Urinary tract problemsUrinary tract problemsOutlinesOutlines::

DefinitionDefinition::

Primary problems in kidney and bladder Primary problems in kidney and bladder diseasesdiseases::

- -Oliguria- Polyuria- NocturiaOliguria- Polyuria- Nocturia

- -Dysuria- EnuresisDysuria- Enuresis

- -Urinary incontinence- PainUrinary incontinence- Pain

- -Hematuria- LeukocyturiaHematuria- Leukocyturia

- -Pyuria- Proteinuria- BacteriuriaPyuria- Proteinuria- Bacteriuria

Disorders of the bladder, kidney, Disorders of the bladder, kidney, urinary tracturinary tract::

- -Cystitis, Urethritis - Acute pyelonephritisCystitis, Urethritis - Acute pyelonephritis - -PyelonephritisPyelonephritis - -

- - Abscesses in the region of the kidneysAbscesses in the region of the kidneys - -Glomerulonephritis - Kidney stonesGlomerulonephritis - Kidney stones

- -Acute renal failureAcute renal failure - - Chronic renal insufficiencyChronic renal insufficiency

- -Renal tumorsRenal tumors

OverviewOverviewThe The urinary systemurinary system is the is the organ system that that

produces, stores, and eliminates produces, stores, and eliminates urine. In . In humans it includes two humans it includes two kidneys, two , two ureters, , the the bladder, and the , and the urethra. The analogous . The analogous organ in invertebrates is the nephridium (in organ in invertebrates is the nephridium (in

animals)animals) . .PhysiologyPhysiology

The The kidneys are bean-shaped organs are bean-shaped organs about the size of a bar of soap. The about the size of a bar of soap. The kidneys lie in the kidneys lie in the abdomen, posterior or , posterior or retroperitoneal to the organs of to the organs of digestion, around or just below the digestion, around or just below the

ribcage and close to theribcage and close to the lumbar spine . .The kidneys are surrounded by what is The kidneys are surrounded by what is

called peri-nephric fat, and situated on called peri-nephric fat, and situated on the superior pole of each kidney is anthe superior pole of each kidney is an adrenal gland . .

The kidneys receive their blood supply of 1.25 The kidneys receive their blood supply of 1.25

L/min (25% of the L/min (25% of the cardiac output) ) from the renal arteries which are fed from the renal arteries which are fed by the by the Abdominal aorta. This is . This is important because the kidneys' main important because the kidneys' main role is to filter water soluble waste role is to filter water soluble waste products from the blood. the products from the blood. the ureters, , which lies more which lies more medial and runs and runs

down to the down to the trigone of the of the bladder..

Functional the kidneysFunctional the kidneys it concentrates urine, plays a crucial it concentrates urine, plays a crucial

role in regulating role in regulating electrolytes, and , and maintainsmaintains acid-base homeostasis..

The kidney excretes and re-absorbs The kidney excretes and re-absorbs electrolytes (e.g. (e.g. sodium, , potassium and and calcium) under the influence of ) under the influence of

local and systemiclocal and systemic hormones . .

pH balance is regulated by the balance is regulated by the excretion of excretion of bound acids and and

ammonium ionsammonium ions . .they remove they remove urea, a nitrogenous , a nitrogenous

waste product from the waste product from the metabolism of proteins fromof proteins from amino acids . .

The end point is a hyperosmolar The end point is a hyperosmolar solution carrying waste for storage solution carrying waste for storage

in the bladder prior toin the bladder prior to urination . .

DefinitionDefinition::

**Altered URINARY ELIMINATIONAltered URINARY ELIMINATION::Urinary frequency, Nocturia, UrgencyUrinary frequency, Nocturia, Urgency , ,

Dysuria , Hesitancy, Enuresis , Dysuria , Hesitancy, Enuresis , Retention , Retention , IncontinenceIncontinence:liguria: Amount

of urine eliminated 100 –

500 ml ( normal urinary output 1 L1.5)Anuria : Elimination of less than 100 ml,

oliguria usually precedes

Causes:-Cardinal symptoms of acute renal failure

-Obstructive uropathy (e.g .- enlarged prostate) - Dehydration ,

frequent in the elderly - because of too little fluid intake

-diarrhea or -vomitings - long term bladder catheterization Important : Anuria is an emergency

situation and requires hospitalization

PolyuriaPolyuria::Definition Definition : urinary output of more than 3 liters: urinary output of more than 3 liters

