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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.

urolithiasis-nursing-care-plan

Materials that make up Kidney Stones

  • Oxalates: This is most common stone forming compound, and high concentration of oxalate in the urine is accountable for almost 60 percent of calcium stones. Food that are high in dietary oxalates are beer, beets, spinach, swiss chard, rhubarb, soy products, and excessive quantities of nuts.
  • Purines: This is a crystalline compound which forms uric acid when broken down during digestion process. If there is an enough amount of uric acids crystals, it could lead to development of kidney stones. Stone made from this material is less common as compared to calcium oxalate stones. Purine can be found in very high quantities of meat as well as fatty fishes, lima beans, mushrooms, lentils, oatmeal, and spinach.     

Types of Kidney Stones

  • Calcium stones is usually form through calcium oxalate. It can also be formed through calcium phosphate.
  • Struvite stones develops in response to an infection just like urinary tract infection. This kind of stone usually grow quickly with few to little warnings.
  • Uric acid stones can be developed among people who do not drink enough water, or to those who lose fluid too much. It may also transpire among individuals who have gout and consumes high protein diet.
  • Cystine stone developed through a hereditary disorder in which the kidney excrete high amount of certain amino acids.

Symptoms

   The symptoms of kidney stones would not transpire unless it starts to move around within the kidney or when it passes through the ureter. If this began to occur, then these signs and symptoms would manifest:

  • Pain on urination
  • Severe pain on the back
  • Pain radiating to the lower abdomen and groin
  • Pink, red, or brown urine
  • Foul- smelling or cloudy urine
  • Nausea and vomiting
  • Urgency or persistent need to urinate
  • Dribbling urination
  • Fever and chills

Treatment

Small stones with minimal symptoms

  • Drinking around 1.9 to 2.8 liters of water to aid in flushing out urinary system.
  • Administration of pain reliever due to the discomfort brought by the passing of stones.
  • Medical therapy such as administration of alpha blocker to relax the muscles of ureter. This will help in passing out the stones quickly and less painful.

Large stones with significant symptoms 

  • Extracorporeal Shock Wave Lithotripsy (ESWL) – sound waves which breaks down the stones.
  • Percutaneous Nephrolithotomy – surgical removal of kidney stones through small telescopes and instruments inserted on a small incision made at the back.
  • Utilizing ureteroscope to remove the stones. This scope can remove smaller stone in the kidney or ureter.
  • Parathyroid gland surgery. A hyperactive or overactive parathyroid gland causes the development of calcium phosphate stones.

Diet

  • Diet should customized based in the specific metabolic disturbance as well as individual dietary habits of the patient. Making it congruent to the person’s dietary habit would help ensure compliance with the assigned diet.
  • Calcium restricted should be avoided except for type II absorptive hypercalcuria. The higher intake of dietary calcium, the lower the risk for oxalic kidney stones will be.
    • Limit intake of food such as beets, nuts, spinach, rhubarb, wheat bran, tea, chocolate, and strawberries. These foods can brought about a profound increase in urinary oxalate excretion.
    • Make sure not to exceed RDA (recommended daily allowance) for Vitamin C for it can also cause increase in urinary oxalate excretion.
  • Intake of salt should also be limited to less than 100 mEq/day, while potassium intake should be encouraged. Increase potassium through 5 or more servings of fruits of vegetables per day.
  • Encourage high fluid intake up to 2 to 3 L/ day, to help produce at least 2 L of urine/ day.
Type of DietFood to Give
Acidify UrineAcid – Ash Diet for Calcium Stones and Struvite StonesMeats, ascorbic, cranberry, eggs, plums prune juice
Alkalanize UrineAlkalinize Ash Diet for Uric Acid and Cystine StonesVegetables, fruits, milk

Source: Balita, C. (2008). Ultimate learning guide to nursing review. Manila, Philippines: Tri-Mega Printing

