 The urinary tract includes the kidneys,

ureters, bladder and urethra. Within each

kidney, urine flows from the outer cortex to
the inner medulla.
 The renal pelvis is the funnel through which
urine exits the kidney and enters the ureter.
THE KIDNEY IS COMPOSED OF AN INNER
MEDULLA AND AN OUTER CORTEX
SURROUNDED BY A TOUGH FIBROUS CAPSULE.
 The kidneys remove wastes, control the body's
fluid balance, and regulate the balance of
electrolytes
 The medulla is composed of a series of conical
masses called the renal pyramids.
 The apex of these pyramids form a papilla
which projects into the lumen of the minor
calyces.
 The cortex extends between these medullary
pyramids as the renal columns
 The minor calyces are cup shaped tubes which
surround the renal papilla. These converge to
form the major calyces, which in turn unite to
 Malignant hypertension caused by
renovascular disease. The renal artery is
narrowed by atherosclerotic plaque
causing an elevation in blood pressure.
 The increased pressure damages the walls
of the small arterioles and glomerular
capillaries in the cortex.
 The vessels rupture causing hemorrhage
and infarction (scarring). The granular
surface of the kidney indicates atrophy and
fibrosis of the cortex due to the destruction of
the small blood vessels
INTRODUCTION
 DEFINITION
 The stones are solid concretions or calculi
(crystal aggregations) formed in the kidneys
from dissolved urinary minerals
 Stones are formed in the urinary tract when
urinary concentrations of substances such as
calcium oxalate, calcium phosphate, and uric
acid increase
 INCIDENCE
 Urinary calculi are more common in men than in
women.
 Incidence of urinary calculi peaks between the
3rd and 5th decades of life.
 CONTINUED……………..
 The incidence of upper urinary tract stones is
greater in industrial countries, such as the
United States and countries of Europe, than in
developing nations.
 50% re-occurrence with in 5-10 years

 Between 70 and 80 percent of stones are made

up primarily of calcium oxalate crystals; the rest
contain calcium phosphate salts, struvite
(magnesium, ammonium, and phosphate), uric
acid, or cystine (an amino acid)
 India-each year 5-7 million cases are diagnosed

 1/1000 need hospitalisation

 CONTINUED………

 There is seasonal variation with stone

occurring more often in the summer months
suspecting the role of dehydration in this
process
 ETIOLOGY AND RISK FACTORS
 Metabolic

Abnormalities that result in increased

urine levels of calcium, oxaluric acid, uric
acid or citric acid.
 Climate

Warm climates that cause increased

fluid loss. Low urine volume and
increased solute concentration in urine
 CONTINUED……………..
 DIET
 Large intake of dietary proteins that increases
uric acid excretion.
 Excessive amounts of tea or fruit juices that
elevate urinary oxalate level.
 Large intake of calcium and oxalate.

 Low fluid intake that increases urinary

concentration
 CONTINUED……………..
 Genetic factors
• Family history of stones formation, cystinuria, gout
or renal acidosis.
 Lifestyle

• Sedentary occupation and immobility.

 A major pre-disposing factor is the presence of
UTI.
 Infection increases the presence of organic matter
around which minerals can precipitate and
increases the alkalinity of the urine by the
production of ammonia. This results in precipitation
of calcium phosphate and magnesium-ammonium
CONTINUED……………..
 Stasis of urine also permits precipitation of
organic matter and minerals.
 Other factors associated with the development
of stones include long-term use of antacids,
vitamin D, large doses of vitamin C and calcium
carbonate.
 Any foreign body in the bladder serves as a
nidus for infection and calculi formation
 Drug-Induced Stones (Indinavir and
Nelfinavir Stones)
 These agents are excreted as urinary
crystals that may result in crystal deposition
or stone formation
 PATHOPHYSIOLOGY
 Many theories have been proposed to explain the
formation of stones in the urinary tract. No single
theory can account for stone formation in all
cases.
 Crystallization appears to be the primary factor in
calculus development from:
1. Supersaturation of urine with increased solutes

2. Matrix formation caused when mucoproteins bind

to the mass of the stone
3. Lack of inhibitors caused by increased or absent
protectors against stone formation
 TYPES OF CALCULI
 Calcium
 Calcium is the most common substance and is
found in up to 90% of stones.
 Calcium stones are usually composed of calcium
phosphate or calcium oxalate. They may range
from very small particles, often called "sand" or
"gravel," to giant staghorn calculi, which may fill
the entire renal pelvis and extend up into the
calyces.
 About 35% of all clients with calcium stones do not
have high serum levels of calcium and
 There are two variants of hypercalciuria
 The primary abnormality is increased intestinal
absorption of calcium or increased bone
reabsorption.
 The resulting higher serum calcium level triggers
increased renal filtration of calcium and parathyroid
hormone (PTH) suppression. This in turn decreases
tubular reabsorption, thereby increasing the
concen-tration of calcium in the urine.
 "Renal leak" of calcium, the other abnormality, is
caused by a tubular defect. The resulting
hypocalcemia stimulates PTH production, which
increases intestinal absorption of calcium. Clients
 2.OXALATE

