Assessment 2: Case study essay
School of Nursing and Midwifery, Edith Cowan University
NUM2306 Adult Health Care 1
Dr Amanda Graf
October 11th, 2021
Table of Contents
Assessment 2: Case study essay
Obstruction to the bladder, ureters and/or kidney can cause Acute Kidney Injury (AKI), and if not treated, can lead to renal failure (Goldfrap, 2016). AKI decreases the functioning abilities of the kidney and the body’s homeostasis, due to the decline in Glomerular Filtration Rate (GFR) (Craft et al., 2019). Kidney stones, also known as renal calculi, are a known cause of postrenal AKI and cause of urinary obstruction (Nevo et al., 2019). In Australia, 10% of the population will experience a kidney stone (Thia & Saluja, 2021). Annually 12,000 hospital admissions are due to renal calculi, noting that 75-90% of incidences pass spontaneously without surgical attention (Cunningham et al., 2016). Key risk factors include poor diet, dehydration, hypercalciuria, PH imbalances, humid climates, and presence of supersaturation in urine (Srivastava et al., 2019). This case study is focussed on patient Sally Jones, a 56-year-old lady, who has a 6mm stone in her right ureter. The pathophysiology of renal calculi and the clinical manifestations that Sally presents will be discussed, along with recommended nursing management and medical interventions that would be put in place for Sally.
Acute Kidney Injury (AKI), previously known as acute kidney failure, is classified by the location of the obstruction/trauma (Goldfrap, 2016). The three classifications are prerenal, intrarenal and postrenal (Craft & Gordon, 2020). Kidney stones are an example of postrenal AKI (Zeimba & Matlaga, 2015), and are characterised by their mineral composition (Shadman & Bastani,2017). Evidence states there are four types of renal calculi, the most being calcium stones, accounting for up to 75% of calculi incidences (Solo et al., 2017). The less common are uric acid stones, struvite stones (Also known as ‘infection stones’, caused by UTIs) and cystine calculi, which are traced to genetic or secondary to a metabolic disorder (Shadman & Bastani, 2017). Moreover, precipitation of these minerals forms small hard crystals due to decrease of urine volume, supersaturation of urine or change in the PH levels (Srivastava et al., 2019). A stone may continue to grow once attached to the urothelium, due to additional organic matter forming around the nidus (Craft et al., 2019). Renal calculi are generally asymptomatic until they enter the ureter (Solo et al., 2017).
Sally may have had an UTI first, that has led to a struvite stone. By consideration of the urinalysis (UA), which displays blood, nitrates, proteins, and a cloudy appearance which is a diagnosis of infection in the bladder (Trimarchi, young & Lombi, 2015). The common symptoms of acute pyelonephritis (caused by a UTI and struvite stone) are fever, chills, cloudy urine, voiding and flank pain, which are all clinical manifestations Sally is experiencing and secondary to kidney stones (Grasso & Goldfrap, 2014). The right sided flank pain that Sally is experiencing is called renal colic, this occurs due to the stone passage causing spasming and contracting of the smooth muscle in the ureter (Cunningham et al., 2016). Additionally, the obstruction due to the calculus in the ureter, initiates the release of prostaglandins and the inflammatory response (Afshar et al., 2015). Prostaglandins generate vasodilation that increases urinary flow, intra-ureteral pressure, oedema, vascular permeability and uretic spasming and hyperperistalsis (Afshar et al., 2015). Moreover, prostaglandins are what causes Sally to feel continuous pain and nausea (Steinberg & Chang, 2016). The presence of haematuria and higher than normal serum creatinine and BUN levels indicate AKI and the decline in kidneys function and glomerular filtration rate (GFR) (Craft et al., 2020). The decline in the GFR means retention of waste products such as creatine and BUN that are otherwise excreted in a normal functioning kidney (Jennette et al., 2015). Moreover, this will also signal the brain centres that the renal BP has decreased, which will initiate a negative feedback response increasing Sally’s heart rate (108bpm), BP (124/87), and respiratory rate (22) to compensate and work to restore the homeostasis (Craft et al., 2019). Immediate medical attention is needed to relieve pain and smooth muscle spasming in the ureter (Thia & Saluja, 2021).
