Renal calculi ppt

HELLO

LEARNING OBJECTIVES

• review the anatomy and physiology of the renal system

• interpret the term renal calculi • describe the etiology of renal calculi• discuss the pathogenesis involved in the

disease process• list the types of renal calculi

LEARNING OBJECTIVES• examine the clinical manifestations closely• differentiate the various diagnostic

measures • explain the medical management• Identify the surgical management of renal

calculi• distinguish the nursing management for

renal calculi including the nursing diagnosis

THE RENAL SYSTEM

THE RENAL SYSTEM

DEFINITION

• Nephrolithiasis refers to renal stone disease; urolithiasis refers to the presence of stones in the urinary system. Stones, or calculi, are formed in the urinary tract from the kidney to bladder by the crystallization of substances excreted in the urine

•

ETIOLOGY

ETIOLOGYMETABOLIC

LIFESTYLE

GENETIC FACTORS

DRUGS

OTHERS

RISK FACTORS

HISTORY OF RENAL CALCULI

RISK FACTORS

HIGH MINERAL CONTENT IN DRINKING WATER

DIETARY INTAKE

UTI & H/O FEMALE GENITAL MUTILATION

PROLONGED INDWELLING CATHETERISATION

NEUROGENIC BLADDER

1PATHOPHYSIOLOGY

• Slow urine flow, resulting in supersaturation of the urine with the particular element that first become crystallized and later become stone

2PATHOPHYSIOLOGY

• Damage to the lining of the urinary tract

3PATHOPHYSIOLOGY

• Decreased inhibitor substances in the urine that would otherwise prevent supersaturation and crystalline aggregation

TYPES OF STONES• Calcium Phosphate• Calcium oxalate• Uric acid• Cystine• Struvite

CLINICAL MANIFESTSTIONS

• Severe abdominal or flank pain

• Frequency and dysuria

• Oliguria and anuria in obstruction

CLINICAL MANIFESTSTIONS

• Hematuria• Renal colic• Nausea• hydronephrosis

DIAGNOSTIC STUDIES

DIAGNOSTIC STUDIES

DIAGNOSTIC STUDIESCY

STO

SCO

PY

DIAGNOSTIC STUDIESIV

P

DIAGNOSTIC STUDIES

USG

DIAGNOSTIC STUDIESRETROGRA

DE PYELOGRA

MCT SCAN

24 HOUR URINE

SPECIMENLAB

INVESTIGATIONS

MANAGEMENT?

MEDICAL• DRUG THERAPY

Opioid agents NSAIDS Spasmolytic agents

COMPLIMENTARY THERAPY•Hypnosis, imagery, therapeutic or healing touch, acupuncture and breathing techniques•Positioning the client to comfortable position aids in pain reduction

OTHER TECHNIQUES• Avoiding over

hydration and under hydration

• Strain the urine• Send any strained

stone to laboratory to aid in preventive treatment in the future

SPECIFIC APPROACHESURINARY

STONECHARACTERISTICS

PREDISPOSING FACTORS

THERAPEUTIC MEASURES

Calcium oxalate35-40

Small often possible to get trapped in ureter ,more frequent in men

Idiopathic hypercalciuria hyperoxaluria ,Independent of urinary pH ,family history

Increase hydrationReduce dietary oxalateGive thiazide diuretics cellulose phosphate,(chelate calcium and prevent GI absorption), potassium citrate(alkaline urine),cholestyramine(bind oxalate),calcium lactate(precipitate oxalate in GI tract)Reduce daily sodium intake

SPECIFIC APPROACHESURINARY

STONECHARACTERISTICS

PREDISPOSING FACTORS

THERAPEUTIC MEASURES

Calcium phosphate8-10%

Mixed stones with struvite or oxalate stones

Alkaline urine, primary hyperthyroidism

Treat underlying cause and other stones

SPECIFIC APPROACHESURINARY

STONECHARACTERISTICS

PREDISPOSING FACTORS

THERAPEUTIC MEASURES

Struvite10-15 %

3 to 4 times common in women ≥ men,always in association with urinary tract infection

urinary tract infections

Antimicrobial agents acetohydroxamic acidSurgical interventions

Measures to acidify urine

SPECIFIC APPROACHESURINARY

STONECHARACTERISTICS

PREDISPOSING FACTORS

THERAPEUTIC MEASURES

Uric acid

5-8 %

Predominant in men high incidence in jewish men

Gout, acid urine ,inherited conditions

Reduce urinary concentration of uric acidAlkanize urine with potassium citrateAdminister allopurinolReduce dietary purines

