Group 3 presented on nephrolithiasis, urolithiasis, and hydronephrosis. The presentation discussed the conditions, including that nephrolithiasis involves stone formation in the kidney. Diagnostic tests including IV pyelogram, retrograde pyelogram, x-rays, and urine tests were covered. Potential complications from the conditions include UTI, hydronephrosis, stone recurrence, and kidney damage. Nursing interventions focus on relieving pain, increasing fluid intake, educating the patient, and monitoring for complications.

1. Case Presentation:Group 3Group 3:This is the Beginning…Nephrolithiasis

2. Urolithiasis

3. HydronephrosisSubmitted by:Group 3BSN III-WatsonSubmitted to:Miss ShenellDelfin, RNNCM 102 Lecturer

4. Feed Your Mind…Presentation SkillsCase Presentation:NephrolithiasisUrolithiasisIntroduction of the Diseaseis the condition where urinary calculi are formed in the kidney

5. 13% in men and 7% in women, increasing in industrialized worldFeed Your Mind…Presentation SkillsCase Presentation:UrolithiasisUrolithiasisIntroduction of the Diseaseis the condition where urinary calculi are formed in any part of the urinary tract.

6. Obstruction of the ureter by the kidney stones causes a renal colic attack which is why intense pain is felt in groin and back.Don’t Be Confused…Presentation SkillsCase Presentation:Urolithiasis/NephrolithiasisUrolithiasis/NephrolithiasisThou Shalt Not Be ConfusedThe term kidney stone (or "renal calculus") is sometimes used to refer to urolithiasis in any part of the urinary tract, however it is more properly reserved for stones that are actually in the collecting duct of the kidney itself.Case Presentation:Urolithiasis/NephrolithiasisUrolithiasis/Nephrolithiasis

7. Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisDetermining EtiologyKey points:Key points:Stone Formation

8. Kidney stones form when there is a decrease in urine volume and/or an excess of stone-forming substances in the urine. The most common type of kidney stone contains calcium in combination with either oxalate or phosphate. Other chemical compounds that can form stones in the urinary tract include uric acid and the amino acid cystine.

9. ↓ Urine Volume

10. Excess of stone forming substance

11. Ca with either Oxalate or Phosphate

12. Others: uric acid and cystine (amino acid)Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisDetermining EtiologyKey points:Key points:Dehydration or Inadequate fluid intake

13. Dehydration from reduced fluid intake or strenuous exercise without adequate fluid replacement increases the risk of kidney stones. Obstruction to the flow of urine or prolonging despite the urge to urinate can also lead to stone formation. Kidney stones can also result from infection in the urinary tract; these are known as struvite or infection stones.

14. Obstruction or Prolongation

15. Infection

16. StruviteCase Presentation:Nephro/UrolithiasisNephro/UrolithiasisDetermining EtiologyKey points:Key points:A number of different medical conditions can lead to an increased risk for developing kidney stones:» Loading…» » Loading…» » » Loading…» » » » Loading…» » » » » Loading…

17. Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisDetermining EtiologyKey points:Key points:Gout

18. Hypercalciuria

19. Hyperparathyroidism

20. Gout – results in an increased amount of uric acid in the urine and can lead to the formation of uric acid stones.

21. Renal tubular acidosis

22. Metabolic Conditions

23. Chronic Diseases

24. Intestinal Surgery or Inflammatory Bowel Disease

25. Some MedicationsCase Presentation:Nephro/UrolithiasisNephro/UrolithiasisDetermining EtiologyKey points:Key points:Gout

26. Hypercalciuria

27. Hypercalciuria (high calcium in the urine), another inherited condition, causes stones in more than half of cases. In this condition, too much calcium is absorbed from food and excreted into the urine, where it may form calcium phosphate or calcium oxalate stones.

28. Hyperparathyroidism

29. Renal tubular acidosis

30. Metabolic Conditions

31. Chronic Diseases

32. Intestinal Surgery or Inflammatory Bowel Disease

33. Some MedicationsCase Presentation:Nephro/UrolithiasisNephro/UrolithiasisDetermining EtiologyKey points:Key points:Gout

34. Hypercalciuria

35. Conditions associated with an increased risk of kidney stones include hyperparathyroidism, kidney diseases such as renal tubular acidosis, and some inherited metabolic conditions including cystinuria and hyperoxaluria. Chronic diseases such as diabetes and HPN are also assoc. with an increased risk of developing kidney stones.

