Edema in urolithiasis
6. Nursing with urolithiasis
7. The role of the nurse in the rehabilitation of patients
Urolithiasis is a chronic disease,which is characterized by the formation in the kidney of urinary stones (concrements) as a result of metabolic disorders and changes in the urinary tract.
Urolithiasis (IBD) occurs at any age, but men are more often ill at the age of 30-55 years. Bilateral stones are observed in 15 - 30% of cases.
Renal concrements arise as a result ofmetabolic (salt, mineral) processes in the human body, avitaminosis, in particular avitaminosis A, hypervitaminosis D, stagnant phenomena in the renal pelvis, when urine salts can crystallize urate salts (urates), which are the basis for the formation of concrements. Violation of the function of the endocrine glands can cause the formation of stones, which cause pain, bleeding, violation of urine outflow and infectious-inflammatory process.). The causes of urolithiasis can also be the structure of nutrition and the quality of drinking water, inflammatory processes in the kidneys, etc.
A study of the various groups of factors thatparticipate in the process of stone formation, presents great difficulties. This is also due to the fact that it is not established whether these factors act separately or together in different combinations. It can be assumed that some of them are permanent, while others may become a trigger for stone formation and cease to exist. It is also not established whether the formation of various types of stones is subject to the same laws. Often formed a small stone, which departs after renal colic, which is never repeated.
1. The reasons for the formation of stones
Currently, exogenous and endogenous factors of the ICD are isolated.
- features of nutrition (consumption of large amounts of protein, alcohol, reduced fluid intake, deficiency of vitamins A and B6, hypervitaminosis D, intake of alkaline mineral waters, etc.);
- features of modern life (hypodynamia, profession, climatic, environmental conditions, etc.);
- taking medications (vitamin D preparations, calcium preparations, sulfonamides, triamterene, indinavir, intake of ascorbic acid more than 4 g / day).
- urinary tract infections;
- endocrinopathy (hyperparathyroidism, hyperthyroidism, Cushing's syndrome);
- anatomical changes in the upper and lower urinary tract, leading to a violation of the outflow of urine (nephroptosis, stenosis of the LMS, urethral structure,
- diseases of internal organs (neoplastic processes, metabolic disorders of various genesis, chronic renal failure and
- genetic factors (cystinuria, Lesch-Nihan syndrome - pronounced deficiency of hypoxanthine-guanine-phosphoribosyltransferase, etc.).
The formation of stones begins when urine is oversaturated with insoluble components due to intense excretion or the influence of factors that reduce solubility.
Under the influence of a different combination of exogenous,endogenous and genetic factors, a metabolic disturbance occurs in biological media, which is accompanied by an increase in the level of stone-forming substances (calcium, uric acid, etc.) in the blood serum. The increase in stone-forming substances in the serum leads to an increase in their excretion by the kidneys, as the main organ involved in maintaining homeostasis, and to urine oversaturation. In the supersaturated solution precipitation of salts in the form of crystals is observed, which can later serve as a factor in the formation of microliths first, and then, due to the settling of new crystals, the formation of urinary stones. However, urine is often supersaturated with salts (due to a change in the nature of nutrition, changes in climatic conditions, etc.), but there is no formation of concrements. The presence of only one glut of urine is not enough to form a calculus. Other factors, such as urinary drainage, urinary tract infection, etc., are also necessary for the development of the ICD. In addition, there are substances in the urine that promote the maintenance of dissolved salts and prevent their crystallization - citrate, magnesium ions, zinc ions, inorganic pyrophosphate, nephrocalcin. In most patients with urolithiasis, the concentration of these substances in the urine is reduced or absent.
2. Chemical composition of stones
Currently used mineralogicalclassification of stones. According to the chemical composition, the stones can be homogeneous (oxalate, urate, phosphate, carbonate, xanthine, cholesterol) and mixed.
Oxalate calculi dark brown, solid withrough surface. Phosphate - light gray, urate (urate) - yellow-red, smooth. Stones can be single and multiple, ranging from a grain of sand to a large egg.
