Ureteral calculi

31 Ureteral calculi




Overview/pathophysiology


Ureteral calculi (stones) constitute the third most common urologic condition after urinary tract infections (UTIs) and pathologic conditions of the prostate. Although the cause of stones is unknown in 50% of reported cases, it is believed that they originate in the kidney and are passed through the kidney to the ureter. About 90% of all stones pass from the ureter into the bladder and out of the urinary system spontaneously.



Health care setting


Primary care; may require hospitalization for complications or surgery



Assessment




Signs and symptoms:


Pain that is sharp, sudden, and intense or dull and aching; located in the flank area; and often radiating toward the groin. Pain may be intermittent (colic) as the stone moves along the ureter and may subside when it enters the bladder. Nausea, vomiting, diarrhea, abdominal pain, and paralytic ileus may occur. Patient may experience urgency and frequency, void in small amounts, and have hematuria. Fever may indicate an infected stone or secondary UTI.



Physical assessment:


Pallor, diaphoresis, tachycardia, and tachypnea may be observed. Costovertebral angle (CVA) tenderness and guarding may be present. Bowel sounds may be absent secondary to ileus, and the abdomen may be distended and tympanic. The patient will be restless and unable to find a position of comfort.



History of:


Sedentary lifestyle; residence in geographic area in which water supply is high in stone-forming minerals; vitamin A deficiency; vitamin D excess; hereditary cystinuria; inflammatory bowel disease; recurrent UTIs; prolonged periods of immobilization; gout or prophylactic therapy with allopurinol; use of indinavir sulfate, a protease inhibitor used in patients with human immunodeficiency virus (HIV) infection; decreased fluid intake; hyperparathyroidism; sarcoidosis; and familial history of calculi or renal disease such as renal tubular acidosis.



Diagnostic tests




Serum tests:


To assess calcium levels greater than 5.3 mEq/L, phosphorus levels greater than 2.6 mEq/L, and uric acid levels greater than 7.5 mg/dL, which have been implicated in stone formation.



Blood urea nitrogen (BUN) and creatinine tests:


To evaluate renal-urinary function. Abnormalities are reflected by high BUN and serum creatinine and low urine creatinine levels.


Note: Be aware that BUN levels are affected by fluid volume excess and deficit. Volume excess will reduce BUN levels, whereas volume deficit will increase levels. For the older adult, serum creatinine level may not be a reliable measure of renal function because of reduced muscle mass and a decreased glomerular filtration rate (GFR). These tests must be evaluated based on an adjustment for the patient’s age and hydration status and in comparison with other renal-urinary tests.



Urinalysis:


To provide baseline data on urinary system functioning, detect metabolic disease, and assess for the presence of UTI. A cloudy or hazy appearance; foul odor; pH greater than 7; and presence of red blood cells, leukocyte esterase, white blood cells (WBCs), and WBC casts signal UTI. A pH less than 5 is associated with uric acid calculi, whereas a pH of 7.5 or greater may signal presence of urea-splitting organisms (responsible for magnesium-ammonium-phosphate or struvite calculi).



Urine culture:


To determine type of bacteria present in the genitourinary tract. To avoid contamination, a midstream specimen should be collected.



24-hr urine collection:


To test for high levels of uric acid, cystine, calcium, magnesium, oxalate, calcium, phosphorus, or creatinine. A second 24-hr urine collection may be done after the patient has been on a diet restricted in sodium, oxalate, and calcium.


Note: All urine samples should be sent to the laboratory immediately after they are obtained or refrigerated if this is not possible (specimens for culture are not refrigerated). Urine left at room temperature has greater potential for bacterial growth, turbidity, and alkaline pH, any of which can distort the reading.



Kidney, ureter, and bladder (KUB) radiography:


To monitor passage of a previously documented opaque stone.



Computed tomography (CT) scan with or without injection of contrast medium:


To distinguish cysts, tumors, calculi, and other masses and determine presence of ureteral dilation and bladder distention.



Excretory urogram/intravenous pyelogram (IVP):


Used to visualize kidneys, renal pelvis, ureters, and bladder. It can identify size of the stone and presence and severity of the obstruction. This test also outlines nonradiopaque stones within the ureters. Nonradiopaque stones (e.g., uric acid calculi) are seen as radiolucent defects in the contrast media.



Renal ultrasound:


To identify ureteral dilation and presence of stones in the ureters.





Nursing diagnosis:


Acute pain

related to presence of a calculus or the surgical procedure to remove it


Desired Outcomes: Patient’s subjective perception of pain decreases within 1 hr of intervention, as documented by a pain scale. Objective indicators, such as grimacing, are absent or diminished.



















ASSESSMENT/INTERVENTIONS RATIONALES
Assess and document quality, location, intensity, and duration of pain. Devise a pain scale with patient that ranges from 0 (no pain) to 10 (worst pain). This assessment evaluates intensity and trend of pain and subsequent relief obtained.
Notify health care provider of sudden and/or severe pain. This is a sign that a stone is passing through the ureter.
Notify health care provider of a sudden cessation of pain. Strain all urine for solid matter, and send to laboratory for analysis. This can signal passage of the stone.
Medicate patient with prescribed analgesics, narcotics, and antispasmodics; evaluate and document response based on pain scale.
Conservative therapy may consist of a trial of analgesia, dissolution agents, and normal fluid intake to 1500-2000 mL/day. Dissolution agents such as orange juice alkalinize urine and work to shrink stones so that they can pass through the ureter.

Note: Morphine increases ureteral peristalsis, which aids in stone passage, but ureteral peristalsis can increase pain.
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Ureteral calculi

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