TABLE OF CONTENTS

I. II. III. IV. V. Introduction Objectives Anatomy and Physiology Vital Information Clinical Assessment A. Past Health History B. Present Health History C. Family Genogram VI. Patterns of Functioning VII. Brief Social, Cultural and Religious Background VIII.Clinical Inspection A. Vital Signs B. Physical Assessment IX. Laboratory and Diagnostic Data X. Developmental Stages (School Age Growth and Development) XI. Case Discussion (NEPHROLITHIASIS) A. Definition B. Kidney Stone (Renal Calculi) a.Definition b. Types c.STAGHORN KIDNEY STONE i. Causes ii. Symptoms d. Causes of Nephrolithiasis e.Signs and Symptoms Nephrolithiasis f. Risk for Kidney Stones

g. Diagnosis of Nephrolithiasis h. Prevention of Kidney Stones i. Treatment of Kidney Stones XII. Pathophysiology XIII.Medical Management XIV. Nursing Management (Nursing Care Plan) XV. Discharge Planning REFERENCES

I.

Introduction

Kidney stones (ureterolithiasis) result from stones or renal calculi (from Latin ren, renes, "kidney" and calculi, "pebbles") in the ureter. The stones are solid concretions or calculi formed in the kidneys from dissolved urinary minerals. Nephrolithiasis (from Greek (nephros, "kidney") and (lithos, "stone")) refers to the condition of having kidney stones. Urolithiasis refers to the condition of having calculi in the urinary tract(which also includes the kidneys), which may form or pass into the urinary bladder.Ureterolithiasis is the condition of having a calculus in the ureter, the tube connecting the kidneys and the bladder. The term bladder stones usually applies to urolithiasis of the bladder in non-human animals such as dogs and cats. Kidney stones typically leave the body by passage in the urine stream, and many stones are formed and passed without causing symptoms. If stones grow to sufficient size before passage on the order of at least 2-3 millimeters they can cause obstruction of the ureter. The resulting obstruction causes dilation or stretching of the upper ureter and renal pelvis as well as muscle spasm of the ureter, trying to move the stone. This leads to pain, most commonly felt in the flank, lower abdomen and groin. Renal colic can be associated with nausea and vomiting. There can be blood in the urine, visible with the naked eye or under the microscope due to damage to the lining of the urinary tract.

Statistics
The overall probability of forming stones differs in various parts of the world: 1-5% in Asia.

II. Objectives
General Objective After our clinical exposure, we should be able to assess and diagnose patients current status and to plan, implement, and evaluate our nursing procedures towards phases. Also to be able to materialized specific objectives on cognitive, psychomotor, and affective domains, and to be able to carry out and practice all these things with Vincentian values. Specific Objectives COGNITIVE 1 To be able to comprehend the pathophysiology of the patients disease. 2 To be able to harness knowledge about the patients condition. 3 To be able to determine the purposes of all the medications being administered to the patient and its actions and mechanism of action. 4 To be able to gather factual information regarding the patient condition. 5 To be able to correlate learned knowledge from the classroom to the clinical area. 6 To be able to formulate nursing diagnoses and collaborative nursing statements. PSYCHOMOTOR 1. To be able to set priorities and goals in collaborative with the patient. 2. To be able to obtain a nursing health history, conduct physical assessment, review records, organize and validate data. 3. To be able to perform planned interventions for the patient. 4. To be able to implement selected nursing strategies and interventions. 5. To be able to collaborate with the patient and collect data desired outcomes. AFFECTIVE

1 2 3

To be able to establish rapport with the patient and folks. To be able to empathize with the patient and folks. To be able to address the spiritual needs of the patient.

4 To be able to know the patient better and encourage verbalization of fear and anxiety. To be able to know the feelings of patient towards his condition.

III. Anatomy and Physiology

The kidneys make up of the bodys main purification system. They control the composition of blood by removing waste products, many of which are toxic, and conserving useful substances. The kidneys help control blood volume and consequently play a role in regulating blood pressure. The kidneys also play an essential role in regulating blood pH. Approximately one-third of one kidney is all that is needed to maintain homeostasis. Even after extensive damage, the kidneys can still perform their life sustaining functions. If the kidneys are damage further, however, death results unless medical treatment is administered. I. Kidneys Anatomy and Histology

a. Location and external anatomy of the kidneys The kidneys are bean-shaped and each is about the size of a tightly clenched fist. They lie behind the peritoneum on the posterior abdominal wall on each side of the vertebral column. Retroperitonea l- are a structures that are behind the peritoneum. Renal capsule - is a layer of fibrous connective tissue surrounding each kidney. Renal fascia - is a thin layer of connective tissue surrounding the fat. Numerous connective tissue strands cross the fat and connect the renal fascia to the renal capsule. The hilum is a small area where the renal artery and nerves enter, and the renal vein and ureter exit the medial side of the kidney. b. Internal anatomy and histology of the kidneys The kidney is divided into outer cortex and the inner medulla. Renal sinus - is a cavity connected to the hilum. It contains blood vessels, urine-collecting chambers that empty into the ureter and fat. Renal column - are extensions of the renal cortex into the renal medulla. Renal pyramids - are the cone-shaped between the renal columns. Renal papillae are the tips of the pyramids point toward the renal sinus. Minor calyces - are funnel-shaped chambers into which the renal papillae extended. Major calyces are the minor calyces of several pyramids merge to form larger funnel. Renal pelvis are the major calyces converge to form an enlarged chamber. Ureter is a renal pelvis narrows into a small-diameter tube which exists the kidney at the hilum and connects to the urinary bladder. Nephron is the functional unit of the kidney. Each nephron consists of;