Renal calculi require immediate nursing management and medical expulsion therapy (MET), to relieve Sally of renal colic (Thia et al., 2021). Sally presents to ED with a pain score of 8 out of 10, which classifies as severe pain (Royal Perth Bentley Group, [RPBG], 2020). The World Health Organisation Pain management guidelines suggest collecting subjective data, pain score, and reduce fear (Berman, 2017). The first step is to offer Sally non-pharmalogical treatment, deep breathing exercises and encouragement of fluid consumption to reduce further stone formation (Cunningham et al., 2016). The use of intravenous (IV) fluids should be implemented to work towards urinary dilution, to prevent further stone growth (Ziemba & Matlaga, 2015).
The second step is dependant on the level of pain andchoosing a medication that will limit side effects and have the most rapid effect (Royal Perth and Bentley Group [RPBG], 2020). Evidence suggests that the use of non-steroid anti-inflammatory drugs (NSAIDS), adjuvant medications (co-analgesics) and alpha blockers, are the most effective relief for renal colic, then that of opioid medications (Watt et al.,2018). NSAIDs decrease the event of vomiting and nausea, require less rescue analgesics and work to directly inhibit the inflammation response initiated by the release of prostaglandins (Cunningham et al., 2016). Alpha-blocker medication, used alongside NSAIDs will reduce muscle contractions/spasms of the smooth muscle of the ureter, and decrease the need for surgical intervention (Sahin et al., 2015). The two immediate medications that can be to help relieve renal colic and distress for Sally are an NSAIDs (Diclofenac) and alpha-blocker (Tamsulosin) (Thia & Saluja, 2021).
There are various non-steroidal anti-inflammatory drugs (NSAIDs), Opioid and adjuvant medications that can be used to treat renal colic, along with Medical Expulsive Therapy (MET) (Leonardo & Thiago, 2019) As previously mentioned, immediate pain relief is needed for Sally and using NSAIDS are most effective and need less rescue than opioids (Watt et al., 2018). The most used NSAIDs for renal colic is Diclofenac (Asfhar et al., 2015). Diclofenac, like all NSAIDs works to inhibit the synthesis of prostaglandins, by blocking cyclooxygenase-1 and cyclooxygenase-2 (COX 1 & 2) (“diclofenac”, n.d). The indications are for tissue inflammation and pain. It can be administrated orally, topically (local), and intravenously (IV). Side effects can be dehydration, headache, salt and fluid retention and individuals with asthma may find it causing bronchospasms and potential exacerbations and GI ulceration or bleeding (“diclofenac”, n.d). Nursing considerations for this medication are minimal for short-term use but monitoring for any of the side effects to ensure treatment is withdrawn immediately (“diclofenac”, n.d).
The second medication to elevate pain and induce expulsion of the stone is an alpha blocker called Tamsulosin hydrochloride (Flomaxtra) (Sahin et al., 2015). This works as an a-adrenoreceptor antagonist, antagonising/inhibiting the a-adrenergic receptors on the ureters smooth muscle, by relaxing the smooth muscles of the ureters (“tamsulosin, n.d). The indications of use are to action relief of benign prostatic hyperplasia (BPH), lower urinary tract symptoms (LUTS) and for renal stones it can be used for up to four weeks for stone passage (“tamsulosin”, n.d). It is to be taken orally once daily. Side effects of tamsulosin are hypotension in first dose, nasal congestion, urinary urgency, headaches, fatigue, and weakness (“tamsulosin”, n.d.). Nursing care required from these medications are to be precautious of dizziness that the patient may manifest. Additionally, the best time to give it would be at bedtime, when standing or moving around is limited (“tamsulosin”, n.d).
Renal calculi are an example of postrenal acute kidney injury that if managed and treated, is a reversible condition. The formation and pathophysiology will vary, dependant on stone type, location, and size. Nursing interventions and management should be focussed on acute pain relief and stone passage. Pharmalogical treatment is varied and by choosing medications that require less rescue medications or surgical interventions, offer fast relief to pain and muscle spasms, are paramount in the nursing considerations when treating kidney stones.
