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Unit 6 Adult Health Nursing
- 1. Unit VI- GENITOURINARY DISEASES Renal Calculi BY SEHRISH NAZ RN, Post RN, MSN Lecturer, Institute of Nursing Sciences, Khyber Medical University Subject: Adult Health Nursing 2/8/2020 Post RN semester one 1
- 2. OBJECTIVES At the end of the unit, students will be able to: •Utilize Functional health pattern to identify patients problems related to Renal Calculi. •Integrate patho-physiology and pharmacology concepts of Renal Calculi. •Apply nursing process with support on Evidence-Based Nursing (EBN) provid to the clients with Renal Calculi. •Discuss the holistic approach for nursing management of the patient with Renal Calculi. •Develop a teaching plan for a client experiencing disorders of the Renal Calculi.
- 4. ANATOMY OF THE KIDNEY • Bean shape organ • Length=12cm • Width=6cm • Thickness=3cm Cross section of the kidney shows • Cortex (the outer light area) • Medulla (the darker area inner to cortex) • Renal Pelvis (v-shaped area at the start of ureter)
- 6. PHYSIOLOGY OF THE KIDNEY “A WET BED” A- ACID-base balance. W- WATER balance. E- ELECTROLYTES balance. T- TOXIN removal. B- BIOOD PRESSURE control. E- ERYTHROPOIETIN. D- VITAMIN D metabolism.
- 8. INTRODUCTION A kidney stone (Renal Calculi, Nephrolithiasis ) is a hard solid mass of material that forms in the kidney from the substances in the urine. Stones may be formed in the kidney, urinary bladder, ureter and urethra The stone- forming chemicals are calcium, oxalate, urate, cystine, xanthine, and phosphate.
- 9. DEFINITION Akidney stone, also known as a renal calculus or nephrolith, is a solid piece of material which Is formed in the kidneys from minerals in urine
- 10. ETIOLOGY Exact cause is unknown High urine acidity. Increased urine alkalinity. Obstruction with urinary stasis UTI with urea – splitting bacteria ( proteus , klebsiella , pseudomonas.)
- 11. RISK FACTOR Imbalance of pHin urine o Alkalic: - Calcium stone o Acidic:- Uric acid & cystine stone Gout Hyperparathyroidism (The kidneys cannot make active vitamin D (needed to absorb calcium)) Immobility Sedentary life style Dehydration
- 12. CONT… Metabolic disturbances Family History of renal calculi Highmineral content in drinking water Dietary intake UTI Prolonged Indwelling Catheterization
- 13. TYPESOF KIDNEYSTONES There are mainly 5 types:- 1.Calcium oxalate stone 2. Calcium phosphate stone 3. Struvite stone (Triple stone) 4. Uric acid stone 5. Cystic stone
- 14. cont…. 1.Calcium oxalate stone :- (Is the most common 80% ) Caused by super -saturation of urine with calcium & oxalate Calcium oxalate stone tend to form in alkaline chemistry ( Avoid food high in oxalate (beer, wheat germ, spinach).
- 16. CONT.. 2. Calcium phosphate stone:- (5-10%):- Caused by super -saturation of urine with calcium phosphate. Calcium phosphate stone tend to form in alkaline chemistry (Avoid food high in calcium (Milk & dairy product)
- 18. CONT… 3.Struvitestone(Triplephosphate stone):- (magnesium, ammonium, phosphate) Caused by urea splitting bacteria (Proteus, Pseudomonas, Klebsiella, Staphylococcus) more common in women then the man because of UTI Struvite stone tend to form in alkaline chemistry Avoid lemonade.
- 20. CONT… 4. Cystine stones(10-15%):- Caused by cystine crystal formation. Cystine stone tend to form in Acidic urine (cystine source Avoid meat, milk ,cheese, Egg)
- 22. CONT… 5.Uricacidstone (5-10%):- Caused by excessive dietary purine or gout Uric acid stone tend to form in Acidic urine (Avoid purine sources eg. Meats, gravies, red wine)
- 25. CLINICALMANIFESTATION Severe pain in the side and back, below the ribs Pain that spreads to the lower abdomen andgroin Pain that comes in waves and fluctuates in intensity Pain on urination Cloudy or foul-smelling urine Nausea and vomiting Fever and chills if an infection is present Urinating small amounts of urine
- 26. DIAGNOSTIC EVALUATION Blood Urine-analysis Cystoscopy X-ray CTscan, MRI Intravenous urogram (IVU) or intravenous pyelogram USG KUB
- 27. CYSTOSCOPY
- 29. ULTRASOUND
- 30. MEDICAL MANAGEMENT Analgesic Spasmodic e.g. Buscopan NSAIDse.g. Brufen or ponstan forte Maintain I/O charting Provide rest
- 31. SURGICALMANAGEMENT Closeprocedure:- Lithotripsy (Extracorporeal Shockwave lithotripsy (ESWL)- Noninvasive Percutaneous Nephrolithotomy
- 35. OPENPROCEDURE Ureterolithotomy Pyelolithotomy Nephrolithotomy Partial or total nephrectomy
- 37. NURSING DIAGNOSIS 1. Acute pain related to irritation and spasm from stone movement in the urinary tract as manifested by complaints of pain, facial grimacing, restlessness. Goal:- Toreduce pain.
- 38. CONT… • Intervention:- o Determine and note location, duration, intensity (0–10 scale), and radiation. o Document nonverbal signs such as elevated BP and pulse, restlessness. o Implement comfort measures (back rub, restful environment). o Encourage use of focused breathing, guided imagery, diversional activities. o Apply warm compresses to back. o Check and sustain patency of catheters when used.
