Med Surge 1 - Urolithiasis

Nursing Priorities

±Alleviate pain. ±Maintain adequate renal functioning. ±Prevent complications. ±Provide information about disease process/prognosis and treatment needs.

Nursing Process - Assessment

±Assess for pain and discomfort, including severity, location, and radiation of pain. ±Assess for associated symptoms, including nausea, vomiting, diarrhea, and abdominal distention. ±Observe for signs of urinary tract infection (chills, fever, frequency, and hesitancy) and obstruction (frequent urination of small amounts, oliguria, or anuria). ±Observe urine for blood; strain for stones or gravel. ±Focus history on factors that predispose patient to urinary tract stones or that may have precipitated current episode of renal or ureteral colic. ±Assess patient's knowledge about renal stones and measures to prevent recurrence.

Ureteral Colic

Stones Lodged in Ureter ±Acute, excruciating, colicky, wavelike pain, radiating down the thigh to the genitalia ±Frequent desire to void, but little urine passed; usually contains blood because of the abrasive action of the stone (known as ureteral colic)

Evaluation

Expected Patient Outcomes ±Reports relief of pain ±States increased knowledge of healthseeking behaviors to prevent recurrence ±Experiences no complications

Diagnosis

Nursing Diagnoses ±Acute pain related to inflammation, obstruction, and abrasion of the urinary tract ±Deficient knowledge regarding prevention of recurrence of renal stones ± Collaborative Problems/Potential Complications ±Infection and urosepsis (from urinary tract infection and pyelonephritis) ±Obstruction of the urinary tract by a stone or edema, with subsequent acute renal failure

Urolithiasis

±Commonly known as renal calculi or kidney stones, is a prevalent and painful condition that affects millions of individuals worldwide. ±These solid mineral and salt deposits form within the urinary tract and can cause excruciating pain and complications if left untreated. ±As nurses, it is imperative to have a comprehensive understanding of urolithiasis to provide effective care, support, and education to patients grappling with this challenging condition.

Assessment and Diagnostic Methods

±Diagnosis is confirmed by xrays of the kidneys, ureters, and bladder (KUB) or by ultrasonography, IV urography, or retrograde pyelography. ±Blood chemistries and a 24hour urine test for measurement of calcium, uric acid, creatinine, sodium, pH, and total volume. ±Chemical analysis is performed to determine stone composition.

Monitoring and Managing Complications

±Encourage increased fluid intake and ambulation. ±Begin IV fluids if patient cannot take adequate oral fluids. ±Monitor total urine output and patterns of voiding. ±Encourage ambulation as a means of moving the stone through the urinary tract. ±Strain urine through gauze. ±Crush any blood clots passed in urine, and inspect sides of urinal and bedpan for clinging stones. ±Instruct patient to report decreased urine volume, bloody or cloudy urine, fever, and pain. ±Instruct patient to report any increase in pain. ±Monitor vital signs for early indications of infection; infections should be treated with the appropriate antibiotic agent before efforts are made to dissolve the stone.

Teaching Points

±Explain causes of kidney stones and ways to prevent recurrence. ±Encourage patient to follow a regimen to avoid further stone formation, including maintaining a high fluid intake. ±Encourage patient to drink enough to excrete 3,000 to 4,000 mL of urine every 24 hours. ±Recommend that patient have urine cultures every 1 to 2 months the first year and periodically thereafter. ±Recommend that recurrent urinary infection be treated vigorously. ±Encourage increased mobility whenever possible; discourage excessive ingestion of vitamins (especially vitamin D) and minerals. ±If patient had surgery, instruct about the signs and symptoms of complications that need to be reported to the physician; emphasize the importance of followup to assess kidney function and to ensure the eradication or removal of all kidney stones to the patient and family. ±If patient had ESWL, encourage patient to increase fluid intake to assist in the passage of stone fragments; inform the patient to expect hematuria and possibly a bruise on the treated side of the back; instruct patient to check his or her temperature daily and notify the physician if the temperature is greater than 38 C (about 101 F), or the pain is unrelieved by the prescribed medication. ±Provide instructions for any necessary home care and followup.

Planning and Goals

±Major goals may include relief of pain and discomfort, prevention of recurrence of renal stones, and absence of complications.

Clinical Manifestations of urolithiasis

±Manifestations depend on the presence of obstruction, infection, and edema. Symptoms range from mild to excruciating pain and discomfort. ±Stones in Renal Pelvis ±Intense, deep ache in costovertebral region ±Hematuria and pyuria ±Pain that radiates anteriorly and downward toward bladder in female and toward testes in male ±Acute pain, nausea, vomiting, costovertebral area tenderness (renal colic) ±Abdominal discomfort, diarrhea

Pharmacologic and Nutritional Therapy

±Opioid analgesic agents (to prevent shock and syncope) and nonsteroidal antiinflammatory drugs (NSAIDs). ±Increased fluid intake to assist in stone passage, unless patient is vomiting; patients with renal stones should drink eight to ten 8oz glasses of water daily or have IV fluids prescribed to keep the urine dilute. ±For calcium stones: reduced dietary protein and sodium intake; liberal fluid intake; medications to acidify urine, such as ammonium chloride and thiazide diuretics if parathormone production is increased. ±For uric stones: low purine and limited protein diet; allopurinol (Zyloprim). ±For cystine stones: low protein diet; alkalinization of urine; increased fluids. ±For oxalate stones: dilute urine; limited oxalate intake (spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran).

