Askep Batu Ginjal

Siswoyo
Dep. KMB-Kritis PSIK UNEJ

INTRODUCTION

Urolithiasis, kidney stones, renal stones, and renal calculi are used
interchangeably to refer to the accretion of hard, solid, nonmetallic
minerals in the urinary tract
Passage of a urinary stone is the most common cause of acute
ureteral obstruction
The pain may be some of the most severe pain that humans
experience
Complications of stone disease may result in severe infection; renal
failure; or, in rare cases, death.
Urinary stones have afflicted humankind since antiquity
The earliest recorded example being bladder and kidney stones
detected in Egyptian mummies dated to 4800 BC
The specialty of urologic surgery was recognized even by
Hippocrates, who wrote, in his famous oath for the physician,
"I will not cut, even for the stone, but leave such procedures to the
practitioners of the craft (obviously, Hippocrates was not a
urologist!!)

Definisi
Batu Ginjal berbentuk kecil, endapan keras
garam mineral dan asam pada permukaan
dalam ginjal
Nama lain:

renal lithiasis
Renal calculi
nefrolitiasis

Batu ginjal diklasifikasikan berdasarkan

lokasi pada sistem kemih dan komposisi
batu.

EPIDEMIOLOGY

The prevalence of urinary tract stonedisease is estimated to be 2% to

3%.
Rare in Blacks; Commoner in Whites and Asians
The likelihood that a white man will develop stone disease by age 70
years is about 1 in 8.
The recurrence rate without treatment for calcium oxalate renal stones is
about
10% at 1 year
35% at 5 years, and
50% at 10 years

Male : Female ratio is 3:1

Peak at 20-40 years old
Ingestion of excessive amounts of purines ,oxalates,calcium, phosphate,
and other elements often results in excessive excretion of these
components in urine
A low fluid intake, with a subsequent low volume of urine production,
produces high concentrations of stone-forming solutes in the urine.
This is an important environmental factor in stone formation .

EPIDEMIOLOGY ctd
Disease associated with stone formation:
Hyperparathyroidism
renal tubular acidosis (partial/complete)
jejunoileal bypass
Crohns disease,
intestinal resection
malabsorptive conditions
sarcoidosis
Hyperthyroidism
Medication associated with stone
formation:
calcium supplements
vitamin D supplements
Acetazolamide
ascorbic acid in megadoses ( > 4
g/day),
Sulphonamides
Triamterene
indinavir

Anatomical abnormalities
associated with stone formation:
tubular ectasia (medullary
sponge kidney)
pelvo-ureteral junction
obstruction
calix diverticulum
calix cyst
ureteral stricture
vesico-ureteral reflux
horseshoe kidney
ureterocele

Letak Batu

Formasi Ginjal Batu

Penyebab:
Urin sangat pekat, stasis urine
Ketidakseimbangan pH urin
Asam: asam urat dan Crystine Stones
Stones Kalsium: Alkaline

gout
hiperparatiroidisme
inflamasi usus
ISK
obat
Lasix, Topamax, Crixivan

Tipe Batu Ginjal

Kalsium Oksalat
paling sering

Kalsium Fosfat
Struvite

Lebih sering terjadi pada wanita dibandingkan pria.

Umumnya akibat dari ISK.

Asam Urat
Disebabkan oleh konsumsi tinggi protein dan asam
urat.

Cystine
Cukup jarang; umumnya terkait dengan keturunan

CLASSIFICATION

Calcium Stones 70-80%

Ca Phosphate 5-10%
Ca Oxalate/Phosphate 30-45% (Mixed)
Ca Oxalate 20-30%

Struvite stones 15-20%

Cystine stones -3%
Uric acid stones

CLASSIFICATIONctd
Oxalate (Calcium Oxalate)

Also Called Mulberry Stone

Covered With Sharp Projections

Sharp Makes Kidney Bleed (Haematuria)

Very Hard

Radio Opaque

Under microscope looks like Hourglass or Dumbbell

shape if monohydrate and Like an Envelope if Dihydrate

CLASSIFICATIONctd
Phosphate stones

Usually Calcium Phosphate

Sometimes Calcium Magnesium Ammonium Phosphate Or

Triple Phosphate

Smooth Minimum Symptoms

Dirty White

Radio Opaque

Calcium Phosphate also called Brushite appears like Needle

shape under microscope

In Alkaline urineEnlarges rapidlyTake the shape of

CalycesStaghorn

CLASSIFICATIONctd
Uric Acid & Urate Stone

Hard & Smooth

Multiple

Yellow or Red-brown

Radio - Lucent (Use Ultrasound)

