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Urolithiasis / Renal Calculi

@Ngee Ann Polytechnic INS1 Oct 2022 semester 1

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Objectives
By the end of the lesson the student will be able to

1. State the definition of renal calculi.

2. Outline the pathophysiology of renal calculi.
3. State the causes/risk factors of renal calculi.
4. List the signs and symptoms of renal calculi.
5. Identify the complications of renal calculi.
6. Identify the investigations that would be undertaken to
aid diagnosis of renal calculi.
7. Discuss the nursing diagnosis and interventions for renal
calculi.

@Ngee Ann Polytechnic INS1 Oct 2022 semester 2

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Definition
Renal calculi is stones in the
urinary tract, the most
common cause of upper
urinary tract obstruction.
Nephrolithiasis--Kidney
Urolithiasis -- The rest of the
urine tract

Bauldoff, Gubrud,& Carno, (2019).

@Ngee Ann Polytechnic INS1 Oct 2022 semester 3

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Pathophysiology
Three factors contribute to urolithiasis:

Supersaturation - when the concentration of insoluble

salt in the urine is high, the urine is supersaturated, crystal
may form.
https://www.youtube.com/watch?v=szrqihux0wc (1 min)

Nucleation - A nucleus of the crystals may develop

stable bonds and form stones.
https://www.youtube.com/watch?v=ky4rIo8Ro4I (3min)

Lack of inhibitory substances in the urine –

Fruits and vegetables provide a wide array of stone-inhibiting substances that can help
prevent all types of urinary tract stones. These inhibitors include citrate and glycoprotein
and pyrophosphate.

@Ngee Ann Polytechnic INS1 Oct 2022 semester 4

Images retrieved from google images
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Risk factors

Family or personal
history of renal
stones

Repeated Excessive dietary

Urinary tract intake of calcium,
Infection oxalate or
proteins

Urinary stasis
due to
prolonged
bed rest or Gout – high
immobility uric acid

@Ngee Ann Polytechnic INS1 Oct 2022 semester 5

Images retrieved from google images
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Clinical Manifestations
Small calculi – no symptoms can be passed out spontaneously

Large calculi -
• Colicky pain as the ureter goes into
strong peristaltic action to force the
stone out.
• Haematuria – ureteral lining is abraded
by the stone.
• Infection – Abraded ureteral lining
predisposes the urinary tract to
infection.
• Obstruction leading to hydronephrosis.
• Gastrointestinal symptoms – nausea,
vomiting due to sympathetic response.
https://specialty.mims.com/topic/managing-
urolithiasis-in-primary-care.

@Ngee Ann Polytechnic INS1 Oct 2022 semester 6

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Characteristic of Renal Colic

• Acute onset, severe intermittent

pain.
• Flank pain to the groin on affected
side.
• Usually due to obstruction by
stone 1mm to 5 mm in diameter.
• Other manifestation of UTI, chills,
fever, urine frequency, urgency,
dysuria.
• Gross hematuria due to trauma to
the urinary tract by the calculi. https://www.melbourneurologist.com.au/renal-colic/

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Complications

• Obstruction
- if slow, few or no symptom
- if sudden, may cause severe manifestations
• Hydronephrosis
• Infection

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Investigations
Ultrasound of
kidney

CT scan
Image source: https://www.medgadget.com/2012/02/finding-
pushing-kidney-stones-using-ultrasound.html

Intravenous
pyelogram of
the kidney [IVP]

X-Ray KUB

Image source: https://www.fairbanksurology.com/ct-scan-for-kidney-

@Ngee Ann Polytechnic INS1 Oct 2022 semester 9
stones
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Investigations

Cystoscopy of the bladder and

ureters

• Blood test for serum calcium,

phosphorus and uric acid
levels
• Urinalysis to assess for
haematuria, WBC.

Images retrieved from google images

@Ngee Ann Polytechnic INS1 Oct 2022 semester 10
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Medical Management

Analgesia

Medication to promote stone passage

Increase fluid intake 2.5 to 3 litre per day

Diet restriction – low calcium, low oxalate and low

purine diet eg. beans

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Dietary advice: reduce intake of the following:

Food high in Asparagus, beer, cola, beet roots, cabbage,
Oxalate celery, chocolate, cocoa, fruits, green beans,
nuts, tea and tomatoes

Purine rich Goose, organ meat, sardines, venison, beef ,

foods chicken, crab, pork, salmon,

Acidifying food Cheese, cranberries, eggs, grapes, meat,

poultry, plums , prunes, tomatoes, whole grains

Alkalizing food Green vegetables, legumes, milk, milk products ,

rhubarb

@Ngee Ann Polytechnic INS1 Oct 2022 semester 12

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Surgical management

• Depends on the location of the stone, the extent of

obstruction, the size of the stone, renal function and
presence of UTI.

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Surgical treatment – Lithotripsy

Percutaneous Ultrasonic Lithotripsy
1. Surgeon uses nephroscope to insert into the kidney through a
small incision on the back.
2. The stone is fragmented using a small ultrasonic transducer or
laser.
3. The fragments are removed through the nephroscope.

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Percutaneous Nephrolithotomy
https://www.youtube.com/watch?v=D6vO2ASsQaU

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Nursing care of patient undergoing Lithotripsy

Preoperative care:
Assess knowledge and Anxiety is reduced, and recovery is
understanding of the procedure, enhanced when patient is fully
providing information as needed. prepared for surgery.

General or spinal anaesthesia is General or spinal anaesthesia is

required. Faecal material in the required. Faecal material in the bowel
bowel may impede fluoroscopic may impede fluoroscopic visualisation
visualisation of the kidney and of the kidney and stone.
stone.

