Renal calculi

RENAL CALCULI
Neelu Aryal
Msc Nursing 2nd
Year
1

CONTENTS
 Definition
 Incidence
 Etiology
 Risk factors
 Types of renal stones
 Pathophysiology
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CONTENTS(CONTD…)
 Clinical manifestations
 Diagnostic studies
 Complications
 Medical management
 Surgical management
 Nursing management
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DEFINITION
 Renal calculi also known as urolithiasis is a
kidney stone disease where a solid piece of
material (kidney stone) occurs in the urinary
tract.
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INCIDENCE
 Between 1% and 15% of people globally are
affected by kidney stones at some point in their
life. In 2013, 49 million cases of occurred,
resulting in about 15,000 deaths.
 In United States the incidence of urinary stone
disease is highest in the Southeast and
Southwest, followed by the Midwest.
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INCIDENCE(CONTD…)
 Except for struvite (magnesium ammonium
phosphate) stones associated with UTI, stone
disorders are more common in men than in
women.
 The majority of patients are between 20 and 55
years of age.
 Stone formation is more frequent in whites than
in African Americans.
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INCIDENCE(CONTD…)
 The incidence is also higher in persons with a
family history of stone formation.
 Recurrence of stones can occur in up to 50% of
patients.
 Stone formation occurs more often in the
summer months, thus supporting the role of
dehydration in this process.
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ETIOLOGY
 Supersaturation of urine: Crystals, when in a
supersaturated concentration, can precipitate
and unite to form a stone. Keeping urine dilute
and free flowing reduces the risk of recurrent
stone formation in many individuals. It is known
that a mucoprotein is formed (the matrix for the
stone) in the kidneys that form stones.
 Urinary PH, solute load, and inhibitors in the
urine affect the formation of stones. The higher
the PH (alkaline), the less soluble are calcium
and phosphate. The lower the PH (acidic), the
less soluble are uric acid and cystine.
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 Obstruction with urinary stasis and urinary tract
infection with urea-splitting bacteria (e.g.,
Proteus, Klebsiella, Pseudomonas, and some
species of staphylococci) is also the factor for
development of stones. These bacteria cause the
urine to become alkaline and contribute to the
formation of struvite stones.
 Lack of inhibitors increases risk of stone
formation. Inhibitor substances, such as citrate
and magnesium, appear to keep particles from
aggregating and forming crystals.
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 Certain medications may induce calculus
formation, such as acetazolamide, absorbable
alkalis (e.g., calcium carbonate and sodium
bicarbonate), and aluminum hydroxide.
 Massive dose of vitamin C increases urinary
oxalate levels.
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RISK FACTORS
It includes anything that either causes stasis or
supersaturation of the urine:
 Immobility and sedentary lifestyle, which
increase stasis.
 Dehydration, which leads to supersaturation.
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RISK FACTORS(CONTD…)
 Metabolic disturbances that result in an increase
in calcium or other ions in the urine.
 Previous history of urinary calculi.
 Living in stone-belt areas (there is an increased
risk of calculus formation in the southeast part of
the United States- an area known as “the stone
belt”, men between ages 30 and 50 years have
three times the risk of calculi).
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 High mineral content in drinking water.
 A diet high in purines, oxalates, calcium
supplements, animal proteins.
 UTIs
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 Prolonged indwelling catheterization.
 Neurogenic bladder
 History of female genital mutilation.
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TYPES OF RENAL STONE
The stones may be of one crystal type or a
combination of types.
 Calcium oxalate
 Calcium phosphate
 Struvite
 Uric acid
 Cystine
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CALCIUM OXALATE
 Incidence (%): 35-40
 Color: Black/dark brown
 Sensitivity: Radio-opaque
 Characteristics: Small, often possible to get
trapped in ureter; more frequent in men than in
women.
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 Predisposing Factors: Idiopathic hypercalciuria,
hyperoxaluria, independent of urinary pH,
family history.
 Therapeutic Measures:
-Increase hydration.
-Reduce dietary oxalate.
-Give thiazide diuretics.
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-Give cellulose phosphate to chelate calcium and
prevent GI absorption.
-Give potassium citrate to maintain alkaline urine.
-Give cholestyramine to bind oxalate.
-Give calcium lactate to precipitate oxalate in GI
tract.
-Reduce daily sodium intake.
