Renal calculi, or kidney stones, form when minerals and salts crystallize and stick together in the kidneys. Kidney stones affect 1 in 11 people in the United States and can cause sharp, severe pain as they move through the urinary tract. Treatment depends on the size and location of the stone and may involve increased fluid intake to pass small stones, medications to treat infections or alter urine chemistry, or surgical procedures like lithotripsy to break up larger stones. Nursing care focuses on pain management, monitoring urine output, educating patients on preventative measures like fluid intake and diet changes, and checking for complications.

1. Renal calculi
Presented by
Ms Jinumol Jacob
2nd Year M.sc Nursing Student
NUINS

2. INTRODUCTION
Kidney stones (renal lithiasis, nephrolithiasis) are hard deposits made of
minerals and salts that form inside in the kidneys. Kidney stones have many
causes and can affect any part of urinary tract from kidneys to bladder. stones
form when the urine becomes concentrated, allowing minerals to crystallize
and stick together. Passing kidney stones can be quite painful, but the stones
usually cause no permanent damage if they're recognized in a timely fashion.

3. .

4. definition
• Renal Calculi or Nephrolithiasis is the formation of stone in the kidney.
( Ignatavicius)
• Kidney stones (renal lithiasis, nephrolithiasis) are hard deposits made of minerals
and salts that form inside in the kidneys.
( Mayo clinic)
• A kidney stone is a hard object that is made from chemicals in the urine. The stone-
forming chemicals are calcium, oxalate, urate, cystine, xanthine, and phosphate.
(National kidney foundation )

5. INCIDENCE
• In the United States, kidney stone affects 1 in 11 people .
• it is estimated that 600,000 Americans suffer from urinary stones every
year.
• In Indian population, about 12% of them are expected to have urinary
stones and out of which 50% may end up with loss of kidney functions

6. ETIOLOGY
Exact etiology is unknown.
 High urine acidity.
Increased urine alkalinity.
Obstruction with urinary stasis
UTI with urea – splitting bacteria ( proteus , klebsiella , pseudomonas.)

7. Risk factors
• Metabolic factors such as increased urine level of calcium , oxalate, uric
acid or citric acid etc.
• Climatic factors such as warm climates that cause increased fluid loss,
low urine volume and increased solute concentration in urine.
• Dietary factors such as excessive amount of tea or fruit juices that
elevate urinary oxalate level.
• Low fluid intake that increases urinary concentration.
• Genetic factors such as family history of stone formation, cystinuria etc.
• Life style factors .

8. Location of stones
• Kidney
• Ureter
• Bladder
• Urethra

9. TYPES OF STONES
• Calcium stone
• Oxalate stone
• Cysteine stone
• Struvite stone

10. • Calcium stone
• Mainly include calcium oxalate and calcium phosphate stone
• Most stones (75%) are composed mainly of calcium oxalate crystals.
• Increased calcium concentrations in blood and urine promote
precipitation of calcium and formation of stones.
• Causes of hypercalcemia (high serum calcium) and hypercalciuria (high
urine calcium) includes Hyperparathyroidism ,Renal tubular acidosis ,
Excessive intake of vitamin D , Excessive intake of milk etc.

11. Uric acid stones
• 5% to 10% of all stones
• Gout, acidic urine leads to formation of uric acid stone
• Diet high in purines such as Alcoholic beverages, seafood and shellfish,
including anchovies, sardines, mussels etc.
• abnormal purine metabolism.

12. Struvite stones
• 15% of urinary calculi
• form in persistently alkaline, ammonia-rich urine
• caused by the presence of urease splitting bacteria such as Proteus,
Pseudomonas, Klebsiella, Staphylococcus, or Mycoplasma species.
• Predisposing factors for struvite stones (commonly called infection
stones) include neurogenic bladder, foreign bodies, and recurrent UTIs.

13. Cystine stones
• 1% to 2% of all stones
• occur in patients with a rare inherited defect in renal absorption of
Cystine (an amino acid) and those who with acidic urine.

