Running Head: CASE STUDY 59 1

Case Study Analysis:

Case Number 59

Mary Heald

University of New Hampshire

CASE STUDY 59 2

Introduction

In order to uphold patient safety, nurses must employ critical thinking in every situation

that he or she faces in the healthcare setting. It is essential to bridge the gap between critical

thinking and clinical judgment, as the utilization of both is imperative in respect to having a

comprehensive understanding of a patient and his or her condition. Nursing educator, Joyce

Victor-Chmil (2013) describes how clinical judgment differs from critical thinking. She explains

that clinical judgment emerges as psychomotor and behavioral responses, which manifest from

the analysis of stored information in the brain, known as critical thinking. Individualized patient-

centered care is a term that is reiterated throughout nursing education and the aforementioned

interrelated process allow for personalized care. Working with case studies helps nurses and

nursing students prepare, in terms of handling real life situations that may not be straightforward.

In Harding and Snyders (2016) collection, case number 59 outlines the journey of a 58-year old

man with type two diabetes mellitus, known as F.F. The patient presents to the emergency

department with acute pain in the right flank, later receiving a diagnosis of a staghorn kidney

stone. Through careful analysis of F.F.s symptoms and health history, a progressive plan of

care is formulated using, not only critical thinking about the pathophysiology of his condition,

but also his unique needs.

Pathophysiology

Struvite calculi have plagued man since the beginning of civilization, dating back

approximately 7000 years ago to the era of the ancient Egyptians, (Healy & Ogan, 2007, p.

363). Renal stones, or nephrolithiasis, are a prevalent cause of hospitalization in the modern era,

over 320,000 each year in the United States alone (Hinkle & Cheever, 2014). The kidneys

function to clear waste that accumulates in the body, while maintaining fluid balance. When
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urine becomes excessively concentrated, as it passes through the kidneys, crystallization of

chemicals like calcium oxalate and calcium phosphate may occur. This process generates stones

that vary greatly in size and may appear in any portion of the genitourinary system. The

composition of the stone depends on the type of excess mineral in the renal system. About 75%

of all renal stones are calcium based, and struvite stones account for 15% of urinary calculi

(p. 1592). These struvite stones tend to form in an alkaline environment, usually resulting from

the existence of bacteria. To some extent, the exact reason for the formation of renal calculi

remains a mystery, although some factors are thought to increase an individuals lifetime risk for

this particular condition such as metabolic disorders, being male, and suffering from

dehydration. Drainage from the renal system can be affected by periods of bed rest and

infection, increasing the likelihood of kidney stone formation. Staghorn calculi are generally

struvite based and are situated in the renal pelvis, the site of urine storage before it enters the

ureters (Preminger, 2005). The large size of staghorn calculi obstructs the kidney, interfering

with excretion of waste products.

Body

F.F.s blood work returns from the laboratory and out of the thirteen results provided,

BUN, creatinine, and serum glucose emerged in the abnormal range. Blood urea nitrogen, or

BUN, levels increase when the kidneys are unable to excrete urea, a byproduct of protein

metabolism that normally exits the body through the urine. In this case, the stone in F.F.s renal

pelvis impedes the flow of urine out of the collecting site, known as the right renal pelvis, and

thus urea accumulates in the serum (Peringer et al., 2005). F.F.s BUN level was 20 mg/dL,

which is out of the expected range of 10 to 20 mg/dL. The normal range for serum creatinine in

males is 0.6 to 1.2 mg/dL and is another indicator of kidney function (ATI, 2013). There is an
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inverse relationship, as kidney function declines, creatinine levels rise and F.F.s lab value was

3.6 mg/dL. Heightened creatinine levels are indicative of kidney damage, which can result from

the renal calculi, but F.F. may also have underlying kidney damage as a result of his type two

diabetes mellitus. The increased glucose production in type two diabetes causes damage to an

individuals microvasculature, such as the small vessels in the kidney. This condition is known

as nephropathy. We do not have a thorough health history for F.F. and it would be beneficial to

know if he has been diagnosed with preexisting kidney deterioration, or if he has had kidney

stones in the past that may have caused damage to the vasculature. Glucose was the last level

that caused concern, as the normal range is 60 to 100 and F.F.s was 260 (ATI, 2013). The case

highlighted that he was not eating much upon arrival, making this level even more concerning,

but we are unsure if he ate more in the hospital. If it were a non-fasting test, higher levels would

be acceptable, but not as elevated as 260 mg/dL. Blood glucose levels rise in the event of stress

and infection and F.F.s reports of severe pain cause a stress response in the body. It would be

beneficial to know if F.F. controls his diabetes adequately or not, but no information is provided

in this regard.