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CALCIUM PHOSPHATE
 Color: Dirty white
 Sensitivity: Radio opaque
 Characteristics: Mixed stone (typically), with
struvite or oxalate stones.
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 Predisposing factors: Alkaline urine, primary
hyperparathyroidism
 Therapeutic measures: Treat underlying causes
and other stones.
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STRUVITE (MAGNESIUM
AMMONIUM PHOSPHATE)
 Incidence (%): 10-15%
 Color: Dirty white
 Sensitivity: Radio opaque
 Characteristics: Three to four times as common
in women as men; always in association with
urinary tract infections; large staghorn type
(usually)
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 Predisposing factors: Urinary tract infections
(usually Proteus organisms)
 Therapeutic measures:
-Administer antimicrobial agents,
acetohydroxamic acid.
-Use surgical intervention to remove stone.
-Take measures to acidify urine.
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URIC ACID
 Color: Yellow/reddish brown
 Sensitivity: Radiolucent
 Characteristics: Predominant in men, high
incidence in Jewish men.
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 Predisposing factors: Gout, acid urine, inherited
condition
-Reduce urinary concentration of uric acid.
-Alkalinize urine with potassium citrate.
-Administer allopurinol.
-Reduce dietary purines.
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CYSTINE
 Color: Pink/Yellow
 Sensitivity: Radio-opaque
 Characteristics: Genetic autosomal recessive
defect; defective absorption of cystine in GI tract
and kidney, excess concentrations causing stone
formation.
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 Predisposing factors: Acid urine
-Increase hydration.
-Give α- penicillamine and tiopronin to prevent
cystine crystallization.
-Give potassium citrate to maintain alkaline urine.
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PATHOPHYSIOLOGY
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PATHOPHYSIOLOGY
(CONTD…)
 Kidney stones are primarily made of a crystalline
components, which requires three major steps for
formation: nucleation, growth and aggregation.
 Nucleation starts or seeds the stone process and may be
initiated by a variety of materials such as protein, foreign
bodies or crystals.
 The initial crystal serves as the core for further growth
and aggregation.
 It is now believed that persons who form stones may
lack inhibitor substances in the urine that naturally slow
or inhibit stone formation.
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 Although it was once thought that a calcium-restricted diet
would reduce the risk of recurrent calcium stone formation,
studies have shown that in some patients a low-calcium diet
may increase the risk for recurrent stone formation.
 However both groups agree on the role of supersaturation.
Crystalization appears to be the primary factor in calculus
development from the following:-
 Supersaturation of urine with increased solutes.
 Matrix formation caused when mucoproteins bind to the mass
of the stone.
 Lack of inhibitors caused by increased or absent protectors
against stone formation.
 A combination of these conditions.
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CLINICAL MANIFESTATION
 The most characteristic manifestation of renal or
ureteral calculi is a sharp, severe pain of
sudden onset caused by movement of calculus
and consequent irritation. (depending on the site
of the stone, this pain may be either renal colic
or ureteral colic.
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CLINICAL
MANIFESTATION(CONTD…)
 Renal colic originates deep in the lumbar region
and radiates around the side and down towards
the testicle in the male and the bladder in the
female.
 Ureteral colic radiates towards the genitalia and
thigh.)
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 When the pain is severe, the client usually has
nausea, vomiting, pallor, grunting respirations,
elevated blood pressure and pulse, diaphoresis
and anxiety.
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CLINICAL
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 Some people, especially those with bladder
stones, experience manifestations of urgency,
frequency, hematuria and chronic cystitis.

CLINICAL
 Pressure against the bladder neck during
micturation (voiding) may cause a heavy feeling
in the suprapubic region, obstruction in voiding,
a decreased bladder capacity, and an intermittent
urinary system.
 If the stone enters the urethra, urine flow is
obstructed. The pain lasts for minutes to days and
can be somewhat resistant to opoid intervention.
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CLINICAL
 Pain may be intermittent, which usually means
that the stone has moved.
 Then, as the stone moves into a new obstruction
site, the pain returns. The pain subsides when the
stone reaches the bladder.
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CLINICAL
 Pain caused by renal stones is not always severe
and colicy. It may be dull or aching or may be
experienced as a heavy feeling.
 Sometimes, there may be no sensation, and the
first clue the client has is seeing blood in the
urine or hearing a “clink” against the toilet when
the stone passes.
