This document provides information about urinary calculi (kidney stones) for nursing students. It defines urinary calculi and where stones can form in the urinary tract. Risk factors, clinical features, pathophysiology, diagnostic tests, and medical, surgical, and nursing management of urinary calculi are described in detail. The objectives are for students to understand urinary calculi, risk factors, features, pathophysiology, diagnosis, and multidisciplinary management. Prevention strategies such as adequate fluid intake and dietary modifications are also covered.

1. Urinary calculi

3. General objective
• At the end of the session, B.Sc. Nursing 3rd year students will
be able to explain about urinary calculi.

4. Specific objectives
• At the end of the session, B.Sc Nursing 3rd year students will
be able to :
• introduce urinary calculi.
• list out the predisposing factors of urinary calculi.
• state the clinical features of urinary calculi.
• describe the pathophysiology of urinary calculi.

5. Specific objectives
• state the diagnostic procedure of urinary calculi.
• describe the medical management of urinary calculi.
• state the surgical management of urinary calculi.
• describe the nursing management of urinary calculi.

6. Introduction
• Urolithiasis (urinary calculi) refers to the presence of stones in the
urinary tract.
• Calculi are formed primarily in kidney but can form anywhere in
urinary system.
• Nephrolithiasis (renal stone) is the condition of having calculi in the
kidney.

7. Contd…
• Cystolithiasis (bladder stone) is presence of stone in the
bladder.
• Ureterolithiasis (ureteric stone) is presence of stone in the
ureter.
• Stones are formed by crystallization of substances that are
present in urine such as: calcium oxalate, calcium phosphate,
cystine and uric acid.

8. Predisposing factors
• Anatomical anomalies: ureteral stricture, horseshoe kidney

9. Contd…
• History of renal calculi (family/personal)
• Prolonged placement of indwelling catheters.
• Low fluid intake and dehydration.
• Deficiency of substances that prevents crystallization in the urine
such as citrate.

10. Calculus around Foley catheter

11. Contd…
• Urinary stasis
• Hypercalciuria
• Excess use of food rich in oxalate e.g spinach, chocolate, tea, coffee,
sweet potatoes, beetroot, peanuts etc.
• History of repeated urinary tract infection.
• Long term use of antacids, vitamin D, calcium etc.

12. Pathophysiology
Supersaturation of urine with increase solute
Formation of crystals
Crystals aggregates to form layer particles
Particle travel down and trapped in narrow point

13. Becomes nidus for stone formation
Further aggregation of solute particles to the crystals if
absence of inhibitory mechanism
Further enlargement of the stone

14. Clinical features
• Renal stone :
Pain (renal colic) deep ache originate in costo-vertebral
region and radiates down toward testicle in male and bladder
in the female.
 Pain is associated with nausea and vomiting.

15. Costo-vertebral angle

16. Contd…
BP and pulse is elevated during acute pain.
Hematuria, pyuria.
Fever with chills, burning micturition if infection present .

17. Contd…
• Ureteric stone:
Pain (ureteric colic) acute excruciating, colicky wave like pain
radiating down the thigh and to the genitalia.
Desire to void but little urine is passed.
Hematuria

18. Contd…
• Bladder stone :
Dysuria, urgency, interrupted stream, dribbling of urine .
Hematuria
Discomfort in suprapubic region.
Urinary retention if the stone obstruct bladder neck.

19. Diagnostic Evaluation
1. History taking and physical examination
2. Urine analysis : microscopic shows presence of crystals, pus
cells in urine and C/S to rule out infection.
3. Blood chemistry: serum calcium, uric acid, sodium, potassium,
renal function test (BUN, creatinine)

20. Contd…
4. Kidney ureter bladder (KUB) x-ray.
5. Stone analysis: to determine underlying cause and prevent the
recurrence of kidney stone.
6. Abdominal USG.
7. Intravenous pyelogram (IVP), retrograde pyelogram.
8. Cystoscopy

21. Medical management
• Administration of antibiotic for treatment of UTI .
• Treatment of underlying cause if any.
• Pain management
Opioids, NSAIDS, analgesics
Antispasmodic drugs

22. Contd…
• Moist heat application at flank area, diversion therapy.
• Increase fluid intake.
• Dietary modification.
• Drugs to decrease production of solutes e.g. allopurinol
10mg/kg/day in 2-3 divided dose for uric acid stones.

23. Surgical management
• Stone removal may be indicated as an emergency due to acute
obstruction or performed electively.
• The choice of modality for stone removal depends on the size,
number and location of stone.

24. 1.Extracorporeal shock wave lithotripsy(ESWL):
• Focuses on shock wave energy at the calculus. Stones are
broken into small dust that can be easily passed through urine.
• It is the preferred treatment in children with calculi below
20mm in size.
• Success rates are lower with hard cystine stones.

