This document discusses nephrolithiasis and urolithiasis, which refer to kidney stones and urinary tract stones respectively. Stones form when substances in urine crystallize. Risk factors include hypercalcemia, dehydration, diet, genetics, and certain medical conditions. Stones are diagnosed using imaging tests and urine/blood tests. Treatment depends on stone size and location, and may include increased fluid intake, shockwave lithotripsy, ureteroscopy, or surgery to remove stones. Nursing care focuses on pain management, preventing infection and obstruction, and educating patients on prevention of recurrent stones.

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2. NEPHROLITHIASIS AND UROLITHIASIS
 Nephrolithiasis refers to renal stone .
 Urolithiasis refers to the presence of stones in the
urinary system.
 Stones, or calculi, are formed in the urinary tract
from the kidney to bladder by the crystallization of
substances excreted in the urine.
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3. Causes and predisposing factors of
kidney stones
Hypercalcemia and hypercalciuria
Excessive intake of vitamin D, milk, and alkali
 Chronic dehydration
 Fluid intake,
 Immobility
Diet high in purines and abnormal purine
metabolism (hyperuricemia and gout)
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4. Contd…
 Genetic predisposition (cystinuria)
 Chronic urinary tract infection (Struvite stone)
 Chronic obstruction with stasis of urine, foreign
bodies within the urinary tract
 Excessive oxalate absorption in inflammatory
bowel disease and bowel resection or ileostomy
 Living in mountainous, desert, or tropical areas
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5. Contd…
Some medications
some diuretics
calcium-containing antacids
Protease inhibitors: Indinavir sulfate
Steroids:
Dietary factors:
 inadequate fluid intake predisposes to dehydration
 high intake of animal protein,
 a high-salt diet,
 excessive vitamin D supplementation,
 excessive intake of oxalate-containing foods such as
spinach
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6. Medical conditions leading kidney
stone
 Gout (uric acid stones)
 Hyperparathyroidism
 kidney diseases such as renal tubular acidosis
 Chronic diseases such as diabetes and
hypertension.
 Inflammatory bowel disease
 Those who have undergone intestinal bypass or
ostomy surgery
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7. Pathophysiology
Inhibitors of stone formation:
 Stones can form when there is a deficiency of
substances that normally prevent crystallization
in the urine, such as Citrate,magnesium,
nephrocalcin, and uropontin.
(that inhibit the nucleation, growth, and
aggregation of calcium-containing crystals)
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8. Supersaturation of urine:
 When the urine becomes supersaturated with one
or more calculogenic (crystal-forming) substances,
a seed crystal may form through the process of
nucleation.
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9. Different types of kidney stones
 Calcium stones: Calcium stones are most common
substance and found in up to 90% of stone.
 They are more common in men between age 20 - 30.
 The peak onset is during a person’s 20.
 They may range from very small particles, often called
SAND or GRAVEL to giant staghorn calculi.
 Calcium can combine with other substances, such as
oxalate (the most common substance), phosphate, or
carbonate, to form the stone.
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11. Causes of hypercalciuria
 A high rate of bone reabsorption E.g Paget’s disease,
hyperparathyroidism, cushing’s syndrome, immobility etc
 Increase calcium reabsorption in gut as in milk-alkali
syndrome,& excessive intake of vitamin D.
 Impaired renal tubular absorption of filtered calcium as
in renal tubular acidosis.
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12. Contd….
 Oxalate: It is the second most common stone,
which is relatively insoluble in urine.
 The mechanism of the oxalate availability is
unclear but may be closely related to diet.
 Oxalate is present in certain foods such as spinach.
It's also found in vitamin C supplements.
 Diseases of the small intestine increase risk of
these stones.
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14.  Cystine stones: Cystine stones can form in people
who have cystinuria. This disorder runs in families
and affects both men and women.
 Uric acid stones: Uric acid stones are more common
in men than in women. They can occur with gout or
chemotherapy.
 Struvite stones: Struvite stones are mostly found in
women who have a urinary tract infection.
 These stones can grow very large and can block the
kidney, ureter, or bladder.
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16. Uric acid stones:
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19. Signs and symptoms
 While some kidney stones may not produce
symptoms (known as "silent" stones)
 The main symptom is severe pain that starts
suddenly and may go away suddenly:
 Pain may move to groin area (groin pain) or
testicles (testicle pain)
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20. Pain pattern depends on site of
obstruction
 Calyx: Flank or costovertebral angle
pain,hematuria, abdominal distention
 Ureteropelvic junction: pain at flank or
costovertebral junction, migrating to groin and
testicle/libia minora
 Ureterovesical junction: Urgency, frequency,
genital pain
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21. Contd..
 Renal colic pain
 Pain relief is immediate after stone passage.
 Large ureteral stones produce symptoms of
obstruction as they pass down the ureter (ureteral
colic).
