Chapter 37
Nursing Care of Patients With Disorders of the Urinary System
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Monitors
Water- filled bags
Patient’s kidney stone
Water column
ECG monitor
Shock wave generator
FIGURE 37.2 Extracorporeal shock- wave lithotripsy.
Ellipsoidal reflector
computed tomography (CT) or renal ultrasound (preferred for pregnant women) initially. Less commonly used tests include abdominopelvic x-ray, magnetic resonance imaging (MRI), and IV pyelography. Therapeutic Measures Renal calculi, usually less than 10 mm, are treated medically, if possible, with hydration and medication for pain. Most small stones can be flushed out during urination. All urine must be strained by the patient or health-care staff to detect passage of stones and for stone analysis. Treatment includes drinking 2 to 3 quarts of fluids; NSAIDs such as ibuprofen (Motrin) for the pain of renal colic, or opioids if NSAIDs are contraindicated, as in CKD or when pain is unrelieved with NSAIDs; and an alpha-blocker medication (such as tamsulosin [Flomax]) to relax ureter muscles. Patients who develop severe renal colic are usually admitted to the hospi- tal for hydration with IV fluids and pain medication. Surgical intervention may be needed depending on the location and size of the stone (often larger than 10 mm) or when obstruction or infection is present, urinary function is impaired, severe pain continues, or the patient is unable to pass the stone. Only rarely is open surgery required. CYSTOSCOPY. For stones within the bladder, cystoscopy (wire basket removal) is used for small stones and cysto- litholapaxy for larger stones. In cystolitholapaxy, an instru- ment is inserted through the urethra to the bladder to crush the stone. The stone is then washed out with an irrigating solu- tion. See postoperative care for cystoscopy in Chapter 36. URETEROSCOPY. The ureteroscope is inserted into the blad- der and advanced along the ureter to view the stone. The stone is then removed with a wire basket or broken up with a laser or electrohydraulic energy to be flushed out in the urine. A stent may be placed for up to 2 weeks. Postoperative care is similar to cystoscopy care. LITHOTRIPSY. Lithotripsy uses sound shock waves or laser energy to break the stone into small fragments. Examples of
types of lithotripsy include shock-wave lithotripsy (SWL), laser lithotripsy, and percutaneous ultrasonic lithotripsy. For SWL, the patient is sedated or anesthetized. Ultrasonic shock waves applied outside the body are focused on the stone to break it up into sandlike particles (Fig. 37.2). The particles are then flushed out with urination over time, with varying degrees of discomfort or pain. Occasionally, a stent is placed in the ureter to facilitate the passage of the stone fragments. SWL is most effective with calcium stones 1 centimeter or smaller that are in the kidney. After the outpatient procedure, the patient is usually discharged. Blood-tinged urine (pink) for about 1 to 3 days and back soreness for several days are common. Bruising may occur on the back or abdomen. Discharge instructions include increase fluid intake to help flush out the stone particles, strain all urine to catch stone fragments for analysis, and notify the HCP for problems. PERCUTANEOUS NEPHROLITHOTOMY. For kidney stones that are large and cannot be removed with SWL, a percutane- ous nephrolithotomy is performed. A small incision is made in the back through which a nephroscope is inserted into the area of the kidney where the stone is located. The stone is broken up and removed. A temporary nephrostomy tube or stent might be placed to help ensure unobstructed urine flow. Nursing Process for the Patient With Renal Calculi DATA COLLECTION. The health history may identify a family or patient history of previous stone formation. The patient is asked about a recent history of UTI, diet or activity changes, or other risk factors for renal calculi. If the cause is iden- tified, specific education can be provided to help prevent recurrent calculi. • WORD • BUILDING • lithotripsy: litho-stones + tripso-breaking stones nephrolithotomy: nephro—kidney + lith—stone + otomy—incision nephrostomy: nephr—pertaining to the kidney + ostomy—surgically formed artificial opening to the outside
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