1.LEARNING OBJECTIVES review the anatomy and physiology ofthe renal system interpret the term renal calculi describe the etiology of renal calculi discuss the pathogenesis involved in thedisease process list the types of renal calculi

2. LEARNING OBJECTIVES examine the clinical manifestations closely differentiate the various diagnosticmeasures explain the medical management Identify the surgical management of renalcalculi distinguish the nursing management forrenal calculi including the nursingdiagnosis 3. THE RENAL SYSTEM 4. THE RENAL SYSTEM 5. DEFINITION Nephrolithiasis refers to renal stonedisease; urolithiasis refers to thepresence of stones in the urinarysystem. Stones, or calculi, are formedin the urinary tract from the kidneyto bladder by the crystallization ofsubstances excreted in the urine 6. ETIOLOGY 7. ETIOLOGYMETABOLICLIFESTYLEGENETIC FACTORSDRUGSOTHERS 8. RISK FACTORSHISTORYOF METABOLICRENAL DISTURBANCES CALCULI DEHYDRATION SEDENTARY LIFE STYLEIMMOBILITY 9. RISK FACTORSHIGH MINERALCONTENT IN DRINKINGWATER DIETARY INTAKE UTI & H/O FEMALE GENITAL MUTILATION PROLONGED INDWELLING CATHETERISATION NEUROGENIC BLADDER 10. PATHOPHYSIOLOGY Slow urine flow, resulting insupersaturation of the urinewith the particular elementthat first become crystallizedand later become stone 11. PATHOPHYSIOLOGY Damage to the lining of theurinary tract 12. PATHOPHYSIOLOGY Decreased inhibitorsubstances in the urine thatwould otherwise preventsupersaturation andcrystalline aggregation 13. TYPES OF STONES Calcium Phosphate Calcium oxalate Uric acid Cystine Struvite 14. CLINICAL MANIFESTSTIONS Severeabdominal orflank pain Frequency anddysuria Oliguria andanuria inobstruction 15. CLINICAL MANIFESTSTIONS Hematuria Renal colic Nausea hydronephrosis 16. DIAGNOSTIC STUDIES 17. DIAGNOSTIC STUDIES 18. CYSTOSCOPY DIAGNOSTIC STUDIES 19. DIAGNOSTIC STUDIES 20. DIAGNOSTIC STUDIES 21. DIAGNOSTIC STUDIESRETROGRADEPYELOGRAMCT SCAN 24 HOUR URINE SPECIMEN LAB INVESTIGATIONS 22. MANAGEMENT 23. MEDICAL DRUG THERAPYOpioid agentsNSAIDSSpasmolytic agents 24. COMPLIMENTARY THERAPYHypnosis, imagery, therapeutic or healing touch, acupuncture and breathing techniquesPositioning the client to comfortable position aids in pain reduction 25. OTHER TECHNIQUES Avoiding overhydration andunder hydration Strain the urine Send any strainedstone to laboratoryto aid in preventivetreatment in thefuture 26. SPECIFIC APPROACHES URINARY CHARACTERIS PREDISPOSINGTHERAPEUTIC MEASURESSTONETICSFACTORS Calcium Small IdiopathicIncrease hydrationoxalateoften hypercalciuriaReduce dietary oxalate 35-40 possible to hyperoxaluria Give thiazide diuretics get ,Independentcellulose phosphate,(chelate trapped inof urinary pH calcium and prevent GI ureter,family history absorption), ,morepotassium citrate(alkaline frequent in urine), men cholestyramine(bind oxalate), calcium lactate(precipitate oxalate in GI tract) Reduce daily sodium intake 27. SPECIFIC APPROACHES URINARYCHARACTPREDISPOSING THERAPEUTIC MEASURESSTONE ERISTICS FACTORS CalciumMixed Alkaline urine, Treat underlyingphosphate stones primarycause and other 8-10%with hyperthyroidismstonesstruviteoroxalatestones 28. SPECIFIC APPROACHES URINARY CHARACTERISPREDISPOSINGTHERAPEUTIC MEASURESSTONETICS FACTORSStruvite 3 to 4 times urinary tract Antimicrobial agents10-15 %common ininfectionsacetohydroxamic acid women Surgical interventions men,alwaysMeasures to acidify urine in association with urinary tract infection 29. SPECIFIC APPROACHES URINARY CHARACTERI PREDISPOSING THERAPEUTIC MEASURESSTONESTICSFACTORS UricPredomiGout, acid Reduce urinaryacid nant inurineconcentration of uric acid men high ,inherited Alkanize urine with5-8 %incidenceconditions potassium citrate in jewish Administer allopurinol men Reduce dietary purines 30. SPECIFIC APPROACHES URINARY CHARACTERISTICSPREDISPOSING THERAPEUTIC MEASURESSTONE FACTORSCystineGeneticAcid urine