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Renal diseases. HLTAP502A Analyse Health Information. Urolithiasis. Urinary stones, they vary in size from microscopic crystals to calculi that are several centimetres in diameter.
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Renal diseases HLTAP502A Analyse Health Information
Urolithiasis • Urinary stones, they vary in size from microscopic crystals to calculi that are several centimetres in diameter. • They can be found in the pelvis of the kidney (the largest being a staghorn), the ureter and the urinary bladder.
The formation of stones relates to factors that: • Increase the supersaturation of urine with calculus forming salts eg • Over-excretion of salt (oxalate) • Urine acidity • Low urine volume • Preformed nuclei eg • Uric acid crystallites
Types of stones • 75% - 80% are composed of calcium (mainly calcium oxalate – found in rhubarb, spinach, cocoa, nuts, pepper, tea) • 5%-10% uric acid crystals – uric acid is a by-product of protein metabolism. It crystallises in acidic environments. • 2% are cystine – due to an inherited defect in the renal tubules which impairs the reabsorption of the amino acids cystine. • The rest are struvite (magnesium ammonium phosphate). Struvite stones are a result of UTI. These stones need to be treated as infected foreign bodies.
Causes of hypercalcaemia • Hyperparathyroidism • Renal tubular acidosis • Cancer – multiple myeloma, bony metastases • Excessive intake of vitamin D
Medications known to cause stones • Antacids • Diamox • Vitamin D • Laxatives • Aspirin
Signs and symptoms • Commonly cause pain, bleeding, obstruction and secondary infections. • Renal colic – typically excruciating and intermittent • Originating in the flank, radiating across the abdomen • Also into the genital region and inner thigh • Calculi in the bladder may cause suprapubic pain
Signs and symptoms (cont) • GI symptoms such as nausea, vomiting and abdominal distention • Chills, fever • Haematuria • Pyuria • Frequency of urination
Diagnosis • History – family, medical, dietary • X-Rays – plain, IVP, urogram, MRI, CT • Ultrasound • Blood chemistries • 24-hour urine collection – calcium, creatinine, uric acid, pH • Analysis of stones to assess for underlying disorder
Medical treatment • Uteroscopy • Chemolysis • Nephrostomy • Electrohydraulic lithrotripsy • Surgical removal
Extracorporeal shock wave lithotripsy • Extracorporeal shock wave lithotripsy (ESWL) is a procedure used to shatter simple stones in the kidney or upper urinary tract. • Ultrasonic waves are passed through the body until they strike the dense stones. • Pulses of sonic waves pulverize the stones, which are then more easily passed through the ureter and out of the body in the urine.
Percutaneous nephrolithotomy • The surgeon makes a tiny incision in the back and creates a tunnel directly into the kidney. • Using an instrument called a nephroscope, the surgeon locates and removes the stone. • For large stones, some type of energy probe (ultrasonic or electrohydraulic) may be needed to break the stone into small pieces. • Generally, patients stay in the hospital for several days and may have a small tube called a nephrostomy tube left in the kidney during the healing process. • One advantage of percutaneous nephrolithotomy over ESWL is that the surgeon removes the stone fragments instead of relying on their natural passage from the kidney
Nursing interventions • Assessments – vitals, pain, urine • Relieve pain • Medication • Positioning • Apply heat • FBC – input/output • Urine observations • Straining • Testing – blood, UTI • Volume • Treat other symptoms – fever, N/V, abdominal distension
Causes • Decreased blood flow – shock, burns, dehydration • Over exposure to metals, solvents, radiographic contrast, some antibiotics • Myoglobinuria • Direct injury to the kidney • Infections – pyelonephritis, septicaemia • Urinary tract obstruction – tumours, stones • Disorders of the blood – transfusion reactions
Clinical Manifestations • Decreased urinary output • Oliguria – less than 100mls per day • Anuria – no urine passed • Hypertension • Oedema • Anorexia • Metallic taste in mouth • Persistent hiccoughs • Changes in mental status or mood • Nausea, vomiting • Bleeding – bruising, GIT, urinary • Pain – flank • Halitosis
Phases of ARF • Initial period – ends when oliguria develops • Period of oliguria – show uraemic symptoms • Period of diuresis • Period of recovery – may take 3-12 months
Treatment • Treat the cause • Maintain fluid balance • Restore and maintain chemical balance • Dietary • Restrict sodium, potassium, proteins • Increase carbohydrates • Diuretics may be used to initiate diuresis • Prevent complications • Dialysis – peritoneal, haemodialysis
Complications of ARF • End stage renal failure • Cardiovascular – CCF, pericarditis • Pulmonary system – APO • Nervous system – generalised seizures, coma • Chronic renal failure • GIT – blood loss, stress ulcers, gastritis • Hypertension • Electrolyte imbalances – hyperkalaemia, hyponatraemia
Continuous ambulatory peritoneal dialysis (CAPD) • The patient has a permanent access port in the abdomen. • Dialysis fluid (1.5-3litres) is drained into the peritoneal cavity and left there for 4-5 hours • The dialysate with wastes is then drained from the peritoneal cavity, and more fluid added. • This is repeated about 4-5 times a day
Vascular access • There are three basic kinds of vascular accesses for haemodialysis: • an arteriovenous (AV) fistula, • an AV graft, and • a venous catheter. • The AV fistula is considered the best long-term vascular access for haemodialysis because it provides adequate blood flow for dialysis, lasts a long time, and has a complication rate lower than the other access types. • The fistula takes 6-8 weeks to mature
Care of access site • Check access site before each treatment. • Be careful of trauma to access. • Don't take blood pressure on arm with access. • Patient not to wear jewellery or tight clothes over access site. • Patient not to sleep with access arm under head or body. • Patient not to lift heavy objects or put pressure on access arm. • Patient to check the pulse in access every day.
