Date: October 3, 2022 Name: Viviana Cadena

Noticing, Interpreting, Responding & Reflecting

Concept: Elimination

Suggested Elimination Nursing Assessment Skills to be Demonstrated

Inspection: skin (coloration, vascularity, striae, scars, lesions, rashes)
• Contour – (flat, rounded, scaphoid, protuberant/distended)
• Umbilicus – contour
• Symmetry (relaxed, supine position)
• Abdominal movement during breathing
• Aortic pulsations
Auscultation: (completed before palpation/percussion to not alter bowel sounds)
• Bowel sounds – 1 minute per quadrant up to 5 minutes with the diaphragm
• Intensity, pitch, frequency
• Vascular sounds – listen for bruits with bell.
Percussion:
• Percuss for tone in a systematic fashion to all quadrants
• Percuss liver span
• Dull percussion to liver and kidney (costovertebral angle – 12 th rib)
• Tympany to other parts of the abdomen
Palpation:
• Light palpation to all quadrants – 1 to 2 cm to detect tenderness
o Deep palpation to all quadrants – 5 to 6 cm for masses (location, size, shape, pulsatility,
mobility, tenderness)
• Palpate bladder- light palpation ONLY; you only want to assess to see if it is distended
• Palpate liver
• Palpate spleen
• Palpate kidneys

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Present Problem:
Jenna Simpson is a 24-year-old Caucasian female who weighs 210 pounds (95.5 kg-BMI of 36.5) who
presents to the emergency department with sudden onset of sharp pain in the right side of her lower back
that radiates to the right side of her abdomen and into her groin. The pain started ten hours ago, but lasted
only 15 minutes and then went away. She took ibuprofen 600 mg PO an hour ago but has not helped, and
the pain persists.
She states that this pain is different than when she has epigastric pain because of gastroesophageal reflux
disease (GERD). She feels nauseated but has not vomited. Jenna appears uncomfortable and pleads with
the triage nurse, “Please do something to get rid of this pain! What is wrong with me?”

What data from the present problem did you NOTICE initially and must be interpreted as clinically
significant by the nurse? (Reduction of Risk Potential)

RELEVANT Data from Present Problem: Clinical Significance:

 Sudden onset of sharp pain in the right side of her
lower back that radiated to the right side of her
abdomen into the groin
 600 mg ibuprofen 1h ago did not help with the pain
 She mentions she suffers from GERD, but that this
pain is different from her GERD pain
 Nausea without vomiting
 Jenna appears uncomfortable and pleads with
the triage nurse, “Please do something to get rid
of this pain! What is wrong with me?”
 Due to the location of the pain, the kidney or
ureters are likely affected. The fact that it’s a
sudden onset is very concerning and requires
further investigation.
 Pain is not getting better with analgesic
medication which is also a reason for concern.
The source of the pain needs to be found so the
problem can be addressed.
 It is important to know that she has other
conditions that may cause epigastric pain and that
the current source of her pain is not the same.
Because this pain is different, this is quite
concerning and the source of the pain needs to be
investigated.
 Nausea and acute onset of pain on the side of
lower back may be an indication of
nephrolithiasis.
 She is in very severe pain which is an additional
cause for concern and indicates that the pain
needs to be addressed (request an order from the
provider for pain medication) and the patient
needs to be assessed and the source of the pain
investigated as soon as possible.

 Due to all the relevant data presented above, labs

and other diagnostic tests are required to pinpoint
the source of the pain. However, the symptoms
she presents with point towards renal calculi.

What is the INTERPRETATION of your patient’s past medical history (PMH) and
current meds? (Which medication treats which condition? Draw lines to connect.)
PMH: Home Meds: Pharm. Class: Mechanism of Action
(own words):

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Anxiet Alprazolam 0.5 mg  Benzodiazepine  Anxiolytic. Acts
y PO every 8 hours through depression of
PRN CNS. Enhances the
effects of GABA

Pantoprazole 10  Proton Pump  Inhibits HCL secretion

Gastroesophageal reflux
disease (GERD)
mg PO Inhibitor in the stomach by
BID binding to an enzyme in
the presence of acid, and
this prevents transport
of H+ into the stomach.