Diagnostic Studies

  1. Urinalysis: Color may be yellow, dark brown, bloody. Commonly shows RBCs, WBCs, crystals (cystine, uric acid, calcium oxalate), casts, minerals, bacteria, pus; pH may be less than 5 (promotes cystine and uric acid stones) or higher than 7.5 (promotes magnesium, struvite, phosphate, or calcium phosphate stones).
  2. Urine (24-hr)Cr, uric acid, calcium, phosphorus, oxalate, or cystine may be elevated.
  3. Urine culture: May reveal UTI (Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas).
  4. Biochemical survey: Elevated levels of magnesium, calcium, uric acid, phosphates, protein, electrolytes.
  5. Serum and urine BUN/Cr: Abnormal (high in serum/low in urine) secondary to high obstructive stone in kidney causing ischemia/necrosis.
  6. Serum chloride and bicarbonate levels: Elevation of chloride and decreased levels of bicarbonate suggest developing renal tubular acidosis.
  7. CBC:
  • Hb/Hct: Abnormal if patient is severely dehydrated or polycythemia is present (encourages precipitation of solids), or patient is anemic (hemorrhage, kidney dysfunction/failure).
  • RBCs: Usually normal.
  • WBCs: May be increased, indicating infection/septicemia.
  1. Parathyroid hormone (PTH)May be increased if kidney failure present. (PTH stimulates reabsorption of calcium from bones, increasing circulating serum and urine calcium levels.)
  2. KUB x-ray: Shows presence of calculi and/or anatomical changes in the area of the kidneys or along the course of the ureter.
  3. IVP: Provides rapid confirmation of urolithiasis as a cause of abdominal or flank pain. Shows abnormalities in anatomical structures (distended ureter) and outline of calculi.
  4. Cystoureteroscopy: Direct visualization of bladder and ureter may reveal stone and/or obstructive effects.
  5. CT scan: Identifies/delineates calculi and other masses; kidney, ureteral, and bladder distension.
  6. Ultrasound of kidney: To determine obstructive changes, location of stone; without the risk of failure induced by contrast medium.

Nursing Priorities

  1. Alleviate pain.
  2. Maintain adequate renal functioning.
  3. Prevent complications.
  4. Provide information about disease process/prognosis and treatment needs.

Nursing Care Plans for Urolithiasis (Based on NANDA)

Nursing Diagnosis: Pain, acute

May be related to

  • Increased frequency/force of ureteral contractions
  • Tissue trauma, edema formation; cellular ischemia

Possibly evidenced by

  • Reports of colicky pain
  • Guarding/distraction behaviors, restlessness, moaning, self-focusing, facial mask of pain, muscle tension
  • Autonomic responses

Desired outcomes/evaluation criteria—patient will:

Pain Level

  • Report pain is relieved with spasms controlled.
  • Appear relaxed, able to sleep/rest appropriately.
Nursing InterventionsRationales
Pain Management

Independent

Document location, duration, intensity (0–10 scale), and radiation. Note nonverbal signs, e.g., elevated BP and pulse, restlessness, moaning, thrashing about.

Helps evaluate site of obstruction and progress of calculi movement. Flank pain suggests that stones are in the kidney area, upper ureter. Flank pain radiates to back, abdomen, groin, genitalia because of proximity of nerve plexus and blood vessels supplying other areas. Sudden, severe pain may precipitate apprehension, restlessness, severe anxiety.
 

Explain cause of pain and importance of notifying caregivers of changes in pain occurrence/characteristics.

Provides opportunity for timely administration of analgesia (helpful in enhancing patient’s coping ability and may reduce anxiety) and alerts caregivers to possibility of passing of stone/developing complications. Sudden cessation of pain usually indicates stone passage.
Provide comfort measures, e.g., back rub, restful environment.Promotes relaxation, reduces muscle tension, and enhances coping.
Assist with/encourage use of focused breathing, guided imagery, diversional activities.Redirects attention and aids in muscle relaxation.
Encourage/assist with frequent ambulation as indicated and increased fluid intake of at least 3–4 L/day within cardiac tolerance.Renal colic can be worse in the supine position. Vigorous hydration promotes passing of stone, prevents urinary stasis, and aids in prevention of further stone formation.
 

Note reports of increased/persistent abdominal pain.

Complete obstruction of ureter can cause perforation and extravasation of urine into perirenal space. This represents an acute surgical emergency.
Nursing InterventionsRationales
Independent

Administer medications as indicated:

Narcotics, e.g., meperidine (Demerol), morphine;

Usually given during acute episode to decrease ureteral colic and promote muscle/mental relaxation.

Antispasmodics, e.g., flavoxate (Urispas) oxybutynin (Ditropan)

Decreasing reflex spasm may decrease colic and pain.

Collaborative

Apply warm compresses to back.

Relieves muscle tension and may reduce reflex spasms.

Maintain patency of catheters when used.

Prevents urinary stasis/retention, reduces risk of increased renal pressure and infection.

Nursing Diagnosis: Urinary Elimination, impaired

May be related to

  • Stimulation of the bladder by calculi, renal or ureteral irritation
  • Mechanical obstruction, inflammation

Possibly evidenced by

  • Urgency and frequency; oliguria (retention)
  • Hematuria

Desired outcomes/evaluation criteria—patient will:

Urinary Elimination 

  • Void in normal amounts and usual pattern.
  • Experience no signs of obstruction.
Nursing InterventionsRationales
Urinary Elimination Enhancement

Independent

Monitor I&O and characteristics of urine.

