN 5: (Trigeminal): S: can feel sharp and dull objects on both sides of face; M:
intact facial expression at both side of face, can masticate, can clench teeth
CN 6 (Abducens): (+) Cardinal gaze, (+) PERRLA
CN 7 (Facial): S: able to identify taste (anterior 2/3 of the tongue – sweet, sour
and salty) when eyes are closed, M: able to smile and frown, raise eyebrows
symmetrically, can puff out cheeks
CN 8 (Auditory): able to hear whispered words at 3 ft distance
CN 9 (Glossopharygneal): (+) gag reflex, able to identify taste (posterior 1/3 of
the tongue - bitter), able to swallow
CN10 (Vagus): (+) Gag reflex, bilateral and symmetrical rise of soft palate and
uvula upon saying “ah”, able to swallow and cough and talk
CN 11 (Accessory): able to shrug shoulder against resistance
CN12 (Hypoglossal): able to protrude tongue at midline and move it from side to
side and up and down
DEEP TENDON REFLEXES
(+2) biceps reflex, (+2) triceps reflex, (+2) brachioradialis reflex, (+2) patellar
reflex, (+2) Achilles Reflex bilaterally
SCALE FOR GRADING REFLEX RESPONSES:
0 – No Reflex Response
+1 – Minimal Activity
+2 – Normal Response
+3 – More Active than Normal
+4 – Maximal Activity (Hyperactive)
Date Performed: May 10, 2010 - 1:00PM
responsive, coherent, with ease in respiration, with IVF 1 PNSS 1L regulated @
20gtts/min infusing well at right hand, and with the ff V/S: BP = 110/80mmHg, PR
= 76bpm, RR = 20cpm, T = 36.8o
C/axilla
Significant Findings:
EYES: cannot read small newspaper print 14 inches from the eyes
MOUTH AND TONSILS: no dentures but has orthodontic appliance, 33 slightly
yellowish teeth
CARDIAC and PERIPHERAL CIRCULATION: +2 peripheral pulse right hand
Pulse Strength
0 - Absent

ABDOMEN: (+) kidney punch sign
CN 2 (Optic): cannot read small newspaper print at 14 inches away from eyes
Date Performed: May 11, 2011 – 10:00AM (Day 1 S/P Laparoscopic
Ureterolithotomy)
30gtts/min infusing well at right hand, with T-tube draining at lumbosacral area,
with FBC attached to urobag, and with the ff V/S: BP = 120/80mmHg, PR =
83bpm, RR = 22cpm, T = 37.2o
C/axilla
EYES: pale palpebral conjunctiva, cannot read small newspaper print 14 inches
from the eyes
MOUTH AND TONSILS: pale, dry lips with sore on the lower lip, no dentures but
has orthodontic appliance, 33 slightly yellowish teeth
Pulse Strength
0 - Absent
ABDOMEN: presence of T- tube draining at lumbosacral area
GENITOURINARY: presence of FBC attached to urobag
EXTREMITIES: IVF attached to right hand, pale nailbeds, palms and soles of
feet
Muscle Strength
R L
5/5 5/5

4/5 4/5
(passive motion)
0 – No Reaction
Date Performed: May 12, 2011 – 10AM
30gtts/min infusing well at left hand, with T-tube draining at lumbosacral area,
and with the ff V/S: BP = 120/80mmHg, PR = 88bpm, RR = 23cpm, T =
36.9o
C/axilla
EYES: pale palpebral conjunctiva, cannot read small newspaper print 14 inches
from the eyes
MOUTH AND TONSILS: pale, dry lips with sore on the lower lip, no dentures but
has orthodontic appliance, 33 slightly yellowish teeth
Pulse Strength
0 - Absent
feet
Muscle Strength

R L
5/5 5/5
4/5 4/5
(passive motion)
0 – No Reaction
Date Performed: May 13, 2011 – 10AM
30gtts/min infusing well at left hand, with T-tube draining at lumbosacral area,
and with the ff V/S: BP = 120/80mmHg, PR = 80bpm, RR = 21cpm, T =
37.0o
C/axilla
EYES: cannot read small newspaper print 14 inches from the eyes
MOUTH AND TONSILS: pale lips with sore on the lower lip, no dentures but has
orthodontic appliance, 33 slightly yellowish teeth
Pulse Strength
0 - Absent
feet