Jenna is quickly brought to a room. You are the nurse and quickly collect the following assessment data:

Current VS: P-Q-R-S-T Pain Assessment:

T: 98.9 F/ 37.2 C (oral) Provoking/Palliative: Nothing changes the level of pain
P: 92 (regular) Quality: Sharp, severe
R: 28 (regular) Region/Radiation: Right back/flank that radiates into RLQ and groin
BP: 148/84 Severity: 10/10
O2 sat: 99% room air Timing: Constant the past hour
What vital signs are abnormal? What is the reason (pathophysiology) for these findings? (Interpreting)
(Reduction of Risk Potential/Health Promotion and Maintenance)
Abnormal VS: Clinical Significance:
 Pain: 10/10  Pain is very severe, indicating that something is very wrong. Pain needs to be
 P: 92 (regular) managed and the source of the pain needs to be investigated. Assessment of the
 BP: 148/84 (high) quality, degree and location of the pain is important to help determine the source
 RR: 28 (high) of the pain.
 O2 Sat = 99%  Although Jena is not tachycardic, her heart rate is quite high. Her blood pressure
is also high and she is tachypneic. All of these are physiological manifestations of
pain and anxiety that goes along with that severe pain.
 O2 Sat is 99%. The fact that her O2 levels are normal points to pain for the source
of her tachypnea, since low O2 saturation is not driving the increase in respiratory
rate.

Current Physical
Assessment:
GENERAL Obese female is sitting upright in bed. Alert, oriented, pleasant, in moderate distress,
APPEARANCE: dress appropriate for the season, hygiene and grooming normal for age and gender,
anxious, body tense, + grimacing, appears to be uncomfortable.
RESP: Breath sounds clear on inspiration and expiration in all lobes anteriorly, posteriorly,
and laterally, with equal aeration bilaterally ant/post, nonlabored respiratory effort
with + tachypneic. Posture erect, sitting in bed, in moderate distress, on room air, AP
diameter 1:2, symmetry of the thoracic cavity noted with inspiration and expiration
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses
strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill,
carotid pulse 3+ and regular bilaterally. Heart tones audible and regular, S1 and S2,
noted over the 5 cardiac landmarks with no abnormal beats or murmurs. No JVD

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 noted at 30-45 degrees.
NEURO: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in
both upper and lower extremities bilaterally.
GI: Abdomen flat, soft, bowel sounds audible per auscultation in all four quadrants,
nontender to gentle palpation in all four quadrants
GU: Voiding without difficulty, dark amber/rusty color with recent void to collect urine
specimen
INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3
seconds. Hair short, brown, soft. Hair distribution normal for age and gender. Skin
integrity intact, skin turgor elastic, no tenting present

What assessment findings are abnormal? What is the reason (pathophysiology) for these
findings? (Interpretation) (Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data: Clinical Significance:
 General Appearance: Anxious,  Indicators of severe pain
body tense, + grimacing, appears
to be uncomfortable.
 Respiratory: Breath sounds clear  No abnormal findings in respiratory assessment aside from the
on inspiration and expiration in all tachypnea, confirming that the high respiratory rate is not due to a
lobes anteriorly, posteriorly, and respiratory problem, but likely due to pain and anxiety
laterally, with equal aeration
bilaterally ant/post, nonlabored
respiratory effort with +
tachypneic.
 Neurological: Alert & oriented to  Once again, she appears anxious. The tingling in her fingers could
person, place, time, and situation be due to hyperventilation. Hyperventilation leads to excessive
(x4), appears anxious, c/o tingling exhalation of CO2 (low O2 in the blood, which leads to
in fingers that just started five vasoconstriction. This vasoconstriction leads to a reduction of
minutes ago. blood supply to the brain, which can result in tingling of fingertips.
 Gastrointestinal: Abdomen flat,  The GI assessment results are normal and she is nontender to
soft, bowel sounds audible per palpation in all four quadrants. This indicates that her problem is
auscultation in all four quadrants, not gastric, pointing once again to a renal issue.
nontender to gentle palpation in all
four quadrants.
 Genitourinary: Voiding without  Amber/rusty colored urine is likely due hematuria. This, along with
difficulty, urine dark amber/rusty the sudden onset of severe flank pain points to kidney stones as the
color with recent void to collect most likely explanation of her symptoms.
urine specimen

Put it All Together and Think Like a Nurse!

