RENAL CALCULI Flashcards
refer to stones (calculi) in the urinary tract and kidney.
Urolithiasis and nephrolithiasis
MOST COMMON Urolithiasis and nephrolithiasis
Renal Pelvis
Urine contains ____ (3) and when they form together it will crystalize = stones
calcium, potassium, uric acid,
blocked stone in the kidneys
Hydronephrosis
PATHOPHYSIOLOGY OF RENAL CALCULI
Stones and masses of crystals and protein that form when the urine becomes supersaturated with a salt capable of forming solid crystals.
▪ Supersaturated due to increased calcium oxalate, calcium phosphate, and uric acid.
▪ In about 70% of people, kidney stones are formed primarily of Calcium Oxalate.
▪ Stones are found anywhere from the kidney to the bladder, and vary in size from minute granular deposits, called sand or gravel, to bladder stones as large as an orange
blocked stones in the ureters.
Hydroureter
4 Different sites of calculi formation in Urinary Tract
Right kidney
Left kidney
Ureters
Bladder
❖ CLINICAL MANIFESTATIONS
– lumbar region and radiates:
▪ down toward the testicle in the male
▪ bladder in the female
→ Renal Colic
❖ CLINICAL MANIFESTATIONS
suggest obstruction possibly at the bladder neck.
▪ If there is less urine output:
➢ Urinary Tract Obstruction is an emergency and must be treated immediately to preserve kidney function.
→ Oliguria and Anuria
❖ CLINICAL MANIFESTATIONS
→ Pain
▪ ____ Pain – location
– severe, colicky, dull, or aching
Flank
❖ CLINICAL MANIFESTATIONS
→ Frequency and dysuria occur when a
stone reaches the bladder.
❖ CLINICAL MANIFESTATIONS
___&____due to severe flank pain, and this pain stimulates the ____ center.
Nausea and vomiting
vomiting
❖ CLINICAL MANIFESTATIONS
Pallor because of the pain, ______
SNS is stimulated to stimulate norepi and can cause vasoconstriction
❖ MEDICAL MANAGEMENT
→ The immediate treatment is to relieve the ____ until its cause can be eliminated.
▪ _____ agents are given to prevent shock and syncope that may result from the excruciating pain.
▪ ____ are effective in treating renal calculus pain because they provide specific pain relief.
pain
Opioid analgesic
NSAIDs
❖ CLINICAL MANIFESTATIONS
→ Vital Signs: ___ T, BP, and PR
→ Diaphoresis (excessive sweating) and Anxiety
→ Elevated ____ count
→ ____ is often present
▪ Blood in the urine which often makes it look pink.
elevated
WBC
Hematuria
❖ CLINICAL MANIFESTATIONS
→ In general, the patient is able to pass stones ___ in diameter
▪ Stones larger than ____ in diameter usually must be removed or fragmented (broken up by lithotripsy) so that they can be removed or passed spontaneously.
➢ Medication that – enlarges the ureter to allow large stones to flow: _____
➢ Medication that ______ – dissolves stone
0.5 cm
I cm
Alpha Blockers
Potassium Citrate
❖ MEDICAL MANAGEMENT
→ Once the stone has passed, the ____
Unless the patient is _____, fluids are encouraged.
▪ This increases the hydrostatic pressure behind the stone, assisting it in its downward passage.
pain is relieved.
vomiting, has heart failure, or any other condition requiring fluid restriction
❖ NURSING INTERVENTIONS FOR RENAL CALCULI
→ Advise patient to avoid protein intake to decrease urinary excretion of calcium and uric.
→ Advise patient to limit sodium intake to 3 to 4 g/day. because sodium competes with calcium for reabsorption in the kidneys.
→ Be aware that low-calcium diets are not generally recommended, except for true absorptive hypercalciuria. evidence shows that limiting calcium, especial in women, can lead to osteoporosis and does not prevent calculi.
→ Advise patient to avoid intake of oxalate-containing foods (e.g., spinach, Swiss chard, chocolate, peanuts, pecans).
