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Kidney Stones Kim Applebee Alex Kaullen 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)

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kidney stones

Kidney Stones

Kim Applebee

Alex Kaullen

definition
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.
statistics
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)

kidney stone formation
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

types of stones
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.
case study
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.
signs and symptoms
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

additional information
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

risk factors
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

abnormal lab values
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

diagnostic studies
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

answer
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
nursing diagnosis
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?

nursing goal interventions
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.
nursing diagnoses
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?

treatment
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

surgical procedures
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

prevention
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

professional resources
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
journal article 1
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.
journal article 2
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.
journal article 3
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.
joey has a kidney stone
Joey has a Kidney Stone….
  • http://www.youtube.com/watch?v=BLO5beZY4zc
references
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/