Kidney Stones: Symptoms, Treatment & Nursing Care

Table of Contents

Kidney Stones (Renal Calculi): Causes, Symptoms, Diagnosis, Treatment and Nursing Care

Kidney stones (renal calculi, nephrolithiasis or urolithiasis) are solid mineral crystals that form in the urinary tract when urine becomes concentrated or its chemical balance favours crystallisation. A stone may remain inside the kidney, move into a ureter, or obstruct urine flow. The clinical problem is shaped by the stone’s size and position, obstruction, infection, renal function and the patient’s overall condition.

Emergency warning: fever or rigors with suspected urinary obstruction, anuria, a solitary functioning kidney with obstruction, rapidly worsening renal function, or pain and vomiting that cannot be controlled require urgent medical review. An infected obstructed kidney is a urological emergency.

These nursing lecture notes explain the causes, pathophysiology, clinical presentation, investigations, treatment, complications and nursing management of renal and ureteric stones. Treatment decisions depend on assessment by a qualified clinician and the resources and referral pathways available locally.

Learning outcomes and key terms
Definition, anatomy and classification
Pathophysiology
Causes and risk factors
Clinical features and red flags
Assessment and diagnosis
Medical and emergency management
Procedural and surgical treatment
Nursing management
Nursing care plans
Complications
Prevention and follow-up
Patient and family education
Revision questions and answers
References

1. Learning outcomes and key terms

By the end of this topic, a learner should be able to:

Define renal calculi and distinguish stones in the kidney from stones in the ureter and bladder.
Describe how concentrated urine, abnormal urinary chemistry, infection and urinary stasis contribute to stone formation.
Recognise common symptoms of renal colic and identify features that suggest infection, obstruction or renal impairment.
Outline the role of urinalysis, blood investigations, ultrasound, low-dose non-contrast CT and stone analysis.
Explain safe initial care, conservative observation, medical expulsive therapy and the main stone-removal procedures.
Plan nursing care that relieves pain, monitors renal function and infection, supports treatment and reduces recurrence.

Calculus means a stone; renal colic describes severe, usually fluctuating pain from ureteric obstruction and pressure; hydronephrosis is dilatation of the renal collecting system due to impaired urine drainage; and urolithiasis refers broadly to stones anywhere in the urinary tract.

2. Definition, anatomy and classification

Definition

A kidney stone is a hard aggregate of crystals and organic material formed in the kidney or elsewhere in the urinary tract. A stone may be asymptomatic while it remains in a calyx, but movement into the ureter can cause obstruction, mucosal irritation, colicky pain and haematuria. Infection may occur behind an obstruction and can progress rapidly.

Relevant urinary anatomy

Urine drains from each kidney’s collecting ducts into the calyces and renal pelvis, then passes down a narrow ureter to the bladder. Peristaltic contractions move urine through the ureter. A stone may lodge at the ureteropelvic junction, where the renal pelvis becomes the ureter; where the ureter crosses the pelvic brim; or at the ureterovesical junction, where it enters the bladder. These narrow sites are common points of obstruction. The bladder stores urine and empties through the urethra.

Classification by location

Location	Meaning	Clinical relevance
Renal calculus	Stone within a calyx, renal pelvis or collecting system.	May be silent, cause haematuria or flank discomfort, grow, become infected, or move into the ureter.
Ureteric calculus	Stone within the ureter.	May obstruct drainage and cause renal colic; pain often moves from the flank toward the lower abdomen or groin.
Bladder calculus	Stone within the urinary bladder.	May cause suprapubic pain, dysuria, frequency, interrupted stream or retention, especially with outlet obstruction.

Classification by composition

The composition is determined by analysing a retrieved stone. Composition matters because it can point to a metabolic cause and guide prevention or, for selected stones, dissolution treatment. Calcium-based stones are the most common overall; the exact proportions vary between populations.