Causes Causes - Most frequent cause : - Most frequent cause : Hyperglycemia (glucose) in Diabetes mellitusHyperglycemia (glucose) in Diabetes mellitus

- - Specific phases in acute or chronic R Specific phases in acute or chronic R F F PollakiuriaPollakiuria::Definition :-Frequent urge to Definition :-Frequent urge to urinate, low output volume, normal output urinate, low output volume, normal output volume within 24 hoursvolume within 24 hours

CausesCauses: - Urinary tract infection or irritable : - Urinary tract infection or irritable bladder -possiblybladder -possibly bladder tumor bladder tumor

- - In males, enlargement of the In males, enlargement of the prostateprostate

Nighttime Urination ( Nocturia)Nighttime Urination ( Nocturia)Definition :Definition :Increase nighttime urinationIncrease nighttime urination

CausesCauses- Cardiac insufficiency , kidney - Cardiac insufficiency , kidney diseases diseases

- - Large quantities of liquids taken in Large quantities of liquids taken in the evening; use of diuretics the evening; use of diuretics

Complications during urination ( Dysuria)Complications during urination ( Dysuria)DefinitionDefinition:Difficulty on urination with :Difficulty on urination with

pain or burningpain or burningCausesCauses

- - Urinary tract infectionUrinary tract infection - - Tumors in the bladder and /or Tumors in the bladder and /or

urethraurethra

White blood cells in the urine White blood cells in the urine ( Leukocyturia)( Leukocyturia)

DefinitionDefinition : :Pathological elimination of red blood cells Pathological elimination of red blood cells

(leukocytes) in the urine(leukocytes) in the urineCausesCauses: Urinary tract infection: Urinary tract infection

Pus in the urine (pyuria)Pus in the urine (pyuria)Definition:Definition: Pus, cloudiness, and streaks in Pus, cloudiness, and streaks in

the urinethe urineCausesCauses: Severe inflammation of the : Severe inflammation of the

kidneys and urinary tractkidneys and urinary tract

Urinary Retention ( AnuresisUrinary Retention ( Anuresis))DefinitioDefinition: Urination impossible despite n: Urination impossible despite

full bladderfull bladder CausesCauses

- - Enlargement of prostate, Enlargement of prostate, obstruction by calculiobstruction by calculi

- - Tumors of the urethra and / or Tumors of the urethra and / or bladder near urethra opening bladder near urethra opening

- - Disorders of the nerve supply to Disorders of the nerve supply to the bladder (disk prolapsedthe bladder (disk prolapsed – –

StressStress((

Blood in the urine Blood in the urine ( Hematuria ( Hematuria ))Pathological blood cells Pathological blood cells with urinewith urine

elimination of redelimination of redCausesCauses- Tumors , calculi, and- Tumors , calculi, and

inflammation of kidneys and bladderinflammation of kidneys and bladder - -Increased bleeding tendencyIncreased bleeding tendency,,

glomerulonephritis Renal tuberculosisglomerulonephritis Renal tuberculosis , , enlarged prostateenlarged prostate

- -Foods and medicines may also color Foods and medicines may also color the urine redthe urine red

The process of urine formationThe process of urine formation: 3 steps : 3 steps includes. includes.

1- Glomerular filtration1- Glomerular filtration: Filtration of the : Filtration of the plasma a by glomerular as water, Na, Urea, plasma a by glomerular as water, Na, Urea, Cl, bicarbonate, K, Glucose , creatinine & Cl, bicarbonate, K, Glucose , creatinine & Uric acid Uric acid 2) Tubular reabsorption2) Tubular reabsorption. The . The filtrate enters. Bowman's capsule through filtrate enters. Bowman's capsule through tubular system of the nephron & either tubular system of the nephron & either reabsorbed or excreted as urine reabsorbed or excreted as urine 3) Tubular 3) Tubular secretions the formed urinesecretions the formed urine drains from drains from the collecting tubules into renal pelvis & the collecting tubules into renal pelvis & down to ureter. Then to the bladder. ]down to ureter. Then to the bladder. ]

Assessment of patients with urinary Assessment of patients with urinary dysfunction:dysfunction:

HistoryHistory: The nurse obtain baseline data : The nurse obtain baseline data concerning concerning a) general healtha) general health, childhood , , childhood , chronic family illness , D.M past medical chronic family illness , D.M past medical history, allergies, sexual & reproductive history, allergies, sexual & reproductive health, exposure to toxic chemicals or gas health, exposure to toxic chemicals or gas b) History of present complain c) Assess b) History of present complain c) Assess risk factors for renal disorder d) Medication risk factors for renal disorder d) Medication history. E) Person's usual voiding patterns history. E) Person's usual voiding patterns as frequency and amount of urine F) Urine as frequency and amount of urine F) Urine characteristics e.g., hematuria risk.characteristics e.g., hematuria risk.

