Renal calculi and bladder calculi

Acknowledged by:Sir Muslim Shah

Nursing InstructorRMISON

GROUP MEMBERS GROUP MEMBERS

NAWAB ALI T.LNAWAB ALI T.L MUHAMMAD BILALMUHAMMAD BILAL

IBRAR AHMADIBRAR AHMAD RABIA BIBIRABIA BIBI GUL NAAZGUL NAAZ

objectivesobjectives

At the end of this presentation the At the end of this presentation the learner will be able to:learner will be able to:

Define and explain different types of Define and explain different types of renal and bladder stones.renal and bladder stones.

Explain the pathophysiology of renal Explain the pathophysiology of renal and bladder calculi.and bladder calculi.

Know the etiology of renal stones.Know the etiology of renal stones.

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Define terms related to Define terms related to nephrolithiasis e,g nephrolithiasis nephrolithiasis e,g nephrolithiasis aand urolithiasis etc. aand urolithiasis etc.

Renal calculi

A kidney stone is a hard mineral and crystalline materil formed within the kidney or urinary tract.

It is also called nephrolithiasis.

Cont…

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 before passage on the order of at least 2-3 millimeters — they can cause obstruction of the ureter.

Renal calculi can vary in size from as small as grains of sand to as large as a golf ball.

Cont…

The resulting obstruction with dilation or stretching of the upper ureter and renal pelvis as well as spasm of muscle, trying to move the stone,

Pain in the abdomen, flank, or groin.

Nephrolithiasis and Urolithiasis

The condition of having kidney stones is termed nephrolithiasis or urolithiasis. (Nephrolithiasis literally means kidney stone, while urolithiasis means urinary tract stone.)

pathophysiologypathophysiology

PathophysiologyPathophysiology• Originate in Originate in

renal pelvisrenal pelvis• Form when an Form when an

excess of excess of insoluble salts insoluble salts or uric acid or uric acid crystallizes in crystallizes in the urinethe urine

Pathophysiology (contPathophysiology (cont’’d)d)

• Calcium stonesCalcium stones Most commonMost common May have a May have a

hereditary hereditary componentcomponent

• Struvite stonesStruvite stones More common in More common in

womenwomen

• Uric acid and Uric acid and cystine stonescystine stones

Least commonLeast common

Causes

Infection Urinary stasis Immobility Urethral stricture Prostatic obstruction Inflammatory bowel disease Patient with ileostomy Dehydration Family history Medications

Cont…

The formation of renal stones is related to the urine pH.

Calcium phosphate, calcium carbonate, and magnesium phosphate stones develop in alkaline urine; when this occurs, the urine is kept acidic.

Uric acid, cystine, and calcium oxalate stones precipitate in acidic urine; in this situation, the urine should be kept alkaline or less acidic than normal

Types of Stones

Calcium oxalate stones The most common type of kidney stone is composed of

calcium oxalate crystals. Current evidence suggests that the consumption of

low-calcium diets is actually associated with a higher overall risk for the development of kidney stones. This is perhaps related to the role of calcium in binding ingested oxalate in the gastrointestinal tract. As the amount of calcium intake decreases, the amount of oxalate available for absorption into the bloodstream increases; this oxalate is then excreted in greater amounts into the urine by the kidneys.

Calcium oxalate dihydrate Calcium oxalate monohydrate

Cont..

Magnesium ammonium phosphate : Also called struvite stones. Formed in alkaline urine

in the presence of bacteria that posses an enzyme urease.

urea-splitting bacteriaCapable of splitting urea into ammonia, decreasing the

acidity of the urine and resulting in favorable conditions for the formation of struvite stones.

Uric acid stones: due to high concentration of uric acid in urine.

Acid/base metabolism disorders where the urine is excessively acid resulting in uric acid precipitation.

Cont…

Kidney stones, cystine: Cystine kidney stones are due to cystinuria, an inherited (genetic) disorder of the transport of an amino acid (a building block of protein) called cystine. The result is an excess of cystine in the urine (cystinuria) and the formation of cystine stones.

