RENAL CALCULI DEFINITION: Renal calculi or urolithiasis refers to stones in the urinary tract Stones are formed when

en urinary concentrations of substances such as calcium oxalate, calcium phosphate, and uric acid increase. Dependent on : amount of the substance, ionic strength & pH of the urine RISK FACTORS: Metabolic Abnormalities in increased urine levels of calcium, oxaluric acid, uric acid, or citric acid Climate Warm climates that cause increased fluid loss, low urine volume, and increased solute concentration in urine Diet Large intake of dietary proteins that increases uric acid excretion Excessive amounts of tea or fruit juices that elevate urinary oxalate level Low fluid intake that increases urinary concentration Genetic Factors Family history of stone formation, cystinuria, gout, or renal acidosis Lifestyle Sedentary occupation, immobility CAUSES OF HYPERCALCEMIA AND HYPERCALCIURIA: Hyperparathyroidism Renal tubular acidosis Cancers Granulomatous diseases (sarcoidosis, tuberculosis), which may cause increased vitamin D production by the granulomatous tissue Excessive intake of vitamin D Excessive intake of milk and alkali Myeloproliferative diseases (leukemia, polycythemia vera, multiple myeloma), which produce an unusual proliferation of blood cells from the bone marrow TYPES OF URINARY TRACT CALCULI Urinary stone Calcium oxalate 35-40 % Characteristics Predisposing factors Therapeutic measures Alkaline urine, primary hyperparathyroidism Increase hydration. Reduce dietary oxalate. Give thiazide diuretics. Give cellulose phosphate to chelate calcium and prevent Gl absorption. Give potassium citrate to maintain alkaline urine. Give cholestyramine to bind oxalate. Give calcium lactate to precipitate oxalate in Gl tract. Reduce daily sodium intake. Treat underlying causes and other stones

Small, often possible to Idiopathic hypercalci uria, get trapped in ureter; more hyperoxaluria, frequent in men than in independent of urinary women pH, family history

Calcium phosphate 8-10 % 1|Page

Mixed stones, with struvite or oxalate stones

Struvite (magnesium ammonium Phosphate) 10-15 %

Three to four times as Urinary tract infections common in women as (Proteus organism) men; always in association with urinary tract infections; large staghorn type Predominant in men Gout high incidence in acid urine Jewish men inherited condition

Administer antimicrobial agents, acetohydroxamic acid. Use surgical intervention to remove stone. Take measures to acidify urine. Reduce urinary concentration of uric acid. Alkalinize urine with potassium citrate. Administer allopurinol. Reduce dietary purines Increase hydration. Give -penicillamine and tiopronin to prevent cystine crystallization. Give potassium citrate to maintain alkaline urine.

Uric acid 5-8 %

Cystine 1-2 %

Genetic autosomal Acid urine recessive defect; defective absorption in Gl tract and kidney, excess concentrations causing stone formation

PATHOPHYSIOLOGY: Stones can also form when there is a deficiency of substances that normally prevent crystallization in the urine, such as citrate, magnesium, nephrocalcin, and uropontin. The fluid volume status of the patient (stones tend to occur more often in dehydrated patients) is another factor playing a key role in stone development. Stones block the flow of urine, obstruction develops, producing an increase in hydrostatic pressure and distending the renal pelvis and proximal ureter. Infection (pyelonephritis and cystitis with chills, fever, and dysuria) can occur from constant irritation by the stone slowly destroying the functional units (nephrons) of the kidney and also cause excruciating pain and discomfort CLINICAL MANIFESTATIONS: 1.Stones in the renal pelvis: Intense, deep ache in the costovertebral region Hematuria Pyuria Pain - originating in the renal area radiates anteriorly and downward toward the bladder in the female and toward the testis in the male. Renal colic: acute pain with tenderness over the costovertebral area, and nausea and vomiting, diarrhea and abdominal discomfort. Due to renointestinal reflexes and the anatomic proximity of the kidneys to the stomach, pancreas, and large intestine 2.Stones lodged in the ureter: Pain - acute, excruciating, colicky, wavelike, radiating down the thigh and to the genitalia. Urine contains blood because of the abrasive action of the stone. Ureteral colic: mediated by prostaglandin E (substance that increases ureteral contractility and renal blood flow and that leads to increased intraureteral pressure and pain) Spontaneous passage of stones 0.5 to 1 cm in diameter. 3.Stones lodged in the bladder : symptoms of irritation associated with UTI and hematuria. urinary retention if the stone obstructs the bladder neck. Infection associated with a stone leads to sepsis threatening the patients life. 2|Page

