Kidney Stones / Renal Calculi

Table of Contents

Kidney Stones/Renal Calculi

Kidney Stones are small, hard deposits of mineral and acid salts on the inner surfaces of the kidneys.

They can also be defined as crystallized minerals around pus, blood or damaged tissues.

Stones are classified by their location in the urinary system and their composition of crystals, they can also be called;

Renal Lithiasis
Renal Calculi
Nephrolithiasis (Kidney Stone Disease)
Urinary stones (urilithiasis)

Most stones consist of calcium salts (calcium oxalate) or magnesium-ammonium phosphate.
Other renal stones are uric acid stones, struvite and cystine stones

Pathophysiology of Kidney Stones

Urinary stones are formed by aggregation/precipitation of mineral crystals deposited in urine.
Most originate in the collecting ducts or renal papillae and pass to the renal pelvis where they may increase in size. Some become too large and fail to pass through the ureters and obstruct the out flow of urine causing kidney damage. Those passed to the bladder are either excreted or increase in size and obstruct the urethra. Some renal stones originate from the bladder
The frequency of different types of renal stones varies between countries due to diet, environmental factors, congenital factors, chronic urinary infection, urine stasis and excessive secretion of stone forming substances.

Causes of Kidney stones

Metabolic diseases: abnormalities that result in increased urine levels of calcium, oxaluric acid or citric acid such as hyperparathyroidism, renal tubular acidosis, medication like diuretics, vitamin C and D abuse and antacids. Other medications include acetazolamide (Diamox) or indinavir (Crixivan)
Diet
Large intake of protein increase uric acid excretion, excessive amounts of tea or fruit juices, elevate urinary oxalate level, large intake of calcium and oxalate and reduced intake of fluid increase concentration of urine
Climate
Warm climates cause increase fluid loss. Low urine volume and increase solute concentration in urine led to stone formation.
Congenital and inherited diseases
Family history of stones formation, cystinuria, gout or renal acidosis, familial hypercalciuria (FHH) and primary oxaluria
Slow urine ﬂow allows accumulation of crystals—damaging the lining of the urinary tract and decreasing the number of inhibitor substances that would prevent crystal accumulation.

Clinical Manifestations

Manifestations depend on the presence of obstruction, infection, and edema. Symptoms range from mild to excruciating pain and discomfort.

Stones in Renal Pelvis

Intense, deep ache in costovertebral region
Hematuria and pyuria
Pain that radiates anteriorly and downward toward bladder in female and toward testes in male
Acute pain, nausea, vomiting, costovertebral area tenderness (renal colic)
Abdominal discomfort, diarrhea

Ureteral Colic (Stones Lodged in Ureter)

Acute, excruciating, colicky, wavelike pain, radiating down the thigh to the genitalia
Frequent desire to void, but little urine passed; usually contains blood because of the abrasive action of the stone (known as ureteral colic)
Uriteric stones led to colicky abdominal pain (flank pain) radiating to the iliac fossa, testis and labia on the same side. There may also be pallor sweating, vomiting , frequency of micturition, dysuria and hematuria

Stones Lodged in Bladder

Symptoms of irritation associated with urinary tract infection and hematuria
Urinary retention, if stone obstructs bladder neck
Possible urosepsis if infection is present with stone
Bladder stones lead to increased frequency of micturition, dysuria, hematuria, severe intraurethral or perineal pain if trigonitis occurs and distended bladder if outflow obstruction
of urine occurs

Diagnosis of Renal Stones

Renal or ureteric stones are suspected on history of colicky abdominal pain with hematuria
The following investigations confirms the diagnosis and should be done to every suspected patient

Xrays of the kidneys, ureters, and bladder or by ultrasonography, to detect size and site of the stones.
IV urography, or retrograde pyelography show hydronephrosis and stone impaction.
CT-Scan to confirm the non radio opaque stones (uric acid stones)
Chemical tests ie urinalysis, serum calcium and serum uric acid levels to determine stone composition.
Blood chemistries and a 24hour urine test for measurement of calcium, uric acid, creatinine, sodium, and urine pH.
CBC: Hb/HCT: Abnormal if patient is severely dehydrated or polycythemia is present (encourages precipitation of solids), or patient is anemic (hemorrhage, kidney dysfunction/failure).
Cystourethroscopy: Direct visualization of bladder and ureter may reveal stone and/or obstructive effects.

