Renal Calculi Nursing Essay

Renal Calculi Nursing Essay

What Is Renal Calculi Nursing Essay

The term calculi refer to the stones that are developed within human body. Calculi (plural) or calculus (singular) do not only occur in the urinary system but they can also occur anywhere in the body. The term use to describe those calculi are different based on which part they are formed. According to Francis (n.d) calculi can present in kidney, gallbladder, bladder, gastrointestinal system and salivary glands. The present of those stones can cause either inflammation or obstruction inside the human body.

Renal calculi refer to solid mass that are developed in the kidneys resulting from aggregation of crystals in the urine. According to National Kidney and Urologic Diseases Information Clearinghouse (n.d) renal calculi are one of the most painful and common urinary tract disorders that can happen in human body. Renal calculi are commonly known as kidney stone or in medical term it is called nephrolithiasis. Renal Calculi Nursing Essay.Generally, renal calculi are formed when the urine becomes concentrated, hence chemical substances that should be dissolved in the urine will crystallize and form a hard mineral deposit that is too large to pass through the urine (Health Central,n.d.). Kidney Stone Diagram

ORDER A PLAGIARISM-FREE PAPER NOW

Figure 1.1: Renal calculus that is formed within the kidney

Renal calculi are classified based on their composition of substances. There are many types of renal calculi that have been found. The presence of certain substances that are exceeding their normal level in the urine will contribute to the types of stone. There are about four types of stones that commonly occur within human body.

The most common type of stones that is formed within human body is calcium stones. These types of stones are developed as a result of combination of calcium with oxalate, phosphate, or carbonate and it is accounted about 75 to 85 percent of all stones (Health Central, n.d.). According to Francis (n.d.) the formation of this stones may be as the result of bowel disease or dietary imbalances. These types of stones mostly affect men rather than women whose aged between 20 to 30 years old and usually easy to see on x-ray.

Other types of stones are uric acid stones which are accounted for 5 to 10 percent of all stones (Health Central, n.d.). It is formed as the uric acid in the urine is too much than other chemical substances and is more likely to occur in men than in women. According to Dugdale (2011) the patients who are having gout or chemotherapy are susceptible to experience uric acid stones. These types of stones can only be seen under special test such as CT, ultrasound, or intavenous pyelography (IVP).

The most common stone that usually affects women is struvite stone which is accounted for 10 to 15 percent of all stones. It is formed by the combination of calcium, magnesium and ammonium phosphate (Health Central, n.d.). As women have short urethra, they are more likely to get urinary tract infection which will cause them susceptible to get struvite stones. This type of stones can be easily seen on x-ray studies (Francis, n.d.) and it can grow very large which can block the kidney, ureter or bladder. Renal Calculi Nursing Essay.

Cystine stones are the types of stones that are less common to occur which is accounted for only 1 percent of all stones. It is a combination of cystine with lysine, arginine and ornithine and usually affects men and women equally. Besides, cystine stones also can be found in the patients who are having cystinuria, a type of hereditary disorder which occurs as kidney tubules do not reabsorbing certain amino acids adequately (Dugdale, 2011).

HISTOPATHOLOGY

2.1 Etiology

Renal calculi can happen if there is an increasing in the certain chemicals that become super saturation in the urine (SingHealth, n.d.). The waste products that are carried by the urine such as calcium oxalate, uric acid and cystine can become extremely concentrated if there is not enough urine. When the salt concentration levels reach the point at which they are no longer dissolved in the urine, these salts will form crystals known as calculi.

It can also form if there is low concentration of urinary inhibitors such as citrate, magnesium, enzymes and pyrophosphate. These substances is needed in human body in order to prevent stone formation by allowing salts in the urine to be at higher than normal concentrations without forming crystals. They also act to coat the crystals and prevent them from sticking to the surface of kidney tubes (Simon, 2009).

2.2 Risk Factors

There are many risk factors that lead to the formation of renal calculi. The common factor is because inadequate intake of fluid by a person. It will cause the chemical substances become too much to be dissolved in the urine. Renal Calculi Nursing Essay.

Besides, a person is also tending to get renal calculi based on dietary habits that he ingests. Mayo Clinic (2012) said that if the person loves to eat food high in protein, sodium and sugar the tendency for him to get renal calculi is high. In addition, the types of stone that will be formed within the body also are different based on which substances have the highest concentration in the urine such as high levels of calcium (hypercalciuria), oxalate (hyperoxaluria) and uric acid (hyperuricosuria) can all lead to the different types of calculi.

If the person have a family member that already suffered from renal calculi before, the probability for him to get the disease is high. Furthermore, if the person had already has the disease before, there are risk for the disease to recur.

