MEDICAL SURGICAL NURSING

LESSON PLAN ON,

RENAL CALCULI

SUBMITTED TO, SUBMITTED BY,

SUBMITTED ON,
GENERAL OBJECTIVES :

At the end of the lecture, the group of student will be able to gain in depth of knowledge
regarding Renal Calculi.

SPECIFIC OBJECTIVE :

At the end of the lecture, the group of student will be able to gain in depth of knowledge
about,

1. To introduce topic.
2. To define the renal calculi.
3. Explain incidence of renal calculi.
4. Discuss etiology of renal calculi.
5. Explain risk factors of renal calculi.
6. Explain types of renal calculi.
7. Explain pathophysiology of renal calculi.
8. Explain clinical manifestation of renal calculi.
9. Explain diagnostic evaluation of renal calculi.
10. Explain medical management of renal calculi.
11. Explain surgical management of renal calculi.
12. Explain complication of renal calculi.
13. Discuss prevention of renal caculi.
14. Explain nutritional therapy of renal calculi.
15. Discuss nursing management of renal calculi.
16. To summarize the topic.
17. To conclude the topic.
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2 min To introduce INTRODUCTION :
topic. B What is mean
A kidney stone is a hard solid mass by kidney
of material that forms in the kidney Lecture stone?
from the substances in the urine. Kidney Cum L
stones or calculi develop as a result of Discussion
various metabolic disorders which affect
the fate of calcium and other mineral A
elements in the body. Stones may be
formed in the kidney, urinary bladder,
ureter and urethra. C

2 min To define the DEFINITION :

Renal K
calculi. A Renal calculi, also known as a Lecture
kidney stone or nephrolith, is a solid Cum
piece of material which is formed in the Discussion B
kidneys from minerals in urine.

2 min Explain INCIDENCE : O

incidence of
renal calculi. ➢ Between 1% & 15% of people
globally are affected stones at A
some point in their life.
➢ In 2016, 49 million cases of Lecture
occurred, resulting in about Cum R
15,000 deaths. Discussion
➢ 80% of stones under 2mm in
size. D
➢ 90% of stones pass through the
urinary system spontaneously.

5 min Explain ETIOLOGY :

etiology of
renal calculi. Supersaturation of Urine :

✓ Crystals, when in a
supersaturated concentration,
can precipitate and unite to form
a stone.
 ✓ Keeping urine dilute and free
flowing reduces the risk of

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 recurrent stone formation in many
individuals.
✓ It also known as that a
Mucoprotein is formed in the
kidneys that form stones.

Urine pH, solute load and inhibitors in

the urine affect the formation of stones.
✓ The higher pH ( alkaline ), the
less soluble are common and
phosphate.
✓ The lower the pH ( acidic ), the
less soluble in uric acid crystine.

Obstruction with urinary stasis and

urinary tract infection with urea –
splitting bacteria ( eg. Proteus,
Klebsiella, Pseudomonas and some
species of staphylococci ) is also the
factor for development of stones.

Lack of inhibitors increases risk of stone

formation. Inhibitor substances, such as
citrate and magnesium, appears to keep
particles from aggregating and forming
crystals.

Certain medications may induce

calculus formation, such as
acetazolamide, absorbable alkalis ( eg.
Calcium carbonate and sodium
bicarbonate ) and aluminium hydroxide.

Massive dose of Vitamine C increases

urinary oxalate levels.

RISK FACTORS :

✓ Immobility and sedentary

lifestyle, which increase stasis
✓ Dehydration, which leads to
supersaturation.
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 ✓ Metabolic disturbances that
result in an increase in calcium
or other ions in the urine.
✓ UTIs
✓ High mineral content in drinking
water
✓ A diet high in purines, oxalates,
calcium supplements, animal
proteins.
✓ Prolonged indwelling
catheterization
✓ Neurogenic bladder
✓ History of female genital
multilation.

8 Explain of TYPES OF RENAL STONES :

min. types of renal
stones. The stones may be of one crystal
type or a combination of types :
1. Calcium oxalate
2. Calcium phosphate
3. Struvite
4. Uric acid
5. Cystine

1. CALCIUM OXALATE :

 Incidence ( % ) : 35 to 40
 Color : Black / dark brown
 Sensitivity : Radio – opaque
 Characteristics is small, often
possible to get trapped in ureter;
frequent in men than in women.

