Renal calculi, types of stones, signs and symptoms, management

1. RENAL CALCULI
Mr. Mahesh Chand
Nursing Tutor

2. RENAL SYSTEM

3. 1. Renal pyramid
2. Interlobular artery
3. Renal artery
4. Renal vein
5. Renal hylum
6. Renal pelvis
7. Ureter
8. Minor calyx
9. Renal capsule
10. Inferior extremity
11. Superiorextremity
12. Interlobular vein
13. Nephron
14. Renal sinus
15. Major calyx
16. Renal papilla
17. Renal column

4. DEFINITION

5. RENAL CALCULI
Nephrolithiasis refers to stones (calculi)
in kidney when urinary concentration of
substances such as calcium oxalate,
calcium phosphate and uric acid
increases, but they can form in or
migrate to the lower urinary system.
They are typically asymptomatic until
they pass into the lower urinary tract.

6. ETIOLOGY ANDRISK
FACTORS

7. SEDENTARY LIFE STYLE
INCREASES STASIS

8. DEHYDRATION
LEADSTO SUPERSATURATION

9. METABOLIC DISTURBANCES
INCREASE IN
CALCIUM OROTHER
IONS IN THEURINE.
HYPERCALCEMIA
AND
HYPERCALCIURIA

10. HIGH MINERAL CONTENT IN
DRINKING WATER.

11. DIET HIGH IN PURINES, OXALATES,
CALCIUM SUPPLEMENTS, ANIMAL
PROTEINS

12. URINARYTRACT
INFECTIONS
PROLONGED
INDWELLING
CATHETERIZATION

13. DRUGS
OR
MEDICINES.
NEUROGENIC
BLADDER.

14. PATHOPHYSOLOGY

15. RENALCALCULI
1.
• SLOW URINE FLOW, RESULTING IN SUPER
SATURATIONOFTHEURINEWITH INCREASED
SOLUTES (ELEMENTTHAT FIRST BECOME
CRYSTALLIZEDAND LATER BECOMESTONE).
2.
• DAMAGETOTHE LININGOFTHEURINARYTRACT.
3.
• DECREASED INHIBITOR SUBSTANCES (CITRATE,
PYROPHOSPHATEAND MAGNESIUM) INTHEURINE
THATWOULD OTHERWISE PREVENT SUPER
SATURATIONAND CRYSTALLINEAGGREGATION.

16. TYPES OFSTONES

17. CALCIUM
OXALATE
STRUVITE
URICACID
CYSTINE
XANTHINE

18. 1. CALCIUM
 Composed of calcium
phosphate or calcium
oxalate may range
from sand or gravel to
giant stag horn calculi,
which may fill entire
renal pelvis and extend
up into the calyces.

19. HYPERCALCIURIA IS CAUSED BY-
High rate of
bone
reabsorption.
Abnormal gut
absorption of
largeamounts
of calcium.
Impaired renal
tubular
absorption of
filtered
calcium, as in
renal tubular
acidosis.
Structural
abnormalities,
such as
“sponge
kidney”

20. 2. OXALATE
Hyper absorption of oxalate, with inflammatory
bowel disease.

21. 3.STRUVITE
Also called triple phosphate, caused by certain
bacteria usually proteus which increases pH.
Difficult to eliminate because the hard stone
forms around a nucleus of bacteria, protecting
them from antibiotic therapy.

22. 4. URIC ACID
Hyperuricuria is the result of either
increased uric acid production or the
administration of uricosuric agents.
People with secondary gout and a
high dietary intake food rich in purine
can lead to uric acid stone formation.

23. 5. CYSTINE
Cystinuria is the result of
congenital metabolic
error inherited as an
autosomal recessive
disorder.

24. 6. XANTHINE
Occurs as a result of a rare
hereditary condition in
which there is a xanthine
oxidase deficiency.This
crystal precipitates readily in
acid urine.

26. CLINICAL MANIFESTATIONS

27. PAIN Pain originating in
the renal area
radiates anteriorly
and downward
toward the bladder
in the female and
toward the testes
in the male.
STONE IN RENAL PELVIS MAY BE ASSOCIATED
WITH AN INTENSE, DEEP ACHE INTHE
COSTOVERTEBRAL REGION.

28. CONT.
Nausea
and
vomiting .
Haemat-
uria,
pyuria.
Diarrhoea
and
abdominal
discomfort
.

29. DIAGNOSTIC TESTS

30. DIETARYAND MEDICATION HISTORYAND
FAMILYHISTORYOF RENALSTONES
COMPUTEDTOMOGRAPHY (CT)SCAN
INTRAVENOUSORRETROGRADE
PYELOGRAM
RENALULTRASONOGRAPHY
24 HOUR URINE SPECIMEN
URINE CULTUREANDCULTURE

31. MEDICAL MANAGEMENT

32. 1.INCREASE FLUIDS
Tofacilitate passage of small stones and to
prevent development of new ones.
Toincrease fluids to 3 to 4 L daily to ensure
urine output of 2.5 to 3L daily, decreases
the concentration of solutes and alleviates
urinary stasis.

33. 2. REDUCE PAIN
Opioids and antispasmodic agents.
NSAIDS (Non steroidal anti-inflammatory drugs).
Morphine sulphate , I/V or I/M to control moderate
to severe pain.
For nausea and vomiting associated with colic,
antiemetic are given.