Person who is obese and have large waist size and weight gain also have a high risk to get renal calculi as their body may excrete more calcium and uric acid (Simon, 2009).Besides, renal calculi are more likely to occur among men over age 40 years old and above. However, women also have the risk to suffer from renal calculi.

Patients who are suffering from diseases such as renal tubular acidosis, cystinuria, hyperparathyroidism and some urinary tract infection may also have the risk of renal calculi. Furthermore, patients who are undergoing gastric bypass surgery, inflammatory bowel disease or chronic diarrhea also have high risk of formation of renal calculi. This is because the disease had cause changes in digestive process which may affect absorption of calcium and water in the urine (Mayo Clinic, 2012).

2.3 Incidence and Prevalence

According to Right Diagnosis (n.d.) incidence means the rate of occurrence of new case of kidney stones diagnosed each year while prevalence means the estimated population of people who are managing kidney stones at any time. Renal Calculi Nursing Essay.

2.4 Mobility and Morbidity

2.5 Pathophysiology

Normally, the waste products that accumulated from our diet are excreted via the function of kidneys. Normal person without renal problem will have no excessive waste products as they are enough to be dissolved in the urine. The formation of renal calculi can happen if the amount of calcium oxalate and uric acid become too high in the urine. As the concentrations become saturated, crystal can form within urine and will lead to the development of stones as they are grouping together with an organic material called matrix (Stoller, 2012). The stones may remain the same size or may also become enlarge if it is not treated early.

Stoller (2012) also said that the calculi can form within the kidneys if the inhibitors presence in small amount in the urine. The substances which are citrate, magnesium and several proteins help to prevent stone formation by coating the crystals and prevent them from sticking to the kidney tubes. The patients who suffered from renal calculi are believed to have low amount of inhibitors and large amount of promoters that alter towards stone formation.

2.6 Signs and Symptoms

Symptoms mean patient’s perception about a disease that he or she can recognize or feel. Usually the patients who are suffering from renal calculi may not felt any symptoms unless the calculus is too large to pass through urine and has stuck in the ureter. It takes time for the person to detect that they are having renal calculi as the calculus also takes time to build up into a large one. Most patients are accidentally known that they have renal calculi as they are going for abdominal x-ray for other purpose.

According to Uddin, (2011) some patients may feel sharp pain in the back or side of lower abdomen as the early warning sign of renal calculi. The pain can be severe and can spread out into the lower abdominal or groin regions.Renal Calculi Nursing Essay.  If the patients are suffering from this pain, their ability to sit up or move can be interfered. This severe pain also can lead to stomach upset in patients. The patients can feel nausea or may begin to vomit because of the pain.

Besides, the patients who are suffering from renal calculi can also see the changes of their urine which may appear dark or red in color. It is because the stone that passes through their urinary tract had damage the small tubes that carry urine out of the body. The red color of the urine results from blood that discharges as stones damage the tubes. This condition also is known as hematuria. Moreover, they may also observe their urine appears cloudy and release unpleasant smell.

Uddin (2012) added that patients who are expecting to have renal calculi also can feel painful during urination. It happens as the stones irritate and inflame the bladder which also can lead to frequent urination. Some patient may also have flulike symptoms that are caused by infection as if stone becomes stuck along the urinary tract. The patients will have early warning signs of fever and chills because of the infection.

IMAGING MODALITIES

Imaging modalities play an important role in detecting patients with renal calculi.

• Urolithiasis refers to stones (calculi) in the urinary tract.
• Stones are formed in the urinary tract when the urinary concentration of substances such as calcium oxalate, calcium phosphate, and uric acid increases.
• Stones vary in size from minute granular deposits to the size of an orange. Renal Calculi Nursing Essay..
• Factors that favor formation of stones include infection, urinary stasis, and periods of immobility, all of which slow renal drainage and alter calcium metabolism.
• The problem occurs predominantly in the third to fifth decades and affects men more often than women.

Pathophysiology

• Presence of stones anywhere in the urinary tract
  • Most commonly found in the renal pelvis and calyces
    • Stones forming in the kidney—nephrolithiasis
    • Stones formed in the ureters—ureterolithiasis
  • May be single or multiple calculi, ranging in size from a grain of salt to the size of a pebble or staghorn calculus
• Composition of calculi
  • Formed of mineral deposits—predominantly calcium oxalate and calcium phosphate
  • Uric acid, struvite, and cystine are also calculus formers

Etiology

• Slow urine flow allows accumulation of crystals—damaging the lining of the urinary tract and decreasing the number of inhibitor substances that would prevent crystal accumulation (Winkleman, 2006).
• May remain asymptomatic until passed into a ureter or urine flow is obstructed, at which time the potential for renal damage is acute and the level of pain is at its highest.
•  Causes: dehydration; heredity; excessive intake of vitamins C and D, grapefruit juice, and purines (gout); congenital renal abnormalities; and some medications, such as acetazolamide (Diamox) or indinavir (Crixivan)

Clinical Manifestations

Manifestations depend on the presence of obstruction, infection, and edema. Symptoms range from mild to excruciating pain and discomfort.

