Supra pubic cystostomy

UROLITHIASIS
Presented by----
Mrs. Usha Rani Kandula,
MSc.Nursing, Assistant professor,
Department of Adult Health Nursing,
College of Health Sciences,
Arsi University, Asella, Ethiopia.

Definition of Urolithiasis
 Urolithiasis refers to stones (calculi) in the
urinary tract.
 Stones are formed in the urinary tract when
urinary concentrations of substances such
as
 --calcium oxalate,
 --calcium phosphate, and
 --uric acid increase.

Con--
 This is referred to as super saturation and
is dependent on--
 -The amount of the substance,
 Ionic strength, and
 pH of the urine.

Types of Urinary Calculi
 The term calculus refers to the stone, and
lithiasis refers to stone formation.
 The five major categories of stones are
 (1) calcium phosphate,
 (2) calcium oxalate,
 (3) uric acid,
 (4) cystine, and
 (5) struvite (magnesium ammonium
phosphate)

Risk factors of Urolithiasis
--Certain factors favor the formation of
stones, including;
 infection,
 urinary stasis, and
 Periods of immobility (slows renal drainage
and alters calcium metabolism).

 In addition, increased calcium
concentrations in blood and urine promote
precipitation of calcium and formation of
stones (about 75% of all renal stones are
calcium-based).
 Causes of hypercalcemia (high serum
calcium) and hypercalciuria (high urine
calcium).

Causes of hypercalcemia include the
following:
 Hyperparathyroidism
 • Renal tubular acidosis
 • Cancers
 • Granulomatous diseases (sarcoidosis,
tuberculosis),
 --which may cause increased vitamin D
production by the granulomatous tissue.

 • Excessive intake of vitamin D
 • Excessive intake of milk and alkali
 • Myelo proliferative diseases
(leukemia, polycythemia vera, multiple
myeloma),
--which produce an unusual proliferation of
blood cells from the bone marrow.

Causes of urolithiasis
 Many factors are involved in the incidence
and type of stone formation, including
 Metabolic,
 Dietary,
 Genetic,
 Climatic, etc.

Con--
 Crystals, when in a supersaturated
concentration, can precipitate and unite to
form a stone.
 Keeping urine dilute and free flowing
reduces the risk of recurrent stone
formation in many individuals.

PATHOPHYSIOLOGY OF
UROLITHIASIS

Pathophysiology of Urolithiasis
Due to etiological factors .
deficiency of substances that normally
prevent crystallization in the urine, such as
citrate, magnesium, nephrocalcin, and
uropontin.

Con--
Decreased water intake of the patient
dehydrated patients
Calculi may be found anywhere from the
kidney to the bladder

CLINICAL MANIFESTATIONS
OF UROLITHIASIS

Clinical manifestations of
urolithiasis
 Signs and symptoms of stones in the
urinary tract depend on
 obstruction,
 infection, and
 edema.

 When the stones block the flow of urine,
obstruction develops, producing an
increase in hydrostatic pressure and
distending the renal pelvis and proximal
ureter.

Con--
 Infection
ex: pyelonephritis and cystitis with chills,
fever, and
dysuria
--can occur from constant irritation by the
stone.

 Some stones cause few, if any, symptoms
while slowly destroying the functional units
(nephrons) of the kidney; others cause
excruciating pain and discomfort.

 -Stones in the renal pelvis may be
associated with an intense, deep ache in
the costovertebral region.

 Hematuria is often present;
 pyuria may also be noted.
 -Pain originating in the renal area radiates
anteriorly and downward toward the
bladder in the female and
 --toward the testis in the male.

 If the pain suddenly becomes acute, with
tenderness over the costovertebral area,
and
 -nausea and vomiting appear, the patient is
having an episode of renal colic.
 -Diarrhea and abdominal discomfort may
occur.

 These GI symptoms are due to
renointestinal reflexes and the anatomic
proximity of the kidneys to the stomach,
pancreas, and large intestine.

 -Stones lodged in the ureter (ureteral
obstruction) cause acute, excruciating,
colicky, wavelike pain, radiating down the
thigh and to the genitalia.

