Management of Kidney Stones, Research Paper Example

Introduction of the problem and clinical manifestations 

Nephrolithiasis is a common condition that yields approximately $2.1 billion in medical costs annually in the U.S. (Pearle et al., 2005). It specifically references the presence of calculi—both renal and ureteral calculi– in a person’s kidneys. Uretal calculi usually germinates in the kidneys, although it should be noted that they also can develop once they are lodged in the ureter. Medical researchers note that this condition has been known and diagnosed for millennia, as kidney and bladder stones have been discovered in mummies from ancient Egypt. Early medical texts and discourses explain how to properly treat stones in the urinary tract (Pearle et al., 2005). Considered to be one of the most painful conditions a person can attain and endure that wracks an individual without warning, acute renal colic has been described as more painful than a gunshot wound, broken bone, surgery, burns, and childbirth. 1.2 million people per year suffer from this debilitating condition, and they account for an estimated 1% of the overall hospital admissions (Pearle et al., 2005). Initial disease management involves properly diagnosing the condition, quickly treating the patient, and obtaining necessary consultations while concurrently educating the patient regarding preventative therapy measures.

Nephrolithiasis refers to the presence of calculi in an individual’s kidneys, but ureteral and renal caluli are conjoined with that condition. Most all of renal calculi have calcium. The pain associated with this condition is fomented by stretching, spasm, and dilation because of the ureteral obstruction. Patients who have Nephrolithiasis, or kidney stones, present with acute renal colic, which results in the sudden onset of acute pain that begins in the flank and radiates for anteriorly and inferiorly. Over 50% of the patients presenting with this condition will also feel nauseated and vomit frequently. Those who have urinary calculi have also reported infection, hematuria, and pain, while those who have non-obstructing stones or who have staghorn calculi usually do not present with symptoms, or they experience symptoms that easily controlled and mild to moderate. The characteristics and location of the pain associated with Nephrolithiasis include: stones within the ureter, which results in severe, abrupt, and colicky pain in the ipsilateral and flank abdomen with radiation to the genital area, causing acute nausea; stones that obstruct the ureteropelvic junction, causing urinary urgency, stranduria, dysuria, bowel symptoms, and mild to severe flank pain that does not radiate to the groin area; upper ureteral stones that radiate to the lumbar or flank; distal uretal stones that radiate to the genital area; mid-ureteral calculi, which radiate caudually or anteriorly; and stones that pass into a person’s bladder, which are usually asymptomatic and cause positional urinary retention.

There are a handful of etiologies associated with this condition. A low fluid intake, which results in very little urine production, results in elevated concentrations of solutes that form the stones in the urine. This represents the most significant environmental factor in the formation of kidney stones, although the precise extent of tubular dysfunction or damage that spawns the formation of stones is relatively unknown still (Chandoke, 2007). The research that has hitherto beem conducted on the etiology and prevention of stone formation in the urinary tract has focused on high urinary levels of oxalate, calcium, and uric acid in the formation of stones in addition to lower levels of urinary citrate. Hypercalcuira has been pointed to as the frequent metabolic abnormality, and it is related to various ensuing conditions such as increased calcium absorption in the intestine. Citrate and magnesium are both significant inhibitors in the formation of stones in the urinary tract which abated levels of those in the urine predisposes and person to the formation of stone. There are more than twenty underlying etiologies associated with four primary chemical types of calculi: struvite, uric acid, calcium, and cystine stones (Chandoke, 2007). An etiology can be identified in over 95% of the cases can be identified through stone analysis in conjunction with 24-hour urine metabolic assessment and serum (Chandoke, 2007). Physicians working in the emergency room should always have a orologic follow-up, especially for those who have recurrences of this condition.

Diagnosis of the problem

Physicians diagnose Nephrolithiasis on the premise of the clinical symptoms the patient presents with, although they also use confirmatory tests to enhance a correct diagnosis. When medical personnel examines a patient with Nephrolithiasis, they will yield these ensuing findings: hypertension, tachycardia, acute costovertebral angle tenderness, which causes radiating pain up to the upper-.lower abdominal quadrant, microscopic hematuria, and unremarkable abdominal assessment with less bowel movements. For testing, physicians comply with the recommendations proffered by the European Association of Urology to treat patients suffering from acute stone episodes: urinary sediment and dipstick test, which exhibits blood cells in addition to a nitrite test and urine culture if a positive reaction manifests; and a serum creatinine level in order to measure the patient’s renal function.  There are other tests that some physicians render quite useful: CBC with differential for patients who are febrile, meaning they are feverish; 24-hour urine profile;  microscopic urinalysis; serum electrolyte assessment—i.e. calcium, sodium, PTH, potassium, and phosphorus–of the patient presents with profuse vomiting; and a test that measured the urinary pH and serum levels, which can uncover information about the renal function of a patient in addition to the type of calculus (uric acid, calcium oxalate, and cystine).