 The second most frequent stone is oxalate,

which is relatively insoluble in urine. Its
solubility is affected only slightly by changes in
urinary pH.
 The mechanism of oxalate availability is
unclear but may be closely related to diet. The
disease is most common in areas where
cereals are a major dietary component and
least common in dairy-farming regions.
 An increased incidence of oxalate stones
may be related to:
 Hyperabsorption of oxalate, seen with
inflammatory bowel disease
 Postileal resection or small-bowel bypass
surgery
 Overdose of ascorbic acid (vitamin C), which
metabo-lizes to oxalate
 Familial oxaluria (oxalate in the urine)
 Concurrent fat malabsorption, which may
cause calcium binding, thus freeing oxalate
for absorption
 3.STRUVITE
 Struvite stones, also called triple phosphate, are
composed of carbonate apatite and magnesium
ammonium phosphate.
 Their cause is certain bacteria, usually Proteus,
which contain the enzyme urease. This enzyme
splits urea into two ammonia molecules, which
raises the urine pH. Phosphate precipitates in
alkaline urine.
 Stones formed in this manner are staghorn calculi
.Abscess formation is common.
 Struvite stones are difficult to eliminate because the
hard stone forms around a nucleus of bacteria,
protecting them from antibiotic therapy.
 Any small fragment left after surgical removal of the
stone begins the cycle again.
4. URIC ACID STONE

 Uric acid stones are caused by increased

urate excretion, fluid depletion, and a low
urinary pH.
 Hyperuricuria is the result of either increased
uric acid production or the administration of
uricosuric agents.
 Approximately 25% of people with primary
gout and about 50% of persons with
secondary gout develop uric acid stones.
 A high dietary intake of food rich in purine (a
protein) may predispose clients to uric acid
stone formation. Also, treating neoplastic
disease with agents that cause rapid cell
destruction may increase the urinary uric acid
concentration.
 It is hypothesized that uric acid crystals absorb
some of the crystal inhibitors normally found in
urine.
 5.CYSTINE
 Cystinuria is the result of a congenital metabolic
error inherited as an autosomal recessive
disorder.
 Cystine stones typically appear during childhood
and adolescence;
 development in adults is very rare
 CLINICAL MANIFESTATION

 sharp, severe pain

 most characteristic manifestation of renal or
ureteral calculi
 caused by movement of the calculus and
consequent irritation
 Renal colic originates deep in the lumbar
region and radiates around the side and
down toward the testicle in the male and the
bladder in the female
 Ureteral colic radiates toward the genitalia
and thigh
 CONTINUED……..

 When the pain is severe, the client usually has

nausea, vomiting, pallor, grunting respirations,
elevated blood pressure and pulse,
diaphoresis, and anxiety
 Urinary tract infection
 Other manifestations of calculi include
infection with an elevated temperature and
white blood cell (WBC) count and urine
obstruction that causes hydroureter,
hy-dronephrosis, or both
 Haematuria

 Pain resulting from the passage of a calculus

down the ureter is intense and collicky. The
patient may be in mild shock with cool, moist
skin
 DIAGNOSTIC EVALUATION
 1. Assessment
 1.HISTORY
 Prior stone formation
 Renal or bladder colic type pain without
objective evidence of calculi formation
 Risk factors

 Location, character, and duration of current

pain
 Current and previous radiation patterns
(indicates possible location and movement of
calculus through the urinary system)
 2. PHYSICAL EXAMINATION
 Vital signs include increased pulse,
respirations, and blood pressure associated
with colicky pain;
 fever indicates serious infection.

 Hyperactive bowel sounds occur with nausea

and vomiting; hypoactive or absent bowel
sounds occur with ileus.
 2.DIAGNOSTIC STUDIES
 Urinalysis, urine culture, and sensitivity testing
determine the presence of urinary tract infection,
hematuria, or urine crystals.
 Radiographic studies