( (Physical examinationPhysical examination: : a) Inspection a) Inspection includes, abdominal scars, abdominal includes, abdominal scars, abdominal movement & pulsation, inspection of back movement & pulsation, inspection of back for bulging & bruising, bfor bulging & bruising, b) Ascult ) Ascult the the abdominal for bruits. (abnormal vascular abdominal for bruits. (abnormal vascular sounds of blood vessels) sounds of blood vessels) C) Percussion C) Percussion above symphysis pubis and toward the above symphysis pubis and toward the bladder (lymphatic or adult sound hered) bladder (lymphatic or adult sound hered) d) palpationd) palpation: palpate suprapubic area, : palpate suprapubic area, assessing the kidneys for tenderness or assessing the kidneys for tenderness or pain by lightly striking the first at the pain by lightly striking the first at the

costovertebral angle (pain tendernesscostovertebral angle (pain tenderness)) . .

urine specimens for culture and urine specimens for culture and sensitivity sensitivity to identify organisms are to identify organisms are usually midstream specimen (MSU) usually midstream specimen (MSU) or catheter specimen of urine. or catheter specimen of urine.

24 how urine collection24 how urine collection: is the : is the collection of the total volume of collection of the total volume of urine voided in 24 hrs period used in urine voided in 24 hrs period used in diagnosis of renal tones & impaired diagnosis of renal tones & impaired renal function. renal function.

Urine specific gravityUrine specific gravity: to assess : to assess kidney ability to concentratekidney ability to concentrate

B) Blood testsB) Blood tests: : Include, Hemoglobin, WBCs, urea, creatinine & Include, Hemoglobin, WBCs, urea, creatinine &

electrolyte estimation e.g., 9Na, potassium, electrolyte estimation e.g., 9Na, potassium, chloride, bicarbonate, calcium & phosphorus). chloride, bicarbonate, calcium & phosphorus). Liver function tests, blood group & Clotting Liver function tests, blood group & Clotting screen. screen.

C) Radiological investigationC) Radiological investigation; i- Plain X-ray of ; i- Plain X-ray of (KUB). (KUB).

ii- Intravenous urogram (IVU) iii- Renal ii- Intravenous urogram (IVU) iii- Renal scanning .scanning .

iv- Computerized tomography iv- Computerized tomography (Ct scanning) V- (Ct scanning) V- ultrasound scan ultrasound scan , VI- Cystoscop VII- Renal , VI- Cystoscop VII- Renal biopsy.biopsy.

Assessing the chief complaint Assessing the chief complaint Voiding changes or disturbancesVoiding changes or disturbances. . Urine volume changes. Urine volume changes. Irrigative voiding symptoms (frequency, Irrigative voiding symptoms (frequency,

urgency, nocturia, dysuria)urgency, nocturia, dysuria) Obstructive voiding symptoms Obstructive voiding symptoms (hesitancy, (hesitancy,

straining residual urine, retention, urinary straining residual urine, retention, urinary stream forece and size). stream forece and size).

Urinary incontinence (toal overflow, stress, Urinary incontinence (toal overflow, stress, urge, functional ) urge, functional )

Urine characteristics changes (color, hematuria, Urine characteristics changes (color, hematuria, darity, odor, pH). darity, odor, pH).

. .

AA) Preoperative nursing care the ) Preoperative nursing care the assessment under taken with assessment under taken with include: include: observation of the patient, observation of the patient, recording baseline observation recording baseline observation (temp, p, R, B.p, unanalyzed & WT) (temp, p, R, B.p, unanalyzed & WT) medical / surgical history, pain, medical / surgical history, pain, breathing eating / drinking , level of breathing eating / drinking , level of independence / dependence, independence / dependence, imbecility problems, elimination , imbecility problems, elimination , sleeping, Body image GIT symptoms sleeping, Body image GIT symptoms (nausea & vomiting ) and assess for (nausea & vomiting ) and assess for pain renal colicpain renal colic . .