About 60-80% of all urinary stones are inorganic calcium compounds: calcium oxalate (weddellite, velvety), calcium phosphate (vitlokite, brushite, apatite, hydroxyapatite, etc.).
Stones consisting of uric acid (uric acid dihydrate) and uric acid salts (sodium urate and ammonium urate) are found in 7-15% of cases.
Magnesium - containing stones (neuberite, struvite)constitute 7-10% of all urinary stones and are often combined with infection. The bacteria contained in the intestine (Oxalobacter formingenes) are an important component in maintaining calcium-oxalate homeostasis, and their absence can increase the risk of calcium-oxalate concrements.
The most rare stones are protein stones- Cystine (detected in 1-3% of cases). In most cases, stones have a mixed composition, which is associated with a violation in several metabolic units and infection
Urate stones consist mainly of urinaryacid. Their formation may be due to a high concentration of uric acid in the urine or a low pH of the urine. The concentration of uric acid depends on both the volume of urine and the amount of excretion of uric acid. Two-thirds of the urate is eliminated through the kidneys. Excretion of uric acid is enhanced in conditions associated with an increase in endogenous urate production or in the consumption of products rich in purines. Increased hyperexecretion of urates can be observed in tumorous diseases, but not always with stones. The presence of a normal level of urate in the blood serum does not exclude high urate excretion, nor does an increase in uric acid in the blood indicate a high urate content in the urine - much more often it is secondary to a low excretion of uric acid in the urine. Many patients with stones from uric acid have a normal concentration of uric acid in the serum and urine. In this case, the stones are formed due to low urinary pH values, which is associated with a decrease in the production of ammonium by the kidneys.
The formation of stones begins when urineis supersaturated with insoluble components due to intense excretion or the influence of factors that reduce solubility. Most stones consist of calcium oxalate; in 30% this is combined with hypercalciuria, hyperoxaluria is rare. Hypercalciuria without hypercalcemia is usually idiopathic, that is, it does not have a specific etiology. Idiopathic hypercalciuria may be caused by a high absorption of Ca in the gastrointestinal tract or an increase in Ca excretion by the kidneys and is usually of a family nature.
Stones can not let know about themselves for many years. The main symptom of the disease is an attack of renal colic.
Sometimes the disease proceeds secretly and is detectedaccidentally when X-ray study on another occasion or its first signs appear when the stone is large, and the patient only notes dull, undefined pain in the lumbar region.
Most often with a small stone diseaseis manifested by attacks of renal colic, and in the period between attacks - blunt pain, changes in urine, the removal of stones and sand. Dull pain in the lumbar region increases with prolonged walking, during a jolting ride, after lifting weights, but more often without certain reasons.
The presence of pus in the urine - a common symptoma disease that, along with the detection of bacteria, indicates infection of the stone. Violation of the outflow of urine can be accompanied by an increase in body temperature, symptoms of intoxication. When the stones move, colic migraine pain and hematuria occur. Possible infection or obstruction of the urinary tract. Coral concavities are accompanied by a recurrent infection of the urinary tract.
Intense paroxysmal pain, violationurination and impurity of blood in the urine are the leading symptoms in the clinical picture of urolithiasis. In addition to severe suffering, the disease can lead to serious complications, and in severe cases to a loss of the kidney. An anuria (lack of urine) is a terrible complication of kidney stone disease. It can be the result of a blockage of the urinary tract on either side (or a single kidney).
The course of the disease consists of an attack and an interictal period. An attack of urolithiasis - renal colic - develops when a sudden occurrence of an obstruction on the way outflow of urine from the kidneys.
The main symptom of an attack of renal colic -severe pain that is localized in the lumbar region and can spread along the ureter towards the bladder, as well as in the groin, thigh, and hypochondrium. The pain is of such intensity that a loss of consciousness is possible. The patient rushes in search of an easing position. The skin becomes pale, covered with cold sticky sweat. There are frequent urge to urinate, in the urine can appear blood. Sometimes there is reflex nausea, vomiting, fever.
Assistance during an attack
- to make an injection of atropine sulfate (1ml 0.1% r-ra) subcutaneously, morphine hydrochloride or omnopone intravenously.
