RENAL CALCULI

Question 1

refer to stones (calculi) in the urinary tract and kidney.

Answer 1

Urolithiasis and nephrolithiasis

Question 2

MOST COMMON Urolithiasis and nephrolithiasis

Answer 2

Renal Pelvis

Question 3

Urine contains ____ (3) and when they form together it will crystalize = stones

Answer 3

calcium, potassium, uric acid,

Question 4

blocked stone in the kidneys

Answer 4

Hydronephrosis

Question 4

PATHOPHYSIOLOGY OF RENAL CALCULI

Answer 4

Stones and masses of crystals and protein that form when the urine becomes supersaturated with a salt capable of forming solid crystals.

▪ Supersaturated due to increased calcium oxalate, calcium phosphate, and uric acid.

▪ In about 70% of people, kidney stones are formed primarily of Calcium Oxalate.

▪ Stones are found anywhere from the kidney to the bladder, and vary in size from minute granular deposits, called sand or gravel, to bladder stones as large as an orange

Question 5

blocked stones in the ureters.

Answer 5

Hydroureter

Question 6

4 Different sites of calculi formation in Urinary Tract

Answer 6

Right kidney
Left kidney
Ureters
Bladder

Question 7

❖ CLINICAL MANIFESTATIONS

– lumbar region and radiates:
▪ down toward the testicle in the male
▪ bladder in the female

Answer 7

→ Renal Colic

Question 8

❖ CLINICAL MANIFESTATIONS

suggest obstruction possibly at the bladder neck.

▪ If there is less urine output:
➢ Urinary Tract Obstruction is an emergency and must be treated immediately to preserve kidney function.

Answer 8

→ Oliguria and Anuria

Question 8

❖ CLINICAL MANIFESTATIONS

→ Pain
▪ ____ Pain – location

Answer 8

– severe, colicky, dull, or aching

Flank

Question 8

❖ CLINICAL MANIFESTATIONS

→ Frequency and dysuria occur when a

Answer 8

stone reaches the bladder.

Question 9

❖ CLINICAL MANIFESTATIONS

___&____due to severe flank pain, and this pain stimulates the ____ center.

Answer 9

Nausea and vomiting

vomiting

Question 10

❖ CLINICAL MANIFESTATIONS

Pallor because of the pain, ______

Answer 10

SNS is stimulated to stimulate norepi and can cause vasoconstriction

Question 11

❖ MEDICAL MANAGEMENT
→ The immediate treatment is to relieve the ____ until its cause can be eliminated.

▪ _____ agents are given to prevent shock and syncope that may result from the excruciating pain.

▪ ____ are effective in treating renal calculus pain because they provide specific pain relief.

Answer 11

pain

Opioid analgesic

NSAIDs

Question 11

❖ CLINICAL MANIFESTATIONS
→ Vital Signs: ___ T, BP, and PR
→ Diaphoresis (excessive sweating) and Anxiety
→ Elevated ____ count
→ ____ is often present
▪ Blood in the urine which often makes it look pink.

Answer 11

elevated

WBC

Hematuria

Question 11

❖ CLINICAL MANIFESTATIONS

→ In general, the patient is able to pass stones ___ in diameter

▪ Stones larger than ____ in diameter usually must be removed or fragmented (broken up by lithotripsy) so that they can be removed or passed spontaneously.

➢ Medication that – enlarges the ureter to allow large stones to flow: _____

➢ Medication that ______ – dissolves stone

Answer 11

0.5 cm

I cm

Alpha Blockers

Potassium Citrate

Question 12

❖ MEDICAL MANAGEMENT

→ Once the stone has passed, the ____

Unless the patient is _____, fluids are encouraged.
▪ This increases the hydrostatic pressure behind the stone, assisting it in its downward passage.

Answer 12

pain is relieved.

vomiting, has heart failure, or any other condition requiring fluid restriction

Question 13

❖ NURSING INTERVENTIONS FOR RENAL CALCULI

Answer 13

→ Advise patient to avoid protein intake to decrease urinary excretion of calcium and uric.

→ Advise patient to limit sodium intake to 3 to 4 g/day. because sodium competes with calcium for reabsorption in the kidneys.

→ Be aware that low-calcium diets are not generally recommended, except for true absorptive hypercalciuria. evidence shows that limiting calcium, especial in women, can lead to osteoporosis and does not prevent calculi.

