PATHOPHYSIOLOGY: URETEROLITHIASIS

LEGEND:

-------------- Signs & Symptoms

Disease Process

Symptoms Manifested by Patient

Current Medications Treatment Undertaken

Precipitating:

Predisposing: Diet:

Age (20-49 y.o.) High Sugar

High Sodium
Sex (Male) High animal protein diet (seafoods/fish)
Consumption of foods high in oxalates
Race (Caucasian)

Family History Low daily fluid intake

Geography: Southern Latitudes Sodium and calcium supplements
Autoimmune disease: Crohn’s Disease TB drug (Rifampicin)

Diabetic

Obese

Recurrent UTI

Changes in Urine PH

Gout (Inflammatory arthritis)

Gastric/intestinal bypass surgery

Nephropathy

Hyperparathyroidism

Immobility
 Increase urinary solutes (Ca+, uric acid, oxalate,
Na+) and Decrease excretion of inhibitors of
crystallization

Urine becomes too concentrated with insoluble

materials Decrease urinary
volume or excessive
increase or decrease
Physico-chemical change in the state of urinary pH
supersaturation

Ions come together in the collecting ducts Crystals are dumped into the renal papillae

Nucleation

(Homogenous and Heterogenous Nucleation)

Crystal growth and aggregation

Obstruction within the tubule

or in the ureter
Crystal cell interaction
 Crystal retention/adhesion Increase pressure in
the ureter

-----------
Stone formation (leaves the renal pelvis and travel Ureteral Renal Colic
-------
into the ureter) hyperperistalsis (flank pain)
------------
------------
N&V

Injures the wall of

the ureter
---------- ----------
Urinary tract Painful urination Low urine output
infection

-------

Hematuria Decreased Hgb

count
Acidosis

URETEROLITHIASIS
 Delayed Treatment:
EARLY DIAGNOSIS: Obstruction
Assessment and Diagnostic Findings Hydronephrosis/Hydroureternephrosis
 Urinalysis Infected stones
 Urine (24-hr): uric acid, calcium, phosphorus, oxalate, or cystine may be elevated
 Electrolyte Panel test (potassium, sodium) Renal abscess
 Serum and urine BUN/Cr
 Serum chloride and bicarbonate levels Chronic kidney disease
 CBC
Infection
 Parathyroid hormone (PTH)
 KUB x-ray Ureteral scarring
 IVP
 CT scan Spontaneous rupture of ureter
 Ultrasound of kidney
 Cystoscopy Urosepsis

Medical and Pharmacologic Management

 antimicrobial agents
 analgesics, such as Hydromorphone (Dilaudid) and morphine (Duramorph)
 diuretics
 thiazides
 Antiurolithic agent (Rowantix)
 Ketoanalogues; essential amino acids; nutritional supplements
POOR PROGNOSIS
Stone Removal Procedures

 Ultrasonic lithotripsy
 Electrohydraulic lithotripsy
 Extracorporeal shock wave lithotripsy (ESWL). DEATH
 Chemolysis (stone dissolution)
 Urethral dilation and calibration

Nursing Interventions

 Assess for pain and discomfort, including severity, location, and radiation of pain.
 Assess for associated symptoms, including nausea, vomiting, diarrhea, and abdominal
distention.
 Observe for signs of urinary tract infection (chills, fever, frequency, and hesitancy) and
obstruction (frequent urination of small amounts, oliguria, or anuria).
 Observe urine for blood; strain for stones or gravel.
 Assess patient’s knowledge about renal stones and measures to prevent recurrence.
 Encourage and assist patient to assume a position of comfort.
 Assist patient to ambulate to obtain some pain relief.
 Encourage increased fluid intake and ambulation.
 Begin IV fluids if patient cannot take adequate oral fluids.
 Monitor total urine output and patterns of voiding.
 Monitor vital signs for early indications of infection; infections should be treated with the
appropriate antibiotic agent before efforts are made to dissolve the stone.
 If patient had surgery, instruct about the signs and symptoms of complications that need
to be reported to the physician; emphasize the importance of follow-up to assess kidney
function and to ensure the eradication or removal of all kidney stones to the patient and
family.
 Provide instructions for any necessary home care and follow-up.
 Encourage regimen to avoid further stone formation; advise patient to adhere to
prescribed diet.

GOOD PROGNOSIS