Laboratory Findings
Complete Blood Count
Purpose: Blood test that helps in determining certain blood disorders,
inflammation, infection and inherited disorders. It evaluates the three major types
of cells in blood: red blood cells, white blood cells, and platelets. The CBC is a
frequently ordered inpatient and outpatient basic screening and diagnostic test
that provide information about the hematologic system and many other systems.
It is also used in monitoring routine physical exam and in diagnosis of wide range
of conditions and disease of children and adults.
Test Result (4/15/11) Reference
WBC 4.4 4.8 – 10.8/uL
RBC 3.90 F: 4.2 – 5.4/uL
HGB 10.9 F: 12 – 16 g/dL
HCT 32.2 F: 37 – 47%
MCV 82.7 27 – 31 fL
MCH 28.0 33.0 – 37.0 pg
Platelet 232 130 – 400/uL
Neutrophils 47.1 40.0 – 74.0%
Lymphocytes 43.2 19.0 – 48.0%
Monocytes 7.5 3.4 – 9.0%
Eosinophils 2.0 0.00 – 7.0%
Basophils 0.2 0.0 – 1.5%
RDW-CV 16.44 11.5 – 14.5%
MPV 7.0 7.2 – 11.1 fL
Implication:
Since patient is going to undergo surgery, the CBC provides valuable information
about the blood and to some extent the bone marrow, which is the blood-forming
tissue. The CBC is used as a preoperative test to ensure both adequate oxygen
carrying capacity and hemostasis. A decrease in the patient's RBC components
may be due to her tortuous aorta as shown in her chest x-ray since the aorta is
the largest blood vessel in the body. It carries freshly oxygenated blood out of the
heart so that it can be distributed to the circulatory system. In most people, the
aorta follows a relatively straight path. In people with tortuous aorta, the vessel
may be twisted or distorted. This can cause blockages in blood flow, leading to
medical complications as a result of poor circulation.

Prothrombin Time
Purpose: Prothrombin time (PT) measures the time it takes for the plasma of
your blood to clot.
Result
Patient (sec) 12.0 sec
Patient Activity 100.0%
Patient (INR) 0.9
Control (sec) 13.4
Control (% activity) 83.9%
Implications: The result has no significant findings but since the patient needs to
undergo surgery, the prothrombin time is used as a preoperative test to ensure
that when a person bleeds (by injury or surgery) her body launches a coagulation
cascade.
Bleeding and Clotting Time (4/15/11)
Purpose: This test measures the time taken for blood vessel constriction and
platelet plug formation to occur.
Result Normal Values
Bleeding time (Simplate
Method)
4.5 minutes 2.3 – 9.5 minutes
Clotting time (Slide Method) 3.45 minutes 2 – 6 minutes
Implication: The result has no significant findings but since the patient needs to
undergo surgery, the bleeding and clotting time is used as a preoperative test to
ensure that she has an effective clotting process to avoid unnecessary blood
loss.
Blood Chemistry (4/15/11)
Purpose: To evaluate fluid electrolyte and acid-base balance and related
neuromuscular, renal and adrenal functions
Result Normal Range
FBS 69.9mg/dL 60.0 – 100.0
Creatinine 1.23mg/dL 0.60 – 1.50
Implication: No significant findings within normal limits.
Electrocardiographic Report (4/15/11)

Purpose: It is a noninvasive routine examination of the electrical activity of the
heart that is used to reflect underlying heart conditions. Regular heart
movements are controlled by a complex set of electrical impulses that direct the
upper and lower heart chambers to contract and relax rhythmically. When these
electrical activities are interrupted or misguided, the arrhythmia can be symptoms
of heart diseases. Furthermore, the impulses can also show signs of structural or
metabolic changes like enlargement or hypoxia of cardiac muscle.
Diagnosis: Sinus rhythm within normal limits.
Radiology Report
Purpose: X-ray is done to demonstrate any cartilage abnormalities, abnormal
bone growth, and to demonstrate the location and size of the organs.
Chest X-ray PA (4/15/11)
Examination Findings: Lung fields are essentially clear. Heart is not enlarged.
Pulmonary vascular markings are within normal limits. Tracheal air column is at
midline. Aorta is tortuous. Both hemidiaphragm and costophrenic sulci are intact.
The visualized osseous are unremarkable.
Impression: Essentially clear lung fields; Tortous Aorta
X-ray Kidneys, Ureter and Bladder (KUB) (5/2/11)
Examination Findings: There is a 2.1 calcific density in the right lumbar region at
the level of the L4 vertebrae along the sparse of the ureter. The lumbar spine and
pelvis show no significant bony abnormalities.
Impression: Consider ureterolithiasis, right. Suggest KUB ultrasound.
Drug Study
1. Tramadol
Class: Centrally acting opioid analgesic
Action: Binds to mu – opioid receptors and inhibits the reuptake of
norepinephrine and serotonin
Indication: Relief of moderate to moderately severe pain
Contraindications: Patient’s hypersensitive to drug or other opioids; in
breastfeeding women; and in those with acute intoxication from alcohol,
hypnotics, centrally acting analgesics, opioids or psychotropic drugs
Side effects: Sedation, dizziness, vertigo, headache, confusion, somnolence,
hypotension, nausea, vomiting, urine retention, diaphoresis, rash, respiratory
depression
Nursing Considerations:

o Monitor patient’s vital signs.
o Assess patient’s level of pain and then reassess after 30 minutes of
drug administration.
o Withhold dose and notify prescriber if RR is below 12cpm and if BP is
lower than 90/60mmHg.
o Monitor patient for drug dependence.
o Withdrawal symptoms may occur if drug is stopped abruptly. Reduce
dosage gradually.
o Advise ambulatory patient to be careful when rising and walking.
Patient should have gradual changes in position.
o Advise patient to avoid activities that require mental alertness.
2. Ketorolac
Class: Nonsteroidal anti-inflammatory drug
Action: Inhibits prostaglandin synthesis to produce anti-inflammatory,
analgesic, and antipyretic effects
Indication: Short term management of moderately severe, acute pain
Contraindications: Patient’s hypersensitive to drug and in those with active
peptic ulcer disease, recent GI bleeding or perforation, advanced renal
impairment, cerebrovascular bleeding, hemorrhagic diathesis, or incomplete
hemostasis, and in those at risk for renal impairment from volume depletion or
at risk of bleeding
Side effects: drowsiness, sedation, dizziness, headache, edema,
hypertension, palpitations, arrythmias, nausea, dyspepsia, GI pain, peptic
ulceration, vomiting, decreased platelet adhesion, purpura, prolonged
bleeding time, pruritus, rash, pain at injection site
o Assess history of peptic ulcer disease or any recent GI bleeding or any
risk of bleeding.
o Teach patient signs and symptoms of GI bleeding, including blood in
vomit, urine or stool.
o Monitor patient’s blood pressure and heart rate.
o Advise patient to avoid activities that require mental alertness.
3. Ranitidine
Class: H2 receptor antagonist
Action: Competitively inhibits action of histamine on the H2 at receptor sites of
parietal cells, decreasing gastric acid secretion
Indication: Patient is on NPO
Contraindications: Patient’s hypersensitive to drug and in those with acute
porphyria
Side effects: vertigo, malaise, headache, blurred vision, jaundice, burning and
itching at injection site, anaphylaxis
o Assess patient for abdominal pain.

o Instruct patient to take without regard to meals because absorption
isn’t affected by food.
o Advise patient to report abdominal pain and blood in stool or emesis.
o Urge patient to avoid foods that may increase gastric acid secretion.
4. Ciprofloxacin
Class: Fluoroquinolones
Action: Inhibits bacterial DNA synthesis, mainly by blocking DNA gyrase;
bactericidal
Indication: Prophylactic treatment
Contraindications: Patient’s hypersensitive to fluoroquinolones.
Side effects: headache, restlessness, tremor, dizziness, thrombophlebitis,
crystalluria, edema, nausea, diarrhea, vomiting, abdominal pain, leukopenia,
joint or back pain, rash, hypersensitivity reactions
o Obtain specimen for culture and sensitivity tests before giving first
dose.
o Monitor patient’s intake and output.
o Monitor for pain and inflammation on joints.
o Advice to take drug as prescribed to prevent growth of resistant
organisms.
o Monitor for signs and symptoms of superinfection.
5. Celecoxib
Class: COX2 inhibitor
Action: Inhibit prostaglandin synthesis, impeding cyclooxygenase-2 to
produce anti-inflammatory, analgesic and antipyretic effects
Indication: Acute pain
Contraindications: Patient’s hypersensitive to drug sulfonamides, aspirin or
other NSAIDs; in those with severe hepatic impairment; in the treatment of
perioperative pain after coronary artery bypass graft; women in the third
trimester of pregnancy; and in those with with history of ulcers or GI bleeding
Side effects: dizziness, headache, insomnia, peripheral edema, pharyngitis,
abdominal pain, dyspepsia, nausea, back pain, accidental injury
o Assess if patient has history of anaphylactic reactions to sulfonamides,
aspirin, or other NSAIDs.
o Assess if patient has history of ulcers or GI bleeding.
o Watch for signs and symptoms of overt and occult bleeding.
o Monitor patient for signs and symptoms of fluid retention.
o Monitor input and output.
o Drug can be given without regard to meals, but food may decrease GI
upset.
6. Diphenhydramine

Class: H1 receptor antagonist
Action: Competes with histamine for H1 receptor site, prevents but doesn’t
reverse histamine mediated responses, particularly those of the bronchial
tues, GI tract, uterus and blood vessels. Drug provides local anesthesia and
suppress cough reflex
Indication: Sedation
Contraindications: Patient’s hypersensitive to drug; newborns; premature
neonates; breastfeeding women; patient’s with angle-closure glaucoma;
stenosing peptic ulcer; symptomatic prostatic hyperplasia; bladder neck
obstruction or pyloroduodenal obstruction; and those having acute asthmatic
attack.
Side effects: drowsiness, confusion, insomnia, headache, vertigo, sedation,
sleepiness, dizziness, palpitations, hypotension, tachycardia, diplopia, blurred
vision, nausea, vomiting, dry mouth, urine retention, thromocytopenia, rash
o Warn patient not to take this drug with any other products that contain
diphenhydramine because it can increase adverse reactions.
o Tell patient to take diphenhydramine with food to reduce GI distress.
o Warn patient to avoid alcohol and hazardous activities that require
alertness.
o Inform patient to increase fluid intake.
7. Fleet enema
Class: Saline Laxatives
Action: Produces an osmotic effect in the small intestines by drawing water
into the intestinal lumen
Indication: Bowel Preparation pre-operatively
Contraindications: Patients on sodium restricted diets and in patients with
intestinal obstruction, intestinal perforation, edema, heart failure, megacolon,
impaired renal function, or signs and symptoms of appendicitis, or acute
surgical abdomen
Side effects: Abdominal cramping, fluid and electrolyte disturbance, laxative
dependence with long term use
o Advise to increase oral fluid intake.
o Teach patient about dietary sources of bulk, including bran and other
cereals, fresh fruit, and vegetables.
o Stress importance of using drug only for a short term therapy.