14. Continue……

15. CLINICAL FEATURES
• A kidney stone usually remains symptomless until it moves into the ureter. When
symptoms of kidney stones become apparent, they commonly include:
• Sharp severe pain in the groin and/or side which results from the stretching, dilating
and spasm of the ureter.
• Hematuria
• vomiting and nausea
• White blood cells or pus in the urine
• Reduced amount of urine excreted
• Burning sensation during urination
• Persistent urge to urinate
• Fever and chills if there is an infection

16. Pain
• Stones in the renal pelvis may be associated with an intense, deep ache
in the costovertebral region. Pain originating in the renal area radiates
anteriorly and downward toward the bladder in the female and toward
the testis in the male.
• if the pain suddenly becomes acute, with tenderness over the
costovertebral area, and nausea and vomiting appear termed as renal
colic

17. Continue..
• Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating,
colicky, wavelike pain, radiating down the thigh and to the genitalia .It is
called ureteral colic .
• Colic is mediated by prostaglandin E, a substance that increases ureteral
contractility and renal blood flow and that leads to increased intraureteral
pressure and pain.
• If the stone present in the bladder and obstruct the urine flow, produces the
pain at suprapubic region along with bladder distension.

18. Hematuria
• Hematuria is often present because of the abrasive action of the stone.
Dysuria
• Painful micturition is termed as dysuria.
• Obstruction in urine flow tend to cause the dysuria.
Edema
• When the stones block the flow of urine, obstruction develops,
producing an increase in hydrostatic pressure and distending the renal
pelvis and proximal ureter.
• Thereby GFR decreases leads to sodium and water retention and gives
rise to edema.

19. Pyuria
• Obstruction in urine flow, urinary retention and urinary stasis may cause the UTI and
featured as pyuria.
Associated symptoms
• Nausea, vomiting, diarrhea, abdominal discomfort.
Features of infection
• Chill
• high grade fever
• dysuria

20. Continue…

21. DIAGNOSTIC MEASURES
• History collection
• General physical examination
• Urine culture
• Urine analysis
• Intravenous pyelography
• Ultra sound or CT Scan
• Blood investigations

22. Continue..
• Urine analysis
• Haematuria and pyuria
• pH lesser 5.5 indicates uric acid stone
• pH greater 7.5 indicates struvite stone
• urine culture and drug sensitivity should done to detect infection.
• 24-hour urine test for measurement of calcium, uric acid, creatinine, sodium, citrate
and oxalate.

23. CONTINUE..
•Blood studies
• Hyperuracemia
• Hypercalcemia
• Neutrophilia
• Elevated serum parathyroid hormone

24. CONTINUE..
Stone chemistry
• Collection of stone through a strainer is useful.
• Analyze the stone chemically to find out the composition which helps in
therapeutic management.

25. MANAGEMENT
• General Principles
• If small stone (< 4 mm) will be able to treat as outpatient,80% will
pass stone spontaneously with hydration.
• Hospitalized for intractable pain, persistent vomiting, high-grade
fever, obstruction with infection.
• Medical management
• Surgical management
• Nursing management

26. Medical management
Goal-
Immediate goal-
• To relieve the pain until its causes can be eliminated.
Long term goal (basic goal)-
• To eradicate the stone
• To determine the stone type
• To prevent nephron destruction
• To control infection
• To relieve any obstruction

27. CONTINUE..
• Opioid analgesics or NSAIDs are administered to prevent shock and
syncope that may result from the excruciating pain.eg Tramadol
• NSAIDs provide specific pain relief because they inhibit the synthesis of
prostaglandin E.
• Most stones are 4mm or less in size and probably pass spontaneously.
• Hot baths or moist heat to the flank areas may also be useful.

28. CONTINUE…
• Fluids are encouraged. This increases the hydrostatic pressure behind
the stone, assisting it in its downward passage.
• A high, around-the-clock fluid intake reduces the concentration of
urinary crystalloids, dilutes the urine, and ensures a high urine
output.
• Calcium stone
• Cellulose sodium phosphate (Calcibind) may be effective in
preventing calcium stones.
• It binds calcium from food in the intestinal tract, reducing the amount
of calcium absorbed into the circulation.

