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Renal diseases. HLTAP502A Analyse Health Information. Urolithiasis. Urinary stones, they vary in size from microscopic crystals to calculi that are several centimetres in diameter.

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Renal diseases

Renal diseases

HLTAP502A

Analyse Health Information


Urolithiasis
Urolithiasis

  • Urinary stones, they vary in size from microscopic crystals to calculi that are several centimetres in diameter.

  • They can be found in the pelvis of the kidney (the largest being a staghorn), the ureter and the urinary bladder.


The formation of stones relates to factors that
The formation of stones relates to factors that:

  • Increase the supersaturation of urine with calculus forming salts eg

    • Over-excretion of salt (oxalate)

    • Urine acidity

    • Low urine volume

  • Preformed nuclei eg

    • Uric acid crystallites


Types of stones
Types of stones

  • 75% - 80% are composed of calcium (mainly calcium oxalate – found in rhubarb, spinach, cocoa, nuts, pepper, tea)

  • 5%-10% uric acid crystals – uric acid is a by-product of protein metabolism. It crystallises in acidic environments.

  • 2% are cystine – due to an inherited defect in the renal tubules which impairs the reabsorption of the amino acids cystine.

  • The rest are struvite (magnesium ammonium phosphate). Struvite stones are a result of UTI. These stones need to be treated as infected foreign bodies.


Causes of hypercalcaemia
Causes of hypercalcaemia

  • Hyperparathyroidism

  • Renal tubular acidosis

  • Cancer – multiple myeloma, bony metastases

  • Excessive intake of vitamin D


Medications known to cause stones
Medications known to cause stones

  • Antacids

  • Diamox

  • Vitamin D

  • Laxatives

  • Aspirin


Signs and symptoms
Signs and symptoms

  • Commonly cause pain, bleeding, obstruction and secondary infections.

  • Renal colic – typically excruciating and intermittent

    • Originating in the flank, radiating across the abdomen

    • Also into the genital region and inner thigh

    • Calculi in the bladder may cause suprapubic pain


Signs and symptoms cont
Signs and symptoms (cont)

  • GI symptoms such as nausea, vomiting and abdominal distention

  • Chills, fever

  • Haematuria

  • Pyuria

  • Frequency of urination


Diagnosis
Diagnosis

  • History – family, medical, dietary

  • X-Rays – plain, IVP, urogram, MRI, CT

  • Ultrasound

  • Blood chemistries

  • 24-hour urine collection – calcium, creatinine, uric acid, pH

  • Analysis of stones to assess for underlying disorder


Medical treatment
Medical treatment

  • Uteroscopy

  • Chemolysis

  • Nephrostomy

  • Electrohydraulic lithrotripsy

  • Surgical removal


Extracorporeal shock wave lithotripsy
Extracorporeal shock wave lithotripsy

  • Extracorporeal shock wave lithotripsy (ESWL) is a procedure used to shatter simple stones in the kidney or upper urinary tract.

  • Ultrasonic waves are passed through the body until they strike the dense stones.

  • Pulses of sonic waves pulverize the stones, which are then more easily passed through the ureter and out of the body in the urine.



Percutaneous nephrolithotomy
Percutaneous nephrolithotomy

  • The surgeon makes a tiny incision in the back and creates a tunnel directly into the kidney.

  • Using an instrument called a nephroscope, the surgeon locates and removes the stone.

    • For large stones, some type of energy probe (ultrasonic or electrohydraulic) may be needed to break the stone into small pieces.

    • Generally, patients stay in the hospital for several days and may have a small tube called a nephrostomy tube left in the kidney during the healing process.

    • One advantage of percutaneous nephrolithotomy over ESWL is that the surgeon removes the stone fragments instead of relying on their natural passage from the kidney



Nursing interventions
Nursing interventions

  • Assessments – vitals, pain, urine

  • Relieve pain

    • Medication

    • Positioning

    • Apply heat

  • FBC – input/output

  • Urine observations

    • Straining

    • Testing – blood, UTI

    • Volume

  • Treat other symptoms – fever, N/V, abdominal distension



Causes
Causes

  • Decreased blood flow – shock, burns, dehydration

  • Over exposure to metals, solvents, radiographic contrast, some antibiotics

  • Myoglobinuria

  • Direct injury to the kidney

  • Infections – pyelonephritis, septicaemia

  • Urinary tract obstruction – tumours, stones

  • Disorders of the blood – transfusion reactions


Clinical manifestations
Clinical Manifestations

  • Decreased urinary output

    • Oliguria – less than 100mls per day

    • Anuria – no urine passed

  • Hypertension

  • Oedema

  • Anorexia

  • Metallic taste in mouth

  • Persistent hiccoughs

  • Changes in mental status or mood

  • Nausea, vomiting

  • Bleeding – bruising, GIT, urinary

  • Pain – flank

  • Halitosis


Phases of arf
Phases of ARF

  • Initial period – ends when oliguria develops

  • Period of oliguria – show uraemic symptoms

  • Period of diuresis

  • Period of recovery – may take 3-12 months


Treatment
Treatment

  • Treat the cause

  • Maintain fluid balance

  • Restore and maintain chemical balance

  • Dietary

    • Restrict sodium, potassium, proteins

    • Increase carbohydrates

  • Diuretics may be used to initiate diuresis

  • Prevent complications

  • Dialysis – peritoneal, haemodialysis


Complications of arf
Complications of ARF

  • End stage renal failure

  • Cardiovascular – CCF, pericarditis

  • Pulmonary system – APO

  • Nervous system – generalised seizures, coma

  • Chronic renal failure

  • GIT – blood loss, stress ulcers, gastritis

  • Hypertension

  • Electrolyte imbalances – hyperkalaemia, hyponatraemia



Continuous ambulatory peritoneal dialysis capd
Continuous ambulatory peritoneal dialysis (CAPD)

  • The patient has a permanent access port in the abdomen.

  • Dialysis fluid (1.5-3litres) is drained into the peritoneal cavity and left there for 4-5 hours

  • The dialysate with wastes is then drained from the peritoneal cavity, and more fluid added.

  • This is repeated about 4-5 times a day



Vascular access
Vascular access

  • There are three basic kinds of vascular accesses for haemodialysis:

    • an arteriovenous (AV) fistula,

    • an AV graft, and

    • a venous catheter.

  • The AV fistula is considered the best long-term vascular access for haemodialysis because it provides adequate blood flow for dialysis, lasts a long time, and has a complication rate lower than the other access types.

  • The fistula takes 6-8 weeks to mature



Care of access site
Care of access site

  • Check access site before each treatment.

  • Be careful of trauma to access.

  • Don't take blood pressure on arm with access.

  • Patient not to wear jewellery or tight clothes over access site.

  • Patient not to sleep with access arm under head or body.

  • Patient not to lift heavy objects or put pressure on access arm.

  • Patient to check the pulse in access every day.



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