Abstract
While attending clinical at DMH I used one of my patients to develop a case study. My case study will require me to use the skills I have been practicing to make a connection between medical and nursing problems. Some of these skills include assessment, rationales, critical thinking, and problem solving. In this paper I will go over my patient’s health history, lab tests, pathophysiology, diagnosis, and her medications. I will also provide a detailed nursing assessment, a detailed nursing process and explain reasons and rationales about my decisions involving her care.

I. Health History
Client Health and History: On April 9, 2014, at Decatur Memorial Hospital, my client was a 76 old Caucasian female with the initials DK. She was born in the small town of Olney, Illinois. Her husband explained that it is about a two and a half hour drive to Decatur Memorial Hospital from their hometown and this was not their first trip here. DK and her husband have been married for 56 years and have three children: two daughters and a son. She worked for McDonalds for 12 years and then retired to be a stay at home mom. My patient was admitted to the hospital based on an abnormal finding from a CAT scan. They CAT scan showed a mass in her right kidney. The patient described that she had no idea of the mass. She went in for a CAT scan because of blood in her urine and experience of her previous diagnosis of kidney cancer, and was informed of the findings. In June of 2013, she had received a total left nephrectomy because of malignant neoplasm in her left renal pelvis. She also informed me that she was born with three kidneys, one left and two rights. However she now only has the two right ones. Malignant neoplasm of the renal pelvis means any new or abnormal growth of tissue found in the renal pelvis associated with cancer.
The kidneys are bean shaped, so the renal pelvis is the hollow collecting area in the center of each kidneys right before the ureters. The renal pelvis and ureters are both lined with a layer of transitional cells, which is the same lining as the bladder. Like with any cancer, the transitional cells continue to multiply causing masses (“Cancer of the renal pelvis”, 2014). Since DK has been a constant smoker for most of her life, her chances of developing this type of cancer were increased. Cancer has been in DK’s generations for years. Her grandmother was diagnosed with breast cancer, her sister died of pancreatic cancer, her sister has been diagnosed with breast cancer, and her other brother and sister both have colon cancer. Cancer is something that has been very familiar to their family. Aside from being diagnosed with malignant neoplasm of the right kidney, DK has other chronic illnesses. She suffers from hypertension, anxiety, depression, arthritis, scoliosis, lower extremity neuropathy, and degenerative spine disease. She is always in a lot of pain and it is painful for her to walk. Her arthritis in her feet and toes is so bad she has hammer feet. Despite from the constant pain she is in, she has a great support system. She has a total of nine brothers and sisters and three children. Her hobbies include reading and cooking. She loves to cook for her family and have family get-togethers. I can tell that she has a close knit family. Her two daughters and husband were by her side the whole time she was admitted to the hospital. Looking at her chart you will find she this definitely isn’t her first operation. Through her childhood she informed me that she was rather healthy. Every once in a while she would suffer from common illnesses such as the flu or a cold, nothing serious. As she got older her health started to decline. It seemed to start when she broke the metatarsal arch of her foot. She has also had her gallbladder removed, hernia surgery, laparoscopy, cholecystectomy, hysterectomy, left ureteroscopy and left robotic-assisted nephroureterectomy.
Apart from being a current smoker and occasional drinker, she has no known allergies that affect her every day health. Unlike her grandmother and siblings, her mother had excellent heath and lived till the age of 97. Her father was killed at the age of 52 during a farming accident. DK seemed quite skeptical as to if it really was an accident or was planned. Both of DK’s daughters and her one son are healthy. The girls have arthritis, but not to the severity of their mother. Both daughters were present on the day I assessed DK. When I went into her room I noticed she had a nephrostomy tube and a catheter inserted into her. The fluid in the nephrostomy bag was pink and the urine in the catheter bag was yellow, which were normal findings.