Clinical manifestation

Infection (pyelonephritis and cystitis with chills,fever and dysuria)

Stones in the renal pelvis may be associated with an intense, deep ache in the costovertebral region

Hematuria Pyuria Nausea/vomiting Diarrhea and abdominal discomfort

Cont…

Pain originating in the renal area radiates anteriorly and downward toward the bladder in the female and toward the testes in the male .

Stones lodged in the ureter Colicky wavelike pain ,radiating down the high and

to the genitalia. Patient has desire to void ,but little urine is passed.

Cont…

Colic is mediated by prostaglandin E (substance Colic is mediated by prostaglandin E (substance increase ureteral contractility and renal blood flow, increase ureteral contractility and renal blood flow, that’s lead to increased intraureteral pressure and that’s lead to increased intraureteral pressure and pain. pain.

If the stone obstruct bladder neck ,urinary retention If the stone obstruct bladder neck ,urinary retention occurs.occurs.

Investigations

KUB X ray Urinalysis Blood urea Ultra sound Family history

Dietary and medication history

24 hour urine sample IVP Serum Ca, Mg,

Phosphate, Uric acid, Cr

Medical management

High fluid intake Bed rest Application of warmth to the site of pain Hot bath Dietary modification Restrict calcium in their diet Dietary restriction of protein and sodium

Management cont…

Analgesics pethedine or voren I/M NSAIDs Antibiotics in case of infection Treating the underlying cause Thiazide diuretics

Cont…

Potassium citrate is also used in kidney stone prevention. This is available both as tablet and liquid preparation. The medication increases urinary pH (makes it more alkaline), as well as increases the urinary citrate level, which helps reduce calcium oxalate crystal aggregation.

Surgical management

Lithotripsy: an instrument is used in which shock waves are generated and focused on stone. These waves crushed the stone and fragments then pass spontaneously through urethra or some time a tube is inserted into the ureter to keep it dilated.

Cont…

Patient is observed for obstruction and infection resulting from blockage of urinary tract stone fragments.

All urine is strained after the procedure , voided gravel or sand is sent to the laboratory for chemical analysis.

SHOCK WAVE LITHOTRIPSYSTONE FRAGMENTATIONSTONE FRAGMENTATION

Cont…

Ureteroscopy: Visualizing the stone then destroying it . Stent may be inserted and left in place for 48

hours or more after the procedure to keep the ureter patent.

Open operations

Nephrolithotomy for renal calculi. Pyelolithotomy for stones in renal pelvis Uereterolitotomy for ureteric stones. Stents

Nursing process

Assessment: Pain ,nausea/vomiting diarrhea ,abdominal distention S/S of UTI (chills,fever ,dysuria ,frquency and

hesitancy ,and obstruction (frequent urination,oliguria or anuria)

Cont… Cont…

Urine is inspected for blood and strained for stone.

Managing potential complication

Risk of infection, sepsis and obstruction of the urinary tract.

Patient is instructed to report decreased urine volume and bloody or cloudy urine.

Increased fluid intake Ambulation Report any sudden increase in pain V/S

Preventive strategies

Drinking enough water to make 2 to 2.5 liters of urine per day. Drink two glasses of water at bedtime ,an additional glass at

each night time awakening to prevent urine from becoming too concentrated during the night

A diet low in protein, and sodium intake. Restriction of oxalate-rich foods and maintenance of an

adequate intake of dietary calcium. Avoidance of cola beverages.

Avoid activities that cause excessive sweating and dehydration.

Patient care after Nephrostomy

Assess for bleeding at nephrostomy site ,infection , inflamation,leakage of urine and skin irritation.

Ensure unobstructed drainage of nephrostomy tube. Obstruction causes pain, trauma, pressure ,infection,

and stress on suture lines. Never clamp a nephrostomy tube ,which could cause

obstruction –pyelonephritis. Never irrigate a nephrostomy tube without specific

order.

Cont…

Encourage fluid intake to promote natural flushing of the kidney and nephrostomy tube.

Using aseptic technique apply dry dressing at nephrostomy site.

Measure urine output separately if both kidneys have a tube in place.

Urinary Bladder Stone Urinary Bladder Stone

Bladder stones are hard buildups of Bladder stones are hard buildups of minerals that form in the urinary minerals that form in the urinary bladder.bladder.