Stones in Renal Pelvis

• Intense, deep ache in costovertebral region
• Hematuria and pyuria
• Pain that radiates anteriorly and downward toward bladder in female and toward testes in male
• Acute pain, nausea, vomiting, costovertebral area tenderness (renal colic) Renal Calculi Nursing Essay..
• Abdominal discomfort, diarrhea

Ureteral Colic (Stones Lodged in Ureter)

• Acute, excruciating, colicky, wavelike pain, radiating down the thigh to the genitalia
• Frequent desire to void, but little urine passed; usually contains blood because of the abrasive action of the stone (known as ureteral colic)

Stones Lodged in Bladder

• Symptoms of irritation associated with urinary tract infection and hematuria
• Urinary retention, if stone obstructs bladder neck
• Possible urosepsis if infection is present with stone

Assessment and Diagnostic Methods

• Diagnosis is confirmed by xrays of the kidneys, ureters, and bladder (KUB) or by ultrasonography, IV urography, or retrograde pyelography.
• Blood chemistries and a 24hour urine test for measurement of calcium, uric acid, creatinine, sodium, pH, and total volume.
• Chemical analysis is performed to determine stone composition.

Diagnostic Studies

• Urinalysis: Color may be yellow, dark brown, bloody. Commonly shows RBCs, WBCs, crystals (cystine, uric acid, calcium oxalate), casts, minerals, bacteria, pus; pH may be less than 5 (promotes cystine and uric acid stones) or higher than 7.5 (promotes magnesium, struvite, phosphate, or calcium phosphate stones).
• Urine (24-hr): Cr, uric acid, calcium, phosphorus, oxalate, or cystine may be elevated.
• Urine culture: May reveal UTI (Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas).
• Biochemical survey: Elevated levels of magnesium, calcium, uric acid, phosphates, protein, electrolytes.
• Serum and urine BUN/Cr: Abnormal (high in serum/low in urine) secondary to high obstructive stone in kidney causing ischemia/necrosis. Renal Calculi Nursing Essay..
• Serum chloride and bicarbonate levels: Elevation of chloride and decreased levels of bicarbonate suggest developing renal tubular acidosis.
• CBC:
  • Hb/Hct: Abnormal if patient is severely dehydrated or polycythemia is present (encourages precipitation of solids), or patient is anemic (hemorrhage, kidney dysfunction/failure).
  • RBCs: Usually normal.
  • WBCs: May be increased, indicating infection/septicemia.
• Parathyroid hormone (PTH): May be increased if kidney failure present. (PTH stimulates reabsorption of calcium from bones, increasing circulating serum and urine calcium levels.)
• KUB x-ray: Shows presence of calculi and/or anatomical changes in the area of the kidneys or along the course of the ureter.
• IVP: Provides rapid confirmation of urolithiasis as a cause of abdominal or flank pain. Shows abnormalities in anatomical structures (distended ureter) and outline of calculi.
• Cystoureteroscopy: Direct visualization of bladder and ureter may reveal stone and/or obstructive effects.
• CT scan: Identifies/delineates calculi and other masses; kidney, ureteral, and bladder distension.
• Ultrasound of kidney: To determine obstructive changes, location of stone; without the risk of failure induced by contrast medium.

Nursing Priorities

1. Alleviate pain.
2. Maintain adequate renal functioning.
3. Prevent complications.
4. Provide information about disease process/prognosis and treatment needs.

Medical Management

• Basic goals are to eradicate the stone, determine the stone type, prevent nephron destruction, control infection, and relieve any obstruction that may be present. Renal Calculi Nursing Essay..

Pharmacologic and Nutritional Therapy

• Opioid analgesic agents (to prevent shock and syncope) and nonsteroidal antiinflammatory drugs (NSAIDs).
• Increased fluid intake to assist in stone passage, unless patient is vomiting; patients with renal stones should drink eight to ten 8oz glasses of water daily or have IV fluids prescribed to keep the urine dilute.
• For calcium stones: reduced dietary protein and sodium intake; liberal fluid intake; medications to acidify urine, such as ammonium chloride and thiazide diuretics if parathormone production is increased.
• For uric stones: lowpurine and limited protein diet; allopurinol (Zyloprim).
• For cystine stones: lowprotein diet; alkalinization of urine; increased fluids.
• For oxalate stones: dilute urine; limited oxalate intake (spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran).