@Ngee Ann Polytechnic INS1 Oct 2022 semester 16

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Nursing care of patient undergoing Lithotripsy

Post-operative care:
Monitor vital signs The kidney is a highly vascular, therefore
frequently. haemorrhage and resulting shock are potential
complications of lithotripsy. Internal bleeding is
difficult to detect.

Monitor colour, amount Urine is often bright red initially, but bleeding
and clarity of urine output. should diminish within 48 to 72 hours. Cloudy
urine may indicate the presence of an infection.
Maintain placement and A kinked catheter may result in hydroureter,
patency of urinary hydronephrosis and kidney damage. Decreased
catheters. Anchor ureteral urinary output and flank pain are possible
catheters or nephrostomy symptoms of obstructed urine flow.
tubes securely. Irrigate Excessive force in irrigation may cause trauma
gently if ordered. and bleeding.

@Ngee Ann Polytechnic INS1 Oct 2022 semester 17

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Nursing care of patient undergoing Lithotripsy

Post-operative care:
Prepare for discharge by teaching care Patient and family need necessary
of the indwelling catheter. Teach the information to promote self-care.
signs and symptoms to report.
Teach measures to reduce risk of Many patients have repeated
further lithiasis. episodes of lithiasis and renal colic.
Prevention of stone formation is
important to preserve renal function.

@Ngee Ann Polytechnic INS1 Oct 2022 semester 18

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Surgical treatment – Lithotripsy

Extracorporeal Shock Wave Lithotripsy (ESWL)

1. It is a non-invasive technique for fragmenting kidney stones by

using shock waves.
2. The shock waves are generated outside the body.
3. These repeated shock waves travel through the soft tissue
without causing any damage but break up the stone into small
enough to be eliminated.
4. Depending on the size it might take 30 minutes to 2 hours for
the procedure.
5. Sedation will be given to promote comfort.

https://www.youtube.com/watch?v=Vp9h2JyCmY4

@Ngee Ann Polytechnic INS1 Oct 2022 semester 19

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Nursing management of a patient post ESWL

SN INTERVENTIONS RATIONALE
1 Monitor vital signs Elevation in temperature indicates
(including…) hourly infection.
Drop in BP, Tachycardia and
increased respiratory rate indicate
bleeding.
2 Inform the patient that To allay anxiety and reassure the
transient haematuria is patient.
expected 1 to 2 days post
procedure.
3 Encourage fluid intake of 2 The increase in fluids helps patient to
to 2.5 litres a day. flush the stone particles and
decrease blood clot formation.

@Ngee Ann Polytechnic INS1 Oct 2022 semester 20

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Nursing management of a patient post

Extracorporeal Shock Wave Lithotripsy (ESWL)
SN INTERVENTIONS RATIONALE
4 Sieve all for stone fragments Stone samples need to sent to the
for each voiding. lab for analysis.
5 Provide adequate analgesia. To provide comfort and pain relief
6 Assist patient to undergo x- To evaluate if there are any
rays of the kidney , ureters residual stones in the urinary
and bladder, if ordered. system.

@Ngee Ann Polytechnic INS1 Oct 2022 semester 21

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Surgical management – Bladder stone

Cystoscope
• Direct visualization of the bladder wall
and urethra.
• Small renal calculi can be removed from
ureter, bladder or urethra during
procedure, tissue biopsy can be done.

@Ngee Ann Polytechnic INS1 Oct 2022 semester 22

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Nursing Diagnosis: Acute pain related to

inflammation, obstruction or abrasion
SN INTERVENTION RATIONALE
1 Assess pain score Administer analgesia and assess its
efficacy .
2 Encourage fluid intake and To increase urine output and facilitate
ambulation unless calculus movement through the ureter
contraindicated. and decrease the pain.
3 Use non-pharmacologic measures Can enhance the effectiveness of
such as positioning , relaxation, analgesics and other prescribed
diversion and adjunctive therapy. treatment.

4 If surgery has been performed , Pain may be a symptom of proximal

monitor urinary output, catheters, distention due to a blocked catheter.
incision sites and drains. Haematoma or infection at the surgical
site can significantly increase pain.

@Ngee Ann Polytechnic INS1 Oct 2022 semester 23

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Nursing Diagnosis: Impaired urinary elimination

related to obstruction in the urinary tract
SN Intervention Rationale

1 Monitor amount and character of The amount of urine output helps

urine output. If catheterizes, determine possible urinary tract
measure output hourly. obstruction and adequate hydration.

2 Document any haematuria, Haematuria is often associated with

dysuria, frequency, urgency and calculi and with procedures used to
pyuria. remove stones. Dysuria, frequency,
urgency and pyuria are the signs of UTI.
3 Maintain patency and integrity of A kinked catheter may damage the
all catheter systems. Secure urinary system. Aseptic technique in
catheter well, label as indicated handling of catheter reduces the risk for
and use sterile technique for all infection.
ordered irrigations or other
procedure.
@Ngee Ann Polytechnic INS1 Oct 2022 semester 24
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Summary

1. State the definition of renal calculi.

2. Outline the pathophysiology of renal calculi.
3. State the causes/risk factors of renal calculi.
4. List the signs and symptoms of renal calculi.
5. Identify the complications of renal calculi.
6. Identify the investigations that would be undertaken to
aid diagnosis of renal calculi.
7. Discuss the nursing diagnosis and interventions for renal
calculi.

@Ngee Ann Polytechnic INS1 Oct 2022 semester 25

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REFERENCES

• Bauldoff, G., Gubrud, P., & Carno, M. (2019). LeMone and

Burke’s Medical-Surgical Nursing: Clinical Reasoning in
Patient Care (7th ed.). Boston: Pearson.

@Ngee Ann Polytechnic INS1 Oct 2022 semester 26