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CLINICAL
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 Other manifestations of calculi include infection
with elevated temperature and white blood cell
(WBC) count and urine obstruction that causes
hydroureter, hydronephrosis, or both.

DIAGNOSTIC STUDIES
 A plain film of the abdomen and renal
ultrasound will identify larger, radiopaque
stones.
 An IVP or retrograde pyelogram is used to
localize the degree and site of obstruction or to
confirm the presence of a radiolucent stone, such
as a uric acid or cystine calculus. IVP should not
be performed in patients with renal failure.
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DIAGNOSTIC
STUDIES(CONTD…)
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 Ultrasonography can be used to identify a
radioopaque or radiolucent calculus in the renal
pelvis, calyx, or proximal ureter. It is less useful
when attempting to locate stones trapped in the
midureter.
 A CT scan may be used to differentiate a
nonopaque stone from a tumor.

DIAGNOSTIC
STUDIES(CONTD…)
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 Retrieval and analysis of stones are important in
the diagnosis of the underlying problem
contributing to stone formation.
 The patient’s serum calcium, phosphorus,
sodium, potassium, bicarbonate, uric acid, BUN
and creatinine levels are also measured.

DIAGNOSTIC
STUDIES(CONTD…)
 A careful history, including previous stone
formation, prescribed and OTC medications,
dietary supplements and family history of urinary
calculi, is useful.
 Measurement of urine pH is useful in the
diagnosis of struvite stones and renal tubular
acidosis (tendency to alkaline or high pH) and
uric acid stones (tendency to acidic or low pH).
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DIAGNOSTIC
STUDIES(CONTD…)
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 Patients who are recurrent stone formers should
undergo a 24-hour urinary measurement of
calcium, phosphorus, magnesium, sodium,
oxalate, citrate, sulfate, potassium, uric acid and
total volume.

COMPLICATIONS
 Complications occur as a result of untreated
obstruction.
 If urine flow is not reestablished, severe pain
and hydronephrosis with resultant kidney
failure may occur.
 In addition, stasis of urine increases the risk of
infection.
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MEDICAL
MANAGEMENT
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SURGICAL MANAGEMENT
• Endourologic Procedures
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 Depending on the position of the calculus,
cystoscopy may be done.
 Small stones may be removed transurethrally
with a cystoscope, ureteroscope, or
ureterorenoscope.
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 Additionally , one or two ureteral catheters or
stents may be inserted past the stone. From this
point, several different interventions are
appropriate.
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 The catheters may be left in place for 24 hours or
longer to drain urine trapped proximal to the
stone and to dilate the ureter, which may prompt
spontaneous movement of the calculus.
 Otherwise, the catheter may mechanically guide
the stone downward as it is removed.
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 At times, a continuous chemical irrigation may
be used to dissolve uric acid, struvite, and
cystine stones.
 Finally, an attempt may be made to manipulate
or dislodge the stone with a variety of special
catheters with loops and expanding baskets used
to snare the stone.
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 Larger stones may be crushed with an instrument
called a lithotrite (stone crusher) to facilitate
removal.
 Cystolitholapaxy is performed when a bladder
stone is soft enough to be crushed.
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 In cystoscopic lithostripsy, an ultrasonic
lithotrite is placed to pulverize the stone,
followed by extensive flushing of the bladder.
 Possible complications associated with this
procedure include hemorrhage, urinary
retension, infection, bladder perforation, and
possibly retained stone fragments.
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 A flexible ureteroscope, passed through a
cystoscope, is used to collect stones in the ureter.
 This procedure, called ureteroscopy, is used to
retrieve 4 to 5 mm stones or, combined with
ultrasonic lithotripsy, to remove fragments after
treatment.
 Minimal sedation or anesthesia is necessary, and
postoperative complications are usually few.
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 A flexible ureterorenoscope can be passed for
access to the entire upper urinary tract, including
the distal ureter and intrarenal collecting system
so that stones or lesions in the lower pole or
lateral calices can be reached.
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 A nephroscope may be inserted to retrieve free-
lying renal stones.
 The stone may be removed with alligator forceps
or a stone basket followed by irrigation.
 Electrohydraulic, laser, or ultrasound lithotripsy
may be completed through the nephroscope.
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 After this procedure, a nephrostomy tube
remains in place for 1 to 5 days. The client can
go home with it in place.
 Increased fluids are essential to achieve a urine
output greater than 3000ml.