Provides information about kidney function and presence of complications, e.g., infection and hemorrhage. Bleeding may indicate increased obstruction or irritation of ureter. Note: Hemorrhage due to ureteral ulceration is rare.
Nursing InterventionsRationales
Urinary Elimination Enhancement 

Independent

Determine patient’s normal voiding pattern and note variations.

Calculi may cause nerve excitability, which causes sensations of urgent need to void. Usually frequency and urgency increase as calculus nears ureterovesical junction.

Encourage increased fluid intake.

Increased hydration flushes bacteria, blood, and debris and may facilitate stone passage.

Strain all urine. Document any stones expelled and send to laboratory for analysis

Retrieval of calculi allows identification of type of stone and influences choice of therapy.

Investigate reports of bladder fullness; palpate for suprapubic distension. Note decreased urine output, presence of periorbital/dependent edema.

Urinary retention may develop, causing tissue distension (bladder/kidney), and potentiates risk of infection, renal failure.

Observe for changes in mental status, behavior, or level of consciousness.

Accumulation of uremic wastes and electrolyte imbalances can be toxic to the CNS.

Collaborative

Monitor laboratory studies, e.g., electrolytes, BUN, Cr.

Elevated BUN, Cr, and certain electrolytes indicate presence/degree of kidney dysfunction.

Obtain urine for culture and sensitivities.

Determines presence of UTI, which may be causing/complicating symptoms.

Administer medications as indicated, e.g.:

Acetazolamide (Diamox), allopurinol (Zyloprim)

Increases urine pH (alkalinity) to reduce formation of acid stones. Antigout agents such as allopurinol (Zyloprim) also lower uric acid production and potential of stone formation.

Hydrochlorothiazide (Esidrix, HydroDIURIL), chlorthalidone (Hygroton)

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.

Ammonium chloride; potassium or sodium phosphate

Reduces phosphate stone formation.

 Antibiotics

Presence of UTI/alkaline urine potentiates stone formation.

 Sodium bicarbonate

Replaces losses incurred during bicarbonate wasting and/or alkalinization of urine; may reduce/prevent formation of some calculi.

Ascorbic acid.

Acidifies urine to prevent recurrence of alkaline stone formation.

Nursing InterventionsRationales
Urinary Elimination Enhancement 

Independent

Maintain patency of indwelling catheters (ureteral, urethral, or nephrostomy) when used.

May be required to facilitate urine flow/prevent retention and corresponding complications. Note: Tubes may be occluded by stone fragments.

Irrigate with acid or alkaline solutions as indicated.

Changing urine pH may help dissolve stones and prevent further stone formation.

Prepare patient for/assist with endoscopic procedures, e.g

Basket procedure

Calculi in the distal and midureter may be removed by endoscopic cystoscope with capture of the stone in a basketing catheter.

Ureteral stents

Catheters are positioned above the stone to promote urethraldilation/stone passage. 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.

Percutaneous or open pyelolithotomy, nephrolithotomy, ureterolithotomy;

Surgery may be necessary to remove stone that is too large to pass through ureters.

Percutaneous ultrasonic lithotripsy

Invasive shock wave treatment for stones in renal pelvis/calyx or upper ureters.

Extracorporeal shockwave lithotripsy (ESWL).Noninvasive procedure in which kidney stones are pulverized by shock waves delivered from outside the body.

Nursing Diagnosis: Fluid Volume, 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; presence of signs or symptoms establishes an actual]

Desired outcomes/evaluation criteria—patient will:

Hydration 

  • Maintain adequate fluid balance as evidenced by vital signs and weight within patient’s normal range, palpable peripheral pulses, moist mucous membranes, good skin turgor.
Nursing InterventionsRationales
 

Fluid/Electrolyte Management
Independent

Monitor I&O.

Comparing actual and anticipated output may aid in evaluating presence/degree of renal stasis/impairment. Note: Impaired kidney functioning and decreased urinary output can result in higher circulating volumes with signs/symptoms of HF.
Document incidence and note characteristics and frequency of vomiting and diarrhea, as well as accompanying or precipitating events.

Nausea/vomiting and diarrhea are commonly associated with renal colic because celiac ganglion serves both kidneys and stomach. Documentation may help rule out other abdominal occurrences as a cause for pain or pinpoint calculi.