→ Advise patient to drink fluids (ideally water) every 1 to 2 hours during the day and one glass or cranberry juice per day.
▪ Drink 2 glasses of water at bedtime and an additional glass at each nighttime awakening to prevent urine from becoming too concentrated during the night.
→ Advise patient to avoid activities leading to sudden increases in environmental temperatures that may cause excessive sweating and dehydration.
→ Instruct the patient to contact the primary provider at the first sign of a urinary tract infection
❖ NUTRITIONAL THERAPY: prevents renal calculi
→ Fluid intake is the mainstay of most medical, therapy for renal calculi.
▪ Unless fluids are contraindicated.
▪ Patients with renal calculi should drink 8 to 10 8-oz glasses of water daily or have IV fluids prescribed to keep the urine dilute.
→ A urine output exceeding 2 L/day is advisable.
→ Foods high in oxalate (potatoes, spinach, beets, and rhubarb) are limited.
❖ STONE TYPES
▪ Characteristics:
➢ Similar to stones in the garden
➢ Most common type of stone
➢ Small, rough, and hard
➢ Color vary from gray to white
→ Calcium Oxalate
❖ STONE TYPES
▪ Characteristics:
➢ Made of magnesium ammonium phosphate
➢ Second most common type of stone
➢ Calculi crumble easily
➢ Stone have a yellow color
→ Struvite
❖ STONE TYPES
▪ Patients with calcium-based renal calculi were advised to restrict calcium in their diet.
➢ Liberal fluid intake is encouraged.
➢ Medications such as ammonium chloride may be used.
➢ If increased parathormone production (resulting in increased serum calcium levels in blood and urine) is a factor in the formation of stones, therapy with thiazide diuretics may be beneficial in reducing the calcium loss in the urine and lowering the elevated parathormone levels.
→ Calcium Stones
❖ STONE TYPES
▪ Characteristics:
➢ Due to high uric acid levels
➢ Small and hard
➢ Color varies from yellow to red
▪ The patient is placed on a low-purine (fruits, vegetables, & whole grains) diet to reduce the excretion of uric acid in the urine.
▪ Foods high in purine (shellfish, anchovies, asparagus, mushrooms, and organ meats) are avoided.
▪ Allopurinol may be prescribed to reduce serum uric acid levels and urinary uric acid excretion, and to dissolve or reduce the size of existing stones.
→ Uric Acid Stones (Calcium Phosphate)
❖ STONE TYPES
▪ A low-protein diet may be prescribed, the urine is alkalinized with potassium alkali salts, and fluid intake is increased.
➢ Fruits: Apples, bananas, pears, peaches, berries, grapefruit.
➢ Vegetables: Tomatoes, asparagus, peppers, broccoli, leafy greens.
➢ Grains: Rice, oats, bread, pasta, barley
→ Cystine Stones
❖ STONE TYPES
▪ A dilute urine is maintained through increasing fluid intake, and the intake of oxalate is limited.
➢ Many foods contain oxalate including spinach, Swiss chard, chocolate, peanuts, and pecans
→ Oxalate Stones
❖ PREVENTIVE MEASURES FOR RENAL CALCULI
→ Drinking Enough fluid
→ Limiting Meat Intake
→ A diet rich in acid should be provided
→ Limiting foods rich in calcium
→ Limiting intake of oxalate-containing foods
→ Drinking Enough fluid
▪ 12 glasses (3L) of fluid a day, preferably water.
▪ Most basic kidney stone prevention step.
▪ This dilutes urine and decreases the risk of crystal formation.
→ Limiting Meat Intake
▪ Because it contains uric acid
▪ Consuming more than 6 to 8 oz of meat daily can increase calcium and uric acid in the urine.
▪ Increase the acidity of urine
▪ Reduce chemicals that inhibit crystal formation
→ A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium.
→ Limiting foods rich in calcium, such as dairy products will help prevent renal calculi.