Genogram Key: O=Female +=Male I=Intergeneration connection lines CC=Colon Cancer PC=Pancreatic Cancer KC=Kidney Cancer BC=Breast Cancer -----=Intrageneration connection lines O-----------------------------------------------------------------------------------+ Mother I Father Deceased I Deceased No known illnesses I No Known illnesses 97 I 52 I O--------------------------O---------------------------- O ----------------------------- O ------------------------+ Sister Client Sister Sister Brother Deceased Alive Alive Alive Alive PC KC/Arthritis BC CC/Arthritis CC/Arthritis 76 I I I I I I O + O Daughter Son Daughter Alive Alive Alive Arthritis No known illnesses Arthritis
II. Pathophysiology
Neoplasm of the Renal Pelvis:
In patients with neoplasm of the renal pelvis (also known as renal pelvis cancer or a specific kidney cancer), some type of mass or over growth of transitional cells is found in the renal pelvis. In the United States over 39,000 new kidney cases are found every year. Around 12,000 people die from this type of cancer in the U.S. every year. This type of cancer arises from the cortex or pelvis of the kidney. The tumors can be benign or malignant. The most common type of tumors found are usually malignant. Renal cell carcinoma (the kind DK has) is the most common kidney cancer. It is most commonly found patients between the age ranges of 50 to 70. It is twice as common in men as it is in women (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011). The highest risk factor for developing cancer of the renal pelvis or ureter is smoking. However, most cancers are the result of many risk factors.
The following factors are known to increase the risk of developing cancer of the renal pelvis or ureter: smoking, heavy use of phenacetin, and Balkan endemic nephropathy. The strongest substance smoked that leads to renal pelvis cancer is tobacco. The risk of developing this cancer increases over the amount a person has spent smoking and the amount of tobacco smoked. The next factor is heavy use of phenacetin which “is a type of analgesic, or pain reliever. People who used phenacetin very heavily (3 or more pills per day over a number of years) are at an increased risk of developing renal pelvis cancer” (“Cancer of the renal pelvis”, 2014).
Medicines that contain phenacetin have been banned since the 80’s; so a person having renal pelvis cancer due to phenacetin is actually a rare finding. The last factor is Balkan endemine nephropathy (BEN). This is a serious kidney disease that affects small clusters of villages in the Balkan peninsula of Eastern Europe. Most of the patients affected with this disease develop multiple tumors, usually in both kidneys. Since we live in the United States, a patients risk of acquiring BEN is very low (“Cancer of the renal pelvis”,2014).
Early detection renal pelvis cancer (RPC) means detecting it at an early stage. Since there are no major characteristics of early symptoms, some patients go on without knowing until the cancer has significantly progressed (Lewis, 2011). However, there are some symptoms that can be identified but may not always mean cancer. Recognizing these symptoms and getting treatment before the cancer affects the whole kidney is the ideal goal. My patient was lucky; she was able to get a diagnosis and removal of the cancer before it affected her whole kidney. Some signs and symptoms of RPC include: blood or blood clots in the urine, flank pain in the area around the back and side of the abdomen, pain or a burning feeling while urinating, difficulty urinating and a palpable mass in the flank or abdomen (Lewis, 2011). DK was experiencing some of the symptoms it mentioned in the Lewis book. She had blood in her pee and also a flank pain where her right kidney is.
To detect RPC physicians use many different procedures. You can get a urinalysis (to check for blood in the urine), a urine cytology (to tests the urine for the presence of cancer cells), a ureteroscopy (an endoscopy that examines the inside of the ureters and renal pelvis), a cystoscopy (also known as bladder exam), a CT Scan (which allows you to see the size, shape and location of the tumor), and also an intravenous pyelography (IVP), which is a special x-ray that uses contrast medium to inspect the kidneys, bladder and ureters (“Cancer of the renal pelvis”, 2014).
On 3/12/14 DK underwent a CT scan of the abdomen and pelvis and also a Chest X-ray. They found a tumor in her right kidney and atherosclerosis of her abdominal aorta. They also reported atelectasis in the lower lung bases. She also had developed a cough while she was admitted. They were afraid she might have acquired pneumonia; however, the results were negative. She also had a urinalysis and a urine culture. Her culture came back negative.
III. Lab Results
Abnormal Lab Values: April 8, 2014 | Patient Value: | Normal Reference Range: | Basic Metabolic Panel: | | | Calcium | 8.3mg/dl (low) | 8.8-10.omg/dl | Hemogram: | | | RBC | 3.36trillion cells/L | 3.90-5.03 trillion cells/L | Hemoglobin | 9.4gm/dl (low) | 12-16mg/dl | Hematocrit | 28.6% (low) | 37%-47% | Lymph | 1.2 (low) | 1.5-3.5 | Platelet | 218 billion/L (high) | 150-450 billion/L | Corrected Calcium: | | | Calcium total | 8.3mg/dl (low) | 8.8-10.0mg/dl | Albumin | 3.0gm/dl (low) | 3.4-4.8gm/dl |

