Kidney Stones Kim Applebee Alex Kaullen Definition

Kidney Stones Kim Applebee Alex Kaullen

Definition l l l Kidney Stones are small, hard deposits of mineral and acid salts on the inner surfaces of the kidneys Alternative names include: l Renal Lithiasis l Renal Calculi l Nephrolithiasis (Kidney Stone Disease) Stones are classified by their location in the urinary system and their composition of crystals.

Statistics l Incidence Rate: l l More than 1 million cases annually in US 1 in 272 or 3. 6 per 1000 Americans develop stones annually. 80% of stones under 2 mm in size 90% of stones pass through the urinary system spontaneously l Generally stone smaller than 6 mm are passable (National Institute of Diabetes and Digestive and Kidney Diseases; NIDDK) (National Kidney and Urologic Disease Information Clearinghouse; NKUDIC)

Kidney Stone Formation l Causes: l l Highly concentrated urine, urine stasis Imbalance of p. H in urine l l l l Acidic: Uric and Crystine Stones Alkaline: Calcium Stones Gout Hyperparathyroidism Inflammatory Bowel Disease UTI Medications l Lasix, Topamax, Crixivan http: //www. pilotfriend. com/aeromed/medical/images 2/25. jpg

Types of Stones l Calcium Oxalate l l l Calcium Phosphate Struvite l l l More common in woman than men. Commonly a result of UTI. Uric Acid l l Most common Caused by high protein diet and gout. Cystine l Fairly uncommon; generally linked to a hereditary disorder.

Case Study l It is a hot summer day, and you are an RN in the emergency department (ED). S. R. , an 18 -year-old woman, comes to the ED with severe flank and abdominal pain and N/V. S. R. looks very tired, her skin is warm to touch, and she is perspiring. She paces about the room doubled-over and is clutching her abdomen. S. R. tells you that the pain started early this morning and has been pretty steady for the past hours. She gives a history of working outside as a landscaper and takes little time for water breaks. Her past medical history (PMH) includes 3 kidney stone attacks, all during late summer. Exam findings are that her abdomen is soft and w/o tenderness, but her left flank is extremely tender to touch, palpation, and percussion. You place S. R. in one of the examination rooms and take the following VS 118/98, 90, 20, 99 F. UA shows RBC of 50 to 100 on voided specimen, WBC 0.

What key factors are important to consider?

Signs and Symptoms l What are the key findings? l l l l l Severe flank pain Abdominal pain Nausea and vomiting Fatigue Elevated temperature, BP, and respirations UA positive for RBC Objective Data: perspiration, clutching of the abdomen, doubled-over. Steady Pain Left flank tendernes l Additional S/S: l l l Presence of UTI Fever or Chills Pain in groin, labia or testicles Cloudy or foul-smelling urine Dysuria Persistent urge to void http: //knol. google. com/k/-/-/27 ifsyywko 3 wx/sqc 1 f 9/kidneystonesymptoms. jpg

What additional information should you ask this patient?

Additional Information l l l Family history Current medications Frequency of urination Do you experience pain while urinating? What is your typical diet? How did patient’s kidney stones resolve themselves in the past? http: //erstories. net/wp-content/uploads/2008/10/kidneystone 1 a. jpg

Identify this patient’s risk factors.

Risk Factors l What are her risk factors? l l Past Medical History l Hx of 3 kidney stone attacks Dehydration/Lack of Fluids Occupational exposure l Labor Intensive l Outdoors Weather/Climate l Hot, dry l Additional risk factors: l l l l Family or Personal Hx Gender (male) Age (20 -55) Race (Caucasian) Diet l High sodium l High protein l Food high in oxalate l Vit A/D, grapefruit juice Sedentary Lifestyle Obesity High Blood Pressure http: //savethelobsters. files. wordpress. com/2009/02/ist 2_4588664_half_empty_glass_of_water_with_clipping_path. jpg

Abnormal Lab Values BUN Creatinine Urine Analysis https: //www. clevelandclinic. org/heartcenter/images/guide/tests/lab. gif http: //www. ganfyd. org/images/f/fb/Dipstick_bottle. jpg

Diagnostic Studies l Test and Diagnostics: l l l l Blood Analysis Urine Analysis CT Scan Abdominal x-ray Ultrasound Retrograde Pyelogram Cystoscopy Intravenous pyelography http: //knol. google. com/k/-/-/PYw. IQr_i/GXb 8 Fg/Stone%20 CT. jpg

What questions do you need to ask before a patient has an IV pyelogram?

Answer: l Do you have a history of renal failure? l l Have you ever have a reaction to iodine? l l l Contrast contains iodine Is there a possibility you could be pregnant? Are you currently taking any medications? l l l Contraindicated with renal failure Metformin may react with contrast Contrast contains iodine Check BUN and Creatinine levels prior to IVP

Nursing Diagnosis: Acute pain r/t obstruction from renal calculi as manifested by patient being doubled-over, pacing around the room, and patient verbalizing pain upon assessment. Goal: patient will state pain is at a manageable level within 2 hours of admission. What are Nursing Interventions?

Nursing Goal/Interventions: l Administer pain medication as ordered by physician. l Provide non-pharmaceutical techniques such as imagery and/or meditation to relieve pain. l Patient will determine manageable pain level. l Patient will be asked about any concerns and/or fears that may be associated with pain. l Provide emotional support for the patient. l Reassess patient’s pain levels within 1 hour after administration of pain medications.

Nursing Diagnoses: Deficient knowledge r/t fluid requirements and dietary restrictions as manifested by reoccurring stones. Goal: Patient will state methods to prevent future stones by the time patient is D/C. A plan of care will also be created with the patient before patient is D/C to prevent reoccurrence of kidney stones. Risk for infection r/t kidney stone obstruction of urinary tract causing stasis of urine. Goal: Patient’s urine will be yellow and clear upon D/C and patient will not have a fever. UA with show no indication of UTI or other infection. What are Nursing Interventions?

Treatment l Two Focuses of Treatment: l l l Treatment of acute problems, such as pain, n/v, etc Identify cause and prevent kidney stones from reoccurring Acute Treatment: l l l l Pain Medication!!! Strain urine for stones Keep Hydrated Ambulation Diet Restrictions Emotional Support Invasive Procedure (may be necessary) http: //www. free-press-release. com/members_pic/200906/img/1245774370. jpg

Surgical Procedures Lithotripsy: used to break into smaller fragments allowing it to pass through the urinary tract. l l l Extracorporeal Shock-Wave (ESWL) Percutaneous Ultrasonic Electrohydraulic Laser Surgical Therapy l l Nephrolithotomy (Kidney) Pyelolithotomy (Renal Pelvis) Ureterolithotomy (Ureter) http: //www. svhm. org. au/Department_Index/Lithotripsy/images/Kidney-Stones. gif

Prevention l Patient Education l Hydration l l Diet l l l Drink 3 liters of fluid per day (14 cups) Water Lemonade (citrate decrease stone formation) Low sodium Watch amounts of oxalate Low protein Exercise/Increase Activity Medication http: //3. bp. blogspot. com/_-gcaht 5 yp_0/Sd. INr. CVuqd. I/AAAAAGw/xe. Ek 4 -F 3 z_I/s 320/foods+rich+in+oxalate+2. gif