 Bladder stones produce symptoms similar to cystitis.
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22. Others symptoms
 Blood in the urine
 Chills
 Fever
 Nausea
 Vomiting
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23. Diagnostic Evaluation
History taking:
 Dietary and medication histories and family history of
renal stones
 Ultrasonography
 X-ray KUB (Kidney, Ureter & Bladder)
 IVU ( Intra Venous Urography) to determine site
and evaluate degree of obstruction
 Spiral CT scan
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24. Contd…
 Urinalysis :hematuria and pyuria; pH < 5.5
indicates uric acid stone; > 7.5 indicates struvite
stone; urine culture and drug sensitivity studies to
detect infection.
 Serum kidney function tests, electrolytes,
calcium, phosphorus, uric acid, and magnesium
levels; serum parathyroid hormone may also be
evaluated
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25. Management
Non operative treatment
 1. Conservative
 2. Extracorporeal shock wave Lithotripsy ( ESWL)
Operative treatments
 Endoscopic procedures
 Open- rocedures
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26. Management
Non - Operative
General Principles
 If small stone (< 5 mm) and able to treat as outpatient,
80% will pass stone spontaneously with hydration,
pain control, and reassurance.
 Intravenous hydrations followed by intravenous
frusemide
 Hospitalized for intractable pain, persistent vomiting,
high-grade fever, obstruction with infection, and
solitary kidney with obstruction.
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27. Extracorporeal Shock Wave
Lithotripsy ( ESWL)
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28. ESWL contd..
 Noninvasive technique and treatment of choice for
stones less than 2 cm in diameter (80% of stones
fall into this category) and located in the ureter
above the iliac crest.
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29. ESWL contd…
 High-energy shock waves are
directed at the kidney stone (
500-1500 shock wave)
 Position of the kidney stone
is located by fluoroscopy, and
the shock waves are targeted
directly at the stone.
 The shock waves do not
affect soft tissue.
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30. ESWL contd…
 ESWL eliminates need for
surgery in majority of patients
and can be repeated for
recurrent stones with no
apparent risk to kidney
structure or function.
 Complications include pain,
urinary infection, and
temporary bleeding around
kidney.
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31. Endoscopic procedures
 Percutaneous Nephrostolithotomy
 Uretero-renoscopic Lithotripsy (URSL)
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32. Percutaneous Nephrostolithotomy
 Percutaneous
nephrolithotomy (PCNL) is a
surgical procedure to remove
stones from the kidney by a small
puncture wound (up to about 1
cm) through the skin.
 It is most suitable to remove
stones of more than 2 cm in size
and which are present near the
Pelvic region.
 It is usually done under general
anesthesia or spinal anesthesia.
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33. Contd….
 For stones in renal collecting
system or upper portion of ureter
and larger than 2.5 cm in diameter.
 Under ultrasound guidance, a
needle is advanced into collecting
system; guide wire is advanced
into renal pelvis or ureter.
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34. Contd…
 Tract is dilated with mechanical dilators or
high-pressure balloon dilator until
nephroscope can be inserted up against
stone.
 Stones can be broken apart with hydraulic
shock waves or a laser beam administered
by way of nephroscope fragments are
removed using forceps, graspers, or basket
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35. Complications of PCNL
 Injury to the colon sepsis
 Injury to the blood vessels
 Urinary leak may persist for a few days.
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36. Uretero-renoscopic Lithotripsy (URSL)
 Ureterorenoscopy is a procedure ,where the kidney
stones are removed mechanically using a thin
telescope called ureteroscope is passed through the
urethra into the bladder, through to the ureter or to
the kidneys where the stone I s stuck .
The stones are broken down into smaller pieces using
lithotripsy.
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37. Contd….
 This is performed under general anesthetic and
sometimes a plastic tube called a stent is inserted
temporarily to facilitate the movement of the stone
particles into the bladder.
 This is most effective for stones having size of 15 mm
or more.
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38. Open Surgical Procedures
Indicated for only 1% to 2% of all stones.
 Pyelolithotomy removal of stones from kidney
pelvis
 Nephrolithotomy a incision into kidney for
removal of stone
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39. Contd…
 Nephrectomy a removal of kidney; indicated
when kidney is extensively and irreparably
damaged and is no longer a functioning organ;
partial nephrectomy sometimes done.
 Ureterolithotomy a removal of stone in ureter
 Cystolithotomy a removal of stone from bladder
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40. Complications of renal stone
 Calculous hydronephrosis
 Calculous pyonephrosis
 Renal failure
 Squamous cell carcinoma
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41. Nursing Assessment
 Obtain history focusing on family history of
calculi, episodes of dehydration, prolonged
immobility, UTI, dietary and medication history.
 Assess pain location and radiation; assess level of
pain using a scale of 1 to 10.