Under microscope appear like irregular plates or

rosettes

CLASSIFICATIONctd
Cystine Stone
Autosomal recesive disorder
Usually in Young Girls
Due To Cystinuria Cystine Not Absorbed by Tubules
Multiple
Soft or Hard can form stag-horns
Pink or Yellow
Radio-opaque
Under microscope appears like hexagonal or
benzene ring

Tanda dan Gejala

Gejala paling sering:

Nyeri pinggang
Nyeri perut
Mual dan muntah
Kelelahan
Peningkatan suhu, BP, dan
pernapasan
Data obyektif: berkeringat,
mencengkeram perut.
Nyeri hebat: mondar
mandir
Kebanyakan pinggang kiri

Tambahan:
Adanya ISK
Demam atau menggigil
Nyeri di selangkangan,
labia atau testis
Bau urin - busuk
Disuria

CLINICAL FEATURES

Renal/Ureteral Colic (PAIN)

Abrupt onset while asleep or at rest

Crescendo of extreme pain
Flank radiating laterally and downward to
groin/testicle or round ligament/labia majora
Impossible to be still

Mid ureter

lateral flank and abdomen

Lower ureter

suprapubic and urethral

urgency and frequency

CLINICAL FEATURESctd

GI Symptoms

Nausea and vomiting autonomic n.s.

Ileus or diarrhea
DDX: gastroenteritis, appendicitis, colitis,
diverticular disease and salpingitis

Hematuria

gross or microscopic
15% no hematuria!

Pyuria/Fever

Pyuria even without infection

Infection especially in females

CLINICAL FEATURESctd

History

Duration, characteristics, and location of pain

History of urinary calculi
Prior complications related to stone manipulation
Urinary tract infections
Loss of renal function
Family history of calculi

Informasi Tambahan
Riwayat keluarga
Pengobatan saat ini
Frekuensi buang air kecil
Apakah pasien mengalami nyeri saat
kencing?
Apa makanan khas pasien?
Bagaimana pasien mengatasi batu ginjal di
masa lalu?

Faktor Resiko

Faktor-Faktor Risiko:
Riwayat pengobatan
Riwayat 3 kali serangan
batu ginjal

Dehidrasi / Kekurangan
Cairan
Paparan
Buruh
Pekerja lapangan

Cuaca / Iklim
Yang Panas, kering

Faktor risiko tambahan:

Riwayat Keluarga
Jenis kelamin (laki-laki)
Umur (20-55)
Ras (Caukasian)
Konsumsi:

Tinggi natrium
Tinggi protein
Makanan tinggi oksalat
Vit A / D, jus jeruk

Lifestyle
Obesitas
Hipertensi

Nilai Lab Abnormal

BUN:
Dewasa:
5 25 mg/dl
Creatinine:
Dewasa:
0,6-1,3 mg/dl.
Urine Analysis
https://www.clevelandclinic.org/heartcenter/images/guide/tests/lab.gif

http://www.ganfyd.org/images/f/fb/Dipstick_bottle.jpg

Tes Diagnostic

Test and Diagnostic:

Analisa Blood
Analisa Urine
CT Scan
Foto Ro Abdominal
USG
Retrograde Pyelogram
Cystoscopy
Intravenous pyelography

http://knol.google.com/k/-/-/PYwIQr_i/GXb8Fg/Stone%20CT.jpg

INVESTIGATIONS
Urinalysis- haematuria ~ 85% of pts
FBP

elevated WBC = renal/ systemic inf.

low RBC= xnic dse/ sev. haematuria

serum eletrolytes, creatinine, calcium, uric acid,

phosphorus: to asses renal function and
metabolic risk factors for stone formation
24 hr urine collection for pH, Ca, oxalate, uric
acid, Na, phosphorus, citrate, magnesium,
creatinine and total volume

INVESTIGATIONctd

Plain abdominal radiograph

KUB for assessing total stone burden, the size, shape, and
location of urinary calculi in some patients.
Calcium-containing stones (~85% of all upper urinary tract
calculi) are radiopaque,
Pure uric acid, indinavir-induced, and cystine calculi are
relatively radiolucent on plain radiography

Renal ultrasound
IVP

determine the size & location

anatomical & functional assessment

Helical CT-scan without contrast

INVESTIGATIONSctd

CALCULUS IN LT
KIDNEY LOWER POLE

INVESTIGATIONSctd

STAGHORN CALCULUS

Dx Keperawatan

Nyeri b.d obstruksi akut batu ginjal ditandai

dengan pasien mondar-mandir di ruangan,
dan pasien menyampaikan secara verbal
adanya nyeri saat pengkajian.

