Advance Nursing Care of Adults Case Study
Diagnosis and Definition
K.D. is a 54 year old female with a primary medical diagnosis of recurrent nephrolithiasis secondary to congenital medullary sponge kidney. Nephrolithiasis, also known as “kidney stones”, is a hard clump of built up minerals that form in the kidneys. Medullary sponge kidney (MSK) occurs when small cysts form either on the tubules or the collecting ducts, creating a sponge like appearance, on either one or both the kidneys.
Doctors and scientists are not fully sure on the cause of medullary sponge kidney. It is believed to be a result of abnormal renal development in utero. MSK is a rare disorder that is thought to occur in 1 percent of the population. It is more likely to affect women than men. Symptoms usually develop during adolescents or in adults between the ages of 30 and 50 years old, but they can appear at any time. Around 13 percent of people who develop kidney stones are eventually diagnosed with Medullary Sponge Kidney.
The outer part of the kidney is known as the cortex. The inner part of the kidney is called the medulla. The cortex and medulla of each kidney contain about one million tiny units called nephrons. Each nephron is made up of a very small filter called the glomerulus. The glomerulus is attached to a tubule. As blood passes through the nephron, fluid and waste products are filtered out.
Normally, most of the fluid is returned to the blood, while the waste products are concentrated in any excess fluid and flow down to the bladder as urine. In a person with medullary sponge kidney, cysts cause the collecting tubules to become abnormally wide. This makes the drainage of urine slow and inefficient. Waste products such as excess calcium then build up in the kidney.
K.D. gets recurrent nephrolithiasis due to her diagnosis of MSK. Symptoms of MSK include frequent nephrolithiasis and urinary tract infections. These symptoms of MSK are due to the cysts causing the tubules to be wide thus making the drainage of urine slow and lack of ability to filter.
Signs and Symptoms
K.D. came into the hospital experiencing fatigue, right sided flank pain radiating to the groin, nausea, chills, pain with urination, blood and gravel like appearance in the urine and a low grade fever. All of K.D. symptoms tie together with signs and symptoms of kidney stones and/or a urinary tract infection. Many people with medullary sponge kidney have vague or no symptoms at all. The first sign that a person has MSK is usually a urinary tract infection or a kidney stone. Both share many of the same signs and symptoms such as burning or painful urination, cloudy or bloody urine, pain in the back, lower abdomen or groin, fever and chills, nausea and vomiting, and foul smelling urine.
Labs/ Diagnostic Tests
|LAB||REASON||RESULT||RANGE||RELTIONSHIP OF RESULT|
|BUN||Check kidney function, kidney stones||11||7-20||WNL|
|Creatine||Check kidney function, kidney stones||0.8||0.6-1||WNL|
|GFR||Check kidney function, kidney stones||58||90-120||MSK|
|Potassium||Check for electrolyte imbalance||2.2||3.5-5.0||WNL|
|Calcium||Check for imbalance||9||8.5-10.2||WNL|
|Sodium||Check for imbalance||137||135-145||WNL|
|UA, Ketones||Check for infection||Negative||Negative||WNL|
|UA, Glucose||Check for infection||Negative||Negative||WNL|
|UA, Protein||Check for infection||30||0-20||UTI related to MSK|
|UA, Blood||Kidney Stones||Large||Negative||Kidney stones related to MSK|
Pagana, K. D., Pagana, T. J., Pike-MacDonald, S. A., & Pagana, K. D. (2019). Mosbys Canadian manual of diagnostic and laboratory tests. Toronto, ON: Elsevier
- At risk for ineffective breathing pattern related to respiratory depression from use of opioid pain medication
Goal: The patient will experience no signs of respiratory distress (nasal flaring, use of accessory muscles, cyanotic) during my whole shift (6-3pm)
- Acute pain related to increased frequency/force of ureteral contractions as evidence by patient rating pain a 8/10 when asked to rate pain in a scale of 1 to 10, with 10 as the highest
Goal: The patient will rate her pain at an acceptable level for her (6 or below) during my whole shift (6-3pm)
- Impaired urinary elimination related to stimulation of the bladder by ureteral irritation as evidence by patient having painful urination and gravel like appearance in urine
Goal: The patient will display no pain during urination and the patient’s urine will be free from gravel like appearance by next Tuesday.
- Activity intolerance related to pain associated with kidney stones as evidence by chronic fatigue and limited physical activity
Goal: The patient will increase her physical activity by walking in the hall twice during my shift
- Risk for deficient fluid volume related to nausea and vomiting
Goal: The patient will stay nausea free for my whole shift (6-3pm)
The main nursing inventions for medullary sponge kidney relate with pain management. Nursing interventions in place for K.D. include pain management, encouraging fluids, and monitoring vitals. Pain management intervention starts with evaluating K.D. pain level. By asking K.D. her pain level the nurse can assess if K.D. pain is getting worse or if the pain is decreasing.
The nurse will ask K.D. to rate her pain, the pain location, intensity, and what it makes it better or worse. After the nurse gets a better understanding of K.D.’s pain the nurse can then further assess on what type of pain management will best benefit K.D. pain. Options to help relieve K.D. pain include her prescribed pain medication and/or a non- pharmacological approach. While working with K.D. some of the non-pharmacological approaches she liked were using a warm blanket, soaking in a warm bath, and applying heat packs to areas of pain. Using both pharmacological and non-pharmacological pain approaches together was effective in helping to decrease K.D. pain levels.
