Urolithiasis Is the process of forming stones in the kidney, bladder or urethra Kidney stones(calculi) are formed of minerals deposits commonly calcium oxalate and calcium phosphate; however uric acid, struvite and cystine are also calculus formers.

1. Renal/Urinary Disorders #3
Prepared by:
Jamilah Saad Alqahtani
Nurse Lecturer, MSN, TOT, OR Nurse Specialist, RGN, BSN,

2. Urolithiasis
• Is the process of forming stones in the
kidney, bladder or urethra
• Kidney stones(calculi) are formed of
minerals deposits commonly calcium
oxalate and calcium phosphate;
however uric acid, struvite and cystine
are also calculus formers.
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3. Urolithiasis
• Although renal calculi can form anywhere in
urinary tract. They are most commonly found
in renal pelvis and calyces.
• Renal calculi can remain a symptomatic until
passed ureter and urine flow is obstructed
when the potential for renal damage is acute.
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• ‫الشكل‬ ‫كأسي‬ ‫=عضو‬calyx

4. There are four main types of kidney stone:
1. calcium stones,
2. uric acid stones,
3. struvite stones and
4. cystine stones

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Calcium Oxalate Calcium Phosphate
Uric Acid (10-15%) Struvite (10-15%)
(60-70%)
STONE TYPES
Cystine stone (4%)

6. Formation of stones
Urine becomes too concentrated, substances in the urine crystalize and stone form
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7. Pathophysiology
• Involves three conditions would
happened:
1. Slow urine flow resulting in
supersaturation of the urine
with the particular element
2. Damage to lining of urinary tract
3. Decreased inhibitor substances
in the urine that would
otherwise prevent
supersaturation and crystal
aggregation
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8. Etiology of urolithiasis
• Metabatic risk factors such as
hyperuricemia, hyperoxaluria or
hypercalcemia
• High dietary calcium not
contributive unless metabolic or
renal tubular defect exists
• Immobilization
• Urinary stasis, dehydration and
urinary retention maybe causative.
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9. Risk Factors For Kidney Stones
• Low daily fluid intake
• Diets high in animal protein and salt
• Moderate restriction of dietary calcium
• Consumption of grapefruit juice, spinach, rhubarb, peanuts, cashews
and almonds by patients predisposed to Stone formation
• Medication: indinavir, triamterene, high-dose vitamin C
• Comorbidities: gout, nephropathy, obesity in diabetic patients,
recurrent UTI, and inflammatory bowel disease.
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Indinavir=Protease inhibitors (PIs) are a class of antiviral drugs that are widely used to treat HIV/AIDS and hepatitis C,
triamterene=Triamterene (trade name Dyrenium) is a potassium-sparing diuretic used in combination with thiazide diuretics for the treatment of hypertension and edema

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Clinical Manifestation

11. Clinical Manifestation
Depend on the presence of obstruction, infection, edema.
Symptoms range from mild to excruciating pain and
discomfort.
Stone in renal pelvis
1. Intense, deep ache in costovertebral region
2. Hematuria and pyuria
3. Pain radiates anteriorly and downward toward bladder in female and
toward teste in male
4. Acute pain, nausea, vomiting, costovertebral area tenderness(renal
colic)
5. Abdominal discomfort, diarrhea.
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12. Clinical Manifestation
Ureteral colic stones lodged in ureter
1. Acute, excruciating, colicky, wavelike pain, radiating down the high to the
genitalia
2. Frequent desire to void, but little urine passed; usually contains blood
because of the abrasive action of the stone (known as ureteral colic)
Stone lodged in bladder
1. Symptoms of irritation associated with urinary tract infection and
hematuria
2. Urinary retention, if stone obstructs bladder neck
3. Possible sepsis in infection preset with stone
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13. Diagnosis –urolithiasis
Most stone are radiopaque and can be detected
by radiography
1. Diagnosis is confirmed by kidney, ureter and
bladder KUB studies,
2. Intravenous urography or retrograde or
pyelography
3. Chemical analysis is performed to determine
stone composition
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14. Medical Management
Basic goal are eradicate the stone,
1. determine the stone type,
2. prevent nephron obstruction,
3. control infection and
4. relieve any obstruction that may be present.
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15. Medical Management Cont’
Stone removed procedures
1. Cystoscopy examination and passage of small ureteral catheter
2. Chemical analysis of stones to determine composition
3. Extracorporeal shock wave lithotripsy (ESWL)
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16. 1. Percutaneous nephrostomy; endourologic
methods
2. Ureteroscopy: stone fragmented with use of laser,
electrohydraulic lithotripsies' or ultrasound and
then removed
3. Chemolysis (stone dissolution ): alternative for
those who are poor risk for other therapies, refuse
other methods, or have easily dissolved
stones(struvite)
4. Surgical removal is performed in only 1% to 2% of
patients
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Medical Management Cont’

