urolithiasis or urinary calculi. refers to the presence of stones in the urinary system stones, or...

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Urolithiasis Urolithiasis or or Urinary Calculi Urinary Calculi

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UrolithiasisUrolithiasis or or

Urinary CalculiUrinary Calculi

Refers to the presence of Refers to the presence of stones in the urinary stones in the urinary systemsystem

Stones, or calculi, are Stones, or calculi, are formed in the urinary formed in the urinary tract from the kidney to tract from the kidney to bladder by the bladder by the crystallization of crystallization of substances excreted in substances excreted in the urine.the urine.

Pathophysiology and EtiologyPathophysiology and Etiology

1. Most stones (75%) are composed mainly 1. Most stones (75%) are composed mainly of calcium oxalate crystals; of calcium oxalate crystals;

the rest are composed of calcium the rest are composed of calcium phosphate salts, uric acid, struvite phosphate salts, uric acid, struvite (magnesium, ammonium, and phosphate)(magnesium, ammonium, and phosphate)

2. Causes and predisposing factors.2. Causes and predisposing factors. Hypocalcemia and hypercalciuria caused Hypocalcemia and hypercalciuria caused

by hyperparathyroidism, renal tubular by hyperparathyroidism, renal tubular acidosis, multiple myeloma, and excessive acidosis, multiple myeloma, and excessive intake of vitamin D, milk and alkali.intake of vitamin D, milk and alkali.

Chronic dehydration, Poor fluid intake, and Chronic dehydration, Poor fluid intake, and immobility.immobility.

Diet high in purines and abnormal purine Diet high in purines and abnormal purine metabolism. (Hyperuricemia and gout)metabolism. (Hyperuricemia and gout)

Genetic predisposition for urolithiasis / Genetic predisposition for urolithiasis / genetic disorders. (Cystinuria)genetic disorders. (Cystinuria)

Chronic infection with urea – splitting Chronic infection with urea – splitting bacteria (bacteria (Proteus vulgarisProteus vulgaris))

Chronic obstruction with stasis of urine, Chronic obstruction with stasis of urine, foreign bodies within the urinary tract.foreign bodies within the urinary tract.

Excessive oxalate absorption in Excessive oxalate absorption in inflammatory bowel disease and bowel inflammatory bowel disease and bowel resection or ileostomy. resection or ileostomy.

Living in mountainous, desert, or tropical Living in mountainous, desert, or tropical areas.areas.

3. Stones may be found anywhere in the 3. Stones may be found anywhere in the urinary system and vary in size from mere urinary system and vary in size from mere granular deposits (called sand or gravel) to granular deposits (called sand or gravel) to bladder stones the size of an orange.bladder stones the size of an orange.

4. Three out of four patients with stones are 4. Three out of four patients with stones are men; in both sexes, the peak age of onset men; in both sexes, the peak age of onset is between ages 20 and 40.is between ages 20 and 40.

5. Most stones migrate downward (causing 5. Most stones migrate downward (causing severe colicky pain) and are discovered in severe colicky pain) and are discovered in the lower ureter. Spontaneous stone the lower ureter. Spontaneous stone passage can be anticipated in 80% of pts passage can be anticipated in 80% of pts with urolithiasis.with urolithiasis.

6. Some stones may lodge in the renal 6. Some stones may lodge in the renal pelvis, ureters, or bladder neck causing pelvis, ureters, or bladder neck causing obstruction, edema, secondary infection obstruction, edema, secondary infection and, in some cases, nephron damage.and, in some cases, nephron damage.

7. People who have had two stones tend to 7. People who have had two stones tend to have recurrences.have recurrences.

Clinical ManifestationsClinical Manifestations Pain pattern depends on site of Pain pattern depends on site of

obstruction.obstruction.

a.a. Renal stones produce an increase in Renal stones produce an increase in hydrostatic pressure and distention of the hydrostatic pressure and distention of the renal pelvis and proximal ureter causing renal pelvis and proximal ureter causing renal colic. Pain relief is immediate after renal colic. Pain relief is immediate after stone passage.stone passage.

b.b. Large ureteral stones produce Large ureteral stones produce symptoms or obstruction as they pass symptoms or obstruction as they pass down the ureter (ureteral colic)down the ureter (ureteral colic)

c. c. Bladder stones produce symptoms similar Bladder stones produce symptoms similar to cystitis.to cystitis.

Obstruction – stones blocking the flow of Obstruction – stones blocking the flow of urine will produce symptoms of UTI; chills urine will produce symptoms of UTI; chills and fever.and fever.

GI symptoms include nausea, vomiting, GI symptoms include nausea, vomiting, diarrhea, abdominal discomfort – due to diarrhea, abdominal discomfort – due to renointestinal reflexes and shared nerve renointestinal reflexes and shared nerve supply (celiac ganglion) between the supply (celiac ganglion) between the ureters and intestine.ureters and intestine.

Assessment Factors Specific to Assessment Factors Specific to Patients with Urinary calculus Patients with Urinary calculus

DiseasesDiseases

Present & Past Present & Past medical historymedical history

Medical treatment & Medical treatment & surgical procedures surgical procedures on and outside GU on and outside GU tract.tract.

