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Objectives: General: Definition: To be able to know what is Nephrolitiasis. To be able to know the different Nursing Interventions about Nephrolitiasis.

Specific: To be able to know the definition of Nephrolitiasis To be able to know the sigs and symptoms of the disease To be able to know what spesific medications are to be given to those patients who are diagnosed with Nephrolitiasis To be able to know the different management to those patient with nephrolitiasis.

A kidney stone, also known as a renal calculus is a solid concretion or crystal aggregation formed in the kidneys from dietary minerals in the urine. Urinary stones are typically classified by their location in the kidney (nephrolithiasis), ureter (ureterolithiasis), or bladder (cystolithiasis), or by their chemical composition (calcium-containing, struvite, uric acid, or other compounds). Kidney stones are a significant source of morbidity. 80% of those with kidney stones are men. Men most commonly experience their first episode between age 3040 years, while for women the age at first presentation is somewhat later.

Kidney stones typically leave the body by passage in the urine stream, and many stones are formed and passed without causing symptoms. If stones grow to sufficient size (usually at least 3 millimeters (0.12 in)) they can cause obstruction of the ureter. Ureteral obstruction causes postrenal azotemia and hydronephrosis (distension and dilation of the renal pelvis and calyces), as well as spasm of the ureter. This leads to pain, most commonly felt in the flank (the area between the ribs and hip), lower abdomen and groin (a condition called renal colic). Renal colic can be associated with nausea, vomiting, fever, blood in the urine, pus in the urine, and painful urination. Renal colic typically comes in waves lasting 20 60 minutes, beginning in the flank or lower back and often radiating to the groin or genitals. The diagnosis of kidney stones is made on the basis of information obtained from the history, physical examination, urinalysis, and radiographic studies. Ultrasound examination and blood tests may also aid in the diagnosis.

When a stone causes no symptoms, watchful waiting is a valid option. For symptomatic stones, pain control is usually the first measure, using medications such as non-steroidal anti-inflammatory drugs(NSAIDs) or opioids. More severe cases may require surgical intervention. For example, some stones can be shattered into smaller fragments using extracorporeal shock wave lithotripsy (ESWL). Some cases require more invasive forms of surgery. Examples of these are cystoscopic procedures such as laser lithotripsy, or percutaneous techniques such as percutaneous nephrolithotomy. Sometimes, a

tube (ureteral stent) may be placed in the ureter to bypass the obstruction and alleviate the symptoms, as well as to prevent ureteral stricture after ureteroscopic stone removal. Epidemiology The prevalence of urinary calculi is estimated to be 5 percent in the general population, with an annual incidence of as much as 1 percent.2 Men are twice as likely as women to develop calculi, with the first episode occurring at an average age of 30 years.3 Women have a bimodal age of onset, with episodes peaking at 35 and 55 years. Without preventive treatment, the recurrence rate of calcium oxalate calculi increases with time and reaches 50 percent at 10 years.3 TABLE 1 Risk Factors for the Development of Urinary Calculi Risk factor Bowel disease Excess dietary meat (including poultry) Excess dietary oxalate Excess dietary sodium Family history Insulin resistance Gout Low urine volume Obesity Primary hyperparathyroidism Prolonged immobilization Renal tubular acidosis (type 1) Mechanisms Promotes low urine volume; acidic urine depletes available citrate; hyperoxaluria Creates acidic urinary milieu, depletes available citrate; promotes hyperuricosuria Promotes hyperoxaluria Promotes hypercalciuria Genetic predisposition Ammonia mishandling; alters pH of urine Promotes hyperuricosuria Allows stone constituents to supersaturate May promote hypercalciuria; other results similar to excess dietary meat Creates persistent hypercalciuria Bone turnover creates hypercalciuria Alkaline urine promotes calcium phosphate supersaturation; loss of citrate

Pathophysiology: Non-Modified
Congenital

Modifiable:
Trauma, ascending UTI

Blunt force

Infection

Hereditary

Cyst
Decreased Glomerular filtration rate Increased Concentration of urine

Formation of crystals

Kidneys
Monitor dicreased GFR

Obstructi on

Ureters
Major dicrease GFR

Pain

Dicreased Urine O. O.Output

Restlessnes s

H2O retention Fluid volume excess Fluid & Electrolyte Imbalance

Signs & Symptoms: The main symptom is severe pain that starts suddenly and may go away suddenly:

Pain may be felt in the belly area or side of the back Pain may move to groin area (groin pain) or testicles (testicle pain)

Other symptoms can include:


Abnormal urine color Blood in the urine Chills Fever Nausea Vomiting

Clinical Clues to the Diagnosis of Urinary Calculi Evaluation Laboratory evaluations Complete blood count Serum chemistry Possible findings

Leukocytosis with struvite calculi Elevation in creatinine levels with obstructing calculi; hypokalemia and hyperchloremia with renal tubular acidosis; elevated serum calcium levels with parathyroid disease Serum parathyroid hormone Elevated in hyperparathyroidism levels Urinalysis Microscopic or gross hematuria; acidic urine; alkaline urine (with struvite

