Lithotripsy

Introduction

Lithotripsy uses high-energy shock waves, which are generated by a machine called a lithotripter. The specifications for delivering the amount of shock per session for individual lithotripters mostly range between 2000 and 4500 shocks per session. The rate of shock administration is typically between 60 and 120 per minute. The estimated time for the procedure ranges from 45 to 90 minutes.

Definition

Lithotripsy is a noninvasive procedure to treat kidney, ureter, or urinary bladder stones by directing a focused ultrasonic energy or shock waves to break the stones.

Purpose

• It is used as a therapeutic intervention to treat renal calculi.

Types

1. Extracorporeal Shock Wave Lithotripsy (ESWL)

The patient is positioned supine on a water-filled cushion. X-rays/USG are used to detect the exact location of the stones. Shock waves are created and focused on the stone with the help of a machine called C-arm X-ray image intensifier. High-energy shock waves are then passed through the body to break down the stones into fine particles that can pass out of the body with urine. A stent can be placed in the ureter.

2. Intracorporeal or Endoscopic Lithotripsy
Insert a tube with a camera and light source into the urethra to the stones where they are located. Shock waves are passed to break down the stones.

• Laser lithotripsy.
• Mechanical lithotripsy.
• Electrohydraulic lithotripsy.
• Ultrasonic lithotripsy.

Indication

• Renal calculi or nephrolithiasis (<10 mm) confirmed by CT scan.

Contraindications

• Kidney infection.
• Pregnancy.
• Aortic aneurysm.
• Horseshoe kidney.
• Uncontrolled arrhythmia.
• Ureteropelvic junction obstruction.

Nursing Care for Patients Undergoing Lithotripsy

Pre procedure

• Assess the following:
• Physician’s order for preparation of the patient.
• Knowledge regarding the procedure.
• Fear and anxiety due to the procedure and level of pain.
• Bleeding disorder, blood thinners, anticoagulant use, smoking history, and all the medicines and supplements used.
• Clinical history, physical examination findings, urinalysis, blood reports (especially coagulation profile), IVP report, and ECG for older adults.
• Allergies to medicine, dye, latex, tape, and anesthesia.
• Administration of prophylactic antibiotics to prevent UTIs.
• Any contraindications.
• Obtain written consent related to the procedure, anesthesia, likelihood of success, and further need for a stent or ureteroscopy.
• Instruct the patient to maintain NPO 6 hours before the procedure and take medication as per the physician’s advice.
• Explain to the patient and ensure that the bowel and bladder are emptied. Provide enema to the patient on the morning of the procedure.
• Instruct the patient to change to a hospital gown and wear a cap, and ensure the removal of all valuables. Ask the patient to empty his or her bladder before the procedure.
• Ensure removal of all metal (or) jewelry.
• Start an IV line. After the test dose, administer a prophylactic antibiotic to the patient.
• Attach the indwelling catheter and ECG electrodes.

During Procedure

• Position the patient supine on top of a water-filled cushion or semireclining position as per the physician’s instruction.
• Ensure the X-ray safety for the team members (lead apron/shielding).
• Assist the physician with administration of sedation and monitor the patient’s hemodynamic status.

Post procedure

• Monitor vital signs (TPR and BP).
• Monitor the patient for signs of complication such as hemorrhage and shock.
• Monitor the amount, color, and volume of urine output. Urine is often bright red initially and this color will diminish within 48-72 hours. Cloudy urine may indicate the presence of infection.
• Monitor for the placement and patency of urinary catheters or nephrostomy tubes (kinked or plugged tubes may result in hydroureter or hydronephrosis and kidney damage).
• Monitor for decreased urine output, flank pain (obstructed urine flow), nausea, vomiting, and bruising.
• Administer antibiotics and analgesics prescribed by the physician.
• Instruct the patient to urinate through the strainer to collect the stone particles and the patient can be tested to determine the cause of the stone.
• Inform the patient that it is normal to experience bruising, stiffness, and soreness in the area of the treatment. Advise him or her to drink plenty of fluids (at least 8-10 glasses/day).
• Plan for discharge teaching of care of the indwelling catheter, urine collection device, and incision site (if present). Patients can take their prescribed medications. Dietary modifications are suggested to prevent reoccurrence of stone formation. Patients are advised to be at complete rest for at least 2 days. They can resume regular activity 2 days postprocedure. They are instructed to report if there occur symptoms of infection, extreme low back pain, bright hematuria, urine leakage from the incision site, fever, chills, and urinary urgency.

Special Considerations

• Larger or lower ureteral stones may require laser lithotripsy or PCNL
• Diaphragmatic movement can displace the stone from the focal point
• Controlled breathing or shallow respiration improves targeting
• Modern lithotriptors use electromagnetic or piezoelectric sources
• Avoid air pockets (e.g., from epidural air) that can dissipate energy and cause tissue injury
• Steinstrasse (stone fragment blockage) may require stenting or repeat procedures

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
8. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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