UTIsUTIsPeriods of prolonged Periods of prolonged

illness with illness with mobilization / mobilization / dehydrationdehydration

GoutGout

Malignant neoplasmsMalignant neoplasms

EndocrinopathiesEndocrinopathies

Family historiesFamily histories Present & Past Present & Past geographic residencesgeographic residences AgeAge SexSex OccupationOccupation Dietary habitsDietary habits Fluid IntakeFluid Intake Vitamin IntakeVitamin Intake Medication HistoryMedication History

SteroidsSteroids Alkalizing agentsAlkalizing agents

PainPain LocationLocation IntensityIntensity Character & QualityCharacter & Quality ChronologyChronology

Pain responsePain response PsychologicalPsychological BehavioralBehavioral AffectiveAffective

Surgical Intervention for Surgical Intervention for UrolithiasisUrolithiasis

SurgerySurgeryOpen ProceduresOpen ProceduresNephrolithotomyNephrolithotomyNephrectomy (partial / Nephrectomy (partial /

total)total)PyelolithotomyPyelolithotomyUreterolithotomyUreterolithotomyCustolithectomyCustolithectomyLitholapaxyLitholapaxy

IndicationsIndications

Crushing of urolithiasis Crushing of urolithiasis with lithotrite; small stone with lithotrite; small stone fragment can then be fragment can then be flushed from UTflushed from UT

Closed proceduresClosed procedures

Percutaneous Percutaneous Ultrasonic lithotripsy Ultrasonic lithotripsy (PUL)(PUL)

Extracorporeal shock Extracorporeal shock wave lithotripsy wave lithotripsy (ESWL)(ESWL)

Ultrasound used to Ultrasound used to fragment large calculus fragment large calculus so fragments can be so fragments can be mechanically removed mechanically removed or flushed out of the or flushed out of the system.system.

Patient is placed in tank Patient is placed in tank of water through which of water through which shock waves are sent to shock waves are sent to pulverize stone that is pulverize stone that is then passed during then passed during urination.urination.

Nursing DiagnosesNursing Diagnoses

Acute pain related to inflammation, Acute pain related to inflammation, obstruction, and abrasions of UT by obstruction, and abrasions of UT by migration of stones.migration of stones.

Impaired Urinary Elimination related to Impaired Urinary Elimination related to blockage of urine flow by stones.blockage of urine flow by stones.

Risk for Infection related to obstruction of Risk for Infection related to obstruction of urine flow and instrumentation during urine flow and instrumentation during treatment. treatment.

Nursing InterventionsNursing Interventions

Controlling PainControlling Pain

1.1. Give opioid analgesic (usually IV or IM) Give opioid analgesic (usually IV or IM) until cause of pain can be removed.until cause of pain can be removed.

a. Monitor pt closely for increasing pain; a. Monitor pt closely for increasing pain; may indicate inadequate analgesia.may indicate inadequate analgesia.

b. Very large doses of opioids are typically b. Very large doses of opioids are typically required to relieve pain, so monitor for required to relieve pain, so monitor for respiratory depression and drop in blood respiratory depression and drop in blood pressure.pressure.

2. Encourage pt to assume position that 2. Encourage pt to assume position that brings some relief.brings some relief.

3. Reassess pain frequently.3. Reassess pain frequently.

4. Administer antiemetics (IM or rectal 4. Administer antiemetics (IM or rectal suppository) as indicated for nausea.suppository) as indicated for nausea.

Maintaining Urine FlowMaintaining Urine Flow1.1. Administer fluids orally or IV (if vomiting) Administer fluids orally or IV (if vomiting)

to reduce concentration of urinary to reduce concentration of urinary crystalloids and ensure adequate urine crystalloids and ensure adequate urine output.output.

2.2. Monitor total urine output and patterns of Monitor total urine output and patterns of voiding. Report oliguria or anuria.voiding. Report oliguria or anuria.

3.3. Strain all urine through strainer or gauze Strain all urine through strainer or gauze to harvest the stone. Uric acid stones to harvest the stone. Uric acid stones may crumble. Crush clots, and inspect may crumble. Crush clots, and inspect sides of urinal / bedpan for clinging sides of urinal / bedpan for clinging stones / fragments.stones / fragments.

Patient Education and Health Patient Education and Health MaintenanceMaintenanceRecovery from surgical Interventions for Recovery from surgical Interventions for Stone DiseaseStone Disease

1.1. Encourage fluids to accelerate passing of Encourage fluids to accelerate passing of stone particles.stone particles.

2.2. Teach about analgesics that still may be Teach about analgesics that still may be necessary for colicky pain, which may necessary for colicky pain, which may accompany passage of stone debris.accompany passage of stone debris.

3.3. Warn that some blood may appear in Warn that some blood may appear in urine for several weeks.urine for several weeks.

4. Encourage frequent walking to assist in 4. Encourage frequent walking to assist in passage of stone fragments.passage of stone fragments.

