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PT DATA

35 year old Married, Hispanic, female; DOB: 5-24-79 who works as a Social Worker presented to ED from home on 03/17/15 with c/o fever, nausea and vomiting, left flank pain, pain upon urination. Surgical Hx: C-section x 2 (1997,
2011), Breast Reduction surgery (2006), Right breast mass biopsy (2006). Family Hx: Pt. has significant family history of renal problems. Pt.s father has one kidney because the other was removed due to impaired renal function. The
pt.s paternal uncle had tumors on his kidneys and eventually died from Renal Failure at age 52. Her paternal grandfather had Chronic Renal Disease and had a kidney removed which resulted in renal failure and passed at age 69. Pt.
is the only one of her siblings that currently has issues with her kidney and kidney stones. The pt.s spouse is her main support system although she does have the additional support of family living in El Paso. Assessment: 03/19/15
at 0820: BP- 127/75, HR- 117, Temp.101.6 F oral, Resp. 17 unlabored and shallow, O 2 Saturation-97%, Height 152 cm, Weight 97.9 kg. Pt. is cooperative, alert and oriented x4. Pt. showed no signs of distress. C/O left flank pain 9/10.
Peripheral pulses strong and bounding bilaterally. No signs of edema to upper and lower extremities bilaterally. Lung sounds auscultated and clear in upper and lower lobes bilaterally anterior and posterior. Bowel sounds active in all
4 quadrants, abdomen non-tender to touch or palpation and non-distended. Pain stated as radiating from left lower back forward to abdomen by pt. LBM 3-16-15. Skin warm, dry, and intact.

MEDICATIONS

PAST MEDICAL HX

Rocephin 1g=50ml IVPB Every 24 hrs.


Toradol 30mg=1ml IV push Every 8 hrs. PRN for pain
Morphine 4mg=1ml IV push Every 6 hrs. PRN for pain
Lovenox 40mg=0.4ml Subcut. Every 24 hrs.

NURSING Dx #1
Acute pain related to kidney stones as evidenced by numeric pain
report of 9/10, burning during urination, and flank pain. This is a
first priority according to Maslows Hierarchy of Needs. Pain is
considered a physiological need that must be met for the pt. to be
able to function properly.

GOALS
Goal 1: Pt. will report a pain no greater than
4/10 on the 1/10 numeric pain scale
throughout the 12 hour shift.

INTERVENTIONS
1. Assess and document the intensity,
character, onset, and location of patient's pain
with routine vital signs and/or a 0-10 numerical
pain scale every 2 hours. RATIONALE: Pain is
expected; pain is subjective and is best
evaluated on a pain scale of 0 to 10 and through
description of characteristics and location, which
are important for identifying cause of discomfort
and for proposing interventions. Continuing pain
may indicate development of neurovascular
problems. (Ackley, 2011).
2. Provide optimal pain relief with prescribed
analgesics when pt. feels pain of more than 4
out of 10 on a 1-10 numeric pain scale.
RATIONALE: The proper pain administration rate
optimizes the efficacy of pain medication. Pain
must be assessed periodically to gauge

EVALUATION
Intervention 1- PARTIALLY MET- On 2
occasions the nurse was unable to meet the
2 hr. time frame for assessing the pt.s pain.
Revise- Assess for pain every 3 hours to
assure goal can be met.
Intervention 2- MET- Pain medication was
administered to pt. when it was verbalized
her pain was at least at a 4/10.

LABS
WBC-14.1
RBC-3.91
Hb-11.5
Hct-35.2
BUN-3.8
AST-40
ALT-57
Alk Phos-136
CO2-19
Urinalysis
-Cloudy
Ketones-Trace
Protein- 2+
Blood- 2+
Bilirubin- 1+
Leukocyte
esterase- 3+
Epithelial
Cells-

NKDA
Chicken Pox at 9 years of age
Immunizations up to date with exception of Flu Shot
PCOS 2008
Kidney Stones since 2007

DIAGNOSITIC STUDIES

MEDICATIONS

CT of Abdomen and Pelvis- 0.3cm


obstructing calculus in the left UVJ
causing mild to moderate left
hydronephroureter and left
perinephric stranding.