CHAPTER VI
THEORETICAL FRAMEWORK
Theoretical Background
“The unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or its recovery, or to
peaceful death, that he would perform unaided if he had the necessary strength,
will or knowledge. And to do this in such a way as to help him gain independence
as rapidly as possible.” Henderson, 1966.
She categorized nursing activities into 14 components, based on human
needs. She described the nurse’s role as substitutive (doing for the person),
supplementary (helping the person), or complementary (working with the
person), with the goal of helping the person become as independent as possible.
► Physiological
1. Breathe normally.
2. Eat and drink adequately
3. Eliminate body wastes.
4. Move and maintain desirable postures.
5. Sleep and rest
6. Select suitable clothes
7. Maintain body temperature within normal range by adjusting clothing
and modifying the environment.
8. Keep the body clean and well groomed and protect the integument.
9. Avoid dangers in the environment and avoid injuring others.
10. Communicate with others in expressing emotions, needs, fears, or
opinions.
11. Learn, discover, or satisfy the curiosity that leads to normal
development and health and use the available health facilities.
► Spiritual
12. Worship according to one’s faith
► Sociological
13. Work in such a way that there is a sense of accomplishment.
14. Play or participate in various forms of recreation.

onceptual Framework
Figure 1: Virginia Henderson’s Humane Holistic Care
Figure 1 shows a framework of Virginia Henderson’s Model. There are three
components that comprise Virginia Henderson’s Humane Holistic Care Theory.
Specifically, these are under the theoretical assertions of the Nurse – patient
relationship. These are: (1) the nurse as a substitute for the patient; (2) the nurse
as a helper to the patient; (3) and the nurse as a partner with the patient. These
said nursing roles range from very dependent to a quite independent relationship.
14 Basic Needs
Substitutive
(Doing for the
person)
Supplementary
(Helping the person)
Complementary
(Working with the person)
G
O
A
L
INDEPENDENCE
Nursing Roles

It is through the implementation of these roles that the client is helped in
achieving his goal- independence.
CHAPTER VII
NURSING CARE PLAN
A. Pre-operative Phase
Date: May 9, 2011
1. Chronic Pain
Cues: Related to presence of stones in the ureter and inflammatory process
secondary to ureterolithiasis as manifested by sudden intermittent sharp pain at
the costovertebral area radiating to the hypogastrium, right aggravated by
movements and relieved by limiting movements with a pain scale of 7/10; X-ray
report of the KUB shows a 2.1cm calcific density in the right lumbar region at the
level of L4 vertebrae along the sparse of the ureter.
Analysis of the Problem: The most characteristic manifestation of renal or
ureteral calculi is a sharp, severe pain of sudden onset caused by movement of
the calculus and consequent irritation. Pain may be intermittent, which usually
means that the stone has moved. Physician hypothesize that the ureter dilates
just proximal to the calculus, which allows urine to pass. Then, as the stone
moves into a new obstruction site, the pain returns.
Source: Joyce M. Black. Medical – Surgical Nursing, page 884, Volume 1.
Statement of Care Objectives: Within 1 hour of nursing intervention, the patient
will be able to report a decrease in pain scale of 3-5/10 with 10 as the highest
and 1 as the lowest.
Nursing Actions Rationale Evaluation
Independent Functions:
1. Monitored vital signs
every 4 hours.
2. Performed a
comprehensive
R: Usually altered in the
presence of pain
R: To assess
etiology/precipitating
Actual Outcome:
May 9, 2011
After 1 hour of nursing
interventions, patient’s
pain is still noted with
a pain scale of 3/10.

assessment of pain using
OLDCARTS.
3. Accepted client’s
description of pain.
4. Observed non-verbal
cues of pain.
5. Provided comfort
measures such as back
rub
6. Encouraged to use
relaxation techniques
such as deep breathing
exercises.
Dependent Functions:
1. Given Celecoxib
400mg one capsule now.
contributory factors.
R: Pain is a subjective
experience and cannot be
felt by others.
R: Observations may or
may not be congruent with
verbal reports indicating
need for further evaluation.
R: To provide non-
pharmacologic pain
management.
R: To assist client to explore
methods for
alleviation/control of pain.
R: Inhibits prostaglandin
synthesis, impeding
cyclooxygenase-2, to
produce anti-inflammatory,
analgesic and antipyretic
effects.
2. Ineffective Health Maintenance
Date Identified: May 9, 2011
Cues: Related to insufficient resources such as lack of money to procure
maintenance medications secondary low income as manifested by verbalization
of, “wala nako palita ang Acalka ug Rowatinez kay mahal man.”
Analysis of the Problem: Many variables influence a person’s health status,
beliefs, and behaviors or practices. An individual standard of living (reflecting
occupation, income, and education) is related to health, morbidity, and mortality.
Hygiene, food habits, and the propensity to seek health care advice and follow
health regimens vary among high income and low income groups.
Source: Kozier et al. Fundamentals of Nursing, 7th
edition, pages 176-178.
Statement of Patient Care Objectives: Within the course of nursing intervention,
patient as well as the SO will be able to understand the importance of being
compliant to the therapeutic regimen. They will be able to understand the