 The tube is removed after diagnostic studies
determine that all stone fragments have been
removed.
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SURGICAL
MANAGEMENT(CONTD…)
Lithotripsy
Laser lithotripsy
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 A newer treatment for calculi is laser lithotripsy.
 Lasers are used together with a ureteroscope to
remove or loosen impacted stones.
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 Constant water irrigation of the ureter is required
to dissipate the heat.
 Complications resulting from the procedure are
the same as those of any endourologic
procedure.
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SURGICAL
 Extracorporeal Shock Wave Lithotripsy
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 It is the use of sound waves applied externally to
break up stones in the kidney or ureter.
 High-energy shock waves, aimed by
fluoroscopy, are transmitted to the stone.
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 The shock waves break the stones into small
fragments, which are passed or retrieved
endoscopically.
 The client may be strapped to a frame in a water
bath or secured on a table, depending on the type
of lithotripsy equipment used.
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 The client is usually offered conscious sedation
or general anesthesia.
 The procedure lasts 30 to 50 minutes with
administration of 500 to 1500 shock waves.
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 Cardiac monitoring is required to synchronize
shock waves with the R waves to prevent cardiac
dysrhythmias.
 Complications include ecchymosis on the
affected flank, retained fragments, urosepsis,
perinephric hematoma and hemorrhage.
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 Stone fragments may bunch up in the distal
ureter, obstructing the kidney.
 To prevent this accumulation and obstruction, a
double J stent is commonly placed via
cystoscopy before ESWL for stones larger than 6
mm.
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 The stent is removed during a follow-up visit.
 After ESWL, the client may experience renal or
ureteral colic that needs to be treated with
antispasmodics.
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 Early ambulation and increased fluid intake are
important for flushing out stone fragments.
 The fragments may be passed for up to 3 months
after the procedure.
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SURGICAL
Percutaneous lithotripsy
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 It involves the insertion of a guide
percutaneously (through the skin) under
fluoroscopy near the area of the stone.
 An ultrasonic wave is aimed at the stone to break
it into fragments.
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SURGICAL
Open Surgical Procedure
 Ureterolithotomy
 Cystolithotomy
 Pyelolithotomy
 Nephrolithotomy
 A partial or total nephrectomy
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NURSING
MANAGEMENT
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NURSING MANAGEMENT OF
MEDICAL CLIENT
Nursing assessment
 Ask the client about any family history of
calculi, previous UTIs, immobility, and recent
dietary habits.
 For instance, a large intake of purines may be
significant, as would be drinking a large amount
of fruit juice or tea, which could cause oxalate
precipitation.
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NURSING ASSESSMENT(CONTD…)
 Assess the amount, pattern and types of fluids
consumed.
 Assess the client for the clinical manifestation as
described earlier.
 Use rating scales to measure the severity of pain.
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 Vital signs should be monitored.
 A decreasing blood pressure may indicate severe
pain and impending shock; increased pulse and
temperature may result from infection.
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 A sudden onset of little or no urine output
suggests obstruction, which is an emergency that
must be treated immediately to preserve kidney
function.
 Frequency and dysuria commonly occur when a
stone reaches the bladder.
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 All the urine voided should be strained through
several layers of gauze or through a commercial
urine strainer.
 Carefully examine all debris caught by straining.
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 Save any stone material so that the stone’s
composition can be analyzed as a basis for
treatment and to show how much has passed
through the urinary tract.
 A routine urinalysis, urine for culture and
sensitivity testing, and a 24 hour urine specimen
may be needed.
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NURSING
Nursing Diagnosis
 Acute pain related to irritation and spasm
from stone movement in the urinary tract.
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NURSING
Interventions
 During the acute phase of treatment, offer pain
medications, antispasmodics and antiemetics, if
necessary.
 For severe pain, give medications on a regular
schedule.
 Use rating scale to help evaluate the client’s
pain.
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Interventions contd…
 Once pain is controlled, the client should force
fluids and ambulate, which facilitates passage of
the stone.
 Relaxation techniques, such as guided imagery
or therapeutic or healing touch, can help relieve
pain.
 Help the client find a comfortable position to
alternate with ambulation.
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Nursing diagnosis
 Effective Therapeutic Regimen Management
related to prevention of recurrent calculi.