❑ Predisposing factors :
▪ Idiopathic hypercalciuria
▪ Hyperoxaluria
▪ Independent of urinary
▪ Family history.
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❑ Therapeutic Measures :
▪ Increased hydration
▪ Reduce dietary oxalate
▪ Reduce daily sodium intake
▪ Give potassium citrate to
maintain alkaline urine.

2. CALCIUM PHOSPHATE :

➢ Incidence is 8 – 10 %
➢ Color is dirty white
➢ Sensitivity is radio opaque.
➢ Characteristics :
▪ Mixed stone ( typically )
▪ Struvite or oxalate stones.

Predisposing factors :
❑ Alkaline urine
❑ Primary hyperparathyroidism

Therapeutic measures :
Treat underlying causes
and other stones.

3. STRUVITE :

➢ Incidence is 10 – 15%
➢ Color is Dirty white
➢ Sensitivity is radio opaque.
➢ Characteristics :
Three to four times as common in
women as men; always in association
with urinary tract infections; large
staghorn type ( usually )

Predisposing factors :
Urinary tract infections
( usually proteus organisms )
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Therapeutic measures :
 Administer antimicrobial
agents, acetohydroxamic acid.
 Use surgical intervention to
remove stone
Take measures to acidify urine.

4. URIC ACID :

➢ Incidence is 5 – 8%
➢ Color is yellow / reddish
brown.
➢ Sensitivity is radiolucent.
➢ Characteristics :
▪ Predominant in men.
▪ High incidence in Jewish men.

Predisposing factors :
✓ Gout
✓ Acid urine
✓ Inherited condition

Therapeutic measures :
✓ Reduce urinary concentration of
uric acid
✓ Alkaline urine with pottasium
citrate
✓ Administer allopurinol
✓ Reduce dietary urines.

5. CYSTINE :

➢ Incidence is 1 – 2%
➢ Color is pink / yellow.
➢ Sensitivity is radio / opaque.
➢ Characteristics :
✓ Genetic autosomal recessive
defect
✓ Defective absorption of cystine
in GI tract and kidney.
✓ Excess concentration causing
stone formation.
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Predisposing factors :
❑ Acid urine

Therapeutic measures :
✓ Increase hydration
✓ Give alpha-penicillamine and
tiopronine to prevent cystine
crystallization.
✓ Give potassium citrate to
maintain alkaline urine.

5 min Explain PATHOPHYSIOLOGY :

pathophysio-
logy of renal Calcium and oxalate come together to
calculi. make the crystal nucleus

Supersaturation promotes their

combination ( as does inhibition )

Continued deposition in the renal

papillae leads to growth to the kidney
stones

Kidney stones grow and collect debris

In the case where the kidney stones

block all route to the renal papillae, this
can cause severe discomfort.

This complete staghorn stone forms and

retention occurs.

Kidney stones are primarily made of a

crystalline components, which requires
three major steps for formation :
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✓ Nucleation
✓ Growth
✓ Aggregation

However both groups agree on the role

of supersaturation. Crystalization
appears to be the primary factor in
calculus development from the
following :
✓ Supersaturation of urine with
increased solutes
✓ Matrix formation caused when
mucoproteins bind to the mass of
the stone
✓ Lack of inhibitirs caused by
increased or absent protectors
against stone formation.
✓ A combination of these
condition

5 min Explain CLINICAL MANIFESTATION :

clinical
manifestation ❑ Pain
of renal ❑ Renal Colic :
calculi. Originates deep in the lumbar
region and radiates around the side and
down towards the testicle in the male
and the bladder in the female.
❑ Urethral colic :
Radiates towards the genitalia
and thigh.
❑ When all pain is severe, the
client usually has,
✓ Nausea
✓ Vomitting
✓ Pallor
✓ Grunting respirations
✓ Anxiety
✓ Diaphoresis
✓ Elevated BP and pulse
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In bladder stone;
✓ Urgency
✓ Frequency
✓ Hematuria
✓ Chronic Cystitis
Pressure against the bladder neck
during micturation (voiding) may
cause;
✓ Heavy feeling in the suprapubic
region
✓ obstruction in voiding
✓ a decreased bladder capacity
✓ an intermittent urinary system

If the stone enters the urethra;

✓ urine flow is obstructed

Other manifestation :
❑ Infection with elevated
temperature and WBC
❑ Urine obstruction that causes
✓ Hypoureter
✓ Hydronephrosis
✓ Both

5 min Explain DIAGNOSTIC EVALUATION :

diagnostic
evaluation of ❑ Ultrasound :
renal calculi. identify large and radiopaque
stones.