Creatinine levels and glomerular filtration rate have an inverse relationship, as creatinine

levels rise, GRF decreases, signaling the progression of kidney failure (Hinkle & Cheever,

2014). Glomerular filtration rate measures plasma filtration per minute and thus when GFR

decreases the glomeruli lose the ability to filter waste products, such as creatinine and urea.

Urine concentration of these filtrates decreases, but serum concentrations increase. Using a

calculation that takes into account age, serum creatinine, and gender, an individuals GFR can be

estimated. The standardized equation, using F.F.s demographics, resulted in an estimated GFR

of 18 mL/min/1.73m^2 (GFR Calculator, 2016). According to Hinkle and Cheever (2016), this
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places F.F. in the stage four chronic kidney disease category, as a normal GFR is 125

mL/min/1.73m^2. F.F. requires education about the implications of chronic kidney disease.

Although many labs were drawn, there is no reported white blood cell count (WBC),

which would indicate the presence of any infection. Pyelonephritis is often associated with the

presence of renal calculi, notably the staghorn type stone (Healy & Ogan, 2007). Staghorn

stones often are composed of struvite, relating to the stones mineral composition; this particular

composition is highly correlated with infection in the genitourinary system. Infection is one

problem that can result from this type of stone, which in severe cases could lead to an infection

in the blood. This blood infection is known as urosepsis, which can lead to organ failure (ATI,

2013). Multiple symptoms that F.F. presents with are typical in staghorn calculi, such as

hematuria, and gastrointestinal symptoms. The stone can tear the inner walls of the renal system

and cause bleeding. As the case progresses, F.F. is placed on antibiotics, specifically gentamicin

and it is assumed that an infection is present. The case never discussed information about the

etiology of F.F.s infection and no WBC count with differential was provided throughout, a

marked limitation within the case.

Renal colic is another issue related to struvite stones and is characterized by abrupt pain

that radiates to the flank and genitals, as the kidneys try to excrete urine in the presence of a

blockage (ATI, 2013). F.F. was treated with morphine for pain control when he presented at the

hospital, although nowhere in the study does it describe whether or not F.F.s pain was

adequately controlled. A randomized-controlled trial conducted by Azizkhani et al., in 2013

compared the effectiveness of morphine and acetaminophen, both given intravenously in the

treatment of renal colic pain. 124 patients with renal colic were treated with either morphine or

acetaminophen pain ratings were recorded using a visual scale. The morphine was more
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effective in treating the pain, though both groups reported decrease pain levels and fewer adverse

effects were reported with the acetaminophen. Intravenous acetaminophen is a safe option for

pain control for F.F., notably if he experiences any adverse effects of the morphine such as

dizziness.

The provider orders gentamicin, an intravenous antibiotic but does not describe the

reason for the order. The dose that he or she prescribes 6 mg/kg/day every eight hours (Harding

& Snyder, 2016). When calculating the total daily dose, converting F.F.s weight of 277 pounds

to 126 kilograms, and multiplying this by the six milligrams, the result is 252 mg/dose.

According to the Prentice Hall Drug Guide by Wilson, Shannon, and Stang (2007) gentamicin is

an aminoglycoside used to treat mostly gram negative infections with a safe dose ranging from 3

to 5 mg/kg/dose. This evidence challenges the safety of the providers dose, especially because

this antibiotic is not advised for patients with renal failure, as it may be nephrotoxic. Stang et al.

(2007) present a multiplicity of side effects that could result from gentamicin toxicity, including

damage to the ears and cardiovascular effects. The drug is ototoxic and can lead to symptoms

like tinnitus, or ringing in the ears. The vestibular system may be affected a result of the drugs

ototoxic nature, potentially causing issues with balance, as well as headaches and dizziness. The

dizziness may also be a result of hypotension, which is a known adverse cardiovascular effect.

The healthcare team is already aware of F.F.s compromised baseline renal function, as

evidenced by his elevated BUN and creatinine. Therefore, the nurse must advocate for a

decreased dose in order to keep the patient safe.

