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UROLITHIASIS (RENAL CALCULI

)

Kidney stones (calculi) are formed of mineral deposits, most commonly calcium oxalate and calcium phosphate;
however, uric acid, struvite, and cystine are also calculus formers. Although renal calculi can form anywhere in the
urinary tract, they are most commonly found in the renal pelvis and calyces. Renal calculi can remain asymptomatic
until passed into a ureter and/or urine flow is obstructed, when the potential for renal damage is acute.

CARE SETTING
Acute episodes may require inpatient treatment on a medical or surgical unit.

RELATED CONCERNS
Fluid and electrolyte imbalances
Metabolic acidosis (primary base bicarbonate deficiency)
Metabolic alkalosis (primary base bicarbonate excess)
Psychosocial aspects of care
Renal failure: acute

Patient Assessment Database
Dependent on size, location, and etiology of calculi.

ACTIVITY/REST
May report: Sedentary occupation or occupation in which patient is exposed to high environmental
temperatures
Activity restrictions/immobility due to a preexisting condition (e.g., debilitating disease,
spinal cord injury)

CIRCULATION
May exhibit: Elevated BP/pulse (pain, anxiety, kidney failure)
Warm, flushed skin; pallor

ELIMINATION
May report: History of recent/chronic UTI; previous obstruction (calculi)
Decreased urinary output, bladder fullness
Burning, urgency with urination
Diarrhea
May exhibit: Oliguria, hematuria, pyuria
Alterations in voiding pattern

FOOD/FLUID
May report: Nausea/vomiting, abdominal tenderness
Diet high in purines, calcium oxalate, and/or phosphates
Insufficient fluid intake; does not drink fluids well
May exhibit: Abdominal distension; decreased/absent bowel sounds
Vomiting

PAIN/DISCOMFORT
May report: Acute episode of excruciating, colicky pain with location depending on stone location,
e.g., in the flank in the region of the costovertebral angle; may radiate to back,
abdomen, and down to the groin/genitalia. Constant dull pain suggests calculi
located in the renal pelvis or calyces.
Pain may be described as acute, severe, not relieved by positioning or any other measures
May exhibit: Guarding; distraction behaviors; self-focusing
Tenderness in renal areas on palpation

DIAGNOSTIC STUDIES Urinalysis: Color may be yellow. 4. 2. 3. phosphorus. electrolytes. .5 (promotes magnesium. 4. phosphate. CBC: Hb/Hct: Abnormal if patient is severely dehydrated or polycythemia is present (encourages precipitation of solids). Urine (24-hr): Cr. (PTH stimulates reabsorption of calcium from bones. IVP: Provides rapid confirmation of urolithiasis as a cause of abdominal or flank pain. 2. crystals (cystine. location of stone. or patient is anemic (hemorrhage. Ultrasound of kidney: To determine obstructive changes. Alleviate pain. or calcium phosphate stones). RBCs: Usually normal. Klebsiella. phosphates.9 days considerations: Refer to section at end of plan for postdischarge considerations. minerals. thiazides. kidney dysfunction/failure). Commonly shows RBCs. struvite. previous abdominal surgery. gout. Serum chloride and bicarbonate levels: Elevation of chloride and decreased levels of bicarbonate suggest developing renal tubular acidosis. Shows abnormalities in anatomical structures (distended ureter) and outline of calculi. excessive intake of calcium or vitamin D Discharge plan DRG projected mean length of inpatient stay: 2. DISCHARGE GOALS 1. 5. without the risk of failure induced by contrast medium. Pseudomonas). increasing circulating serum and urine calcium levels. Prevent complications. Parathyroid hormone (PTH): May be increased if kidney failure present. Maintain adequate renal functioning. WBCs: May be increased. Plan in place to meet needs after discharge. or cystine may be elevated. protein. antihypertensives. calcium oxalate). Biochemical survey: Elevated levels of magnesium. uric acid.SAFETY May report: Use of alcohol Fever. Urine culture: May reveal UTI (Staphylococcus aureus. allopurinol. calcium. WBCs. sodium bicarbonate. NURSING PRIORITIES 1. bloody. 3. pus. casts. Fluid/electrolyte balance maintained. hyperparathyroidism Use of antibiotics. Proteus. CT scan: Identifies/delineates calculi and other masses. pH may be less than 5 (promotes cystine and uric acid stones) or higher than 7. Pain relieved/controlled. kidney disease. uric acid. hypertension. uric acid. calcium. dark brown. indicating infection/septicemia. ureteral. bacteria. Serum and urine BUN/Cr: Abnormal (high in serum/low in urine) secondary to high obstructive stone in kidney causing ischemia/necrosis. Disease process/prognosis and therapeutic regimen understood. Provide information about disease process/prognosis and treatment needs. and bladder distension. chronic UTI History of small-bowel disease. phosphates. kidney. Complications prevented/minimized. oxalate.) KUB x-ray: Shows presence of calculi and/or anatomical changes in the area of the kidneys or along the course of the ureter. chills TEACHING/LEARNING May report: Family history of calculi. Cystoureteroscopy: Direct visualization of bladder and ureter may reveal stone and/or obstructive effects.