17. Medical Management Cont’
Pharmacologic and nutritional therapy
• Analgesic agents(morphine or meperidine to prevent shock and syncope) and
nonsteroidal inflammatory drugs (NSAIDs)
• Increased fluid intake to assist in stone passage, unless patient vomiting
• Increased round-the-clock fluid intake to dilute urine and insure high urine output
• For calcium stones:
1. Reduced dietary protein and sodium intake;
2. Medications to acidity urine, such as ammonium chloride, sodium cellulose
phosphate (calcibind) and thiazide diuretics if parathormone production in
increased
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18. Medical Management Cont’
• For uric stones: low-purine and limited protein diet; allopurinol
(zyloprim);alkalization of urine.
• For cystine stones: low protein diet; alkalization of urine
penicillamine
• For oxalate stones: dilute urine; limit oxalate intake (green leafy
vegetables such as spinach; strawberries; rhubarb; wheat bran;
chocolate; tea and peanuts.
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19. Treatment and Procedures
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• Depending on the location of the stone, various procedures are
done for stone extraction
• In the kidney -ESWL or PNL or Open methods
• Pyelolithotomy for a stone in the extrarenal pelvis
– Nephrolithotomy for a stone deep into the renal parenchyma
– Partial nephrectomy if there is a stone impacted into the lower
most calyx
In the ureter
• Upper ureter: ESWL is ideal
• Mid ureter: ESWL, ureteroscopy or uretero lithotomy
• Lower Ureter: Ureteroscope or uretero lithotomy

20. Treatment and Procedures cont’s
• In the Bladder
- Litholopaxy: through a cystoscopy, the stone is grasped firmly
and broken. Small fragments are evacuated by evacuator
- Suprapubic cystolithotomy if the stone is too big or too hard
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22. Prevention
• High Fluid Intake
• Restrict Salt
• Avoid high intake of purine food
• Increased citrus fruits may help
• If hypercalciuria restrict Ca intake
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23. Nursing Process
• Assessment
1. Assess for pain and discomfort including severity location and radiation of pain
2. Assess for associated symptoms including nausea, vomiting. Diarrhea and
abdominal distention
3. Observe for signs of urinary tract infection (chills, fever, dysuria, frequency and
hesitancy) and obstruction (frequent urination of small amounts, oliguria or
anuria)
4. Observe urine for blood; strain for stones or gravel
5. Focus history on factors that predispose patient to urinary tract stones or that
may have precipitate current episode of renal or ureteral colic
6. Assess patient’s knowledge about renal stone and measures to prevent
recurrence.
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24. Nursing Process
• Nursing diagnosis
Acute pain related to inflammation, obstruction and abrasion of
urinary tract
Knowledge deficient regarding prevention of recurrence of renal
stones
 Collaborative problems/potential complications
Infection and sepsis ( from urinary tract infection and pyelonephritis)
Obstruction of urinary tract by stone or edema with subsequent
acute renal failure
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25. Nursing Process
 Planning and goal
• Major goals may include relief of pain and discomfort, prevention of
recurrence of renal stones and prevent complications.
 Nursing interventions
• Relieving pain includes analgesics as prescribed. Suggest hot baths or
applications of moist heat to flank areas. Assist for Comfortable position.
• Monitoring and managing complications
• Promoting home and community based care ‘’teaching patients self care’’
• Providing home and follow-up care
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26. Nursing process
• Evaluation
Patient’s Expected outcomes are:
• Reports relief of pain
• Experiences no complications
• State increased knowledge of health-seeking behavior to prevent
recurrence
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28. References
• Smelter S.C.,Bare B.G.,(Brunner and suddarths Medical-surgical
Nursing ,.lippencot
• Lewis S.W., Heitkemper M.M., Dirkson S.R., Medical Surgical Nursing
Assessment And Management of clinical problems
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