MANILA DOCTORS COLLEGE

COLLEGE OF NURSING

ASSIGNMENT IN FLUIDS AND ELECTROLYTES

RENAL CALCULI

Submitted by:
Alcantara, Karl
Belgira, Ma. Farah
Dela Peña, Melissa
Delos Santos, Bianca
Dorimon, Keith
Guinto, Alfred
Roncales, Rechel
Tiongson, Hilcon

BSNIIIA7 Group 1

Submitted to:
Mr. Ronaldrey Menor

March 4, 2010
RENAL CALCULI
 Objectives Content Learning Domain Evaluation
At the end of this lecture. RENAL CALCULI I. Renal Calculi I. Identification
The learner should be able ● To define Renal Calculi and its __________1. It is a hard, crystalline
to: components. mineral material formed within the kidney
I. DEFINITION ● To explain the etiologies/causes of renalor urinary tract.
● Identify the factors Renal Calculi is a hard, crystalline mineral material calculi. __________2. Calculi in the kidneys.
contributing to Renal formed within the kidney or urinary tract. Renal calculi ● To enumerated different types of renal __________3. The mineral crystals found
calculi are the common cause of blood in the urine and often calculi according to its components. in any part of urinary track.
__________4. What is the most common
severe pain in the abdomen, flank, or groin. Kidney
● Illustrate and explain the II. Pathophysiology fluid status of the patient that forms
athophysiology of the stones are sometimes called renal stones. ● To be able to explain properly the calculus?
disease Urolithiasis - condition of having calculi/stones at any functional changes associated with or __________5. Give one factor that can
location in the urinary tract resulting from disease. affect or slows the renal drainage.
● Identify and explain the Nephrolithiasis - condition of having kidney ● To be able to know the composition of
signs and symptoms calculi/stones urinary calculi II. Multiple Choice
● To be able to know the signs and 1. This is the most effective management
● Enumerate and explain the Etiologies of Renal Calculi symptoms that affect the person’s body by strategy for renal calculi:
different diagnosis used for ● Deficiency of substance that normally prevents the disease a. High protein diet
Renal Calculi crystallization in the urine, such as citrates, magnesium, ● To be able to understand why a person b. increase fluid intake
nephrocalcin, and uropontin. was affected by Renal Calculi c. Low oxalate diet
● Identify the causative ● To be able to know how Renal calculi
factors, People at risk and ● Dehydration or fluid volume status: renal calculus affects our body 2. This medication prevents excess
treatment of Renal calculi. occurs more often in dehydrated patients. ● To be able to explain and understand the calcium loads in the urine:
formation of calculi in the body a. Hydrochlorothiazide
● Apply health teachings to ● High calcium concentration in blood and urine can ● To be able to explain and understand the b. NSAIDS
prevent Renal Calculi. cause precipitation of calculi. Some other factors may disease process of renal calculi c. Oxybutynin chloride
favor formation of calculi. These factors slows renal
drainage and alters the calcium metabolism: III. Signs and Symptoms 3. Below are foods that contain oxalate
● To be aware in oral fluid intake except:
- Infections
● To administer diuretics as prescribed by a. strawberries
- Urinary stasis the physician b. mushroom
- Periods of long immobility ● To teach patient ways to prevent further c. spinach
complications such as to never ignore
Different types of Renal Calculi
● Calcium stones
● Uric acid stones
● Cystine stones
● Oxalate stones
Reference:
1. http://www.medicinenet.com/kidney_stone/article.htm
2. Brunner and Suddhart’s Textbook of Medical-Surgical
Nursing (pp1589-1594)
II. PATHOPHYSIOLOGY
The exact mechanism of stone formation has not been
clearly defined. Some researchers believe that a low
dietary calcium intake contributes, whereas others intnd
that a high calcium intake contribute. Both groups agree
in the role of super saturation, however, crystallization
appears to be the primary factor in calculus development
from the following:
● Super saturation of urine with increase solutes
● Matrix formation caused when muco proteins bind to
the mass of the stone.
● Lack of inhibitors caused by increased or absent
proteins against stone formation
● A combination of these conditions
In general, crystal growth involves nucleation, in which
crystals are formed from super saturated urine. Growth
