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Urolithiasis (Renal Calculi)


Description

  • Urolithiasis refers to stones (calculi) in the urinary charge.
  • Stones are formed in the urinary charge when the urinary concentration of substances such as calcium oxalate, calcium phosphate, and uric piercing extensions.
  • Stones change in extent from detailed granular deposits to the extent of an orange-colored.
  • Factors that boon construction of stones embrace infection, urinary stasis, and periods of imperturbability, all of which gradual renal drainage and modify calcium metabolism.
  • The height occurs predominantly in the third to fifth decades and affects men more repeatedly than women.

Pathophysiology

  • Presence of stones anywhere in the urinary charge
    • Most uniformly root in the renal pelvis and calyces
      • Stones forming in the kidney—nephrolithiasis
      • Stones formed in the ureters—ureterolithiasis
    • May be separate or multiple calculi, ranging in extent from a tittle of salt to the extent of a pebble or staghorn calculus
  • Compose of calculi
    • Formed of inanimate deposits—predominantly calcium oxalate and calcium phosphate
    • Uric piercing, struvite, and cystine are too calculus formers

Etiology

  • Slow urine flow allows hoard of crystals—damaging the integument of the urinary charge and decreasing the estimate of inhibitor substances that would thwart crystal hoard (Winkleman, 2006).
  • May continue asymptomatic until passed into a ureter or urine flow is clogged, at which age the possible for renal mischief is sharp and the plane of aversion is at its chief.
  •  Causes: dehydration; heredity; immoderate inaccept of vitamins C and D, grapefruit juice, and purines (gout); incarnate renal abnormalities; and some medications, such as acetazolamide (Diamox) or indinavir (Crixivan)

Clinical Manifestations

Manifestations halt on the influence of impediment, taint, and edema. Symptoms collocate from calm to excruciating aversion and disquiet.

Stones in Renal Pelvis

  • Intense, mysterious ache in costovertebral region
  • Hematuria and pyuria
  • Pain that radiates anteriorly and downward inparty bladder in effeminate and inparty standardes in male
  • Acute aversion, nausea, vomiting, costovertebral area clemency (renal colic)
  • Abdominal disquiet, diarrhea

Ureteral Colic (Stones Lodged in Ureter)

  • Acute, excruciating, colicky, prosperlike aversion, radiating down the televated to the genitalia
  • Frequent hanker to empty, but slight urine passed; usually contains blood consequently of the abrasive exercise of the stone (notorious as ureteral colic)

Stones Lodged in Bladder

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Assessment and Diagnostic Methods

  • Diagnosis is developed by xrays of the offsprings, ureters, and bladder (KUB) or by ultrasonography, IV urography, or ebb pyelography.
  • Blood chemistries and a 24hour urine standard for measurement of calcium, uric piercing, creatinine, sodium, pH, and sum volume.
  • Chemical resolution is produced to mention stone structure.

Diagnostic Studies

  • Urinalysis: Color may be yellow, ebon brown, lineagey. Uniformly shows RBCs, WBCs, crystals (cystine, uric piercing, calcium oxalate), casts, inanimates, bacteria, pus; pH may be close than 5 (promotes cystine and uric piercing stones) or elevateder than 7.5 (promotes magnesium, struvite, phosphate, or calcium phosphate stones).
  • Urine (24-hr): Cr, uric piercing, calcium, phosphorus, oxalate, or cystine may be elevated.
  • Urine culture: May divulge UTI (Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas).
  • Biochemical survey: Elevated planes of magnesium, calcium, uric piercing, phosphates, protein, electrolytes.
  • Serum and urine BUN/Cr: Abordinary (elevated in serum/low in urine) inferior to elevated counteractive stone in offspring causing ischemia/necrosis.
  • Serum chloride and bicarbonate planes: Elevation of chloride and decreased planes of bicarbonate allude-to developing renal tubular piercingosis.
  • CBC:
    • Hb/Hct: Abordinary if enduring is severely dehydrated or polycythemia is exhibit (encourages dregs of solids), or enduring is anemic (hemorrhage, offspring dysfunction/failure).
    • RBCs: Usually ordinary.
    • WBCs: May be extensiond, indicating taint/septicemia.
  • Parathyroid hormone (PTH): May be extensiond if offspring scarcity exhibit. (PTH stimulates reabsorption of calcium from bones, increasing circulating serum and urine calcium planes.)
  • KUB x-ray: Shows influence of calculi and/or scant changes in the area of the offsprings or concurrently the anxietyer of the ureter.
  • IVP: Provides flying assent of urolithiasis as a producer of abdominal or flank aversion. Shows abnormalities in scant structures (distended ureter) and plan of calculi.
  • Cystoureteroscopy: Direct visualization of bladder and ureter may divulge stone and/or counteractive proceeds.
  • CT scan: Identifies/delineates calculi and other masses; offspring, ureteral, and bladder distension.
  • Ultrasound of offspring: To mention counteractive changes, colonization of stone; delayout the waste of scarcity redundant by oppose adjust.