26. 2. Percutaneous nephrolithotomy (PCNL):
•It is a minimal invasive procedure to remove stones from the
kidney by small puncture wound (1cm).
•Stones above 1.5 cm or lower pole stone above 1cm can
benefit with PCNL.
•Used for calculi that cannot be safely removed by other
methods such as ESWL.

27. Percutaneous nephrolithotomy

28. 3. Ureteroscopic Lithotripsy (URSL)
• Uses a small lighted viewing scope (ureteroscope) to examine
the ureters.
• Ureteroscope is a small rigid tube with tiny light and camera on
head.

29. Ureteroscopic Lithotripsy

30. Open Surgical Procedures
1. Nephrolithotomy
• It is invasive method to remove stone from kidney by using incision
of 10-15 cm.
• It is most suitable to remove stones of more than 2 cm in size which
are nearer the pelvic region.

31. Contd…
2. Pyelolithotomy
• It is the removal of stone from the renal pelvis (funnel shape area).
• It is done through a 10-15 cm incision in the flank area which expose the
position of stone.

32. Contd…
3. Ureterolithotomy
• It refers to surgical removal of stone from the ureters.
• Stent is placed in the ureter to keep ureter open.

33. Contd…
4. Cystolithotomy
• It is typically performed to remove large and multiple stones in bladder.
• First step is to examine bladder through cystoscope.
• Then, an incision is made in lower abdomen to remove stone.

34. Contd…
5. Nephrectomy
• It is the surgical removal of kidney or its part.
• Types of nephrectomy:
Partial nephrectomy
Total nephrectomy

35. Contd…
• Chemolysis:
Stone dissolution using infusion of chemical solution e.g. alkylating
agents (uric acid stone), acidifying agents (calcium stone).

36. Nursing management
• Assess risk factor, pain, and associated symptoms like nausea,
vomiting, features of obstruction, symptoms of UTI.

37. Preoperative nursing diagnosis
• Acute pain related to kidney injury by the stone.
• Impaired urinary elimination related to bladder obstruction.
• Parental knowledge deficit related to surgical procedure

38. Post operative Nursing Diagnosis
• Acute pain related to surgical incision
• Deficient fluid volume related to nausea and vomiting.
• Impaired urinary pattern related to presence of indwelling catheter.
• Risk for infection.

39. Nursing Interventions
Relieving pain
• Assess the level of pain and its characteristics.
• Provide emotional support to the child and parents.
• Involve the child in diversional activities.
• Provide analgesics as prescribed by the doctor.

40. Maintaining urinary elimination
• Assess fluid intake/output of the child.
• Encourage fluids (3-4 litres/day) to promote increased excretion of
waste products before surgery unless contraindicated.
• Observe for bloody urine (hematuria).
• Catheterize if needed.
• Provide catheter care (ensure patency and position).

41. Maintaining fluid volume
• Monitor urine output, heart rate, blood pressure.
• Assess sign of dehydration (skin turgor, mucous membrane).
• Provide adequate fluids (ORS, juices, soups, water).
• Provide IV fluid and blood replacement after surgery as necessary.

42. Provide parental teaching
• Current status of child and treatment plan
• Nutrition
• Medicines (if any) follow up
• Prevention of infection
• Measures to prevent recurrent renal stone: not to hold urine for long time,
adequate fluid intake, dietary precautions according to type of renal stone

43. Reducing Infections
• Assess for signs of infections.
• Avoid unnecessary exposure to other people.
• Use strict medical and surgical asepsis while providing care.
• Proper hand washing should be done and taught to patient and family
members.
• Encourage use of face mask, gloves, gown for care givers.
• Complete the treatment regimen of UTI.

44. Prevention
• Encourage adequate fluid intake of child to prevent urinary stasis.
• Instruct to avoid holding of urine and encourage to void frequently.
• Dietary modification according to type of stone.
• Low animal protein (red meat, organ meat) intake if uric acid stone.
• Limit oxalate intake in diet like spinach, asparagus, cabbage, tomatoes,
chocolate etc. if oxalate stone.
• Do not exceed calcium intake 1200-1500 mg/day.

45. References
• Black, J.M., & Hawks, J.H. (2005). Medical Surgical Nursing (8th ed).
St.Louis, MO: Saunders/Elsvier.
• Datta, P. (2009). Pediatric nursing (2nd ed). New Delhi: Jaypee
Brothers.
• Ghai, O.P. (2009). Essential Pediatrics (7th edition). New Delhi: CBS
Publishers, 502-504
• Shrestha, T. (2016). Essential Child Health Nursing (2nd ed).
Kathmandu, Nepal: Medhavi Publication, 512-517