Post operative Ng-care: Maintain Post operative Ng-care: Maintain safe environment pain control / safe environment pain control / communication breathing, communication breathing, elimination (I & O chart), eating & elimination (I & O chart), eating & dinking (I.V fluid replacement & diet dinking (I.V fluid replacement & diet gradually when bowel complications gradually when bowel complications as (hemorrhage / shock, as (hemorrhage / shock, pneumothorax, chest infection, pneumothorax, chest infection, wound infection , UTI due to wound infection , UTI due to uretheral catheter & deep vein uretheral catheter & deep vein thrombosis (DUT) due to immobilitythrombosis (DUT) due to immobility . .

Patient education on dischargePatient education on discharge: : Rest & activity: Return to normal Rest & activity: Return to normal

routine in 3-4 wks. routine in 3-4 wks. Wound healingWound healing: observe s & s of w. : observe s & s of w.

infection as (redness, discharge.) infection as (redness, discharge.) applied appropriate dressing. applied appropriate dressing.

Elimination:Elimination: drink 2 L / 42 hrs. drink 2 L / 42 hrs. Return to work : depend on type of Return to work : depend on type of

work a manual sedentary work has a work a manual sedentary work has a longer period of convalescence than a longer period of convalescence than a sedentary workersedentary worker

Risk factor for various renal Risk factor for various renal or urologic disorders or urologic disorders

Risk factorRisk factorPossible renal or urologic Possible renal or urologic

disorder disorder Childhood diseases step Childhood diseases step

throat impetigo, Nephrotic throat impetigo, Nephrotic syndrome syndrome

Chronic renal failure Chronic renal failure Advanced age Advanced age Incomplete emptying of Incomplete emptying of

bladder, leading to urinary bladder, leading to urinary tract infection tract infection

Instrumentation of urinary Instrumentation of urinary tract cystoxicity, tract cystoxicity, catheterization catheterization

Immobilization Immobilization

Kidney stone formation Kidney stone formation Occupational, recreational or Occupational, recreational or

environmental exposure to environmental exposure to chemicals plastics, patch, tar chemicals plastics, patch, tar rubber) rubber)

Acute renal failureAcute renal failure Diabetes mellitus Diabetes mellitus Chronic renal failure , Neurogenic Chronic renal failure , Neurogenic

bladder bladder

Kidney StonesKidney Stones

dr/ amany lotfydr/ amany lotfy

Kidney StonesKidney Stones

Formation of concretions in the Formation of concretions in the urinary tract, frequently with urinary tract, frequently with cramp-like pains (colic)cramp-like pains (colic)

Stones formed when urine is Stones formed when urine is supersaturated with a stone supersaturated with a stone forming saltforming salt

CausesCauses ••11 - -Small crystals form when Small crystals form when

there is excessive concentration of there is excessive concentration of certain urine components: they certain urine components: they become become larger, larger, e.g. Calcium-e.g. Calcium-containing stones (calcium oxalate containing stones (calcium oxalate or Phosphate); uric acid calculior Phosphate); uric acid calculi

22 - -Bacterial infection and urinary Bacterial infection and urinary retentionretention

signs &Symptomssigns &Symptoms-:-: • •Difficult urination, blood in the urine Difficult urination, blood in the urine

(injuries caused by calculi)(injuries caused by calculi) • •Nausea, vomitingNausea, vomiting , ,

• •persistent painpersistent pain..- - constant irritation of the renal constant irritation of the renal

mucosamucosa - - Inflammation and permanent Inflammation and permanent

damage, as serious Kidney with damage, as serious Kidney with chronic renal failurechronic renal failure..

signs &Symptomssigns &Symptoms Dysuria: burning on urination when passing : burning on urination when passing

stones (rare). More typical of infection. stones (rare). More typical of infection. Oliguria: reduced urinary volume caused by : reduced urinary volume caused by

obstruction of the bladder or urethra by stone, obstruction of the bladder or urethra by stone, or extremely rarely, simultaneous obstruction or extremely rarely, simultaneous obstruction of both ureters by a stone. of both ureters by a stone.

Pyuria: pus (white blood cells) in the urine. : pus (white blood cells) in the urine. Abdominal distension.. Loss of appetite Loss of weight

Risk factorsRisk factors::TThe exact cause of stone formation is he exact cause of stone formation is

unknownunknown , ,SSocioeconomic factors, renal stones ocioeconomic factors, renal stones

are more common in industrialized are more common in industrialized countriescountries . .