continues by aggregation to form larger particles. One of
these particles may travel down the urinary tract until it
is trapped at some narrow point where stone formation VI. Surgical Management
occurs.
urgency to void
IV. Assessment and Diagnostic Findings
● To be able to know the assessment
parameters that could have an effect to
clients developing renal stones.
● To identify the different diagnostic
techniques regarding renal stones. Also,
it’s advantages and disadvantages.
V. Medical Management
● To know what nursing interventions are
to be given to the patient depends on a
specific complication.
● To have the knowledge about the
different medical management in treating
the said complication.
● To know what pharmacological
interventions should a nurse give to his/her
patient having a calculi / renal stones.
● To know the different medications in
relieving pain and preventing of excess
calcium loads in the urine
● To learn specific diet and medications in
every type of renal stones
● To know the interventional and non-
invasive procedures in treating renal stones
● To identify the surgical procedures done
4. This is a type of surgery wherein a laser,
ultrasonic and mechanical form of energy
is being used to fragment large stones:
a.Extracorporeal shock wave
lithotripsy(ESWL)
b. Ureteroscopic fragmentation
c. Percutaneous nephrolithotomy
5. What is the surgery done when an
incision is made into the kidney with
removal of stone?
a. Nephrectomy
b. Nephrolitothomy
c. Ureterolithotomy
6. What is the surgery done when the
stones are removed from the kidney
pelvis?
a. Nephrectomy
b. Nephrolitothomy
c. Pyelotithotomy
7. What surgery is done if the stones are
removed from the ureter?
a. Nephrectomy
b. Nephrolitothomy
c. Ureterolithotomy
8. When is surgical intervention indicated
for patients with renal calculi?
 in patients with renal calculi. a. When lungs are removed.
Inhibitor substances (citrate, pyrophosphate and b. It may be performed to correct
magnesium) have been identified as chelating agents. VII. nursing Management anatomic abnormalities within the
When present in adequate amount, they act to keep ● To relieve pain and discomfort
kidney
crystals from aggregating and forming stones. When ● To prevent recurrence of renal stones
inhibitors are absent, stone formation following crystal and absence of complication c. Whenever the patient just feels like to.
aggregation is more likely. Also, a fibrous matrix of
urinary organic material may form in the kidney or 9. What must be the first thing the nurse
bladder, producing a substance into which crystallite are should instruct to the patient who
deposited and trapped. This, then, become nidus of the underwent a surgical procedure for stone
stone. The excessive production of this may, in part, removal?
account for a family history of urolithiasis in clients with
a. Increase oral fluid intake
calculi.
b. Limit Sodium in the diet
Risk Factors: c. Signs and symptoms of complications
● Gender; especially male between 30-45 years old
● Immobility and sedentary lifestyle 10. Which of the following is not kind of
● Dehydration renal stone?
● Metabolic disturbances a. Cyctine
● Previous history of urinary calculi b. Calcium
● High mineral content in drinking water c. Pebble
● Living in stone-belt areas like Europe and Asia
● Gender; especially male between 30-45 years old 11. Which is not indicative of renal stones
in urinalysis?
a. Presence of WBC
Urinary stasis Supersaturation of b. Absence of crystal
urine with poorly c. Presence of RBC
soluble crystalloids
12. What do you need to assess before the
procedure IVP?
Increased soluble concentration occurs because of a. Assess for allergy
b. Full bladder
fluid depletion or an increased soluble load. c. BOTH
Precipitation of crystals
 13. What is the normal color of the urine?
a. Red
Abnormal pH occurs in renal tubular acidosis with b. Amber
the administration of carbonic annhydrase c. Gray-colored urine
inhibitors
14. What is the best indicator for
glomerular function?
a. Creatinine Clearance
Development of stones b. BUN
c. KUB Xray
Formation of calculi 15. Which of these foods would be
appropriate with a patient having
diagnosed with renal calculi?
Presence of precipitors has been noted in the urine a. Chicken adobo
b. Steamed chicken
Reference: c. Fried chicken
Medical-Surgical Nursing Clinical Management for
Positive Outcomes, 8th Ed., Joyce M. Black and Jane
Hokanson Hawks