cellular ischemia Possibly evidenced by Reports of colicky pain Guarding/distraction behaviors. stasis. Flank pain radiates to back. and aids in prevention of further stone formation. prevents urinary cardiac tolerance. restlessness. reduces muscle tension. muscle tension Autonomic responses DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Pain Level (NOC) Report pain is relieved with spasms controlled. Complete obstruction of ureter can cause perforation and extravasation of urine into perirenal space. moaning. imagery. e. Flank pain suggests that stones are in the pulse. acute May be related to Increased frequency/force of ureteral contractions Tissue trauma. severe pain may precipitate apprehension. able to sleep/rest appropriately. severe anxiety. Encourage/assist with frequent ambulation as indicated Renal colic can be worse in the supine position. facial mask of pain. kidney area.g.. intensity (0–10 scale). Provide comfort measures. genitalia because of proximity of nerve plexus and blood vessels supplying other areas. groin. duration. restlessness. analgesia (helpful in enhancing patient’s coping ability and may reduce anxiety) and alerts caregivers to possibility of passing of stone/developing complications. and Helps evaluate site of obstruction and progress of calculi radiation. NURSING DIAGNOSIS: Pain. edema formation. Explain cause of pain and importance of notifying Provides opportunity for timely administration of caregivers of changes in pain occurrence/characteristics. Note reports of increased/persistent abdominal pain. moaning. back rub. Appear relaxed. This represents an acute surgical emergency. Note nonverbal signs. e. Sudden cessation of pain usually indicates stone passage. thrashing about. ..g. ACTIONS/INTERVENTIONS RATIONALE Pain Management (NIC) Independent Document location. guided Redirects attention and aids in muscle relaxation. Sudden. elevated BP and movement. Assist with/encourage use of focused breathing. Vigorous and increased fluid intake of at least 3–4 L/day within hydration promotes passing of stone. restful Promotes relaxation. and environment. enhances coping. self-focusing. diversional activities. restlessness. upper ureter. abdomen.

e.. ACTIONS/INTERVENTIONS RATIONALE Urinary Elimination Enhancement (NIC) Independent Monitor I&O and characteristics of urine. morphine. Note: Hemorrhage due to ureteral ulceration is rare. meperidine (Demerol). reduces risk of increased renal pressure and infection.g. Provides information about kidney function and presence of complications. e. Bleeding may indicate increased obstruction or irritation of ureter. oliguria (retention) Hematuria DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Urinary Elimination (NOC) Void in normal amounts and usual pattern. flavoxate (Urispas). NURSING DIAGNOSIS: Urinary Elimination.. May be used to reduce tissue edema to facilitate movement of stone. . Usually given during acute episode to decrease ureteral colic and promote muscle/mental relaxation. Collaborative Apply warm compresses to back.. infection and hemorrhage.g. Experience no signs of obstruction. Corticosteroids. impaired May be related to Stimulation of the bladder by calculi. Relieves muscle tension and may reduce reflex spasms. Prevents urinary stasis/retention. e.ACTIONS/INTERVENTIONS RATIONALE Pain Management (NIC) Independent Administer medications as indicated: Narcotics. renal or ureteral irritation Mechanical obstruction. Decreasing reflex spasm may decrease colic and pain.g. Antispasmodics. inflammation Possibly evidenced by Urgency and frequency. Maintain patency of catheters when used. oxybutynin (Ditropan).