 Ninety percent of calculi are visible on

radio-graphic images.
 Calcium phosphate stones are brightest on
radio-graph; uric stones are least visible
(radiolucent).
 KUB using plain abdominal film detects larger,
radiopaque stones.
 Intravenous urography (IVU) locates radiopaque
stones, allowing evaluation of associated
obstructive uropathy and crude eval-uation of
renal function (i.e., the ability to concen-trate
and excrete contrast material).
 it is a standard method for examining the urinary
tract for obstruction in cases of renal colic
 Tomograms locate stones in the pericaliceal
sys-tem. They are performed in combination
with IVP.
 Renal and bladder ultrasound locates stone,
creates hypoechogenic "shadow”and gives
some indication of associated obstructive
 Computed tomography scan locates
radiopaque stones.
 Radionuclide study is an alternative technique
tor locating calculi among patients allergic to
contrast materials or in a nonfunctioning
kidney
 Among endoscopic procedures, cystoscopy is
performed for bladder stone, ureteroscopy for
ureteral calculus, and nephroscopy for stone in
the pericaliceal system.
D. LABORATORY STUDIES
 Serum chemistry tests identify calcium,
phosphate, oxalate, cystine metabolism, and
renal function (creatinine, BUN)
abnormalities.
 Complete blood count detects systemic
infection
 Twenty-four-hour urine collection measures
ex-cretion of phosphorous, calcium, uric acid,
and creatinine levels.
 Stone analysis determines the composition
of the calculus and assists in designing a
preventive pro-gram.
 COMPLICATIONS

 Obstructive uropathy compromises the

function of the affected kidney.
 Microscopic or gross hematuria is rarely
associated with significant hemorrhage.
 Urosepsis is infection that may cause shock
or death without prompt intervention.
 Ileus may occur
MANAGEMENT.
CALCIUM OXALATE:

 Increase hydration.
 Reduce dietary oxalate.
 Give thiazide diuretics.
 Give cellulose phosphate to cholate calcium and
pre-vent GI absorption.
 Give potassium citrate to maintain alkaline
urine.
 Give cholestyramine to bind oxalate.
 Give calcium lactate to precipitate oxalate in GI
tract.
CALCIUM PHOSPHATE

 Treat underlying causes and other stones

 Administer antimicrobial agents,
acetohydroxamic acid and antibiotics.
 Use surgical intervention to remove stone.

 Take measure to acidify urine

URIC ACID STONES

 Reduce urinary concentration of uric acid.

 Alkalinize urine with potassium citrate.

 Administer allopurinol.

 Reduce dietary purines.

CYSTINE

Increase hydration.
 Give alpha-penicillamine and tiopronin to
prevent cystin crystallization.
 Give potassium citrate to maintain alkaline
urine
 STRUVITE STONES

 Complete removal of the stone with

subsequent sterilization of the urinary tract is
the treatment of choice for patients who can
tolerate the procedures.
 Percutaneous nephrolithotomy is the preferred
surgical approach for most patients.
 At times, extracorporeal lithotripsy may be
used in combination with a percutaneous
approach. Open surgery is rarely required.
 CONTINUED……….

 Irrigation of the renal pelvis and calyces with

hemiacidrin, a solution that dissolves struvite,
can reduce recurrence after surgery. Stone-free
rates of 50–90% have been reported after
surgical intervention.
 Antimicrobial treatment is best reserved for
dealing with acute infection and for maintenance
of a sterile urine after surgery.
CONTINUED…………….

 Urine cultures and culture of stone fragments

removed at surgery should guide the choice
of antibiotic.
 For patients who are not candidates for
surgical removal of stone, acetohydroxamic
acid, an inhibitor of urease, can be used.
 side effects-headache, tremor,and
thrombophlebitis, that limit its use
SURGICAL MANAGEMENT
1. URETEROSCOPY-
 involves first visualizing the stone and then
destroying it.
 Access to the stone is accomplished by
inserting a ureteroscope into the ureter and then
inserting a laser, electrohydraulic lithotriptor, or
ultrasound device through the ureteroscope to
fragment and remove the stones.
 A stent may be inserted and left in place for 48
hours or more after the procedure to keep the
ureter patent.
 Hospital stays are generally brief, and some
patients can be treated as outpatients.
 LITHOTRIPSY
 LASER LITHOTRIPSY. A newer treatment for
calculi is laser lithotripsy. Lasers are used
together with a uretero-scope to remove
or loosen impacted stones. Constant
wa-ter irrigation of the ureter is required
to dissipate the heat
 EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY
(ESWL)
 ESWL is a noninvasive procedure used to
break up stones in the calyx of the kidney.
 In ESWL, a high-energy amplitude of pressure,
or shock wave, is generated by the abrupt
release of energy and transmitted through
water and soft tissues. When the shock wave
encounters a substance of different intensity (a
renal stone), a compression wave causes the
surface of the stone to fragment. Repeated
shock waves focused on the stone eventually
reduce it to many small pieces.
CONTINUED………….

