Urolithiasis
(Renal Calculi)
PRINCE JUNE CRUZ KITANE, RN MAN
Facts
• Urolithiasis refers to stones (calculi) in the urinary tract.
• Stones are formed in the urinary tract when the urinary
concentration of substances such as calcium oxalate, calcium
phosphate, and uric acid increases.
• Stones vary in size from minute granular deposits to the size of an
orange.
• Factors that favor formation of stones include infection, urinary
stasis, and periods of immobility, all of which slow renal drainage and
alter calcium metabolism.
• The problem occurs predominantly in the third to fifth decades and
affects men more often than women.
Pathophysiology
• Presence of stones anywhere in the urinary tract
• Most commonly found in the renal pelvis and calyces
• Stones forming in the kidney—nephrolithiasis
• Stones formed in the ureters—ureterolithiasis
• May be single or multiple calculi, ranging in size from a grain of salt to the
size of a pebble or staghorn calculus
• Composition of calculi
• Formed of mineral deposits—predominantly calcium oxalate and calcium
phosphate
• Uric acid, struvite, and cystine are also calculus formers
Etiology
• Slow urine flow allows accumulation of crystals
• May remain asymptomatic until passed into a ureter or
urine flow is obstructed
• Causes:
• dehydration; heredity; excessive intake of vitamins C and D,
grapefruit juice, and purines (gout); congenital renal
abnormalities; and some medications, such as acetazolamide
(Diamox) or indinavir (Crixivan)
Clinical Manifestations
• Manifestations depend on the presence of obstruction, infection, and
edema. Symptoms range from mild to excruciating pain and
discomfort.
• Stones in Renal Pelvis
• Intense, deep ache in costovertebral region
• Hematuria and pyuria
• Pain that radiates anteriorly and downward toward bladder in female and
toward testes in male
• Acute pain, costovertebral area tenderness (renal colic)
• Abdominal discomfort
• Ureteral Colic (Stones Lodged in Ureter)
• Acute, excruciating, colicky, wavelike pain, radiating down the thigh to the
genitalia
• Frequent desire to void, but little urine passed; usually
contains blood because of the abrasive action of the stone (known as ureteral
colic)
• Stones Lodged in Bladder
• Symptoms of irritation associated with urinary tract infection and hematuria
• Urinary retention, if stone obstructs bladder neck
• Possible urosepsis if infection is present with stone
Diagnostic Methods
• Urinalysis
• Urine culture
• Biochemical survey
• Serum and urine BUN and Creatinine.
• Serum chloride and bicarbonate levels
• CBC
• Parathyroid hormone (PTH)
• KUB x-ray
• IVP (intravenous pyelogram)
• Cystourethroscopy
• CT scan
• Ultrasound of kidney
Medical Management
• Basic goals are to eradicate the stone, determine the stone type,
prevent nephron destruction, control infection, and relieve any
obstruction that may be present.
• Pharmacologic and Nutritional Therapy
• Opioid analgesic
• Increased fluid
• For calcium stones: reduced dietary protein and sodium intake
• For uric stones: low purine and limited protein diet
• For cystine stones: low protein diet
• For oxalate stones: dilute urine; limited oxalate intake
• Stone Removal Procedures
• Ureteroscopy
• Extracorporeal shock wave lithotripsy (ESWL).
• Percutaneous nephrostomy
• Electrohydraulic lithotripsy.
• Chemolysis (stone dissolution)
• Surgical removal is performed in only 1% to 2% of patients.
Nursing Management
• Nursing Assessment
• Assess for pain and discomfort
• Assess for associated symptoms
• Observe for signs of urinary tract infection
• Observe urine for blood
• Focus history on factors that predispose patient to urinary tract
• Assess patient’s knowledge about renal stones and measures to prevent
recurrence.
• Nursing Diagnoses
• Acute pain related to inflammation, obstruction, and abrasion of the urinary
tract
• Deficient knowledge regarding prevention of recurrence of renal stones
• Collaborative Problems/Potential Complications
• Infection and urosepsis (from urinary tract infection and pyelonephritis)
• Obstruction of the urinary tract by a stone or edema, with subsequent acute
renal failure
• Planning and Goals
• Major goals may include relief of pain and discomfort, prevention of
recurrence of renal stones, and absence of complications.
• Nursing Interventions
• Relieving Pain
• Administer opioid analgesics (IV or intramuscular)
• Position of comfort.
• Ambulate
• Pain Monitoring
• Monitoring and Managing Complications
• Increase Fluid Intake
• Monitor Input and Output
• Ambulation
• Strain urine through gauze.
• Crush any blood clots passed in urine.
• Instruct patient to report decreased urine volume, bloody or cloudy urine, fever, and
pain.
• Instruct patient to report any increase in pain.
• Monitor vital signs.
Health Education
• Explain causes of kidney stones and ways to prevent recurrence.
• Encourage patient to drink fluids
• Urine Culture.
• Encourage increased mobility whenever possible
• If patient had surgery, instruct about the signs and symptoms of
complications
• If patient had ESWL, encourage patient to increase fluid intake to
assist in the passage of stone fragments;
• Provide instructions for any necessary home care and follow-up.
ESWL home and follow up care
• Instruct patient to increase fluid intake
• Instruct patient about signs and symptoms of complications:
• Inform patient that hematuria is anticipated
• Give appropriate dietary instructions.
• Encourage regimen to avoid further stone formation;
• Teach patient to take sufficient fluids in the evening
Continuing Care
• Closely monitor the patient
• Assess the patient’s understanding of ESWL and
possible complications
• Assess the patient’s ability to monitor urinary pH
• Ensure that the patient understands the signs and symptoms of
stone formation
• If medications are prescribed for the prevention of
stone formation, explain their actions, importance, and side effects
to the patient.