Observe for changes in mental status. Document any stones expelled and send to laboratory for analysis. Cr. potassium or sodium phosphate. Reduces phosphate stone formation. Strain all urine. Collaborative Monitor laboratory studies. Increased hydration flushes bacteria.g. which may be causing/complicating symptoms. Antibiotics. Urinary retention may develop. Ammonium chloride. Elevated BUN. Obtain urine for culture and sensitivities. and debris and may facilitate stone passage. Usually frequency and urgency increase as calculus nears ureterovesical junction. Cr. palpate for suprapubic distension. and certain electrolytes indicate presence/degree of kidney dysfunction. blood. Hydrochlorothiazide (Esidrix. Encourage increased fluid intake. and potentiates risk of infection. renal failure. e. HydroDIURIL). Replaces losses incurred during bicarbonate wasting and/or alkalinization of urine. Accumulation of uremic wastes and electrolyte imbalances can be toxic to the CNS.ACTIONS/INTERVENTIONS RATIONALE Urinary Elimination Enhancement (NIC) Independent Determine patient’s normal voiding pattern and note Calculi may cause nerve excitability. Sodium bicarbonate. causing tissue distension presence of periorbital/dependent edema. Presence of UTI/alkaline urine potentiates stone formation. Note decreased urine output. may reduce/prevent formation of some calculi. allopurinol (Zyloprim). Investigate reports of bladder fullness. e. sensations of urgent need to void.: Acetazolamide (Diamox).. (bladder/kidney). BUN. Ascorbic acid. Administer medications as indicated. Increases urine pH (alkalinity) to reduce formation of acid stones. Acidifies urine to prevent recurrence of alkaline stone formation. behavior. Antigout agents such as allopurinol (Zyloprim) also lower uric acid production and potential of stone formation. electrolytes.g. or level of consciousness. Retrieval of calculi allows identification of type of stone and influences choice of therapy. chlorthalidone (Hygroton). Determines presence of UTI. May be used to prevent urinary stasis and decrease calcium stone formation if not caused by underlying disease process such as primary hyperthyroidism or vitamin D abnormalities. which causes variations. .

Invasive shock wave treatment for stones in renal pelvis/calyx or upper ureters. Catheters are positioned above the stone to promote urethraldilation/stone passage. Percutaneous ultrasonic lithotripsy.ACTIONS/INTERVENTIONS RATIONALE Urinary Elimination Enhancement (NIC) Independent Maintain patency of indwelling catheters (ureteral. Calculi in the distal and midureter may be removed by endoscopic cystoscope with capture of the stone in a basketing catheter. risk for deficient Risk factors may include Nausea/vomiting (generalized abdominal and pelvic nerve irritation from renal or ureteral colic) Postobstructive diuresis Possibly evidenced by [Not applicable. good skin turgor.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Hydration (NOC) Maintain adequate fluid balance as evidenced by vital signs and weight within patient’s normal range. Percutaneous or open pyelolithotomy. presence of signs or symptoms establishes an actual diagnosis. palpable peripheral pulses. Prepare patient for/assist with endoscopic procedures. Surgery may be necessary to remove stone that is too nephrolithotomy. large to pass through ureters. Note: Tubes may be occluded by stone fragments. Continuous or intermittent irrigation can be carried out to flush kidneys/ureters and adjust pH of urine to permit dissolution of stone fragments following lithotripsy. and corresponding complications. moist mucous membranes. May be required to facilitate urine flow/prevent retention urethral. Ureteral stents.: Basket procedure. ureterolithotomy. e. Changing urine pH may help dissolve stones and prevent further stone formation. Extracorporeal shockwave lithotripsy (ESWL).g. Irrigate with acid or alkaline solutions as indicated. . Noninvasive procedure in which kidney stones are pulverized by shock waves delivered from outside the body. NURSING DIAGNOSIS: Fluid Volume. or nephrostomy) when used.

