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Urolithiasis

Urolithiasis is the process of forming stones in the kidney, bladder, and/or urethra (urinary tract). Kidney stones (calculi) are formed of mineral deposits, most commonly calcium oxalate and calcium phosphate; however, uric acid, struvite, and cystine are also calculus formers. Although renal calculi can form anywhere in the urinary tract, they are most commonly found in the renal pelvis and calyces. Renal calculi can remain asymptomatic until passed into a ureter and/or urine flow is obstructed, when the potential for renal damage is acute.

There are four main types of kidney stones — calcium stones, uric acid stones, struvite stones and cystine stones.

Nursing Care Plans

Here are four nursing care plans for Urolithiasis.

1. Acute Pain

Nursing Diagnosis

  • Acute Pain

May be related to

  • Increased frequency/force of ureteral contractions
  • Tissue trauma, edema formation; cellular ischemia
  • Possibly evidenced by
  • Reports of colicky pain
  • Guarding/distraction behaviors, restlessness, moaning, self-focusing, facial mask of pain, muscle tension
  • Autonomic responses

Desired Outcomes

  • Report pain is relieved with spasms controlled.
  • Appear relaxed, able to sleep/rest appropriately.
Nursing Interventions Rationale
Determine and note location, duration, intensity (0–10 scale), and radiation. Document nonverbal signs such as elevated BP and pulse, restlessness, moaning, thrashing about. Aids to evaluate site of obstruction and progress of calculi movement. Flank pain suggests that stones are in the kidney area, upper ureter. Flank pain radiates to back, abdomen, groin, genitalia because of proximity of nerve plexus and blood vessels supplying other areas. Sudden, severe pain may precipitate apprehension, restlessness, severe anxiety.
Justify and clarify cause of pain and the need of notifying caregivers of changes in pain occurrence and characteristics. Provides opportunity for timely administration of analgesia (helpful in enhancing patient’s coping ability and may reduce anxiety) and alerts caregivers to possibility of passing of stone and developing complications. Sudden cessation of pain usually indicates stone passage.
Implement comfort measures (back rub, restful environment). Promotes relaxation, reduces muscle tension, and enhances coping.
Encourage use of focused breathing, guided imagery, diversional activities. Redirects attention and helps in muscle relaxation.
Assist with frequent ambulation as indicated and increased fluid intake of at least 3–4 L a day within cardiac tolerance. Renal colic can be worse in the supine position. Vigorous hydration promotes passing of stone, prevents urinary stasis, and aids in prevention of further stone formation.
Document reports of increased and persistent abdominal pain. Complete obstruction of ureter can cause perforation and extravasation of urine into perirenal space. This represents an acute surgical emergency.
Apply warm compresses to back. Relieves muscle tension and may reduce reflex spasms.
Check and sustain patency of catheters when used. Prevents urinary stasis or retention, reduces risk of increased renal pressure and infection.

2. Impaired Urinary Elimination

Nursing Diagnosis:

  • Urinary Elimination, impaired

May be related to

  • Stimulation of the bladder by calculi, renal or ureteral irritation
  • Mechanical obstruction, inflammation

Possibly evidenced by

  • Urgency and frequency; oliguria (retention)
  • Hematuria

Goals: 

  • Void in normal amounts and usual pattern.
  • Experience no signs of obstruction.
Nursing Interventions Rationale
Record I&O and characteristics of urine. Provides information about kidney function and presence of complications (infection and hemorrhage). Bleeding may indicate increased obstruction or irritation of ureter. Note: Hemorrhage due to ureteral ulceration is rare.
Determine patient’s normal voiding pattern and note variations. Calculi may cause nerve excitability, which causes sensations of urgent need to void. Usually frequency and urgency increase as calculus nears ureterovesical junction.
Encourage the patient to walk if possible. To facilitate spontaneous passage.
Promote sufficient intake of fluids. Increased hydration flushes bacteria, blood, and debris and may facilitate stone passage.
Offer fruit juices ,particularly cranberry juice. To help acidify urine.
Strain all urine. Document any stones expelled and send to laboratory for analysis. Retrieval of calculi allows identification of type of stone and influences choice of therapy.
Investigate reports of bladder fullness; palpate for suprapubic distension. Note decreased urine output, presence of periorbital and dependent edema. Urinary retention may develop, causing tissue distension (bladder, kidney), and potentiates risk of infection, renal failure.
Observe for changes in mental status, behavior, or level of consciousness. Accumulation of uremic wastes and electrolyte imbalances can be toxic to the CNS.
Maintain patency of indwelling catheters (urethral, urethral, or nephrostomy) when used. May be required to facilitate urine flow and prevent retention and corresponding complications. Note: Tubes may be occluded by stone fragments.
Irrigate with acid or alkaline solutions as indicated. Changing urine pH may help dissolve stones and prevent further stone formation.
Check laboratory studies (electrolytes, BUN, Cr). Elevated BUN, Cr, and certain electrolytes indicate presence and degree of kidney dysfunction.
Obtain urine for culture and sensitivities. Determines presence of UTI, which may be causing or complicating symptoms

