NCP 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

SAFETY

May report: Use of alcohol
Fever; chills

TEACHING/LEARNING

May report: Family history of calculi, kidney disease, hypertension, gout, chronic UTI
History of small-bowel disease, previous abdominal surgery, hyperparathyroidism
Use of antibiotics, antihypertensives, sodium bicarbonate, allopurinol, phosphates,
thiazides, excessive intake of calcium or vitamin D

Discharge plan

DRG projected mean length of inpatient stay: 2.9 days

Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

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).
Urine (24-hr): Cr, uric acid, calcium, phosphorus, oxalate, or cystine may be elevated.
Urine culture: May reveal UTI (Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas).
Biochemical survey: Elevated levels of magnesium, calcium, uric acid, phosphates, protein, electrolytes.
Serum and urine BUN/Cr: Abnormal (high in serum/low in urine) secondary to high obstructive stone in kidney causing ischemia/necrosis.
Serum chloride and bicarbonate levels: Elevation of chloride and decreased levels of bicarbonate suggest developing renal tubular acidosis.
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.
Parathyroid hormone (PTH): May be increased if kidney failure present. (PTH stimulates reabsorption of calcium from bones, increasing circulating serum and urine calcium levels.)
KUB x-ray: Shows presence of calculi and/or anatomical changes in the area of the kidneys or along the course of the ureter.
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.
Cystoureteroscopy: Direct visualization of bladder and ureter may reveal stone and/or obstructive effects.
CT scan: Identifies/delineates calculi and other masses; kidney, ureteral, and bladder distension.
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.

DISCHARGE GOALS

1. Pain relieved/controlled.
2. Fluid/electrolyte balance maintained.
3. Complications prevented/minimized.
4. Disease process/prognosis and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.