CHAPTER 26 / Nursing Care of Clients with Urinary Tract Disorders 719
NURSING CARE OF THE CLIENT HAVING LITHOTRIPSY
PREOPERATIVE CARE
• Assess knowledge and understanding of the procedure, pro-
viding information as needed. Anxiety is reduced, and recovery
is enhanced and hastened when the client is fully prepared for
surgery.
• Follow directions from the radiology department, physician, or
anesthetist for withholding food and fluids and for bowel
preparation prior to surgery. Conscious sedation, general anes-
thesia, or spinal anesthesia may be required, depending on the
procedure. Fecal material in the bowel may impede fluoroscopic
visualization of the kidney and stone.
POSTOPERATIVE CARE
• In the initial period, monitor vital signs frequently. The kidney is
highly vascular; therefore, hemorrhage and resulting shock are
potential complications of lithotripsy. Bleeding may be internal or
retroperitoneal and difficult to detect.
Eyepiece
Irrigation fluid
Skin
Ultrasonic
probe
Irrigation
drain
Nephroscope
Kidney stone
Figure 26–4 ■ Percutaneous ultrasonic lithotripsy. A nephro-
scope is inserted into the renal pelvis, and ultrasonic waves are used
to fragment the stone. The fragments then are removed through
the nephroscope.
moved through the nephroscope. Laser lithotripsy is an alter-
native to ultrasonic lithotripsy. Laser beams are used to disin-
tegrate the stone, without damaging soft tissue. A nephroscope
or a ureteroscope (passed up the ureter from the bladder during
cystoscopy) is used to guide the laser probe into direct contact
with the stone (Meeker & Rothrock, 1999).
A double J stent may be inserted into the affected ureter to
maintain its patency following ESWL or other lithotripsy pro-
• Monitor amount color, and clarity of urine output. Urine is often
bright red initially, but bleeding should diminish within 48 to
72 hours. Cloudy urine may indicate the presence of an infection.
• Maintain placement and patency of urinary catheters. Anchor
ureteral catheters or nephrostomy tubes securely. Irrigate gen-
tly if ordered. A kinked or plugged catheter may result in hy-
droureter,hydronephrosis,and kidney damage.Decreased urinary
output and flank pain are possible symptoms of obstructed urine
flow. Excessive force in irrigation may cause bleeding.
• Prepare for discharge by teaching care of indwelling catheter,
urine-collection device, and incision site (if present). Teach signs
and symptoms to report: urine leakage from incision for more
than 4 days,symptoms of infection,pain,bright hematuria.Many
clients are discharged with dressings and catheters in place. The
client and family need necessary information to provide self-care.
• Teach measures to reduce the risk of further lithiasis.Many clients
have repeated episodes of lithiasis and renal colic. Prevention of
stone formation is important to preserve renal function.
cedures. See Box 26–7 for nursing care of the client with a
ureteral stent.
On rare occasions, surgical intervention is necessary to re-
move a calculus in the renal pelvis or ureter. Ureterolithotomy
is incision in the affected ureter to remove a calculus.
Pyelolithotomy is incision into and removal of a stone from the
kidney pelvis. A staghorn calculus which invades the calices
and renal parenchyma, may require a nephrolithotomy for re-
moval. See Chapter 7 for care of the surgical client.
Bladder stones may be removed using an instrument
passed through a cystoscope to crush the stones. The remain-
ing stone fragments are then irrigated out of the bladder using
an acid solution to counteract the alkalinity that precipitated
stone formation.
Nursing Care
Nursing care for the client with urolithiasis is directed at pro-
viding for comfort during acute renal colic, assisting with diag-
nostic procedures, ensuring adequate urinary output, and teach-
ing the client information necessary to prevent future stone
formation.
Health Promotion
Discuss the importance of maintaining an adequate fluid intake
with all clients. Stress the need to increase fluid intake during
warm weather and strenuous exercise or physical labor. Dis-
cuss the relationship between weight-bearing activity and re-
tention of calcium in the bones. Encourage all clients to remain
as physically active as possible to prevent bone resorption and
possible hypercalciuria.
Instruct clients with known gout to maintain a generous fluid
intake so as to produce at least 2 L of urine every day. Discuss the
risk of lithiasis with clients who have frequent UTIs, and teach
measures to reduce the incidence of UTI and the risk for lithiasis.