2. LEARNING OBJECTIVES
• review the anatomy and physiology of
the renal system
• interpret the term renal calculi
• describe the etiology of renal calculi
• discuss the pathogenesis involved in the
disease process
• list the types of renal calculi

3. LEARNING OBJECTIVES
• examine the clinical manifestations closely
• differentiate the various diagnostic
measures
• explain the medical management
• Identify the surgical management of renal
calculi
• distinguish the nursing management for
renal calculi including the nursing
diagnosis

4. THE RENAL SYSTEM

5. THE RENAL SYSTEM

6. DEFINITION
• Nephrolithiasis refers to renal stone
disease; urolithiasis refers to the
presence of stones in the urinary
system. Stones, or calculi, are formed
in the urinary tract from the kidney
to bladder by the crystallization of
substances excreted in the urine
•

7. ETIOLOGY

8. ETIOLOGY
METABOLIC
LIFESTYLE
GENETIC FACTORS
DRUGS
OTHERS

9. RISK FACTORS
HISTORY
OF
METABOLIC RENAL
DISTURBANCES CALCULI
DEHYDRATION
SEDENTARY
LIFE STYLE
IMMOBILITY

10. RISK FACTORS
HIGH MINERAL
CONTENT IN DRINKING
WATER
DIETARY INTAKE
UTI & H/O FEMALE
GENITAL MUTILATION
PROLONGED
INDWELLING
CATHETERISATION
NEUROGENIC BLADDER

11. PATHOPHYSIOLOGY
• Slow urine flow, resulting in
supersaturation of the urine
with the particular element
that first become crystallized
and later become stone

12. PATHOPHYSIOLOGY
• Damage to the lining of the
urinary tract

13. PATHOPHYSIOLOGY
• Decreased inhibitor
substances in the urine that
would otherwise prevent
supersaturation and
crystalline aggregation

14. TYPES OF STONES
• Calcium Phosphate
• Calcium oxalate
• Uric acid
• Cystine
• Struvite

15. CLINICAL MANIFESTSTIONS
• Severe
abdominal or
flank pain
• Frequency and
dysuria
• Oliguria and
anuria in
obstruction

16. CLINICAL MANIFESTSTIONS
• Hematuria
• Renal colic
• Nausea
• hydronephrosis

17. DIAGNOSTIC STUDIES

18. DIAGNOSTIC STUDIES

19. CYSTOSCOPY DIAGNOSTIC STUDIES

20. DIAGNOSTIC STUDIES

21. DIAGNOSTIC STUDIES

22. DIAGNOSTIC STUDIES
RETROGRADE
PYELOGRAM
CT SCAN
24 HOUR URINE
SPECIMEN
LAB INVESTIGATIONS

23. MANAGEMENT

24. MEDICAL
• DRUG THERAPY
Opioid agents
NSAIDS
Spasmolytic agents

25. COMPLIMENTARY THERAPY
•Hypnosis, imagery, therapeutic
or healing touch, acupuncture
and breathing techniques
•Positioning the client to
comfortable position aids in pain
reduction

26. OTHER TECHNIQUES
• Avoiding over
hydration and
under hydration
• Strain the urine
• Send any strained
stone to laboratory
to aid in preventive
treatment in the
future

27. SPECIFIC APPROACHES
URINARY CHARACTERIS PREDISPOSING THERAPEUTIC MEASURES
STONE TICS FACTORS
Calcium Small Idiopathic Increase hydration
oxalate often hypercalciuria Reduce dietary oxalate
35-40 possible to hyperoxaluria Give thiazide diuretics
get ,Independent cellulose phosphate,(chelate
trapped in of urinary pH calcium and prevent GI
ureter ,family history absorption),
,more potassium citrate(alkaline
frequent in urine),
men cholestyramine(bind
oxalate),
calcium lactate(precipitate
oxalate in GI tract)
Reduce daily sodium intake

28. SPECIFIC APPROACHES
URINARY CHARACT PREDISPOSING THERAPEUTIC MEASURES
STONE ERISTICS FACTORS
Calcium Mixed Alkaline urine, Treat underlying
phosphate stones primary cause and other
8-10% with hyperthyroidism stones
struvite
or
oxalate
stones

29. SPECIFIC APPROACHES
URINARY CHARACTERIS PREDISPOSING THERAPEUTIC MEASURES
STONE TICS FACTORS
Struvite 3 to 4 times urinary tract Antimicrobial agents
10-15 % common in infections acetohydroxamic acid
women ≥ Surgical interventions
men,always Measures to acidify urine
in
association
with urinary
tract
infection

30. SPECIFIC APPROACHES
URINARY CHARACTERI PREDISPOSING THERAPEUTIC MEASURES
STONE STICS FACTORS
Uric Predomi Gout, acid Reduce urinary
acid nant in urine concentration of uric acid
men high ,inherited Alkanize urine with
5-8 % incidence conditions potassium citrate
in jewish Administer allopurinol
men Reduce dietary purines

