it is just a presentation

1. Renal calculi and
bladder calculi
Acknowledged by:
Sir Muslim Shah
Nursing Instructor
RMISON

2. GROUP MEMBERSGROUP MEMBERS
 NAWAB ALI T.LNAWAB ALI T.L
 MUHAMMAD BILALMUHAMMAD BILAL
 IBRAR AHMADIBRAR AHMAD
 RABIA BIBIRABIA BIBI
 GUL NAAZGUL NAAZ

3. objectivesobjectives
 At the end of this presentation theAt the end of this presentation the
learner will be able to:learner will be able to:
 Define and explain different types ofDefine and explain different types of
renal and bladder stones.renal and bladder stones.
 Explain the pathophysiology of renalExplain the pathophysiology of renal
and bladder calculi.and bladder calculi.
 Know the etiology of renal stones.Know the etiology of renal stones.

4. continuecontinue
 Define terms related toDefine terms related to
nephrolithiasis e,g nephrolithiasisnephrolithiasis e,g nephrolithiasis
aand urolithiasis etc.aand urolithiasis etc.

5. Renal calculi
 A kidney stone is a hard mineral and crystalline
materil formed within the kidney or urinary tract.
 It is also called nephrolithiasis.

6. Cont…
 Kidney stones typically leave the body by passage in
the urine stream, and many stones are formed and
passed without causing symptoms.
 If stones grow to sufficient size before passage on
the order of at least 2-3 millimeters — they can cause
obstruction of the ureter.
 Renal calculi can vary in size from as small as grains
of sand to as large as a golf ball.

7. Cont…
 The resulting obstruction with dilation or stretching
of the upper ureter and renal pelvis as well as spasm
of muscle, trying to move the stone,
 Pain in the abdomen, flank, or groin.

9. Nephrolithiasis and Urolithiasis
 The condition of having kidney stones is termed
nephrolithiasis or urolithiasis. (Nephrolithiasis
literally means kidney stone, while urolithiasis means
urinary tract stone.)

10. pathophysiologypathophysiology
 PathophysiologyPathophysiology
• Originate inOriginate in
renal pelvisrenal pelvis
• Form when anForm when an
excess ofexcess of
insoluble saltsinsoluble salts
or uric acidor uric acid
crystallizes incrystallizes in
the urinethe urine

11. Pathophysiology (contPathophysiology (cont’d)’d)
• Calcium stonesCalcium stones
 Most commonMost common
 May have aMay have a
hereditaryhereditary
componentcomponent
• Struvite stonesStruvite stones
 More common inMore common in
womenwomen
• Uric acid andUric acid and
cystine stonescystine stones
 Least commonLeast common

12. Causes
 Infection
 Urinary stasis
 Immobility
 Urethral stricture
 Prostatic obstruction
 Inflammatory bowel disease
 Patient with ileostomy
 Dehydration
 Family history
 Medications

13. Cont…
 The formation of renal stones is related to the urine
pH.
 Calcium phosphate, calcium carbonate, and
magnesium phosphate stones develop in alkaline
urine; when this occurs, the urine is kept acidic.
 Uric acid, cystine, and calcium oxalate stones
precipitate in acidic urine; in this situation, the urine
should be kept alkaline or less acidic than normal

14. Types of Stones
 Calcium oxalate stones
 The most common type of kidney stone is composed
of calcium oxalate crystals.
 Current evidence suggests that the consumption of
low-calcium diets is actually associated with a higher
overall risk for the development of kidney stones.
This is perhaps related to the role of calcium in
binding ingested oxalate in the gastrointestinal
tract. As the amount of calcium intake decreases,
the amount of oxalate available for absorption into
the bloodstream increases; this oxalate is then
excreted in greater amounts into the urine by the
kidneys.

15. Calcium oxalate dihydrate Calcium oxalate monohydrate

16. Cont..
Magnesium ammonium phosphate :
 Also called struvite stones. Formed in alkaline urine
in the presence of bacteria that posses an enzyme
urease.
 urea-splitting bacteria
Capable of splitting urea into ammonia, decreasing the
acidity of the urine and resulting in favorable
conditions for the formation of struvite stones.

17. Uric acid stones: due to high concentration of uric
acid in urine.
 Acid/base metabolism disorders where the urine is
excessively acid resulting in uric acid precipitation.

18. Cont…
 Kidney stones, cystine: Cystine kidney stones
are due to cystinuria, an inherited (genetic) disorder
of the transport of an amino acid (a building block of
protein) called cystine. The result is an excess of
cystine in the urine (cystinuria) and the formation of
cystine stones.