- put the patient in bed, attach hot water bottles to the waist;
- if possible put the patient in a hot bath;
- Do not leave the patient unattended, tk. there may be a syncope;
After the removal of the stone, renal colic may stop on its own.
ureter renal colic stone
Diagnosis of ureteral stones consists of a complex of diagnostic measures, such as: survey and excretory urography; Ultrasound, computed tomography and clinical analysis.
In urine, after an attack, a smallamount of protein, fresh erythrocytes, white blood cells. In most cases, hematuria occurs, which occurs as a result of damage to the mucosa of the urinary tract and small capillaries in the submucosa.
The main place in the diagnosis of urolithiasisoccupy X-ray methods of research, which are the most common and informative. A survey of urinary tracts allows us to establish not only the presence of an X-ray stone, its magnitude, but also localization.
Introduction of ultrasound research methodhas expanded the possibilities of detecting not only X-ray positive, but also X-ray negative kidney stones. The stones of any consistency and of various sizes are found, not only in the cup-and-pelvis system, but also in inlaid cups. Especially valuable is the ultrasound examination with dynamic observation of patients with X-ray negative lithotripsy therapy after remote lithotripsy, when non-invasiveness and accessibility of the method makes it possible to perform ultrasound monitoring for the degree of expansion of the cup-and-pelvic system, the presence of intra- and pararenal hematomas.
According to excretory urographyto establish the anatomical and functional state of the kidneys and urinary tract, the type of pelvis (intralesional or extrarenal), localization of the calculus (in the pelvis, calyx or ureter). A stone that breaks the outflow of urine can cause hydrocalicosis, pyeloectasia, ureterohydronephrosis. When the X-ray is negative, against the background of the radiopaque substance, the "filling defect" corresponding to the localization of the calculus is seen.
Retrograde pyelography is extremelyrarely on strict indications. Renal angiography is used in coral nephrolithiasis to determine the angioarchitectonics of the kidney and its functional state when an open surgical intervention with a clamping of the renal artery is planned.
Emergency hospitalization of patients with urolithicthe disease is carried out in the urological department of the emergency room for acute urinary retention, severe attacks of renal colic, acute secondary pyelonephritis.
Treatment of urolithiasis can beoperative (ESWL, X-ray - endourological operations and "traditional" open operations), medicinal and preventive. The choice of the method of treatment is based on the results of a clinical examination of the patient, the chemical structure of the calculus, the presence of concomitant diseases. Indication for planned surgery for urolithiasis is determined by a urologist.
- phytotherapy (herbal treatment);
- fight against urinary tract infection;
- lithotripsy (crushing stones with ultrasonic waves).
Of the drugs recommend hypothiazide. In the treatment of hypothiazide, it is necessary to increase the content of potassium in the diet.
Assign 200 g of dried fruits (dried apricots, raisins) or potassium chloride 2 g per day. Treatment should be carried out under strict control of electrolyte blood.
Indication for the use of antibacterial and anti-inflammatory therapy is the presence of acute or chronic calculous pyelonephritis.
Anti-inflammatory drugs are used togetherwith antibiotics to eliminate the focus of inflammation when an infection is detected. The most commonly used anti-inflammatory drugs are nonsteroidal anti-inflammatory drugs (NSAIDs) - ketoprofen, diclofenac, ketorolac and others.
Antibiotic treatment was shown to patients withwith stones. This is due to the fact that stones from the mixed phosphoric acid salt of magnesium and ammonium (struvite) are formed due to an infection caused by microorganisms (Proteus and Pseudomonas). But even with stones of another chemical structure, an inflammatory process can take place. At the same time, the most common pathogen of urinary tract infection is the E. coli, and less often other gram-negative bacteria - staphylococci and enterococci. When an infectious process is detected in the urinary tract, antibacterial treatment is prescribed in accordance with the results of urine culture, antibioticograms, endogenous creatinine clearance, and liver dysfunction. Empirical selection of antibiotics should be considered adequate only at the initial stage of therapy. The introduction of antibacterial drugs is carried out depending on the severity of the disease by oral or intravenous route. Do not prescribe at the same time bacteriostatic and bactericidal antibiotics. Important for an antibacterial drug is the ability to penetrate and accumulate in the focus of inflammation in the required concentrations. You can prescribe an antibacterial drug only when there is no disturbance in the outflow of urine, otherwise a bacterio-toxic shock may occur, which is associated with the lysis of gram-negative bacteria and the release of a large amount of lipopolysaccharide, which is an antigen. The minimum duration of treatment with antibacterial drugs is 7-14 days
Despite the development of modern methods of treatment,the need for the use of pharmacological drugs is preserved. Their use reduces the risk of recurrent stone formation by correcting biochemical changes in blood and urine, and also contributes to the removal of stones up to 0.5 cm in size.