The tool known as, SBAR, is an effective way to communicate between healthcare

workers, piecing together the relevant information, as a result of critical thinking. The brief

synopsis also employs the use of clinical judgment, as it requires the speaker to make
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recommendations based on the situation. In the case of F.F. and the unsafe gentamicin dose, the

nurse must use SBAR to communicate her concerns based on F.F.s condition. In terms of the

situation aspect of SBAR, the nurse would begin by greeting the doctor and introducing his or

herself, stating that she is with patient F.F. in room 22. The nurse may ask if the provider is

familiar with this patient and if not, explain that he is a 58-year-old male found to have a

staghorn calculus in the right renal pelvis. He presented with severe right flank pain, abdominal

tenderness, and nausea/vomiting in the emergency department this morning. The nurse should

make sure to include any relevant procedures, describing that he will undergo lithotripsy

tomorrow morning. The relevant background information includes that this patient has a history

of type 2 diabetes and no known drug allergies, but further health history information is missing

from the case. The assessment would be described as follows: the patient is stable and the

patient is receiving IV morphine for pain control. His most recent vitals are: BP=142/80, HR=

88, RR= 20, Temp = 99 F (37.2 C). His BUN level is 30 and creatinine is 3.6. The patient is

126 kilograms. While recommending actions, remind the provider what he ordered, which was

gentamicin 6 mg/kg q8h. Explain that this dose is outside of the recommended safe parameters,

as the maximum safe dose is 5 mg/kg. The patients renal function is also compromised and this

drug must be used cautiously in patients with renal impairment. Update the provider and explain

that the right kidney appeared enlarged when pyelogram results came back and that staghorn

calculi are present. The nurse should recommend reducing the dose and ordering daily labs,

notably for BUN and creatinine to avoid toxicity in order to individualize patient care and

maximize safety.

One method of treating renal calculi is termed, shock wave lithotripsy, a procedure that

causes calculi to break into smaller, passable particles through shock waves (ATI). Patient
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education is necessary hours before the procedure, as the moderate sedation required might cause

retrograde amnesia, thus the teaching would be useless. Communicate to the patient that ECG

monitoring will continue throughout and to expect bruising and hematuria after the procedure.

Stones that exceed a one-centimeter diameter are not passable through the human anatomy, and

so this noninvasive procedure is essential to allow for passage of the stone after it has been

broken into pieces (Hinkle & Cheever, 2014). As it is noninvasive, it is the most prevalent form

of treatment, but according to Healy and Ogan (2007), it is not always effective with staghorn

calculi. The study argues that some patients do have successful clearance and that ESWL should

be utilized, depending on volume of the calculi, but that some patients will require further

intervention. Results are conflicting and extremely patient specific. The 2005 guideline

(Peringer et al.) argues that ESWL therapy may not be effective if used as the sole treatment.

The researchers argue that the evidence for the use of lithotripsy monotherapy, did not

experiment in patients with large staghorn calculi, concluding that no evidence supports the

intervention on its own.

In 2000, Delesky and Massi-Ventura published an article outlining vital information in

regard to care of a patient who is to undergo a lithotripsy. Although it is relatively old in terms

of publication date, after extensive analysis, it is newer than most in terms of nursing care for

these patients. The provider must do a thorough analysis of lab values, particularly in order to

evaluate for infection. The patients must fast, starting at midnight prior to the procedure, but

afterwards require excessive clear liquids to facilitate the broken-up stone to pass through the

genitourinary system. It is crucial to instruct the patient to remain completely still during the

procedure to reduce risk for harm. Patient education about urine straining is essential, as patients

must save the fragments found in the urine for further analysis. Information presented in a 2008
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study by Naja et al., argues that the use of tamsulosin, an alpha one blocker, after a lithotripsy

procedure aids in clearance of fragments and at a faster rate. As F.F. has a staghorn stone, there

is a higher risk that remnants of the stone will remain, requiring further intervention, and so a

medication that aids the clearance process could be beneficial to this patient in particular.

F.F. expresses concern regarding the expenses associated with his lithotripsy, as he does

not have insurance, worrying that surgery will be imminent if the ESWL is unsuccessful. The

nurse should educate F.F. on the importance of the procedure and warned of the aforementioned

risks of a full blockage from a staghorn stone, such as urosepsis. A 2005 guideline by Preminger

et al., discusses the standard for managing staghorn calculi. This article emphasizes the

importance of educating patients about options for treatment, as well as the risks and benefits of

each. The medical cost associated with the complications that could occur if F.F. abstains from

the procedure would be much greater in the long run and it is important to explain this to him. It

is important to discuss the potential need for surgery and its implications, assuring that F.F. will

receive the care that he needs as this is the priority, finances aside. Refer F.F. to a case manager

who can mediate financial issues and provide a vast range of options and information to the

patient. It is crucial to utilize all members of the healthcare team when necessary, in order to

generate a highly individualized patient-specific plan.

As the case study progresses, the nurse passes F.F.s room and he is actively crawling off

of his hospital bed (Harding & Snyder, 2016). The nurse should immediately enter the room and

ask the patient why he is trying to get out of bed and offer assistance to the bathroom if needed.

