Saint Louis University

Baguio City
School of Nursing

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Mark Christian Dumaguin
Jake Gonzales
Seth LouiseMagnaye
Mark Angelo Mata
Rowena Alvarez
JayvilynCosme
Jyka Nava Delson
Marklin Kay Donato
Jeremiah Durana
Emielyn Mae Galang
Trisha Gonzales
Dandel Mary Joy Lagoy

August 23, 2010

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Urolithiasis, kidney stones, renal stones, and renal calculi are interchangeably used to
refer to the accretion of hard, solid, nonmetallic minerals in the urinary tract.

Urolithiasis is a general term referring to stones anywhere in the urinary tract, ureter,
bladder, or urethra. Most stones form in the kidney and are usually silent until breaking
loose from the kidney and obstructing the ureter where they produce sever pain known
as ureteral colic.

The development of the stones is related to decreased urine volume or increased

excretion of stone-forming components such as calcium, oxalate, urate, cystine,
xanthine, and phosphate. The stones form in the urine collecting area (the pelvis) of the
kidney and may range in size from tiny to staghorn stones the size of the renal pelvis
itself.

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Urinary stones account for more than 320,000 hospital admissions each year. The
occurrence of urinary stones occurs predominantly in the 3rd to 5th decades of life and
affects men more than women. About half of patients with a single renal stone have
another episode within 5 years.

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The reasons why some people develop kidney stones are not fully understood. Aside
from more obvious risk factors, metabolic conditions e.g. hyperparathyroidism,
cystinuria (inherited disease), and hyperoxaluria (inherited disease) are also common
causes of stone formation.

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1. Autoimmune
§ Ulcerative Colitis- when the immune system triggers inflammation in other
parts of the body because of ulcerative colitis, kidney stones may result.
This influence is usually mild and stones may not be a problem once the
colitis is treated.
§ Sarcoidosis- Kidney stone formation can be a sign.It is a granulomatous
disease in which inflammation may occur in lymph nodes, lungs, liver,
eyes, skin, joints, kidneys, liver and spleen, and other tissues.
2. Diet
§ Excess Protein Consumption- High protein intakes may lead to loss of
calcium, leading in turn to the development of kidney stones.
3. Family History

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 § Kidney stones in family members- There is a strong familial
predisposition to kidney stones.
4. Hormones
§ Hyperparathyroidism- Increased calcium and phosphorous excretion in
the urine may cause kidney stones.
5. Musculo-skeletal
§ Gout / Hyperuricemia- Gout (excess uric acid) is a common cause of
kidney stones.
6. Nutrients
§ Potassium Need- When potassium levels fall too low, urine citrate also
drops, decreasing your protection against stones.
7. Supplements and Medications
§ (Discontinued) diuretic use- Excessive intake of diuretics may give rise to
excess calcium in the urine.
§ Much vitamin D supplementation- Excessive intake of vitamin D may give rise
to excess calcium in the urine.
8. Beverages
§ Insufficient water consumption- Restricted water consumption is an important
causative factor.
9. Food
§ Short-term/long-term low-carb dieting or discontinued low-carb diet- The
American Academy of Family Physicians notes that high animal protein intake
is largely responsible for the high prevalence of kidney stones in the United
States, which can cause severe pain or even urinary obstruction and kidney
damage. Plant protein did not seem to have a harmful effect. [American
Family Physician 60 (1999): p.2269]
10. Urinary
§ History of kidney stones

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Sign and Symptoms will vary according to the size and location of the stone. Symptoms
also vary with the presence of infection and/or obstruction.

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a. Pain
b. Diarrhea
c. Vomiting
d. Abdominal discomfort

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a. Acute renal area pain, radiating anteriorly and downward
b. Nausea

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 c. Vomiting
d. Loin tenderness
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a. Acute, colicky pains radiating to genital area and down the thigh
b. Frequent desires to void, with little urine passed
c. Hematuria


  
1. Assess for pain and discomfort as well as associated symptoms such as nausea,
vomiting, diarrhea, and abdominal distention
2. Urines is inspected for blood and is strained for stones
3. Observe for signs and symptoms of UTI and obstruction (frequent urination of
small amounts, oliguria or anuria)


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1. Ultra sonography, IV urography, or retrograde pyelography
2. Blood chemistries and a 24-hour urine test for measurement of calcium,uric acid,
creatinine, sodium, pH, and total volume.
3. X-rays of the kidneys, ureters and bladder

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1. Restrict calcium in the diet
2. Low purine diet
3. Allopurinol may be prescribed
4. Low protein diet is prescribed
5. Increase fluid intake
6. Limited intake of oxalate

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1. Chemolysis
- Stone dissolution using infusion of chemical solution
2. Ureteroscopy
- Visualizing the stone and then destroying it
3. Extracorporeal Shock Wave Lithotripsy
-this process is guided by ultrasound and is used mostly for symptomatic
nonpassable upper urinary tract stones.