→ Advise patient to avoid intake of oxalate-containing foods (e.g., spinach, Swiss chard, chocolate, peanuts, pecans).

→ Advise patient to drink fluids (ideally water) every 1 to 2 hours during the day and one glass or cranberry juice per day.
▪ Drink 2 glasses of water at bedtime and an additional glass at each nighttime awakening to prevent urine from becoming too concentrated during the night.

→ Advise patient to avoid activities leading to sudden increases in environmental temperatures that may cause excessive sweating and dehydration.

→ Instruct the patient to contact the primary provider at the first sign of a urinary tract infection

Question 13

❖ NUTRITIONAL THERAPY: prevents renal calculi

Answer 13

→ Fluid intake is the mainstay of most medical, therapy for renal calculi.
▪ Unless fluids are contraindicated.
▪ Patients with renal calculi should drink 8 to 10 8-oz glasses of water daily or have IV fluids prescribed to keep the urine dilute.

→ A urine output exceeding 2 L/day is advisable.

→ Foods high in oxalate (potatoes, spinach, beets, and rhubarb) are limited.

Question 14

❖ STONE TYPES

▪ Characteristics:
➢ Similar to stones in the garden
➢ Most common type of stone
➢ Small, rough, and hard
➢ Color vary from gray to white

Answer 14

→ Calcium Oxalate

Question 15

❖ STONE TYPES

▪ Characteristics:
➢ Made of magnesium ammonium phosphate
➢ Second most common type of stone
➢ Calculi crumble easily
➢ Stone have a yellow color

Answer 15

→ Struvite

Question 15

❖ STONE TYPES
▪ Patients with calcium-based renal calculi were advised to restrict calcium in their diet.

➢ Liberal fluid intake is encouraged.
➢ Medications such as ammonium chloride may be used.
➢ If increased parathormone production (resulting in increased serum calcium levels in blood and urine) is a factor in the formation of stones, therapy with thiazide diuretics may be beneficial in reducing the calcium loss in the urine and lowering the elevated parathormone levels.

Answer 15

→ Calcium Stones

Question 15

❖ STONE TYPES
▪ Characteristics:
➢ Due to high uric acid levels
➢ Small and hard
➢ Color varies from yellow to red

▪ The patient is placed on a low-purine (fruits, vegetables, & whole grains) diet to reduce the excretion of uric acid in the urine.

▪ Foods high in purine (shellfish, anchovies, asparagus, mushrooms, and organ meats) are avoided.

▪ Allopurinol may be prescribed to reduce serum uric acid levels and urinary uric acid excretion, and to dissolve or reduce the size of existing stones.

Answer 15

→ Uric Acid Stones (Calcium Phosphate)

Question 16

❖ STONE TYPES
▪ A low-protein diet may be prescribed, the urine is alkalinized with potassium alkali salts, and fluid intake is increased.

➢ Fruits: Apples, bananas, pears, peaches, berries, grapefruit.
➢ Vegetables: Tomatoes, asparagus, peppers, broccoli, leafy greens.
➢ Grains: Rice, oats, bread, pasta, barley

Answer 16

→ Cystine Stones

Question 17

❖ STONE TYPES
▪ A dilute urine is maintained through increasing fluid intake, and the intake of oxalate is limited.

➢ Many foods contain oxalate including spinach, Swiss chard, chocolate, peanuts, and pecans

Answer 17

→ Oxalate Stones

Question 18

❖ PREVENTIVE MEASURES FOR RENAL CALCULI
→ Drinking Enough fluid
→ Limiting Meat Intake
→ A diet rich in acid should be provided
→ Limiting foods rich in calcium
→ Limiting intake of oxalate-containing foods

Answer 18

→ Drinking Enough fluid
▪ 12 glasses (3L) of fluid a day, preferably water.
▪ Most basic kidney stone prevention step.
▪ This dilutes urine and decreases the risk of crystal formation.

→ Limiting Meat Intake
▪ Because it contains uric acid
▪ Consuming more than 6 to 8 oz of meat daily can increase calcium and uric acid in the urine.
▪ Increase the acidity of urine
▪ Reduce chemicals that inhibit crystal formation

→ A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium.

→ Limiting foods rich in calcium, such as dairy products will help prevent renal calculi.