Tujuan: Pasien menyatakan rasa sakit

berkurang dalam waktu 2 jam dari
penerimaan.

Intervensi:

Berikan obat nyeri sesuai resep dokter.

Latih teknik non-farmasi seperti guided imagery dan / atau

meditasi untuk menghilangkan rasa sakit.

Pasien dapat mengelola tingkat nyerinya.

Pasien dapat menyampaikan fokus perhatiannya atau rasa

takutnya yang mungkin berhubungan dengan nyeri.

Memberikan dukungan emosional bagi pasien.

Menilai kembali tingkat nyeri pasien dalam waktu 1 jam setelah

pemberian obat nyeri

Diagnosa Keperawatan

Defisit pengetahuan b.d kurangnya informasi

tentang kebutuhan cairan dan asupan diet
ditandai dengan terjadinya batu ginjal
Tujuan: Pasien memahami bagaimana mencegah
terjadinya batu ginjal dibuktikan dengan adanya rencana
perawatan untuk mencegah terjadinya kembali batu ginjal.

Risiko infeksi b.d stasis urin akibat obstruksi

batu ginjal di saluran kemih.
Tujuan: urine Pasien akan bening/kuning jernih, pasien
tidak mengalami demam, tidak terdapat indikasi ISK atau
infeksi lainnya.

Tindakan:

Dua fokus tindakan:

Pengobatan masalah akut, seperti nyeri,
neurovaskuler, dll
Mengidentifikasi penyebab dan mencegah
terbentuknya batu ginjal lebih lanjut

Pengobatan masalah akut:

Pengobatan Nyeri
Menjaga asupan cairan
Pembatasan diet
Dukungan emosional
Prosedur invasif (mungkin diperlukan)

TREATMENT MODALITIES
MEDICAL

SURGICAL

MEDICAL RX

The cornerstone of management of ureteral colic is analgesia

Morphine sulfate is the narcotic analgesic drug of choice for
parenteral use.
Antiemetic agents [metoclopramide ] may also be added as
needed.
The calcium channel blocker[ nifedipine] relaxes ureteral
smooth muscle and enhances stone passage
The alpha blockers, [ terazosin], also relax musculature of the
ureter and lower urinary tract, markedly facilitating passage of
ureteral stones
Uric acid and cystine calculi can be dissolved with medical
therapy
stones are dissolved with alkalinization of the urine.
Sodium bicarbonate can be used as the alkalinizing agent

MEDICAL RXctd

High Fluid Intake and Alkalinized Urine dissolve

most of the smaller cystine stones

D-Pencillamine or MPG
(Mercaptopropionylglycine) binds to cystine that
is soluble in urine

Side effects of Pencillamine restricts it use

Allergic rashes, GI problems- Nausea, Vomiting,
Diarrhoea

MPG better tolerated

Large obstructive stones Surgery required first

Prosedur Bedah

Lithotripsy: digunakan untuk memecah batu

menjadi fragmen yang lebih kecil agar dapat
melewati saluran kemih.

Extracorporeal Shock-Wave (ESWL)

Percutaneous Ultrasonic
Electrohydraulic
Laser

Terapi Bedah
Nephrolithotomy (Ginjal)
Pyelolithotomy (Renal Pelvis)
Ureterolithotomy (ureter)

SURGERY
Extracorporeal

Shock Wave Lithotripsy

(ESWL)
Percutaneous Nephrolithotomy (PNL)
Ureteroscopy
Open surgery

Choice of approach depends on stone

burden (size and number), stone
composition, and stone location.

ESWL

Shock waves generated under water can travel through body

without any appreciable loss of energy.
When they encounter stones, the changes in density causes
energy to be absorbed and reflected by the stone.
This results in fragmentation of the stones.
Before lithotripsy the stone is localized by either Ultrasound or
Flouroscopy.
Complications:
Haematuria is quite common (hemorrhage and edema
within or around the kidney)
Incomplete stone Fragmentation & Obstruction;
Stienstrasse ( stone street ) usually due to a large
Leading fragment ( Stents Recommended prior to ESWL for
Calculi > 1.5 cm )

ESWL

Steinstrasse (Stone street)

