UROLITHIASIS (URINARY CALCULI)

1. UROLITHIASIS (URINARY CALCULI) Medical Surgical Nursing III By : Rahayu Setyowati, SKp. Nursing Academy of YPIB Majalengka

2. OBJECTIVE At the end of this session, student should be able to: 1. Understand and explainof the definition of urolithiasis 2. Understand and explain of the pathophisiology of urolithiasis 3. Understand and explain of the risk factor of urolithiasis 4. Understand and explainof the clinical manifestation of urolithiasis 5. Understand and explainof the complication of urolithiasis 6. Understand and explainof the diagnostic test of urolithiasis 7. Understand and explainof the medical management of urolithiasis 8. Understand and explainof the nursing process of urolithiasis

3. DEFINITION Urinary Calculi adanya batu didalam sal. Kemih . Lithiasis formasi batu - di dlm ginjal : nephrolitiasis - pada sal kemih lain : urolithiasis Lemone,P & Burke,K(2004) Batu terbentuk karena konsentrasi yang tinggi zat2 seperti calcium oxalate, calcium phosphate and asam urat didalam darah dan Urin. Smeltzer,SC & Bare,B(2004)

5. cont… pathophysiology • TIPE BATU • Batu Calcium 75% to 80% dari batu ginjal . Batu Calcium biasanya karena konsentrasi yang tinggi dalam darah dan urin. • Batu Asam Urat adanya konsentrasi yang tinggi asam urat didalam darah dan biasanya dihubungkan dengan penyakit gout • Batu Sturvite dikaitkan dengan infeksi sal kemih • Batu Cystine stones • jarang terjadi tetapi boasanya berhub dgn keturunan • Lemone,P & Burke,K(2004)

6. RISK FACTORS Calcium stones : Hypercalciuria and hypercalcemia : hyperparathyroidm, immobility, bone disease,vit D intoxication,multiple myeloma,renal tubular acidosis, prolonged steroid intake Uric acid stones: Gout, tinggi intake purine, acid urine Sturvite stones : UTI, especially Proteus infections. Cystine stones : genetic defect. Lemone,P & Burke,K(2004)

7. CLINICAL MANIFESTATIONS • KIDNEY STONES • sering asymptomatic • sakit pada bagian pinggang • microscopic hematuria • manifestations of UTI (demam, frequency, urgency, dysuria) URETERAL STONES • Renal colic : - nyeri pinggang akut • - sering menjalar pada area suprapubik, pangkal paha dan external genitals • mual, muntah, pucat, kulit lembab BLADDER STONE • bisa asymptomatic • sakit area suprapubic • gross or mocroscopic hematuria • manifestasi ISK

8. COMPLICATIONS MANAGEMENT OF URINARY CALCULI • OBSTRUCTIONS- • HYDRONEPHROSIS- • INFECTION- • relieving acute symptom • removing stone • preventing further • stone formation

9. DIAGNOSTIC TESTS • Urinalysis  assess for hematuria, WBCs and crystal, pH urine. • Urine calcium, uric asid, and oxalate. (nursing responsibilities for collecting at 24-hour urine specimen) • X-Ray (Kidney Ureter Bladder – KUB) • Ultrasonography • CT Scan • IVP ( Intravenous Pyelography) Created by ma2 kiyya

11. MEDICATIONS and DIETARY medications dietary Calcium Phospha te and or oxalate Sturvite Uric acid Cystine Thiazid diuretics, Phosphates, calcium- binding agents Antibotic therapy for UTI Potassium citrate, Allopurinol Penicillamine, Sodium bicarbonate Kurangi makanan tinggi calcium and oxalate, Tingkatkan intake vit C, Perbanyak minum, Exercise (olah Raga) operasi or lithotripsy Diet rendah purine , Tingkatkan jml minum Kurangi garam Tingkatkan minum Smeltzer,SC & Bare,B(2004)

12. Examples of Food and Fluids for Teaching Clients with Urolithiasis Food high in Calcium Food high in Oxalate Purine-rich foods acidifying foods Beans and lentils, chocolate, dried fruits, flour, milk and milk products canned or smoked fish except tuna. Asparagus, beer & colas, beets, cabbage, celery, Cocolate, fruits, green beans, nuts, tea, tomatoes. Goose, organ meats, sardines and herring, venison Moderate in beef, chicken, crab, pork, salmon, veal. Cheese, cranberries, eggs, grapes, meat and poultry Plum and prunes, tomatoes, whole grains

13. OPERASI • Tindakan operasi tergantung dari : • the location of the stone, • the extent of obstruction, • renal function, • the presence or absence of UTI • the client’s general state of health. In general, the stone is removed if it causing severe obstruction, infection, unrelieved pein, or serious bleeding (Braunwald et al., 2001)

14. Cont…surgery • LITHOTRIPSY = using sound or shock waves to crush a stone. Extracorporeal Shock Wave Lithotripsy (ESWL) is a noninvasive Technique for fragmenting kidney stone using shock waves generated outside the body. Percutaneous Ultrasonic Lithotripsy uses a nephroscope inserted into the kidney through a small flank incision. Surgical intervention (rare) to remove a calculus in the renal pelvis or Ureter  Ureterolitotomy, Pyelolithotomy, nephrolitotomy.