As illustrated in the chart, abnormal laboratory findings include: red blood cell count, hemoglobin, hematocrit, calcium, albumin, platelet count and lymphocyte count. DK exhibits hypoalbumenia, which can be caused by poor nutrition or an increase in albumin excretion from your kidneys. Poor nutrition that can cause hypoalbumenia would include a diet with low protein. After surgery a person’s body uses an increased amount of protein to recover and heal your wounds and incisions. If DK’s intake was less than her body’s use, it would account for her low levels. Another cause can be from an increase in excreted albumin in her urine, due to renal dysfunction caused by a tumor in her renal pelvis. Age can also be a factor. Albumin levels have been shown to decline in older adults (Potter & Perry, 2009). An intervention to treat hypoalbumenia would be to enforce a high protein diet and assess her medications and dosages to see if her diurects are releasing too much fluid and albumins (AFHS Consumer Medication, 2014). DK’s labs also displayed low calcium levels. This can be resulted from hypothyroidism, vitamin D deficiency, and/or hypoalbumenia (Potter & Perry, 2009). Since hypocalcemia can be related or caused by hypoablumenia, nursing interventions for hypoalbumenia could increase calciums levels too. DK was taking a calcium carbonate (vitamin D and calcium supplement); this drug will increase her intake of vitamin D and calcium, which would cause her calcium levels to rise. By the time I was her nurse her calcium levels had already been corrected; therefore this intervention was successful. DK also experiences low RBC count, low Hemoglobin, low platelet count, and a decreased hematocrit. DK’s low hematocrit results a low number of red blood cells. She may have been experiencing some anemia, which accounted for her low hemoglobin and low platelet count too. This can be caused from the amount of blood that was lost during surgery. Most patients who have decreased red blood cell counts and low hemoglobin experience fatigue, shortness of breath, pallor, and decreased activity tolerance (Potter & Perry, 2009). These symptoms were accurate with the way DK was feeling. She expressed fatigue and shortness of breath. DK has been given blood transfusions to help increase her red blood cell count.
IV. Diagnostic Studies
CT Scan: On March 12, 2014 DK received a CT scan of her abdomen and pelvis. DK had been complaining of pain in her abdomen and also in her back. The CT scan showed a small mass in her kidney. It also showed atherosclerosis of her abdominal aorta, small right lung effusion, and lower lobe atelectasis. These results led to her percutaneous resection of her right renal pelvis. Preforming his procedure is out of the jurisdiction of the nurse.
Chest X-Ray: DK received a PA lateral chest x-ray on March 3, 2014. This also showed the persistent bibasilar atelectasis. She received another PA later chest x-ray on April 8, 2014, which only a few changes. A small amount of pleural fluid was seen at the base of her lungs. Preparing patients for x-rays is not the duty of the nurse, but monitoring lung sounds for this patient is definitely a must. The nurse is responsible for noting any changes or differences in lung sounds, consciousness, and color of the patient since any of these changes could be the result of something dangerous.
V. Medications
Prescribed Scheduled Medications: Medication | Dose | Route | Frequency | Start | Calcium Carb | 500mg | Oral | QDWM | 0900 | Gabapentin | 300mg | Oral | TID | 0900 | Valsartan | 80mg | Oral | QD | 0900 | Cefazolin | 1gm | IV | | 0800 | Lansoprazole | 15mg | Oral | QDAC | 1100 | Lorazepam | 1mg | Oral | QHS | | Oxycodone | 60mg | Oral | AM/PM | 0900 | Levofloxacin | 500mg | Oral | QDAC | 1100 |