 Observe for presence of associated symptoms:
nausea, vomiting, diarrhea, abdominal distention.
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42. Contd…
 Monitor for signs and symptoms of UTI, such as
chills, fever, dysuria, frequency. Examine urine for
hematuria.
 Observe for signs and symptoms of obstruction,
such as frequent urination of small amounts,
oliguria, anuria.
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43. Nursing Diagnoses
 Acute Pain related to inflammation, obstruction, and
abrasion of urinary tract by migration of stones
 Impaired Urinary Elimination related to blockage of
urine flow by stones
 Risk for Infection related to obstruction of urine flow
and instrumentation during treatment
 Deficient knowledge regarding prevention of
recurrence of renal stones
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44. Nursing Interventions
Controlling Pain
 Give prescribed opioid analgesic (usually I.V. or
I.M.) until cause of pain can be removed.
 Monitor patient closely for increasing pain; may
indicate inadequate analgesia.
 Very large doses of opioids are typically required to
relieve pain, so monitor for respiratory depression
and drop in blood pressure
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45. Controlling pain contd…
 Encourage patient to assume position that brings
some relief.
 Reassess pain frequently using pain scale.
 Administer antiemetic if needed.
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46. Maintaining Urine Flow
 Administer fluids orally or I.V. (if vomiting) to
reduce concentration of urinary crystalloids and
ensure adequate urine output.
 Monitor total urine output and patterns of voiding.
report oliguria or anuria.
 Strain all urine through strainer or gauze to
harvest the stone; uric acid stones may crumble.
Crush clots, and inspect sides of urinal/bedpan for
clinging stones or fragments 46

47. Contd..
 For outpatient treatment, the patient may use a
coffee filter to strain urine.
 Help patient to walk, if possible, because
ambulation may help move the stone through the
urinary tract.
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48. Controlling Infection
 Administer parenteral or oral antibiotics as
prescribed during treatment, and monitor for
adverse effects.
 Assess urine for color, cloudiness, and odor.
 Obtain vital signs, and monitor for fever and
symptoms of impending sepsis (tachycardia,
hypotension).
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49. Prevention of Recurrent Stone
Formation
 For patients with calcium oxalate stones
 Instruct on diet avoid excesses of calcium and
phosphorus; maintain a low-sodium diet
 Teach purpose of drug therapy allopurinol
therapy to reduce uric acid concentration.
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50. Contd…
 For patients with uric acid stones
 Teach methods to alkalinize urine to enhance
urate solubility.
 Instruct on testing urine pH.
 Teach purpose of taking allopurinol to lower
uric acid concentration.
 Provide information about reduction of dietary
purine intake (low protein red meat, fish, fowl).
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51.  For patients with infection (struvite) stone
 Teach signs and symptoms of urinary infection
(in patients with neurologic or spinal cord
disease, teach use of dipsticks to evaluate urine
for nitrites and leukocytes); encourage him to
report infection immediately; must be treated
vigorously.
 Try to avoid prolonged periods of recumbency
slows renal drainage and alters calcium
metabolism.
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52.  For patients with cystine stones(occur in
cystinuria, a hereditary disorder of amino acid
transport).
 Teach patient to alkalinize urine by taking
sodium bicarbonate tablets (Soda Mint) to
increase cystine solubility; instruct patient how
to test urine pH with a pH indicator.
 Teach patient about drug therapy with D-
penicillamine (Depen) to lower cystine
concentration
 Explain importance of maintaining drug therapy
consistently.
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53. For all patients with stone disease
 Explain need for consistently increased fluid
intake (24-hour urinary output greater than 2 L)
lowers the concentration of substances involved
in stone formation.
 Drink enough fluids to achieve a urinary
volume of 2,000 to 3,000 mL or more every 24
hours.
 Drink larger amounts of fluid during periods
of strenuous exercise, if patient perspires
freely.
 Take fluids in evening to guarantee a high
urine flow during the night.
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54.  Encourage a diet low in sugar and animal
proteins refined carbohydrates appear to lead to
hypercalciuria and urolithiasis; animal proteins
increase urine excretion of calcium, uric acid,
and oxalate.
 Increase consumption of fiber inhibits calcium
and oxalate absorption.
 Save any stone passed for analysis. (Only
patients with more than one episode of
urolithiasis are advised to have a metabolic
evaluation.)
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55. References
 http://en.wikipedia.org/wiki/Kidney_stone retrieved
on 2012/08/08
 http://www.medicinenet.com/kidney_stone/article.ht
m retrieved on 2012/08/08
 Nettina, Sandra , M., & Elizabeth ,J. (2006).
Lippincott Manual of Nursing Practice. (8th
ed.).published by Lippincott Williams & Wilkins.
 Black, J.M., & Hawks, J.H.(2009).Medical Surgical
Nursing.(8th ed.). Published by Elsevier India.
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