34. 3. PREVENT STONE RECURRENCE
Diet modifications
and medications.
Increased fluid
intake.

35. 4. IMPLEMENT DIETARY CHANGES
Increasing dietary intake of
calcium-rich foods. A high-
protein diet increases urinary
calcium, oxalate and uric acid
secretion and increases
probability of stone formation.

36. Cont.
Clients with oxalate stones should
avoid high oxalate foods, such as
tea, tomatoes, instant coffee, cola
drinks, green beans, spinach,
cabbage, chocolate, citrus fruits,
apples, grapes, peanuts and vitamin
C as it increases oxalate excretion in
the urine and should be avoided.

37. Cont.
For uric acid
stones,
should follow
a low-purine
diet wine,
bony fish and
organ meats.

38. 5. ADMINISTER MEDICATIONS
For calcium stones, a thiazide diuretic such
as hydrochlorothiazide promotes calcium
reabsorption from the renal tubules,
prevents excess calcium loads in the urine.
For calcium oxalate stones, vitamin B6
(pyridoxine), magnesium oxide, or
cholestyramine is given.

39. Cont.
For hyperuricosuria and calcium oxalate
stones, allopurinol is given only if a
reduced reduced purine diet fails and
stones persist.
Sodium bicarbonate or citrate may be
indicated to increase urine pH because
uric acid and xanthine stones form in
acidic urine.

40. Cont.
Cystine are treated with tiopronin
(Thiola) and d-penicillamine, make
cysteine more soluble for excretion.
Long term antibiotics are used to
control infection that leads to
struvite stone formation.

41. NURSING MANAGEMENT OFTHE
MEDICALCLIENT

42. ASSESSMENT
Family history of calculi, previous
UTIs, immobility, and dietary habits.
Assess the amount, pattern and
types of fluids consumed.
Assess pain score level.
Vital signs.

43. Cont.
Decreased blood pressure may indicate severe
pain and impending shock, increased pulse rate
and temperature may result from infection.
Little or no urine output suggests obstruction,
must be treated immediately to preserve kidney
functions.
Frequency and dysuria commonly occur when a
stone reaches the bladder.
Urine analysis, urine culture, and sensitivity
testing, and a 24 hour urine specimen.

44. NURSING DIAGNOSIS
1.Acute pain related to irritation and spasm
from stone movement in the urinary tract.
• Analgesics, antispasmodics and antiemetic.
• Comfortable position.
• Relaxation technique
2.Effective therapeutic regimen management
related to prevention of recurrent calculi.
• Increase fluids
• Diet modifications

45. SURGICAL MANAGEMENTOFCLIENTWITH
RENALCALCULI

46. ENDOUROLOGIC PRECEDURES
small stones may be removed transurethrally
with a urethroscope, cystoscope, or
ureterorenoscope.
• One or two ureteral catheters or stents inserted past
the stone.
• Continuous chemical irrigation to dissolve uric acid,
struvite and cysteine stones is done.
• Special catheter is used to dislodge the stone.
larger stone may be crushed with an instrument
called lithotrite.

47. Cystoscopic lithotripsy, an
ultrasonic lithotrite probe is used
to pulverize the stone, followed
by extensive flushing of the
bladder.
Uretroscopy, used to retrieve 4 to 5
mm stones or combined with
ultrasonic lithotripsy to remove
fragments after treatment. In this a
flexible uretroscope, passed through
a cystoscope, to collect stones in the
ureter.

48. Ureterorenoscope passed for
assess to the entire upper
urinary tract, including the
distal ureter and intrarenal
collecting system.
Nephroscope inserted to
retrieve free lying renal
stones, stone may be removed
with alligator forceps followed
by irrigation.

49. LITHOTRIPSY
Laser Lithotripsy-
lasers are used
together with a
ureteroscope to
remove or loosen
impacted stones
with water
irrigation.

50. ESWL Extracorporeal shock wave
lithotripsy (ESWL)-Non-
invasive therapy in which
sound wave applied
externally to break up
stones in the kidney or
ureter. High energy shock
waves, are transmitted to
the stone.This procedure
lasts 30 to 50 minutes with
administration of 500 to
1500 shock waves.

51. Percutaneous
lithotripsy-Involves the
insertion of a guide
percutaneously under
fluoroscopy near the
area of stone. An
ultrasonic wave is
aimed at the stone to
break it into fragments.

52. Partial or total nephrectomy
It is done in extensive kidney damage, renal
infection, or abnormal renal parenchyma
which is responsible for stone formation.

53. OPEN SURGICAL PROCEDURES
k
URETEROLITHOTOMY,
removal of a stone from
the ureter through a flan
incision for higher stones
or an abdominal incision
is made and ureteral
catheter are usually placed postoperatively for
healing and drainage of urine.

54. NURSING MANAGEMENT OF SURGICAL
CLIENT
INCREASE FLUIDS
MONITOR INTAKEOUTPUT
HEALTHPROMOTION ACTIVITIESAND RANGE OFMOTION
POSTOPERATIVELY.
PREVENTCOMPLICATIONS-HAEMORRHAGE, URINARY
RETENTION, INFECTION, BLADDER PERFORATION, INCREASED
WBC, AND RISE INTEMPERATURE.