→ Limiting intake of oxalate-containing foods such as beets, strawberry, coffee, cola drinks, tea, chocolate drinks, grapes, kiwi.

Question 19

❖ MEDICATIONS FOR STONES
→ Allopurinol (Zyloprim)
→ Tiopronin (Thiola)

Answer 19

→ Allopurinol (Zyloprim)
▪ To lower uric acid concentration
▪ Prescribed only if a reduced purine diet fails and stones persist.

→ Tiopronin (Thiola)
▪ For cystine stones, which make cystine more soluble for excretion.
▪ Long-term Antibiotics are used to control the infection.

Question 20

❖ INTERVENTIONAL PROCEDURES
▪ It is used for removing small stones located in the ureter close to the bladder, a ureteroscope is inserted into the ureter to visualize the stone. The stone is then fragmented or captured and removed.

▪ A stent may be inserted and left in place for 48 hours or more after the procedure to keep the ureter patent.

▪ Length of hospital stay is generally brief, and some patients can be treated as outpatients

Answer 20

→ Ureteroscopy

Question 21

❖ INTERVENTIONAL PROCEDURES
▪ It is a noninvasive procedure used to break up stones in the calyx of the kidney.

➢ It is not 100% cure for stones.
➢ Procedure is done within 40 minutes.

▪ It uses high-energy shock waves to break the stone into tiny pieces that can be more easily passed.

▪ Electrohydraulic lithotripsy is a similar method in which an electrical discharge is used to create a hydraulic shock wave to break up the stone.

Answer 21

→ Extracorporeal Shock Wave Lithotripsy (ESWL)

Question 22

❖ INTERVENTIONAL PROCEDURES
▪ It is used to extract kidney calculi that cannot be removed by other procedures.

Answer 22

→ Endourologic (percutaneous) Methods

Question 23

❖ INTERVENTIONAL PROCEDURES
is used to treat larger stones.

▪ A percutaneous tract is formed, and a nephroscope is inserted through it. Then, the stone is extracted or pulverized.
➢ Patient is in a ____ Position.

▪ A ____ is introduced through a percutaneous route into the renal parenchyma.
➢ Depending on its size, the stone may be extracted with forceps or by a stone retrieval basket.
➢ If the stone is too large to initially be removed, an ultrasound probe inserted through a _____ is used to pulverize the stone.
➢ Small stone fragments and stone dust are then removed.

Answer 23

→ Percutaneous Nephrolithotomy

Sim’s

nephroscope

nephrostomy tube

Question 24

NURSING INTERVENTION FOR Extracorporeal Shock Wave Lithotripsy (ESWL)

Answer 24

➢ Advise to increase fluid intake to flush out the stones broke down due to the procedure.

➢ Pain may be experienced as the stone fragments pass down the urine and may hit the nerves. Antispasmodics are given:
* Meberverine HCL (Duspatalin) –100 mg tab
* Pinaverium BR (Eldicet) – 50 mg tab

➢ Advised to drink 2-3 L in 24 hours to help flush out stone fragments and clear any blood in the urine.
* The fragments may be passed for up to 3 months after the procedure.

➢ Early Ambulation increases peristalsis and fast movement of the stones.

Question 25

▪ Postoperative Care

Answer 25

➢ Check that the nephrostomy and drainage tubing are not kinked or that the patient is not compressing the tubing.
➢ Assess the tube insertion for bleeding and drainage.
➢ Notify the physician immediately if there is an absence of urinary drainage.
➢ Encourage fluid intake of 2-3L in 24 hours (IV and oral fluids) to flush out any blood or stone fragments that might be present.

Question 26

❖ SURGICAL MANAGEMENT
If the stone is in the kidney; an incision into the kidney with removal of the stone.

Answer 26

Nephrolithotomy

Question 27

❖ SURGICAL MANAGEMENT
If the kidney is nonfunctional secondary to infection or hydronephrosis.

Answer 27

Nephrectomy

Question 28

❖ SURGICAL MANAGEMENT
Laparoscopic surgical removal of a stone from the ureter.

Answer 28

Ureterolithotomy

Question 29

❖ SURGICAL MANAGEMENT
Those in the bladder.

Answer 29

Cystotomy

Question 29

❖ SURGICAL MANAGEMENT
It is a procedure to break up bladder stones into smaller pieces and remove them.

Answer 29

Cystolitholapaxy