36. Hyperparathyroidism

37. Renal tubular acidosis

38. Metabolic Conditions

39. Chronic Diseases

40. Intestinal Surgery or Inflammatory Bowel Disease

41. Some MedicationsCase Presentation:Nephro/UrolithiasisNephro/UrolithiasisDetermining EtiologyKey points:Key points:Gout

42. Hypercalciuria

43. Hyperparathyroidism

44. People with inflammatory bowel disease or who have had an intestinal bypass or ostomy surgery are also more likely to develop kidney stones.

45. Renal tubular acidosis

46. Metabolic Conditions

47. Chronic Diseases

48. Intestinal Surgery or Inflammatory Bowel Disease

49. Some MedicationsCase Presentation:Nephro/UrolithiasisNephro/UrolithiasisDetermining EtiologyKey points:Key points:Gout

50. Hypercalciuria

51. Some medications also raise the risk of kidney stones. These medications include some diuretics, calcium-containing antacids, and the protease inhibitor indinavir (Crixivan), a drug used to treat HIV infection

52. Hyperparathyroidism

53. Renal tubular acidosis

54. Metabolic Conditions

55. Chronic Diseases

56. Intestinal Surgery or Inflammatory Bowel Disease

57. Some MedicationsRelease of Chemical Mediators (prostaglandin)Nerves becomes irritated thus eliciting (pain)Modifiable FactorScarring/ InflammationTypes of CalculiSevere painIrritation of smooth musclesDietCalciumUTI, Prolonged indwelling catheterAnxietyNausea/ VomitingInflammatory ProcessStruvite↑ PulseLifestyle sedentary lifestyle increase stasis↓ Intestinal motilityRenalColic PainUretralcolicVisceral painUric acid↑BP↑ Resp. RateParalytic ileusDiaphoresisUrinary Stasis and SupersaturationFormation of kidney stonesObstructed Kidneys↑ Fluid Volume↑ Blood volume↑ Blood PressureNon modifiable FactorHydronephrosisSex (Male)Frequency of urination↓ Urine CapacityXanthineAge (30 and 50 have three times risk of calculi)HydroureterStones in the UretersCystineCompromised bladder sizeUretral ColicOxalateStones in the BladderStones scar the bladderHematuria Living in stone-belt areaFamily of urolithiasis –excessive production of the mucoproteinPressure against the bladder neckHeavy feeling during micturation (voiding)Stones in the urethraObstructionDifficulty of urinatingHereditary (oxalate; oxaluria, Xanthine, Cystine)Pain upon urinating especially for menScarringPainCase Presentation:Nephro/UrolithiasisNephro/UrolithiasisTracing its Pathophysiology

58. Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisThe Assessment…Nausea and VomitingAbdominal or Flank PainRenal Colic Radiating to the groinUretral colic –pain that radiates towards the genetalia and thighCold Moist SkinHematuria

59. Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisThe Diagnostics…IV Pyelogram: Procedure An injection of x-ray contrast media is given to a patient via a needle or cannula into the vein, typically in the arm. The contrast is excreted or removed from the bloodstream via the kidneys, and the contrast media becomes visible on x-rays almost immediately after injection.

60. Is a radiological procedure used to visualize abnormalities of the urinary system, including the kidneys, ureters, and bladder.IV Pyelogram: Diagnosing X-rays are taken at specific time intervals to capture the contrast as it travels through the different parts of the urinary system. This gives a comprehensive view of the patient's anatomy and some information on the functioning of the renal system.

61. used to identify non-radio opaque stones.IV Pyelogram

62. Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisThe Diagnostics…

63. Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisThe Diagnostics…Retrograde Pyelogram: Procedure Injection of a contrast into the ureter in order to visualize the ureter and kidney. The flow of contrast (up from the bladder to the kidney) is opposite the usual flow of urine, hence the retrograde name.

64. The procedure requires cystoscopy and the placement of a small tube into the lower part of the ureter to inject contrast and opacify the ureter and renal pelvis. Fluoroscopy, or dynamic X-Rays, is typically used for visualization. The procedure is usually done under general or regional anesthesia.Retrograde Pyelogram: Diagnosing It is generally done when an intravenous excretory study (IVP or contrast CT scan) cannot be done because of renal disease or allergy to intravenous contrast.

65. Retrograde Pyelogram is performed to identify filling defects from obstructions such as stones or tumors). At the same time narrow parts can be widened, stones taken out, pieces of the lining taken out, and diseased parts burnt out as needed.Retrograde Pyelogram

66. Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisThe Diagnostics…

67. Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisThe Diagnostics…X-ray and UTZStone AnalysisCBC and UrinalysisX-rays of the kidneys, ureters, and bladder (KUB) and ultrasonography – to locate the stone(s) and determine the size and quantity.