Renal corpuscles; a proximal convoluted tubule; a loop of Henle, or nephronic loop; and a distal convoluted tubule. Bowmans capsule - is the enlarged end of the nephron surrounding the glomerulos, which is a network of capillaries. Fluid from the blood in the glomerulos enters Bowmans capsule and then flows into the proximal convoluted tubule. From there, it flows into the loop of Henle. Each loop of Henle has a descending limb, which extends back toward the cortex. The fluid flows through the ascending limb of the loop of Henle to the distal conviluted tubule. Many distal convoluted tubules empty into a collecting duct, which carries the fluid from the cortex, through the medulla. Many collecting ducts empty into a papillary duct, and the papillary ducts empty their contents into a minor calyx. Juxtamedullary nephrons - have loops of Henle that extend deep into the medulla of the kidney. Cortical nephrons - have loops of Henle that do not extend deep into the medulla. Fenestrae - is the endothelium of the glomerular capillaries has pores. Filtration slits - is the podocytes have numerous cell processses with gaps between them. Filtration membrane is formed between the endothelium of the glomerular capillaries, the podocytes, and the basement membrane . Filtrate - The fluid that passes across the filtration membrane. II. Functions of urinary system The urinary system consists of two kidneys; which produce urine; two ureters, which carry urine from the kidneys to the urinary bladder; a single, midline urinary bladder, which stores urine; and a single urethra, which carries urine from the urinary bladder to the outside of the body. The following functions are performed by the kidneys: 1. Excretion- the kidneys filter blood, and a large volume of filtrate is produced. Large molecules, such as proteins and blood cells, are retained in the blood, whereas smaller molecules and ions enter the filtrate. 2. Regulation of blood volume and pressure- the kidneys play a major role in controlling the extra cellular fluid volume in the body by producing either large volume of dilute urine or a small volume of concentrated urine. Consequently, the kidneys regulate blood volume and blood pressure. 3. Regulation of the concentration of solutes in the blood- the kidneys help regulate the concentration of the major ions, such as Na+, Cl- , K+, Ca2+ , HCO3- and HPO42-. 4. Regulation of extracellular fluid pH- the kidneys secrete variable amounts of H+ to help regulate the extracellular fluid pH. 5. Regulation of red blood cell synthesis- the kidneys secrete a hormone, erythropoietin, which regulates the synthesis of red blood cells in bone marrow. 6. Vitamin D synthesis- the kidneys play an important role in controlling blood levels of Ca2+ by regulating the synthesis of vit. D. III. Arteries and Veins of the Kidneys A renal artery branches off the abdominal aorta and enters the renal sinus of each kidney. Within the kidney, there is repeated branching of the artery, with the branches becoming smaller and smaller. These branches pass along the sides and bases of the renal pyramids, project into the cortex, and give rise to afferent arterioles supplying the glomerular capillaries inside Bowmans capsule. Efferent arteriolesarise from the glomerular capillaries and carry blood away from the glomeruli. After each efferent arteiole existsthe glomerulus, it gives rise to a plexus of capillaries, called peritubular capillaries, around the proximal and distal convoluted tubules. The vasa recta are specialized portions of the peritubular capillaries that extend deep into the medulla of the kidney and surrounds the loop of Henle and collecting ducts. Juxtaglomerular apparatus - is formed where the distal convoluted tubule comes into contact with the efferent arteriole next to Bowmans capsule.

Granular cells - are specialized smooth muscle cells in the wall of the afferent arteriole thet secrete renin. Macula densa - is specialized epithelial cells of the distal convoluted tubule thet monitor the flow of filtrate.

IV. Vital Information

Patient Name: I.M.I Age: 8 years old Sex: Male Nationality: Filipino Civil Status: Single Religion: Roman Catholic Address: #26 Teachers Village Pres. Roxas, Capiz Date and Time admitted: November 19, 2010 at 4:45 pm Ward: St. Joseph Ward Chief Complain: Vomiting Diagnostic Impression: Acute Gastritis; Nephrolithiasis Final Diagnosis: Acute Gastritis with some dehydration; Nephrolithiasis, S/P on Stagorn calculi Attending Physician: Dr. P.

V. Clinical Assessment
A. Nursing Assessment 1. History of Present Illness 3 days prior to admission, I.M.I. had a hypogastric pain and self medicated with Ranitidine, 160 mg for 3 days. On November 19, 2010, I.M.I. had several episodes of vomiting. He was brought to St. Anthony College Hospital with the diagnostic impression of Acute Gastritis and Nephrolithiasis, under the service of Dr. P. Dr. P. referred I.M.I. to Dr. B, since the case is Nephrolithiasis. 2. History of Past Illness Patient completed his immunization. Accordinig to the mother, I.M.I. was hospitalized when he was 6 months old with a Diagnostic Impression of Urinary Track Infection. Because of it, he was circumcised at that young age. On May 7, 2010, I.M.I. was brought to St.Pauls Hospital Iloilo because of hypogastric pain. He underwent ultrasound examination and found a kidney stone

(staghorn calculi). He underwent percutaneous nephrolithotomy. After two weeks, I.M.I. urinated with white particles like the size of monggo seeds.
Patterns of Functioning Breathing Pattern Circulation Home Hospital no adventitious sounds heard. R.R ranges to 25-18 cycles per minute. B.P ranges to 150/100- 110/70 mmHg. C.R ranges to 102-76 beats per minute. Pulse Rate ranges to 100-75 beats per minute. He sleeps at around 8-9 oclock and wakes up 5 oclock. He sleeps in a side lying position or sometimes lateral. His mother gave him water before he go to sleep and upon waking up in the morning. Intake ranges to 300-200 cc every shift. Eat the served foods and sometimes those foods that his family brings. Tipped sponge bath, oral care and other care is done by his mother. Urine output ranges to 800-550 cc every shift. Eliminates two times upon admission until he is discharge. Watching television and robot cars magazine. He does not have exercise.

Sleeping Pattern Drinking Pattern

Usually sleeps at around 8-9 oclock and wakes up 6 oclock in the morning. Drinks 8-10 glasses of water daily. Seldom drinks juice and soft drinks. Eat three times a day with sometimes snacks in the middle. He does not like to eat cheese snacks and he is vigilant in what he eats. Takes a bath regularly, brush his teeth three times a day and very conscious on the way he looks. Urinates depending on how much fluid he intake. Eliminates depending also the amount of foods he eats. Wakes up early in the morning and go to school with his mother. He enrolled in some workshops like dancing and drawing. He plays with his classmates during break time.