- 39. CONT… 2. Anxiety related to uncertain outcome and lack of knowledge regarding possible surgery as manifested by expressions. Goal:- Toreduce anxiety. Intervention:- oProvide calm environment. oExplain every procedure to the pt. oKeep family members informed of the disease process.
- 40. CONT… 3. Impaired urinary elimination related to trauma or blockage of ureters or urethra as manifested by decreased urinary output and bloody urine. Goal:- Toincrease the urine out put.
- 41. CONT… Intervention • Determine patient’s normal voiding pattern and note variations. • Record I&O and characteristics of urine. • Promote sufficient intake of fluids. • Encourage the patient to walk if possible. • Irrigate with acid or alkaline solutions as indicated. • Check laboratory studies (electrolytes, BUN, Cr). • Obtain urine for culture and sensitivities.
- 42. NURSING DIAGNOSIS 5. Acute pain r/t obstructing urinary Calculus. 6. Altered urinaryelimination related Topresence of urinary calculi 7. Riskforinfection r/t obstructing Urinary calculus. 8.Altered renal peripheral tissue Perfusionr/t post renal Obstruction
- 43. Patientteaching Avoid protein intake;- Usually protein is restricted to 60g/day to decrease urinary excretion of calcium and uric acid. A sodium intake of 3 to 4 g/day is recommended. Table salt and high-sodium foods should be reduced, because sodium competes with calcium for reabsorption in the kidneys. Low-calcium diets are not generally recommended ,except for true absorptive hypercalciuria. Evidence shows that limiting calcium, especially in women, can lead to osteoporosis and does not prevent renal stones.
- 44. CONT.. Avoid intake of oxalate-containing foods (e.g. spinach, strawberries, tea, peanuts, wheat bran). Duringtheday,drink fluids (ideally water)everyday1 to 2 hours. Drinktwoglassesof water at bedtime and an additional glass at each night time awakening to prevent urine from becoming too concentrated during the night
- 45. CONT.. Avoidactivities leading to sudden increases in environmental temperatures that may cause excessive sweating and dehydration. Contactyourprimary health care provider at the first sign of a urinary tract infection.
- 46. BIBLIOGRAPHY Brunner and Suddarth's text book of medical –surgical nursing twelfth edition .Page no. 1295. Lewis’s medical –surgical nursing , assessment and management of clinical problems , second edition . Page no. 1131.
- 47. THANK YOU SO MUCH FOR YOUR ATTENTION
Editor's Notes
- The liver and kidneys convert vitamin D (produced in the skin and taken up in the diet), into the active hormone, which is called calcitriol. Active vitamin D helps to increase the amount of calcium the gut can absorb from eaten food into the bloodstream and also prevents calcium loss from the kidneys.
- Secondary hyperparathyroidism occurs when the parathyroid glands become enlarged and release too much PTH, causing a high blood level of PTH. There are several reasons why this happens in patients with kidney disease: Higher blood phosphorus levels. The kidneys cannot make active vitamin D (needed to absorb calcium)
- Oxalate is a naturally occurring molecule found in abundance in plants and humans. It's not a required nutrient for people, and too much can lead to kidney stones. In plants, oxalate helps to get rid of extra calcium by binding with it. That is why so many high-oxalate foods are from plants.
- Upper urinary tract stones that involve the renal pelvis and extend into at least 2 calyces are classified as staghorn calculi [1] (see image below). Although all types of urinary stones can potentially form staghorn calculi, approximately 75% are composed of a struvite-carbonate-apatite matrix. Struvite is magnesium ammonium phosphate; a Swedish geologist named Ulex discovered the substance in bat droppings and named it after his friend and mentor, the 19th-century Russian diplomat and naturalist Baron von Struve. [2] Diet may not be effective at preventing struvite stones because they're caused by infections. But certain fluids may make the environment in your urinary tract more inhospitable to stone growth. These include: lemonade.
- Cystine stones are a type of kidney stone made from a chemical called cystine. This chemical is often a product of a condition called cystinuria. A large part of treatment is to prevent the cystine stones from forming. This is often done through diet changes and increases the amount of water you drink.
- Purines are a natural substance found in some foods. ... When your body digests purine, it produces a waste product called uric acid. A buildup of uric acid crystals in the joints can cause certain health issues. The main ones are kidney stones and a type of arthritis known as gout. Xanthine is a purine base found in most body tissues and fluids, certain plants, and some urinary calculi. It is an intermediate in the degradation of adenosine monophosphate to uric acid, being formed by oxidation of hypoxanthine.
- Nucleation is the first step in the formation of either a new thermodynamic phase or a new structure via self-assembly or self-organization. Nucleation is typically defined to be the process that determines how long an observer has to wait before the new phase or self-organized structure appears.
- Urine analysis Haematuria and pyuria pH lesser 5.5 indicates uric acid stone pH greater 7.5 indicates struvite stone urine culture and drug sensitivity should done to detect infection. 24-hour urine test for measurement of calcium, uric acid, creatinine, sodium, citrate and oxalate. Blood studies Hyperuracemia Hypercalcemia Neutrophilia Elevated serum parathyroid hormone Stone chemistry Collection of stone through a strainer is useful. Analyze the stone chemically to find out the composition which helps in therapeutic management.
- The introduction of extracorporeal shock wave lithotripsy (ESWL) in the early 1980s revolutionized the treatment of patients with kidney stone disease. ... ESWL involves the administration of a series of shock waves generated by a machine called a lithotripter.
- Lithotripsy uses sound waves to break up large kidney stones into smaller pieces. These sound waves are also called high-energy shock waves
- Percutaneous nephrolithotomy is a minimally-invasive procedure to remove stones from the kidney by a small puncture wound through the skin. It is most suitable to remove stones of more than 2 cm in size and which are present near the pelvic region. It is usually done under general anesthesia or spinal anesthesia.