Urinary Calculi

Urinary calculikidney stones

Lithiasisstone formation
Nephrolithiasisstones form in kidney
Urolithiasisstones form elsewhere in urinary tract
Factors contributing to urolithiasis
o Supersaturation
o Hyperparathyroidism (increased Calcium)
o Increased vitamin D intake
o Cancer
o Prolonged bed rest (stasis)
o Nucleation
o Lack of inhibitory substances in urine
o Fluid intake
Risk Factors And Interventions for Renal Calculi
Stone Type & Incidence
Risk Factors
Management
Calcium phosphate and/or oxalate
Hypercalciuria & hypercalcemia:
Meds: thiazide diuretics,
(70-80%)
hyperparathyroidism, immobility,
phosphates
bone disease, vit D intoxication,
Dietary: limit foods high in Na and
multiple myeloma, renal tubular
protein, increase foods that acidify
necrosis, prolonged steroid use
urine
Alkaline urine
Other: increase hydration, exercise
Dehydration
Inflammatory bowel disease
Struvite (15-20%)
UTIs, especially Proteus infections Meds: antibiotic therapy for UTI
Other: surgical intervention or
lithotripsy to remove stone
Uric Acid (5-10%)
Gout, increased purine intake, acid Meds: Potassium citrate,
urine
allopurinol
Dietary: low purine diet
Other: increase hydration
Cystine (uncommon)
Genetic defect, acid urine
Meds: penicillimine, sodium bicarb
Dietary: Na restriction
Other: increase hydration

Composition of kidney stones

o Calcium oxalate and/or calcium phosphate (*most common type*)
o Uric acid
o Struvite stones
Etiology
o Most form in renal pelvis
o Composed of calcium salts
Risk Factors
o Most idiopathic
o Prior personal or family history
o Dehydration
o Excess dietary intake

o Loss of calcium from bones

Clinical Manifestations
o Kidney Stones
Often asymptomatic
Dull, aching flank pain
Microscopic hematuria
Manifestations of UTI
o Ureteral Stones
Renal colic (when stone causes obstructionureteral spasm): Acute, severe flank pain on
affected side; often radiates to suprapubic region, groin, and external genitals
N/V, pallor, cool/clammy skin
o Bladder Stones
May be asymptomatic
Dull suprapubic pain, possibly associated with exercise or voiding
Gross or microscopic hematuria
Manifestations of UTI
Complications
o Obstruction
o Hydronephrosis
Kidneys produce urine behind obstruction
Pressure builds up
Colicky pain on affected side
Hematuria, UTI
Diagnostic Testing
o Urinalysis- assess for hematuria, presence of WBCs, and crystal fragments; urine pH is helpful in
identifying type of stone
o Chemical analysis of any stones passed in the urine - determines the type of stone; strain ALL
urine and save ALL stones
o 24 hour urine collection- measure the amount of calcium, uric acid, and oxalate levels over 24
hours to identify causes of lithiasis
o Kidneys, ureters, and bladder (KUB)- x-ray of the lower abdomen may show calculi as opacities
in the kidneys, ureters, and bladder
**1st tx for kidney stones
o Renal ultrasonography- uses reflected sound waves to detect stones and evaluate the kidneys for
possible hydronephrosis
o CT scan with/without contrast- shows calculi, ureteral obstruction, and other renal disorders
o Cystoscopy- used to visualize and possibly remove calculi from the urinary bladder and distal
ureters
Pharmacologic Therapy
o Acute episode
Analgesia- Morphine sulfate
Hydration
Inhibit, prevent further lithiasis
Thiazide diureticcalcium stones
Potassium citratestones that form in acidic urine
Nursing responsibilities: Education
Surgery
o Depends on location, obstruction, renal function, UTI, overall health

o Make sure pt. knows that their urine may be pink tinged after any of these procedures, but that
should decrease over time
o Lithotripsy
Extracorporeal shock wave lithotripsy (ESWL)- fragmenting stones, noninvasive
Percutaneous ultrasonic lithotripsy- neprhoscope inserted into kidney
Laser lithotripsy- sound/shock waves crush stone up
o Ureterolithotomy- incision in the affected ureter to remove a calculus
o Pyelolithotomy- incision into and removal of stone from the kidney pelvis
o Nephrolithotomy- a staghorn calculus that invades the calyces and renal parenchyma may require
this type of surgery
Nursing Process:
o Assessment
o Health history
o Pain assessment- check q15-30 mins
o Other symptoms
o Contributing factors
o Physical examination
General appearance
Tenderness
Characteristics of urine
Kidney assessment
o Nursing Diagnoses: Acute Pain, Impaired Urinary Elimination, Deficient Knowledge, Anxiety, Risk for
Imbalanced Nutrition, Risk for Infection
o Plan
o Client requests analgesics as needed
o Maintain urine output of 2500mL/24 hours
o Verbalize understanding of disease
o Demonstrate reduced anxiety
o Implementation: Acute Pain
o Assess pain using standard pain scale
o Encourage fluid intake and ambulation
o Use nonpharmacologic measures
Positioning
Moist heat
Relaxation techniques
Guided imagery and diversion
o If surgery performed: monitor I&Os, catheters, incision, wound drainage
o Implementation: Impaired Urinary Elimination
o Report symptoms of hydronephrosis
o Monitor amount, character of urine output
o Maintain patency of catheter systems
o Implementation: Deficient Knowledge
o Assess understanding
o Present material at appropriate level
o Teach about all diagnostic and treatment procedures
o Home management
o Prevention of further urolithiasis
o Relationship between urinary calculi and UTI

o Evaluation
o Client reports pain of 3 or less
o Able to perform ADLs
o Client remains infectionfree
o Client chooses appropriate diet
o Client demonstrates adequate fluid intake
Preparing Client for Discharge
o Fluid intake
o Medication management
o Calcium phosphates stones: Calcibind (cellulose sodium phosphate)
o Uric acid stones: Zyloprim (allopurinol)
o Diet recommendations
o Calcium phosphate stonesincrease acidity of urine
o Uric acid stoneslowering uric acid levels, limit sources of purine (sardines, liver, herring, and
sweetbreads.
o Oxalate stoneslimit spinach, strawberries, rhubarb, chocolate, tea, peanuts, wheat bran
o UTI
o Further diagnostic or treatment measures
Health Promotion
o Discuss importance of fluid intake
o Client with known gout
o Discuss risk of lithiasis with frequent UTIs
o Postoperative care if appropriate
Nursing Diagnoses & Interventions
Acute Pain
o Assess pain using a standard pain scale and its characteristics; admin analgesia as ordered and monitor
its effectiveness
o Unless contraindicated, encourage fluid intake and ambulation
o Use non-pharmacological interventions such as positioning, moist heat, relaxation techniques, guided
imagery, and diversion
o If sx is performed, monitor urinary output, catheters, incisions, and wound drainage
Impaired Urinary Elimination
o Monitor amount and character of urine output
o Maintain patency and integrity of all catheter systems, secure catheters well, label as indicated, and use
sterile technique for all ordered irrigations or other procedures
Readiness for Enhanced Knowledge
o Assess understanding and previous learning
o Present all material in a manner appropriate to knowledge base, developmental and educational level,
and current needs.
o Teach about all diagnostic and treatment procedures
o Teach measures to prevent further urolithiasis
o Teach ab the relationship between urinary calculi and UTIs emphasizing preventative measures and the
importance of prompt treatment