Eating Pattern

Hygiene Pattern Elimination Pattern

Recreation and Exercise Pattern

I.M.I had lactose intolerance when he was a baby. 3. Genogram

VI. PATTERNS OF FUNCTIONING VII. BREIF SOCIAL, CULTURAL AND RELIGIOUS BACKGROUND
EDUCATIONAL BACKGROUND He is studying at St. Michaels Montessori School. An active student, a member of Student Pastoral Council, an artistic child, and most outstanding student of their class. OCCUPATIONAL BACKGROUND His mother is own a sari-sari store that helps them for their basic needs. RELIGIOUS PRACTICE They believe in Jesus Christ and they hear masses every Sunday. ECONOMIC STATUS They belong to a middle class family. Except for his mother, his grandparents provide them their basic need

VIII. CLINICAL INSPECTION

1. VITAL SIGNS
Upon Admission Temperature Respiration Rate Cardiac Rate Blood Pressure During Care Nov. 22, 2010 Temperature Pulse Rate Respiration Rate Blood Pressure Cardiac Rate Nov. 23, 2010 Temperature Pulse Rate Respiration Rate Blood Pressure Cardiac Rate @ 12:00 a.m 36.6 75 22 110/70 77 @ 2:00 a.m 36 75 21 110/70 78 @ 12:00 a.m 36.3 75 18 120/80 77 36.6 C 22 cpm 88 bpm 130/100 mmhg @ 4:00 a.m 36.3 75 19 110/80 76 @6:00 a.m 36.5 77 20 110/70 80 @ 4:00 a.m 36.5 83 22 130/70 85

2. PHYSICAL ASSESSMENT
SKIN Brown complexion Dry, smooth and warm to touch Poor skin turgor no fever HAIR Black hair evenly distributed no dandruff or lice no hair abnormalities NAILS Slightly pinkish nails capillary refill returns in 2 seconds neatly cut nails measures 160 degrees EYES Rounded eyes

black colored pupils equally round reacts to light and accommodation sometimes experiencing blurred vision. NOSE nasal septum locates at the center of the face same color with the skin no discharges noted. MOUTH Lips are dry, cracks, pinkish in color Gums are pink and slightly moist Tongue locates at the center, slightly moist, pinkish and can move freely Presence of mouth sore. NECK Proportion to head and shoulders same color with the skin can bend downward, upward and sideward. AXILLA slightly odorous no palpable lymph nodes. RESPIRATORY SYSTEM Respiration rate ranges to 25-18 cpm. Chest is smooth, dry and warm to touch, symmetrical chest expansion is even no deformities no adventious sounds can be heard. CARDIOVASCULAR SYSTEM Cardiac rate ranges to 102-76 bpm and blood pressure ranges to 150/100-110/70 mmHg, Heart is distinct S1 and S2 sounds, no murmurs or bruits pulse can be locate and feel easily. GASTROINTESTINAL SYSTEM Presence of epigastric and hypogastric pain MUSCULOSKELETAL SYSTEM Move freely on the bed and can stand with two feet no deformities or edema. NEUROLOGIC SYSTEM Oriented to time and date, responds to question accurately and speaks clearly. GENITOURINARY SYSTEM Undergone circumcision at 2 years old due to UTI pass out yellow colored urine with crystals.

IX.Laboratory and Diagnostic Data

ULTRASOUND REPORT
11/20/10 Kidneys: (R) kidney - coronal measures 92.7 x 50.2 x 33.8 mm (LWT) - cortical thickness measures 14.7 mm. - The right kidney is normal ultrasonically (L) kidney - coronal measures 94.7 x 62 x 50.4 mm (LWT) - cortical thickness measures 16.6 mm. - The borders are well-defined - The parenchyma have homogenous echo pattern - The calyces are dilated measuring 8.6 16.6 mm - The dilated renal pelvis measures 16.9 mm - The dilated proximal meter measures 8.1 mm - There are lithiasis noted measuring 10.3 mm (superior pole) and 5.0 mm (inferior pole) Urinary bladder: Well-defined, smooth walls with a thickness of 4.1 6.0 mm No intraluminal echoes seen Full urinary bladder has a volume of approximately 81.4 ml Post void scan shows 11.2 (14%) residual urine volume Impression: Urinary retention, 11.2 ml (14%) Normal right Kidney ultrasonically Hydronephrosis with nephrolithiais, (L) kidney. ULTRASOUND REPORT 11/23/10 Kidneys: (R) kidney - coronal measures 89.7 x 48.8 x 35 mm (LWT) - cortical thickness measures 15.1 mm. - The border are well-defined - The parenchyma have homogenous echo pattern - No lithiasis - No caliectasia (L) kidney - coronal measures 95.2 x 44 x 37.5 mm (LWT) - cortical thickness measures 17.5 mm - the borders are well-defined - parenchyma has homogenous echo pattern - dilated calyces measures 8.5 21 mm (previous size = 8.6 16.6) - dilated renal pelvis measures 17.5 mm (previous 16.9 mm) - dilated ureter measures 8.7 mm (proximal ureter) (previous 8.1 mm) 9.5 mm distal ureter - high intensity echo measuring 7.6 x 9.1 x 6.1 mm (LWH)is noted in the distal Ureter . - The calyceal lithiasis measures 10.3 mm and 4.3 mm