Calcium Carbonate- It is a Vitamin D and Calcium dietary supplement. It is prescribed to patients who are not taking in enough calcium in their diet. Healthy bones, muscles, nervous system, and heart are all results of proper calcium intake. Calcium carbonate can also be used as an antacid to relieve heartburn, acid indigestion, and upset stomach. My patient was prescribed this for her low levels of calcium. It is available with or without a prescription. It comes as a tablet, capsule, or liquid to be taken orally. Some side effect the nurse would need to watch for include: upset stomach, vomiting, stomach pain, belching, constipation, dry mouth, increased urination, loss of appetite, and metallic taste (AHFS Consumer Medication, 2014).
Gabapentin- This drug is classified as an anticonvulsant. It used to help control certain types of seizures by decreasing the excitement in the brain. If taken orally it is used to relieve pain. Gabapentin extended-release tablets are used to treat restless legs syndrome. This medication should be taken at evenly spaced times throughout the day and night. DK was administered this for pain relief. When administering, a nurse should not let more than 12 hours pass between doses. Some side effects that need to be watched for include: dizziness, drowsiness, fatigue, headache, nausea, shakiness, diarrhea, anxiety, and dry mouth (AHFS Consumer Medication, 2014).
Valsartan- This drug is classified as a Renin angiotensin system antagonist and antihypertensive. This drug is used alone or with another medication to treat hypertension. Before administering this medication a nurse should always take the patient’s blood pressure. Valsartan can also be used to treat CHF (Congestive Heart Failure). Valsartan works by blocking certain natural substances that cause the blood vessels to tighten. This results in the blood vessels not tightening and a more smooth blood flow. This medication is taken twice a day by mouth. A patient can take it with or without food. Nurses need to make note of when the drug is given so they can try to give it at the same time every day. DK has had a history of hypertension so her doctor prescribed her valsartan to try to lower her blood pressure (AHFS Consumer Medication, 2014).
Cefazolin- This is an antibiotic given through an IV. This drug is used to treat infections. Since DK is a postop patient, her surgical openings and wounds are at risk for infection. Cefazolin works by eliminating bacteria that can cause many different kinds of infections. Some of the infections it can treat include lung, skin, bone, joint, stomach, blood, heart valve, and UTI’s (urinary tract infections). Side effects include diarrhea, stomach pain, fever, cramps, upset stomach and vomiting (AHFS Consumer Medication, 2014).
Lansoprazole- This drug is classified as an antisecretory medication. It is used to treat gastroesophageal reflux disease. This is a condition where the backward flow of acid from your stomach possible injury to the esophagus and heartburn. It is very uncomfortable. DK was prescribed this to prevent her heartburn. It is to be taken orally, two or three times daily before a meal. Some side effects the nurse needs to watch are constipation, nausea, headache, dizziness, fatigue (AHFS Consumer Medication, 2014).
Lorazepam- This drug is used as an anxiety reliever, classified as a benzodiazepine. The drug slows the activity in the brain allowing for relaxation. It is common for postop patients to be anxious after surgery, so DK was prescribed this medication to relieve some of that anxiety she may have been feeling. Lorazepam is usually taken two or three times a day with or without food. Along with anxiety lorazepam can be used to treat irritable bowel syndrome, epilepsy, insomnia and nausea and vomiting from cancer treatments. Some side effects to be aware of include drowsiness, dizziness, weakness, depression (AHFS Consumer Medication, 2014).
Oxycodone- This is a narcotic used to relieve serious pain. Narcotics are serious medications because they can be habit forming. It is classified as an opiate analgesic. The drug changes the body and nervous system’s response to pain. This medication is on a strict time schedule. It should be taken every 4 to 6 hours with food. Narcotics are prescribed to patient who have undergone surgery and have major pain. DK is on this medication for pain. Pain reassessment is essential when administering narcotics. Side effects to look for include nausea, slow breathing, vomiting, dizziness, drowsiness, sweating, itching, headaches, weakness (AHFS Consumer Medication, 2014).
Levofloxacin- This is used to treat infections such as pneumonia, chronic bronchitis, sinus, urinary tract, kidney, prostrate, and skin infections. DK was prescribed this as an intervention to prevent infection. It is usually taken once a day by mouth. Side effects include nausea, vomiting, diarrhea, stomach pain, constipation, heartburn, headache, vaginal itching or discharge (AHFS Consumer Medication, 2014).

PRN Medication (As Needed): Medication | Dose | Route | Frequency | Start | Hydrocodone | 5mg | Oral | Q4HP | | Hydromorphone | .2ml | IV | Q2HPRN | |

Hydrocodone- is a Narcotic, it is used to relieve pain. It is also used to relieve a hyperactive, nonproductive cough like the one DK is experiencing. The doctor prescribed this drug to treat DK’s cough because he is unsure of the cause. This drug is to be taken orally, and some side effects to look out for include dry mouth, constipation, nausea, light-headedness, drowsiness, and dizziness (AHFS Consumer Medication, 2014). Hydromorphine- This is a Narcotic, or Analgesic. It is used to manage pain. It is a prn drug so it is there for whenever DK is experiencing severe pain. It is an oral route drug. It has some common side effects of nausea, vomiting, constipation, euphoria, dizziness, and drowsiness (AHFS Consumer Medication, 2014).