❑ An IVP or retrograde
pyelogram :
It is used to localize the
degree and site of obstruction or to
confirm the presence of a radiolucent
stone, such as a uric acid or cystine
Calculus.

❑ CT Scan :
It may be used to differentiate a
non-opaque stone from a tumor.
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❑ Ultrasonography :
It can be used to identify
the radioopaque or radiolucent calculus
in the renal pelvis, calyx or proximal
ureter.

Retrival and Analysis of stones are

important in the diagnosis of the
underlying problem contributing to
stone formation.

❑ Blood Tests :
✓ Serum Calcium : 8.6 – 10.3
mg/dl.
✓ Phosphorus : 3.4 – 4.5 mg/dl
✓ Serum Pottasium : 3.5 to 5.5
mEq/L
✓ Serum Bicarbonate : 19.9
mEq/L
✓ BUN : 7 to 20 mg/dl.
✓ Uric Acid : Men : 4.0 – 8.5
mg/dl
Women :2.7 – 7.3 mg/dl.
✓ Serum Creatinine : Men : 0.9 to
1.3 mg/dl
Women : 0.6 to 1.1 mg/dl

A careful history, Including;

✓ Previous stone formation
✓ Prescribed and OTC
medications
✓ Dietary supplements
✓ Family history of urinary calculi

Cystoscopy :
Cystoscopy is an examination of
the inside of the bladder.

Patient s who are recurrent stone

formers should undergo a 24 hour
urinary measurement of calcium,
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Phosphorus, magnesium, sodium,
oxalate, citrate, sulfate, potassium, uric
acid and total volume.

Measuremenrt of Urine pH :

It is useful in the diagnosis of struvite

stones and renal tubular acidosis
( tendancy to alkaline or high pH ) and
uric acid stones ( tendancy to acidic or
low pH ).

5 min Explain MEDICAL MANAGEMENT :

management
of medical Drug therapy for calcium stone :
management ❑ Hypercalciuria : Thiazide
of renal diuretics
calculi. ✓ Thiazide therapy can lower
calcium excretion by as much as
150 mg/day.
✓ Eg. Inj. Metolazone ( 2.5mg,
5mg, 10mg ), Tab. Indapamide
( 1.25mg, 2.5mg ),
Inj. Chlorothiazide ( 250 mg / 5ml )
❑ Hyperuricosuria : Allopurinol (
100mg ) or K citrate
✓ Raising the urine ph above 6.0
will convert insoluble uric acid
to much more soluble urate salt.

❑ Hypocitraturia : K citrate
✓ Alkalinizing urine enhances
citrate excretion. Dose : Tablet
form, 5mEq, 10mEq, 15mEq.
• Mild to Moderate
Hypocitraturia: >150mg/day
• Severe Hypocitraturia : <
150mg/day.
• Maintainance : 320 – 640
mg/day & urinary pH 6.0 – 7.0
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( maximum dose 100 mEq/day ).
❑ Hyperoxaluria :
✓ Aim to diminish intestinal
oxalate absorption ( high fluid,
K citrate, oral calcium carbonate,
low fat and low oxalate diet )

✓ Possible drug therapy

o Pyridoxine ( 30 to 50 mg ) may
reduce production of oxalate.
o Cholestyramine ( oral
suspension ) reduces intestinal
absorption of oxalate
o Probiotic treatment with
Oxalobacter has been shown to
decrease urinary oxalate
concentraton.