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1. Interpreting relevant clinical data, what is the most likely primary problem? What body system(s)
will you assess most thoroughly based on the primary/priority concern?
What’s the What’s causing the PRIORITY Body
problem? problem? (explain System to Assess:
pathophysiology in OWN
words)
Urolithiasis Urolithiasis, or renal stones form due to three factors:  Genitourinary
1) Supersaturation: Crystals may form when the  Gastrointestinal/Abdominal
concentration of an insoluble salt in the urine is too
high, Normally, these crystals are eliminated due to the
week bonds that hold these crystals together. 2)
Nucleation is when the nuclei of crystals develop
stronger bonds such that the crystals do not disperse,
and instead form stones. An increase in the high
ingestion of insoluble salts or a decrease in fluid intake
can trigger the formation of renal calculi. 3) The third
factor that affects the formation of kidney stones is the
presence or absence of substances that inhibit the
formation of calculi and how acidic or alkaline is the
urine.

2. How will you RESPOND? What is the current nursing priority and plan of care?
Nursing PRIORITY:

PRIORITY Nursing Rationale: Expected Outcome:

Response :
 Administer pain  The patient is in a lot of pain and it
medication as ordered by needs to be managed
physician
 Monitor I & O  Because urinary obstruction can
occur with renal calculi, it is
important to monitor urinary
output to be alert for this
complication. Patient should also
have a 2L intake of water/day,
which will help to pass the stone.
 Administer all  Dr. might order thiazide diuretics
medications as or other medications to promote
prescribed passing/breaking up of the stone,
or to prevent future stones from
 Encourage activity such forming
as walking  This increases metabolism, which
increases thirst and urination. This
will help pass the stone
 Patient will report a decrease in
pain to a manageable level
according to the patient’s
tolerance, 30 minutes after
medication administration.
 The patient will drink at least 2L of
water, and pass 2L of urine every
24 h of stay at the hospital
 Patient will be able to pass the
stone within 24 h of presenting to
the ED
 Patient will not develop new kidney
stones in the future
 Patient will be able to pass the
stone within 24 h of presenting to
the ED. Patient will not develop

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 Educate patient
regarding dietary
changes necessary to
prevent formation of
renal calculi
 If surgery is necessary,
provide patient with
preoperative education
 Reduced intake of oxalate-rich
foods, salt, animal protein and
calcium will help prevent future
formation of kidney stones
 To prepare the patient for the
procedure
new kidney stones in the future
 Patient verbalizes understanding of
new dietary limitations and
willingness to follow new diet.
 Patient will verbalize understanding
of the procedure they will undergo
and of any preparatory measures
they need to take

3. State the rationale and expected outcomes for the medical plan of care.
Medical Management: Rationale: Expected Outcome:
Establish peripheral IV To be able to administer fluids and medication IV is established and will
remain patent

Hydromorphone 1 mg Narcotics are powerful medications in the Patient will report a

IVP management of severe pain. Adequate pain decrease in pain to a
management will improve the patient’s quality of manageable level to the
life, and their ability to cope with the situation and patient 15 minutes after
reduce anxiety. Hydromorphone provides pain pain medication
relief in 10 -15 min of administration administration.

Ketorolac 15 mg IVP
The combination of an opioid with an NSAID Patient will report a
provides rapid pain control. Pain relief is achieved decrease in pain to a
after 10 minutes of administration and lasts 6-8 h. manageable level to the
patient 15 minutes after
pain medication
administration.

Ondansetron is an antiemetic medication that will Patient will report a

Ondansetron 4 mg IVP help control the patient’s nausea decrease in nausea to a
tolerable level

Radiology Reports:
What diagnostic results are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
Radiology: CT Pelvis
Results: Clinical Significance:
4 mm stone in the distal The reason for the patient’s severe pain is a kidney stone
right ureter
Lab Results:
Urinalysis + UA
Micro
Color: Clarity: Sp.Gr. Glucose Ketone LET RBCs WBCs Bacteria Epithelial
Pearson Light straw Transparen 1.005- Neg Neg Neg None <4 None None
p. 284 to amber t 1.030
yellow Clear

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Current: Dark Clear 1.012 Neg Neg Neg >100 2 None None
amber/
Rusty
LET (Leukocyte Esterase Test) wbc. Normal to have a few, high number will yield a + result.