 Often, the patient has a desire to void, but
little urine is passed, and it usually
contains blood because of the abrasive
action of the stone.
 - This group of symptoms is called ureteral
colic.

 Stones lodged in the bladder usually
produce symptoms of irritation and may be
associated with UTI and hematuria.
 - If the stone obstructs the bladder neck,
urinary retention occurs.

 -If infection is associated with a stone, the
condition is far more serious, with sepsis
threatening the patient’s life.

Diagnostic investigations
 The diagnosis is confirmed by
 x-ray films of the kidneys, ureter, and
bladder (KUB)
 or by ultrasonography,
 intravenous urography,
 or retrograde pyelography.

 Blood chemistries and a 24-hour urine test
for measurement of
 calcium,
 uric acid,
 creatinine,
 sodium, pH, and total volume are part of
the diagnostic workup.

History and physical examination
 Dietary and medication histories and family
history of renal stones are obtained to
identify factors predisposing the patient to
the formation of stones.

 When stones are recovered (stones may
be freely passed by the patient or removed
through special procedures), chemical
analysis is carried out to determine their
composition.

 -Stone analysis can provide a clear
indication of the underlying disorder.

 In some situations,
 --ultrasound and
 -- IVP (intravenous pyelography) are used.

 -A complete urinalysis helps confirm the
diagnosis of a urinary stone by assessing
for hematuria, crystalluria, and urinary pH.

Medical Management
 The basic goals of management are to
 -eradicate the stone,
 -to determine the stone type,
 -to prevent nephron destruction,
 -to control infection,
 -and to relieve any obstruction that may be
present.

 The immediate objective of treatment of
renal or ureteral colic is to relieve the pain
until its cause can be eliminated.

 -Opioid analgesics are administered to
prevent shock and syncope that may result
from the excruciating pain.
 -NSAIDs may be as effective as other
analgesics in treating renal stone pain.

 Hot baths or moist heat to the flank areas
may also be useful.
 -Unless the patient is vomiting or has heart
failure or any other condition requiring fluid
restriction, fluids are encouraged.

 This increases the hydrostatic pressure
behind the stone, assisting it in its
downward passage.

 -A high, around-the-clock fluid intake
reduces the concentration of urinary
crystalloids, dilutes the urine, and ensures
a high urine output.
 -Nutritional therapy plays an important role
in preventing renal stones.

 -Fluid intake is the mainstay of most
medical therapy for renal stones.
 -Unless contraindicated, any patient with
renal stones should drink at least eight 8-
ounce glasses of water daily to keep the
urine dilute.
 -A urine output exceeding 2 L a day is
advisable.

-Calcium Stones.
 patients with calcium-based renal stones
were advised to restrict calcium in their
diet.
 supports a liberal fluid intake along with
dietary restriction of protein and sodium.

Uric Acid Stones.
 For uric acid stones, the patient is placed
on a low-purine diet to reduce the
excretion of uric acid in the urine.
 -Foods high in purine (shellfish, anchovies,
asparagus, mushrooms, and organ meats)
are avoided, and other proteins may be
limited.

-Oxalate Stones.
 -For oxalate stones, a dilute urine is
maintained and the intake of oxalate is
limited.
 -Many foods contain oxalate;
 -These include spinach, strawberries,
chocolate, tea, peanuts.

SURGICAL MANAGEMENT
 If the stone is not passed spontaneously or
if complications occur, treatment modalities
may include surgical, endoscopic, or other
procedures—for example,
 ureteroscopy,
 Extracorporeal shock wave lithotripsy
(ESWL), or endourologic
(percutaneous)stone removal.

Ureteroscopy
 -Ureteroscopy involves first visualizing the
stone and then destroying it.
 Access to the stone is accomplished by
inserting a ureteroscope into the ureter and
then inserting a laser, electrohydraulic
lithotriptor, or ultrasound device through
the ureteroscope to fragment and remove
the stones.

 -A stent may be inserted and left in place
for 48 hours or more after the procedure to
keep the ureter patent.
 -Hospital stays are generally brief, and
some patients can be treated as
outpatients.