Chronic kidney disease can lead to compromised neurological function (Hinkle & Cheever,

2014) and so the nurse should ask questions to determine if F.F. is alert and oriented, along with

performing a head to toe assessment with vital signs. Any changes in baseline neurological
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status should be reported to the provider and documented. As the patient is diabetic, the nurse

should take a blood sugar reading, as changes in glucose levels can cause confusion and

disorientation. It may be necessary to implement fall precautions, some of which include a bed

alarm, a fall risk bracelet, and nonskid footwear, while ensuring that the bed is in the low and

locked position with side rails up. The nurse should reorient F.F.to his surroundings, as

appropriate, and make certain that he has his call bell in reach before leaving the room. He likely

does not require a sitter, as this was an isolated incident.

The case study presented required critical thinking, drawing from previous knowledge, as

well as clinical judgment skills in order to formulate answers that addressed the unique needs of

the patient. The case study is lacking a thorough medical history and the progression does not

address the vital connection between diabetes and kidney disease. As stated by Hinkle and

Cheever (2014), the principal cause of chronic kidney disease in the modern era is diabetes

mellitus. This case study failed to focus on this connection, as it did not provide adequate

information in regards to the patients glycemic control. The reader does not know if the patient

is on oral anti-diabetic medication or if he is insulin dependent. Although it was not emphasized,

his diagnosis of diabetes had a major impact on his plan of care. Discharge teaching about

diabetes management should be incorporated in order to reduce further damage to the kidneys.

Further research about the effectiveness of lithotripsy in staghorn type renal calculi is essential in

order to provide optimal patient care and reduce complications or recurrent episodes. More

current nursing research is required about patient care before, during, and after a lithotripsy in

order to identify best practices. Also, researchers should extend studies that examine the use of

tamsulosin after lithotripsy, specifically in patients who present with a staghorn stone. Positive

results could help prevent stones from returning and inflicting more damage.
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It is essential to perform double checks in regards to orders. The nurse must not do

perform interventions out of trust for the doctors, but on the basis of his or her own knowledge

and judgment. The case study proves this sentiment, as the nurse recognized an error in the

providers orders. In some cases, the mistake may not have been drastic, but in her particular

patients condition, there was potential for devastating effects. This is why it is imperative to

gain a thorough understanding of a patient and his or her overall health status. Learning

occurred on a vast spectrum through analysis of this case. The concept of individualized plans of

care has new meaning, as it is evident that patient safety is compromised when healthcare

workers do not address a patients unique needs. A solid knowledge base of pathophysiology is

not adequate in the field of nursing, as a flexible, creative mindset is required. Nurses take every

aspect of an individual into consideration during care and it helps guides the rest of the

healthcare team when making decisions. Nurses are the chief advocates for patients and it is a

fundamental duty to uphold in order to ensure optimal patient outcomes.

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References

Azizkhani, R., Pourafzali, S. M., Baloochestani, E., & Masoumi, B. (2013). Comparing the

analgesic effect of intravenous acetaminophen and morphine on patients with renal colic

pain referring to the emergency department: A randomized controlled trial. Journal Of

Research In Medical Sciences, 18(9), 772-776.

ATI. (2013). RN Medical Surgical Nursing: Review Module (9.0th ed.). Assessment

Technologies Institute LLC.

GFR Calculator. (2016) Retrieved from

https://www.kidney.org/professionals/kdoqi/gfr_calculator

Harding, M., & Snyder, J. S. (2016). Critical Thinking Cases in Nursing (6th ed.). St. Louis, MI:

Mosby

Healy, K., & Ogan, K. (2007). Pathophysiology and management of infectious staghorn

calculi. Urologic Clinics Of North America, 34(3), 363-374.

Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth's Textbook of Medical-surgical

Nursing (13th ed.). Lippincott Williams & Wilkins.

Naja, V., Agarwal, M., Mandal, A., Singh, S., Mavuduru, R., Kumar, S., & ... Gupta, N.

(2008). Tamsulosin facilitates earlier clearance of stone fragments and reduces pain after

shockwave lithotripsy for renal calculi: results from an open-label randomized study.

Urology, 72(5), 1006-1011.

Preminger, G., Assimos, D., Lingerman, J., Nakada, S., Pearle, M., & Wolf, S. (2005). Report on

the Management of Staghorn Calculi. Retrieved from

https://www.auanet.org/education/guidelines/staghorn-calculi.cfm
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Victor-Chmil, J. (2013). Critical thinking versus clinical reasoning versus clinical judgment:

differential diagnosis. Nurse Educator, 38(1), 34-36.

doi:10.1097/NNE.0b013e318276dfbe

Wilson, Shannon, & Stang. (2007). Gentamicin sulfate. Retrieved from

http://www.robholland.com/Nursing/Drug_Guide/data/monographs/monoframe.html?vfil

e=G012.html