importance of prevention and be able to verbalize the importance of health and
wellness.
1. Assessed patient’s
level of cognitive,
emotional and physical
functioning.
ability and desire to learn.
health regimen.
4. Assessed patient’s age
and level of dependency.
5. Determined level of
adaptive behavior,
knowledge, and skills
about health
maintenance,
environment and safety.
6. Noted setting where
patient lives.
7. Noted patient’s use of
professional services and
resources.
8. Discussed with patient
and SO beliefs about
health and reasons for
R: To know patient’s
ability to comprehend his
situation.
R: To determine any
barriers to learning.
R: To identify if patient
understands about health
and wellness; to know
what approach to use in
dealing with the patient
during health teachings.
R: To identify patient’s
level of understanding
and to identify support
persons to whom patient
can rely to.
R: Determines beginning
point for planning and
interventions to assist
client in addressing
needs.
R: To be able to give
appropriate health
teachings or interventions
at home setting.
R: To be able to have a
view on what the
patient’s source of
income.
R: Determines patient’s
view about current
situation and potential for
Actual Outcome:
May 9, 2011
After 2 hours of patient,
SO and nurse interaction,
patient verbalized, “mao
lagi, kailangan maminaw
sa unsay storya sa doctor
kay sila ang mas
nakahibaw.”

not following prescribed
care plan.
9. Provided anticipatory
guidance.
10. Evaluated patient and
SO’s comprehension on
the health teachings
made.
1. Discharge instructions
given by Dr. Aponesto
change.
R: To maintain and
manage effective health
practices during periods
of wellness and identify
ways patient can adapt
when progressive illness
or long term health
problems occur.
R: To determine patient
and SO’s learning on the
patient’s condition.
R: To inform patient of
take home medicines and
follow up check up.
B. Post-operative Phase
1. Acute Pain
Date Identified: May 11-12, 2011
Cues: Related to surgical incision on the right lumbar area secondary to S/P
Laparoscopic Ureterolithomy Right as manifested by presence of T-tube drain,
limitation of movements, verbalization of, “sakit siya gamay”, aggravated by
movements, relieved by pain medications and with a pain scale of 5/10.
Analysis of the Problem: Pain is an unpleasant sensory and emotional
experience associated with actual or potential tissue damage. It occurs with
many disorders, diagnostic tests, treatments and invasive procedures.
Source: Smeltzer and Bare. Medical Surgical Nursing, Volume 1, page 217.
All cellular damage caused by thermal, mechanical or chemical stimuli results in
the release of excitatory nerutransmitters such as prostaglandins. These pain
synthesizing substances surround pain receptors in the extracellular fluid
creating the spread of the pain message and causing an inflammatory response.
Source: Potter and Perry. Fundamentals of Nursing, 6th
ed., page 1230.
Statement of Patient Care Objectives: Within 1 hour of nursing interventions,
patient will verbalize pain scale of 0-3/10.

every 4 hours.
2. Performed a
comprehensive
assessment of pain using
OLDCARTS.
3. Accepted client’s
description of pain.
4. Observed non-verbal
cues of pain.
5. Provided comfort
measures such as back
rub
6. Encouraged to use
relaxation techniques
such as deep breathing
exercises.
1. Given Tramadol 50mg
IVTT every 6
hours/Tramadol
50mg/tab 1 tab every 6
hours PRN for pain.
R: Usually altered in the
presence of pain
R: To assess
etiology/precipitating
contributory factors.
R: Pain is a subjective
experience and cannot be
felt by others.
R: Observations may or
may not be congruent with
verbal reports indicating
need for further evaluation.
R: To provide non-
pharmacologic pain
management.
R: To assist client to explore
methods for
alleviation/control of pain.
R: Binds to mu – opioid
receptors and inhibits the
reuptake of norepinephrine
and serotonin
Actual Outcome:
May 11, 2011
pain is still noted with
a pain scale of 2/10.
May 12, 2011
pain is not noted.
2. Impaired Tissue Integrity
Cues: Related to mechanical breakdown of skin secondary to S/P Laparoscopic
Ureterolithotomy as manifested by surgical incision and presence of T-tube at
lumbar area right
Analysis of the Problem: The creation of a surgical wound disrupts the integrity of
the skin and its protective function.
The skin serves as the primary defense against bacterial invasion. When skin is
incised for surgical procedure, this important line of defense is lost. Strict

adherence to aseptic technique during surgery and in days following the
procedure is necessary to compensate for impaired defense.
Source: Adele Pillitteri. Maternal and Child Health Nursing, 4th
edition, page 613.
Statement of Patient Care Objectives: Within 8 hours of nursing interventions,
patient’s surgical incision with T-tube drain will be free from redness and purulent
discharges.
1. Practiced proper
handwashing before and
after patient contact.
2. Noted signs and
symptoms of infection.
3. Inspected surgical
incision and monitored T-
tube drain.
4. Changed T-tube
drainage bag when
necessary.
5. Stressed hygienic
measures.
6. Instructed to avoid use
of constrictive clothing.
7. Instructed to increase
fluid intake.
8. Encouraged to eat
foods rich in protein and
Vitamin C.
1. Given Ciprofloxacin
200mg IVTT every 12
hours/Ciprofloxacin
R: To reduce
transmission of
microorganisms
R: Fever, chills,
diaphoresis, altered level
of consciousness, and
positive blood cultures.
R: Early reacognition for
signs of infection
prevents complication.
R: Soiled bags potentiate
skin breakdown and
bacterial growth.
R: Reduces accumulation
of microorganisms
preventing infection.
R: To promote circulation
for better wound healing.
R: To prevent
dehydration due to
presence of T-tube drain.
R: To promote tissue
healing and boost
immune system.
R: Inhibits bacterial DNA
synthesis, mainly by
blocking DNA gyrase;
Actual Outcome:
May 11, 2011
After 8 hours of nursing
surgical incision was free
from signs and symptoms
of infection such as
redness and presence of
purulent discharges.
May 12, 2011
May 13, 2011