5. Teach pt to strain urine through a coffee 5. Teach pt to strain urine through a coffee filter.filter.

6. For outpatient treatment, the patient may 6. For outpatient treatment, the patient may use a coffee filter to strain urine.use a coffee filter to strain urine.

7. Help pt to walk, if possible, because 7. Help pt to walk, if possible, because ambulation may help move the stone ambulation may help move the stone through the UT.through the UT.

Avoid over hydration, which may result in Avoid over hydration, which may result in increased distension at stone location, increased distension at stone location, causing an increase in pain and causing an increase in pain and associated symptoms.associated symptoms.

Prevention of Recurrent Prevention of Recurrent Stone FormationStone Formation

1.1. For pts with calcium oxalate stonesFor pts with calcium oxalate stones

a. Instruct on diet – avoid excess of calcium and a. Instruct on diet – avoid excess of calcium and phosphorus; maintain a low sodium diet (sodium phosphorus; maintain a low sodium diet (sodium restriction decreases amount of calcium absorbed restriction decreases amount of calcium absorbed in intestine)in intestine)

b. Teach purpose of drug therapy – thiazide diuretics b. Teach purpose of drug therapy – thiazide diuretics to reduce urine calcium excretion, allopurinol to reduce urine calcium excretion, allopurinol therapy to reduce uric acid concentration.therapy to reduce uric acid concentration.

2. For pts with uric acid stones2. For pts with uric acid stones

a. Teach methods to alkalinize urine to a. Teach methods to alkalinize urine to enhance urate solubility.enhance urate solubility.

b. Instruct on testing urine pH.b. Instruct on testing urine pH.

c. Teach purpose of taking allopurinol – to c. Teach purpose of taking allopurinol – to lower uric acid concentration.lower uric acid concentration.

d. Provide information about reduction of d. Provide information about reduction of dietary purine intake (low protein – red dietary purine intake (low protein – red meat, fish, fowl)meat, fish, fowl)

3. For pts with infection (Struvite) stone3. For pts with infection (Struvite) stone

a. Teach signs and symptoms of urinary a. Teach signs and symptoms of urinary infection; encourage him to report infection infection; encourage him to report infection immediately; must be treated vigorously.immediately; must be treated vigorously.

b. Try to avoid prolonged periods of b. Try to avoid prolonged periods of recumbency – slows renal drainage and recumbency – slows renal drainage and alters calcium metabolism.alters calcium metabolism.

c. Teach pt with drug therapy with D – c. Teach pt with drug therapy with D – Pencillamine (Depen) – to lower cystine Pencillamine (Depen) – to lower cystine concentration, or dissolution by direct concentration, or dissolution by direct irrigation with thiol derivatives.irrigation with thiol derivatives.

d. Explain importance of maintaining drug d. Explain importance of maintaining drug therapy consistently.therapy consistently.

4. For all pts with stone disease,4. For all pts with stone disease, a. Explain need for consistently increased a. Explain need for consistently increased

fluid intake (24 – hour urinary output fluid intake (24 – hour urinary output greater than 2l) – lowers the greater than 2l) – lowers the concentration of substances involved in concentration of substances involved in stone formation.stone formation.

i.i. Drink enough fluids to achieve a urinary Drink enough fluids to achieve a urinary volume of 2000 – 3000 ml or more every 24 volume of 2000 – 3000 ml or more every 24 hours.hours.

ii.ii. Drink larger amounts during periods of Drink larger amounts during periods of strenuous exercise, if pt perspires freely.strenuous exercise, if pt perspires freely.

iii.iii. Take fluids in evening to guarantee a high Take fluids in evening to guarantee a high urine flow during the night.urine flow during the night.

b. Encourage a diet low in sugar and animal b. Encourage a diet low in sugar and animal proteins – refined carbohydrates appear to proteins – refined carbohydrates appear to lead to hypercalciuria and urolithiasis; lead to hypercalciuria and urolithiasis; animal proteins increase urine excretion of animal proteins increase urine excretion of calcium, uric acid, and oxalate. calcium, uric acid, and oxalate.

c. Increase consumption of fiber – inhibits c. Increase consumption of fiber – inhibits calcium and oxalate absorption.calcium and oxalate absorption.

d. Save any stone passed for analysis. (Only d. Save any stone passed for analysis. (Only pts with more than one episode of pts with more than one episode of urolithiasis are advised to have a urolithiasis are advised to have a metabolic evaluation.)metabolic evaluation.)

e. Can discontinue urine straining 72 hours e. Can discontinue urine straining 72 hours after symptoms resolve.after symptoms resolve.

ManagementManagement

1.1. If small stone (< 4 mm) and able to If small stone (< 4 mm) and able to treat as out pt, 80% will pass stone treat as out pt, 80% will pass stone spontaneously with hydration, spontaneously with hydration, pain control, and reassurance.pain control, and reassurance.

2.2. Hospitalized for intractable pain, Hospitalized for intractable pain, persistent vomiting, high – grade persistent vomiting, high – grade fever, obstruction with infection, fever, obstruction with infection, and solitary kidney with infection.and solitary kidney with infection.