Urinary Bladder: Impression: Normal urinary bladder and right kidney ultrasonically. Hydronephrosis, Left kidney with: 1. Hydroureter 2. Nephrolithiasis 3. Obstruction distal uterolithiasis LABORATORIES AND DIAGNOSTIC DATA 11/19/10 Result Normal values 0.38 vol. (fr) 0.32 0.42 126 Gms/L 11-16 g/dl 4.43 x 10^12/L 4 5.2 x 10^12/L 9 13.3 x 10 /L 4 10 x 109/L 0.7 50 65 0.01 13 0.24 25 35 0.03 49 adequate 150 450 x 109/L 11/19/10 Result Pale straw hazy 1.010 8.0 Trace (-) 33 - 52 7 12 Occasional Few 11/23/10 Result Pale straw Slightly hazy 1.010 6.5 (-) (-) 3-6 0-4 few 11/21/10 Normal Values straw to dark yellow Clear 1.005-1.035 4.5 8 (-) (-) 03 04 05 none Normal Values straw to dark yellow Clear 1.005-1.035 4.5 8 (-) (-) 0 3/hpf 0-4 0-5 It is well-distended with smooth walls with a thickness of 37.38mm No intraluminal echoes seen Full urinary bladder has a volume of approximately 154 ml Post void scan shows no residual urine volume

a. Hematology Name of Test Hematocrit Hemoglobin Red cell count White cell count Segmenters Eosinophils Lymphocytes Monocytes Platelet B. Urinalysis Name of Test Color Transparency Specific gravity Reaction Protein Sugar *Microscopic RBC WBC Epithelial cells Bacteria Urinalysis Name of Test Color Transparency Specific gravity Reaction Protein Glucose RBC WBC Epithelial cells C. Stool

Significance WNL WNL WNL Infection Infection Infection Infection Infection WNL Significance WNL Infection/WBC problem WNL WNL Indicates kidney dysfunction WNL Hematuria/kidney infection Indicate the presence of inflammatory process WNL Infection Significance WNL WNL WNL WNL WNL WNL WNL WNL WNL

Name of test Color Consistency E. coli Yeast cells

Result Yellowish Brown Soft None None

Normal values Brown Solid None none Normal Values 7.35 7.45 35 45 mmHg 22 26 mmol/L +2 to -2 mEq/L 20 30 mmHg 80 100 mmHg 97 100%

Significance WNL Steatorrhea WNL WNL Significance WNL WNL WNL WNL WNL Respiratory muscle weakness Infection

D. ABG analysis Result form 11/20/10 Name of test Result pH 7.4 pCO2 41 HCO3 25.4 BE (B) (mmol/L) 0.5 A aDO2 (mmol/L) 29 paO2/pAO2 (mmol/L) 0.7 O2 sat 94 %

E. Bacteriology Report 11/24/10 Sensitive to: Amo/penicill.gr.a, gentamicim Amox/Clav.ac, netilmicin Piper + tazobactem; c:profloxacin Tirarcillin Ticar/clav.ac Cefepime Cefuroxime Meropenem Imipenem Contramoxazole Tobramycin Amikacin Resistant to: Cefoxitin ceftazidine

X.Developmental Stages
School Age Growth and Development 6-12 Years of Age General Parameters Girls usually grow faster than boys and commonly surpass them in height and weight Immune system- localization of infections and better antigen-antibody response Schoolagers develop immunity to wide number of organisms Nutritional Requirements 2400 calories/day Balanced diet- body is storing resources for the increased growth needs of adolescence May still be picky eater; May trade, sell or throw away home-packed school lunches Food jags Nutrition (FOOD PYRAMID) -- Patient is eating 3 meals a day. His mother prepares him a snack whenever he goes to school. Sleep Patterns Average sleep- 8-9.5 hours nightly

Reading before bedtime may facilitate sleep and set-up a positive bedtime pattern Children may be unaware of fatigue -- Patient sleeps 8-10 hours nightly in their home and sometimes he is requesting his mother to read his favorite bedtime story. Dental Health Beginning around age 6- permanent teeth erupt and child gradually loses teeth Regular dental visits are important, and fluoride supplements Brush hir teeth after meals with soft nylon toothbrush Caries, malocclusion, and periodontal disease become evident in age group -- Patient is brushing his teeth after meals and uses Colgate to prevent him from tooth decay. Elimination By age 6 years- 85% of children have full bowel and bladder habits Bowel Movement- 1-2 times per day Urination- 6-8 times per day --Urinates depending on how much fluid he intake. Eliminates depending also the amount of foods he eats. Urine output ranges to 800-550 cc every shift.Eliminates two times upon admission until he is discharge. Problems Nocturnal Enuresis (Bedwetting) Encopresis Bed wetting -- Patient is still experiencing Nocturnal Enuresis upto now. Gross and Fine Motor Skills Bicycling Roller skating, roller blading, and skateboarding Progressively improved running and jumping Swimming Printing in early years; script in later years (by age 8) Greater dexterity for crafts and video games Computer competence (manual skills) -- Patient is fond of riding bikes, playing arcade games and video games. He is also fond of surfing the internet and has a Facebook account. Safety Concerns Accept more responsibility for personal health care and injury prevention Still prone to accidents Should receive education about the use of alcohol, tobacco, and other drugs -- Patient is being taught by the mother not to try any vices. Psychosocial Development (Erik Erikson) Industry VS Inferiority Mastering industry--- desire for achievement INFERIORITY- sense of failing to meet standards others set for child Fears and Stressors

Parents and caregivers help reduce fear by communicating empathy and concern without being overproductive Common Fears Failure at school Bullies Intimidating teachers Something bad happening to parents Socialization Period of dynamic change and maturation Learns more about her body, social development centers on the body and capabilities Peer relationships gain new importance Group activities consume much time and energy -- Patients mother told us that his child is very curious when it comes to his body. He has his own best buddy at school. Play and Toys More competitive and complex Team sports, secret clubs, gang activities, scouting, other organizations, complex puzzles, collections, quiet board games, reading and hero worship Rules and Rituals are important Video games (Encourage parental monitoring of content to avoid exposure to gratuitous violence and sexual situations) -- Patient is energetic and is fond of playing games. Psychosexual Development (Sigmund Freud) Latency Period 5-12 years Represents a stage of relative sexual indifference before puberty and adolescence Development of sense of industry- Produce a concept of ones value and worth Language Formal adult articulation- ages 7-9 y.o. Ability to read is one of the most significant skills -- Patient is fluent in speaking and can understand simple English. Nursing Management Encourage healthy eating patterns Limit junkfood Teach basic food pyramid Foster sense of industry by encouraging the childs skill development Counsel families about safety measures for latchkey children Encourage open communication Foster responsibility with chores and adherence to family rules and schedules Encourage decision-making and individuality Encourage parents to get to know the childs peer group Reactions to Hospitalization Primary defense mechanism- REACTION FORMATION Reacts to separation by demonstrating boredom, isolation, and depression Fear of bodily injury and pain -- Patient cries whenever he feels pain. And sleeps when he is feeling bored.