Types of urinary stones Types of urinary stones

Urinary stones may be following types Urinary stones may be following types Calcium oxalate monohydrate Calcium oxalate monohydrate Calcium oxalate dihydrate Calcium oxalate dihydrate Calcium phosphateCalcium phosphate Magnesium phosphateMagnesium phosphate Ammonium phosphateAmmonium phosphate

cotninuecotninue

Ammonium magnesium phosphate Ammonium magnesium phosphate (struvite)(struvite)

Calcium hydroxyphosphate Calcium hydroxyphosphate Uric acid and its salts Uric acid and its salts CystineCystine

CausesCauses Bladder stones are most often caused by Bladder stones are most often caused by

another urinary system problem, such as:another urinary system problem, such as: Bladder diverticulum Bladder diverticulum Enlarged prostateEnlarged prostate Neurogenic bladderNeurogenic bladder Urinary tract infectionUrinary tract infection

pathophysiologypathophysiology

Almost all bladder stones occur in Almost all bladder stones occur in men. Bladder stones are much less men. Bladder stones are much less common than kidney stones.common than kidney stones.

Bladder stones may occur when Bladder stones may occur when urine in the bladder is concentrated urine in the bladder is concentrated and materials form crystals. Bladder and materials form crystals. Bladder stones may also result from foreign stones may also result from foreign objects in the bladder.objects in the bladder.

SymptomsSymptoms Symptoms occur when the stone Symptoms occur when the stone

irritates the lining of the bladder or irritates the lining of the bladder or blocks the flow of urine from the blocks the flow of urine from the bladder. bladder.

Symptoms can include:Symptoms can include: Abdominal pain, pressureAbdominal pain, pressure Abnormally colored or dark-colored Abnormally colored or dark-colored

urineurine

Continued Continued

Blood in the urineBlood in the urine Difficulty urinatingDifficulty urinating Frequent urge to urinateFrequent urge to urinate Inability to urinate except in certain Inability to urinate except in certain

positionspositions Interruption of the urine streamInterruption of the urine stream Pain, discomfort in the penisPain, discomfort in the penis

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Signs of urinary tract infection Signs of urinary tract infection (such as fever, pain when (such as fever, pain when urinating, and need to urinate urinating, and need to urinate often) often)

Loss of urine control may also Loss of urine control may also occur with bladder stones.occur with bladder stones.

Exams and TestsExams and Tests

The health care provider will perform The health care provider will perform a physical exam. This will also a physical exam. This will also include a rectal exam. The exam include a rectal exam. The exam may reveal an enlarged prostate or may reveal an enlarged prostate or other problems.other problems.

The following tests may be done:The following tests may be done: Bladder or pelvic x-ray Bladder or pelvic x-ray CystoscopyCystoscopy UrinalysisUrinalysis Urine culture (clean catch) Urine culture (clean catch)

Treatment of urinary stonesTreatment of urinary stones

You may be able to help small stones pass You may be able to help small stones pass on their own by drinking 6 - 8 glasses of on their own by drinking 6 - 8 glasses of water or more per day to increase water or more per day to increase urination.urination.

Your health care provider may remove Your health care provider may remove stones that do not pass using a cystoscope stones that do not pass using a cystoscope (a small telescope that passes through the (a small telescope that passes through the urethra into the bladder).urethra into the bladder).

Some stones may need to be removed Some stones may need to be removed using open surgery.using open surgery.

Drugs are rarely used to dissolve the Drugs are rarely used to dissolve the stonesstones..

Causes of bladder stones should be Causes of bladder stones should be treated. Most commonly bladder stones treated. Most commonly bladder stones are seen with benign prostatic hyperplasia are seen with benign prostatic hyperplasia (BPH--enlarged prostate) or bladder outlet (BPH--enlarged prostate) or bladder outlet obstruction.obstruction.

For patients with BPH and bladder stones, For patients with BPH and bladder stones, transurethral resection of the prostate transurethral resection of the prostate (TURP) can be performed with stone (TURP) can be performed with stone removalremoval

Nusing intervention Nusing intervention

•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.

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•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.

Thank youThank you