→ Limiting intake of oxalate-containing foods such as beets, strawberry, coffee, cola drinks, tea, chocolate drinks, grapes, kiwi.
❖ MEDICATIONS FOR STONES
→ Allopurinol (Zyloprim)
→ Tiopronin (Thiola)
→ Allopurinol (Zyloprim)
▪ To lower uric acid concentration
▪ Prescribed only if a reduced purine diet fails and stones persist.
→ Tiopronin (Thiola)
▪ For cystine stones, which make cystine more soluble for excretion.
▪ Long-term Antibiotics are used to control the infection.
❖ INTERVENTIONAL PROCEDURES
▪ It is used for removing small stones located in the ureter close to the bladder, a ureteroscope is inserted into the ureter to visualize the stone. The stone is then fragmented or captured and removed.
▪ A stent may be inserted and left in place for 48 hours or more after the procedure to keep the ureter patent.
▪ Length of hospital stay is generally brief, and some patients can be treated as outpatients
→ Ureteroscopy
❖ INTERVENTIONAL PROCEDURES
▪ It is a noninvasive procedure used to break up stones in the calyx of the kidney.
➢ It is not 100% cure for stones.
➢ Procedure is done within 40 minutes.
▪ It uses high-energy shock waves to break the stone into tiny pieces that can be more easily passed.
▪ Electrohydraulic lithotripsy is a similar method in which an electrical discharge is used to create a hydraulic shock wave to break up the stone.
→ Extracorporeal Shock Wave Lithotripsy (ESWL)
❖ INTERVENTIONAL PROCEDURES
▪ It is used to extract kidney calculi that cannot be removed by other procedures.
→ Endourologic (percutaneous) Methods
❖ INTERVENTIONAL PROCEDURES
is used to treat larger stones.
▪ A percutaneous tract is formed, and a nephroscope is inserted through it. Then, the stone is extracted or pulverized.
➢ Patient is in a ____ Position.
▪ A ____ is introduced through a percutaneous route into the renal parenchyma.
➢ Depending on its size, the stone may be extracted with forceps or by a stone retrieval basket.
➢ If the stone is too large to initially be removed, an ultrasound probe inserted through a _____ is used to pulverize the stone.
➢ Small stone fragments and stone dust are then removed.
→ Percutaneous Nephrolithotomy
Sim’s
nephroscope
nephrostomy tube
NURSING INTERVENTION FOR Extracorporeal Shock Wave Lithotripsy (ESWL)
➢ Advise to increase fluid intake to flush out the stones broke down due to the procedure.
➢ Pain may be experienced as the stone fragments pass down the urine and may hit the nerves. Antispasmodics are given:
* Meberverine HCL (Duspatalin) –100 mg tab
* Pinaverium BR (Eldicet) – 50 mg tab
➢ Advised to drink 2-3 L in 24 hours to help flush out stone fragments and clear any blood in the urine.
* The fragments may be passed for up to 3 months after the procedure.
➢ Early Ambulation increases peristalsis and fast movement of the stones.
▪ Postoperative Care
➢ Check that the nephrostomy and drainage tubing are not kinked or that the patient is not compressing the tubing.
➢ Assess the tube insertion for bleeding and drainage.
➢ Notify the physician immediately if there is an absence of urinary drainage.
➢ Encourage fluid intake of 2-3L in 24 hours (IV and oral fluids) to flush out any blood or stone fragments that might be present.
❖ SURGICAL MANAGEMENT
If the stone is in the kidney; an incision into the kidney with removal of the stone.
Nephrolithotomy
❖ SURGICAL MANAGEMENT
If the kidney is nonfunctional secondary to infection or hydronephrosis.
Nephrectomy
❖ SURGICAL MANAGEMENT
Laparoscopic surgical removal of a stone from the ureter.
Ureterolithotomy
❖ SURGICAL MANAGEMENT
Those in the bladder.
Cystotomy
❖ SURGICAL MANAGEMENT
It is a procedure to break up bladder stones into smaller pieces and remove them.
Cystolitholapaxy