SPECIFIC APPROACHESURINARY

STONECHARACTERISTICS PREDISPOSING

FACTORSTHERAPEUTIC MEASURES

Cystine

1-2 %

Genetic autosomal recessive defect,defective absorption of gi cystine from gi tract and kidney excess concentrations causing stone formation

Acid urine Increase hydrationGive α pencillamine and tiopronin to prevent cystine crystallizationPotassium citrate to alkaline urine

SURGICAL MANAGEMENT

SURGICAL MANAGEMENTESWL

RETROGRADE URETEROSCO

PY

ANTEGRADE

NEPHROURETEROLITHOTO

MY

STENTING

ALONEPERCUTANEOUS URETER

O LITHOTO

MY

NEPHROLITHOTO

MY

PRO

XIM

AL U

RETE

R

SURGICAL MANAGEMENT

RETROGRADE URETEROSCOPY ESWL

ANTEGRADE NEPHROSTOURETEROLITHOTOM

Y

OPEN URETERO-LITHOTOMY

MID

URE

TER

SURGICAL MANAGEMENT

ESWL/ureteroscopyAntegrade nephrostoureterolithotomyStenting alone

Open ureterolithotomyDIS

TAL

URE

TER

SURGICAL MANAGEMENT

LASER

PERCUTANEOUS

ESWL

LITH

OTRI

PSY

OPEN SURGICAL PROCEDURES

NEPHROLITHOTOMY

PYELOLITHOTOMY

URETHROLITHOTO

MYCYSTOTO

MY

NURSING MANAGEMENT

NURSING DIAGNOSIS

• Acute pain related to irritation and spasm from stone movement in the urinary tract as manifested by complaints of pain, facial grimacing, restlessness

• Anxiety related to uncertain outcome and lack of knowledge regarding possible surgery as manifested by expressions

NURSING DIAGNOSIS

• Ineffective therapeutic regimen management related to lack of knowledge as manifested by repeated questions

NURSING DIAGNOSIS

• Impaired urinary elimination related to trauma or blockage of ureters or urethra as manifested by decreased urinary output and bloody urine

NURSING DIAGNOSIS

• Risk for infection related to introduction of bacteria following manipulations of the urinary tract and obstructed urinary blood flow

NURSING DIAGNOSIS

PREVENTION

• Avoid protein intake; usually protein is restricted to 60g/day to decrease urinary excretion of calcium and uric acid.

• A sodium intake of 3 to 4 g/day is recommended. Table salt and high-sodium foods should be reduced, because sodium competes with calcium for reabsorption in the kidneys.

• 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 renal stones.

• Avoid intake of oxalate-containing foods (eg, spinach,strawberries, rhubarb, tea, peanuts, wheat bran).

PREVENTION

• During the day, drink fluids (ideally water) every1 to 2 hours.

• 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.

PREVENTION

• Avoid activities leading to sudden increases in environmental temperatures that may cause excessive sweating and dehydration.

• Contact your primary health care provider at the first sign of a urinary tract infection

PREVENTION

JOURNAL PRESENTATIONS

CA B D E

QUESTIONS

???

?a)Cystic fibrosis b) sjogrens syndrome c) gout d) myasthenia gravis

Genetic factor involved in renal calculi formation:

?a) nephrolithiasisb) ureterolithiasisc ) cystolithiasisd ) cholelithiasis

Stone in the kidney is called as

?a)Allopurinol b)thiazide diureticc)pencillamine d)potassium citrate

Uric acid stones can be reduced or prevented by the use of:

?a)Morphine b) ketorolac c)propanthelene d)tramadol hydrochloride

Preferred opioid agent used in renal calculi pain management initially is:

REFERENCES

• Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, et al., editors. Harrison’s principles of internal medicine. 17th ed. New York: McGraw Hill; 2008

• Johnson J.Y.Brunner anD Suddharth`s:Textbook of Medical Surgical Nursing. 11th edn. Philadelphia:Lippincott;2008.

REFERENCES

• Black M.J, Hawks H.K. Medical Surgical Nursing. 7th edn. Missouri: Saunders;2005

REFERENCES

• Taal M.W,Cherton G,Marsden P.A. Brenner and Rector`s: The Kidney. 9th edn.Philadelphia: Elsevier;2012

REFERENCES

•Walsh C.Urology. 10th edn. Philadelphia: Elsevier;2012

REFERENCES

• Nettina S M, Mills E.J.Lippincott Manual of Nursing Practice. 8th edn.Philadelphia :Lippincott Williams & Wilkins; 2006

REFERENCES