N512-19A Module 5 Discussion: Disorders of the Urinary System Across the Life Span

Nephrolithiasis

Nephrolithiasis, renal calculi, also known as renal stones, may form anywhere within the urinary system; however, calculi mainly form in the kidney within the renal pelvis as a result of a high concentrated accumulation of undissolved salt and minerals (Pathophysiology Made Incredibly Easy!, 2019, pp. 1–3). There is a higher incidence of renal calculi, found in Caucasian males than females within the United States. If the calculi remain in the renal pelvis of the kidney, the patient may have occasional symptoms associated with a dull backache, however this may create future issues with kidney function at a later time (Pathophysiology Made Incredibly Easy!, 2019, pp. 1–3). As larger renal calculi break off and travel through the urinary system, the pain can be unbearable.

Louis J. presented in the emergency department (ED) with severe pain, exclaiming the pain he was experiencing was like he had never experienced before. Patients will complain of flank pain that radiates in a peristaltic wave-like form as it fluctuates in intensity from the back to the abdomen, down into the groin and upper thigh region. Nausea, vomiting, hematuria, chills, and a fever may be present when assessing the patient with renal calculi. As renal calculi obstruct the ureter, pain and symptoms may mimic an episode of acute appendicitis, pancreatitis, peptic ulcer, and cholecystitis which will need to be ruled out when making a diagnosis (Pathophysiology Made Incredibly Easy!, 2019, pp. 1–3). Some patients can pass the renal calculi without noticing a lot of symptoms; however, some may need to have a cystoscopy procedure to remove the calculi, lithotripsy to break up the calculi, or surgery to remove the calculi. This is all case dependent taking into account the patients’ physical health history as well as underlying conditions (What Are Kidney Stones, 2020).

Pathophysiology

According to The Urology Care Foundation, there are four types of renal stones which have their etiology:

-Calcium stones: comprised of calcium oxalate which is found more commonly than the calcium phosphate stones making up 80 percent of the calcium stones. Patients have a higher risk of developing calcium stones when diagnosed with primary hyperparathyroidism, idiopathic hypercalciuria inherited, or from calcium malabsorption as seen in patients after bowel surgery.  Diets that are high in oxalate and low in calcium play a part in stone development as well. Eating a low oxalate diet, low sodium, and calcium intake as well, even though it is about how your body processes the calcium, not as much of a dietary issue (What Are Kidney Stones, 2020).

-Uric acid stones: make up 5 to 10 percent of the stones that occur from an accumulation of waste product from the chemical changes seen within the body when uric acid breaks down. This increase of uric acid does not rapidly dissolve, leaving the urine very acidic, thus creating stone formation. Several predisposing factors contribute to uric acid stones, including chronic diarrhea, type II diabetes, gout, and obesity. A diet high in animal protein or purine-rich foods should be avoided or kept to a minimum while increasing your fruits and vegetable intake (What Are Kidney Stones, 2020).

-Struvite stones: also known as infection stones make up 10 percent of the stones. These stones occur as a result of chronic urinary tract infections (UTI’s). Many individuals with a history of neurological disorders affected by poor bladder emptying have a greater incidence of struvite stones development. Staghorn calculus, a type of struvite stone, forms in the calyx and renal pelvis getting its name from the “stag” deer as the calculi formation of the branches resemble horns on a stag deer (What Are Kidney Stones, 2020).

-Cystine stones: a rare occurrence in less than one percent of the stones. There are several foods high in cystine, which is an amino acid. Cystinuria is an inherited metabolic disorder that causes an amino acid build-up as a result of a deficiency in metabolism which decreases transport and reabsorption of the amino acids (What Are Kidney Stones, 2020).