DIAGNOSTIC STUDIES: History collection Urinalysis Urine culture IVP or retrograde pyelogram - to localize the degree and site of obstruction or to confirm the presence of a radiolucent stone, such as a uric acid or cystine calculus Ultrasound - to identify a radiopaque or radiolucent calculus in the renal pelvis, calyx, or proximal ureter. Cystoscopy. Xray of abdomen Renal ultrasound Blood studies: serum calcium, phosphorus, sodium, potassium, bicarbonate, uric acid, BUN, and creatinine levels , pH COLLABORATIVE CARE: 1. First concurrent approach Directed towards management of the acute attack Involves treating symptoms of pain, infection, or obstruction Administration of opioids for relief of renal colic pain. Many stones pass spontaneously. Insertion of a ureteral stent to prevent obstruction from passage of stone fragments stones larger than 4 mm 2. Second concurrent approach Directed toward evaluation of the cause of the stone formation and the prevention of further development of stones. Information to be obtained includes family history of stone formation geographic residence nutritional assessment including the intake of vitamins A and D activity pattern history of periods of prolonged illness with immobilization or dehydration history of disease or surgery involving the Gl or genitourinary tract 3. Concerted management approach Therapy for people who are active stone formers Primary emphasis on teaching and on developing a therapeutic regimen Adequate hydration, dietary sodium restrictions, dietary changes and the use of drugs Drugs prevent stone formation by: including altering urine pH, preventing excessive urinary excretion of a substance, or correcting a primary disease (e.g., hyperparathyroidism). Nutritional Therapy: Advised to drink adequate fluids to avoid dehydration. High fluid intake (approximately 3000 ml/day) after an episode of urolithiasis to produce a urine output of at least 2 l/day). prevents supersaturation of minerals and flushes them out before the minerals. Limitation of consumption of colas, coffee, and tea Low-sodium diet Restricting protein to 60 g/day Sodium restriction of 34 g/day. Restriction of oxalate-containing foods (spinach, strawberries, rhubarb, tea, peanuts, wheat bran) 3|Page

SURGICAL THERAPY: Indications for surgical therapy: 1. Stones too large for spontaneous passage 2. Stones associated with bacteriuria or symptomatic infection 3. Stones causing impaired renal function 4. Stones causing persistent pain, nausea, or ileus 5. Inability of patient to be treated medically 6. Patient with one kidney Open surgical therapy: Indicated for very obese patient or the individual with complex abnormalities in the calyces or at the UPJ Nephrolithotomy : incision into the kidney Pyelolithotomy : incision into the renal pelvis Ureterolithotomy : stone is located in the ureter Cystotomy : indicated for bladder calculi Endourologic Procedures: Cystoscopy : Stone is located in the bladder, done to remove small stones. Cystolitholapaxy: large stones can be broken up with an instrument called a lithotrite (stone crusher). Cystoscopic lithotripsy : uses an ultrasonic lithotrite to pulverize stones. Complications include hemorrhage, retained stone fragments, and infection. Percutaneous nephrolithotomy: Nephroscope is inserted through a sinus tract from the skin into the kidney pelvis. Stones can be fragmented using ultrasound, electrohydraulic, or laser lithotripsy. The stone fragments are removed and the pelvis irrigated. Complications include bleeding, injury to adjacent structures, and infection. Extracorporeal shock-wave lithotripsy: Noninvasive procedure used to break up stones in the calyx of the kidney. . High-energy amplitude of pressure, or shock wave, is generated and transmitted through water and soft tissues. Compression wave causes the surface of the stone to fragment. Repeated shock waves on the stone reduce it to many small pieces which are spontaneously voided LIST OF NURSING DIAGNOSES: 1. Acute pain related to effects of renal stone and inadequate pain control or comfort measures as evidenced by complaints of pain, facial grimacing, restlessness. 2. Impaired urinary elimination related to trauma or blockage of ureters or urethra as evidenced by decreased urinary output, hematuria. 3. Ineffective therapeutic regimen management related to lack of knowledge regarding disease process, prevention of recurrence, diet, and fluid requirements as evidenced by questions about how to prevent future renal stones. 4. Deficient knowledge regarding prevention of recurrence of renal stones Pain Management: Perform a comprehensive assessment of pain to include location, characteristics, onset/ duration, frequency, quality, intensity or severity, and precipitating factors to plan appropriate interventions. Ensure that patient receives attentive analgesic care as renal colic is a severe type of pain. Implement use of PCA, if appropriate, to permit patient control of analgesic dosing. Use pain control measures before pain becomes severe to prevent breakthrough pain that is difficult to control. Teach use of nonpharmacologic techniques for patient to use in lieu of or in conjunction with analgesics to obtain pain relief. 4|Page

Urinary Elimination Management: Monitor urinary elimination, including frequency, consistency, odor, volume, and color, to evaluate patency of urinary system and degree of hematuria. Teach patient to drink eight ounces of liquid with meals, between meals, and in early evening to provide fluids for hydration but not to an excess that may increase renal colic. Teach patient signs and symptoms of urinary tract infection as infection may result from renal stones.

Ineffective therapeutic regimen management: Teaching: Disease Process Appraise the patient's current level of knowledge related to specific disease process to plan appropriate teaching. Describe the disease process. Identify possible etiologies to decrease or avoid recurrence. Describe rationale behind management/therapy/treatment recommendations to increase compliance. Teaching: Prescribed Diet Explain the purpose of the diet to increase compliance with the diet. Assist patient to accommodate food preferences into the prescribed diet.

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