Management of Kidney Stones

Acute attack

Aims of management.

Alleviate pain.
Maintain adequate renal functioning.
Prevent complications.
Provide information about disease process/prognosis and treatment needs.

Medical management also aims at to eradicate the stone, determine the stone type, prevent nephron destruction, control infection, and relieve any obstruction that may be present.

Patients with renal stones may be acutely ill suffering from excruciating/piercing pain arising in loin radiating to the groin which can last for 5 – 6 hours due to small calculi being moved along the ureters by peristalsis so bed rest and worth to the site of pain is needed for relief. Read this Research on how rest is important in passing out kidney stones.
Narcotics are use to relieve renal colic’s such as morphine.
Stones less than 5mm are non obstructive and may be passed through the urinary tract to be excreted in urine. Alpha-blockers like tamsulosin can be used to aid passage of renal stones.
Increased fluid intake to assist in stone passage, unless patient is vomiting; patients with renal stones should drink eight to ten glasses of water daily or have IV fluids prescribed to keep the urine dilute.
Take and record observation such as temperature, pulse, respiration, blood pressure and observe for signs of infection such dark colored urine, cloudy urine with abnormal odour e.t.c.
Prochlorperazine is given to treat nausea and vomiting
Do investigation to rule infections and treat the accordingly.
Larger stones more than 1cm can be crushed by extracorporeal shock-waves lithotripsy(ESWL). and removed through urine
Chemo lysis (stone dissolution) which is an alternative for those who are poor risks for other therapies, or have easily dissolved stones (struvite).
Impacted large stone are managed by endoscopic surgery or open surgery (nephrolithotomy or uretero-lithotomy). Surgical removal is performed in only 1% to 2% of patients.

Continuous care/prevention further kidney stone development

Give moderate proteins and restrict sodium in diet
Take 3-4 litres of fluids a day
Diet containing plenty calcium prevents oxalate stones like mils, cheese, ice-cream, yoghurt , all beans, dried fruits and fish with fine bones (sardines, kippers, herring, salmon)
Avoid food rich in oxalate such peanuts, spinach, rhubarb, cabbage, tomatoes, chocolate, cocoa, tea etc
Thiazide diuretics calcium stone in a patient with hypercalciuria
Allopurinol prevent urate stones in hyperuricemia
Avoid vitamin D supplements as they increase calcium absorption and excretion.
Calcium lactate can be given to precipitate oxalate in the GIT or give cholestyramine to bind oxalate and prevent GIT absorption for calcium oxalate stones.
In cystine stones give alpha-penicillamine and tiopronin to prevent crystallization. In all types stones give potassium citrate to maintain alkalinity of urine

SPECIFIC NURSING MANAGEMENT

Pain Management: Assess the patient’s pain level and administer pain relief medications as prescribed. Monitor the effectiveness of pain management and document pain levels.
Fluid Intake: Encourage the patient to drink plenty of fluids to help flush out the stones and prevent dehydration. Adequate hydration can reduce the risk of stone formation.
Monitoring Vital Signs: Regularly check the patient’s vital signs, including blood pressure, heart rate, and temperature, to identify signs of infection or complications.
Strain Urine: Provide a urine strainer or sieve to the patient and instruct them to strain their urine to catch any stone fragments for analysis. Document the results.
Assessment for Hematuria: Monitor for the presence of blood in the urine (hematuria). Document the color and amount of blood.
Education: Educate the patient about their condition, the importance of following treatment plans, and lifestyle modifications to prevent recurrence.
Nutritional Counseling: Provide guidance on dietary changes that can help reduce the risk of stone formation. This may include recommendations to limit certain foods high in oxalates, salt, and animal proteins.
Ambulation: Encourage the patient to ambulate and stay active, which can facilitate the passage of kidney stones and reduce complications.
Medication Administration: Administer prescribed medications such as alpha-blockers to relax the ureter, helping stones pass more easily, or medications to control pain and manage infections.
Assessment for Signs of Infection: Monitor for signs of urinary tract infections, such as fever, chills, or cloudy and foul-smelling urine. Report any changes to the healthcare provider.
Prevention Measures: Discuss preventive measures with the patient, including increased fluid intake, dietary changes, and lifestyle modifications to reduce the risk of stone recurrence.
Emotional Support: Recognize that kidney stones can be painful and distressing. Offer emotional support to the patient and address any anxiety or concerns they may have about the condition or its treatment.