III. SIGNS AND SYMPTOMS

Abdominal Pain
● Depending on the location of renal calculi, severe
abdominal or back pain that travels from the CVA to the
flank, suprapubic region, and external genitalia.
● The pain may be excruciating or dull and constant.
● Pain – induced agitation, nausea, vomiting, abdominal
distention, fever, chills, hypertension, and urinary
urgency with hematuria and dysuria may occur.
Back pain
● The colicky pain of renal calculi usually results from
irritation of peristaltic contractions.
● The pain travels from the costovertebal angle to the
flank, suprapubic region and external genitalia.
● Its intensity varies but may become excruciating if
calculi travel down a ureter.
● If calculi are in the renal pelvis and calyces, dull and
constant flank pain may occur.

Hematuria
● Renal calculi produce hematuria which may be
associatedwith UTI such as dysuria and urinary
frequency and urgency.
● Renal calculi may produce microscopic or gross
hematuria.
●The cardinal symptom, though, is colicky pain that
travels from the CVA to the flank, suprapubic region,
and external genitalia when a calculus is passed.
● Pain may be excruciating at its peak. Other signs
andsymptoms include nausea and vomiting, restlessness,
fever, chills, abdominal distention, and decreased bowel
sounds.

Reference: Brunner

IV. ASSESSMENT AND DIAGNOSTIC FINDINGS

Assessment
1. Heredity
● Some rare hereditary diseases also predispose some
people to form kidney stones. Examples include people
with renal tubular acidosis and people with problems
metabolizing a variety of chemicals including cystine (an
amino acid), oxalate, (a type of salt), and uric acid (as in
gout).

2. Geographical location
● The hot climate and poor fluid intake may cause people
to be relatively dehydrated, with their urine becoming
more concentrated and allowing chemicals to come in
closer contact to form the nidus, or beginning, of a stone.

3. Diet
● High in purines, calcium oxalate, and phosphate

4. Medications
● People taking diuretics (or "water pills") and those who
consume excess calcium-containing antacids can increase
the amount of calcium in their urine and potentially
increase their risk of forming stones. Taking excess
amounts of vitamins A and D are also associated with
higher levels of calcium in the urine.

5. Underlying illnesses
● Patients with HIV who take the medication indinavir
(Crixivan) can form indinavir stones.
● Cystic fibrosis, hypertension, gout, chronic UTI,
inflammatory bowel disease

Diagnosis
1.Urinalysis
● Commonly shows RBC, WBC, crystals, cast, mineral,
bacteria and pus.
● pH < 5: promotes cystine and uric acid stones
pH > 7.5: promotes struvite, calcium phosphate stones.
2. 24-hour urine collection
● Uric acid, calcium, phosphorus, oxalate, or cystine may
be elevated

3. Serum and Urine BUN/ Creatinine

● Abnormal (high in serum but low in urine)
● Secondary to high obstructive stone in kidneys causing
ischemia or necrosis

4. KUB X-ray
● Shows presence of calculi
● Can only detect calcium stones
● Can be done quickly and cheaply and are a quick,
inexpensive, and useful technique for monitoring growth
of a kidney stone.

5. Ultrasound U/S
● This test can detect both calcium and non-calcium
types of stones.
● Not a good test to find a stone that is suddenly passing
from the kidney through the ureter on its way to the
bladder.
● It is used by some for routine monitoring of new stones
or growth of old stones.
● It has the benefit of no radiation.

6. Computerized Tomography (CT or CAT Scan

● This is one of the best methods to detect kidney stones,
especially when someone comes to the emergency room
with severe pain (colic) due to a passing stone
● It can detect both calcium and non-calcium stone.
● It is more expensive than an xray and requires more
radiation.
● it can sometimes detect non stone causes of severe pain

7. Intravenous Pyelogram (IVP)

● This is one of the older techniques for detecting kidney
stone and still sometimes used.
● A special dye is injected into a vein. Then xrays are
taken of mid to lower abdomen.
● It is very useful for detecting stones in the ureter,
especially if not seen by CT scan. This sometimes
happens when the ureter is dilated/obstructed but no
stone is seen.
● One disadvantage is that the injected dye can cause
allergic reactions, usually temporary kidney damage, and
symptoms including nausea.
● If the patient has kidney disease other than stones,
sometimes it is better to perform a Retrograde Urogram.
In this test, a catheter is placed into the bladder and the
dye is injected to visualize the bladder and ureters for
stones. This technique avoids absorption of the dye
outside of the urinary tract.

8. CT Urography
● CT urography is a combination of CT and IVP.
● An injection of intravenous dye is given which outlines
the parts of the kidney, ureterers, and bladder where
urine collects. The images are viewed with a CT
scanner.
● This test is particularly helpful as a step in the
evaluation for blood in the urine (hematuria). It can
show causes other than just stones.

Reference:
1. http://www.scribd.com
2. http://www emedicinehealth.com
3. http:// www.mayoclinic.com
4. Medical-Surgical Nursing: Concepts and Clinical
Application, 2nd Ed. 2009, Udan

V. MEDICAL MANAGEMENT
Management of the Disease:
1. Analgesics
● To reduce the pain experienced by the patient.
Administer NSAIDS or opioids.
ROUTE:
Intravenously - emergency setting (acetaminophen)
Oral – effective for less severe discomfort

2. Antispasmodic agents
● Are very effective for relieving and controlling colic
pain associated with spasms of the utreter
ex. Oxybutynin chloride (Ditrophan)

3. Increased fluid intake

● This is the most effective management strategy
● It facilitate passage of small stones and to prevent the
development of a new ones

4. Thiazide Diuretics
● Such as hydrochlorothiazide (HydroDIURIL),
promotes calcium resorption from the renal tubules,
thereby preventing excess calcium loads in the urine
● Potassium citrate, this may also added with diuretic to
replace potassium as needed

