RENAL/GENITO-URINARY DISORDER

CASE: You are a registered nurse assigned in the emergency department (ED) on warm summer day.
Russel, an 18-year-old woman, comes to the ED with severe left flank and abdominal pain and nausea
and vomiting. Russel looks very tired, her skin is warm to the touch, and she is perspiring. She paces
about the room doubled-over and is clutching her abdomen. Russel tells you that the pain started early
this morning and has been pretty steady for the past 6 hours. She gives a history of working outside as a
landscaper and takes little time for water breaks. Her past medical history includes three kidney stone
attacks, all during late summer.
Exam findings are that her abdomen is soft and without tenderness, but her left flank is extremely
tender to the touch, palpation, and percussion. You place Russel in one of the examination rooms and
take the following vital signs (VS): 188/98, 90, 20, 99° F. A voided urinalysis (UA) shows RBC of 50 to 100
on voided specimen and WBC of zero.

1. What could be the cause of the blood in her urine? How could you rule out some of these causes?
• Severe or frequent dehydration is a cause of her having blood in her urine because, as stated in the
scenario, she takes short water breaks and is a landscaper, so the patient is exposed to sunlight and
sweats most of the time. She must rehydrate in order for his body to regain strength and for toxins in
her body to be released through urination. Water is extremely important to our human bodies.

2. The physician orders an intravenous pyelogram (IVP). Discuss briefly IVP. What questions do you need
to ask Russel before the test is conducted? What blood tests do you need to check before her having an
IVP?
• IVP is a type of x-ray that uses iodinated contrast material injected into the veins to examine your
kidneys, ureters, and urinary bladder.
• The following questions will be asked: "How many times have you urinated in a day?"
", "Have you eaten in the last few hours or after midnight before your surgery?"
 Creatinine is a blood test that must be checked prior to the IVP.

3. Russel states she had an allergic reaction during her last IVP and was instructed, “Don't let anyone
give you dye for any testing.” The physician cancels the IVP; what alternative test will be conducted?
 Computerized tomography (CT) scan
 Magnetic Resonance Imaging (MRI)

CASE STUDY PROGRESS: The non-contrast CT scan shows a left 2-mm ureteral vesicle junction stone.

4. What are the two most common types of stones?

 Calcium oxalate stones
 Struvite

5. What is the most likely cause of Russel 's stone?

 The cause of Russel’s stone is chronic dehydration.

6. Identify two methods of treating a patient with a ureteral vesicle junction stone.
 - Ureteroscopy - this procedure uses an ureteroscope to locate a stone in the kidney or
ureter.
 Shock Wave Lithotripsy (SWL) - uses a machine called a lithotripter to break up stones.
CASE STUDY PROGRESS: Russel was discharged with instructions to strain all urine and return if she
experienced pain unrelieved by the pain medication or increased nausea and vomiting (N/V).

7. What specific instructions will you give Russel about her urine, fluid intake, medications, and
activity?
- Avoid dehydration or overhydration to make the stone's passage less painful.
- Teach the patient how to strain the urine to check for stone

CASE STUDY PROGRESS: Russel returns to the ED in 6 hours with complaints of pain unrelieved by the
pain medication and increased blood in her urine. She is being held in the ED until she can be
transported to surgery.

8. What is the immediate plan of care for Russel?

- The immediate plan of care is to relieve the patient's pain and eliminate the cause.
CASE STUDY PROGRESS: A 2-mm calculus was removed by basket extraction. Pathologic examination
reported the stone to be calcium oxalate.

9. If Russel continues to form stones, what recommendations would the physician make for Russel?
- Monitor pH of her urine
- Drink at least 3L of water per day to reduce the formation of stones

10. Now that Russel's stone has been reported as calcium oxalate, she is referred to a registered
dietitian for guidance on a diet that will prevent further development of stones. Which statements are
true regarding recommendations for Russel's diet? (Select all that apply.)
A. Decrease animal protein intake.
B. Avoid eating organ meats, poultry, fish, gravies, red wine, and sardines.
C. Avoid spinach, black tea, coffee, rhubarb, chocolate, beets, wheat bran, and nuts.
D. Decrease sodium intake.
E. Drink at least 3 to 4 liters of water each day.

CASE STUDY OUTCOME: Russel recovers from this most recent episode and continues to follow the
protocol for fluid intake and dietary measures. One year later, she has yet to report a recurrence of
stones.