Diagnosis

Nursing Diagnoses

Acute pain related to inflammation, obstruction, and abrasion of the urinary tract
Deficient knowledge regarding prevention of recurrence of renal stones

Nursing Care Plan

Assessment	Nursing Diagnosis	Expected Outcomes/Goals	Interventions	Rationale	Evaluation
Acute Pain	Acute pain related to tissue trauma evidenced by reports of colicky pain, restlessness, moaning, facial mask of pain.	- Report pain is relieved with spasms controlled. - Appear relaxed, able to sleep/rest appropriately.	- Determine and note location, duration, intensity (0–10 scale), and radiation of pain -. Document nonverbal signs such as elevated BP and pulse, restlessness, moaning.	- Aids to evaluate site of obstruction and progress of calculi movement. - Justify and clarify cause of pain and the need of notifying caregivers of changes in pain occurrence and characteristics.	The patient did not complain or report any pain episode. - Patient was relaxed and was able to get sleep appropriately.
Failure to pass urine.	Impaired Urinary Elimination related to inflammation or obstruction of the bladder by calculi, renal or ureteral irritation as evidenced by urgency and frequency of urination(oliguria) and haematuria.	- Pass urine in normal amounts and usual pattern. - Experience no signs of obstruction.	- Record input and output and characteristics of urine. - Encourage the patient to walk if possible. - Promote sufficient intake of fluids. - Investigate reports of bladder fullness; palpate for suprapubic distension. Note decreased urine output, presence of periorbital and dependent edema.	- Provides information about kidney function and presence of complications (infection and hemorrhage) - To facilitate spontaneous passage. - Calculi may cause nerve excitability, which causes sensations of urgent need to pass urine. - Increased hydration flushes bacteria, blood, and debris and may facilitate stone passage. - Urinary retention may develop, causing tissue distension (bladder, kidney), and potentiates risk of infection, renal failure.	- Patient was able to pass urine in sufficient amounts following a usual pattern. - Obstruction was relieved.
Dehydration	Risk for Deficient Fluid Volume may be related to nausea and vomiting	- Maintain adequate fluid balance as evidenced by vital signs and weight within patient’s normal range, palpable	- Monitor and document fluid input and output and daily weight. - Promote fluid intake to 3–4 L a day within cardiac tolerance.	- Comparing actual and anticipated output may aid in evaluating presence and degree of renal stasis or impairment. - Maintains fluid balance for homeostasis and “washing” action that may flush the stone(s) out.	its potential Dx, so it hasn't happened

Complications of Kidney Stones.

Obstruction: One of the most common complications is the obstruction of the urinary tract. Small stones can obstruct the flow of urine, causing severe pain and discomfort. Larger stones may block the ureter or urethra completely, leading to excruciating pain and potential damage to the kidneys.
Infections: When urine flow is obstructed, bacteria can grow in the stagnant urine, leading to urinary tract infections (UTIs). UTIs can cause symptoms like fever, chills, and pain during urination.
Kidney Damage: Prolonged obstruction of urine flow can damage the kidneys. Kidney function may deteriorate, leading to kidney failure if the condition is not treated promptly.
Hematuria: Kidney stones can cause bleeding in the urinary tract, leading to blood in the urine (hematuria). This can be painful and may indicate injury to the urinary tract.
Recurrence: Some individuals are more prone to developing kidney stones, and they may experience recurrent episodes over time.
Severe Pain: The passage of kidney stones through the urinary tract can cause severe pain, commonly referred to as renal colic. This pain can be debilitating and may require medical intervention for relief.
Complications during Pregnancy: Kidney stones can pose a risk to pregnant women. If a stone becomes trapped in the urinary tract during pregnancy, it can lead to complications and require specialized care.
Formation of New Stones: Having kidney stones once increases the risk of developing more in the future. Patients with a history of kidney stones should take measures to prevent their recurrence.