Hydronephrosis Fred Luce
Hydronephrosis Fred Luce
Hydronephrosis Fred Luce
COLLEGE OF NURSING
SEX: Female
NATIONALITY: Filipino
RELIGION Roman Catholic
Pulse Rate 80
Respiratory Rate 20
PHYSICAL ASSESSMENT
AREA ASSESSED METHOD FINDINGS ANALYSIS
Skin Inspection the color of skin NORMAL
is the same as
Palpation with other body
parts
NORMAL
>Absence of
edema
NORMAL
>Pinna recoils after
pinna is being folded
Nose Inspection > no discharges NORMAL
Palpation >symmetrically NORMAL
aligned NORMAL
>not tender
Sinuses Palpation >Frontal and NORMAL
maxillary
sinuses are not
tender
>Capillary NORMAL
refill 3 sec.
(normal 2-3
sec)
Lower >Inspection and > no edema NORMAL
extremities Palpation
SUMMARY OF
PHYSICAL ASSESSMENT
When I assessed my patient’s skin color I
found out that the color is the same with her
other body parts and it is normal, also there is no
presence of edema and her skin is not tender
also I so the inspection of her hair and it is long
and white which is normal with aged people, in
her scalp there is also absence of seborrhea
which is normal and her nails are pink in color
,normal, but I see that she has a long dirty nails
both in hand and feet, it indicates poor personal
hygiene. In her head I do the inspection, and
there is no presence of masses and nodules her
head also is symmetrical which is normal . And
her facial features and movement are
symmetrical which is normal. In her neck there is
no enlargement of lymph nodes.
And her shoulders are symmetrically
aligned, but her thyroid gland is enlarged
which indicates problem such as goiter
and according to her it’s true she was
positive of having goiter because she was
diagnosed having goiter when she was not
yet married but according to the doctor it is
non toxic as she say’s to me. Assessing
her eyes I see that her eye brows are
symmetrical, and her eye lashes have
normal distribution
Also the color of her conjunctiva is pink and that’s all
are normal, in her ears upon inspection and
palpation I found out that her auricles are mobile,
firm, and it is symmetrically aligned also the color of
the auricle is the same with the face. And I do also
the inspection of presence of discharges and she
has yellowish foul smell discharges in her ears
which indicates poor personal hygiene, and the
pinna recoils after it is folded. The nose are
symmetrically aligned and there is no discharges
which is normal.
Also I do the Palpation of her sinuses and her
frontal and maxillary sinuses are not tender and
it is normal, also I see that her lips have cracks
which indicates dehydration, and her teeth are
yellowish in color which indicates poor oral
hygiene. And her tongue are moist and it is in
the middle. Upon inspection and auscultation of
my patient’s lungs there is no crackles and it is
normal, she has 19 breaths/min. normal, also
she has normal heart beat with 80 beats/min.
Her abdomen is symmetrically aligned, and she
has active bowel sound heard every min.
normal.
Also there is presence of dull sound which I heard
upon percussion, it is abnormal because it
indicates presence of gas floating inside the
abdomen, also her left side is hare upon
palpation. Inspection and palpation of her hand I
noted the presence of IV which is D5NSS which
help in replacing the fluid loss in the body she
has strong grip when I hold her other hand, her
distal pulse are palpable, normal. I also inspect
her nail beds for the capillary refill it is 2-3 sec.
and she has 3 sec. for the capillary refill and that
is normal, and lastly doing the inspection of her
lower extremities there is no presence of edema.
LABORATORY AND
DIAGNOSTIC
EXAMINATION
TEST RESULT NORMAL VALUES ANALYSIS
EXAMINATION
Production of RBC
indicates anemia
disease .
25.66pg/cell ABNORMAL, decrease
MHC 26-34pg/cell in MHC indicates
microcytic anemia .
anemia
NEUTROPHILS 3-7X10g/L ABNORMAL, decrease
0.640 in Neutrophil indicates
neutropenia,
septicemia.
EOSINOPHILS 0-0.7X10g/L ABNORMAL,
0.012 Decrease in Eosinophil
indicates Eosionopenia,
and acute bacterial
infection
BASOPHILS 0.002 ABNORMAL, decrease
0.02-0.05X10g/L in Basophil count
indicates Basopenia,
acute phase of
infection
MPV 7fL ABNORMAL, decrease
7.4-10.4fL in MPV indicates Renal
.
insufficiency
Carbohydrate diet .
1.08mg/dL NORMAL
FT4 0.71-1.85mg/dL
called the renal artery supplies blood to them and the renal vein drains them.
The excretory system consists of paired kidneys and associated blood supply.
Ureters transport urine from the kidneys to the bladder and the urethra with associated
sphincter muscles controls the release of urine.
The kidneys have an important role in maintaining homeostasis in the body.
They excrete the waste product urea, control the concentrations of water and salt in the
body fluids, and regulate the acidity of the blood.
A kidney consists of an outer region or cortex, inner medulla and a cavity called
the pelvis that collects the urine and carries it to the ureter.
The tissue of a kidney is composed of masses of tiny tubes called kidney
tubules or nephrons. These are the structures that make the urine.
PROGNOSIS
The prognosis is fair, because of the
continuous care that is given to the client.
Although there is a high risk for infection as well
as other problem that may arise because o the
client’s condition, it is also depends on how
severe the condition is.
DISCHARGE PLANNING
M Instructed the patient and significant others to give home medications that
the physician will prescribe upon discharge.
>Ceftriaxome Sodium 125mg, 2x a day
>ketorolac 15mg, every 6 hrs.
>Buscopan 0.3-0.8mg, once a day
E Taught the patient about the appropriate passive range of motion and
exercise for the client.