31. SPECIFIC APPROACHES
URINARY CHARACTERISTICS PREDISPOSING THERAPEUTIC MEASURES
STONE FACTORS
Cystine Genetic Acid urine Increase hydration
autosomal Give α pencillamine and
1-2 % recessive tiopronin to prevent cystine
defect,defective crystallization
absorption of gi Potassium citrate to
cystine from gi alkaline urine
tract and kidney
excess
concentrations
causing stone
formation

32. SURGICAL MANAGEMENT

33. PROXIMAL URETER SURGICAL MANAGEMENT
ANTEGRADE
NEPHROURETER STENTING ALONE
OLITHOTOMY
PERCUTANEOUS
RETROGRADE
URETERO
URETEROSCOPY LITHOTOMY
ESWL NEPHROLITHOTOMY

34. MIDURETER SURGICAL MANAGEMENT
RETROGRADE
ESWL
URETEROSCOPY
ANTEGRADE
OPEN URETERO-
NEPHROSTOURETE
LITHOTOMY
ROLITHOTOMY

35. DISTAL URETER SURGICAL MANAGEMENT
ESWL/ureteroscopy
Antegrade
nephrostoureterolithotomy
Stenting alone
Open ureterolithotomy

36. SURGICAL MANAGEMENT
LASER
PERCUTANEOUS
ESWL

37. OPEN SURGICAL PROCEDURES
NEPHROLITHO PYELOLITHOT
TOMY OMY
URETHROLIT
CYSTOTOMY
HOTOMY

38. NURSING MANAGEMENT

39. NURSING DIAGNOSIS
• Acute pain related to irritation
and spasm from stone
movement in the urinary tract as
manifested by complaints of
pain, facial grimacing,
restlessness

40. NURSING DIAGNOSIS
• Anxiety related to uncertain
outcome and lack of
knowledge regarding possible
surgery as manifested by
expressions

41. NURSING DIAGNOSIS
• Ineffective therapeutic regimen
management related to lack of
knowledge as manifested by
repeated questions

42. NURSING DIAGNOSIS
• Impaired urinary elimination
related to trauma or blockage of
ureters or urethra as manifested
by decreased urinary output and
bloody urine

43. NURSING DIAGNOSIS
• Risk for infection related to
introduction of bacteria
following manipulations of the
urinary tract and obstructed
urinary blood flow

44. PREVENTION
• Avoid protein intake; usually protein is
restricted to 60g/day to decrease urinary
excretion of calcium and uric acid.
• A sodium intake of 3 to 4 g/day is
recommended. Table salt and high-sodium
foods should be reduced, because sodium
competes with calcium for reabsorption
in the kidneys.

45. PREVENTION
• Low-calcium diets are not generally
recommended,except for true absorptive
hypercalciuria. Evidence shows that limiting
calcium, especially in women, can lead to
osteoporosis and does not prevent renal
stones.
• Avoid intake of oxalate-containing foods
(eg, spinach,strawberries, rhubarb, tea, peanuts,
wheat bran).

46. PREVENTION
• During the day, drink fluids (ideally water)
every1 to 2 hours.
• Drink two glasses of water at bedtime
and an additional glass at each nighttime
awakening to prevent urine from
becoming too concentrated during the
night.

47. PREVENTION
• Avoid activities leading to sudden
increases in environmental temperatures
that may cause excessive sweating and
dehydration.
• Contact your primary health care
provider at the first sign of a urinary
tract infection

48. JOURNAL PRESENTATIONS

49. QUESTIONS
???

50. ?
Genetic
a)Cystic fibrosis
factor
b) sjogrens syndrome
involved in c) gout
renal d) myasthenia gravis
calculi
formation:

51. ?
Stone in the
kidney is a) nephrolithiasis
b) ureterolithiasis
called as
c ) cystolithiasis
d ) cholelithiasis

52. ?
Uric acid
stones can a)Allopurinol
be reduced b)thiazide diuretic
or c)pencillamine
prevented d)potassium citrate
by the use
of:

53. ?
Preferred
opioid agent a)Morphine
used in renal b) ketorolac
calculi pain
c)propanthelene
management
d)tramadol hydrochloride
initially is:

54. REFERENCES
• Fauci AS, Braunwald
E, Kasper DL, Hauser
SL, Longo DL, Jameson
JL, et al., editors. Harrison’s
principles of internal
medicine. 17th ed. New York:
McGraw Hill; 2008

55. REFERENCES
• Johnson J.Y.Brunner anD
Suddharth`s:Textbook of
Medical Surgical Nursing.
11th edn.
Philadelphia:Lippincott;20
08.

56. REFERENCES
• Black M.J, Hawks H.K.
Medical Surgical Nursing. 7th
edn. Missouri:
Saunders;2005

57. REFERENCES
• Taal M.W,Cherton G,Marsden
P.A. Brenner and Rector`s:
The Kidney. 9th
edn.Philadelphia:
Elsevier;2012

58. REFERENCES
• Walsh C.Urology. 10th edn.
Philadelphia:
Elsevier;2012

59. REFERENCES
• Nettina S M, Mills E.J.Lippincott
Manual of Nursing Practice. 8th
edn.Philadelphia :Lippincott
Williams & Wilkins; 2006