What lab results are RELEVANT and must be recognized as clinically significant by the
nurse? (Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Clinical Significance:
Lab(s):
 Color: Dark  Dark urine can mean dehydration. The rusty color is probably due to hematuria
amber/rusty
 RBCs > 100  Elevated due to bleeding from the stone scraping/scratching the epithelial walls of
the ureters. This is expected with kidney stones.

Complete Blood Count (CBC)

Pearson WBC HGB PLTs % Neuts Bands
Page 579 (4.5-10) (12-16 g/dL) (150-450 x103/µl) (50-70%) (0-5 or 8%)
Current: 10.2 14.2 285 72 0

Neutrophils: 50-70% (most abundant type) of all white blood cells-first line of defense against
bacteria.
Bands: 0-5 or 8% young, immature polymorphonuclear neutrophils, found in acute
infections.

RELEVANT Clinical Significance:

Lab(s):
 WBC: 10.2  All labs WNL, indicating absence of infection or anemia, and normal clotting factors.
 Hgb: 14.2
 Platelets: 285
 Neutrophil %:
 72 Bands: 0
Reflection: Thirty Minutes Later…
Evaluate the response to nursing and medical interventions.
All orders have been implemented.
What would be the EXPECTED response in clinical data collected if her pain and anxiety are
decreased?

Current VS: Most Recent: Current PQRST:

T: 98.9 F T: 98.9 F/ 37.2 C Provoking/Palliative:
(oral)
P: 70 P: 92 (regular) Quality:
R: 18 R: 28 (regular) Region/Radiation:

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BP: 110/70 BP: 148/84 Severity: 2/10
O2 sat: 99% O2 sat: 99% room air Timing:

Current Assessment:
GENERAL Patient appears comfortable and calm
APPEARANCE:
RESP: Breath sounds clear on inspiration and expiration in all lobes anteriorly, posteriorly, and
laterally, with equal aeration bilaterally ant/post, nonlabored respiratory effort.
Respiratory rate WNL
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses
strong, equal with palpation at radial/pedal/post-tibial landmarks. Pulse and BP WNL
NEURO: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both
upper and lower extremities bilaterally. No complaints of tingling in her fingers
GI: Abdomen flat, soft, bowel sounds audible per auscultation in all four quadrants,
nontender to gentle palpation in all four quadrants, nausea has subsided.
GU: Amber colored urine, 4 mm stone in the distal right ureter, stone has not passed yet
INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. Skin integrity intact, skin turgor
elastic, no tenting present

1. What data is RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction
of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data:
All of the data is relevant
RELEVANT
Assessment
Data:
 Resting comfortably,
appears in no acute
distress
 Nonlabored respiratory
effort
 Nausea has subsided
 4 mm stone in the distal
right ureter, stone has
not passed yet
Clinical Significance: TREND:
Improve/Worsening/Stable:
Reduction in pain level and all VS Improved
WNL indicate a reduction in pain and
anxiety, in response to pain medication
administration
Clinical Significance: TREND:
Improve/Worsening/Stable:
 Pain is being adequately managed Improved
but the stone still needs to pass
which means continuous monitoring
of pain and physiological responses
to pain, so it can continue to be
adequately managed.

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2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care
need to be modified after this evaluation assessment? (Management of Care, Physiological Adaptation)
Evaluation of Current Status: Modifications to Current Plan of Care:
Status has improved No modifications to the current plan are necessary at this
point

3. What did you learn that you can apply to future patients in your care? Reflect on your current
strengths and weaknesses this case study identified. What is your plan to make any weakness a
future strength?
What Did You Learn? What did you do well in this case study?
Signs and symptoms of urolithiasis, and Identify possible interventions to aid in passing
nursing interventions and preventing kidney stones
What could have been done better? What is your plan to make any weakness a future
strength?
Understand the pharmacology for treatment and Study the medications and understand their
prevention of kidney stones mechanisms of action