29. CONTINUE…
• Restrict calcium in diet
• Therapy with thiazide diuretics may be beneficial in reducing the calcium
loss in the urine and lowering the elevated paratharmone levels.
• The urine may be acidified by use of medications such as ammonium
chloride or aceto-hydroxamic acid.
• Sodium and protein restriction diet.

30. CONTINUE…
Uric acid stone
• Purine diet such as shellfish, anchovies, asparagus, mushrooms, and
organ meats are avoided.
• Allopurinol may be prescribed to reduce serum uric acid levels and
urinary uric acid excretion.
• Proteins may be limited in diet

31. CONTINUE…
Cystine stone
• Low-protein diet
• Penicillamine is administered to reduce the amount of cystine in the
urine.
Struvite stones
. Control of infections by using antibiotic therapy. Eg Acetohydroxamic
acid

32. others
• Tamsuloin or terazosin , ∝ - adrenergic blockers is administered (that relax the
smooth muscle in the ureter can be used to facilitate the stone passage.)
• Adequate hydration should be maintained
• dietry changes changes should be made ( sodium , potassium, calcium, purines
should be limited in cusines)

33. Surgical management
Indications
• Stones are too large for spontaneous passage. ( usually greater than 7mm).
• Stones associated with bacteruria or symptomatic infections.
• Stones causing impaired renal functions.
• Stones causing persistent pain , nausea.
• Inability of patient to treat medically.
• Patients with only one kidney.

34. CONTINUE….
• Nephrolithotomy – Incision into the kidney to remove the stone.
• Pyeloilthotomy - Incision on the renal pelvis for the stone removal.
• Ureterolithotomy - Removal of stone from the ureter,
• Cystotomy - Indicated for bladder calculi
• Cystolitholapaxy - an instrument is inserted through the urethra into
the bladder, and the stone is crushed in the jaws of this instrument

35. Percutaneous Nephrolithotomy
• This is the removal of stone in the kidney through the skin.
• Patient lies in prone position
• Urologist identifies the ideal entry point with fluoroscopy and then passes a
needle into the collecting system of the kidney.
• Once tract has been made in the kidney, other equipment such as an
intracorporeal ultrasonic or laser lithotriptor can be used to break up and
remove the stone.

36. Non surgical management
• Ureteroscopy
• Lithotripsy
• Endoscopic procedures
• Electrohydrolic lithotripsy
• Chemolysis

37. Ureteroscopy
• Ureteroscopy involves visualizing the stone and then destroying it.
• Access to the stone is accomplished by inserting a ureteroscope into the
ureter and then inserting a laser, electrohydraulic lithotriptor, or
ultrasound device is inserted through the ureteroscope to fragment and
remove the stones.
• A stent may be inserted and left in place for 48 hours or more after the
procedure to keep the ureter patent.

38. LITHOTRIPSY
Lithotripsy is a procedure used to eliminate calculi from the urinary tract.
Lithotripsy technique includes
• Laser Lithotripsy.
• Extracorporeal shock – wave lithotripsy ( ESWL).
• Percutaneous ultrasonic lithotripsy.
• Electrohydraulic lithotripsy.

39. Laser lithotripsy
• Used to fragment urethral and large bladder stones.
• To access urethral stones , a ureteroscope is used to get close to the stone.
• A small fiber is inserted up the ureteroscope( tip which emit laser energy) can
come in contact with stone.
• The intense energy break the stone into small pieces which can excreated or
flushed out.
• Usually done under general anaesthesia.

40. Continue…

41. Extracorporeal shock – wave lithotripsy (ESWL).
• ESWL is a noninvasive procedure used to break up stones in the calyx of the kidney
• In ESWL, a high-energy amplitude of pressure, or shock wave, is generated by the abrupt release of
energy and transmitted through water and soft tissues.
• When the shock wave encounters a substance of renal stone, a compression wave causes the
surface of the stone to fragment.
• Repeated shock waves focused on the stone eventually reduce it to many small pieces. These small
pieces are excreted in the urine, usually without difficulty.

