Mcm

This

is a case of Mr. R.K., a 42 year old, married male and is residing at Muntinlupa City. He was admitted to Medical Center of Muntinlupa on August 9, 2009 at 3:15 am. Upon admission, patient chief complaint was low back

a

Blood Pressure of 130/100mmHg, Pulse Rate of 74, Respiratory Rate of 24 and a Temperature of 36.7 C. 3 days prior to admission the patient experienced pain in his back.

He

take buscopan to relief the pain but unfortunately the pain does not relief so the patient and his wife decided to consult the doctor in MCP. The final diagnosis is urolythiasis.

After

the case discussion, the student’s will be able to obtain knowledge regarding the case: UROLYTHIASIS

Obtaining

a good nursing history and how the disease of the patient progressed. To be able to perform Physical Examination To be able to understand the underlying process/Pathophysiology basis of the patient

To

be able to explain the laboratory values

  To

be able to understand the medications taken

To

be able to formulate a good and reliable nursing interventions

To

be able to implement those nursing interventions and learn to evaluate its effects on the patients condition

According

to the care giver the patient’s activity before hospitalization was going to gym for 1-1 1/2 hours. Financing health care wouldn’t be a problem for his children’s are capable of providing everything.

He is taking buscopan with doctor’s prescription. Patient has no allergies. His father has hypertension. He was hospitalized on August 09, 2009 due to low back pain.

Patient’s

present diet is low salt low fat diet. There are no religious restrictions in terms of food. His usual meal is composed of carbohydrates, protein, fats, and water.

He doesn’t take any food supplements. He has a good appetite. His highest weight 140 lbs and his lowest weight is 130 lbs.

Patient

usually urinates 56 times per day during his stay in the hospital as a measurement for his voiding pattern. His urine has a characteristic of yellow in color and aromatic.

His bowel pattern is ones a day with a characteristic of soft and brown stool. He perspires heavily in certain instances like when walking, and when the weather is humid or hot. Patient drinks a lot of water. He has no disease on digestive and

The

patient exercises 1 to 1 1/2 hour 3 times a week before he was hospitalized by means of going to gym. He doesn’t feel any serious discomfort after patient exercised.

The

patient has no problem with his eyes and other senses. He is able to express himself clearly and logically.

The

patient normally sleeps 7 hours at night and 1 hour nap within the day. And patient feels restless when the pain occurs.

Patient

was able to express his perception because. Patient is a jolly type of person. And has an attitude of being happy go lucky.

According

to patient care giver the patient cares about his family and community. He was then a good provider and very supportive to his children. But now due to his job, he has limited time for his

his children take good care of him sometimes. He considers God to be the most important in his life and next is his family. His love ones helped him solve all the problems and worries in life.

The

patient has no problems in his genitals and other area of it.

As

what the care giver noticed when there are family problems he copes up by expressing emotions. The patient has not undergone treatment for emotional distress.

Patient

is Roman Catholic. And has no other significant beliefs that affect his health status. He is not active to any organizational group in his community.

Weight:

70 kgs Height: 5’4 Vital Signs: Temperature:

36.1 0C PR: 86 bpm RR: 19 cpm BP: 90/60 mmHg

The

Client is conscious, coherent and oriented to place and person. Looks according to his age.

Inspection:

General color of the skin is brown, uniform in color except on part not exposed to the sun. Palpation: Skin has a good skin turgor; with flush skin and warm to



Inspection:

Normocepahalic, appears round, evenly distributed hair with no dandruff, lesions and infestations. Palpation:

noted.

No mass

Inspection:

Eyes are symmetrical, the conjunctiva is pink and with anicteric sclera. Cornea and lens are smooth and clear. Pupil is equally round and reactive to light.

Inspection:

Symmetrical and proportional to the head. The external canal has no purulent discharge.

Palpation:

Upon palpation, both ears are non-tender with no presence of mass or nodules.

Inspection:

Nasal folds are symmetrical. Nasal septum is located at the midline. Mucosa is pink and moist, and intact without presence of discharge.  Palpation: Airways are patent on both nasal nares. No tenderness on frontal and

Inspection:

Upon inspection of the mouth, the lips are pinkish and dry with tongue located at the midline. Gums and mucosa are pinkish and with missing teeth.

Inspection:

Uvula is midline. Right tonsils and posterior pharyngeal wall are not inflamed.

Inspection:

Neck is symmetrical with full range of motion. No visible deformities seen

Palpation:

Trachea is midline. No swelling and tenderness of lymph nodes noted. Thyroid gland is non-palpable, no mass

Inspection:

Shape of the chest is symmetrical. No lesions noted. I&E ratio is 1:2 . Palpation: Anterior-PosteriorLateral ratio is 1:2 with symmetrical lung expansion and symmetrical vocal/tactile fremitus.



