Urinary Calculi

What does Lithiais Mean?

" Stone formation" When stones are in Kidney = Nephrolithiasis When stones elsewhere in urinary tract = Urolithiasis

Renal Colic

* Acute, severe flank pain on the affected side which develops when stone obstructs the ureter, causing ureter spasms. * Pain may radiate to suprapubic region, groin, and external genitals. * Pain causes N&V; pallor and cool, clammy skin * May have signs of UTI * Gross hematuria often only sign of bladder stones. **Intensity of this pain can cause vasovagal response resulting in hypotension and syncope.

Types of kidney stones

* Calcium- composed of calcium oxalate &/or calcium phosphate. *Uric acid stones- urine concentration of uric acid is high; more common in men, and associated with gout. *Struvite (mag ammonium phosphate) stones- associated with UTI caused by urease-producing bacteria (Proteus) These stones can grow large filling renal pelvis & calyces. Often called staghorn stones cuz of shape. *Cystine stones- are rare, and associated with genetic defect.

Hydronephrosis

* Kidneys cont to produce urine causeing increase pressure and distention of the urinary tract behind the obstruction. * Distention of the renal pelvis and calyces, and hydroureter, distention of ureter are possible result. * If pressure is unrelieved the collecting tubules, proximal tubules, and glomeruli are damages causing loss of renal function.

Meds to inhibit or prevent lithiasis

* thiazide diuretic - for calcium calculi, reduce urinary calcium excretion. *potassium citrate alkalinizes ( raises PH) - prevents stones that form acidic urine

Meds

*Analgesia- promote stone passage and hydration *Narcotic Analgesic (morphine)- relieve pain, dec spasms *NSAID- reduce narcotic analgesia for renal colic *Oral Alpha adrenergic blocker (tamsulosin (Flomax)) or calcium channel blocker (nifedipine (Adalat CC, Procardia)) to relax uteral muscle. *Oral or IV fluids - reduce risk of further stone formation and promote urine output.

Treatment Lithotripsy

*Depends on locaiton, extent of obstruction, renal funciton, presence or absence of UTI. Lithotripsy= using sound or shock waves to crush a stone. *Extracorporeal shock wave lithotripsy (ESWL)- shock waves generated outside the body fragment kidney stones. Percutaneous nephrolithotomy- nephroscope inserted into kidney pelvis thru small flank incision. *Ureteroscopy procedure- disintergrtes the stone by laser without damaging soft tissue. * J stent may be placed following ESWL or othe lithotripsy procedures.

Diagnostics

*Urinalysis- hematuria, WBC's, Crystal fragments, PH for type of stones. *Chemical analysis- of the stones determine type and suggest preventiv measures for further stone formation. *Urine, calcium, uric acid, oxalate levels- measures amount of these over 24hr period, may identify causes of lithiasis. *Serum calcium, phosphorus, and uric acid levels-identifys factors contributing to calculus formation * KUB- kidneys, ureters, and bladder x-ray shows calculi * Renal ultrasonography- used reflective sound waves to detect stones and kidneys for hydronephrosis. * Spiral computed tomography (CT)- can use contrast or not; shows calculi, ureteral obstruction, other renal d/os *Cystoscopy- visualize and poss remove calculi

Urinary Calculi Manifestations

*Vary with their size and location; develop as result of obstructed urine flow with distention, and tissue trauma caused by passage of rough edged crystalline stone. KIDNEY: Asymptomatic, dull, aching flank pain, microscopic hematuria, manifestations of UTI URETERAL: Renal colic- Acute flank pain on affected side; often radiates to suprapubic region, groin, and external genitals. Nausea, Vomitting, pallor, and cool clammy skin. BLADDER: Asymptomatic; dull suprapubic pain, possibly associated with exercise or voiding; gross or microscopic hematuria; manifestations of UTI.

Memory Cue of Urinary Calculi

-Most urinary stones form in renal pelvis and are composed primarily of calcium salts. - Men are more often frequently affected by urinary stones than women -Loss of calcium from bones and dehydration are major risk factors for urinary stones.

Risk Factors of Urinary Calculi

Greatest is family history or genetic predisposition: Gout, Hyperparathyroidism, Uriniary stasis, Repeated UTIs Behavioral: Dehydration, Immobility, Diet ( excess calcium, oxalate, or proteins)

Complications

Stones may obstruct urine flow at any point of the urinaryl tract. Urinary tract obstruction can lead to renal failure. Degree of obstruction, its location, and duration of impaired urin flow determine effect on renal function.

Nursing Diagnoses

Acute Pain Impaired Urinary Elimination Readiness for enhanced knowledge

Manifestations of Acute Hydronephrosis

Acute, colicky pain; may radiate into groin Hematuria, pyuria Fever Nausea, vomitting, abd pain

Urinari Calculi

Are stones in urinary tract; most common cause of upper urinary tract obstruction.

Interventions

Assess pain; Enc fluid intake, ambulation in renal colic; Use nonpharmacologic measures ( moist heat, relaxation, guided imagry, diversions); If surgery monitor urinary output, catheters, incision, and wound drains. Catheters record output hourly, strain urine for stones, Maintain patency of catheters Assess understanding or previous learning; Teach about diagnostics and tx's; Teach measures to prevent further urolithiasis; Teach relationship about calculi and UTI.

Pathophy of Urinary Calculi

Contributing factors in urolithiasis: -Supersaturation- when concentration of an insoluble salt in urine is very high crystals may form. -Nucleation- a nucleus of crystals may develop stable bonds to form a stone. -Acidity or alkalinity of urine and presence or absence of calculus-inhibiting cmpounds also affect lithiasis.

Manifestations of Chronic Hydronephrosis

Develops slowly Dull, aching flank pain Hematuria, pyuria, N&V, and ABD pain. Fever Palpable flank mass when significant

Community based care

Important of maintaining fluid intake, dietary recommendations. Information about meds Prevention,recognition, and management of UTI How to change dressings, assessment of wound and skin Management and emptying of drainage systems; assessment of urine output.

Nutrition and Management

Increase fluid intake 2.5-3.0 L per day is recommended Fluid is to produce approx 2.0-2.5L of urine a day Calcium & Cystine- low sodium, restricted protein diet Uric acid stones- diet low in purines ( goose, organ meats, sardines, herring, venison, mod in beef, pork, crab, chicken, salmon, and veal) Diet may be modified to maintain a urinary pH that does not promote lithiasis. Uric acid and cystine- foods that alkalinize urine All types of calculi- Increase fluid intake

Incidence of Urinary Calculi

It is common ( 2 million Dr visits, 166,000 hospitals stays annually). Highest in southern and midwestern states Males affected more than females Calculi more common in Whites than Blacks Most young or middle adulthood are affected.

Surgical Intervention

Ureterolithotomy- incision in affected ureter to remove calculus. Pyelolithotomy- incision into and removal of stone from kidney pelvis. Nephrolithotomy- removal of staghorn calculus