Medical Management PDF

10/19/23, 4:00 AM Realizeit for Student Medical Management The goals of management are to eradicate the stone, determine the stone type, prevent nephron destruction, control infection, and relieve any obstruction that may be present. The immediate objective of treatment of renal or ureteral colic...

10/19/23, 4:00 AM Realizeit for Student Medical Management The goals of management are to eradicate the stone, determine the stone type, prevent nephron destruction, control infection, and relieve any obstruction that may be present. The immediate objective of treatment of renal or ureteral colic is to relieve the pain until its cause can be eliminated. Opioid analgesic agents are given to prevent shock and syncope that may result from the excruciating pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are effective in treating renal calculus pain because they provide specific pain relief. They also inhibit the synthesis of prostaglandin E, reducing swelling and facilitating passage of the stone. Generally, once the stone has passed, the pain is relieved. Unless the patient is vomiting or has heart failure or any other condition requiring fluid restriction, fluids are encouraged. This increases the hydrostatic pressure behind the stone, assisting it in its downward passage. A high, around-theclock fluid intake reduces the concentration of urinary crystalloids, dilutes the urine, and ensures a high urine output. Nutritional Therapy Nutritional therapy plays an important role in preventing renal calculi (Flagg & Joiner, 2017) (see Chart 49-11). Fluid intake is the mainstay of most medical therapy for renal calculi. Unless fluids are contraindicated, patients with renal calculi should drink eight to ten 8-oz glasses of water daily or have IV fluids prescribed to keep the urine dilute. A urine output exceeding 2 L/day is advisable. Calcium Stones Historically, patients with calcium-based renal calculi were advised to restrict calcium in their diet. However, evidence has questioned this practice, except for patients with type 2 absorptive hypercalciuria (half of all patients with calcium stones), as stones in these patients are clearly the result of excess dietary calcium. Liberal fluid intake is encouraged. Medications such as ammonium chloride may be used, and if increased parathormone production (resulting in increased serum calcium levels in blood and urine) is a factor in the formation of stones, therapy with thiazide diuretics may be beneficial in reducing the calcium loss in the urine and lowering the elevated parathormone levels (Cahill & Haras, 2017). Uric Acid Stones For uric acid stones, the patient is placed on a low-purine diet to reduce the excretion of uric acid in the urine. Foods high in purine (shellfish, anchovies, asparagus, mushrooms, and organ meats) are avoided, and other proteins may be limited. Allopurinol may be prescribed to reduce serum uric acid levels and urinary uric acid excretion, and to dissolve or reduce the size of existing stones (Cahill & Haras, 2017). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 1/7 10/19/23, 4:00 AM Realizeit for Student Cystine Stones A low-protein diet may be prescribed, the urine is alkalinized with potassium alkali salts, and fluid intake is increased (Norris, 2019). Oxalate Stones A dilute urine is maintained through increasing fluid intake, and the intake of oxalate is limited. Many foods contain oxalate including spinach, Swiss chard, chocolate, peanuts, and pecans (Norris, 2019). Interventional Procedures If the stone does not pass spontaneously or if complications occur, common interventions include endoscopic or other procedures. For example, ureteroscopy, extracorporeal shock wave lithotripsy (ESWL), or endourologic (percutaneous) stone removal may be necessary (Norris, 2019). Ureteroscopy involves first visualizing the stone and then destroying it. Access to the stone is accomplished by inserting a ureteroscope into the ureter and then inserting a laser, electrohydraulic lithotripter, or ultrasound device through the ureteroscope to fragment and https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 2/7 10/19/23, 4:00 AM Realizeit for Student remove the stones. A stent may be inserted and left in place for 48 hours or more after the procedure to keep the ureter patent. Length of hospital stay is generally brief, and some patients can be treated as outpatients. ESWL, commonly referred to as lithotripsy, is a noninvasive procedure used to break up stones in the calyx of the kidney. After the stones are fragmented to the size of grains of sand, the remnants of the stones are spontaneously voided. In ESWL, a high-energy amplitude of pressure, or shock wave, is generated by the abrupt release of energy and transmitted through water and soft tissues. When the shock wave encounters a substance of different intensity (a renal calculus), a compression wave causes the surface of the stone to fragment. Repeated shock waves focused on the stone eventually reduce it to many small pieces that are excreted in the urine. Discomfort from the multiple shocks may occur, although the shock waves usually do not cause damage to other tissue. The patient is observed for obstruction and infection resulting from blockage of the urinary tract by stone fragments. All urine is strained after the procedure; voided gravel or sand is sent to the laboratory for chemical analysis. Several treatments may be necessary to ensure disintegration of stones. Endourologic