T Encourage the patient to have a therapy that is suited for her condition.
H Encourage and advised the patient to have good personal hygiene.
D Advised the patient and significant other’s to provide foods rich in protien,
iron, vit. C, etc.
S Advised the whole family to keep their faith in God and never forget to ask
for guidance and good health.
ACKNOWLEDGEMENT
First and foremost I want to thank God for
giving me the knowledge, strength, and courage to do this
case study. Also to my parents for being supportive, for
giving me advices all the time, and for their love and trust on
everything that I wanted to do. As well as to my brother’s and
sister’s who helps me financially or emotionally. And of
course to my friends and love ones who makes me laugh
and inspires me to focus on my studies and not to take the
wrong path which will make my life miserable. Also to the
librarian for letting me lend books in the library and also to
my group mates THANK YOU for your willingness to answer
my questions all the time. And to my beautiful and loving
clinical instructor thank you so much for sharing your
knowledge and for the love and care that you gave to our
group. THANKS FOR ALL MAAM WE LOVE YOU.
BIBLIOGRAPHY
Medical Surgical Nursing, Smeltzer, et al.
MEDICAL Surgical Nursing Critical Thinking for
Collaborative care 15th Edition
Health assessment and Physical Examination,
Estes
Laboratory and Diagnostic Test with Nursing
Implication 7th Edition
Nurse’s Pocket Guide 11th Edition
Human Anatomy and Physiology
Drug Handbook
PATHOPHYSIOLOGY
NON –MODIFIABLE RISK FACTOR MODIFIABLE RISK FACTOR
65y/o
LIFESTYLE
FEMALE ENVIRONMENT
KIDNEY
URETHRAL MEATUS
URETERAL PRESSURE
URINARY TRACT
GLUMERULAR FILTRATION
TUBULAR ATROPHY
NEPHRON LOSS
HYDRONEPHROSIS
SUMMARY OF
PATHOPHYSIOLOGY
Hydronephrosis can result from anatomic and
functional process interrupting the flow of urine.
This interruption can occur anywhere along the
urinary tract from the kidney to the urethral
meatus. The rise in ureteral pressure leads to
marked changes in glomerular filtration, tubular
function, and renal blood flow. The GFR declines
significantly within hours following obstruction.
This significant decline in GFR causes inability
of the renal tubular to transport sodium,
potassium, and protons and concentrate and to
dilute urine is severely impaired. The existence
of persistence of these can cause tubular
atrophy and permanent nephron loss and then
lead to swelling of the kidney that causes
HYDRONEPHROSIS.
NURSING CARE PLANS
ASSESS NURSIN SCIENTI PLANNI INTERV RATION EVALUA
MENT G FIC NG ENTION ALE TION
DIAGNO EXPLAN
SIS ATION
S>Hindi Anxiety A state in After 2hrs. >monitored >serve as The client
ako related to which a of nursing vital signs a baseline expressed
mapakali perceived person interventio data her
hindi ko health experience n patient >Promote >reduces feelings
alam kung threat to uneasiness will identify expression anxiety and
maoopera health /apprehens ways to of feelings attributable participate
han ako as status. ion and deal with and fears to fear of in her
verbalized application anxiety. the health care
by the of ANS in >explain
purposes unknown
patient. response diagnosis
to a vague tests and
O>poor procedures and
eye non- prognosis
contact specific >encourag
ed family >reassures
>restless threat.
member to client that
>facial treat client role in the
tension as before family has
not been
altered
ASSESS NURSIN SCIENTI PLANNIN INTERVE RATION EVALUA
MENT G FIC G NTION ALE TION
DIAGNO EXPLAN
SIS ATION
T.I.D.
NAME OF CLASSIFICATI INDICATION ADVERS CONTRAINDICAT NURSI MONITO
ON E ION NG RING
DRUG REACTIO RESPO PARAM
N NSIBILI
ETERS
TY
NSAID’s >Short term >head ache >Contraindicated >correct >May
Action: management >dizziness to patient hypovol increase
Ketorolac May inhibit of moderately >drowsines hypersensitive to emia ALT and
severe acute s drug and those before AST
prostaglandin
pain for single >edema with active peptic giving>
Generic synthesis, to >May
dose treatment >nausea ulcer disease us increase
name: produce anti-
>Short term >constipati >Contraindicated single bleeding
inflammatory, on
analgesics and management in children dose in time
Toradol >vomiting young
anti pyretic of moderately younger than 2y/o
effects severe acute and for patient children
Dosage: pain for with history of
multiple dose peptic ulcer
treatment disease
15mg/ml
>Use cautiously in
patient especially
Rout: I.V. elders
Frequency
:q6
DRUG CLASSIFICATIO INDICATI ADVERSE CONTRAIN NURSING MONITORI
NAME N ON REACTIO DICATION RESPONSI NG
N BILITY PARAMETE
RS
Third Generation >UTI >fever >Contra >Obtain >May
cephalosporin >Meningiti >head indicated to specimen increase
Ceftriaxom Action: s ache patient for culture alkaline
e sodium Third generation >Acute >dizziness hypersensiti and phosphate,
cephalosporin bactericida >phlebitis ve to drug sensitivity ALT, AST,
that inhibits cell- l and other test before and BUN.
Generic >diarrhea cephalospor giving first
name: wall synthesis, >May falsely
promoting in >Use dose increase
osmotic cautiously >Before serum/urine
Rocephin instability, in patient giving first creatinine
usually hypersensiti dose ask level
Dosage: bactericidal ve to patient if
penicillin>U he/she has
se any
125mg cautiously allergies
in breast
Rout: feeding
women
I.M.
Frequency
:
B.I.D.