Flomax 0.4mg=1 cap Oral Nightly at bedtime,


Xanax 0.25mg=1 tab Nightly at bedtime PRN for
sleep,
Zofran 4mg=2mlIV push Every 6 hrs. PRN for nausea
Acetaminophen 650mg=2 tabs Oral Every 4 hrs. PRN

MEDICAL DIAGNOSIS

NURSING Dx #2

Ureterolithiasis with Pyelonephritis

Infection related to pyelonephritis as evidenced by fever of


101.6 degrees Fahrenheit, flank pain, and increased WBC of
14.1. This is first priority according to Maslows Hierarchy of
Needs. Infection control is critical in assuring that a persons
physiological state is preserved for proper function and well

PATHOPHYSIOLOGY
A kidney stone, also known as a renal calculus or nephrolith, is a
calculus formed in the kidneys from minerals in the urine. 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 (usually at least 3 millimeters
(0.12 in)) they can cause blockage of the ureter. This leads to pain,
most commonly beginning in the flank or lower back and often
radiating to the groin or genitals. Stones are typically classified by
their location in the kidney (nephrolithiasis), ureter (ureterolithiasis),
or bladder (cystolithiasis), or by their chemical composition. Slightly
more men are affected than women. Blockage of the ureter causes
decreased kidney function and dilation of the kidney. Other
associated symptoms include: nausea, vomiting, fever, blood in the
urine, pus in the urine, and painful urination (2015, February 26).
Retrieved from http://www.mayoclinic.org/diseasesconditions/kidney-stones/basics/definition/con-20024829.
Pyelonephritis is an ascending urinary tract infection that has
reached the pyelum or pelvis of the kidney. It is a form of nephritis
that is also referred to as pyelitis. Pyelonephritis is a potentially
serious kidney infection that can spread to the blood, causing severe
illness. It is commonly caused by bacterial infection that has spread
up the urinary tract or travelled through the bloodstream to the
kidneys. Fortunately, pyelonephritis is almost always curable with
antibiotics. Pyelonephritis presents with fever, accelerated heart
rate, painful urination, abdominal pain radiating to the back, nausea,
and tenderness at the costovertebral angle on the affected side.
Most cases of pyelonephritis are complications of common bladder
infections. Bacteria enter the body from the skin around the urethra.
They then travel up the urethra to the bladder.Pyelonephritis may
start with similar symptoms. However, once the infection has spread
to the kidney, signs of more severe illness usually result: Back pain
or flank pain, fever (usually present) and/or chills, feeling sick
(malaise), nausea and vomiting, and confusion (especially in the

SIGNS & SYMPTOMS


Nursing Dx #1
Pt. reported pain of 9 on 1/10 numeric
pain scale
Burning during urination
Flank pain in left side of back that
radiates to front

Nursing Dx #2
Fever of 101.6 degrees F
Flank pain in left side of back that
radiates to front
Elevated WBC of 14.1

POTENTIAL
COMPLICATIONS

Recurring kidney infections


The infection spreading to
areas around the kidneys
Acute kidney failure

Kidney abscess

REFERENCE
Ackley, Betty J., Ladwig, Gail B., (2011). Nursing Diagnosis Handbook, (9th Edition). Missouri: Mosby Elsevier Publishing.
Fulop, T., & Vecihi, B. (2014, April 18). Acute Pyelonephritis . Retrieved March 27, 2015, from http://emedicine.medscape.com/article/245559-overview
Gulanick, Meg, Myers, Judith L., (2011). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Missouri: Mosby Elsevier Publishing
Kidneystones.(2015,February26).RetrievedMarch27,2015,fromhttp://www.mayoclinic.org/diseasesconditions/kidneystones/basics/definition/con20024829

GOALS
Goal 1: Pt. will show no signs of progression
of infection during the next 24 hours.

INTERVENTIONS

1. Assess vital signs every 4 hours and


monitoring temperature during hospital
stay. RATIONALE: Urinary tract infection
can result in very high fever. Elevated
WBC count is a sign of infection
(Gulanick, 2011).
2. Administer antibiotics as prescribed in
a timely manner during hospital stay.
RATIONALE: Specific antibiotics will
reduce pathogens and resolve infection
(Gulanick, 2011).

EVALUATION

Intervention 1- MET- Vital signs were


taken at least every 4 hours in order to
be proactive of any s/s of worsening
condition.
Intervention 2- MET- All medication
antibiotics were given within their

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