Physicians also use various imaging studies in order the evaluation and assess Nephrolithiasis. The favored imaging studied used is a non-contrast CT scan of the pelvis and abdomen, which is the preferred imaging modality for doctors to assess acute renal colic and other associated urinary tract disease. In addition, renal ultrasonography helps determine if a renal stone is present in addition to ureteral dilation or hydronephrosis, and it can be utilized in combination with regular radiography for the abdominal or alone. To assess the total burden of a stone in addition to its size, composition, locale, and shape, plain abdominal radiography is used in conjunction with CT scanning or ultrasound of the renal area. For a clearer visualization of a patient’s urinary system, pinpointing a specific stone amidst other pelvic calcifications, and testing kidney function, Urography, or IVP, is used. In order to monitor stone activity following therapy, clarify stones that are difficult to detect using other measures, find minute renal calculi, and ascertain how many calculi present in the renal area prior to implementing a stone-prevention intervention, plain renal tomography is used. Nuclear renal scanning is utilized by physicians to objectively measure the renal function, especially if the patient has a dilated system, and the extent of the obstruction is unknown. For pregnant patients, exposure to radiation must be kept at a minimum. Finally, retrograde pyelography remains the most accurate method for ascertaining the anatomy of the renal and ereter pelvis, which aids physicians in making a definitive diagnosis of any calculus located within the ureter (Borghi et al., 2002). Imaging tests are quite pricey, which is why patients usually opt to do urine or blood tests.

Treatment

The treatment for kidney stones varies and depends on the cause of the kidney stone as well as the type. If a patient presents with smaller stones with little to no symptoms, no invasive treatment is required, and patients just have to let the stone pass. To pass a small kidney stone, patients should: drink 2-3 quartz of water daily to facilitate the flushing of the stone out of their urinary system; medical therapy when a physician gives alpha blockers to the patient to help the kidney stone pass with less pain and in a celeritous manner; or taking pain relievers such as Motrin IB or Aleve, which helps relieve the pain associated with the passing of small kidney stones. Large kidney stones that cause symptoms, however, must be treated with more proactive measures because they cause kidney damage, bleeding, and/or persistent urinary tract infections or they are simply too immense to pass on their own. In these instances, less conservative measures are taken. One procedure utilizes sound waves to dismantle the kidney stones vis-a-vis a medical procedure called extracorporeal shock wave lithotripsy (ESWL).  Shock waves cut the stones into very small pieces that subsequently exit the urinary system when the patient urinates. It is approximately a one hour long procedure that induces moderate pain, which is why patients often opt to be sedated. While the stone passes through the urinary tract, patients who choose this procedure report having bruising on their abdomen or back, finding blood in urine, diffuse discomfort, and bleeding around organs adjacent to the kidneys.

Medical treatment involves both the administration of certain pharmacological agents that vary in dose and frequency on an idiosyncratic basis and supportive care. These agents include intravenous hydration; non-narcotic analgesics such as APAP, PO/IV narcotic analgesics such as codeine, oxycodone,  butorphanol, and morphine sulfate;  NSAIDS such as ibuprofen and ketorolac; uricosuric agents such as allopurinol; antiemetics such as metoclopramide; antidiuretics; antibiotics such as ampicillin and gentamicin; an alkalinizing agent such as potassium citrate; corticosteroids such as prednisone;  calcium channel blockers; and alpha blockers. Narcotic analgesics are the standard treatment of care for treating kidney stones, and they act at the central nervous system. These analgesics are quite effective and relatively inexpensive. The adverse ramifications of these analgesics include muscle spasms, sedation, respiratory depression, and the potential to be addicting, thereby leading to abuse and dependence. The use of NSAIDS is beneficial in managing kidney stones, and they abate inflammatory reactions and pain. While they are effective and cause less sedation and less nausea than narcotic analgesics do, they are quite costly and have some potentially adverse consequences on the GI system and renal function.

For more serious cases in which the stones are larger than 7 millimeters, surgery is required because of the immensity of the stone in the kidney. The most common surgical procedure is called percuteneous nephrolithptomy, which calls for a surgeon to remove the kidney stone using small instruments and telescopes that they insert via an incision cut in the back.  Patients receive general anesthesia and are required to remain hospitalized for up to a week in order to recover adequately. If the surgery does not work, physicians recommend the patients undergo ESWL thereafter. Another option is for doctors to use a ureterscope with a camera harnessed to it to remove the stones from the kidney or ureter via the patient;s bladder and urethra to the ureter. Once the physician locates the stone, other special tools are require to break up the stone into tiny pieces that would later pass in the urine. To promote quicker healing and abate the swelling, doctors often insert a stent in the ureter. This procedure requires local or general anesthesia, according to the patient’s tastes. Finally, doctors sometimes perform parathyroid gland surgery in the case when overactive parathyroid glands cause calcium phosphates stone. If too much of the parathyroid hormone is produced, calcium levels are also elevated, which results in the production of kidney stones. If hyperparathyroidism manifests when a small, benign tumor is present in one of the patient’s parathyroid gland, the growth needs to be excised in order to prevent any further kidney stones from forming.