500mg/tab 1 tab twice a
day.
bactericidal
3. Fatigue
Cues: Related to stress of surgical operation secondary to S/P Laparoscopic
Ureterolithotomy as manifested by nonverbal cues of weak presentation, tired
and pallor appearance, decrease in performance, muscle strength of 4/5 both in
upper and lower extremities, and verbalization of, “kapoy jud akong paminaw
ron.”
Analysis of the Problem: As a common symptom, fatigue is associated with a
variety of physical and psychological conditions. Other factors that influence the
occurrence of fatigue may include inability to obtain enough rest, stress and
anxiety. People with disabilities frequently experience fatigue. Physical weariness
maybe caused by discomfort and pain associated with a health problem, and
reconditioning associated with prolonged periods of bed.
Source: Potter and Perry. Fundamentals of Nursing, 5th
edition, page 1254
patient will be able to achieve optimal amount of sleep and verbalize decrease of
stress and manifest a rested appearance.
1. Noted presence of
factors contributing to
fatigue such as
underlying diseases.
2. Noted reports of
weakness, fatigue, pain
and difficulty in
accomplishing tasks.
3. Assisted in scheduling
a gradual increase in
daily activities.
4. Planned care with rest
periods.
5. Provided an
environment comfortable
R: To identify
precipitating factors.
R: To identify causative
factors.
R: To improve respiratory
and cardiac conditioning
thus improving activity
tolerance.
R: To promote rest and
sleep.
R: To promote relaxation
and sleep.
Actual Outcome:
May 11, 2011
interventions, the patient
was able to take naps
with a duration of 2
hours, but still looks tired
and has weak
presentation, muscle
strength of 4/5 both in
upper and lower
extremities, and has
verbalized, “nakatulog
naman ko gamay pero
kapoy gihapon ko.”

for sleep and rest.
6. Encouraged SO to
assist patient with self
care needs.
7. Encouraged to do
relaxation activities such
as deep breathing
exercises and listening to
music.
foods high in
carbohydrate and
calories such as rice,
bread and cereals as
desired.
R: Energy conservation
in doing activities can
help relieve fatigue.
R: This helps reduce
fatigue and promotes
relaxation.
R: Calories give the body
energy.
4. Partial Self Care Deficit
Cues: Related to energy deficit, weakness, tiredness and fatigue secondary to
S/P Laparoscopic Ureterolithotomy, Right as manifested by assistance in toileting
and ambulating and muscle strength of 4/5 both in upper and lower extremities,.
Analysis of the Problem: Self care deficits may range from not being able to react
with a weak arm to full dependence on others. Client’s experiencing weakness,
tiredness, pain, discomfort, neuromuscular skeletal impairment may have
difficulties in their activities of daily living.
Source: Kozier et. al. Fundamentals of Nursing, 7th
edition, page 702.
patient will be able to decrease level of dependency through cooperation in
performing ADL’s such as toileting and ambulating.
1. 1. Assessed usual
level of functioning
2. Assessed barriers to
participation in self care
R: May be able to
continue usual activity
with necessary
adaptations to current
condition.
R: Prepares for increased
independence which
Actual Outcome:
May 11, 2011
interventions, patient
showed cooperation
when performing ADL’s
with little assistance, still
looks tired and weak.

and identified
environmental
medications.
3. Collaborated with SO
of the patient in caring for
and assisting the patient.
4. Arranged patient’s bed
linens.
5. Assisted patient when
turning to sides and in
sitting up on bed.
measures.
7. Advised patient to
have gradual changes in
position.
8. Promoted environment
conducive for sleep and
rest.
enhances self esteem.
R: Enhances
coordination and
continuity of care
optimizing outcomes.
R: To promote comfort
R: To prevent pressure
sores and muscle
weakness from disuse.
R: To promote comfort
R: To avoid orthostatic
hypotension.
R: To promote relaxation
and increase energy
levels.
5. Risk for Infection
Cues: Related to mechanical break on the skin surgical incision with presence of
T-tube drain at lumbar area right secondary to S/P Laparoscopic
Ureterolithotomy and presence of peripheral IV line.
Analysis of the Problem: The creation of a surgical wound disrupts the integrity of
the skin and its protective function.
The skin serves as the primary defense against bacterial invasion. When skin is
incised for surgical procedure, this important line of defense is lost. Strict
adherence to aseptic technique during surgery and in days following the
procedure is necessary to compensate for impaired defense.
edition, page 613.
Statement of Patient Care Objectives:

Within 8 hours of nursing interventions, patient will be free from any signs of
infection on the incision site with T-tube drain such as redness, purulent
discharges and elevated temperature.
1. Assessed incision with
the T-tube for redness,
increased pain and
2. Assessed stability of
tube.
3. Performed
handwashing before and
after patient contact.
measures.
5. Changed T-tube
drainage bag when
necessary.
6. Instructed to avoid use
of constrictive clothing.
7. Instructed to increase
fluid intake.
foods rich in protein and
Vitamin C.
1. Given Ciprofloxacin
200mg IVTT every 12
hours/Ciprofloxacin
500mg/tab 1 tab twice a
day.
R: To monitor signs and
symptoms of infection.
R: Improperly secured
drains allow access of
pathogens where tubes
are placed.
R: To prevent
transmission of
microorganisms.
R: To reduce bacterial
growth.
R: Soiled bags
potentiate skin
breakdown and bacterial
growth.
R: To promote circulation
for better wound healing.
R: To prevent
dehydration due to
presence of T-tube drain.
R: To promote tissue
healing and boost
immune system.
R: Inhibits bacterial DNA
synthesis, mainly by
blocking DNA gyrase;
bactericidal
Actual Outcome:
May 11, 2011
interventions, patient was
free from any signs of
infection such as redness
and purulent discharges
on incision site with T-
tube drain and T =
37.2o
C/axilla.

6. Risk for Impaired Tissue Perfusion: Peripheral
Cues: Related to prolonged time in the OR: approximately 4 hours of surgery,
positioning in the operating room, and blood loss during the surgery secondary to
S/P Laparoscopic Ureterolithotomy.
Analysis of the Problem: Those who are confined to bed or wheelchair for longer
periods of time, triggers vasoconstriction due to pressure which results in
decreased blood flow in the skin. In addition, because vasoconstriction of the
skin reduces body heat loss, the difference between the core temperature and
skin temperature may increase.
(http://www1.us.elsevierhealth.com/MERLING/Gulanick/Constructor)
Although vessels that must be cut for surgery are immediately clamped and
ligated, some blood loss occurs with surgery. This could lead to ineffective tissue
perfusion of all body tissues if the problem is not quickly recognized and
corrected.
edition, page 568.
Statement of Patient Care Objectives:
Within 8 hours of nursing interventions, patient maintains optimal tissue perfusion
as manifested by strong peripheral pulses, V/S within normal range, CRT < 2
secs on both upper and lower extremities, pink nailbeds, lips and palpebral
conjunctiva.
1. Assessed for normal
skin color. Palpated
peripheral pulses.
2. Assessed CRT, pallor,
pulse rate, cyanosis and
temperature changes of
extremities.
every 4 hours.
4. Elevated patient’s
head of bed.
5. Assisted patient when
turning to sides and in
ambulating.
R: These are indicators
of adequate tissue
perfusion.
R: Indicates capability to
provide blood supply to
distal tissues.
R: To have baseline data.
R: To promote venous
return and facilitate
gravitational blood flow.
R: Promotes increased
circulation to distal
tissues.
Actual Outcome:
May 11, 2011
vital signs are BP =
120/80mmHg, PR =, + 3
peripheral pulses on left
hand and
+2 peripheral pulses on
right hand, CRT < 2 secs
on both lower and upper
extremities, pale
nailbeds, lips and pink
palpebral conjunctiva.

6. Advised patient not to
wear constrictive
clothing.
7. Encouraged to sleep
and rest
R: To promote adequate
circulation.
R: To decrease oxygen
consumption and
demand.
CHAPTER VIII
DISCHARGE PLAN
Date Implemented Time Frame Health Teachings Outcome
May 13, 2011 Within 15
minutes of
nurse – patient
interaction,
nurse will be
able to give
discharge
instructions to
patient and SO.
Medications
- Instructed patient to
take medications as
advised by the
doctor and do not
discontinue
medications if not
indicated.
take prescribed
medication at the
right route, right
dose, and right
frequency at the right
time.
- Instructed to take
the antibiotics for the
full course of therapy
even when feeling
well already.
- Advised to keep
track with the
medications by
having a list of it all
with their
corresponding time
and dosage.
Environment
After 15 minutes of
nurse – patient
interaction, patient
verbalized,
“mubalik ko diri
Maam sa akong
schedule and
paningkamutan
nako na masunod
tanan imong gi-
storya nako kay
para man pud ni
sa akong
kaayohan.
Salamat kaayo.”

- Encouraged patient
to maintain
cleanliness of the
house and
surroundings.
to place medicines in
a medicine cabinet
or in a container
away from harmful
substances.
- Encouraged to
keep environment
conducive for
resting.
- Encouraged to
provide adequate
lighting at home.
Treatment
- Instructed to return
on the follow up
check up one week
after discharge or as
instructed by the
doctor.
- Instructed not to
take OTCs without
consulting doctor.
- Advised not to self
medicate as much as
possible.
- Instructed patient
that whenever she
has questions, she
must not hesitate to
ask her doctor.
Health Teachings
avoid calcium rich
and highly acidic
foods.
- Encouraged to
have oral fluid intake
of at least 1L/day.