Renal calculi come in all different shapes, sizes, and colors which may indicate where they originated from as seen with the staghorn calculus. Stones may form due to several predisposing factors as previously noted with metabolic disorders, hereditary disorders, chronic infections as UTIs, neurological disorders, diabetes, diet, and obesity to name a few (Hammer & McPhee, 2018, pp. 513-516). Stone analysis is an important part of diagnosis if possible so proper measures may be discussed to decrease potential reoccurrence since once diagnosed with renal calculi, you are likely to have a reoccurrence within five years (What Are Kidney Stones, 2020).

According to Hammer and McPhee (2018, pp. 513-516), there is a delicate balance when educating our patients about renal stone formation and reoccurrence since each patient’s history is individualized. Providing our patients with a generic brochure, teaching them the generalized information is not enough. A detailed plan of care (POC) needs to be reviewed with the patient after the proper diagnosis has been established. POC must include how Hydration is a necessity, especially in the warmer climates when sweating during exercise occurs. Dehydration alters the normal pH of the urine, setting up a hospitable environment for stone formation to occur or reoccur. Diet, supplements, and prescribed medications need to be monitored as previously discussed to make sure they are appropriate to enhance protection from renal calculi, not cause them. Lifestyle changes may need to occur if the patient is eating a lot of processed foods high in sodium, as well as decreasing body mass index (BMI) if the patient is obese. N512-19A Module 5 Discussion: Disorders of the Urinary System Across the Life Span

 

Conclusion

 As previously discussed, Louis J., a Caucasian male, presented in the ED with excruciating unremitting right flank pain which he has never experienced before, however, on assessment, his right flank is mildly tender to palpation, abdomen benign. Louis is afebrile, denies dysuria and vomiting; however, Louis complains of nausea. After a complete history and physical, several tests were completed, including blood and urine specimens which were positive for hematuria as noted by the increase in red blood cells (RBCs). Louis’ blood pressure (BP) and pulse rate (P) are elevated which is typically seen when patients are experiencing pain especially associated with renal calculi. Louis’ BP and P will be re-evaluated after intravenous fluids (IV) are given for hydration, and pain medication administered for pain. I expect these to be lowered as Louis becomes more comfortable. If BP and P continue to be an issue, further investigation may be necessary. An ultrasound and/or CT scan will be ordered to check for renal calculi and placement, as well as ruling out other possible symptoms associated with other diagnoses, as previously discussed.

            I will review all of the findings keeping Louis until the pain medication wears off, making sure Louis is more comfortable after hydration, BP and P is within normal limits (WNL). After re-evaluation, it may be necessary for Louis to be admitted for an observational overnight stay to make sure he doesn’t return to the ED within 48hrs after discharge. This is important because we don’t want him to experience an increase in discomfort or a change in symptoms presented initially. Louis will be well educated before discharge as noted above. It is a huge financial burden to the health care system as people present in the ED each year from episodes of renal calculi formation/kidney stones.

He will be instructed to make a follow-up appointment with his primary care physician (PCP) or certified nurse practitioner (CNP) within a few days of discharge or sooner if his condition worsens. Louis will be sent home with a strainer to be used with each void to catch potential stones if passed. Once Louis collects the stones using the strainer, he will be advised to bring them into his PCP or CNP for further evaluation and analysis. Once information is obtained, he will be able to take action in reducing the reoccurrence of stones formulating in the future by having a better understanding of why they formed initially. Unless Louis’ status changes, I would not advise surgery at this time, due to feeling confident that Louis will pass the kidney stones on his own without any complications.

 

           

References

 

Hammer, G. D., & McPhee, S. J. (2018). Pathophysiology of Disease: An Introduction To

Clinical Medicine 8E (8th ed.). McGraw-Hill Education / Medical.

Pathophysiology made incredibly easy! (6th ed.). (2019). Cherie R. Rebar, Nicole M.

Heimgertner, Caroline J. Gersch.

Treatment for Kidney Stones. (2020, August 20). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/urologic-diseases/kidney-stones/treatment

What are kidney stones? (2020, April). Urology Care Foundation. https://urologyhealth.org