 These small pieces are excreted inthe urine,

usually without difficulty.the fragments may
be passed upto 3 months after the procedure
 Stone size should be 1.5-2 cm
 PERCUTANEOUS LITHOTRIPSY
 Percutaneous litho-tripsy involves the insertion
of a guide percutaneously (through the skin)
under fluoroscopy near the area of the stone.
An ultrasonic wave is aimed at the stone to
break it into fragments.
 stone size should be >2.5 cm
 POST OPERATIVE COMPLICATIONS
 IMMEDIATE
 Pain
 Urinary infection
 Obstructive uropathy
 Haematuria
 Urinoma-URINOMA HAPPENS AS A RESULT OF
URETERAL TEAR WHICH ALLOWS THE ENTRY OF
FREE FLUID INTO THE RETROPERITONEUM
 Renal and perirenal haematoma
 Surrounding organ injury
CONTINUED,……….

 DELAYED
 Renal functional loss

 Hypertension

 Residual calculi

 Recurrent calculi
OPEN SURGICAL PROCEDURES
 OPEN SURGICAL PROCEDURES
 If the stone is too large or if endourologic and
lithotripsy procedures fail to remove it, an open
surgical procedure is performed
 ureterolithotomy is the surgical removal of a
stone from the ureter through a flank incision
for higher stones or an abdominal incision for
lower ones. A Penrose drain and ureteral
catheter are usually placed postoperatively for
healing and drainage of urine
CONTINUED…………….
 Cystolithotomy, removal of bladder calculi
through a suprapubic incision, is used only
when stones cannot be crushed and
removed transurethrally. Stricture (abnormal
narrowing) is the most common
postoperative complica-tion.
 A stone is removed from the renal pelvis by
pyelo-lithotomy and from the renal calyx by
a nephrolithotomy
MEDICATIONS

 Lortab (500) mg one tab by mouth every 6

hours as needed for pain
 Percocet (325) mg one tab by mouth every 6
hours as needed for pain
 Pyridium (100, 200) mg one tab per mouth
every 8 hours for dysuria (burning)
 Cipro (250, 500) mg one tab per mouth
twice a day
 PROGNOSIS
 Despite advances in the treatment of urinary
calculi, it is often impossible to remove all stone
fragments com-pletely. From 5 to 30 percent of
patients have residual stone burden requiring
ongoing treatment.
 Recurrence rate is approximately 30 percent
within years.
 Extracorporeal shock wave lithotripsy and
endoscopic stone removal techniques have
significantly improved long term prognosis of rena
function after calculus removal.
NURSING INTERVENTION
 adequate hydration, dietary sodium
restrictions, dietary agrees, and the use of
above-stated medication minimise stone
formation
 High fluid intake at least 3000 ml per day is
recommended.
 Dietary intervention may be important in the
management of formation urolithiasis.
 nutritional management should include
limiting oxalate- foods and thereby reducing
oxalate excretion. Foods high in , calcium or
oxalate contents are as follows:
RICH SOURCES OF CALCIUM

 Cereals such as ragi, whole bengal,

gram(chana), moth beans(matki),Rajmah,
soyabeans, horsegram
 All green leafy vegetables

 Oilseeds such as dry coconut, gingelly seeds

(til), mustard seeds
 Figs and all dry fruits such as cashewnuts,
almonds, dried figs
 All kinds of fish.

 Snail, mutton muscle

RICH SOURCES OF PHOSPHORUS

 Cereals such as bajra, barley, millet, jowar,

dry maize, ragi, oatmeal
 Soya bean. Moderate sources of phosphorus
are bengal gram (chana),Cowpea (chawli),
rajmah
 Dry fishes

 Milk powder, milk

RICH SOURCES OF OXALIC ACID

 Horsegram (kuleeth), kesari dalAlmonds,

 cashewnuts, gingelly seeds, ripe chillies,
amla, woodapple.
 Cocoa, coffee, tea

 Green leafy vegetables such as amaranth,

curry leaves, drumstick leaves, mustard
leaves, neem leaves,
FOODS CONTAINING PURINE

 Foods with high Purine content.Organ

meats such as kidney, liver, pancreas, brain.
Sweet breads. Sardines. Meat extracts.
 Foods with moderate amounts of Purine
Meat, Fish, Shell fish, Alcohol ,Chickoo,
apple
 Foods with small amounts of Purine
Asparagus, Mushrooms, Cauliflower,
Spinach, Peas, Dry beans ,Pulses, Coffee,
Tea
 NURSING DIAGNOSIS
 ACUTE PAIN R/T OBSTRUCTING URINARY
CALCULUS
 ALTERED URINARY ELIMINATION RELATED
TO PRESENCE OF URINARY CALCULI
 RISK TOR INFECTION R/T OBSTRUCTING
URINARY CALCULUS
 ALTERED RENAL PERIPHERAL TISSUE
PERFUSION R/T POSTRENAL
OBSTRUCTION