Presentors:

Jhea C. Alolino Jennifer P. Barroso Claire R. Corpuz Hazel Ann Jamis Joffrey Rizon Apple Grace Hingpit Cherryl Salo

Mr. X had been experiencing recurrent urinary tract infections in the past years. Two days ago, he had been experiencing intractable pain that is not relieved by ordinary measure and had vomited 5 times within the day and had fever for the past 3 days with temperature ranging from 38.8-39.4oC that prompted him to consult medical advice. He is a 30 years old call center agent who was born in Florida-a southeast state of the United States of America, single and lives alone in his house. Due to the nature of his job, he seldom leaves his station even for a bladder break. Patient loves to eat calcium enriched bread or waffles with cheese or sardines as filling for his breakfast and dark green leafy salads during lunch containing spinach, turnips or collard greens. For his dinner he usually eats pork meat or any animal meat.

On top of this diet, he also loves to drink 2 glasses of soya milk once in the morning and before retiring to bed. He feels nauseated when drinks too much water such that he only consumes 2-4 glasses of water per day. In between meals, he takes a cup of coffee to calm himself from his busy job. Upon assessment at the hospital, he complained of pain in the back that radiates down to the groin and inner thigh with a scale of 8/10. The pain increases in intensity when pressure is applied on the area. Patient also reported of urinary output of around 1 glass per day, urgency and burning sensation during urination and difficulty urinating for the past five days.

He had also 5 episodes of vomiting the whole day prior to his consultation. During the physical examination, the patient appeared restless, pale with warm flushed skin, and with distended abdomen. Vital signs are temperature: 39.8C; Blood Pressure: 130/90 mmHg; pulse: 110 bpm; Respiration: 25 cpm and weighs 115 kg. Urinalysis revealed dark brown turbid urine, presence of abundant RBCs and too many to count bacteria; pH of 9.5, and with presence of crystals.

Complete blood count showed hemoglobin of 7.5 g/dL and hematocrit count of 31 vols%, with white blood cell count of 22,000/mm3. Creatinine level was analyzed at 2.3 mg/dL and BUN level of 25 mg/dL. He was then admitted in the ward for further test and for medical management.

a. Calcium is the most common substance and is found in up to 90% of stones. Calcium stones are usually composed of calcium phosphate or calcium oxalate. Hypercalciuria - an increased solute load of calcium in urine b. Oxalate the second most frequent stone is oxalate , which is relatively insoluble in urine. Its solubility is affected only slightly by changes in urinary pH.

c. Struvite also called triple phosphate, are composed of carbonate apatite and magnesium ammonium phosphate. Their cause is certain bacteria, usually Proteus.
d. Uric Acid are caused by increased urate excretion, fluid depletion, and a low urinary pH. Hypercalciuria is the result of either increased uric acid production

e. Cystine cystinuria is the result of a congenital metabolic error inherited as an autosomal recessive disorder f. Xanthine occur as a result of a rare hereditary condition in which there is xanthine oxidase deficiency.

Pathophysiology
Predisposing Factors:
Age 30-50 y. o. Sex Male Heredity

Legend:

Sx/S

Treatment

Medication

Precipitating Factors:
Immobility dehydration Diet changes in urine Infection Obstruction Metabolic factors

Diet or underlying condition Increased concentration of substances Dehydration Immobilization Supersaturation

Presence of bacteria (eg., proteus)

Hereditary condition or defect Xanthine oxidase deficiencya Acidic urine Xanthine crystal precipitation Renal absorption of cystine Autosomal recessive disorder of cystinuria

Alkaline, ammonia rich urine (struvite)

Presence of anti-inhibitors (aluminum, iron & silicon)

Decrease number of inhibitor substances in urine (citrate, pyrophosphate, magnesium)

If due to infection Obstruction Oliguria/ anuria May cause back flow hydronephrosis Examine for distention Administer morphine SO4, NSAIDs as ordered Stone formation Movement of calculi Spasm & consequent irritation Antispasmodic as ordered Uereteral colic Radiates down the thigh to the genitalia Nausea & vomiting, pallor, diaphoresis, & increased pulse

Fibrous matrix of urinary organic material (mostly mucoproteins) may form

Crystals are deposited and trap

Antipyretic as ordered

fever tachycardia

Lithotripsy Adequate hydration Surgery Minimally invasive Open surgical procedures

Facilitate passage of urine Strain all urine Laboratory analysis

Turbid and malodorous urine Administer antibiotic as ordered

Treatment vary on specific type of calculi

Nursing Diagnosis Acute pain related to irritation and spasm of stone movement in the urinary tract 1. Provide comfort measures, e.g., back rub, restful environment. Promotes relaxation, reduces muscle tension, and enhances coping 2. Assist with/encourage use of focused breathing, guided imagery, diversional activities. Redirects attention and aids in muscle relaxation

3. Encourage/assist with frequent ambulation as indicated and increased fluid intake of at least 34 L/day within cardiac tolerance Renal colic can be worse in the supine position. Vigorous hydration promotes passing of stone, prevents urinary stasis, and aids in prevention of further stone formation 4. Apply warm compresses to back Relieves muscle tension and may reduce reflex spasms.