DDiet, intake of foods high in purine, iet, intake of foods high in purine, calcium, and oxalate. level of activity, calcium, and oxalate. level of activity, PPersons who have a sedentary lifestyle ersons who have a sedentary lifestyle or limited mobility, because of calcium or limited mobility, because of calcium loss from bones combined with urinary loss from bones combined with urinary stasisstasis . .

CClimate, persons lived in warm limate, persons lived in warm weather develop calculi, to be a weather develop calculi, to be a result of higher chance for result of higher chance for DDehydration and more ehydration and more concentrated urineconcentrated urine..

PPositive family historyositive family history,,HHypercalceamia (high ypercalceamia (high

concentration of blood calcium concentration of blood calcium compoundscompounds) ) HHypercalciuria ypercalciuria (concentration of calcium in urin(concentration of calcium in urin

HypercalceamiaHypercalceamia (high concentration of (high concentration of blood calcium compounds) blood calcium compounds) hypercalciuria (concentration of hypercalciuria (concentration of calcium in urine) calcium in urine) precipitation of precipitation of calcium and formation of renal stonescalcium and formation of renal stones . .

HypercalacemiaHypercalacemia may be may be caused bycaused by : : HyperparathyroidismHyperparathyroidism . .

Excessive intake of vitamin C or DExcessive intake of vitamin C or D . . Antacids.Antacids. Renal tubular acidosis Renal tubular acidosis . .

Excessive intake of milkExcessive intake of milk

Types of urinary calculiTypes of urinary calculi : :

such assuch as:: 11--Uric AcidUric Acid . .

22--Cystine stonesCystine stones . . 33--Calcium oxalateCalcium oxalate . .

44--Calcium phosphateCalcium phosphate . . 55--Magnesium phosphateMagnesium phosphate . .

66--Struvite stones (ammonio-Struvite stones (ammonio-managesiummanagesium phosphate stonesphosphate stones))

Types of calculiTypes of calculicalcium stonescalcium stones (Ca++ in complex (Ca++ in complex

with oxalate or phosphate or both) with oxalate or phosphate or both) – most common stone– most common stone

triple (Mg NH4 PO4)triple (Mg NH4 PO4) struvite stonesstruvite stones – quite common– quite common

uric acid stonesuric acid stones – 5%– 5%cystinecystine or pure oxalate stones - or pure oxalate stones -

inborn errors of metabolisminborn errors of metabolism

How urine PH affected calculus formationHow urine PH affected calculus formation ? ?Normally the PH or urine fluctuates from Normally the PH or urine fluctuates from

slightly acidic to slightly alkaline over 24slightly acidic to slightly alkaline over 24 hrs period. If urine PH is consistently hrs period. If urine PH is consistently acidic or alkaline, the urine provides a acidic or alkaline, the urine provides a

medium suitable for stone formationmedium suitable for stone formation . .Acidic urineAcidic urine: : promotes formation of promotes formation of

cystine and uric acid calculicystine and uric acid calculi . .Alkaline urineAlkaline urine: : promotes formation of promotes formation of

calcium phosphate & ammonic calcium phosphate & ammonic magnesium phosphate calculimagnesium phosphate calculi . .

N.B: N.B: Calcium oxalate calculiCalcium oxalate calculi can form in can form in urine of varying PHurine of varying PH..

DiagnosisDiagnosisPhysical examinationPhysical examination

11--the location and severity of the painthe location and severity of the pain, , which is typically which is typically colicky in nature in nature&&

) ) in spasmodic wavesin spasmodic waves .( .(Pain in the back Pain in the back &produce an obstruction in the kidney&produce an obstruction in the kidney . .

Diagnostics InvestigationDiagnostics Investigation11..X-raysX-rays

radio-opaque and they can be detected by a radio-opaque and they can be detected by a traditional traditional X-ray of the abdomen that of the abdomen that

includes the includes the Kidneys, Ureters and BladderKidneys, Ureters and Bladder——KUB..