68. Stone analysis – freely passed stones or removed thru special procedures are recovered and chemical analysis is carried out to determine their composition.

69. provides a clear indication of underlying disorder (e.g. uric acid metabolism disturbances and calcium metabolism disorders)

70. 24 hr urine test- to measure calcium, uric acid, creatinine, normal pH and total volumeLet’s Make it SimpleLte’s Make it Simple

71. Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisNursing Care and Management for Diagnostic ProceduresClearance Tests such as urinalysis and blood studiesExplain to the patient that these tests assess kidney function.

72. For the creatinine clearance test, tell the patient that he need not to restrict fluids but should not eat too much meat before the test, and should avoid strenuous exercise during the collection period.

73. For the urea clearance test, instruct him to fast from midnight before the test and to avoid exercising before and after the test.

74. Tell the patient how the urine will be collected; who will perform the testCase Presentation:Nephro/UrolithiasisNephro/UrolithiasisNursing Care and Management for Diagnostic ProceduresRadiologic Studies (tests involving contrasts media)Ensure adequate fluid intake for a patient with a suspected urinary tract lesion (unless the doctor orders otherwise)

75. Keep emergency resuscitation equipment readily available in case the patient has an anaphylactic reaction to the contrast medium. Closely observe him for adverse reactions during and after the test.

76. MIO after any invasive test. Notify the doctor if the patient can’t void or if hematuria persists after the third voiding.

77. Watch for signs of urinary sepsis (such as fever, chills, or hypotension) after any invasive test involving the urinary system.Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisThe Complications…UTIHydronephrosisRecurrence of StoneObstruction of the Ureter, Acute UnilateralObstructive Urophaty↓ or loss of function of kidneyKidney damage, scarring

78. Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisNursing DiagnosisAcute PainRelating Factors: Inflammation, obstruction and abrasion of the urinary tract.Impaired Urinary Elimination Related Factors: Mechanical Obstruction, Inflammation and Stimulation of the Bladder by Calculi, Renal or Ureteral IrritationRisk For Fluid Volume DeficientRelating Factors: Nausea and Vomiting (generalized pelvic nerve irritation) and Post-Obstructive Distress

79. Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisInterventionsGoal:Eradicate the stone

80. Determine the stone type

81. Prevent nephron destruction

82. Control infection

83. Relieve any obstruction that may be presentImmediate objective of treatment:Relieve pain from renal or urethral colic until its cause can be eliminatedHot Baths or Hot Sitz BathAdminister NSAIDsOpioid AnalgesicsNutritional Therapy↑Fluid IntakeCase Presentation:Nephro/UrolithiasisNephro/UrolithiasisInterventions: Medicalprovides specific pain relief from renal stone pain

84. 3,000 to 4,000cc daily with regular bowel emptying

85. inhibits the synthesis of prostaglandin E, reducing swelling and facilitating passage of the stone.

86. ↑hydrostatic pressure behind the stone, assisting downward passage

87. Contraindicated to some patients

88. to prevent shock and syncope that may result from excruciating pain.

89. May be found to be useful

90. Includes diet modifications to prevent stone reformationsCase Presentation:Nephro/UrolithiasisNephro/UrolithiasisInterventions: MedicalInterventional Procedures:Interventional Procedures:Extracorporeal Shock Wave Lithotripsy (ESWL)Non invasive procedure used to break up stones in the calyx of the kidney and fragmented to the size of grains of sands. Stone remnants are spontaneously voided.

91. A high energy amplitude of pressure, or shockwave is generated by the abrupt release of energy and transmitted thru H2O and soft tissues.

92. Substances of different intensity ( a renal stone) are eventually fragmented.

93. Discomfort may occur, although the shock waves usually do not cause damage to other tissuesCase Presentation:Nephro/UrolithiasisNephro/UrolithiasisInterventions: MedicalInterventional Procedures:Interventional Procedures:Uteroscopy– insert, visualize and destroy…insertion of a uteroscope into the ureter and then inserting a laser (electrohydrauliclithotriptor) or ultrasound device thru the uteroscope to fragment and remove the stones.

94. a stent may be inserted and left in place for at least 48 hours after the procedure to keep the ureter patent.Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisInterventions: MedicalInterventional Procedures:Interventional Procedures:Endourologic stone removal methodsprocedures that may be used to extract renal calculi that cannot be removed by other procedures.