- post ESWL

PNL

Percutaneous approach allows stone removal with less morbidity,

shorter convalescence, and reduced cost compared with open
techniques
PNL has replaced open surgical procedures for removal of large or
complex renal calculi at most institutions
PNL can be performed with general, epidural, or local anesthesia
The kidney should be approached from below the 12th rib to reduce the
risk of pleural complications
The position of the retroperitoneal colon is usually anterior or
anterolateral to the lateral renal border. Therefore, risk of colon injury is
minimal
The liver and spleen may also be at risk of injury during percutaneous
access. However, in the absence of splenomegaly or hepatomegaly,
injury to these organs is extremely rare with a puncture below the 12th
rib
Once the point of puncture and the preferred calyx have been selected,
a C-arm fluouroscope is entered. The tract is dilated by special dilators
The urologist can proceed with stone removal using endoscopic
techniques e.g with Randall's forceps, a grssper or stone baskets under
fluoroscopic guidance

PNL. Ureteroscope

There is a concurrence in the literature regarding the need for

postoperative drainage with a nephrostomy tube after
percutaneous procedures.
The main function of a nephrostomy tube is the drainage of urine
and possibly the tamponade of bleeding originating from the
structures acutely expanded during dilatation.

URETEROSCOPY:
A ureteroscope is passed through the ureteral orifices
It is performed under general or regional anaesthesia
Once the stone is visualized, fragmentation with of the stone can be
done with laser, or mechanically
If significant ureteral edema or manipulation occurs, a stent should
be placed to prevent colic and obstruction

PNL

Open surgery

Generally indicated for large stones that would

require multiple ESWL or PNL
obese patients are poor candidates for ESWL and
may be difficult to manage with PNL; Open
surgery might be the best option
Open surgery may be

Pyelolithotomy
Nephrolithotomy
Ureterolithotomy
Cystolithotomy

Open surgery

Summary

Depending on the location of the stone, various

procedures are done for stone extraxtion
In the kidney
ESWL
PNL
Open methods
Pyelolithotomy for a stone in the extrarenal pelvis
Nephrolithotomy for a stone deep into the renal parenchyma
Partial nephrectomy if there is a stone impacted into the lower most
calyx

In the ureter
Upper ureter: ESWL is ideal
Mid ureter: ESWL, ureteroscopy or ureterolithotomy
Lower Ureter: Ureteroscope or ureterolithotomy

Summary
In the Bladder
Litholapaxy:
through a cystoscopy, the stone is grasped firmly and
broken. Small fragments are evacuated by evacuator
Suprapubic cystolithotomy
if the stone is too big or too hard

Complications
Ureteral scarring and stenosis
Nidus for infectionserious infection of the
kidney that diminishes renal function
Urinary fistula formation
Ureteral perforation
Extravasation
Urinary outflow obstruction
hydronephrosisCRF

Prevention

High Fluid Intake

Restrict Salt

Avoid high intake of purine food

Increased citrus fruits may help

If hypercalciuria restrict Ca intake

Pencegahan

Pendidikan pasien
hidrasi
Minum 2-3 liter cairan per hari (14 gelas)
air
Lemon (asam sitrat dapat mencegah pembentukan
batu)

Konsumsi diet
Rendah sodium/natrium
Kurangi makanan mengandung oksalat
Rendah protein

Latihan/Meningkatkan Kegiatan
Pengobatan segera

Jurnal 1
Tujuan: Menentukan efektivitas suplemen herbal yang
terbuat dari Varuna dan batang pisang, "Herbmed,"
pada batu ginjal
Sampel: 77 pasien random, menggunakan plasebo,
dilakukan di India dari bulan Juli 2007 hingga Februari
2008. Dua kelompok dibentuk: Grup A dengan d. batu
5-10mm dan Grup B dengan d. batu > 10mm.
Hasil: Pasien yang mengurangi suplemen herbal
menunjukkan pengecilan sebesar 33% ukuran batu
ginjal.
Kesimpulan: Herbmed adalah pengobatan herbal yang
mungkin memiliki efek yang menjanjikan dalam
mengurangi ukuran batu ginjal.

Jurnal II

Tujuan: Untuk menentukan kemungkinan peran

fruktosa dalam pembentukan batu ginjal.
Sampel: Peneliti melihat tiga kohort yang berbeda
(wanita tua, wanita yang lebih muda, dan laki-laki).
Hasil: Hasil dari penelitian menunjukkan bahwa ada
korelasi positif antara asupan fruktosa dan
pembentukan batu ginjal.
Kesimpulan: Asupan fruktosa dapat meningkatkan
resistensi insulin yang menurunkan pH dalam urin
dan meningkatkan resiko pembentukan batu ginjal
akibat kadar asam urat yang meningkat.

PAPUMA BEACH-JEMBER

TERIMAKASIH
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