XI.Case Discussion and Pathophysiology

NEPHROLITHIASIS
The process of stone formation, nephrolithiasis, is also called urolithiasis. "Nephrolithiasis" is derived from the Greek nephros(kidney) lithos (stone) = kidney stone . The stones themselves are also called renal caluli. The word "calculus" (plural: calculi) is the Latin word for pebble. Kidney stones typically leave the body by passage in the urine stream, and many stones are formed and passed without causing symptoms. If stones grow to sufficient size before passage on the order of at least 2-3 millimeters they can cause obstruction of the ureter. The resulting obstruction causes dilation or stretching of the upper ureter and renal pelvis (the part of the kidney where the urine collects before entering the ureter) as well as muscle spasm of the ureter, trying to move the stone. This leads to pain, most commonly felt in the flank, lower abdomen and groin (a condition called renal colic). Renal colic can be associated with nausea and vomiting. There can be blood in the urine, visible with the naked eye or under the microscope (macroscopic or microscopic hematuria) due to damage to the lining of the urinary tract.

What is a KIDNEY STONE? A kidney stone is a hard, crystalline mineral material formed within the kidney or urinary tract. Kidney stones are a common cause of blood in the urine (hematuria) and often severe pain in the abdomen, flank, or groin. Kidney stones are sometimes calledrenal calculi. Types of Kidney Stones:

Calcium Oxalate Kidney Stones

Calcium oxalate kidney stones are the most common, and are caused by a large amount of the needle shaped crystals in the kidney. These crystals can be found in the urine based on the food we eat and what we drinks. Calcium oxalate is common in rhubarb, kiwifruit, agave and spinach, or can also develop in beverages that are stored or brewed in barrels. These types of kidney stones cause about 80 percent of all cases, and also develop due to various metabolic issues.

Calcium Phosphate Kidney Stones

This is a larger group of compound that are defined as being any mineral containing calcium ions. These are the second most common type of kidney stones, and are developed due to various conditions within the metabolic system. Various thyroid diseases and acidosis can cause these stones to develop. While it was once believed that calcium rich diets encourage the development of these kidney stones, there is current evidence to the contrary.

Struvit Kidney Stones/ Staghorn Kidney Stones

This type of kidney stone is always associated with a UTI, or urinary tract infection. Bacteria that grows due to the urinary tract infection causes the development of the stone. Urea-splitting bacteria can be found in either the blood or directly in the kidneys, causing the stones to develop. The formation of staghorn kidney stones are which is the struvite stones are form in the urine infection which made by the mixture of calcium,ammonia and also the phosphate.Then the staghorn calculus is large strutive stone and it has irregular shape of staghorn kidney stone formation.

Uric Acid Kidney Stones

Acidic blood can cause this type of kidney stone, which is the cause of about 5 to 10 percent of all kidney stones. These are most commonly tested for by the examination of the pH level of a person's urine. People with this type of condition or a condition that causes acidic urine can have frequent kidney stones.

Cystine Kidney Stones

Cystinuria is a metabolic condition that form cystine crystals and kidney stones result. Cystinuria results in acidic urine, which encourages the development of the crystals. The condition also causes these body to not absorb these crystals like it normally would. These types of kidney stones are typically a chronic condition, with sufferers having multiple stones over time. STAGHORN KIDNEY STONE What is staghorn kidney stone? Normally kidney stones are smaller in size and varied in shapes which their range from sand particles to large size stone.According to that size and shape of the kidney stones which are struvite stones and its shape is large.so that we called that has a a staghorn kidney stone causes of staghorn kidney stones - chronic urinary infections are caused the staghorn kidney stone. - The urinary tract infection(UTI) which is caused by bacteria that produce the enzyme and increase the ammonia amount in urine which leads in produce of struvite stones and make it large and in the form of staghorn shape.

- some times uric acid stones also leads to become a cause for staghorn kidney stone. symptoms of staghorn kidney stone - common symptoms like ordinary kidney stone such as nausea vomiting pain while urination. - staghorn kidney stone which the staghorn calculi are on irregular in shape and large in size.so that common kidney stones like it is large in size and difficult to pass in ureter. How does staghorn kidney stones are formed? The formation of staghorn kidney stones are which is the struvite stones are form in the urine infection which made by the mixture of calcium,ammonia and also the phosphate.Then the staghorn calculus is large strutive stone and it has irregular shape of staghorn kidney stone formation. staghorn kidney stone treatment and staghorn kidney stone surgery The staghorn stones are treated by the ESWL(Extracorporeal Shock Wave Lithotripsy) which is a method that uses the high energy shock waves from the source outside of the body with the energy crush the stones into tiny pieces which is easy to pass out the body. Percutaneous Nephrolithotripsy which is done in the operation room which the staghorn kidney stone contain person has been given anesthesia.Then a small incision made in the persons flank through that a small instrument inserts and which is monitored and break the kidney stones and remove the stone fragments.This is staghorn kidney stone treatment because the large size kidney stones are removed through this method of treatment. Laser Lithotripsy surgery method of treatment which is also the inserts into the urether and focus the laser energy on the stone and fregment the stone. Causes of NEPHROLITHIASIS: Kidney stones form when there is a decrease in urine volume and/or an excess of stone-forming substances in the urine. The most common type of kidney stone containscalcium in combination with either oxalate or phosphate. Other chemical compounds that can form stones in the urinary tract include uric acid and the amino acid cystine. Dehydration from reduced fluid intake or strenuous exercise without adequate fluid replacement increases the risk of kidney stones. Obstruction to the flow of urine can also lead to stone formation. In this regard, climate may be a risk factor for kidney stone development, since residents of hot and dry areas are more likely to become dehydrated and susceptible to stone formation. Kidney stones can also result from infection in the urinary tract; these are known as struvite or infection stones. A number of different medical conditions can lead to an increased risk for developing kidney stones:

Gout results in chronically increased amount of uric acid in the blood and urine and can lead to the formation of uric acid stones. Hypercalciuria (high calcium in the urine), another inherited condition, causes stones in more than half of cases. In this condition, too much calcium is absorbed from food and excreted into the urine, where it may form calcium phosphate or calcium oxalate stones. Other conditions associated with an increased risk of kidney stones include hyperparathyroidism, kidney diseases such as renal tubular acidosis, and some inherited metabolic conditions, including cystinuria and hyperoxaluria. Chronic diseases such as diabetes and high blood pressure (hypertension) are also associated with an increased risk of developing kidney stones. People with inflammatory bowel disease or who have had an intestinal bypass or ostomy surgery are also more likely to develop kidney stones. Some medications also raise the risk of kidney stones. These medications include some diuretics, calcium-containing antacids, and the protease inhibitorindinavir (Crixivan), a drug used to treat HIV infection. Dietary factors and practices may increase the risk of stone formation in susceptible individuals. In particular, inadequate fluid intake predisposes todehydration, which is a major risk factor for stone formation. Other dietary practices that may increase an individual's risk of forming kidney stones include a high intake of animal protein, a high-salt diet, excessive sugar consumption, excessive vitamin D supplementation, and possible excessive intake of oxalate-containing foods such as spinach. Interestingly, low levels of dietary calcium intake may alter the calcium-oxalate balance and result in the increased excretion of oxalate and a propensity to form oxalate stones.

Signs and Symptoms of NEPHROLITHIASIS: SIGNS and SYMPTOMS MANIFESTED BY THE PATIENT /

Flank pain or back pain

o o o o o

on one or both sides progressive severe colicky (spasm-like) may radiate or move to lower in flank, pelvis, groin, genitals

/ / / / -

Nausea, vomiting Urinary frequency/urgency, increased (persistent urge to urinate) Blood in the urine Abdominal pain Painful urination Excessive urination at night Urinary hesitancy Testicle pain Groin pain Fever Chills Abnormal urine color

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Who is at risk for kidney stones? Anyone may develop a kidney stone, but people with certain diseases and conditions (see below) or those who are taking certain medications are more susceptible to their development. It is estimated that one out of every 10 people in the U.S. will develop stones in the urinary tract at some point in their lives. Most urinary stones develop in people 20-49 years of age, and those who are prone to multiple attacks of kidney stones usually develop their first stones during the second or third decade of life. In residents of industrialized countries, kidney stones are more common than stones in the bladder. The opposite is true for residents of developing areas of the world, where bladder stones are the most common. This difference is believed to be related to dietary factors. Urinary tract stones are about three times more common in males than in females. The prevalence of kidney stones begins to rise when men reach their 40s, and it continues to climb into their 70s. A Caucasian male has a one in eight chance of developing a kidney stone by age 70. People who have already had more than one kidney stone are prone to developing further stones. A family history of kidney stones is also a risk factor for developing kidney stones. Kidney stones are more common in Asians and Caucasians than in Native Americans, Africans, or African Americans. Uric acid kidney stones are more common in people with chronically elevated uric acid levels in their blood. A small number of pregnant women (about one out of every 1,500-3,000 pregnancies) develop kidney stones, and there is some evidence that pregnancy-related changes may increase the risk of stone formation. Factors that may contribute to stone formation during pregnancy include a slowing of the passage of urine due to increased progesterone levels and diminished fluid intake due to a decreasing bladder capacity from the enlarging uterus. Healthy pregnant women also have a mild increase in their urinary calcium excretion. However, it remains unclear whether the changes of pregnancy are directly responsible for kidney stone formation or if these women have another underlying factor that predisposes them to kidney stone formation. Diagnosis of Nephrolithiasis: The diagnosis of a kidney stone can be confirmed by radiological studies and/or ultrasound examination; urine tests and blood tests are also commonly performed. When a stone causes no symptoms, watchful waiting is a valid option. In other cases, pain control is the first measure, using for example non-steroidal anti-inflammatory drugs or opioids. Using soundwaves, some stones can be shattered into smaller fragments (this is called extracorporeal shock wave lithotripsy). Sometimes a procedure is required, which can be through a tube into the urethra, bladder and ureter (ureteroscopy), or a keyhole or open surgical approach from the kidney's side. Sometimes, a tube may be left in the ureter (a ureteric stent) to prevent the recurrence of pain. Preventive and structive measures are often advised such as drinking sufficient amounts of water and milk although the effect of many dietary interventions has not been rigorously studied.

X-rays
The relatively dense calcium renders these stones radio-opaque and they can be detected by a traditional X-ray of the abdomen that includes the kidneys, ureters and bladderKUB.[25] This may be followed by an IVP (intravenous pyelogramintravenous urogram (IVU) is the same test by another name) which requires about 50 ml of a special dye to be injected into the bloodstream that is excreted by the kidneys and by its density helps outline any stone on a repeated X-ray. These can also be detected by a retrograde pyelogram where similar "dye" is injected directly into the ureteral opening in the bladder by a surgeon, usually a urologist. About 10% of stones do not have enough calcium to be seen on standard X-rays (radiolucent stones).

Computed tomography
Computed tomography without contrast is considered the gold standard diagnostic test for the detection of kidney stones. All stones are detectable by CT except very rare stones composed of certain drug residues in the urine. If positive for stones, a single standard X-ray of the abdomen (KUB) is recommended. This gives a clearer idea of the exact size and shape of the stone as well as its surgical orientation. Further, it makes it simple to follow the progress of the stone by doing another X-ray in the future. Drawbacks of CT scans include radiation exposure and cost.