17. NURSING CARE OF THE CLIENT HAVING LITHOTRIPSI • PREOPERATIVE CARE • assess knowledge and understanding of the procedure, providing information as needed. • follow directions from the radiologis departement, psycian, or anestheties for withholding food and fluids and for bowel preparation prior to surgery. POSTOPERATIVE CARE • in the initial period, monitor vital sign frequently. • monitor amount, color, and clarity of urine output • maintain placement and patency of urinary catheters • prepare for discharge by teching care of indwelling catheter, urine- collection device. Teach signs and symptoms of infection. • teach measures to reduce the risk of further lithiasis

18. NURSING PROCESS • ASSESSMENT Health history : - complaints of flank, back, or abdominal pain, radiation, - characteristic and timing, aggravating or relieving factor; - nausea and vomiting; - posible contributing such as dehydration; - family history of kidney stone; - current or previous treatment measures. Physical examination : - position, vital sign, skin color, temperature, moisture, turgor - costovertebral tenderness; - amount, color and characteristics urine

19. Cont…nursing process • NURSING DIAGNOSES 1. Acut Pain releated to inflammation, obstruction, and abrasion of the urinary tract. 2. Potential complication releated to obstruction 3. Deficient knowledge regarding prevention of recurrence of renal stone.

20. Cont…nursing process • PLANNING 1. Acut Pain releated to inflammation, obstruction, and abrasion of the urinary tract. Goal : relieving pain Nursing interventions : # assess pain using standard pain scale and its caracteristics. # administer analgesia as ordered and monitor its effectiveness. (intensity, type of pain, and responsiveness to analgetic) # encourage fluid intake and ambulation in the client with renal colic (increased fluid and ambulation increase urinary output, facilitating movement of the calculus through the ureter and decreasing pain) # use nonpharmacologic measures such as positioning, moist heat, relaxation technique, guided imagery. (adjunctive pain relief measures can enhance the effeciveness of analgesics) # if surgery has been performed, monitoring urinary output, catheters, incision, and wound care. (pain may be a symptom of proximal distention due to a blocked catheter. Infection or hematoma at the surgical site can significantly increase pain)

21. Cont…nursing process 2. Potential complication releated to obstruction Goal : monitoring and managing potential complications Nursing interventions : # monitor amount and character of urine output. If catheterized, measure output hourly. (the amount of urinary output helps determine possible urinary tract obstruction and adequacy hydration) # document any hematuria, dysuria, frequency, urgency, and pyuria. (hematuria is often associated with calculi and with procedure used to remove stones)(dysuria, frequency, urgency are symptom of UTI, often associated with urolithiasis) # strain all urine for stone, saving any recovered stone for laboratory analysis. (analysis of stone recovered from the urine can direct measures to prevent further lithiasis) # maintain patency and integrity of all catheter system. # secure catethers well, label is indicated, and use sterile tech- nique for all ordered irrigations or other procedure.

22. Cont…nursing process 3. Deficient knowledge regarding prevention of recurrence of renal stone. Goal : teaching patient self care Nursing interventions : # assess understanding and previous learning. # teach about all diagnostic and treatment procedures. # teach measures to prevent further urolithiasis - increase fluid intake to 2500-3500 ml per day - follow recommended dietary guidelines - maintain actifity level to prevent urinary statis and bone resorption. - take medications as prescribed. (the risk current lithiasis is approximately 50%) # teach about the relationship between urinary calculi and UTI.

23. Cont…nursing process • IMPLEMENTATION • EVALUATION Expected patient outcome may include : 1. report relief of pain 2. experiences no complications : - report no sign or symptom of sepsis or infection - voids 200 – 400 ml per voiding of clear urine without evidence bleeding. - experiences absence of dysuria, frequency, and urgency - maintains normal body temperature 3. state increased knowledge : - consumes increased fluid intake (2500-3000ml/day) - participates in appropriate activity - consumes diet prescribed - takes prescribed medication as directed to reduce stone formation.