Increase fluid intake to 3–4 L/day within cardiac tolerance.Maintains fluid balance for homeostasis and “washing” action that may flush the stone(s) out. Dehydration and electrolyte imbalance may occur secondary to excessive fluid loss (vomiting and diarrhea).
Monitor vital signs. Evaluate pulses, capillary refill, skin turgor, and mucous membranes.Indicators of hydration/circulating volume and need for intervention. Note: Decreased GFR stimulates production of renin, which acts to raise BP in an effort to increase renal blood flow.
Weigh daily.Rapid weight gain may be related to water retention.
Collaborative

Monitor Hb/Hct, electrolytes.

Assesses hydration and effectiveness of/need for interventions.
Administer IV fluids.Maintains circulating volume (if oral intake is insufficient), promoting renal function.
Provide appropriate diet, clear liquids, bland foods as tolerated.Easily digested foods decrease GI activity/irritation and help maintain fluid and nutritional balance.
Administer medications as indicated: antiemetics, e.g., prochlorperazine (Compazine).Reduces nausea/vomiting.

Nursing Diagnosis: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs.

May be related to

  • Lack of exposure/recall; information misinterpretation
  • Unfamiliarity with information resources

Possibly evidenced by

  • Questions; request for information; statement of misconception
  • Inaccurate follow-through of instructions, development of preventable complications

Desired outcomes/evaluation criteria—patient will:

Knowledge: Illness Care 

  • Verbalize understanding of disease process and potential complications.
  • Correlate symptoms with causative factors.
  • Verbalize understanding of therapeutic needs.
  • Initiate necessary lifestyle changes and participate in treatment regimen.
Nursing InterventionsRationales
Teaching: Disease Process 

Independent

Review disease process and future expectations.

Provides knowledge base from which patient can make informed choices.
Stress importance of increased fluid intake, e.g., 3–4L/day or as much as 6–8 L/day. Encourage patient to notice dry mouth and excessive diuresis/diaphoresis and to increase fluid intake whether or not feeling thirsty.Flushes renal system, decreasing opportunity for urinary stasis and stone formation. Increased fluid losses/dehydration require additional intake beyond usual daily needs.
Review dietary regimen, as individually appropriate:Diet depends on the type of stone. Understanding reason for restrictions provides opportunity for patient to make informed choices, increases cooperation with regimen, and may prevent recurrence.
Low-purine diet, e.g., limited lean meat, turkey, legumes, whole grains, alcoholDecreases oral intake of uric acid precursors.
Low-calcium diet, e.g., limited milk, cheese, green leafy vegetables, yogurtReduces risk of calcium stone formation. Note: Research suggests that restricting dietary calcium is not helpful in reducing calcium-stone formation, and researchers, although not advocating high-calcium diets, are urging that calcium limitation be reexamined.
Low-oxalate diet, e.g., restrict chocolate, caffeine-containing beverages, beets, spinach.Reduces calcium oxalate stone formation.
Nursing InterventionsRationales
Teaching: Disease Process 

Independent

Shorr regimen: low-calcium/phosphorus diet with aluminum carbonate gel 30–40 mL, 30 min pc/hs.

Prevents phosphatic calculi by forming an insoluble precipitate in the GI tract, reducing the load to the kidney nephron. Also effective against other forms of calcium calculi. Note: May cause constipation.

Discuss medication regimen; avoidance of OTC drugs, and reading all product/food ingredient labels.

Drugs will be given to acidify or alkalize urine, depending on underlying cause of stone formation. Ingestion of products containing individually contraindicated ingredients (e.g., calcium, phosphorus) potentiates recurrence of stones.

Encourage regular activity/exercise program.

Inactivity contributes to stone formation through calcium shifts and urinary stasis.

Active-listen concerns about therapeutic regimen/lifestyle changes.

Helps patient work through feelings and gain a sense of control over what is happening.

Identify signs/symptoms requiring medical evaluation, e.g., recurrent pain, hematuria, oliguria.

With increased probability of recurrence of stones, prompt interventions may prevent serious complications.

Demonstrate proper care of incisions/catheters if present.

Promotes competent self-care and independence.

References

  • Balita, C. (2008). Ultimate learning guide to nursing review. Manila, Philippines: Tri-Mega Printing
  • Mayo Clinic Staff. (2015). Kidney stones. Mayo Clinic. Retrieved September 29, 2015 from http://www.mayoclinic.org/diseases-conditions/kidney-stones/basics/treatment/con-20024829
  • Rovito, M. (2014). Clinical nutrition for dummies. Hoboken, NJ: John Wiley & Sons Inc. 
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