Nephrolithiasis

Molly Tonder and Britta Jepsen

November 11, 2009 Seminar

Pathophysiology
1. Ultra-concentrated urine allows crystals to form more easily and also inhibits urine from flowing freely.
2. Altered pH affects solubility of crystals Calcium and phosphate (higher) Uric acid and cystine (lower)

Risk Factors
Inadequate fluid intake

Exposure to warm, dry weather

Male (except struvite stones) 20-55 years of age

Caucasian
Family history Occupation that is outdoors and/or requires a great deal of physical activity

Increased oxalate, calcium, sodium or phosphate intake

Sedentary lifestyle

What signs and symptoms does S.R. present to the ED with?

Presenting Signs and Symptoms

Flank, back and/or abdominal pain (can radiate to groin as passing)

Guarding
Warm, moist skin Nausea, vomiting Restlessness Fatigue Urinary infection (fever, chills) Hematuria

Decreased urinary output

Frequency, urgency, feeling of bladder fullness

Question 2: What questions do you need to ask before an IVP? What do you need to check in her blood? Question 3: Alternative tests

Normal IVP

IVP showing stone

Other Diagnostic Tests

Serum calcium, phosphorus, sodium, potassium, bicarbonate, uric acid, creatinine, BUN (for renal function and stone formation)
Urine pH

X-ray (will identify larger stones)

CT (differentiates stone from tumor) IVP

Question 4: Common types Question 5: Causes

Question 6: Treatment

Percutaneous Ultrasonic Lithotripsy (PUL)

Extracorporeal Shock Wave Lithotripsy (ESWL)

Discuss Brown article

Question 7: Specific instructions Discuss Larkin article

Question 8: Care plan

Nursing Diagnoses
Acute pain related to ureteral stone as evidenced by pt stating lots of pain, doubled over, clutching abdomen.
Ineffective therapeutic regimen management related to not following prior advice for prevention as evidenced by PMH indicating 3 previous kidney stone attacks. Risk for deficient fluid volume related to inadequate fluid intake and occupation requiring work outside in the hot weather. Anxiety related to extreme prolonged pain as evidenced by pacing, doubled over.

Question 9/10: Prevention

Discuss Moyad article

Prevention
Increase fluid intake to produce UO of 2L/day (prevents supersaturation of minerals) Glass of lemonade per day (citrate binds with calcium, so its not free and cant form a stone) Low sodium diet (high sodium increases calcium excretion, want to reabsorb so it doesnt get into urine which also aids bone strength) Normal calcium intake (promotes normal oxalate excretion) Low oxalate diet (if oxalate stone)

Oxalate Foods
HIGH
Spinach, Asparagus, Beets, Celery
Rhubarb, Blackberries, Blueberries, Raspberries Beans, Tomatoes Nuts, Chocolate Instant coffee, Ovaltine Dark beer, Soy Pretzels

LOW
Lemonade, certain herbal teas, Milk, Cola, Wine
Cabbage, Cauliflower, Cucumber, Radishes Cheese, Grapefruit, Nectarines, Bananas, Melons Bacon, Fish, Lamb Cheerios, Macaroni, Pasta Graham crackers

High fiber cereal

English muffins, Honey

Jello

References
Brown, S.M. (1990). Quantitative measurement of anxiety in patients undergoing surgery for renal calculus disease. Journal of Advanced Nursing, 15, 962-970. Deglin, J.H., & Vallerand, A.H. (2007). Daviss drug guide for nurses. Philadelphia: F.A. Davis Company. Harwood, C.T. (1985). Pulverizing kidney stones: What you should know about lithotripsy. RN, 48(7), 32-37. Larkin, G.L., Peacock, W.F., Pearl, S.M., Blair, G.A., & DAmico, F. (1999). Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic. American Journal of Emergency Medicine 17(1), 6-10.

Levine, D.Z. (1983). Care of the renal patient. Philadelphia: W.B. Saunders Company.
Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., OBrien, P.G., & Bucher, L. (2007). Medical-surgical nursing. St. Louis: Mosby Elsevier. Low oxalate diet. (2003). University of Pittsburgh Medical Center. Retrieved from http://www.upmc. com/ HealthAtoZ/patienteducation/Documents/LowOxalateDiet.pdf. Mayo clinic staff. (2008). Kidney stones. Retrieved from http://www.mayoclinic.com/health/kidney-stones/DS00282.

References Continued
Moyad, M.A. (2003). Calcium oxalate kidney stones: Another reason to encourage moderate calcium intakes and other dietary changes. Urologic Nursing, 23(4), 310-313. OBrien, P.G., Dirksen, S.R., Lewis, S.L., Heitkemper, M.M., & Bucher, L. (2007). Medical-surgical nursing: clinical companion. St. Louis: Mosby Elsevier. Preusser, B.A. (2009). Critical thinking cases in nursing. St. Louis: Mosby, Inc. Swearingen, P.L., & Ross, D.G. (1999). Manual of medical-surgical nursing care. St. Louis: Mosby, Inc.

(2008). Adult conditions: stones. Retrieved from http://www.urologyhealth.org/adult/index.cfm?cat =12&topic=102.