5. Administer medications as indicated: Narcotics, e.g., meperidine (Demerol), morphine;

Usually given during acute episode to decrease ureteral colic and promote muscle
Antispasmodics, e.g., flavoxate (Urispas), oxybutynin (Ditropan); Decreasing reflex spasm may decrease colic and pain. Corticosteroids.

May be used to reduce tissue edema to facilitate movement of stone.

Nursing Diagnosis Impaired urinary elimination related to mechanical obstruction 1. Monitor I&O and characteristics of urine. Provides information about kidney function and presence of complication. Bleeding may indicate increased obstruction or irritation of ureter. 2. Encourage increased fluid intake. Increased hydration flushes bacteria, blood, and debris and may facilitate stone passage.

3. Strain all urine. Document any stones expelled and send to laboratory for analysis. Retrieval of calculi allows identification of type of stone and influences choice of therapy 4. Administer medications as ordered: Hydrochlorothiazide (Esidrix, HydroDIURIL), chlorthalidone (Hygroton) May be used to prevent urinary stasis and decrease calcium stone formation if not caused by underlying disease process such as primary hyperthyroidism or vitamin D abnormalities.

Nursing Diagnosis Infection related to stasis 1. Encourage the patient to drink extra fluid Fluid promotes renal blood flow and flushes bacteria from the urinary tract.
2. Instruct the patient to void often (every 2 to 3 hours during the day) and to empty bladder completely. This enhances bacterial clearance, reduces urine stasis, and prevents reinfection.

3. Suggest intake of vitamin C contaning juice To acidify urine 4. Administer antibiotics as prescribed To eliminate infection

Test: a. Urinalysis b. Urine Culture c. Unenhanced helical Computed Tomography (CT scan) d. Intravenous pyelogram e. Renal Ultrasound f. KUB (kidney, ureters, Bladder)

Medications: a. Antipyretic Acetaminophen b. NSAIDs or opoid analgesics c. Antispasmodic Oxybutynin Chloride (Ditropan) d. Thiazide diuretic hydrochlorothiazide e. Potassium or sodium Citrate f. Vitamin B6 (pyridoxine), magnesium oxide, or cholestyramine g. Allopurinol (Zyloprim) h. Sodium Bicarbonate or citrate i. Tiopronin (thiola) and d-penicillamine j. Long term antibiotics

a. Cystolitholapaxy is performed when a bladder stone is soft enough to be crushed. b. Lithotripsy Laser Lithotripsy Lasers are used together with a ureteroscope to remove or loosen impacted stones.

Extracorporeal Shock Wave Lithotripsy Is the use of sound waves applied externally to break up stones in the kidney or ureter.

c. Ureterolithotomy is the surgical removal of a stone from the ureter through a flank incision for higher stones or an abdominal incision for lower ones.

d. Cystolithotomy removal of bladder calculi through a suprapubic incision, is used only when stones cannot be crushed and removed transurethrally.

e. Pyelolithotomy a stone remove from the renal pelvis

f. Nephrolithotomy removal of stones from the renal calyx g. Nephrectomy may be partial or total. Is necessary because of extensive kidney damage, overwhelming renal infection, or abnormal renal parenchyma

Drinking enough water to make 2 to 2.5 liters of urine per day. A failure to intake sufficient liquids will mean the urine is concentrated and the substances that create kidney stones are more likely to clump together. Limiting animal protein intake to no more than 2 meals daily, with less than 6 8 ounces per day. Diet should be low in protein, as a diet high in protein may lead to kidney stones because extra protein causes calcium to be excreted from the body, raising calcium levels in the urine.

Prevention strategies include restriction of oxalate-rich foods, or consumption of more calcium. Some fruit juices, such as orange, blackcurrant, and cranberry, may be useful for lowering the risk factors for specific types of stones. Orange juice may help prevent calcium oxalate stone formation, blackcurrant may help prevent uric acid stones, and cranberry may help with UTI-caused stones. limiting vitamin C intake to less than 4590 mg per day.

Limit coffee, tea, and cola to one or two cups a day. The caffeine may cause a rapid loss of fluid. Attempt to maintain a calcium intake of 1000 1500 mg per day. Limiting sodium intake to less than 2300 mg per day. Limiting consumption of foods containing high amounts of oxalate (such as spinach, strawberries, nuts, rhubarb, wheat germ, dark chocolate, cocoa, brewed tea).

THE END