as well as with renal colic because celiac ganglion serves both accompanying or precipitating events. Increase fluid intake to 3–4 L/day within cardiac Maintains fluid balance for homeostasis and “washing” tolerance. Administer medications as indicated: antiemetics. promoting renal function. . Comparing actual and anticipated output may aid in evaluating presence/degree of renal stasis/impairment. and mucous membranes. Note: Impaired kidney functioning and decreased urinary output can result in higher circulating volumes with signs/symptoms of HF. e. Note: Decreased GFR stimulates production of renin. Reduces nausea/vomiting. Evaluate pulses.ACTIONS/INTERVENTIONS RATIONALE Fluid/Electrolyte Management (NIC) Independent Monitor I&O. action that may flush the stone(s) out.g. capillary refill. Collaborative Monitor Hb/Hct. electrolytes. kidneys and stomach. Rapid weight gain may be related to water retention. Documentation may help rule out other abdominal occurrences as a cause for pain or pinpoint calculi. Maintains circulating volume (if oral intake is insufficient).. prochlorperazine (Compazine). clear liquids. Assesses hydration and effectiveness of/need for interventions. skin Indicators of hydration/circulating volume and need for turgor. Weigh daily. Document incidence and note characteristics and Nausea/vomiting and diarrhea are commonly associated frequency of vomiting and diarrhea. bland foods as Easily digested foods decrease GI activity/irritation and tolerated. which acts to raise BP in an effort to increase renal blood flow. Dehydration and electrolyte imbalance may occur secondary to excessive fluid loss (vomiting and diarrhea). Administer IV fluids. intervention. Monitor vital signs. Provide appropriate diet. help maintain fluid and nutritional balance.

Low-purine diet. request for information. prognosis. and may prevent recurrence. yogurt. caffeine. Review dietary regimen. containing beverages. Note: Research leafy vegetables.. decreasing opportunity for urinary 4L/day or as much as 6–8 L/day. Encourage patient to stasis and stone formation. NURSING DIAGNOSIS: Knowledge. e. Understanding reason for restrictions provides opportunity for patient to make informed choices. beets. e. limited milk... spinach. information misinterpretation Unfamiliarity with information resources Possibly evidenced by Questions. e..g. . Provides knowledge base from which patient can make informed choices. 3– Flushes renal system. self-care. turkey. e. Increased fluid notice dry mouth and excessive diuresis/diaphoresis and losses/dehydration require additional intake beyond usual to increase fluid intake whether or not feeling thirsty. restrict chocolate. statement of misconception Inaccurate follow-through of instructions. Low-calcium diet. as individually appropriate: Diet depends on the type of stone.g. increases cooperation with regimen. development of preventable complications DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Knowledge: Illness Care (NOC) Verbalize understanding of disease process and potential complications. suggests that restricting dietary calcium is not helpful in reducing calcium-stone formation. and discharge needs May be related to Lack of exposure/recall. green Reduces risk of calcium stone formation. Decreases oral intake of uric acid precursors. Low-oxalate diet. limited lean meat. treatment. and researchers. whole grains. legumes. are urging that calcium limitation be reexamined.g.g. Verbalize understanding of therapeutic needs. alcohol. daily needs. Stress importance of increased fluid intake. although not advocating high-calcium diets. cheese. ACTIONS/INTERVENTIONS RATIONALE Teaching: Disease Process (NIC) Independent Review disease process and future expectations. Initiate necessary lifestyle changes and participate in treatment regimen. Correlate symptoms with causative factors. Reduces calcium oxalate stone formation. deficient [Learning Need] regarding condition.

Note: May cause constipation. Drugs will be given to acidify or alkalize urine. phosphorus) potentiates recurrence of stones. and life responsibilities) Urinary Elimination. Ingestion of products containing individually contraindicated ingredients (e. Identify signs/symptoms requiring medical evaluation. personal resources. impaired—recurrence of calculi. precipitate in the GI tract. Demonstrate proper care of incisions/catheters if present.ACTIONS/INTERVENTIONS RATIONALE Teaching: Disease Process (NIC) Independent Shorr regimen: low-calcium/phosphorus diet with Prevents phosphatic calculi by forming an insoluble aluminum carbonate gel 30–40 mL. oliguria. and reading all product/food ingredient labels. Discuss medication regimen. depending on underlying cause of stone formation. . e.g. calcium. Encourage regular activity/exercise program. control over what is happening. POTENTIAL CONSIDERATIONS following acute hospitalizations (dependent on patient’s age. reducing the load to the kidney nephron. hematuria. Promotes competent self-care and independence. physical condition/presence of complications. Active-listen concerns about therapeutic regimen/lifestyle Helps patient work through feelings and gain a sense of changes. With increased probability of recurrence of stones. recurrent pain. prompt interventions may prevent serious complications. avoidance of OTC drugs. 30 min pc/hs.g.. Inactivity contributes to stone formation through calcium shifts and urinary stasis. Also effective against other forms of calcium calculi..