Treatment of Uric Acid Stones :

✓ Hydration, dietary purine
moderation ( lower meat,
poultry, fish )
✓ Alkalinization urine with K
citrate to maintain urine pH
between 6.0 – 7.0.
✓ If nocturnal urine pH falls,
Acetazolamide
( Tablet : 125mg, 250mg : Inj. : 500mg )
✓ Can add Allopurinol ( 100mg )

Cystine stones :
✓ Penicillamine ( 250 mg )
✓ Tiopronin ( Tablet : 100mg,
300mg )
✓ Captopril ( Tablet : 12.5mg,
25mg, 50mg, 100mg )

5 min Explain SURGICAL MANAGEMENT :

surgical
management 1. EXTRACORPOREAL SHOCK
of renal stone WAVE LITHOTRYPSY :
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Extracorporeal shock wave lithotripsy
uses shock waves to break a kidney
stone into small pieces that can more
easily travel through the urinary tract
and pass from the body.

Preparation :
✓ Given medication for pain – to
help for relax before procedure
start.
✓ Give Antibiotics as per doctors
Prescription.
✓ Given Anesthesia for the
procedure start – for sleep or
pain free.

URETEROSCOPY :

Ureteroscopy (URS) is a type of

minimally – invasive treatment that
involves using a small – calibre
endoscope to detect, breakup and
remove stone from the kidney with one
single procedure. URS offers patients
high success rates and low
complications.

Preparation for the procedure :

✓ Fasting for 6 to 8 hours before
the procedure to prepare body
for anaesthesis.

NEPHROLITHOTOMY :

❑ Nephrolithotomy is a minimally
invasive procedure to remove
stones from the kidney by a
small puncture wound ( up to
about 1cm ) through the skin.
❑ It is most suitable to remove
stones of more than 2cm in size
and which are present near the
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pelvic region.
✓ It is usually done under general
anesthesis or spinal anesthesis.

PERCUTANEOUS LITHOTRIPSY :

✓ It 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.

3 min Explain COMPLICATION :

complication
of the renal 1. Complication occur as a result of
calculi. untreated obstruction.
2. If urine flow is not
reestablished;
✓ Severe pain
✓ Hydronephrosis
✓ With resultant kidney failure
3. In addition, stasis of urine
increases the risk of infection.
4. Ecchymosis on the affected flank
5. Retained fragments
6. Urosepsis
7. Perinenephric hematoma
8. Hemorrhage

7 min Discuss PREVENTION :

prevention of
renal calculi. Teach stone prevention measures :
❑ Health promotion activities
include;
✓ frequent turning and range of
motion for immobilized clients,
✓ increased fluid intake,
✓ decreased intake of stone –
forming solutes in the diet.
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✓ such as oxalates, purines, and
animal proteins.

Increased Fluids :
✓ Teach the client to drink 3 to 4
L of fluid daily to flush the
urinary system.
✓ At least half the fluid consumed
should be water.
✓ Encourage the client to drink a
full glass of water every hour
during the day and two glasses
just before going to bed. This
schedule may create the need to
void during the night, at which
time the client should drink
another glass of water.

❑ Low – calcium diets are not

generally recommended, except
for true absorptive
hypercalciuria. Evidence shows
that limiting calcium, especially
in women, can lead to
osteoporosis and does not
prevent renal.

❑ Avoid intake of oxalate –

containing foods
Eg. Spinach, Strawberries, tea,
peanuts, wheat bran.

❑ During the day , drink fluids (

ideally water ) every day 1 to 2
hours.

❑ Drink two glasses of water at

bedtime and an additional glass
at each night time awakening to
prevent urine from becoming too
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concentrated during the night.

❑ A sodium intake of 3 to 4 g/day

is recommended. Table salt and
high sodium competes with
calcium for reabsorption in the
kidney.

❑ Avoid protein intake : Usually

protein is restricted to 60g/day to
decrease urinary excretion of
calcium and uric acid.

5 min Explain NUTRITIONAL THERAPY :

nutritional
therapy of ✓ Nutritional therapy plays an
renal calculi. important role in preventing
renal stones.
✓ Drink 8 to 10 ounce glasses of
water daily.
✓ A urine output exceeding 2
L/day is advisable.

❑ Food high in Calcium :

Milk, cheese, ice cream, yogurt, sauces
containing milk, all beans ( except green
beans), lentils, fish with fine bones
( sardines, kippers herring, salmon);
dried fruits, nuts, chocolate, cocoa.