Stone Removal Procedures

• Ureteroscopy: stones fragmented with use of laser, electrohydraulic lithotripsy, or ultrasound and then removed.
• Extracorporeal shock wave lithotripsy (ESWL).
• Percutaneous nephrostomy; endourologic methods.
• Electrohydraulic lithotripsy. Renal Calculi Nursing Essay..
• Chemolysis (stone dissolution): alternative for those who are poor risks for other therapies, refuse other methods, or have easily dissolved stones (struvite).
• Surgical removal is performed in only 1% to 2% of patients.

Nursing Process

Assessment

• Assess for pain and discomfort, including severity, location, and radiation of pain.
• Assess for associated symptoms, including nausea, vomiting, diarrhea, and abdominal distention.
• Observe for signs of urinary tract infection (chills, fever, frequency, and hesitancy) and obstruction (frequent urination of small amounts, oliguria, or anuria).
• Observe urine for blood; strain for stones or gravel.
• Focus history on factors that predispose patient to urinary tract stones or that may have precipitated current episode of renal or ureteral colic.
• Assess patient’s knowledge about renal stones and measures to prevent recurrence.

Diagnosis

Nursing Diagnoses

• Acute pain related to inflammation, obstruction, and abrasion of the urinary tract
• Deficient knowledge regarding prevention of recurrence of renal stones

Collaborative Problems/Potential Complications

• Infection and urosepsis (from urinary tract infection and pyelonephritis)
• Obstruction of the urinary tract by a stone or edema, with subsequent acute renal failure. Renal Calculi Nursing Essay..

Planning and Goals

• Major goals may include relief of pain and discomfort, prevention of recurrence of renal stones, and absence of complications.

Nursing Care Plans

Main Article: 4 Urolithiasis Nursing Care Plans

Nursing Interventions

Relieving Pain

• Administer opioid analgesics (IV or intramuscular) with IV NSAID as prescribed.
• Encourage and assist patient to assume a position of comfort.
• Assist patient to ambulate to obtain some pain relief.
• Monitor pain closely and report promptly increases in severity. Renal Calculi Nursing Essay..

Monitoring and Managing Complications

• 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.
• Crush any blood clots passed in urine, and inspect sides of urinal and bedpan for clinging stones.
• Instruct patient to report decreased urine volume, bloody or cloudy urine, fever, and pain.
• 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.

Teaching Points

• Explain causes of kidney stones and ways to prevent recurrence.
• Encourage patient to follow a regimen to avoid further stone formation, including maintaining a high fluid intake.
• Encourage patient to drink enough to excrete 3,000 to 4,000 mL of urine every 24 hours.
• Recommend that patient have urine cultures every 1 to  2 months the first year and periodically thereafter.
• Recommend that recurrent urinary infection be treated vigorously.
• Encourage increased mobility whenever possible; discourage excessive ingestion of vitamins (especially vitamin D) and minerals. Renal Calculi Nursing Essay..
• If patient had surgery, instruct about the signs and symptoms of complications that need to be reported to the physician; emphasize the importance of followup to assess kidney function and to ensure the eradication or removal of all kidney stones to the patient and family.
• If patient had ESWL, encourage patient to increase fluid intake to assist in the passage of stone fragments; inform the patient to expect hematuria and possibly a bruise on the treated side of the back; instruct patient to check his or her temperature daily and notify the physician if the temperature is greater than 38C (about 101F), or the pain is unrelieved by the prescribed medication.
• Provide instructions for any necessary home care and  followup.
• ORDER A PLAGIARISM-FREE PAPER NOW

PROVIDING HOME AND FOLLOWUP CARE AFTER ESWL

• Instruct patient to increase fluid intake to assist passage of stone fragments (may take 6 weeks to several months after procedure).
• Instruct patient about signs and symptoms of complications: fever, decreasing urinary output, and pain.
• Inform patient that hematuria is anticipated but should subside in 24 hours.
• Give appropriate dietary instructions based on composition of stones.
• Encourage regimen to avoid further stone formation; advise patient to adhere to prescribed diet.
• Teach patient to take sufficient fluids in the evening  to prevent urine from becoming too concentrated at  night.

CONTINUING CARE

• Closely monitor the patient to ensure that treatment has been effective and that no complications have developed.
• Assess the patient’s understanding of ESWL and possible complications; assess the patient’s understanding of factors that increase the risk of recurrence of renal calculi and strategies to reduce those risks.
• Assess the patient’s ability to monitor urinary pH and interpret the results during followup visits.
• Ensure that the patient understands the signs and symptoms of stone formation, obstruction, and infection and the importance of reporting these signs promptly.
• If medications are prescribed for the prevention of stone formation, explain their actions, importance, and side effects to the patient.

Evaluation

Expected Patient Outcomes

• Reports relief of pain
• States increased knowledge of healthseeking behaviors to prevent recurrence
• Experiences no complications . Renal Calculi Nursing Essay.