Diagnostics InvestigationDiagnostics Investigation 2- IVP ))Intravenous Pyelogram; Urogram Intravenous Pyelogram; Urogram

..(IntraVenous(IVU)(IntraVenous(IVU)

About 50 ml of a special dye to be injected About 50 ml of a special dye to be injected into the bloodstream that is excreted by into the bloodstream that is excreted by the kidneys and by its density helps the kidneys and by its density helps outline an stone on a repeated X-rayoutline an stone on a repeated X-ray

22..Computed tomographyComputed tomography

All stones are detectable by All stones are detectable by CTCT except very except very

rarerare stones stones

Diagnostics InvestigationDiagnostics Investigation

33..UltrasoundUltrasoundAs it gives details about the presence of As it gives details about the presence of

hydronephrosis (swelling of the kidney— (swelling of the kidney—suggesting the stone is blocking the outflowsuggesting the stone is blocking the outflow

of urineof urine.(.(Used to detect stones Used to detect stones during pregnancy during pregnancy

when x-rays or CT are discouragedwhen x-rays or CT are discouraged..

Microscopic studyMicroscopic study of urine, which may show of urine, which may show proteins, red blood cells, bacteria, cellular proteins, red blood cells, bacteria, cellular casts and crystals. casts and crystals.

Culture of a urine sample Culture of a urine sample to exclude urine to exclude urine infection (either as a infection (either as a differential cause of the cause of the patient's pain, or secondary to the presence patient's pain, or secondary to the presence of a stone) of a stone)

Blood testsBlood tests: : Full blood count for the for the presence of a raised presence of a raised white cell count ( count (Neutrophilia) suggestive of infection, a ) suggestive of infection, a check of check of renal function & abnormally high & abnormally high blood calcium blood levels blood calcium blood levels hypercalcaemia). ).

24 hour urine collection 24 hour urine collection to measure to measure total daily urinary volume, magnesium, total daily urinary volume, magnesium, sodium, uric acid, calcium, citrate, sodium, uric acid, calcium, citrate, oxalate and and phosphate. .

Catching of passed stones Catching of passed stones at home at home (usually by urinating through a (usually by urinating through a tea strainer or stone screen) for later or stone screen) for later examination and evaluation by a examination and evaluation by a doctor. doctor.

Medical interventionMedical intervention:: two primary goalstwo primary goals , ,

1-removing the calculi 22--preventing recurrencepreventing recurrence

through correcting calculus-induced through correcting calculus-induced pathophysiologic changes, pathophysiologic changes, eliminating urinary infection and eliminating urinary infection and

preventing renal damagepreventing renal damage . . ( (

90%90% of stones 4 mm or less in size of stones 4 mm or less in size pass spontaneously without medical pass spontaneously without medical interventionintervention . .

A- TreatmentA- Treatment pain, nausea, and pain, nausea, and vomitingvomiting

B-B-if it the stone is not moving if it the stone is not moving fluid fluid therapytherapy is needed is needed , ,

C- pain managementC- pain management, , antibioticsantibiotics to to prevent or treat infection caused by prevent or treat infection caused by stasis of urine and or stasis of urine and or obstructionobstruction

Conservative treatmentConservative treatment : :

Urologic interventionsUrologic interventions - -SurgerySurgery is necessary when the pain is is necessary when the pain is

persistent and severepersistent and severe non-invasivenon-invasive

extracorporeal shock wave lithotripsy (ESWL) (ESWL)Ureteroscopic Ureteroscopic fragmentationfragmentation

laser, ultrasonic laser, ultrasonic or mechanical (pneumatic, or mechanical (pneumatic, shock-wave) forms of energy to fragment the shock-wave) forms of energy to fragment the larger stoneslarger stones..

Percutaneous nephrolithotomy Percutaneous nephrolithotomy open surgery open surgery may be necessary for large or complicated may be necessary for large or complicated stonesstones..

Nursing managementNursing management : :AssessmentAssessment A) History takenA) History taken; ask the patient ; ask the patient

about; 1. Prior stone formationabout; 1. Prior stone formation . .22 . .Risk factors. .3- location, character, and Risk factors. .3- location, character, and

duration for current pain. 4. Current and duration for current pain. 4. Current and previous radiationprevious radiation

))BB ( (Physical examinationPhysical examination which include which include : :11 . .Vital signs include increase pulse, respiration, Vital signs include increase pulse, respiration,

and blood pressure associated with colicky pain; and blood pressure associated with colicky pain; fever indicates serious infectionfever indicates serious infection . .

22..Hyperactive bowel sounds occur with nausea Hyperactive bowel sounds occur with nausea and vomiting hypoactive or absent bowel soundsand vomiting hypoactive or absent bowel sounds..

