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  1. Kidney Stones Kim Applebee Alex Kaullen

  2. Definition • 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.

  3. Statistics • 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)

  4. Kidney Stone Formation • Causes: • Highly concentrated urine, urine stasis • Imbalance of pH in urine • Acidic: Uric and Crystine Stones • Alkaline: Calcium Stones • Gout • Hyperparathyroidism • Inflammatory Bowel Disease • UTI • Medications • Lasix, Topamax, Crixivan http://www.pilotfriend.com/aeromed/medical/images2/25.jpg

  5. Types of Stones • Calcium Oxalate • Most common • Calcium Phosphate • Struvite • More common in woman than men. • Commonly a result of UTI. • Uric Acid • Caused by high protein diet and gout. • Cystine • Fairly uncommon; generally linked to a hereditary disorder.

  6. 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.

  7. What key factors are important to consider?

  8. What are the key findings? Severe flank pain Abdominal pain Nausea and vomiting Fatigue Elevated temperature, BP, and respirations UA positive for RBC Objective Data: perspiration, clutching of the abdomen, doubled-over. Steady Pain Left flank tendernes Additional S/S: Presence of UTI Fever or Chills Pain in groin, labia or testicles Cloudy or foul-smelling urine Dysuria Persistent urge to void Signs and Symptoms http://knol.google.com/k/-/-/27ifsyywko3wx/sqc1f9/kidneystonesymptoms.jpg

  9. What additional information should you ask this patient?

  10. 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? http://erstories.net/wp-content/uploads/2008/10/kidneystone1a.jpg

  11. Identify this patient’s risk factors.

  12. What are her risk factors? Past Medical History Hx of 3 kidney stone attacks Dehydration/Lack of Fluids Occupational exposure Labor Intensive Outdoors Weather/Climate Hot, dry Additional risk factors: Family or Personal Hx Gender (male) Age (20-55) Race (Caucasian) Diet High sodium High protein Food high in oxalate  Vit A/D, grapefruit juice         Sedentary Lifestyle Obesity High Blood Pressure Risk Factors http://savethelobsters.files.wordpress.com/2009/02/ist2_4588664_half_empty_glass_of_water_with_clipping_path.jpg

  13. Abnormal Lab Values BUN Creatinine Urine Analysis https://www.clevelandclinic.org/heartcenter/images/guide/tests/lab.gif http://www.ganfyd.org/images/f/fb/Dipstick_bottle.jpg

  14. Diagnostic Studies • Test and Diagnostics: • Blood Analysis • Urine Analysis • CT Scan • Abdominal x-ray • Ultrasound • Retrograde Pyelogram • Cystoscopy • Intravenous pyelography http://knol.google.com/k/-/-/PYwIQr_i/GXb8Fg/Stone%20CT.jpg

  15. What questions do you need to ask before a patient has an IV pyelogram?

  16. Answer: • 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

  17. Nursing Diagnosis: Acute pain r/t obstruction from renal calculi as manifested by patient being doubled-over, pacing around the room, and patient verbalizing pain upon assessment. Goal: patient will state pain is at a manageable level within 2 hours of admission. What are Nursing Interventions?

  18. Nursing Goal/Interventions: • Administer pain medication as ordered by physician. • Provide non-pharmaceutical techniques such as imagery and/or meditation to relieve pain. • Patient will determine manageable pain level. • Patient will be asked about any concerns and/or fears that may be associated with pain. • Provide emotional support for the patient. • Reassess patient’s pain levels within 1 hour after administration of pain medications.

  19. Nursing Diagnoses: Deficient knowledge r/t fluid requirements and dietary restrictions as manifested by reoccurring stones. Goal: Patient will state methods to prevent future stones by the time patient is D/C. A plan of care will also be created with the patient before patient is D/C to prevent reoccurrence of kidney stones. Risk for infection r/t kidney stone obstruction of urinary tract causing stasis of urine. Goal: Patient’s urine will be yellow and clear upon D/C and patient will not have a fever. UA with show no indication of UTI or other infection. What are Nursing Interventions?

  20. 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) http://www.free-press-release.com/members/members_pic/200906/img/1245774370.jpg

  21. Surgical Procedures • Lithotripsy: used to break into smaller fragments allowing it to pass through the urinary tract. • Extracorporeal Shock-Wave (ESWL) • Percutaneous Ultrasonic • Electrohydraulic • Laser • Surgical Therapy • Nephrolithotomy (Kidney) • Pyelolithotomy (Renal Pelvis) • Ureterolithotomy (Ureter) • Basket Extraction http://www.svhm.org.au/Department_Index/Lithotripsy/images/Kidney-Stones.gif

  22. Prevention • 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 http://3.bp.blogspot.com/_-gcaht5yp_0/SdINrCVuqdI/AAAAAAAAAGw/xeEk4-F3z_I/s320/foods+rich+in+oxalate+2.gif

  23. Professional Resources • Renal Disease: A Manual of Patient Careby Lynn Wenig Kagan, RN, PhD • Differential Diagnosis: Renal and Electrolyte Disordersby Saulo Klahr, MD • MedLine Plus • www.nlm.nih.gov/medlineplus/kidneystones.html

  24. Journal Article #1 • Purpose: Determine effectiveness of an herbal supplement made out of varuna and banana stems, “Herbmed,” on kidney stones • 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.

  25. 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 stones.

  26. 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 scores. • 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.

  27. Joey has a Kidney Stone…. • http://www.youtube.com/watch?v=BLO5beZY4zc

  28. References • Ackley, B.J., & Ladwig, G.B. (2006). Nursing diagnosis handbook. St. Louis: Mosby, INC.. • 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. . • Pagana, K.D., & Pagana, T.J. (2007). Diagnostic and laboratory test reference. 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. • (2008, June 16). Kidney Stones. Retrieved from http://www.methodisthealth.com/tmhs/basic.do?channelId=-1073830932&contentId=1073791018&contentType=HEALTHTOPIC_CONTENT_TYPE • (2009). Kidney Stones. Retrieved from http://www.wrongdiagnosis.com/k/kidney_stones/stats.htm • (2009, June 23). Kidney Stones. Retrieved from http://www.mayoclinic.com/health/kidney-stones/DS00282 • (2009, September 30). Kidney Stones. Retrieved from http://www.nlm.nih.gov/medlineplus/kidneystones.html • (2009, October 8). Kidney Stones in Adults. Retrieved from http://kidney.niddk.nih.gov/Kudiseases/pubs/stonesadults/ • (2009, October 8). Kidney and Urologic DiseasesSstatistics for the United States. Retrieved from http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/