5. Nursing process with urolithiasis
Studying an anamnesis, a nurse needs to know aboutprevious episodes of renal colic, hereditary aggravation, diet disorders, low fluid intake, urinary tract infections, gout, intestinal diseases, or a specific cause of hypercalciuria.
Determine the concentration of Ca, HCO3 and creatinine inblood serum. In urine, cystine, struvite, or other crystals may be detected; when suspected of an infectious process, urine is taken to sow and isolate cultures of microorganisms.
If the composition of the stone is not determined, the volume of urine is increased, increasing the fluid intake.
All patients with infection, uric acid orCystine stones are examined and prescribed treatment. When a calcium stone is found, the doctor examines the patient for hypercalcaemia and hyperparathyroidism. Collect urine daily to determine hypercalciuria (> 300 mg in men,> 250 mg in women); pH, excretion of uric acid and oxalate. The results obtained make it possible to prescribe a specific therapy.
General recommendations include: diet therapy, monitoring of daily fluid intake, physical therapy, physiotherapy and balneology procedures.
The nature of nutrition is one of the mainrisk factors for the development of urinary stones and, taking this into account, diet therapy, adequate maintenance of water balance, etc., plays an important role. Dietary recommendations are based on chemical analysis of the removed stone and are aimed at correcting biochemical changes in the body.
Targets of nursing interventions The plan of nursing interventions
The patient will not experience fear due to bloody urine
Explain to the patient the essence of his illness.
Inform patient about upcoming methods of examination, preparation for urine, blood, X-ray studies.
3. Prepare hemostatic means: calcium chloride 10%. vikaool 1%. dicinone (ethamylate) 12.5%, aminocaproic acid 5%.
4. Enter haemostatic funds for the appointment of the first doctor.
5. Talk with relatives about the rules of patient care.
After 30 minutes, the patient will not experience pain in the lumbar region
1. Provide the patient with a warm dry bed.
2. Set the temperature in the room 22--23'С.
3. Place the patient in a warm bath (if possible, apply a heating pad to the lumbar region and abdomen).
4. Enter intramuscularly 2--4 ml of 50% solution of analgin or 1 ml of 0.2% solution of platifillin
6. If the pain is not stopped, 1 ml of a 2 (1)% solution of promedol is injected intravenously, along with 10 ml of 0.9% sodium chloride, as prescribed by the doctor.
7. Follow the abundant drink of liquids
The patient's edema decreases
1. Provide the patient with a diet with a restriction of liquid to 1 liter per day and salt to 6-10 g per day.
2. Monitor the high temperature in the room to remove moisture through the skin.
3. When the urine is delayed by a stone, perform a catheterization of the bladder.
4. Perform all the doctor's appointments.
5. Conduct a conversation with relatives about authorized product transfers
The patient will not experience fever and chills
1. Give the patient a comfortable position in bed.
2.Heat warm blankets, put warmers to the waist, limbs - with chills.
3. Abundant drinking of liquid by the patient (juices, compotes, tea) - with heat.
4. Bubble with ice to hang over the patient's head - with heat.
5. In the diet limit the acute, extractive, salty foods. To forbid alcohol.
6.Timely fulfill the appointment of a doctor for the introduction of antibacterial drugs
The patient will not experience the danger of exacerbation of symptoms at home after discharge from the hospital
1. To teach the patient the skills of self-management with swelling, nausea; dietary rules.
2. Conduct a conversation with family members of the family about
- the content of bed linen is dry;
rules of preparation of dietary dishes,
-use of necessary literature on the prevention of kidney disease.