Evaluation 24-hour urinalysis Radiographic evaluations Abdominal, kidney, and upper bladder radiography CT (stone protocol)

Possible findings calculi); pyuria; crystals from involved calculi Elevated urinary calcium, oxalate, and sodium levels; decreased urinary volume and citrate levels Urinary calculi larger than 2 mm may be visible. Nearly all calculi are visible on CT. Evaluates renal parenchyma, hydronephrotic changes, and surrounding organs for other etiologies of abdominal pain. Calculi visible on scout film. Delay in contrast excretion if obstruction is present. Calculi may appear as filling defect. Conventional MRI is not useful for imaging calculi. Calculi appear as hyperechoic lesions that cast acoustic shadows. Not reliable for ureteral calculi. May demonstrate dilation of collecting system.

Intravenous pyelography MRI Ultrasonography

Treatment:

Increasing fluid intake of citrate-rich fluids (especially citrate-rich fluids such as lemonade and orange juice), with the objective of increasing urine output to more than 2 liters per day Attempt to maintain a calcium (Ca) intake of 1000 1200 mg per day Limiting sodium (Na) intake to less than 2300 mg per day Limiting vitamin C intake to less than 1000 mg per day (A positive association between animal protein consumption and recurrence of kidney stones has been shown in men, but not yet in women.]) Limiting animal protein intake to no more than 2 meals daily, with less than 170 230 gram per day Limiting consumption of foods containing high amounts of oxalate (such as spinach, strawberries, nuts, rhubarb, wheat germ, dark chocolate, cocoa, brewed tea)

Drugs: Urine alkalinization Acetazolamide (Diamox) is a medication that alkalinizes the urine. In addition to acetazolamide or as an alternative, certain dietary supplements are available that produce a similar alkalinization of the urine. Diuretics thiazide and thiazide-like diuretics this drugs inhibit the formation of calcium-containing stones by reducing urinary calcium excretion Allopurinol interferes with the production of uric acid in the liver

Medical Management:

Nursing Interventions The nurse should:

Perform pain assessments to include Visual Analog, numerical, or Wong-Baker scales as appropriate for patient population to assess level of pain and effectiveness of outcome with pain interventions. Provide pharmacological education. Narcotics are usually used liberally, such as parenteral (IM/IV) narcotics (ketorolac, [Toradol], meperedine [Demerol], morphine, and oral narcotics/analgesic combinations (Department of the Navy Bureau of Medicine and Surgery, 2004). Use of narcotic medication needs to be explained as well as side effects, such as nausea, vomiting, constipation, and caution with driving or operating machinery. Review bowel patterns and suggest interventions to prevent constipation due to pain medication.

Assess contributing factors of dehydration such as nausea, vomiting, and diarrhea and administer antiemetics, such as metoclopramine (Reglan), prochlorperazine (Compazine), granisetron (Kytril), or ondansetron (Zofran). Administer antidiarrheal agents such as loperamide (Imodium), diphenoxylate, atropine (Lomotil), or paregoric and assess effectiveness of outcomes. If severe nausea and vomiting occur, patients must be aware that prevention of dehydration and electrolyte imbalance, may require IV hydration, prescription of anti-emetics, and solutions such as such as Gatorade or Pedialyte to replace electrolytes lost via the GI tract. Assess for vital signs checking for orthostatic hypotension (lowering of blood pressure and increase in pulse with positional changes) and monitoring patient weights. Encourage increases in daily fluid intake, especially water, and monitor outcomes of interventions through patient voiding history and 24-hour urine reports. The most important lifestyle change to prevent stones is drinking more fluids, especially water up to 2 quarts/day. Educate the patient on completing a voiding diary to track daily urine output. Educate the patient on the importance of completing laboratory tests ordered, especially 24hour urines. This can become an imposition on the patient's quality of life, especially if he is active and working. Educate the patient on collecting urine specimens and straining urine. Educate the patient on diagnostic testing, including required dietary or bowel preparation to reduce anxiety. Educate the patient on the importance of weight loss, maintaining weight loss, and daily exercise. Provide counseling on health promotion and maintenance, stressing the importance of followup care to evaluate causes of stone formation in an effort to prevent future recurrences.

References: http://emedicine.medscape.com/article/437096-treatment http://www.annualreviews.org/doi/abs/10.1146/annurev.me.39.020188.002023 http://www.aafp.org/afp/2006/0701/p86.html http://www.ccjm.org/content/76/10/583.full Medical Surgical Nursing by Joyce Black 11th edition Fundamentals of Nursing by Barbara Kozier 9th edition

Health Teaching Nephrolitiasis (Renal Calculi/ Kidney Stones)


Submitted by: III-C4 Bencion, Janine De Guzman, Gerard Garcia, Yras Ilas, Kristina Magandia, Afida Orbeta, Alyssa Wendy Reyes, Rose Rowe, Charmaine Silvestre, Elaine Marie Soliven, Ben Tahup, Angelyne

Submitted to: Ms. Caridad Cabral R.N. Clinical Instructor Nov. 4 2011