By encouraging fluids, it not only help K.D. overall hydration status but it aided in the help of passing her kidney stones. Frequently obtaining K.D. vitals and assessing gave the nurse a quick overview on how K.D. was doing. A big risk for K.D. was going into respiratory distress from the type of pain medications she was using. With the nurse frequently monitoring her vitals, the nurse was able to build a baseline to help evaluate if K.D. was going towards having a respiratory distress issue. Both encouraging fluids and frequently assessing K.D. was effective in her care plan.
|DRUG NAME||DOSE||ROUTE||TIME||FREQUENCY||REASON||COMMON SIDE EFFECTS||NURSING ASSESSMENT||EFFECTIVENESS|
|Esomeprazole||40mg||Oral||0830||Once Daily||Acid reflex||HA
|Give an hour before eating||Yes, help patient decrease acid reflex|
|Fentanyl||25mcg||PCA PUMP||N/A||10mintues||Pain||Respiratory depression||Monitor pain and vitals||Yes, help patient with her pain management|
|Lorazepam||1mg||IV PUSH||PRN||Every 5 hours as needed||Anxiety||Drowsiness
|Assess patients anxiety level before and after||Yes, help patient decrease anxiety and restlessness|
|Magnesium Chloride||64 mg||Oral||0830
|3 times per day||Low magnesium levels||Nausea
|Monitor magnesium labs||N/A do not know current magnesium levels|
|3 times per day||Hypotension||hypertension||Monitor B/P||Yes, patient is having “stable” B/P|
|Naloxone||1mg||IV Push||N/A||PRN||Respiratory distress||Dizzy
|Monitor vitals and S/S of distress||N/A did not use with patient|
|Ondansetron||4mg||IV Push||PRN||Every 6 hours as needed||Nausea||HA
|Assess patients nausea status before and after||N/A did not use with patient|
|Oxycodone Extended Release||20mg||Oral||0830
|2 times per day||Pain||Respiratory depression||Monitor pain and vitals||Yes, help patient with her pain management|
|4 times per day||Pain||Respiratory depression||Monitor pain and vitals||Yes, help patient with her pain management|
|2 times per day||Low potassium levels||Upset stomach
|Monitor potassium levels||N/A do not know current potassium levels|
|Potassium Citrate Extended Release||30 mEq||Oral||0830
|2 times per day||Low potassium levels||Confusion
|Monitor potassium levels||N/A do not know current potassium levels|
|Sodium Chloride 0.9%||75mL||IV||N/A||Continuous||Help with the release of kidney stones||Fluid retention
|Monitor patient IV site
Monitor hydration status
|Yes, patient is starting to pass kidney stones|
|Sodium Chloride Flush||10mL||IV Push||N/A||PRN||Keep port patent||Fluid retention||Monitor IV site while flushing
Monitor hydration status
|N/A did not use with patient|
|Tamsulosin||0.8mg||Oral||0830||Once Daily||Help with urination while passing kidney stones||Weakness
|Monitor patient I&O||Yes, help patient with urinary pattern|
Two teaching plans I incorporated into K.D. care included non-pharmacological pain management ideas and ways to help prevent a urinary tract infection. To incorporate teaching I met with K.D. after an adequate amount of time had went by since she had her past pain medication. I didn’t want her to be in pain nor to be drowsy while I gave her some teaching information. I went over different non-pharmacological pain management ideas that she already incorporated such as the warm bath and heat pad. I then went over new ideas such as essential oils, salt rock, and guided imagery. My objective for this teaching was for K.D. to be able to repeat back to me 3 different non-pharmacological pain management ideas and how she could incorporate them into her daily living.
For the second part of the teaching, I went over ways to prevent a urinary tract infection (UTI). K.D has a history of frequently getting UTI’s when she gets kidney stones, so I thought this would be a good way to help aid her in preventing them. I told her by drinking adequate fluids, wiping her perineal area from front to back, avoid using irritating/scented soaps on her perineal area, and urinate when the needs arrives (don’t wait). My objective for this teaching was for K.D. to repeat back the different ways she could help prevent a UTI.
Overall, I was able to create a therapeutic relationship with K.D. along with increasing my nursing education by being able to work with her. Medullary sponge kidney (MSK) is a rare disorder that creates cysts on the tubules in the kidneys, giving the middle of the kidney a “sponge like” appearance. Due to the cysts, patient with MSK have reoccurring kidney stones and urinary tract infections. Doctors are unsure on why MSK happens and are still researching many aspects of the disease.
Although, I was able to teach K.D. different ways to aid in her coping of the disease, I feel like she taught me more. Her strength she showed me dealing with her illness everyday was very humbling. Even though she is constant pain and is in the hospital quite frequently she was still able to smile and in good spirts. I am very grateful for the opportunity I had to work with K.D.
- Medullary Sponge Kidney. (2017, February 03). Retrieved from https://www.kidney.org/atoz/content/medullary-sponge-kidney
- Medullary Sponge Kidney. (2015, August 01). Retrieved February 24, 2019, from https://www.niddk.nih.gov/health-information/kidney-disease/children/medullary-sponge-kidney
- Medullary Sponge Kidney. (n.d.). Retrieved February 23, 2019, from https://rarediseases.org/rare-diseases/medullary-sponge-kidney/
- Pagana, K. D., Pagana, T. J., Pike-MacDonald, S. A., & Pagana, K. D. (2019). Mosbys Canadian manual of diagnostic and laboratory tests. Toronto, ON: Elsevier
- Williams, L. S., & Hopper, P. D. (2015). Understanding medical surgical nursing. Philadelphia: F.A. Davis Company.