Ultrasound
Ultrasound imaging is useful as it gives details about the presence of hydronephrosis (swelling of the kidneysuggesting the stone is blocking the outflow of urine). It can also be used to detect stones during pregnancy when x-rays or CT are discouraged. Radiolucent stones may show up on ultrasound however they are also typically seen on CT scans. Some recommend that US be used as the primary diagnostic technique with CT being reserved for those with negative US result and continued suspicion of a kidney stone. This is due to its lesser cost and avoidance of radiation. Other Other investigations typically carried out include:

Microscopic study of urine, which may show proteins, red blood cells, bacteria, cellular casts and crystals. Culture of a urine sample to exclude urine infection (either as a differential cause of the patient's pain, or secondary to the presence of a stone). Blood tests: Full blood count for the presence of a raised white cell count (Neutrophilia) suggestive of infection, a check of renal function and to look for abnormally high blood calcium blood levels (hypercalcaemia). 24 hour urine collection to citrate, oxalate and phosphate. measure total daily urinary volume, magnesium, sodium, uric acid, calcium,

Catching of passed stones at home (usually by urinating through a tea strainer or stonescreen) for later examination and evaluation by a doctor.

Prevention of Kidney Stones: 1. Eat less meat. Due to increased intake of animal proteins, the incidence of kidney stones is 10 times more prevalent now than it was at the turn of the century. 2. Drink plenty of fluids - one study has shown that people who drink more than 2 1/2 liters of water every day have almost a 40 percent decrease in the risk of developing a stone than those who drank less water. 3. Limit consumption of grapefruit juice and cola drinks. Studies have shown that these may actually increase the risk of developing stones. 4. Adopt a diet high in potassium and magnesium - these minerals decrease the likelihood of kidney stones. 5. Talk to your doctor about taking supplements such as pyridoxine and magnesium. Taken together, these reduce oxalate, a mineral salt found in kidney stones. 6. Limit your calcium and salt intake. Other:

Eat nutritious food: Cut down meat, calcium, and salt intake from your diet. Drink plenty of water: Drinking more than 2 liters of fluid every day will decrease the risk of developing kidney stones. Cut down consumption of grapefruit and soda drinks. These can actually increase the risk of having kidney stones. Consume food items that are high in potassium: (bananas, prunes, apricots, watermelon, and strawberries) and magnesium (cashews, almonds, pumpkin seeds, brazil nuts, spinach, white and black beans) because they decrease the likelihood of kidney stones.

Consult your doctor about taking supplements like pyridoxine and magnesium. These will reduce oxalate, a mineral salt found in kidney stones.

If kidney stones have developed already, you can dissolve them with 1 cup of concentrated lemon juice mixed with 1 quart of water. Simply drink it twice a day. But if it cant dissolve the stones, then see your doctor. You should also pay attention to other organs like your gallbladder. You can prevent gall stones by watching the level of your cholesterol. Try visiting web md for other helpful health tips. These are the things that you can do to prevent gallbladder and kidney stones. So the next time you crave for meat think again. Watch your diet! Treatment of Kidney Stones: If your doctor thinks the stone can pass on its own, and you feel you can deal with the pain, he or she may suggest home treatment, including:

Using pain medicine. Nonprescription medicine, such as nonsteroidal anti-inflammatories (NSAIDs), may relieve your pain. Your doctor can prescribe stronger pain medicine if needed. Drinking enough fluids. You'll need to keep drinking water and other fluids when you are passing a kidney stone. If you don't get enough fluids, you could get dehydrated. Drink enough fluids to keep your urine clear, about 8 to 10 glasses a day. If you have kidney, heart, or liver disease and are on fluid restrictions, talk with your doctor before increasing your fluid intake.

Your doctor may prescribe medicine to help your body pass the stone. Alpha-blockers have been shown to help kidney stones pass more quickly with very few side effects. Ask your doctor if these medicines can help you. If your pain is too severe, if the stones are blocking the urinary tract , or if you also have an infection, your doctor will probably suggest medical or surgical treatment. Your options are:

Extracorporeal shock wave lithotripsy (ESWL) . ESWL uses shock waves that pass easily through the body but are strong enough to break up a kidney stone. This is the most commonly used medical treatment for kidney stones. See a picture of ESWL . Ureteroscopy. The surgeon passes a very thin telescope tube (ureteroscope) up the urinary tract to the stone's location, where he or she uses instruments to remove the stone or break it up for easier removal. Occasionally, you may need a small hollow tube (ureteral stent) placed in the ureter for a short time to keep it open and drain urine and any stone pieces. Ureteroscopy is often used for stones that have moved from the kidney to the ureter. See a picture of ureteroscopy . Percutaneous nephrolithotomy or nephrolithotripsy. The surgeon puts a narrow telescope into the kidney through a cut in your back. He or she then removes the stone (lithotomy) or breaks it up and removes it (lithotripsy). This procedure may be used if ESWL does not work or if you have a very large stone. See a picture ofnephrolithotomy. Open surgery. The surgeon makes a cut in the side or the belly to reach the kidneys and remove the stone. This treatment is rarely used.

PREVENTION Avoid protein intake; usually protein is restricted to 60g/day to decrease urinary of calcium and uric acid. A sodium intake of 3-4 g/day is recommended. Table salt and high-sodium foods should be reduced, because sodium competes with calcium for reabsorption in the kidneys. Low-calcium diets are not generally recommended, except for true arsorbtive hypercalciuria. Evidence shows that limiting calcium, especially in women, can lead to osteoporosis and does not prevent renal stones.

Avoid intake of oxalate-containing foods (e.g, spinach, strawberries, rhubarb, tea, peanuts, and wheat bran). During the day, drink fluids (ideally water) every 1 to 2 hours. Drink two glasses of water at bedtime and an additional glass at each nighttime awakening to prevent urine from becoming too concentrated during the night. Avoid activities leading to sudden increases in environmental temperatures that may cause excessive sweating and dehydration. Contact your primary health care provider at the first sign of a urinary tract infection.