42. ESWL

43. PERCUTANEOUS ULTRASONIC LITHOTRIPSY
• An ultrasonic probe is placed in the renal pelvis via a percutaneous nephroscope
inserted through a small incision in the flank and is then positioned against the
stone.
• The patient is given general or spinal anaesthesia for this procedure.
• The probe produces ultrasonic waves , which break the stone into sandlike particles.

44. CONTINUE…

45. Electrohydraulic lithotripsy
• An electrical discharge is used to create a hydraulic shock wave to break up
the stone.
• A probe is passed through the cystoscope, and the tip of the lithotripter is
placed near the stone.
• This procedure is performed under topical anesthesia.
• Continous saline irrigation flushes out the stone particles and all of the
outflow drainage is strained, so that the particles can be analyzed.
• The calculi can also be removed by basket extraction.

46. CONTINUE….

47. Chemolysis
• Chemolysis,is the stone dissolution using infusions of chemical
solutions (eg, alkylating agents, acidifying agents)
• A percutaneous nephrostomy is performed, and the warm irrigating
solution is allowed to flow continuously into the stone

48. NURSING DIAGNOSIS
• Acute pain related to effect of stones and inadequate pain relief
measures
INTERVENTIONS
1. Determine and note location, duration, intensity (0–10 scale), and
radiation.
2. Document nonverbal signs such as elevated BP and pulse, restlessness.
3. Implement comfort measures (back rub, restful environment).
4. Encourage use of focused breathing, guided imagery, divertsional
activities.
5. Apply warm compresses to back.
6. Check and sustain patency of catheters when used.

49. CONTINUE…
• Impaired urinary elimination related to trauma or obstruction of ureters or
urethra.
INTERVENTIONS
1. Determine patient’s normal voiding pattern and note variations.
2. Record I&O and characteristics of urine.
3. Promote sufficient intake of fluids.
4. Encourage the patient to walk if possible.
5. Irrigate with acid or alkaline solutions as indicated.
6. Check laboratory studies (electrolytes, BUN, Cr).
7. Obtain urine for culture and sensitivities.

50. CONTINUE…
• Deficient knowledge related to unfamiliarity with information resources
and lack of experience with urinary stones.
Interventions
1. Recall and analyze disease process and future expectations.
2. Emphasize importance of increased fluid intake of 3–4L a day or as much
as 6–8 L a day.
3. Encourage patient to notice dry mouth and excessive diuresis and
diaphoresis and to increase fluid intake whether or not feeling thirsty.
4. Review dietary regimen, as individually appropriate.
5. Promote regular activity and exercise program.
6. Avoid the use of OTC drugs.
7. Identify signs and symptoms requiring medical evaluation (recurrent pain,
hematuria, oliguria).
8. Demonstrate proper care of incisions and catheters if present.

51. conclusion
Renal calculi are a common cause of blood in the urine (hematuria) and pain in the
abdomen, flank, or groin. They occur in one in 11 people at some time in their
lifetimes with men affected 2 to 1 over women. Development of the stones is
related to decreased urine volume or increased excretion of stone-forming
components such as calcium, oxalate, uric acid, cystine, xanthine, and phosphate.

52. Research study
• A case–control study on environmental and biological risk factors for renal
calculi persisting in a coastal Union Territory, India.
• RESULTS
• Study conclude that in costal union territories of India, female gender, illiteracy, high BMI, high
sodium in drinking water, inadequate water consumption, borewell drinking water, soft-drink
consumption, sedentary work, and family history of renal stones can lead to a significant
increase in the risk of renal stone disease.

53. BIBLIOGRAPHY
• Ignatavicius, Linda workman ,Text book of “ Medical Surgical Nursing”Elsevier
Publications,united states,7th edition, 2nd Volume, Pg no : 1508 -1510.
• Lewis,Chintamani , “ Text book of Medical Surgical Nursing” Elsevier Publications , New
Delhi,3rd Edition, 2 nd Volume , Pg no : 1003 -1008.
• B.T Basuvanthappa,Text book of “Medical surgical Nursing” Jaypee Publications , New Delhi ,
3rd Edition, volume – II , Pg no : 1152 -1154.