3. Risk for Deficient Fluid Volume

Nursing Diagnosis

  • Risk for Deficient Fluid Volume

Risk factors may include

  • Nausea/vomiting (generalized abdominal and pelvic nerve irritation from renal or ureteral colic)
  • Post obstructive diuresis

Desired Outcomes

  • Maintain adequate fluid balance as evidenced by vital signs and weight within patient’s normal range, palpable
  • peripheral pulses, moist mucous membranes, good skin turgor.
Nursing Interventions Rationale
Monitor and document I&O and daily weight. Comparing actual and anticipated output may aid in evaluating presence and degree of renal stasis or impairment. Note: Impaired kidney functioning and decreased urinary output can result in higher circulating volumes with signs and symptoms of HF.
Note incidence and document characteristics and frequency of vomiting and diarrhea, as well as accompanying or precipitating events. Nausea and vomiting and diarrhea are commonly associated with renal colic because celiac ganglion serves both kidneys and stomach. Documentation may help rule out other abdominal occurrences as a cause for pain or pinpoint calculi.
Promote fluid intake to 3–4 L a day within cardiac tolerance. Maintains fluid balance for homeostasis and “washing” action that may flush the stone(s) out. Dehydration and electrolyte imbalance may occur secondary to excessive fluid loss (vomiting and diarrhea).
Monitor vital signs. Evaluate pulses, capillary refill, skin turgor, and mucous membranes. Indicators of hydration and circulating volume and need for intervention. Note: Decreased GFR stimulates production of renin, which acts to raise BP in an effort to increase renal blood flow.
Weigh daily. Rapid weight gain may be related to water retention.
Check Hb and Hct, electrolytes. Assesses hydration and effectiveness or need for interventions.
If patient can’t drink required amount of fluids, supplemental IV fluids may be given. Maintains circulating volume (if oral intake is insufficient), promoting renal function.
Encourage appropriate diet, clear liquids, bland foods as tolerated. Easily digested foods decrease GI activity and irritation and help maintain fluid and nutritional balance.
Administer medications as indicated Reduces nausea and vomiting.

4. Deficient Knowledge

Nursing Diagnosis

  • Deficient Knowledge regarding condition, prognosis, treatment, self-care, and discharge needs.

May be related to

  • Lack of exposure/recall; information misinterpretation
  • Unfamiliarity with information resources

Possibly evidenced by

  • Questions; request for information; statement of misconception
  • Inaccurate follow-through of instructions, development of preventable complications

Outcome Evaluation

  • Verbalize understanding of disease process and potential complications.
  • Correlate symptoms with causative factors.
  • Verbalize understanding of therapeutic needs.
  • Initiate necessary lifestyle changes and participate in treatment regimen.
Nursing Interventions Rationale
Recall and analyze disease process and future expectations. Provides knowledge base from which patient can make informed choices.
Emphasize importance of increased fluid intake of 3–4L a day or as much as 6–8 L a day. Encourage patient to notice dry mouth and excessive diuresis and diaphoresis and to increase fluid intake whether or not feeling thirsty. Flushes renal system, decreasing opportunity for urinary stasis and stone formation. Increased fluid losses or dehydration require additional intake beyond usual daily needs.
Review dietary regimen, as individually appropriate: Diet depends on the type of stone. Understanding reason for restrictions provides opportunity for patient to make informed choices, increases cooperation with regimen, and may prevent recurrence.
Low-purine diet Decreases oral intake of uric acid precursors.
Low-calcium diet Reduces risk of calcium stone formation. Note: Research suggests that restricting dietary calcium is not helpful in reducing calcium-stone formation, and researchers, although not advocating high-calcium diets, are urging that calcium limitation be reexamined.
Low-oxalate diet Reduces calcium oxalate stone formation.
Short regimen: low-calcium or phosphorus diet with aluminum carbonate gel 30–40 mL, 30 min pc or hs. Prevents phosphatic calculi by forming an insoluble precipitate in the GI tract, reducing the load to the kidney nephron. Also effective against other forms of calcium calculi. Note: May cause constipation.
Discuss medication regimen; avoidance of OTC drugs, and reading all product or food ingredient labels. Drugs will be given to acidify or alkalize urine, depending on underlying cause of stone formation. Ingestion of products containing individually contraindicated ingredients (calcium, phosphorus) potentiates recurrence of stones.
Promote regular activity and exercise program. Inactivity contributes to stone formation through calcium shifts and urinary stasis.
Active-listen concerns about therapeutic regimen and lifestyle changes. Helps patient work through feelings and gain a sense of control over what is happening.
Identify signs and symptoms requiring medical evaluation (recurrent pain, hematuria, oliguria). With increased probability of recurrence of stones, prompt interventions may prevent serious complications.
Demonstrate proper care of incisions and catheters if present. Promotes competent self-care and independence.

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