- Encourage to do
regular exercise of at
least 30 minutes in a
day.
- Stressed the
importance of having
proper hygienic
measures.
- Encouraged to
have adequate rest
and sleep with at
least 8 hours in a
day.
- Advised patient that
whenever she feels
the urgency to void
she must do so.
- Instructed to watch
out for signs and
symptoms of
infection on surgical
site and T-tube drain
such as redness,
swelling, pain and
- Advised to change
T-tube drainage bag
as necessary.
- Advised to perform
handwashing
regularly.
Observable Signs
and Symptoms
- Advised to watch
out for intermittent
sudden sharp pain
on lumbosacral
radiating to the
hypogastrium.
- Instructed to watch
out for signs of
infection such as
redness, swelling,
purulent discharges
and elevated

temperature.
refer all unusualities
to the doctor.
Diet
avoid foods that are
calcium rich and
highly acidic.
- Foods to avoid:
Cheese,
- Avoid alcoholic and
caffeinated
beverages.
- Encouraged to eat
fruits, vegetables,
and meat to facilitate
tissue healing.
Safety, Security
and Spirituality
- Encouraged to
continue faith and
belief in God.
to continue praying
everyday and
attending mass
every Wednesday
and Sunday.
- Advised to seek
medical help to
ensure safety with
regards to her health
condition.
- Advised to always
seek family support
whenever problems
arise.

CHAPTER IX
CONCLUSION
The increasing prevalence rates of acquiring urinary calculi have ushered to
create an adequate number of possible interventions to the patient’s condition.
Ureterolithiasis when not managed can lead to devastating effects. Patient has
had an operation of Laparoscopic Uretrolithotomy, Right.
Total care was given to the patient. The different aspects of health: physical,
emotional, and mental were given consideration and priority. Both external and
internal environmental stimuli were altered positively as best as possible since
these are contributing factors to the adaptation of the patient. These were done
through health assessment, plans, interventions and health teachings that were
all aimed for the patient.
Dependent functions done were giving of medications such as Tramadol,
Ketorolac, Ranitidine, Ciprofloxacin, Celecoxib, Diphenhydramine, and Fleet
enema; and administration of IVF as ordered. Independent functions done to the
patient were vital signs monitoring, providing comfort measures, health
teachings, maintaining a therapeutic and secured environment, assisted in her
activities of daily living, assessed presence of pain, and preventing and
evaluating any signs of infections.
On the substitutive role, nurse does morning care to our patient to
promote proper hygiene, assist the patient when moving and toileting. And on our
complimentary role we help the client in keeping oriented to her environment as
much as possible by talking to her of what is happening around her. And on the
supplementary role we provided health teachings necessary about the condition
to the SO of the client. On the 14 basic needs of the patient, the following
interventions were done:
►Physiological
1. Breathe normally. (Maintaining patent airway by elevating head of
bed)

2. Eat and drink adequately (Encouraged patient to eat balanced
meals a day and to avoid foods that may trigger crystal formation.)
3. Eliminate body wastes.
4. Move and maintain desirable postures. (Assisting her in attaining the
desired position that she wants and that is comfortable to her.)
5. Sleep and rest (Promoted an environment conducive to sleeping
and resting.)
6. Select suitable clothes (help in dressing up the patient).
7. Maintain body temperature within normal range by adjusting clothing
and modifying the environment. (Placing blanket and assessing body
temperature every 4 hours.)
8. Keep the body clean and well groomed and protect the integument.
(Assisted in grooming and stressed hygienic measures and in doing
morning care)
9. Avoid dangers in the environment and avoid injuring others.
(Encouraged SO to keep watch at all times)
10. Communicate with others in expressing emotions, needs, fears, or
opinions. (Talking to the patient about life experiences and establishing
rapport.)
11. Learn, discover, or satisfy the curiosity that leads to normal
development and health and use the available health facilities.
► Spiritual
12. Worship according to one’s faith (Encouraged to continue her
religious practices even if she is hospitalized.)
► Sociological
13. Work in such a way that there is a sense of accomplishment. (We
also make sure that the interventions done are for the best of the client)
14. Play or participate in various forms of recreation.
Since the patient is responsive, coherent and cooperative, the researcher
assisted the patient in performing activities that contributes to her recovery in
order for her to gain independence as rapidly as possible.

CHAPTER X
RECOMMENDATIONS
That patients suffering from the same disease should always have proper
management as to what are the regimens or procedures that need to be done in
order to control the disease or prevent further complications.
That all members of the health care team must maintain or if not enhance their
capabilities in promoting, preventing, treating and rehabilitating patients suffering
from the disease. Also, to always educate the patients about their condition since
health education is still the best intervention they can do. Furthermore, they must
also recognize the challenges of the disease management and keep abreast of
new information.
That the future researchers/nurse trainees would do better to indulge in a more
advanced assessment and review of the topic in order to come up with a more
comprehensive study and to aid other researchers conducting further study of the
chronic complications of ureterolithiasis .
That the general public should be aware of that implementing lifestyle
changes certainly helps in the prevention of lifestyle related diseases. In the
great many among people who are at risk, the familiarity of ureterolithiasis to
prevent needless possibilities of ureterolithiasis.
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