Nursing Priorities

  1. Alleviate aversion.
  2. Maintain wide renal powering.
  3. Prevent complications.
  4. Provide acquirements environing sickness process/prognosis and matter scarcitys.

Medical Management

  • Basic goals are to root-out the stone, mention the stone type, thwart nephron perdition, govern taint, and relieve any impediment that may be exhibit.

Pharmacologic and Nutritional Therapy

  • Opioid analgesic agents (to thwart surprise and syncope) and nonsteroidal antiinflammatory drugs (NSAIDs).
  • Increased mellifluous inaccept to befriend in stone route, unless enduring is vomiting; endurings delay renal stones should draught eight to ten 8oz glasses of breathe-into daily or accept IV mellifluouss prescribed to obey the urine attenuate.
  • For calcium stones: depressed nourishmentary protein and sodium intake; bounteous mellifluous intake; medications to piercingify urine, such as ammonium chloride and thiazide diuretics if parathormone genesis is extensiond.
  • For uric stones: lowpurine and moneyless protein nourishment; allopurinol (Zyloprim).
  • For cystine stones: lowprotein nourishment; alkalinization of urine; increased mellifluouss.
  • For oxalate stones: attenuate urine; moneyless oxalate intake (spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran).

Stone Dissolution Procedures

  • Ureteroscopy: stones fragmented delay use of laser, electrohydraulic lithotripsy, or ultrasound and then removed.
  • Extracorporeal surprise prosper lithotripsy (ESWL).
  • Percutaneous nephrostomy; endourologic methods.
  • Electrohydraulic lithotripsy.
  • Chemolysis (stone neutrality): modifynative for those who are moneyless wastes for other therapies, offscourings other methods, or accept largely dispersed stones (struvite).
  • Surgical dissolution is produced in merely 1% to 2% of endurings.

Nursing Process

Assessment

  • Assess for aversion and disquiet, including injustice, colonization, and radiation of aversion.
  • Assess for associated symptoms, including qualm, vomiting, diarrhea, and abdominal distention.
  • Observe for signs of urinary charge taint (chills, fever, frequency, and hesitancy) and impediment (general urination of mean amounts, oliguria, or anuria).
  • Observe urine for lineage; percolate for stones or gravel.
  • Focus fact on factors that predispose enduring to urinary charge stones or that may accept precipitated vulgar episode of renal or ureteral colic.
  • Assess enduring’s acquirements environing renal stones and measures to thwart return.

Diagnosis

Nursing Diagnoses

  • Acute aversion allied to inflammation, impediment, and peeling of the urinary charge
  • Deficient acquirements respecting thwartion of return of renal stones

Collaborative Problems/Potential Complications

  • Infection and urosepsis (from urinary charge taint and pyelonephritis)
  • Obstruction of the urinary charge by a stone or edema, delay subsequent sharp renal scarcity

Planning and Goals

  • Major goals may embrace aid of aversion and disquiet, thwartion of return of renal stones, and scantiness of complications.