MEDICAL MANAGEMENT The goals of management are to eradicate the stone, determine the stone type, prevent nephron destruction, control infection and relieve any obstruction that may be present. The immediate objective of treatment of renal or ureteral colic is to relieve the pain until its cause can be eliminated. Opioid analgesic agents are administered to prevent shock and syncopethat may result from the excruciating pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating renal stone pain because they provide specific pain relief. They also inhibit the synthesis of prostaglandin E, reducing swelling and facilitating passage of the stone. Generally once the stone has passed, the pain is relieved. Hot baths or moist heat to the flank areas may also be helpful. Unless the patient is vomiting or has heart failure or any other condition requiring fluid restriction, fluids are encouraged. This increases the hydrostatic pressure behind the stone, assisting it in its downward passage. A high, around-the-clock fluid intake reduces the concentration of urinary crytalloids, dilutes the urine, and ensures a high urine output. NURSING INTERVENTION/MANAGEMENT Relieving pain Severe acute pain is often the presenting symptom of a patient with renal or urinary calculi and requires immediate attention. Opioid analgesic agents (IV or intramuscular) may be prescribed and administered to provide rapid relief along with an IV NSAID. The patient is encouraged and assisted to assume a position of comfort. If activity brings pain relief, the patient is assisted to ambulate. The pain level is monitored closely, and an increase in severity is reported promptly to the physician so that relief can be provided and additional treatment initiated. Monitoring and Managing Potential Complications Increase fluid intake is encouraged to prevent dehydration and increase hydrostatic pressure within the urinary tract to promote passage of the stone. If the patient cannot take adequate fluids orally, IV fluids are prescribed. The total urine output and patterns of voiding are monitored. Ambulation is encouraged as a means of moving the stone through the urinary tract. All urine is strained through gauze because uric acid stones may crumble. Any blood clots passed in the urine should be crushed and the sides of the urenal and bedpan inspected for clinging stones. Because renal stones increase the risk o infection, sepsis, and obstruction of the urinary tract, the patient is instructed to report decrease urine volume, bloody or cloudy urine, fever and pain. Patients with calculi require frequent nursing observation to detect the spontaneous passage of a stone. The patient is instructed to immediately report any sudden increases in pain intensity because of the possibility of a stone fragment obstructing a ureter. Vital signs, including temperature, are monitored closely to detect early signs of infection. UTIs may be associated with renal stones due to an obstruction from the stone or from the stone itself. All infections should be treated with the appropriate antibiotic agent before efforts are made to dissolve the stone. Promoting Home and Community Based Care TEACHING PATIENT SELF-CARE. Because the risk of recurring renal stones is high the nurse provides education about the causes of kidney stones and recommendations to prevent the recurrence. The patient is encouraged to follow a regimen to avoid further stone formation, including maintaining a high fluid intake because stones form from more readily concentrated urine. A patient who has shown a tendency to form stones should drink enough fluid to excrete greater than 2000 ml (preferably 3000-4000 ml) of urine every 24 hrs.

Urine culture may be performed every 1 to 2 months the first year and periodically thereafter. Recurrent UTI is treated vigorously. Because prolonged immobilization slows renal drainage and alters calcium metabolism, increase mobility is encouraged whenever possible. In addition, excessive ingestion of vitamins (esp. vitamin D) and minerals is discouraged. If lithotripsy, percutaneous stone removal, ureteroscopy, or other surgical procedures for stone removal have been performed, the nurse instructs the patient about the signs and symptoms of complication that need to be reported to the physician. The importance of follow-up to assess kidney function and to ensure the eradication or removal of all kidney stones is emphasized to the patient and family. Is ESWL has been performed, the nurse must provide instructions for home care and necessary follow-up. The patient is encouraged to increase fluid intake to assist in the passage of stone fragments, which may occur for 6 weeks several months after the procedure. The patient ad the family are instructed about signs and symptoms of complication. It is also important to inform the patient to expect hematuria (it is anticipated in all patients), but it should disappear within 4 t 5 days. If the patient has a stent in the ureter, hematuria may be expected until the stent is removed. The patient is instructed to check his or her temperature daily and notify the physician if the temperature is greater than 38 c (about 101 F) or the pain is unrelieved by the prescribed medication. The patient is already informed that a bruise may be observed on the treated side of the back. CONTINUING CARE. Close monitoring of the patient in follow up case ensures that treatment has been effective and that no complications have developed.

XIII.Medica l Manageme nt

XIV.Nursing Management (Nursing Care Plan)

XV.Discharge Planning
Medications: Encourage the significant others to have a strict compliance with regards to the medication to attain therapeutic effects. Instruct to take the following take home medications at the right dose, time frequency and route. 1. Ranitidine 25 mg Instruct the significant others to report adverse reaction promptly. Explain the medication how they work, there side effects, and precautions.

 Advise to continue the medication as ordered by the physician. Environment: Instruct the significant others to maintain a clean environment conductive to health for immediate recovery and maintenance of health. Emphasize proper environmental sanitation. Home environment must be free from slipping or accident hazards. Treatment: Comply with the medication administration prescribed by the doctor. Encourage the client to relax and have adequate rest. Emphasize the importance of regular follow-up check-ups and as instructed by physician.

Health Teachings: Practice good hygiene by brushing teeth, taking a bath and grooming. Practice good preventive measures by eating proper diet. Encourage the patient to have adequate rest. Instruct patient to increase intake of protein-rich foods to promote faster wound healing. Advised significant others to accompany the patient at all times.

Observable Signs and Symptoms: Instruct the significant others to return to their attending physician for scheduled follow up visit. Encourage the significant others to take good care of patients health. Diet: Instruct the patient to eat at the right time. Encourage the patient to increase fluid intake. Inform patient that there are no restrictions in the diet except for foods that could interact & delay absorption of some medications, & those that are included in his food allergy- list. Eat food low in protein, nitrogen and sodium. Take some fruit juices , such as orange, and cranberry. Orange juice may help prevent calcium oxalate stone formation, and cranberry may help with UTI-caused stones. Spirituality: Emphasized the importance of prayers in healing. Encouraged to ask for divine assistance in everything. Encouraged to continue to pray to God. Encouraged to continue to have a positive outlook in life.

 Encouraged to keep faith in God and not to give up easily when hard times come. Encouraged patient and Family members to go to church every Sunday. Recognize the importance for familys support in dealing such situation.