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Nursing care of patients with urolithiasis involves:
a. Controlling pain
· Administer pain medications as prescribed and assess patient frequently,
as this pain can be excruciating.

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 · Hot bath or moist heat to painful area.
b. Relief of Obstruction
· Encourage fluids- Prevention is very important especially in those with a
high likelihood of developing this condition since the recurrence rate of
stone formation is very high. Drinking a lot of water is the best
preventative measure: drink enough to produce approximately 2 liters
(one-half gallon) of urine per day. Adequate fluid intake helps prevent
kidney stone problems by allowing most small stones to pass through.
· Observe strict I & O
· Assist physician in catheterization or cystoscopy , as ordered.
**Cystoscopy is the use of a scope (cystoscope) to examine the bladder.
This is done either to look at the bladder for abnormalities or to help with
surgery being performed on the inside of the urinary tract (transurethral
surgery).
c. Determine Stone type
· Strain all urine
· Send stones to laboratory for identification
d. Diet Modification
· Implement diet modification as ordered
Those with a tendency to form calcium stones may want to
avoid foods rich in calcium, such as dairy products.
A study published September, 2004 in the journal Urology
suggests people prone to kidney stones should limit their
intake of caffeine and cut down on the amount of coffee they
drink. People who consumed caffeine in amounts equal to two
cups of coffee showed elevated levels of calcium in their urine,
which can increase the risk of developing stones, especially
for people prone to stones. "Caffeine consumption may
modestly increase risk of calcium oxalate stone formation,"
concluded the researchers.
Those prone to getting calcium oxalate stones are advised to
avoid the consumption of foods high in oxalates.
$%*"!": Acid ash diet with Ļdairy, protein, and sodium intake
%"!": Alkaline ash diet with Ļpurine (organ meat) intake
0%%"!"' ĻTea, spinach, nuts, chocolate, and rhubarb intake
· Alter the pH of the urine to reduce stone formation
To acidify urine, give citrus juices or ascorbic acid (vit C)
To alkalinize urine, give sodium bicarbonate
· Prepare patient for surgery. Surgical intervention is indicated if the stone
is causing:
An obstruction that cannot be relieved
Infection that is not responsive to treatment

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 Unrelenting pain
Damage to the urinary system
**Lithotripsy is a medical procedure that uses shock waves to break up stones
in the kidney, bladder, or ureter (tube that carries urine from your kidneys to your
bladder). After the procedure, the tiny pieces of stones pass out of your body in your
urine.

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The bladder is a hollow organ in the lower abdomen. It stores urine, the liquid
waste produced by the kidneys. Urine passes from each kidney into the bladder through
a tube called a ureter.

Cancer is a group of many related diseases. All cancers begin in cells, the
body's basic unit of life. Cells make up tissues, and tissues make up the organs of the
body.

Normally, cells grow and divide to form new cells as the body needs them.
When cells grow old and die, new cells take their place.

Sometimes this orderly process goes wrong. New cells form when the body
does not need them, and old cells do not die when they should. These extra cells can
form a mass of tissue called a growth or tumor.

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Bladder cancer is a type of malignancy that occurs when there is an uncontrolled growth
of cancer cells that forms a malignant tumor in the bladder.

  
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A Stage 0 -- The cancer cells are found only on the surface of the inner lining of the
bladder. The doctor may call this superficial cancer or carcinoma in situ.
A Stage I -- The cancer cells are found deep in the inner lining of the bladder. They
have not spread to the muscle of the bladder.
A Stage II -- The cancer cells have spread to the muscle of the bladder.
A Stage III -- The cancer cells have spread through the muscular wall of the
bladder to the layer of tissue surrounding the bladder. The cancer cells may have
spread to the prostate (in men) or to the uterus or vagina (in women).
A Stage IV -- The cancer extends to the wall of the abdomen or to the wall of the
pelvis. The cancer cells may have spread to lymph nodes and other parts of the
body far away from the bladder, such as the lungs.

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· Cancer of the urinary bladder is more common in people between the ages of 50
and 70 years.
· It affects more men than women (4:1) and is more common in Caucasians than
in African Americans.
· Bladder cancer, combined with prostatic cancer, is the most common urologic
malignancy, accounting for 90% of all tumors seen. Cancers arising from the
prostate, colon, and rectum in males and from the lower gynecologic tract in
females may metastasize to the bladder.