Increase hydration autosomal Give pencillamine and1-2 %recessive tiopronin to prevent cystine defect,defectivecrystallization absorption of giPotassium citrate to cystine from gi alkaline urine tract and kidney excess concentrations causing stone formation 31. SURGICAL MANAGEMENT 32. PROXIMAL URETER SURGICAL MANAGEMENT ANTEGRADENEPHROURETER STENTING ALONE OLITHOTOMYPERCUTANEOUS RETROGRADE URETEROURETEROSCOPYLITHOTOMYESWL NEPHROLITHOTOMY 33. MIDURETERSURGICAL MANAGEMENTRETROGRADE ESWL URETEROSCOPYANTEGRADE OPEN URETERO-NEPHROSTOURETELITHOTOMY ROLITHOTOMY 34. DISTAL URETER SURGICAL MANAGEMENTESWL/ureteroscopyAntegradenephrostoureterolithotomyStenting aloneOpen ureterolithotomy 35. SURGICAL MANAGEMENTLASER PERCUTANEOUSESWL 36. OPEN SURGICAL PROCEDURES NEPHROLITHO PYELOLITHOTTOMY OMYURETHROLIT CYSTOTOMY HOTOMY 37. NURSING MANAGEMENT 38. NURSING DIAGNOSIS Acute pain related to irritationand spasm from stonemovement in the urinary tract asmanifested by complaints ofpain, facial grimacing,restlessness 39. NURSING DIAGNOSIS Anxiety related to uncertainoutcome and lack ofknowledge regarding possiblesurgery as manifested byexpressions 40. NURSING DIAGNOSIS Ineffective therapeutic regimenmanagement related to lack ofknowledge as manifested byrepeated questions 41. NURSING DIAGNOSIS Impaired urinary eliminationrelated to trauma or blockage ofureters or urethra as manifestedby decreased urinary output andbloody urine 42. NURSING DIAGNOSIS Risk for infection related tointroduction of bacteriafollowing manipulations of theurinary tract and obstructedurinary blood flow 43. PREVENTION Avoid protein intake; usually protein isrestricted to 60g/day to decrease urinaryexcretion of calcium and uric acid. A sodium intake of 3 to 4 g/day isrecommended. Table salt and high-sodiumfoods should be reduced, because sodiumcompetes with calcium for reabsorptionin the kidneys. 44. PREVENTION Low-calcium diets are not generallyrecommended,except for true absorptivehypercalciuria. Evidence shows that limitingcalcium, especially in women, can lead toosteoporosis and does not prevent renalstones. Avoid intake of oxalate-containing foods(eg, spinach,strawberries, rhubarb, tea, peanuts, wheat bran). 45. PREVENTION During the day, drink fluids (ideally water)every1 to 2 hours. Drink two glasses of water at bedtimeand an additional glass at each nighttimeawakening to prevent urine frombecoming too concentrated during thenight. 46. PREVENTION Avoid activities leading to suddenincreases in environmental temperaturesthat may cause excessive sweating anddehydration. Contact your primary health careprovider at the first sign of a urinarytract infection 47. JOURNAL PRESENTATIONS 48. QUESTIONS??? 49. ?Genetica)Cystic fibrosisfactorb) sjogrens syndromeinvolved in c) goutrenal d) myasthenia graviscalculiformation: 50. ?Stone in thekidney isa) nephrolithiasis b) ureterolithiasiscalled as c ) cystolithiasis d ) cholelithiasis 51. ?Uric acidstones can a)Allopurinolbe reducedb)thiazide diureticor c)pencillaminepreventedd)potassium citrateby the useof: 52. ?Preferredopioid agenta)Morphineused in renal b) ketorolaccalculi painc)propanthelenemanagementd)tramadol hydrochlorideinitially is: 53. REFERENCES Fauci AS, BraunwaldE, Kasper DL, HauserSL, Longo DL, JamesonJL, et al., editors. Harrisonsprinciples of internalmedicine. 17th ed. New York:McGraw Hill; 2008 54. REFERENCES Johnson J.Y.Brunner anDSuddharth`s:Textbook ofMedical Surgical Nursing.11th edn.Philadelphia:Lippincott;2008. 55. REFERENCES Black M.J, Hawks H.K.Medical Surgical Nursing. 7thedn. Missouri:Saunders;2005 56. REFERENCES Taal M.W,Cherton G,MarsdenP.A. Brenner and Rector`s:The Kidney. 9thedn.Philadelphia:Elsevier;2012 57. REFERENCES Walsh C.Urology. 10th edn.Philadelphia:Elsevier;2012 58. REFERENCES Nettina S M, Mills E.J.LippincottManual of Nursing Practice. 8thedn.Philadelphia :LippincottWilliams & Wilkins; 2006