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Intervention
Increase Fluids
 Teach the client to drink 3 to 4 L of fluid daily to
flush the urinary system. At least half the fluid
consumed should be water. Intake should be as
consistent as possible throughout the 24-hour
period.
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Intervention(contd..)
 As a rule, encourage the client to drink a full
glass of water every hour during the day and two
glasses just before going to bed. This schedule
may create the need to void during the night, at
which time the client should drink another glass
of water.
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Intervention(contd…)
Teach stone prevention measures
 Teach the client about the measures to prevent
stone recurrence, such as diet modifications,
medications if required, and avoidance of
urinary stasis.
 Prompt treatment of UTIs and early recognition
of manifestations of stone recurrence are also
important.
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 Health promotion activities include frequent
turning and range of motion for immobilized
clients, increased fluid intake, and decreased
intake of stone-forming solutes in the diet, such
as oxalates, purines and animal proteins.
 Health maintenance interventions include
monitoring high-risk clients with indwellimg
cathers or obstructions for client.
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Nursing diagnosis
 Risk for injury related to postoperative
complications.(with any endourologic procedure,
lithotripsy, or surgery)
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Intervention
Increase fluids
 Increase the client’s IV or oral fluids to 3 to 4 L
daily as described earlier, unless contraindicated.
Monitor urine output
 Maintain the client’s urine output at 0.5 ml/kg/hr
or more.
 Assess any indications of hemorrhage, stone
retention, urinary retension, or infection.
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 As needed, irrigate the client’s bladder to wash
out possible stone fragments.
 Nursing care after a ureterolithotomy involve
care of a ureteral catheter.
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 Output of at least 0.25ml/kg/hr from the ureteral
catheter should be expected and closely
monitored.
 Because the renal pelvis holds only 5ml, ureteral
catheters must be kept patent (open) and are
never clamped.
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 Institute prompt intervention with any
unexpected reduction in urine flow.
 Several conditions-such as mucus shreds, blood
clots, and chemical sediment can interfere with
the flow of urine through these catheters.
 Pus, ureteral peristalsis occasionally pushes the
catheters out of the ureter into the bladder.
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 Closely monitor the catheter output. Each
ureteral, suprapubic, and urethral catheter should
drain into its own collection bag so that the
source of the reduced urine flow is noticed
immediately.
 Label each tube or bag.
 Measure and record the output of each catheter
every hour for the first 24 hours.
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 Output from each catheter should be monitored
every 4 to 8 hours until removal.
 Most of the urine will drain from the ureteral
catheters for the first 48-72 hours post-
operatively.
 As the inflammation decreases, urine flows
around ureteral catheters and is drained by the
urethral or suprapubic catheters.
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 Report a total urine output of less than 0.5
ml/kg/hr or a lack of output from ureteral
catheters for more than 15 minutes to the
physician immediately.
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 Use a strict sterile technique if the physician
orders ureteral catheter irrigation.
 A maximum of 3 to 5 ml of irrigating solution,
usually sterile saline solution, should be allowed
to flow in by gravity. Very gentle force should be
used.
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 Notify the physician immediately, if the patency
cannot be confirmed.
 Use extreme care to ensure that the catheter is
not disloged. If it is not sutured in place, secure
it carefully to the client’s skin with tape.
 Moniter carefully the drainage from
nephrostomy tube. Irrigation amouts, if ordered,
are no more than 3 to 5 ml.
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 Maintain sterile technique to prevent infection
because the tube goes directly into the kidney.
 Teach the client about any type of catheter care
(how to clean around them, empty them, prevent
kinking and irrigate them) before returning
home.
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BIBLIOGRAPHY
 Black JM, Hawks JH. Medical surgical
nursing.7th
ed.vol-1.Elsevier; p.882-90
 Lewis, Heitkemper, Dirksen O’Brien, Bucher.
Medical surgical nursing.7th
ed.New
Delhi.Elsevier;p.1169-73
 Monahan FD, Sands JK, Neighbors M, Marek
JF, Green CJ. Phipps’ Medical surgical nursing.
8th
ed. U.P.(India).Elsevier; p.977-81
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BIBLIOGRAPHY(CONTD…)
 URL:http://www.clinmed.rcpjournal.org/content/
12/5/467.long
 URL:https://en.wikipedia.org/wiki/Kidney_stone
_disease
 URL: http://study.com/academy/lesson/what-are-
renal-calculi-definition-causes-symptoms-
treatment.html
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