20. Clinical manifestation
 Infection (pyelonephritis and cystitis with chills,fever
and dysuria)
 Stones in the renal pelvis may be associated with an
intense, deep ache in the costovertebral region
 Hematuria
 Pyuria
 Nausea/vomiting
 Diarrhea and abdominal discomfort

21. Cont…
 Pain originating in the renal area radiates anteriorly
and downward toward the bladder in the female and
toward the testes in the male .
 Stones lodged in the ureter
 Colicky wavelike pain ,radiating down the high and
to the genitalia.
 Patient has desire to void ,but little urine is passed.

22. Cont…
 Colic is mediated by prostaglandin E (substanceColic is mediated by prostaglandin E (substance
increase ureteral contractility and renal blood flow,increase ureteral contractility and renal blood flow,
that’s lead to increased intraureteral pressure andthat’s lead to increased intraureteral pressure and
pain.pain.
 If the stone obstruct bladder neck ,urinary retentionIf the stone obstruct bladder neck ,urinary retention
occurs.occurs.

23. Investigations
 KUB X ray
 Urinalysis
 Blood urea
 Ultra sound
 Family history
 Dietary and medication
history
 24 hour urine sample
 IVP
 Serum Ca, Mg,
Phosphate, Uric acid, Cr

24. Medical management
 High fluid intake
 Bed rest
 Application of warmth to the site of pain
 Hot bath
 Dietary modification
 Restrict calcium in their diet
 Dietary restriction of protein and sodium

25. Management cont…
 Analgesics pethedine or voren I/M
 NSAIDs
 Antibiotics in case of infection
 Treating the underlying cause
 Thiazide diuretics

26. Cont…
 Potassium citrate is also used in kidney stone
prevention. This is available both as tablet and liquid
preparation. The medication increases urinary pH
(makes it more alkaline), as well as increases the
urinary citrate level, which helps reduce calcium
oxalate crystal aggregation.

27. Surgical management
 Lithotripsy: an instrument is used in which shock
waves are generated and focused on stone. These
waves crushed the stone and fragments then pass
spontaneously through urethra or some time a tube is
inserted into the ureter to keep it dilated.

28. Cont…
 Patient is observed for obstruction and infection
resulting from blockage of urinary tract stone
fragments.
 All urine is strained after the procedure , voided
gravel or sand is sent to the laboratory for chemical
analysis.

29. SHOCK WAVE LITHOTRIPSY
STONE FRAGMENTATIONSTONE FRAGMENTATION

30. Cont…
 Ureteroscopy:
 Visualizing the stone then destroying it .
 Stent may be inserted and left in place for 48
hours or more after the procedure to keep the
ureter patent.

31. Open operations
 Nephrolithotomy for renal calculi.
 Pyelolithotomy for stones in renal pelvis
 Uereterolitotomy for ureteric stones.
 Stents

33. Nursing process
 Assessment:
 Pain ,nausea/vomiting diarrhea ,abdominal distention
 S/S of UTI (chills,fever ,dysuria ,frquency and
hesitancy ,and obstruction (frequent urination,oliguria
or anuria)

34. Cont…Cont…
 Urine is inspected for blood and strained for
stone.

35. Managing potential complication
 Risk of infection, sepsis and obstruction of the
urinary tract.
 Patient is instructed to report decreased urine volume
and bloody or cloudy urine.
 Increased fluid intake
 Ambulation
 Report any sudden increase in pain
 V/S

36. Preventive strategies
 Drinking enough water to make 2 to 2.5 liters of urine per day.
 Drink two glasses of water at bedtime ,an additional glass at
each night time awakening to prevent urine from becoming too
concentrated during the night
 A diet low in protein, and sodium intake.
 Restriction of oxalate-rich foods and maintenance of an
adequate intake of dietary calcium. Avoidance of cola
beverages.
 Avoid activities that cause excessive sweating and
dehydration.

37. Patient care after Nephrostomy
 Assess for bleeding at nephrostomy site ,infection ,
inflamation,leakage of urine and skin irritation.
 Ensure unobstructed drainage of nephrostomy tube.
 Obstruction causes pain, trauma, pressure ,infection,
and stress on suture lines.
 Never clamp a nephrostomy tube ,which could cause
obstruction –pyelonephritis.
 Never irrigate a nephrostomy tube without specific
order.

38. Cont…
 Encourage fluid intake to promote natural flushing of
the kidney and nephrostomy tube.
 Using aseptic technique apply dry dressing at
nephrostomy site.
 Measure urine output separately if both kidneys have
a tube in place.

39. Urinary Bladder StoneUrinary Bladder Stone
 Bladder stones are hard buildups ofBladder stones are hard buildups of
minerals that form in the urinaryminerals that form in the urinary
bladder.bladder.