Nursing diagnosisNursing diagnosis ; ; 11--PainPain R / TR / T irritation by presence of irritation by presence of

obstruction, or movement of the stoneobstruction, or movement of the stone . . 22--Knowledge deficitKnowledge deficit R /TR /T Unfamiliarity Unfamiliarity

with factors related to development of with factors related to development of urolithiasis, management, need for long urolithiasis, management, need for long term management, diet therapy term management, diet therapy according to type of stone, or need for according to type of stone, or need for prevention of recurrence of urolithiasisprevention of recurrence of urolithiasis . .

33--High risk for infectionHigh risk for infection R /TR /T Urinary Urinary stasis, instrumentation of urinary tract, stasis, instrumentation of urinary tract, surgical incisionsurgical incision , ,

Nursing interventionNursing intervention::

11--Releive of painReleive of pain &Administer &Administer prescribed narcotic or analgesicprescribed narcotic or analgesic

apply hot application to the pain area my apply hot application to the pain area my relieve pain&encourage and assist the patient relieve pain&encourage and assist the patient to ambulate to "free" the stoneto ambulate to "free" the stone

22--Supply fluid intakeSupply fluid intake sufficient to sufficient to urinary output of approximately 2000 ml to urinary output of approximately 2000 ml to 30000 ml per day30000 ml per day

33--Health teachingHealth teaching : :Assesses the patient's understanding of Assesses the patient's understanding of

common risk factors. proper dietcommon risk factors. proper diet . .

A-Teach patients the following A-Teach patients the following regarding dietregarding diet . .

11 . .For patients with stones R/T For patients with stones R/T hypecalciumahypecalciuma : :

Calcium intake should be limitedCalcium intake should be limited (diary products, beans, nuts, and (diary products, beans, nuts, and chocolate,VitaminDchocolate,VitaminD

22--For patients with stones related to For patients with stones related to uric aciduric acid, an , an alkaline ash dietalkaline ash diet is is recommended. include diary products; recommended. include diary products; fruits, fruits, exceptexcept cranberries, plums, and cranberries, plums, and purnes and vegetables especially purnes and vegetables especially beansbeans..

33--for patients with for patients with Oxalates stonesOxalates stones, , foods encouraged on an foods encouraged on an acid ash dietacid ash diet includeinclude meat, eggs, poultry, fish, meat, eggs, poultry, fish, cereals, and most fruits and vegetablescereals, and most fruits and vegetables

B-Teach patient aboutB-Teach patient about medications medications used to prevent the used to prevent the recurrence of renal stonesrecurrence of renal stones

such assuch as sodium cellulose phosphate sodium cellulose phosphate (SCP), which binds calcium so that GI (SCP), which binds calcium so that GI absorption of calcium is decreasedabsorption of calcium is decreased. .

- - Cholestyamine binds oxalate and Cholestyamine binds oxalate and enhances GI excretion and allopurinol enhances GI excretion and allopurinol reduce uric acid productionreduce uric acid production . .

B-Teach patient aboutB-Teach patient about medicationsmedications

thiazides, potassium citrate, thiazides, potassium citrate, magnesium citrate and allopurinol, magnesium citrate and allopurinol, ((ZyloprimZyloprim) depending on the cause ) depending on the cause

of stone formationof stone formation . ...Potassium citrate is also used in kidneyPotassium citrate is also used in kidney

stone preventionstone prevention increases urinary pH which helps reduce increases urinary pH which helps reduce

calcium oxalate crystalcalcium oxalate crystal..

C-Teach patient toC-Teach patient to increase activity to prevent increase activity to prevent

stasis of urinestasis of urine..D-Teach patient to reportD-Teach patient to report any any

of the following signs of of the following signs of infection; nausea, vomiting, infection; nausea, vomiting, chills; change in appearance chills; change in appearance

or odor of urineor odor of urine . .

Follow up careFollow up care:: After all treatment modalities the patient should After all treatment modalities the patient should

be closely monitored forbe closely monitored for

11--signs of infectionsigns of infection, renal dysfunction, , renal dysfunction, bleedingbleeding . .

22--postoperative serum electrolyte postoperative serum electrolyte evaluations, 3-CBC counts and creatinine evaluations, 3-CBC counts and creatinine studiesstudies

44--Continuous appropriateContinuous appropriate parentrally parentrally administered antibiotic. If an indwelling administered antibiotic. If an indwelling ureteral stent was placedureteral stent was placed

55--infectious complicationsinfectious complications,( Pyelonephritis ,( Pyelonephritis and sepsis, )and sepsis, )