ESWL
(Extracorporeal shock wave
lithotripsy)
 -ESWL is a noninvasive procedure used to
break up stones in the calyx of the kidney.
 -After the stones are fragmented to the
size of grains of sand, the remnants of the
stones are spontaneously voided.


 In ESWL, high-energy amplitude of
pressure, or shock wave, is generated by
the abrupt release of energy and
transmitted through water and soft tissues.

 -When the shock wave encounters a
substance of different intensity (a renal
stone), a compression wave causes the
surface of the stone to fragment.

 -Repeated shock waves focused on the
stone eventually reduce it to many small
pieces. These small pieces are excreted in
the urine, usually without difficulty.

 -An average treatment comprises between
1,000 and 3,000 shocks.
 -The first-generation lithotriptors required
use of either regional or general
anesthesia.

 -Second- and thirdgeneration lithotriptors,
many of which also employ ultrasound
guidance, require little to no anesthesia.

 -Although the shock waves usually do not
damage other tissue, discomfort from the
multiple shocks may occur.

 -The patient is observed for obstruction
and infection resulting from blockage of the
urinary tract by stone fragments.

 - All urine is strained after the procedure;
voided gravel or sand is sent to the
laboratory for chemical analysis.
 -Several treatments may be necessary to
ensure disintegration of stones.

-Endourologic methods of stone
removal
 -Endourologic methods of stone removal
may be used to extract renal calculi that
cannot be removed by other procedures.

percutaneous nephrostomy
 -A per-cutaneous nephro-stomy or a per-
cutaneous nephro-lithotomy (which are
similar procedures) may be performed, and
a nephro-scope is introduced through the
dilated per-cutaneous tract into the renal
parenchyma.

 Depending on its size, the -stone may be
extracted with forceps or by a stone
retrieval basket.
 -Alternatively, an ultrasound probe may be
introduced through the nephrostomy tube.

 -Then, ultrasonic waves are used to
pulverizethe stone.
 -Small stone fragments and stone dust are
irrigated and suctioned out of the collecting
system.

 -Larger stones may be further reduced by
ultrasonic disintegration and then removed
with forceps or a stone retrieval basket.

 -Electrohydraulic lithotripsy is a similar
method in which an electrical discharge is
used to create a hydraulic shock wave to
break up the stone.

 -A probe is passed through the cystoscope,
and the tip of the lithotriptor is placed near
the stone.
 -The strength of the discharge and pulse
frequency can be varied.

 -This procedure is performed under topical
anesthesia.
 -After the stone is extracted, the
percutaneous nephrostomy tube is left in
place for a time to ensure that the ureter is
not obstructed by edema or blood clots.

 - The most common complications are
hemorrhage, infection, and urinary
extravasation.
 -After the tube is removed, the
nephrostomy tract closes spontaneously.

 A percutaneous nephrostomy is performed,
and the warm irrigating solution is allowed
to flow continuously onto the stone.
 -The irrigating solution exits the renal
collecting system by means of the ureter or
the nephrostomy tube.

 -The pressure inside the renal pelvis is
monitored during the procedure.
 -Several of these treatment modalities may
be used in combination to ensure removal
of the stones.

 A nephrolithotomy is an incision into the
kidney to remove a stone.
 A pyelolithottoomy is an incision into the
renal pelvis for stone removal.

 If the stone is located within the ureter, a
ureterolithotomy is performed.
 A cystotomy may be indicated for bladder
calculi.

Nephrolithotomy
 If the stone is in the kidney, the surgery
performed may be a nephrolithotomy
(incision into the kidney with removal of the
stone) or a nephrectomy, if the kidney is
nonfunctional secondary to infection or
hydronephrosis.

 -Stones in the kidney pelvis are removed
by a pyelolithotomy, those in the ureter by
ureterolithotomy, and those in the bladder
by cystotomy.