6. The role of the nurse in the rehabilitation of patients
Tips for patients with urolithiasis
- it is necessary to determine the basic chemical compositionstones (determined by the appearance of the stones or by the increased amount of certain salts in the biochemical analysis of urine) and the acidity of urine (determined in the general analysis of urine), t. from this depends the choice of mineral water and diet;
- to observe the correct drinking regime - you needtake 2-3 liters of fluid per day (mineral water, compote, fruit juice, juices, herbal medicinal herbs, watermelons); - to observe a diet with restriction of products containing those salts from which stones are formed; - do not delay visiting the toilet when urinating to urinate - do not allow urine to stagnate; - avoid hypothermia; - timely treatment if there are signs of a urinary tract infection.
Dietotherapy reduces to limiting the totalthe amount of food consumed, fats, table salt. It is advisable to completely exclude broths, chocolate, coffee, cocoa, fried and spicy food. With normal glomerular filtration, it is recommended to take at least 1.5 liters of fluid per day.
Dietary recommendations for urate urolithiasis: Exclusion of products with a high content of purine compounds (which are sources of uric acid formation), such as various meat products (sausages, broths, offal), beans, coffee, chocolate, cocoa. Low pH of urine and excretion of citrate is associated with high consumption of animal protein and alcohol due to metabolic acidosis. Eliminating alcohol and reducing protein in a balanced diet leads to an increase in pH and excretion of citrate. The patient should recommend a daily intake of 2.5-3.0 liters of fluid to achieve a volume of urine of more than 2 liters / day.
Dietary recommendations for calcium oxalateurolithiasis consists in limiting the intake of foods high in calcium, ascorbic acid and oxalate. These products include milk and dairy products, cheese, chocolate, green vegetables, black currant, strawberries, strong tea, cocoa. The daily volume of the liquid must be at least 2 liters per day.
Diet with calcium phosphate urolithiasisprovides for limiting the consumption of food products rich in inorganic phosphorus: food, cheese, milk and dairy products. Daily fluid intake should reach 2-2.5 liters per day.
When detecting cystine urolithiasis, it is recommended to increase the daily volume of consumed liquid to 4 liters / day with a urine output of more than 3 liters / day.
Monitoring the effectiveness of thepreventive treatment in the first year of observation is carried out every 3 months. In the subsequent control is carried out once every 6 months. The complex control includes the performance of general and biochemical analyzes of blood and urine, ultrasound of the urinary system, X-ray study, etc. In chronic pyelonephritis, bacteriological culture of urine is performed once every 3 months. Control over the conduct of preventive treatment is carried out for 5 years after the detection of urolithiasis. If necessary, it is possible to adjust the medication.
Patients are observed in the clinic at the urologist.
The work of patients with urolithiasis should not be associated with significant physical exertion, the effect on the body of cold, dampness
Urolithiasis (IBD) is one ofprevalent urological diseases, meets at least 3% of the population. In countries around the world, out of 10 million people, 400,000 suffer from urolithiasis. The endemicity of the Russian regions is proved not only in frequency but also in the form of the formed urinary stones (for example, in the Southern regions stones from uric acid compounds dominate, and in the Moscow region - oxalates). Patients account for 30-40% of the total contingent of urological hospitals.
The variety of causes and clinical forms of ICD makesprevention of the disease is a complex task that should be maximally individualized depending on the clinical form of the disease, the chemical composition of urinary stones, the detected changes in laboratory indicators, and so on.
Preventive treatment is based on dietary recommendations, correction of biochemical changes.
Preventive measures and metaphylaxis (warningrelapse) of urolithiasis is based on the treatment of metabolic disturbances leading to stone formation, timely treatment of chronic pyelonephritis, and restoration of impaired urine outflow.
Treatment for urolithiasisshould consist not only in removing the stone (or its independent withdrawal), but also in conducting the necessary preventive treatment in order to prevent recurrent stone formation. Relapses of the disease depending on this or that form of urolithiasis occur in 10-40% of patients with ICD without preventive treatment
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