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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
       Imbalance of pH in urine
         Acidic: Uric and Crystine Stones
         Alkaline: Calium Stones
       Gout
       Hyperparathyroidism
       Inflammatory Bowel Disease
       Urine stasis
       UTI
       Medications
         Lasix
         Topamax
         Crixivan
Types of Stones
   -Types of Stones (Chart pg1170)
     -Most stones contain more than one crystals. Classified by crystal that
    makes up the majority of the stone.
   Calcium Oxalate: Most common. Foods high is oxalate, rhubarb, star
    fruit, beets, beet greens, collards, okra, refried beans, spinach, Swiss
    chard, sweet potatoes, sesame seeds, almonds and soy products,
    vitamin D, metabolic disorders, and bypass surgery increase calcium
    oxalate concentration in urine.
   Calcium Phosphate
   Struvite stones: Most often found in women. Result of UTI. Tend to be
    a stag’s-horn shape.
   Uric acid stones. Formed of uric acid, a byproduct of protein
    metabolism. Caused by high protein diet and gout.
   Cystine stones: Fairly uncommon. Caused by kidneys over excreting
    amino acid which is general 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 are key factors are
important to consider?
Signs and Symptoms
   What are the key findings?          Additional S/S:
       Severe flank pain                   Presence of UTI
       Abdominal pain                      Fever or Chills
       Nausea and vomiting                 Pain in groin, labia or
       Fatigue                              testicles
       Elevated temperature, BP,           Cloudy or foul-smelling
        and respirations                     urine
       UA positive for RBC                 Dysuria
       Objective Data:                     Persistent urge to void
        perspiration, clutching of
        the abdomen, doubled-
       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
Diagnostic Studies
   -Test and Diagnostics
        -Blood Analysis: Search for elevated calcium or uric acid.
        -Urine Analysis: Search for stone-forming minerals,
        -Urine Culture
        -CT Scan
        -Abdominal xray: helps monitor stone size
        -Ultrasound: may miss small stones
        -Retrograde Pyelogram
        -Cystoscopy:
   -Intravenous pyelography: A contrast dye is injected into a vein in
    your arm and a series of X-rays is taken as the dye moves
    through your kidneys, ureters and bladder. Helps determine
    stone location and extent of blockage. Not for pt with renal
 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 Dx
Our outcomes and Interven.
   Invention for casestudy and general
   treatment
   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 eliminate the stone form
    the urinary tract.
       Types: extracorporeal shock-wave, percutaneous
        ultrasonic, electrohydraulic, and laser.
   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….

   Asselman, M., & Verkoelen, C. (2008). Fructose intake as a risk factor for kidney stone disease. Kidney
    International, 73(2), 139-140. Retrieved from CINAHL with Full Text database.
   Brown, S. (1990). Quantitative measurement of anxiety in patients undergoing surgery for renal calculus
    disease. Journal of Advanced Nursing, 15(8), 962-970. Retrieved from CINAHL with Full Text database.
   Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G., & Bucher, L. (2007). Medical surgical
    nursing. St.Louis: Mosby, INC. .
   Patankar, S., Dobhada, S., Bhansali, M., Khaladkar, S., & Modi, J. (2008). A prospective, randomized,
    controlled study to evaluate the efficacy and tolerability of Ayurvedic formulation "varuna and banana
    stem" in the management of urinary stones. Journal of Alternative & Complementary Medicine, 14(10),
    1287-1290. Retrieved from CINAHL with Full Text database.
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   (2009, October 8). Kidney Stones in Adults. Retrieved from
   (2009, October 8). Kidney and Urologic DiseasesSstatistics for the United States. Retrieved from

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