VI. Nursing Assessment
Review of Systems: The next information was documented and obtained on April 9, 2014 at Decatur Memorial Hospital.

Isolation | No | Fall Risk | Yes Use gray non-skid footies Star on door Sticker on chart Clear obstacles Keep clear path Uses a walker Cords under bed Bed low position Call light in reach | Code Status | Full code | Patient Conditions & Concerns | Patient complains of right flank pain | General Appearance | Excellent hygene | Cooperation | Cooperative | Level of Consciousness | Alert, friendly | Clarity of Speech | Clear, responsive | Orientation | Oriented X3, to person, place, time | Family Visit | Family present and supportive | Mobility | Slightly limited mobility 1 person assist Reinforce safety Receiving PT/OT Items in reach | Hygiene | Good, family assists with hygiene | Skin Color | Pink | Skin Condition | Dry, warm | Mucous Membranes | Pink, moist | Skin Turgor | Normal | Pressure Devices | Pillows behind back | Pressure Points | Heels, elbows, scapulae free of redness Pressure ulcer on sacrum | Pressure Points From Equipment | NA | Skin Temperature | Warm | Interventions to Prevent Skin Breakdown | Bed clean and dry Bed without wrinkles Inspect skin every hour Dietary consult Rotate every 2 hr or more | Blood Pressure | 154/80 | Pulse | 72 apical | Respiration Rate | 14 breaths per minute | Temperature | 97.8F oral | SpO2 | 96% Room air | Pain Level | Right flank pain where surgical incision was Did not rate pain Stated she’s always in constant pain Pain level tolerable at that time | Motor/Verbal Response | Normal, appropriate | Facial Symmetry | Symmetric | Swallowing | Ability intact with no trouble | Respiratory Effort | Normal | Respiratory Pattern | Regular, unlabored | Lung Sounds | Clear, equal all lobes | Cough | Present | Nasal Flaring | No | Nail Beds | Pink | Retractions | No | Heart Sounds | Regular, normal | Heart Rate | 72 beats per minute, regular | Pedal Pulse | 1+ weak bilaterally | BM Quality | Soft, brown, small, formed | Bowel Control | Continent | Abdomen | Soft, non-tender, non-distended | Bowel Sounds | Active | Patient Indicates | Fatigue | Appetite | Excellent | Diet | Regular | Void | Has catheter | Urine Odor | Normal | Urine Character | Yellow, clear | Bladder | Non-distended | Mobility Abnormalities | Slightly limited due to bad arthritis in feet | Reason For Hospitalization | Percutaneous resection of a right renal pelvis tumor | Special Equipment | Incentive Spirometer | Wound#1 Type | Incision on back right | Incision Appearance | Dry, clean, intact | Incision Color | Pink | Incision Dressing | Gause | Incision Drainage | Bloody | Wound#2 Type | Skin Tear on Right cheek bone | Puncture Appearance | Dry, clean, intact, pink | Puncture Dressing | None |

VII. Nursing Process
Diagnoses, Goals, Interventions, Evaluations: DK’s chief medical diagnosis was malignant neoplasm of renal pelvis. She was admitted for a percutaneous resection of the right renal pelvis tumor. Priority assessments for DK include: Pain, wound care, respiratory system, skin integrity, mucous membranes, cardiovascular system, and urinary system. Nursing Diagnosis/Etiology/Defining Characteristics:Priority # __1___Mild to severe pain related to impaired comfort from recent surgery, defined by verbal complaints of pain | Goal: Patient will be able to remain at a tolerable pain level for at least one shift. | Evaluation of the goal: Goal met. Patient was administered pain medication to maintain her pain severity. Patient stated pain to be a level 3 and tolerable. | Interventions: Get doctor’s orders on which pain medication to administerMonitor pain administrations and reassess pain scale and hour after administratingTry involving the patient in non-pharmaceutical interventions such as music, games, relaxation therapy | Rationales:Always check orders, patient ID, and wrist bandReassessment helps the nurse know if the pain medication is affect and also the patients body’s reaction to itSometimes the best cure can be not to think about it. Patients tend to overthink, this approach redirects their thoughts toward a different subject | References: (List in APA format)Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical-surgical nursing assessment and management of clinical problems (Eighth ed.). St. Louis, MO: Elsevier.Potter, P. A. (2009). Fundamentals of nursing. St. Louis, MO: Elsivier Inc. |