Percussion:

The sound of resonance was found at the 1st to 4th ICS and dullness at left 5th ICS midclavicular line. Auscultation: Bronchial sound is heard over trachea, bronchovesicular sound at 2nd and 3rd ICS and vesicular sound at the base of the lung. With crackles heard on the lower



Inspection:

Precordium is normo-dynamic  Palpation: No presence of abnormal pulsations at precordium

Auscultation:

The point of maximum impulse is th located at the 5 ICS MCL with regular heart rhythm. Heart sounds S1 is louder at the apex; S2 is louder at the base. No extra heart sound noted.

Inspection:

The client’s abdomen is flat with symmetrical configuration. No scars, lesions, striae noted. The color of the skin is slightly lighter than those areas exposed to sun.

Auscultation:

Bowel sound was

Percussion:

Tympanic sounds are heard over areas of RLQ and LLQ. Dullness was heard over RUQ (liver), dullness over LUQ (spleen)

Palpation:

There was no tenderness when

Four

organs: •kidneys •ureters •bladder •urethra

retroperitoneal,

paravertebral/paralumb ar right kidney is lower than the left dimension: 11 cm x 57.5 x 2.5 cm

covered

by renal capsule, Gerota’s fascia and adipose areas: cortex (glomeruli), medulla (collecting ducts terminating in papilla), renal pelvis.

25-35

cm long, along the psoas muscle, then into the pelvis points of obstruction: ureteropelvic junction, pelvic brim, ureterovesical junction

retropubic,

stretch cranially when filled

4

cm in length in female 20 cm in male: three sections: prostatic (3cm), membranous (12), penile (15)

1. Regulation of plasma ionic composition. 2. Regulation of plasma osmolarity 3. Regulation of plasma volume 4. Regulation of plasma hydrogen ion concentration 1.

4. Removal of metabolic waste products and foreign substances from the plasma. 5. Removal of metabolic waste products and foreign substances from

Name

of drug

Generic Name: Ciprofloxacin Brand Name: Ciproxin Classification

Anti infectives

Dosage

/ Frequency

500 mg 1 tab

Route

Oral

Action

Inhibits bacterial DNA synthesis, mainly by blocking DNA gyrase; bacterial

Indication

- Mild to moderate UTI - Severe or complicated UTI - Chronic bacterial prostatsis caused by E. coli, P. mirabilis. - Complicated intra abdominal infections - uncomplicated UTI

 Nursing

Responsibilities

- Monitor patient intake and out

put and observe patients for signs of crystalluria - Tell patient to take drug as prescribed, even after he feels better. - Advise patient to drink plenty of fluids to reduce risk of urine crystals - Advise patient that hypersensitivity reactions may occur even after first dose.

Name

of drug Rowtinex Cineol

Classification

Antiurolithic

Dosage

/ Frequency

1 capsule

Route

Oral

Action

promotes a diuresis and relaxes urinary tract spasm, thus assisting the passage of stones..

The

therapeutic effect of the balanced combination of terpenes reduces urinary tract inflammation, stimulating renal blood flow through the kidneys and increasing the output of less concentrated urine.

Indication

For the treatment of urinary tract spasm and inflammation associated with urolithiasis. Assists in the dissolution and expulsion of stones in the renal system.

Nursing

Responsibilities

Liquid intake should be increased during therapy. Store at temperatures not exceeding 30 degrees Celcius.

Assessment:

Subjective: “masakit and likuran ko”, as verbalized by the patient.

Objectives:

● Facial grimace (Pain Scale Score 9/10) ● Restlessness. ● V/S taken as follows: T: 38°C PR: 92 RR 26 BP: 130/90mmHg

Acute

pain related to biological factors such as trauma or activity of disease process.

After

8 hours of nursing interventions, the patient’s pain will be relieved or controlled, with a pain scale score of 3/10.

Independent:

1. Assess pain, noting location, intensity (scale of 0 – 10), duration.

R:

1. Provides information to aid in determining choice or effectiveness of interventions.

2.

Explain Cause of pain and importance of caregivers changes in pain occurrence / characteristics

R:

Provides oopurtunity for timely administration of analgesia.

3.

ENCOURAGE/ASSIST WITH FREQUENT AMBULATION AS INDICATED AND INCREASED FLUID INTAKE OF AT LEAST 3–4 L/DAY WITHIN CARDIAC TOLERANCE.

R:

RENAL COLIC CAN BE WORSE IN THE SUPINE POSITION.

4.

Observe for changes in mental status, behaviour or level of consciousness.