40. Types of urinary stonesTypes of urinary stones
 Urinary stones may be following typesUrinary stones may be following types
 Calcium oxalate monohydrateCalcium oxalate monohydrate
 Calcium oxalate dihydrateCalcium oxalate dihydrate
 Calcium phosphateCalcium phosphate
 Magnesium phosphateMagnesium phosphate
 Ammonium phosphateAmmonium phosphate

41. cotninuecotninue
 Ammonium magnesium phosphateAmmonium magnesium phosphate
(struvite)(struvite)
 Calcium hydroxyphosphateCalcium hydroxyphosphate
 Uric acid and its saltsUric acid and its salts
 CystineCystine

42.  CausesCauses
 Bladder stones are most often caused byBladder stones are most often caused by
another urinary system problem, such as:another urinary system problem, such as:
 Bladder diverticulumBladder diverticulum
 Enlarged prostateEnlarged prostate
 Neurogenic bladderNeurogenic bladder
 Urinary tract infectionUrinary tract infection

43. pathophysiologypathophysiology
 Almost all bladder stones occur inAlmost all bladder stones occur in
men. Bladder stones are much lessmen. Bladder stones are much less
common than kidney stones.common than kidney stones.
 Bladder stones may occur whenBladder stones may occur when
urine in the bladder is concentratedurine in the bladder is concentrated
and materials form crystals. Bladderand materials form crystals. Bladder
stones may also result from foreignstones may also result from foreign
objects in the bladder.objects in the bladder.

44.  SymptomsSymptoms
 Symptoms occur when the stoneSymptoms occur when the stone
irritates the lining of the bladder orirritates the lining of the bladder or
blocks the flow of urine from theblocks the flow of urine from the
bladder.bladder.
 Symptoms can include:Symptoms can include:
 Abdominal pain, pressureAbdominal pain, pressure
 Abnormally colored or dark-coloredAbnormally colored or dark-colored
urineurine

45. ContinuedContinued
 Blood in the urineBlood in the urine
 Difficulty urinatingDifficulty urinating
 Frequent urge to urinateFrequent urge to urinate
 Inability to urinate except in certainInability to urinate except in certain
positionspositions
 Interruption of the urine streamInterruption of the urine stream
 Pain, discomfort in the penisPain, discomfort in the penis

46. continuedcontinued
 Signs of urinary tract infectionSigns of urinary tract infection
(such as fever, pain when(such as fever, pain when
urinating, and need to urinateurinating, and need to urinate
often)often)
 Loss of urine control may alsoLoss of urine control may also
occur with bladder stones.occur with bladder stones.

47. Exams and TestsExams and Tests
 The health care provider will performThe health care provider will perform
a physical exam. This will alsoa physical exam. This will also
include a rectal exam. The examinclude a rectal exam. The exam
may reveal an enlarged prostate ormay reveal an enlarged prostate or
other problems.other problems.

48.  The following tests may be done:The following tests may be done:
 Bladder or pelvic x-rayBladder or pelvic x-ray
 CystoscopyCystoscopy
 UrinalysisUrinalysis
 Urine culture (clean catch)Urine culture (clean catch)

49. Treatment of urinary stonesTreatment of urinary stones
 You may be able to help small stones passYou may be able to help small stones pass
on their own by drinking 6 - 8 glasses ofon their own by drinking 6 - 8 glasses of
water or more per day to increasewater or more per day to increase
urination.urination.
 Your health care provider may removeYour health care provider may remove
stones that do not pass using a cystoscopestones that do not pass using a cystoscope
(a small telescope that passes through the(a small telescope that passes through the
urethra into the bladder).urethra into the bladder).
 Some stones may need to be removedSome stones may need to be removed
using open surgery.using open surgery.

50.  Drugs are rarely used to dissolve theDrugs are rarely used to dissolve the
stonesstones..
 Causes of bladder stones should beCauses of bladder stones should be
treated. Most commonly bladder stonestreated. Most commonly bladder stones
are seen with benign prostatic hyperplasiaare seen with benign prostatic hyperplasia
(BPH--enlarged prostate) or bladder outlet(BPH--enlarged prostate) or bladder outlet
obstruction.obstruction.
 For patients with BPH and bladder stones,For patients with BPH and bladder stones,
transurethral resection of the prostatetransurethral resection of the prostate
(TURP) can be performed with stone(TURP) can be performed with stone
removalremoval

51. Nusing interventionNusing intervention
•Encourage increased fluid intake and
•ambulation.
•Begin IV fluids if patient cannot take
•adequate oral fluids.
•Monitor total urine output and patterns
•of voiding.
•Encourage ambulation as a means of
•moving the stone through the urinary
•tract.
•Strain urine through gauze.

52. ContinuedContinued
•Instruct patient to report any increase in pain.
•Monitor vital signs for early indications
•of infection; infections should be treated with
•the appropriate antibiotic agent before efforts
are
• made to dissolve the stone.

53. Thank youThank you