Kidney Stones Dysuria

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					      Kidney Stones

Kim Applebee
 Alex Kaullen
   Kidney Stones are small, hard deposits of mineral
    and acid salts on the inner surfaces of the kidneys
   Alternative names include:
     Renal Lithiasis

     Renal Calculi

     Nephrolithiasis (Kidney Stone Disease)

   Stones are classified by their location in the urinary
    system and their composition of crystals.
   Incidence Rate:
       More than 1 million cases annually in US
       1 in 272 or 3.6 per 1000 Americans develop
        stones annually.
   80% of stones under 2mm in size
   90% of stones pass through the urinary
    system spontaneously
       Generally stone smaller than 6mm are passable
         (National Institute of Diabetes and Digestive and Kidney Diseases; NIDDK)
        (National Kidney and Urologic Disease Information Clearinghouse; NKUDIC)
Kidney Stone Formation
   Causes:
       Highly concentrated urine, urine stasis
       Imbalance of pH in urine
           Acidic: Uric and Crystine Stones
           Alkaline: Calcium Stones
       Gout
       Hyperparathyroidism
       Inflammatory Bowel Disease
       UTI
       Medications
           Lasix, Topamax, Crixivan
Types of Stones
   Calcium Oxalate
       Most common
   Calcium Phosphate
   Struvite
       More common in woman than men.
       Commonly a result of UTI.
   Uric Acid
       Caused by high protein diet and gout.
   Cystine
       Fairly uncommon; generally linked to a hereditary disorder.
Case Study
   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
                                                    Additional S/S:
   What are the key findings?
                                                          Presence of UTI
       Severe flank pain
                                                          Fever or Chills
       Abdominal pain
                                                          Pain in groin, labia or testicles
       Nausea and vomiting
                                                          Cloudy or foul-smelling urine
       Fatigue
                                                          Dysuria
       Elevated temperature, BP, and
                                                          Persistent urge to void
       UA positive for RBC
       Objective Data: perspiration,
        clutching of the abdomen,
       Steady Pain
       Left flank tendernes

What additional information
should you ask this patient?
Additional Information
   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?
Identify this patient’s risk
Risk Factors
    What are her risk factors?                                             Additional risk factors:
          Past Medical History                                                   Family or Personal Hx
            Hx of 3 kidney stone                                                 Gender (male)
             attacks                                                              Age (20-55)
          Dehydration/Lack of Fluids                                             Race (Caucasian)
          Occupational exposure                                                  Diet
            Labor Intensive                                                        High sodium
            Outdoors                                                               High protein
          Weather/Climate                                                          Food high in oxalate
            Hot, dry                                                               Vit A/D, grapefruit juice
                                                                                  Sedentary Lifestyle
                                                                                  Obesity
                                                                                  High Blood Pressure
Abnormal Lab Values


          Urine Analysis

Diagnostic Studies
   Test and Diagnostics:
       Blood Analysis
       Urine Analysis
       CT Scan
       Abdominal x-ray
       Ultrasound
       Retrograde Pyelogram
       Cystoscopy
       Intravenous pyelography
 What questions do you need
to ask before a patient has an
        IV pyelogram?
   Do you have a history of renal failure?
       Contraindicated with renal failure
   Have you ever have a reaction to iodine?
       Contrast contains iodine
   Is there a possibility you could be pregnant?
   Are you currently taking any medications?
       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:
   Administer pain medication as ordered by physician.

   Provide non-pharmaceutical techniques such as imagery and/or
    meditation to relieve pain.

   Patient will determine manageable pain level.

   Patient will be asked about any concerns and/or fears that may be
    associated with pain.

   Provide emotional support for the patient.

   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

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?
   Two Focuses of Treatment:
       Treatment of acute problems, such as pain, n/v, etc
       Identify cause and prevent kidney stones from reoccurring

   Acute Treatment:
       Pain Medication!!!
       Strain urine for stones
       Keep Hydrated
       Ambulation
       Diet Restrictions
       Emotional Support
       Invasive Procedure (may be necessary)

Surgical Procedures
       Lithotripsy: used to break into smaller fragments
        allowing it to pass through the urinary tract.
        Extracorporeal Shock-Wave (ESWL)
        Percutaneous Ultrasonic
        Electrohydraulic
        Laser
       Surgical Therapy
        Nephrolithotomy (Kidney)
        Pyelolithotomy (Renal Pelvis)
        Ureterolithotomy (Ureter)
       Basket Extraction
   Patient Education
       Hydration
           Drink 3 liters of fluid per day (14 cups)
           Water
           Lemonade (citrate decrease stone formation)
       Diet
           Low sodium
           Watch amounts of oxalate
           Low protein
       Exercise/Increase Activity
   Medication

Professional Resources

   Renal Disease: A Manual of Patient Care by
    Lynn Wenig Kagan, RN, PhD
   Differential Diagnosis: Renal and Electrolyte
    Disorders by Saulo Klahr, MD
   MedLine Plus
Journal Article #1
   Purpose: Determine effectiveness of an herbal supplement
    made out of varuna and banana stems, “Herbmed,” on kidney
   Study: 77 patients participated in a randomized, placebo,
    double-blinded study that was conducted in India from July 2007
    to February 2008. Two groups were formed: Group A with calculi
    5-10mm and Group B with calculi >10mm.
   Results: Patients relieving the herbal supplement showed a
    33% reduction in the size of their kidney stone.
   Conclusion: Herbmed is an herbal treatment that may have
    promising effects in reducing kidney stone size and expulsion.
Journal Article #2
   Purpose: To determine the possible effects fructose has on the
    formation of kidney stones.
   Study: The researchers looked at three different cohorts (older
    woman, younger women, and men) over combined 48 years of
    follow up. 4902 new symptomatic kidney stones were documented
    among these three cohorts.
   Results: The results from the study showed that there is a positive
    correlation between the intake of fructose and the development of
    kidney stones.
   Conclusion: Fructose intake can increase insulin resistance which
    lowers the pH in the urine and increases ones’ risk for the
    development of uric acid kidney stone. Nurses need to adequately
    assess the patient’s diet and educate patients on ways to prevent
Journal Article #3
   Purpose: The study looked specifically at anxiety associated with
    treatment, surgery, for kidney stones.
   Study: The anxiety of 66 patients was assessed before and after
    treatment, using three forms of measurement tools: palmar sweat
    test, visual analogue scale, and Speilberger state anxiety
    questionnaire. The two groups that were compared were open
    surgery to minimally/non-invasive treatment.
   Results: The results from the study showed no significant change in
    the questionnaire answers between the three indicators of anxiety.
    But, there was a fair reduction in the analogue scores post-
    operatively in-patients who had open surgery. These same patients
    also had a lower palmar sweat response. But, pre-operatively
    patients who going to have open surgery had higher analogue
   Conclusion: The two primary causes of anxiety were pain and
    being under anesthesia. Open surgery treatment resulted in lower
    levels of anxiety than non-invasive treatments.
Joey has a Kidney Stone….

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