NURSING
PROCESS: THE PATIENT WITH KIDNEY STONES
The
patient with suspected renal stones is assessed for pain and discomfort as well
as associated symptoms, such as nausea, vom-iting, diarrhea, and abdominal
distention. The severity and loca-tion of pain are determined, along with any
radiation of the pain. Nursing assessment also includes observing for signs and
symp-toms of UTI (chills, fever, dysuria, frequency, and hesitancy) and
obstruction (frequent urination of small amounts, oliguria, or anuria). The
urine is inspected for blood and is strained for stones or gravel.
The
history focuses on factors that predispose the patient to urinary tract stones
or that may have precipitated the current episode of renal or ureteral colic.
Predisposing factors include family history of stones, the presence of cancer
or bone marrow disorders or the use of chemotherapeutic agents, inflammatory
bowel disease, or a diet high in calcium or purines. Factors that may
precipitate stone formation in the patient predisposed to renal calculi include
episodes of dehydration, prolonged immo-bilization, and infection. The
patient’s knowledge about renal stones and measures to prevent their occurrence
or recurrence is also assessed.
Based
on the assessment data, the nursing diagnoses in the patient with renal stones
may include the following:
· Acute pain related to
inflammation, obstruction, and abra-sion of the urinary tract
· Deficient knowledge
regarding prevention of recurrence of renal stones
Based
on assessment data, potential complications that may de-velop include the
following:
· Infection and sepsis
(from UTI and pyelonephritis)
· Obstruction of the
urinary tract by a stone or edema with subsequent acute renal failure
The
major goals for the patient may include relief of pain and dis-comfort,
prevention of recurrence of renal stones, and absence of complications.
Immediate
relief of the severe pain from renal or ureteral colic is accomplished with the
administration of opioid analgesic agents (intravenous or intramuscular
administration may be prescribed to provide rapid relief) or NSAIDs (ie,
ketorolac). The patient is encouraged and assisted to assume a position of
comfort. If ac-tivity brings some pain relief, the patient is assisted to
ambulate. The pain level is monitored closely, and increases in severity are
reported promptly to the physician so that relief can be provided and
additional treatment initiated. The patient is prepared for other treatment
(eg, lithotripsy, percutaneous stone removal, ureteroscopy, or surgery) if
severe pain is unrelieved and the stone is not passed spontaneously.
Because
renal stones increase the risk for infection, sepsis, and ob-struction of the
urinary tract, the patient is instructed to report decreased urine volume and
bloody or cloudy urine. The total urine output and patterns of voiding are
monitored. Increased fluid intake is encouraged to prevent dehydration and
increase hydrostatic pressure within the urinary tract to promote passage of
the stone. If the patient cannot take adequate fluids orally, in-travenous
fluids are prescribed. Ambulation is encouraged as a means of moving the stone
through the urinary tract.
Patients
with calculi require frequent nursing observation to detect the spontaneous
passage of a stone. All urine is strained through gauze because uric acid stones
may crumble. Any blood clots passed in the urine should be crushed and the
sides of the urinal and bedpan inspected for clinging stones. The patient is
instructed to report any sudden increases in pain immediately be-cause of the
possibility of a stone fragment obstructing a ureter. Analgesic medications are
administered as prescribed for the re-lief of pain and discomfort.Vital signs,
including temperature, are monitored closely to detect early signs of
infection. UTIs may be associated with renal stones due to an obstruction from
the stone or from the stone it-self. All infections should be treated with the
appropriate anti-biotic agent before efforts are made to dissolve the stone
(DeLeskey & Massi-Ventura, 2000).
Because
the risk of recurring renal stones is high, the nurse pro-vides education about
the causes of kidney stones and ways to prevent their recurrence (Chart 45-12).
The patient is encour-aged to follow a regimen to avoid further stone
formation. One facet of prevention is to maintain a high fluid intake because
stones form more readily in concentrated urine. A patient who has shown a
tendency to form stones should drink enough fluid to excrete greater than 2,000
mL of urine every 24 hours (prefer-ably 3,000 to 4,000 mL), should adhere to
the prescribed diet, and should avoid sudden increases in environmental
tempera-tures, which may cause a fall in urinary volume. Occupations and
activities that produce excessive sweating can lead to severe tem-porary
dehydration; therefore, fluid intake should be increased. Sufficient fluids
should be taken in the evening to prevent urine from becoming too concentrated
at night.
Urine
cultures may be performed every 1 to 2 months the first year and periodically
thereafter. Recurrent UTI is treated vigor-ously. Because prolonged
immobilization slows renal drainage and alters calcium metabolism, increased
mobility is encouraged whenever possible. In addition, excessive ingestion of
vitamins (especially vitamin D) and minerals is discouraged.
If
lithotripsy, percutaneous stone removal, ureteroscopy, or other surgical
procedures for stone removal have been performed, the patient is instructed
about the signs and symptoms of com-plications that need to be reported to the
physician. The impor-tance of follow-up to assess kidney function and to ensure
the eradication or removal of all kidney stones is emphasized to the patient
and family.
If the patient underwent ESWL, the nurse must provide in-structions for home care and necessary follow-up. The patient is encouraged to increase fluid intake to assist in the passage of stone fragments, which may occur for 6 weeks to several months after the procedure. The patient and family are instructed about signs and symptoms that indicate complications, such as fever, decreasing urine output, and pain.
It is also important to tell the patient to expect
hematuria (it is anticipated in all patients), but it should disappear within 4
to 5 days. If the patient has a stent in the ureter, hematuria may be expected
until it is removed. The patient is in-structed to notify the physician if
nausea or vomiting, a tempera-ture greater than 38°C
(about 101°F), or pain unrelieved
by the prescribed medication occurs. The patient is also informed that a bruise
may be observed on the treated side of the back.
The
patient is monitored closely in follow-up care to ensure that treatment has
been effective and that no complications, such as obstruction, infection, renal
hematoma, or hypertension, have developed. During the patient’s visits to the
clinic or physician’s office, the nurse has the opportunity to assess the
patient’s un-derstanding of ESWL and possible complications. Additionally, the
nurse has the opportunity to assess the patient’s understand-ing of factors
that increase the risk for recurrence of renal calculi and strategies to reduce
those risks.
The
patient’s ability to monitor urinary pH and interpret the results is assessed
during follow-up visits to the clinic or physi-cian’s office. Because of the
high risk for recurrence, the patient with renal stones needs to understand the
signs and symptoms of stone formation, obstruction, and infection and the
importance of reporting these signs promptly. If medications are prescribed for
the prevention of stone formation, the actions and importance of the
medications are explained to the patient.
Expected
patient outcomes may include:
1) Reports relief of pain
2) States increased
knowledge of health-seeking behaviors to prevent recurrence
a)
Consumes increased fluid intake (at least eight
8-ounce glasses of fluid per day)
b)
Participates in appropriate activity
c)
Consumes diet prescribed to reduce dietary factors
pre-disposing to stone formation
d)
Recognizes symptoms to be reported to health care
provider (fever, chills, flank pain, hematuria)
e)
Monitors urinary pH as directed
f)
Takes prescribed medication as directed to reduce
stone formation
3) Experiences no
complications
a)
Reports no signs or symptoms of sepsis or infection
b)
Voids 200 to 400 mL per voiding of clear urine
with-out evidence of bleeding
c)
Experiences absence of dysuria, frequency, and
hesi-tancy
d)
Maintains normal body temperature
Related Topics
Privacy Policy, Terms and Conditions, DMCA Policy and Compliant
Copyright © 2018-2024 BrainKart.com; All Rights Reserved. Developed by Therithal info, Chennai.