Afshar, K., Jafari, S., Marks, A. J., Eftekhari, A., & MacNeily, A. E. (2015). Nonsteroidal anti-inflammatory drugs (nsaids) and non-opioids for acute renal colic. The Cochrane Database of Systematic Reviews, 6(6), 006027. https://doi.org/10.1002/14651858.CD006027.pub2
Berman, A. (2016). Skills in clinical nursing ebook. Pearson Australia Pty.
Cunningham, P., Noble, H., Al-Modhefer, A.-K., & Walsh, I. (2016). Kidney stones: pathophysiology, diagnosis and management. British Journal of Nursing, 25(20), 1112–1112. https://doi.org/10.12968/bjon.2016.25.20.1112
Craft, J. A., Gordon, C. J., Huether, S. E., McCance, K. L., Brashers, V. L., & Rote, N. S. (2019). Understanding pathophysiology (3e, Australian and New Zealand). Elsevier.
Diclofenac. (n.d.). In MIMs online. Retrieved October 7, 2021, from www.mimsonline.com.au
Goldfarb, D. S. (2016). The exposome for kidney stones. Urolithiasis, 44(1), 3–7. https://doi.org/10.1007/s00240-015-0847-4
Grasso, M., & Goldfarb, D. (2014). Urinary stones: medical and surgical management. Wiley.
Jennette, J. C., Olson, J. L., Silva, F. G., & D’Agati, V. D. (Eds.). (2015). Heptinstall’s pathology of the kidney (7th ed.). Lippincott Williams & Wilkins/Wolters Kluwer.
Leonardo, F. F., & Thiago, D. S. (2019). Kidney Stones: Treatment and Prevention. American Family Physician, 99(8), 490-496.
Nevo, A., Shahait, M., Shah, A., Jackman, S., & Averch, T. (2019). Defining a clinically significant struvite stone: a non-randomized retrospective study. International Urology and Nephrology, 51(4), 585–591. https://doi.org/10.1007/s11255-019-02117-1
Royal Perth Bentley group. (2020). Pain management NPS. Blackboard. www.blackboard.ecu.edu.au
Shadman, A., & Bastani, B. (2017). Kidney calculi: pathophysiology and as a systemic disorder. Iranian Journal of Kidney Diseases, 11(3), 180–191.
Solo, S., Sharp, M., Devendorf, C., & Murray, C. (2017). Renal calculi revealed. Nursing Made Incredibly Easy.15(6), 20–22. https://doi.org/10.1097/01.NME.0000525562.75150.54
Srivastava, A., Swain, K. K., Chahar, V., Bhardwaj, S., Ajith, N., Mete, U., Garg, U., & Srivastava, T. (2019). Role of diet and trace elements in lithogenesis of renal calculi. Journal of Radioanalytical and Nuclear Chemistry: An International Journal Dealing with All Aspects and Applications of Nuclear Chemistry, 319(1), 271–278. https://doi.org/10.1007/s10967-018-6335-x
Steinberg, P. L., & Chang, S. L. (2016). Pain relief for acute urolithiasis: the case for non-steroidal anti-inflammatory drugs. Drugs, 76(10), 993–7. https://doi.org/10.1007/s40265-016-0595-y
Tamsulosin. (n.d.). In MIMS online, Retrieved October 8, 2021, from www.mimsonline.com.au
Thia, I., & Saluja, M. (2021). An update on management of renal colic. Australian Journal of General Practice, 50(7), 445-449.
Trimarchi, H., Young, P., & Lombi, F. (2015). Milky urine and struvite crystals. Kidney International, 88(1), 205–205. https://doi.org/10.1038/ki.2014.314
Ziemba, J. B., & Matlaga, B. R. (2015). Guideline of guidelines: kidney stones. Bju International, 116(2), 184–189. https://doi.org/10.1111/bju.13080