95. includes:Percutaneousnephrostomy /PercutaneousnephrolithotomyElectrohydraulic lithotripsyChemolysis

96. Presentation SkillsCase Presentation:Nephro/UrolithiasisNephro/UrolithiasisInterventions: MedicalInterventional Procedures:Interventional Procedures:Electrohydraulic lithotripsy

97. Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisInterventions: SurgicalSurgical intervention is indicated if the stones does not respond to other forms of treatment

98. May be performed to correct anatomic abnormalities within the kidney to improve urinary drainage

99. Surgical interventions includes:

100. Nephrolithotomy

101. Nephrectomy

102. Pyelolithotomy

103. Ureterolithotomy

104. CystotomyCase Presentation:Nephro/UrolithiasisNephro/UrolithiasisInterventions: NursingAdminister opioid analgesics (IV or IM) as ordered along with IV NSAID

105. Assume position of comfort

106. Assist to ambulate( if activity brings pain relief)Relieve PainRelieve PainRelieve PainClosely monitoring pain level; promptly report to physician if pain has increased in severity

107. Splinting of incision site (after surgery)Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisInterventions: NursingAssess patient knowledge of disease

108. Encourage to follow a regimen to avoid further stone formation( e.g. diet modification, fluid intake of 3000- 4000 ml in 24 hrs active lifestyle)

109. Educate on signs and symptoms that indicate stone formation or complication ( fever, decrease urine output, pain, hematuria.Relieve PainRelieve PainTeaching Self-care

110. Case Presentation:Nephro/UrolithiasisNephro/UrolithiasisInterventions: NursingIncrease fluid intake & monitor total urine output and patterns of voiding

111. Encourage Ambulation

112. Strain urine thru gauze; inspecting sides of urinals and bed pan for clinging stones; crush blood clots passed in the urineMonitor and Manage ComplicationsInstruct patients to report decrease urine volume and bloody or cloudy urine

113. Monitoring vital signs including temperature

114. Administer antibiotics as orderedA Case Presentation on Renal SystemHydronephrosisIntroduction of the DiseaseThe dilation of the renal pelvis and calyces.

115. May be considered a physiologic response to the interruption of urine.

116. Not always caused by obstruction.Group 3Group 3Group 3NCM-102

117. A Case Presentation on Renal SystemHydronephrosisIntroduction of the DiseaseNormalDilatedGroup 3Group 3Group 3NCM-102

118. A Case Presentation on Renal SystemHydronephrosisDetermining Etiology…Almost any type of obstructive of obstructive urophaty. Most common: Benign Prostatic Hyperplasia, Urethral Strictures, Calculi Less common: Strictures or stenosis of the ureter or bladder, Congenital Abnormalities, Abdominal TumorsBiilateralHydronephrosis: caused by the obstruction in the ureter or bladder

119. Unilateral Hydronephrosis: if the obstruction is in the ureter

120. Distal Bladder Obstructions cause the bladder to dilate and act as buffer zone, delaying hydronephrosisGroup 3Group 3Group 3NCM-102

121. A Case Presentation on Renal SystemHydronephrosisTracing its PathophysiologySustained or intermittent pressureIrreversible nephron destructionPrecipitating:Calculus

122. Tumor

123. Scar Formation

124. Kink in the UreterDilation of structure behind obstructionUrine backflowNormal urine flow obstructionDilation of kidney pelvisPredisposing:Heridity

125. Age

126. SexPressure on kidney structuresStasis of urineAccumulation of urineLow-Moderate pressureInfection in the calculiInfection in the calculiPressure on renal arteriesKidney may dilate slowlyPressure on the renal pelvis wallIschemiaNo obvious loss of functionTUBULAR DAMAGEGroup 3Group 3Group 3NCM-102

127. A Case Presentation on Renal SystemHydronephrosisThe Assessment… Flank Pain

128. Distended bladder and kidneys are tender upon palpation

129. Nausea and Vomiting

130. Fever (may be due to UTI)

131. Dysuria

132. ↑ urinary frequency

133. ↑ urinary urgencyGroup 3Group 3Group 3NCM-102

134. A Case Presentation on Renal SystemHydronephrosisThe Diagnostics…Excretory Urography, Retrograde Pyelography, Renal UTZ, and Renal Function Studies will confirm the diagnosis

135. Visualizations tests, such as Retrograde Pyelogram or Renal Ultrasound, show concave (early stage) or convex (later stage) calyces as dilation progresses.