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1. Cigarette smoking: risk proportional to number of packs smoked daily and
number of years of smoking
>The use of tobacco is a major risk factor. Cigarette smokers are two to three
times more likely than nonsmokers to get bladder cancer. Pipe and cigar
smokers are also at increased risk.
2. Exposure to environmental carcinogens: dyes, rubber, leather, ink or paint.
>Some workers have a higher risk of getting bladder cancer because of
carcinogens in the workplace. Workers in the rubber, chemical, and leather
industries are at risk. So are hairdressers, machinists, metal workers, printers,
painters, textile workers, and truck drivers.
3. Recurrent or chronic bacterial infection of the urinary tract
4. Bladder stones
5. High urinary pH
6. High cholesterol intake
7. Pelvic radiation therapy
8. Cancers arising from the prostate, colon, and rectum in males.
9. Age. The chance of getting bladder cancer goes up as people get older. People
under 40 rarely get this disease.

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Common symptoms of bladder cancer include:
a) Blood in the urine (making the urine slightly rusty to deep red),
b) Pain during urination, and
c) Frequent urination, or feeling the need to urinate without results.
d) Pelvic or back pain- metastasis


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If a patient has symptoms that suggest bladder cancer, the doctor may check general
signs of health and may order lab tests. The person may have one or more of the
following procedures:

† Physical exam -- The doctor feels the abdomen and pelvis for tumors. The
physical exam may include a rectal or vaginal exam.

† Urine tests -- The laboratory checks the urine for blood, cancer cells, and other
signs of disease.

† Intravenous pyelogram -- The doctor injects dye into a blood vessel. The dye
collects in the urine, making the bladder show up on x-rays.

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 † Cystoscopy -- The doctor uses a thin, lighted tube (cystoscope) to look directly
into the bladder. The doctor inserts the cystoscope into the bladder through the
urethra to examine the lining of the bladder. The patient may need anesthesia for
this procedure.

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1. Transurethral resection/ fulguration (cauterization)- performed for simple
papillomas (benign epithelial tumors). It eradicates the tumors through surgical
incision or electrical current with the use of instruments inserted through the
urethra. After this bladder-spraying surgery, intravesical administration of
bacilleCalmette-Guerin (BCG) is the treatment of choice.
***BCG- an attenuated live strain of Mycobacterium bovis (CA of tuberculosis).
The exact action is unknown, but is thought to produce a local inflammatory as
well as a systemic immunologic response.

2. Simple Cystectomy/ radical cystectomy- performed for invasive or multifocal

bladder cancer.
Radical cystectomy (men)- removal of the bladder, prostate, and seminal
vesicles and immediate adjacent perivesical tissues.
Radical cystectomy (women)- removal of the bladder, lower ureter, uterus,
fallopian tubes, ovaries, anterior vagina, and urethra. It may include removal of
pelvic lymph nodes.

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1. Chemotherapy with a combination of methotrexate, 5-fluorouracil, vinblastine,
doxorubicin (Adriamycin), and cisplatin ± effective in producing partial remission of
transitional cell carcinoma of the bladder in some patients.
2. Topical chemotherapy (intrevesical chemotherapy or instillation of antineoplastic
agents into the bladder, resulting in contact of the agent with the bladder wall)-
considered when there is a high risk of recurrence, when cancer in situ is present,
or when tumor resection has been incomplete. (thiotepa, doxorubicin, mitpmycin,
ethoglucid, and BCG).
3. BCG- most effective intravesical agent for recurrent bladder cancer, especially
superficial transitional cell carcinoma, because it is an immunotherapeutic agent
that enhances the body¶s immune response to cancer.

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1. External radiation: A large machine outside the body aims radiation at the
tumor area. Most people receiving external radiation are treated 5 days a week
for 5 to 7 weeks as an outpatient. This schedule helps protect healthy cells

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 and tissues by spreading out the total dose of radiation. Treatment may be
shorter when external radiation is given along with radiation implants.

2. Internal radiation: The doctor places a small container of a radioactive

substance into the bladder through the urethra or through an incision in the
abdomen. The patient stays in the hospital for several days during this
treatment. To protect others from radiation exposure, patients may not be able
to have visitors or may have visitors for only a short period of time while the
implant is in place. Once the implant is removed, no radioactivity is left in the
body.

3. Photoradiation- Treatment of cancer by intravenous injection of a

photosensitizing agent, such as hematoporphyrin, followed by exposure to
visible light of superficial tumors or of deep tumors by a fiberoptic probe.

Reference/s:
http://www.wrongdiagnosis.com/treat/internal_radiation.htm
http://www.diagnose-me.com/cond/C159909.html
http://www.tpub.com/content/armymedical/MD0918/MD09180122.htm
http://bicolnurses.blogspot.com/2008/10/urolithiasis.html
Textbook of Medical-Surgical Nursing (11th ed.) by Brunner &Suddarth¶s

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