5. Alpha adrenergic Blockers - may increase the

spontaneous passage of the stone by 30%.
6. Nutritional Therapy
● Plays an important role in preventing renal stones
● Below are the different stones with specific treatment
and diet:

a. Calcium stones
● Liberal fluid intake is encouraged along with dietary
restriction of protein and sodium
● High protein diet is associated with increased urinary
excretion of calcium and uric acid, thereby causing a
supersaturation of these substances in the urine
● Medications: ammonium chloride and thiazide
diuretics (to reduce the calcium loss in the urine and
lowering the elevated parathormone levels)

b. Uric acid stones

● Low protein diet is recommended to reduce the
excretion of uric acid in the urine
● Avoid high in purine foods (shellfish, anchioves,
asparagus, mushrooms and organ meats)
● Medication: Allopurinol (Zyloprim) to reduce serum
acid levels and urinary uric acid excretion

c. Cystine stones
● Low protein diet is prescribed, the urine is alkalinized
and fluid intake is prescribed

d. Oxalate stones
● Limitations of oxalate and dilute urine is maintained
● Foods that increase the urinary excretion of oxalate:
spinach, strawberries, rhubarb, chocolate, tea, peanuts
and wheat bran
Interventional Procedures:

1. Extracorporeal shock wave lithotripsy(ESWL)

- non-invasive treatment of kidney stones (urinary
calculosis) and biliary calculi (stones in the gallbladder
or in the liver) using an acoustic pulse or SHOCK
WAVE.
- it works by using shockwaves to disintegrate the stone.
The continuous exposure of the stone to shock wave it
gradually crush the stone into pieces making an easy
passage for the stone out from the kidney.

2. Ureteroscopic fragmentation
- using laser, ultrasonic or mechanical (pneumatic,
shock-wave) forms of energy to fragment the larger
stones.

3. Percutaneous nephrolithotomy
– a direct open surgery to remove the stone from the
kidney. This procedure is done when all non invasive
procedures failed and it will be necessary for large and
complicated stones.
 Most kidney stones do not require surgery and
will pass on their own.
 Surgery is necessary when the pain is persistent
and severe, in renal failure and when there is a
kidney infection.

Reference:
1. Collins, C. Edward (2005). A Short Course in Medical
Terminology. Lippincott Williams & Wilkins.
2. Parmar, Malvinder S. (2004). "Kidney stones". British
Medical Journal 328 (7453): 1420–1424.

VI. SURGICAL MANAGEMENT

Surgical Removal
Surgical intervention is indicated if the stone does not
respond to other forms of treatment. It may also be
performed to correct anatomic abnormalities within the
kidney, to improve urinary drainage.

Nephrolithotomy
● If the stone is in the kidney; an incision into the kidney
with removal of stone
Nephrectomy
● If the kidney is nonfunctional secondary to infection or
hydronephrosis.
Pyelolithotomy
● Stones in the kidney pelvis are removed
Ureterolithotomy
● Stones in the ureter are removed
Cystotomy
● Stones in the bladder are removed

Reference:
Source: Brunner and Suddarth's Textbook of Medical -
Surgical Nursing

VII. NURSING MANAGEMENT

Relieving Pain
● Administer opioid analgesic agents( IV or IM ) as
prescribed to relieve pain rapidly together with IV
NSAID
● Encourage and assist patient to a assume a position of
comfort
● Monitor the patient in increase severity of the pain and
report to the physician to provide relief and an additional
treatment is initiated

Monitoring and Managing Potential Complication

● Encourage patient to increased his/her oral fluid intake
to prevent dehydration and increase hydrostatic pressure
within the urinary tract to promote passage of the stone,
if patient cannot take adequate fluids orally, IV fluids is
prescribed.
● Encourage ambulation to move the stone through the
urinary tract.
● All urine is strained through gauze because uric acid
stones may crumble.
● Any blood clots passed in the urine should be crushed
and the sides of the urinal/bedpan inspected for clinging
stones to prevent infection, sepsis, and obstruction of the
urinary tract.
● Instruct patient to report decreased urine volume and
bloody or cloudy urine
● Instruct patient to report severity of the pain intensity
because of the possibility that a stone fragment
obstructing a ureter
● Monitor vital signs for early detection of infection

Patient Teaching Self-Care

● The nurse should provide education about the causes of
kidney stones and recommendations to prevent the
recurrence.
● Encourage patient to follow regimen to avoid further
stone formation and maintaining a high fluid intake
because stones form easily in concentrated urine.

Reference:
Medical-Surgical Management by Brunner and Suddarth
page 1594