136. Urinalysis: inability to concentrate urine, proteinuria, possibly, pyuria (if presence of infection) or hematuria

137. Extensive Disease: atrophied proximal and distal tubles and obstructionGroup 3Group 3Group 3NCM-102

138. A Case Presentation on Renal SystemHydronephrosisThe Complications…Complete Cortical Atrophy and cessation of glomerular filtration

139. Pyelonephritis - most common and life threatening; caused by urinary stasis that exacerbates renal damageParalytic Ileus- results from acute obstructive uropathyRenal Failure (Acute, Chronic)- life threatening, from Acute Bilateral HydronephrosisGroup 3Group 3Group 3NCM-102

140. A Case Presentation on Renal SystemHydronephrosisNursing DiagnosisAcute Pain Relatted to Urinary Stasis

141. Impaired Urinary Elimination Related to Urinary Tract obstruction

142. Risk for Infection Related to Urinary StasisGroup 3Group 3Group 3NCM-102

143. A Case Presentation on Renal SystemHydronephrosisInterventions: MedicalNarcotics such as morphine and meperidine and anti spasmodic drugs such as propantheline bromide and belladonna preparations are usually necessary to relieve severe colicky pain. As soon as nausea subsides large amounts of fluids are urged.

144. Patients who have only one kidney, who have immune-compromising disorders such as diabetes or HIV, or who have received a transplant should be treated promptly.

145. Affected Renal Function: Low Na, Protein, and K -Designed to stop progression to Renal Failure before surgeryGroup 3Group 3Group 3NCM-102

146. A Case Presentation on Renal SystemHydronephrosisInterventions: SurgicalA urinary obstruction can cause acute pain or potentially serious problems if the urine is backing up into the kidneys. In these cases, the patient may need immediate relief. Depending on the location of the obstruction, these short-term treatments can include:

147. A catheter (small tube) inserted through the urethra into the bladder to drain urine from the bladder.

148. A stent (hollow tube) in the ureter (between the kidney and bladder) to keep the ureter open.

149. A nephrostomy tube can inserted through the patient's lower back to drain urine directly from the kidney (percutaneousnephrostomy).

150. CystoscopyGroup 3Group 3Group 3NCM-102

151. A Case Presentation on Renal SystemHydronephrosisInterventions: NursingControlling Pain:Give prescribed narcotic analgesics until cause of pain can be removed

152. monitor patient closely for increasing pain may indicate inadequate analgesia

153. Reassess pain frequently using pain scale to identify extent of pain.

154. Encourage patient to assume position that brings some relief

155. Administer anitiemetics for nausea

156. Observe or monitor signs and symptoms associated with pain. Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain.Group 3Group 3Group 3NCM-102

157. A Case Presentation on Renal SystemHydronephrosisInterventions: NursingMaintaining Urine Flow:Catheterize and measure residual urine if incomplete emptying is suspected. Retention of urine in the bladder predisposes that patient to urinary tract infection and may indicate the need for an intermittent catheterization program.

158. Determine balance between intake and output. Intake greater than output may indicate retention

159. If indwelling catheter is in place, assess for patency and kinking

160. Insert indwelling (Foley) catheter as ordered. To relieve bladder distention by maintaining normal excretion of urine

161. Instruct patient or caregiver on signs and symptoms of over distended bladder

162. Perform Credé’s method over bladder. Credé’s method (pressing down over the bladder with the hands) increases bladder pressure, and this in turn may stimulate relaxation of sphincter to allow voidingGroup 3Group 3Group 3NCM-102

163. A Case Presentation on Renal SystemHydronephrosisInterventions: NursingMaintaining Urine Flow:Administer antibiotic as prescribed during treatment and monitor side effects these agents are toxic to the pathogen or retard the pathogen’s growth..

164. Encourage intake of cranberry juice daily. This keeps urine acidic. This helps prevent infection because cranberry juice metabolizes to hip puric acid, which maintains an acidic urine; acidic urine is less likely to become infected.

165. Assess amount, frequency, and character (e.g., color, odor, and specific gravity) of urineGroup 3Group 3Group 3NCM-102

166. A Case Presentation on Renal SystemReferencesFinally, it’s the end…Textbook of Medical-Surgical Nursing 11th edition,2008, by S. Smeltzer, et. al. p. 1589-1595

167. Medical-Surgical Nursing 6th edition,2001, by J. Black et. al. p.821-828, p.858

168. llustrated Manual of Nursing Practice 2nd edition, 1994, by S. Loeb, p.603-652

169. Medical Surgical Nursing: A nursing Process Approach 3rd edition, 1994, by Long et. al. p. 1042-1045

170. http://en.wikipedia.org/wiki/Urolithiasis

171. http://www.medicinenet.com/kidney_stone/article.htm

172. http://en.wikipedia.org/wiki/Intravenous_pyelogram

173. http://en.wikipedia.org/wiki/Retrograde_pyelogram

174. www.midindia.com

175. http://emedicine.medscape.com/article/436259-treatmentGroup 3Group 3Group 3NCM-102