Pathophysiology of urolithiasis

±Presence of stones anywhere in the urinary tract ±Most commonly found in the renal pelvis and calyces ±Stones forming in the kidney—nephrolithiasis ±Stones formed in the ureters—ureterolithiasis ±May be single or multiple calculi, ranging in size from a grain of salt to the size of a pebble or staghorn calculus ±Composition of calculi ±Formed of mineral deposits—predominantly calcium oxalate and calcium phosphate ±Uric acid, struvite, and cystine are also calculus formers

Nursing Interventions

±Relieving Pain ± ±Administer opioid analgesics (IV or intramuscular) with IV NSAID as prescribed. ±Encourage and assist patient to assume a position of comfort. ±Assist patient to ambulate to obtain some pain relief. ±Monitor pain closely and report promptly increases in severity.

Etiology of urolithiasis

±Slow urine flow allows accumulation of crystals—damaging the lining of the urinary tract and decreasing the number of inhibitor substances that would prevent crystal accumulation (Winkleman, 2006). ±May remain asymptomatic until passed into a ureter or urine flow is obstructed, at which time the potential for renal damage is acute and the level of pain is at its highest. ± Causes: dehydration; heredity; excessive intake of vitamins C and D, grapefruit juice, and purines (gout); congenital renal abnormalities; and some medications, such as acetazolamide (Diamox) or indinavir (Crixivan)

Stones Lodged in Bladder

±Symptoms of irritation associated with urinary tract infection and hematuria ±Urinary retention, if stone obstructs bladder neck ±Possible urosepsis if infection is present with stone

Stone Removal Procedures

±Ureteroscopy: stones fragmented with use of laser, electrohydraulic lithotripsy, or ultrasound and then removed. ±Extracorporeal shock wave lithotripsy (ESWL). ±Percutaneous nephrostomy; endourologic methods. ±Electrohydraulic lithotripsy. ±Chemolysis (stone dissolution): alternative for those who are poor risks for other therapies, refuse other methods, or have easily dissolved stones (struvite). ±Surgical removal is performed in only 1% to 2% of patients.

Diagnostic Studies

±Urinalysis: Color may be yellow, dark brown, bloody. Commonly shows RBCs, WBCs, crystals (cystine, uric acid, calcium oxalate), casts, minerals, bacteria, pus; pH may be less than 5 (promotes cystine and uric acid stones) or higher than 7.5 (promotes magnesium, struvite, phosphate, or calcium phosphate stones). ±Urine (24-hr): Cr, uric acid, calcium, phosphorus, oxalate, or cystine may be elevated. ±Urine culture: May reveal UTI (Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas). ±Biochemical survey: Elevated levels of magnesium, calcium, uric acid, phosphates, protein, electrolytes. ±Serum and urine BUN/Cr: Abnormal (high in serum/low in urine) secondary to high obstructive stone in kidney causing ischemia/necrosis. ±Serum chloride and bicarbonate levels: Elevation of chloride and decreased levels of bicarbonate suggest developing renal tubular acidosis. ±CBC: ±Hb/Hct: Abnormal if patient is severely dehydrated or polycythemia is present (encourages precipitation of solids), or patient is anemic (hemorrhage, kidney dysfunction/failure). ±RBCs: Usually normal. ±WBCs: May be increased, indicating infection/septicemia. ±Parathyroid hormone (PTH): May be increased if kidney failure present. (PTH stimulates reabsorption of calcium from bones, increasing circulating serum and urine calcium levels.) ±KUB x-ray: Shows presence of calculi and/or anatomical changes in the area of the kidneys or along the course of the ureter. ±IVP: Provides rapid confirmation of urolithiasis as a cause of abdominal or flank pain. Shows abnormalities in anatomical structures (distended ureter) and outline of calculi. ±Cystoureteroscopy: Direct visualization of bladder and ureter may reveal stone and/or obstructive effects. ±CT scan: Identifies/delineates calculi and other masses; kidney, ureteral, and bladder distension. ±Ultrasound of kidney: To determine obstructive changes, location of stone; without the risk of failure induced by contrast medium.

What is Urolithiasis?

±Urolithiasis refers to stones (calculi) in the urinary tract. ±Stones are formed in the urinary tract when the urinary concentration of substances such as calcium oxalate, calcium phosphate, and uric acid increases. ±Stones vary in size from minute granular deposits to the size of an orange. ±Factors that favor formation of stones include infection, urinary stasis, and periods of immobility, all of which slow renal drainage and alter calcium metabolism. ±The problem occurs predominantly in the third to fifth decades and affects men more often than women.