NURSING PROCESS:
THE PATIENT WITH KIDNEY
STONES

Assessment
 The patient with suspected renal stones is
assessed for pain and discomfort as well
as associated symptoms, such as nausea,
vomiting, diarrhea, and abdominal
distention.
 The severity and location of pain are
determined, along with any radiation of the
pain.

 Nursing assessment also includes
observing for signs and symptoms of UTI
(chills, fever, dysuria, frequency, and
hesitancy) and obstruction (frequent
urination of small amounts, oliguria, or
anuria).

 The urine is inspected for blood and is
strained for stonesor gravel.
 -The history focuses on factors that
predispose the patient to urinary tract
stones or that may have precipitated the
current episode of renal or ureteral colic.

 Predisposing factors include family history
of stones, the presence of cancer or bone
marrow disorders or the use of
chemotherapeutic agents, inflammatory
bowel disease, or a diet high in calcium or
purines.

 -Factors that may precipitate stone
formation in the patient predisposed to
renal calculi include episodes of
dehydration, prolonged immobilization, and
infection.

 -The patient’s knowledge about renal
stones and measures to prevent their
occurrence or recurrence is also assessed.

NURSING DIAGNOSES
-Based on the assessment data, the nursing
diagnoses in the patient with renal stones
may include the following:
 • Acute pain related to inflammation,
obstruction, and abrasion of the urinary
tract
 • Deficient knowledge regarding prevention
of recurrence of renal stones

POTENTIAL COMPLICATIONS
 Based on assessment data, potential
complications that may develop include the
following:
 • Infection and sepsis (from UTI and
pyelonephritis)
 • Obstruction of the urinary tract by a stone
or edema with subsequent acute renal
failure

Planning and Goals
 The major goals for the patient may
include relief of pain and discomfort,
prevention of recurrence of renal stones,
and absence of complications.

Nursing Interventions
 RELIEVING PAIN
 Immediate relief of the severe pain from
renal or ureteral colic is accomplished with
the administration of opioid analgesic
agents (intravenous or intramuscular
administration may be prescribed to
provide rapid relief) or NSAIDs (ie,
ketorolac).

 - The patient is encouraged and assisted to
assume a position of comfort.
 - If activity brings some pain relief, the
patient is assisted to ambulate.

 Retrieval and analysis of the stones are
important in the diagnosis of the underlying
problem contributing to stone formation.
 -The patient’s serum calcium, phosphorus,
sodium, potassium, bicarbonate, uric acid,
BUN, and creatinine levels are also
measured.

 -A careful history should include any
previous episodes of stone formation,
prescribed and OTC medications, dietary
supplements, and family history of urinary
calculi.

 The pain level is monitored closely, and
increases in severity are reported promptly
to the physician so that relief can be
provided and additional treatment initiated.

 The patient is prepared for other treatment
(eg, lithotripsy, percutaneous stone
removal, ureteroscopy, or surgery) if
severe pain is unrelieved and the stone is
not passed spontaneously.

MONITORING AND MANAGING POTENTIAL
COMPLICATIONS
 -Because renal stones increase the risk for
infection, sepsis, and obstruction of the
urinary tract, the patient is instructed to
report decreased urine volume and bloody
or cloudy urine.
 -The total urine output and patterns of
voiding are monitored.

 - Increased fluid intake is encouraged to
prevent dehydration and increase
hydrostatic pressure within the urinary tract
to promote passage of the stone.

 -If the patient cannot take adequate fluids
orally, intravenous fluids are prescribed.
 Ambulation is encouraged as a means of
moving the stone through the urinary tract.

 -Patients with calculi require frequent
nursing observation to detect the
spontaneous passage of a stone.
 -All urine is strained through gauze
because uric acid stones may crumble.

 -Any blood clots passed in the urine should
be crushed and the sides of the urinal and
bedpan inspected for clinging stones.
 -The patient is instructed to report any
sudden increases in pain immediately
because of the possibility of a stone
fragment obstructing a ureter.

 -Analgesic medications are administered
as prescribed for the relief of pain and
discomfort.
 -Vital signs, including temperature, are
monitored closely to detect early signs of
infection.