methods of stone removal may be used to extract kidney calculi that cannot be removed by other procedures. A percutaneous nephrostomy or a percutaneous nephrolithotomy (which are similar procedures) may be performed. A nephroscope is introduced through a percutaneous route into the renal parenchyma. Depending on its size, the stone may be extracted with forceps or by a stone retrieval basket. If the stone is too large to initially be removed, an ultrasound probe inserted through a nephrostomy tube is used to pulverize the stone. Small stone fragments and stone dust are then removed. Electrohydraulic lithotripsy is a similar method in which an electrical discharge is used to create a hydraulic shock wave to break up the stone. A probe is passed through the cystoscope, and the tip of the lithotripter is placed near the stone. The strength of the discharge and pulse frequency can be varied. This procedure is performed under topical anesthesia. After the stone is extracted, the percutaneous nephrostomy tube may be left in place for a time to ensure that the ureter is not obstructed by edema, blood clots, or fragmented calculi (Norris, 2019). The most common complications are hemorrhage, infection, and urinary extravasation. After the tube is removed, the nephrostomy tract usually closes spontaneously. Chemolysis, stone dissolution using infusions of chemical solutions (e.g., alkylating agents, acidifying agents) for the purpose of dissolving the stone, is an alternative treatment sometimes used in patients who are at risk for complications with other types of therapy, who refuse to https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 3/7 10/19/23, 4:00 AM Realizeit for Student undergo other methods, or who have stones (struvite) that dissolve easily. A percutaneous nephrostomy is performed, and the warm chemical solution is allowed to flow continuously onto the stone. The solution exits the renal collecting system by means of the ureter or the nephrostomy tube. The pressure inside the renal pelvis is monitored during the procedure. Several of these treatment modalities may be used in combination to ensure removal of the stones. Surgical Management Surgical intervention may be indicated if the stone does not respond to other forms of treatment. It may also be performed to correct anatomic abnormalities within the kidney to improve urinary drainage. If the stone is in the kidney, the surgery performed may be a nephrolithotomy (incision into the kidney with removal of the stone) or a nephrectomy, if the kidney is nonfunctional secondary to infection or hydronephrosis. Stones in the kidney pelvis are removed by a pyelolithotomy, those in the ureter by ureterolithotomy, and those in the bladder by cystotomy. If the stone is in the bladder, an instrument may be inserted through the urethra into the bladder, and the stone crushed. Such a procedure is called a cystolitholapaxy. Nursing Process The Patient With Kidney Stones Assessment The patient with suspected renal calculi is assessed for pain and discomfort as well as associated symptoms, such as nausea, vomiting, diarrhea, and abdominal distention. The severity and location of pain are determined, along with any radiation of the pain. Nursing assessment also includes observing for signs and symptoms of UTI (chills, fever, frequency, and hesitancy) and obstruction (frequent urination of small amounts, oliguria, or anuria). The urine is inspected for blood and is strained for stones or gravel. The history focuses on factors that predispose the patient to urinary tract stones or that may have precipitated the current episode of renal or ureteral colic. The patient’s knowledge about renal calculi and measures to prevent their occurrence or recurrence is also assessed. Diagnosis https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 4/7 10/19/23, 4:00 AM Realizeit for Student NURSING DIAGNOSES Based on the assessment data, nursing diagnoses may include the following: Acute pain associated with inflammation, obstruction, and abrasion of the urinary tract Lack of knowledge regarding prevention of recurrence of renal calculi COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: Infection and urosepsis (from UTI and pyelonephritis) Obstruction of the urinary tract by a stone or edema with subsequent acute kidney injury Planning and Goals The major goals for the patient may include relief of pain and discomfort, prevention of recurrence of renal calculi, and absence of complications. Nursing Interventions RELIEVING PAIN Severe acute pain is often the presenting symptom of a patient with kidney and urinary calculi and requires immediate attention. Opioid analgesic agents may be prescribed and given to provide rapid relief along with an IV NSAID. The patient is encouraged and assisted to assume a position of comfort. If activity brings pain relief, the patient is assisted to ambulate. The pain level is monitored closely, and an increase in severity is reported promptly to the primary provider so that relief can be provided and additional treatment initiated. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Increased fluid intake is encouraged to prevent dehydration and increase hydrostatic pressure within the urinary tract to promote passage of the stone. If the patient cannot take adequate fluids orally, IV fluids are prescribed. The total urine output and patterns of voiding are monitored. Ambulation is encouraged as a means of moving the stone through the urinary tract. All urine is strained as it be necessary to determine the type of calculi the patient has formed (Flagg & Joiner, 2017). Any blood clots passed in the urine should be crushed and the sides of the urinal and bedpan inspected for clinging calculi. Renal calculi increase the risk of infection, sepsis, and obstruction of the urinary tract. Therefore, the patient is instructed to report decreased urine volume, bloody or cloudy urine, fever, and pain to the primary provider. Patients with calculi require frequent nursing observation to detect the spontaneous passage. The patient is instructed to immediately report any sudden increases in pain intensity because of the possibility of a stone fragment obstructing a ureter. Vital signs, including temperature, are https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 5/7 10/19/23, 4:00 AM Realizeit for Student monitored closely to detect early signs of infection. UTIs may be associated with renal calculi due to an obstruction from the stone or from the stone itself. All infections should be treated with the appropriate antibiotic agent before efforts are made to dissolve the stone. PROMOTING HOME, COMMUNITY-BASED, AND TRANSITIONAL CARE Educating Patients About Self-Care. Because the risk of recurring renal calculi is high, the nurse provides education about the causes of renal calculi and recommendations to prevent their recurrence (see Chart 49-11). Chart 49-11 PATIENT EDUCATION Preventing Renal Calculi The nurse instructs the patient to: Avoid protein intake to decrease urinary excretion of calcium and uric acid. Limit sodium intake to 3 to 4 g/day. Table salt and high-sodium foods should be reduced, because sodium competes with calcium for reabsorption in the kidneys. Be aware that 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 calculi. Avoid intake of oxalate-containing foods (e.g., spinach, Swiss chard, chocolate, peanuts, pecans). Drink fluids (ideally water) every 1 to 2 hours during the day and one glass of cranberry juice per day. Drink two glasses of water at bedtime and an additional glass at each nighttime awakening to prevent urine from becoming too concentrated during the night. Avoid activities leading to sudden increases in environmental temperatures that may cause excessive sweating and dehydration. Contact the primary provider at the first sign of a urinary tract infection. Adapted from Norris, T. L. (2019). Porth’s pathophysiology: Concepts of altered health state (10th ed.). Philadelphia, PA: Wolters Kluwer. The patient is encouraged to follow a regimen to avoid further stone formation, including maintaining a high fluid intake because stones form more readily in concentrated urine. A patient who has shown a tendency to form stones should drink enough fluid to excrete greater than 2000 mL (preferably 3000 to 4000 mL) of urine every 24 hours (Flagg & Joiner, 2017). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 6/7 10/19/23, 4:00 AM Realizeit for Student Urine cultures may be performed every 1 to 2 months in the first year and periodically thereafter. Recurrent UTI is treated promptly. Because prolonged immobilization slows renal drainage and alters calcium metabolism, increased mobility is encouraged whenever possible. In addition, excessive ingestion of vitamins (especially vitamin D) and minerals is discouraged. If lithotripsy, percutaneous stone removal, ureteroscopy, or other surgical procedures for stone removal have been performed, the nurse educates the patient about the signs and symptoms of complications (e.g., urinary retention, infection) that need to be reported to the primary provider. The importance of follow-up is to assess kidney function and to ensure the eradication or removal of all renal calculi is emphasized to the patient and family. If ESWL has been performed, the nurse must provide instructions for home care and necessary follow-up. The patient is encouraged to increase fluid intake to assist in the passage of stone fragments, which may occur for 6 weeks to several months after the procedure. The patient and family are educated about signs and symptoms of complications. It is also important to inform the patient to expect hematuria (it is anticipated in all patients), but it should disappear within 4 to 5 days. If the patient has a stent in the ureter, hematuria may be expected until the stent is removed. The patient is instructed to check their temperature daily and notify the primary provider if the temperature is greater than 38°C (about 101°F) or the pain is unrelieved by the prescribed medication. The patient is also informed that a bruise may be observed on the treated side of the back. Continuing and Transitional Care. Close monitoring of the patient in follow-up care is essential to ensure that treatment has been effective and that no complications develop. The nurse has the opportunity to assess the patient’s understanding of ESWL and possible complications. In addition, the nurse has the opportunity to assess the patient’s understanding of factors that increase the risk of recurrence of renal calculi and strategies to reduce those risks. The nurse must assess the patient’s ability to monitor urinary pH and interpret the results during follow-up visits. Because of the high risk of recurrence, the patient with renal calculi needs to understand 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, the nurse explains their actions, importance, and side effects to the patient. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 7/7