Patient education

Physicians and medical personnel should take on the responsibility of educating the patient and his or her family members about preventative treatment and testing for stones despite the fact that the underlying cause of a patient’s kidney stones and commencing preventative therapy is not the their primary duty. Preventative treatment plans, when performed and assessed properly. can ameliorate a patient’s state of health in relation to kidney stones. By law, physicians are required to provide patients with stone-prevention advice, because if they did not they were be subject to medico-legal liability. Patients have testified that they were never educated about preventing stones. Even patients who only develop single stones should follow a stone-prevention program in order to optimize kidney stone prophylaxis. Medical personnel need to articulate the benefits and disadvantages of implementing a comprehensive kidney stone prevention program with patients who have a documented history of kidney stone disease rather than just those who are at high-risk for it. Patients need to understand the etiology of problem, follow-up procedures, indication for referral side effects of treatment that may be prescribed and warning signs of ensuing danger regarding having kidney stones both small and large. Warning signs include painful urination and urination frequency despite not drinking vast quantities of water; radiating back pain beginning under the rib cage where the kidneys are located; blood evident in urine; nausea and vomiting; urine that has a pungent odor; inability to sit because of aggravation; chills and fever; and swelling in the kidneys and abdominal area.

Patients who suffer from kidney stones often end up in the emergency room to get treatment for their acute and debilitating pain, or they had to undergo imaging studies. Both of these medical services quickly generates high medical costs, which suggests that dealing with the direct impact of kidney stones is merely beginning for those who have kidney stones. Often, patients suffer from the obstruction of their upper urinary tract in addition to getting physical scars in the luminal parts of the urologic system (Parmer, 2015). These consequences together can profoundly damage a patient’s physiologic function. If untreated, kidney stones can cause permanent renal damage that sometimes leads to failure. Unfortunately, it does not seem likely there will be any more innovative, cost-effective diagnostic techniques or measures of procedural treatment for the kidney stone care. As such, prevention is the more optimal intervention that currently exists, which would result in less medical attention being required and thus less costs. Disseminating better information about the prevention and management of kidney stones, patients and clinicians together can abate the utilization of healthcare resources that were already in demand. Preventative measures for kidney stone have already been quite cost-effective, so sharing information could result in enhanced health outcomes, less recurrence of acute outbreaks, faster recovery age, and the reduction of costs link to lost productivity and clinical management.

Nursing theory

Nursing theory is useful as a tool for providers to administer healthcare for patients and families with kidney stones. The Roy Adaptation theory is one theory that could be used for kidney stones patients. It explicitly assumes that individuals are constantly interacting with shifting environments. In order to cope with a shifting world, people tap into both acquired and intrinsic mechanisms that are psychological, biological and social in nature. As such, health and illness encroach on all dimensions of a person’s life, so people need to adapt in a positive manner to these environmental changes. Nurses embrace such a humanistic approach that values the views and perceptions of their patients and through interpersonal relationships nurses can facilitate patients’ efforts to engage in preventitive health measures. Such a dynamic approach to healthcare is of paramount importance for nurses in order to maintain the integrity and dignity of the profession. Indeed, within this paradigm, the nursing profession is one based on causality in which the values and opinions of patients are respected and taken into consideration. The goal of nursing is adaptation, so it is the job of a nurse to stress the need for patients suffering from kidney stones to change their lifestyle habits such as drinking more water in order to minimize recurrences in the future.

References

Borghi, L., Schianchi, T., Meschi, T., Guerra, A., Allegri, F., Maggiore, U. et al. (2002). Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. New England Journal of Medicine, 346(2), 77-84.

Chandhoke, P.S. (2007).  Evaluation of the recurrent stone former. Journal of Urology Clinical in North America, 34(3),315-22.

Parmar, P. (2015). Kidney stones: Prevention requires education for patients and providers. Advanced Healthcare Network. Retrieved Octoner 12, 2015 from http://nurse-practitioners-and-physician-assistants.advanceweb.com/Features/Articles/Kidney-Stones.aspx

Pearle, M.S., Calhoun, E.A., & Curhan, G.C. (2005). Urologic diseases in America project: Urolithiasis. Journal of Urology, 173(3), 848-57.