 UTIs may be associated with renal stones
due to an obstruction from the stone or
from the stone itself.
 -All infections should be treated with the
appropriate antibiotic agent before efforts
are made to dissolve the stone.

PROMOTING HOME AND COMMUNITY-BASED
CARE
 Teaching Patients Self-Care
 -Because the risk of recurring renal stones
is high, the nurse provides education about
the causes of kidney stones and ways to
prevent their recurrence (Chart 45-12).

 -The patient is encouraged to follow a
regimen to avoid further stone formation.
 -One facet of prevention is to maintain a
high fluid intake because stones form more
readily in concentrated urine.

 - A patient who has shown a tendency to
form stones should drink enough fluid to
excrete greater than 2,000 mL of urine
every 24 hours (preferably 3,000 to 4,000
mL), should adhere to the prescribed diet,
and should avoid sudden increases in
environmental temperatures, which may
cause a fall in urinary volume.

 Occupations and activities that produce
excessive sweating can lead to severe
temporary dehydration; therefore, fluid
intake should be increased.

 -Sufficient fluids should be taken in the
evening to prevent urine from becoming
too concentrated at night.
 -Urine cultures may be performed every 1
to 2 months the first year and periodically
thereafter.
 Recurrent UTI is treated vigorously.

 -Because prolonged immobilization slows
renal drainage and alters calcium
metabolism, increased mobility is
encouraged whenever possible.
 -In addition, excessive ingestion of
vitamins (especially vitamin D) and
minerals is discouraged.

 -If lithotripsy, per-cutaneous stone removal,
uretero-scopy, or other surgical procedures
for stone removal have been performed,
the patient is instructed about the signs
and symptoms of complications that need
to be reported to the physician.

 The importance of follow-up to assess
kidney function and to ensure the
eradication or removal of all kidney stones
is emphasized to the patient and family.
 -If the patient underwent ESWL, the nurse
must provide instructions for home care
and necessary follow-up.

 The patient is encouraged to increase fluid
intake to assist in the passage of stone
fragments, which may occur for 6 weeks to
several months after the procedure.

 -The patient and family are instructed
about signs and symptoms that indicate
complications, such as fever, decreasing
urine output, and pain.

 It is also important to tell the patient to
expect hematuria (it is anticipated in all
patients), but it should disappear within 4
to 5 days.
 - If the patient has a stent in the ureter,
hematuria may be expected until it is
removed.

 -The patient is instructed to notify the
physician if nausea or vomiting, a
temperature greater than 38°C (about
101°F), or pain unrelieved by the
prescribed medication occurs.
 The patient is also informed that a bruise
may be observed on the treated side of the
back.

Continuing Care
 The patient is monitored closely in follow-
up care to ensure that treatment has been
effective and that no complications, such
as obstruction, infection, renal hematoma,
or hypertension, have developed.

 During the patient’s visits to the clinic or
physician’s office, the nurse has the
opportunity to assess the patient’s
understanding of ESWL and possible
complications.

 Additionally, the nurse has the opportunity
to assess the patient’s understanding of
factors that increase the risk for recurrence
of renal calculi and strategies to reduce
those risks.

 The patient’s ability to monitor urinary pH
and interpret the results is assessed during
follow-up visits to the clinic or physician’s
office.

 -Because of the high risk for recurrence,
the patient with renal stones needs to
understand the signs and symptoms of
stone formation, obstruction, and infection
and the importance of reporting these
signs promptly.

 If medications are prescribed for the
prevention of stone formation, the actions
and importance of the medications are
explained to the patient.

Nephrolithotomy or Pyelolithotomy
-A large staghorn renal calculus that does
not dislodge from the calyces or renal
pelvis may need to be removed through an
open incision.

 -A nephroscope may be used during the
surgical procedure for direct visual
examination of the nephrons to locate and
remove residual calculi.

-Ultrasound may also be used to identify
retained fragments.
- Localized hypothermia provides the
surgeon with a bloodless surgical field and
lengthens the time in which the renal artery
may be clamped safely without a loss of
renal function during the search for and
extraction of calculi.

Supra pubic cystostomy

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