Renal Stones Lecture Notes PDF

# Renal Stones ## Prof. Dr. Manal Hamed - التمريض الباطني والجراحي (2) - الفصل الدراسي الأول - الفرقة الثانية - 2023/10/28 السبت - 10 صباحاً ## Learning Objectives: By the end of this lecture, each student should be able to: - Interpret terms related to renal stones - Describe the etiology of ren...

# Renal Stones ## Prof. Dr. Manal Hamed - التمريض الباطني والجراحي (2) - الفصل الدراسي الأول - الفرقة الثانية - 2023/10/28 السبت - 10 صباحاً ## Learning Objectives: By the end of this lecture, each student should be able to: - Interpret terms related to renal stones - Describe the etiology of renal stones - List the types of renal stones - Examine the clinical manifestations - Differentiate the various diagnostic measures. - Explain the medical management. - Identify the surgical management of renal stones. - Formulate a care plan for a patient with renal stones ## Outline: - Definition of renal stones - Etiology of renal stones - Types of renal stones - Clinical manifestations of renal stones - Diagnostic measures for renal stones - Medical management for a patient with renal stones - Surgical management of renal stones - Nursing management for renal stones ## Renal Stones: - **Definition:** Renal stones or renal calculi, or urolithiasis means hard masses that form within the kidney or urinary tract. - **Description:** Stones are formed in the urinary tract when the urinary concentration of substances such as calcium oxalate, calcium phosphate, and uric acid increases. ## Types of Stones: - **Stones forming in the kidney:** nephrolithiasis - **Stones formed in the ureters:** ureterolithiasis - Stones vary in size from minute granular deposits to the size of an orange. ### Types of Kidney Stones (Pie Chart): - **Calcium oxalate:** 80% - **Calcium phosphate:** 5-10% - **Uric acid:** 5-10% - **Struvite:** 10 - 15% - **Cysteine:** 1-2% ## Calcium Stones: - Often made of calcium oxalate. - Rarely consist of calcium phosphate. - Eating fewer oxalate-rich foods can reduce the risk of developing this type of stone. - **High-oxalate foods:** potatoes, peanuts, chocolate, beets, and spinach. - Even though some kidney stones are made of calcium, getting enough calcium in your diet can prevent stones from forming. ## Uric Acid Stones: - This type of kidney stone is more common in men than in women. - They can occur in people with gout or those going through chemotherapy. - This type of stone develops when urine is too acidic. - A diet rich in purines can increase urine’s acidic level. - **Purine:** a colorless substance in animal proteins, such as fish, shellfish, and meats. ## Struvite Stone: - Also called magnesium ammonium phosphate stone. - Type of stone found mostly in women with urinary tract infection (UTI). - These stones can be large and cause urinary obstruction. - Treating an underlying infection can prevent the development of struvite stones. ## Cystine Stone: - **Cystine:** an amino acid that occurs naturally in the body. - Cystine stones are rare. - They occur in both men and women who have the genetic disorder cystinuria (is a rare, inherited metabolic disorder). - It is when the kidneys do not reabsorb cystine from the urine. - When high amounts of cystine are in the urine, cystine is common in many foods, such as eggs, meat, dairy products, and whole grains, as well as skin and hair. ## Risk Factors: - Immobility - Sedentary lifestyle - Dehydration - Metabolic disturbances. - History of renal stones. - Sex: Common among males than females. ## Causes: - Decreased fluid intake. - Urinary tract infections. - Obesity. - Hypertension. - A diet with high levels of protein, salt, or glucose. - A diet with low levels of calcium which leads to movement of calcium from bones into blood. - Long-term use of vitamin (D) and calcium supplements. - Hyperparathyroidism, which increases absorption of calcium. - Gastric bypass surgery that affects calcium absorption. - Inflammatory bowel diseases that increase calcium absorption. - Taking medications such as diuretics, antiseizure drugs, and calcium-based antacids. - Gout. ## Clinical Manifestations: - Severe pain in the back, side, or groin that may come and go - Nausea and vomiting - **Blood in the urine:** hematuria - **Pain with urination:** dysuria - Reduced amount of urine excreted: oliguria - Burning sensation during urination - Persistent urge to urinate: urgency - Fever and chills if there is an infection. ## Diagnostic Studies: - **Urinalysis:** - Color may be yellow, dark brown, bloody. - Commonly shows RBCs, WBCs, crystals, casts, minerals, bacteria, pus. - pH may be less than 5 (promotes cystine and uric acid stones) or higher than 7.5 (promotes struvite or calcium phosphate stones). - **Urine culture:** May reveal a urinary tract infection (UTI). - **Serum and urine BUN/Cr:** Abnormal (high in serum/low in urine) secondary to a high obstructive stone in the kidney causing ischemia/necrosis. - **Complete blood count (CBC):** - Hb/Hct: Abnormal if the patient is severely dehydrated or anemic. - RBCs: Usually normal. - WBCs: May be increased, indicating infection/septicemia. - **KUB x-ray:** An image of the kidneys, ureters, and bladder. This can show the presence of stones, but it may not be able to tell the size or composition of the stones. - **Intravenous pyelogram (IVP):** a series of x-rays that are taken after a dye is injected into a vein. This dye helps to outline the kidneys, ureters, and bladder, and can show the presence of stones. It may not be able to tell the size or composition of the stones. - **Cystoureteroscopy:** a procedure in which a thin, flexible tube with a camera on the end is inserted into the urethra and bladder. This allows the doctor to visualize the inside of the bladder and ureters, and can be used to remove stones. - **CT Scan:** a type of x-ray that provides detailed images of the inside of the body. A CT scan can be used to diagnose stones and assess the size and location of the stones. - **Ultrasound of kidney:** a non-invasive procedure that uses sound waves to create images of the inside of the body. An ultrasound can be used to diagnose stones and assess the size and location of the stones. - **Renal stone analysis:** This involves examining the composition of a kidney stone that has been passed. This can help to determine the cause of the stone and to recommend ways to prevent future stones. ## Medical Management of Renal Stones: - **Opioid analgesic agents:** To prevent shock and syncope. - **Nonsteroidal anti inflammatory drugs (NSAID).** - **Oral Stone Dissolution:** - Specific to uric acid stones. - Can be managed with urine alkalinization with potassium citrate. ## Surgical Management: - **Extracorporeal shock wave lithotripsy (ESWL):** A non-invasive procedure that uses shock waves to break up stones. - **Ureteroscopy and Laser Lithotripsy:** A minimally invasive procedure in which a thin, flexible tube with a camera on the end is inserted into the urethra and bladder. A laser is then used to break up the stones. - **Percutaneous Nephro-lithotomy or Nephro-lithotripsy:** A minimally invasive procedure in which a small incision is made in the back and a special instrument is inserted into the kidney to remove the stones. - **Open Nephro-lithotomy:** A surgical procedure in which a large incision is made in the back to access the kidney. This procedure is usually used for large stones or stones that cannot be removed with other methods. ## Dietary Management: - **Increase fluid intake:** About 3 liters per day. - **For calcium stones:** Reduced dietary protein and sodium intake. When sodium intake becomes too high, the body gets rid of sodium via the urine, taking calcium with it. - **For uric acid stones:** Low purine and protein diet. - **Increased dietary citrate:** Found in lemons and oranges; a major buffer for urinary pH. - **Normal urine pH:** Is slightly acidic, with usual values of 6.0 to 7.5. - **For cystine stones:** Low protein diet. - **For oxalate stones:** Avoid high-oxalate foods, including chocolate, instant coffee, tea, beans, berries, dark leafy greens, oranges, and sweet potatoes. - **Moderate calcium:** A certain amount of calcium is needed in the diet to bind oxalate and prevent hyperoxaluria. ## Nursing Management: - **Administer opioid analgesics:** (IV or intramuscular) with IV NSAID as prescribed. - **Encourage and assist the patient** to assume a position of comfort. - **Monitor pain closely** and report promptly increases in severity. - **Encourage increased fluid intake.** - **Begin IV fluids** if the 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 the sides of the urinal and bedpan for clinging stones. - **Instruct the patient to report** decreased urine volume, bloody or cloudy urine, fever, and pain. - **Instruct the 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. - **Explain causes of kidney stones** and ways to prevent recurrence. - **Encourage the patient** to follow a regimen to avoid further stone formation, including maintaining a high fluid intake. - **Encourage the patient** to drink enough to excrete 3,000 to 4,000 mL of urine every 24 hours. - **Recommend** that recurrent urinary infection be treated vigorously. - **Recommend** that the patient have urine cultures every 1 to 2 months the first year and periodically thereafter. - **Discourage excessive ingestion** of vitamins (especially vitamin D) and minerals. - **Emphasize the importance of follow-up** to assess kidney function and to ensure the eradication or removal of all kidney stones to the patient and family.