Nursing Diagnosis/Etiology/Defining Characteristics:Priority # __2___Impaired physical mobility related to muscle weakness and pain, demonstrated by limitations while walking | Goal: Patient will experience an increase in muscle strength by day of discharge and a decrease of pain rating using the pain scale at the end of shift. | Evaluation of the goal: Goal partially met. Patient expressed pain at a level of 3 and stated pain to be tolerable. | Interventions: Maintain pain management. Administer pain medication before beginning physical activities.Have patient out of bed more than in bed doing ROM or physical activitiesAllow adequate time for restPromote and insure good intake and nutrition | Rationales:Physical activity can be more difficult and hard to do preform with a high pain levelHaving patient out of bed gives them the ability to use every muscle and not develop muscle weaknessAfter doing physical activity allow patients time to rest to recooperateNutrition is an important part of maintain and attaining strong healthy muscles. | References: (List in APA format)Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical-surgical nursing assessment and management of clinical problems (Eighth ed.). St. Louis, MO: Elsevier.Potter, P. A. (2009). Fundamentals of nursing. St. Louis, MO: Elsivier Inc. | Nursing Diagnosis/Etiology/Defining Characteristics:Priority # _2_Impaired skin integrity due to recent surgery | Goal: Patient will still remain free from symptoms of infection by discharge. | Evaluation of the goal: Goal met; wound was checked and dressed, patient had no signs of infection. | Interventions:Asses skin carefully along incisionTurn and reposition patient at least every 2 hours when in bedConsult with registered dietitian to optimize nutritional intake | Rationales:Signs of infection will start at the point of incisionContinuously turning the patient reduces the risk for skin breakdownNutrition is a major part of the body’s healing process | References: (List in APA format)Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical-surgical nursing assessment and management of clinical problems (Eighth ed.). St. Louis, MO: Elsevier.Potter, P. A., Perry, A. G., Stocker, P. A., & Hall, A. M. (2009). Fundamentals of nursing (Eighth ed.). St. Louis: MO. | |

VIII. Applying the Systems Theory
Hospital Departments: The system theory explains how a system is made up of separate parts, and each part is interconnected to share a common goal or purpose. Thus, each part comes together to make a whole (Potter & Perry, 2009). This system theory was demonstrated by each different department of Decatur Memorial Hospital that provided my patient with care. Each department worked together as a whole. The house keepers and environmental services came by throughout the day making sure my patient’s room was equipped with clean laundry, bed linen, towels, supplies, clean hallways and rooms. During meal times the dietary department kept track of the things my patient, DK, ordered and received. During surgery, surgeons, physician assistants, and techs provided my patient with care.
The anesthesilogy department provided my patient with care making sure she was unable to feel her surgical procedure. The laboratory department provided my patient with care, not physically, but by making sure her blood and urine tests were sent back as quickly as possible. Physical therapy and occupational therapy provided care by helping strengthen her muscles and supply her with adequate knowledge on healthy living. The volunteer workers provided DK with a newspaper each morning and fresh coffee at her disposal. When a person reflects on the different parts of the hospital, you come to realize each department has more than just one meaning; it has a meaning in working together to represent the reputation of care of the hospital.

References
AHFS Consumer Medication Information. (2014). The American Society of Health-System Pharmacists. Retrieved from: http://www.nlm.nih.gov/medlineplus/druginformation.html
“Cancer of the renal pelvis or ureter.” (2014). Canadian Cancer Society. Retrieved from: http://www.cancer.ca/en/cancer-information/cancer-type/bladder/pathology anstaging/malignant-tumours/renal-pelvis-and-ureter-cancer/?region=on
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. M. (2011). Medical-surgical nursing assessment and management of clinical problems (Eighth ed.). St. Louis, MO: Elsevier.
Potter, P. A., Perry, A. G., Stocker, P. A., & Hall, A. M. (2009). Fundamentals of nursing (Eighth ed.). St. Louis: MO.