Nursing Anxiety Plans

Main Article: 4 Urolithiasis Nursing Anxiety Plans

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Nursing Interventions

Relieving Pain

  • Administer opioid analgesics (IV or intramuscular) delay IV NSAID as prescribed.
  • Encourage and befriend enduring to mismiswithhold a pose of self-approval.
  • Assist enduring to ambulate to procure some aversion aid.
  • Monitor aversion air-tight and announce undeviatingly extensions in severity.

Monitoring and Managing Complications

  • Encourage extensiond mellifluous inaccept and ambulation.
  • Begin IV mellifluouss if enduring cannot accept wide unwritten mellifluouss.
  • Monitor sum urine output and patterns of emptying.
  • Encourage ambulation as a media of tender the stone through the urinary charge.
  • Strain urine through gauze.
  • Crush any lineage clots passed in urine, and search partys of urinal and bedpan for clinging stones.
  • Instruct enduring to announce decreased urine capacity, lineagey or dead urine, heat, and aversion.
  • Instruct enduring to announce any extension in aversion.
  • Monitor life-containing signs for forthcoming indications of taint; taints should be treated delay the mismiswithhold antibiotic agent anteriorly efforts are made to disperse the stone.

Teaching Points

  • Explain producers of offspring stones and ways to thwart recurrence.
  • Encourage enduring to prosper a nourishment to aempty elevate stone construction, including maintaining a elevated mellifluous intake.
  • Encourage enduring to draught abundance to excrete 3,000 to 4,000 mL of urine total 24 hours.
  • Recommend that enduring accept urine cultures total 1 to  2 months the leading year and periodically thereafter.
  • Recommend that revulgar urinary taint be treated vigorously.
  • Encourage extensiond disturbance whenever possible; intimidate immoderate ingestion of vitamins (chiefly vitamin D) and inanimates.
  • If enduring had surgery, indoctrinate environing the signs and symptoms of complications that scarcity to be announceed to the physician; emphaextent the signification of prosperup to assess offspring power and to secure the extirpation or dissolution of all offspring stones to the enduring and nobility.
  • If enduring had ESWL, promote enduring to extension mellifluous inaccept to befriend in the route of stone waste-matter; inform the enduring to foresee hematuria and haply a pound on the treated party of the back; indoctrinate enduring to hinder his or her atmosphere daily and communicate the physician if the atmosphere is superior than 38C (environing 101F), or the aversion is unrelieved by the prescribed medication.
  • Provide indoctrinateions for any indispensable abode anxiety and  followup.

PROVIDING HOME AND FOLLOWUP CARE AFTER ESWL

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  • Instruct enduring to extension mellifluous inaccept to befriend route of stone waste-matter (may accept 6 weeks to different months following procedure).
  • Instruct enduring environing signs and symptoms of complications: heat, decreasing urinary output, and aversion.
  • Inform enduring that hematuria is anticipated but should subparty in 24 hours.
  • Give mismiswithhold nourishmentary indoctrinateions installed on structure of stones.
  • Encourage nourishment to aempty elevate stone construction; advise enduring to accord to prescribed nourishment.
  • Teach enduring to accept satisfactory mellifluouss in the evening  to thwart urine from beseeming too close at  night.

CONTINUING CARE

  • Closely adviser the enduring to secure that matter has been serviceable and that no complications accept developed.
  • Assess the enduring’s intellect of ESWL and possible complications; assess the enduring’s intellect of factors that extension the waste of return of renal calculi and strategies to narrow those wastes.
  • Assess the enduring’s force to adviser urinary pH and interpret the results during prosperup visits.
  • Ensure that the enduring understands the signs and symptoms of stone construction, impediment, and taint and the signification of announceing these signs undeviatingly.
  • If medications are prescribed for the thwartion of stone formation, interpret their exercises, signification, and party proceeds to the enduring.

Evaluation

Expected Enduring Outcomes

  • Reports aid of aversion
  • States extensiond acquirements of healthseeking behaviors to thwart return
  • Experiences no complications

Discharge Goals

  1. Pain relieved/controlled.
  2. fluid/electrolyte adjust maintained.
  3. Complications thwarted/minimized.
  4. Disease process/prognosis and sanitary nourishment implied.
  5. Plan in establish to as scarcitys following perform.

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