❑ Uric acid stones :

✓ A patient is placed on a low –
purine diet to reduce the
excretion of uric acid in the
urine.
✓ Food high in purine ( Shelfish,
anchovies, aparagus,
mushrooms and organ meats )
are avoided.
❑ Purine :
✓ High : Sardines, herring,
mussels, liver, kidney,
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goose, venison, meat soups,
sweet breads
✓ Moderate : Chicken, salmon,
crab, veal, mutton, bacon, beef,
ham.

❑ Oxalate Stones :
✓ A dilute urine is maintained,
and the intake of oxalate is
limited.
✓ Many foods contain oxalate;
however, only certain foods
increase the urinary excretion of
oxalate.
✓ Eg. Spinach, Strawberries,
rhubarb, chocolate, tea, peanuts,
wheat bran, asparagus, cabbage,
tomatoes, beets, nuts, celery,
parsley.

❑ Cystine stones :
✓ A low – protein diet is
prescribed, the urine is
alkalinized and fluid intake is
increased.

8 min Discuss NURSING MANAGEMENT :

nursing
management NURSING PRIORITIES :
of renal
calculi. ✓ Alleviate pain.
✓ Maintain adequate renal
functioning.
✓ Prevent complication
✓ Provide information about
disease process / prognosis and
treatment needs.

ASSESSMENT :

✓ Assess for pain and discomfort

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✓ severity, location and radiation
of pain.
✓ Assess for associated symptoms
: nausea, vomiting, abdominal
distension.
✓ Collect history
✓ Observe for signs of UTI :
chills, fever, hesitancy.
✓ Observe for obstruction :
frequent urination of small
amount, oliguria and anuria.

NURSING DIAGNOSIS :

1. Acute pain related to irritation

and spasm from stone movement
in the urinary tract as evidenced
by complaints of pain, facial
grimacing, restlessness.
2. Impaired urinary elimination
related to trauma or blockage of
ureters or urethra as manifested
by decreased by urinary output
and bloody urine.
3. Anxiety related to uncertain
outcome and lack of knowledge
regarding possible surgery as
evidenced by expression.
4. Risk of infection related to
introduction of bacteria
following manipulation of the
urinary tract and obstructed
urinary blood flow.

INTERVENTION :

Relieving Pain :
✓ Administer opioids analgesics
( IV or intramuscular ) with IV
NSAIDas prescribed.
✓ Encourage and assist patient to
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✓ Assume a position of comfort.
✓ Assist patient to ambulate to
obtain some pain relief.
✓ Monitor pain closely and report
promptly increases in severity.

Monitoring and Managing

complication :

✓ Encourage increased fluid intake

ambulation.
✓ Begin IV fluids if patient cannot
take adequate oral fluids.
✓ Monitor total urine output and
patterns of voiding.
✓ Strain urine through gauze.
✓ Instruct patient to report any
increase in pain.
✓ Instruct patient to report
decreased urine volume, bloody
or cloudy urine, fever and pain.
✓ Encourage ambulation as a
means of moving the stone
through the urinary tract.

3 min To SUMMARY :
summarize
the topic. In todays lecture we are discuss
regarding renal calculi in that
introduction, definition, incidence,
etiology, risk factors, types of renal
stones, pathophysiology, clinical
manifestation, diagnostic evaluation,
medical management, surgical
management, complication, prevention,
nutritional therapy, nursing
management.
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2 min To conclude CONCLUSION :
the topic.
Renal calculi is a prevalent,
frequently recurrent, and occasionally
morbid condition associated with
increased risk of bone disease, chronic
kidney disease and hypertension.
Many physicians including family
practitioners, internists, nephrologists,
urologists, emergency room physicians
and interventional radiologists will see
stone patients in their routine practice.
Many underlying disorders have
been associated with stone formation;
recognizing these disorders is important
in stone prophylaxis.
 BIBLIOGRAPHY

1. Brunner and Suddarth’s Textbook of Medical –Surgical Nursing, Volume – 2, 13th

Edition, Janice L. Hinkle Kerry H. Cheever. Page No. : 1120 to 1122
2. Lewis’s Medical –Surgical Nursing, Assessment and Management of Clinical problems,
Chintamani. Page No. : 785 to 786.
3. Essential of Medical –Surgical Nursing, BT Basavanthappa, Jaypee brothers medical
publishers (P) Ltd. Page No. : 548 to 549.