Stone type	Typical associations	Useful teaching point
Calcium oxalate	Low urine volume, high urinary calcium or oxalate, low citrate, excess sodium, some bowel malabsorption disorders.	Often visible on plain radiography, but imaging choice should be based on the clinical situation.
Calcium phosphate	Alkaline urine, hypercalciuria, hyperparathyroidism or renal tubular acidosis; some cases are associated with infection.	Investigate and treat the underlying metabolic or endocrine abnormality where indicated.
Struvite and other infection stones	Urease-producing urinary bacteria, recurrent infection and urinary stasis; may form large branching stones.	Infection plus obstruction is urgent; complete stone clearance and culture-directed infection care are important.
Uric acid	Persistently acidic urine, low urine volume, gout, metabolic syndrome or high cell turnover.	Often not visible on plain X-ray; selected uric acid stones may dissolve with clinician-supervised urine alkalinisation.
Cystine	Inherited cystinuria with recurrent stone formation, often beginning in childhood or young adulthood.	Requires specialist assessment and sustained prevention because recurrence risk is high.
Drug-related or uncommon stones	Some medicines or rare metabolic disorders can produce stones or crystals.	Review the medication history; do not stop prescribed medicines without advice.

Existing media image: common types of kidney stones classified by composition.

3. Pathophysiology

Stone formation is a multi-step process. Crystals form when urine contains a high concentration of stone-forming substances relative to the fluid and inhibitors that keep them dissolved. A small crystal does not always become a clinically significant stone; it must grow, aggregate and remain in the urinary tract.

Urinary supersaturation: Low urine volume or increased excretion of calcium, oxalate, uric acid, phosphate or cystine makes urine more concentrated. Urine pH also changes the solubility of different substances. Uric acid tends to crystallise in acidic urine; infection stones develop in alkaline urine produced by urease-forming bacteria.
Nucleation: Molecules join to form a tiny crystal. This may begin spontaneously or around a surface such as cellular debris or a pre-existing crystal.
Crystal growth and aggregation: More material deposits on the crystal, and crystals may join together. Urinary citrate and other inhibitors normally reduce this process. Low inhibitor levels, ongoing supersaturation or urinary stasis allow growth.
Retention: Crystals are more likely to develop into stones if they attach to renal tissue or remain in a calyx or collecting system instead of being washed out with urine.
Migration and obstruction: A stone may move into the ureter. Obstruction increases pressure above the stone, stretches the collecting system and triggers ureteric smooth-muscle activity. This produces waves of severe pain and may impair drainage.
Inflammation and infection: The stone can abrade the urothelium, causing haematuria. Stagnant urine behind an obstruction allows infection to worsen. Infection in an obstructed system can lead to sepsis and requires urgent drainage.

Clinical link: Pain intensity does not reliably indicate stone size. A small ureteric stone may cause severe colic, while a large stone within the kidney may produce few symptoms until it obstructs or becomes infected.

4. Causes and risk factors

Most stones develop through a combination of metabolic, dietary, environmental, anatomical and genetic factors. A patient may have more than one risk factor, and many people with a first stone do not have a single obvious cause.

Metabolic and medical factors

Low urine volume: Inadequate fluid intake, vomiting, diarrhoea, fever, heavy sweating or hot working conditions concentrate urine.
Hypercalciuria: Excess urinary calcium may be related to high sodium intake, hyperparathyroidism, some renal disorders or other causes. It does not mean the patient should automatically avoid dietary calcium.
Hyperoxaluria: May occur with intestinal malabsorption, chronic diarrhoea, inflammatory bowel disease, bowel resection or rare inherited conditions.
Hyperuricosuria and low urine pH: May be associated with gout, high cell turnover, insulin resistance, metabolic syndrome or dietary excess of purines and animal protein.
Low urinary citrate: Citrate inhibits some crystal formation. Low levels can occur with metabolic acidosis, chronic diarrhoea, low intake or selected medicines.
Urinary infection: Urease-producing bacteria can cause alkaline urine and struvite or carbonate-apatite stones.
Urinary stasis or obstruction: Congenital narrowing, ureteropelvic junction obstruction, urinary diversion, neurogenic bladder, enlarged prostate, urethral stricture, bladder diverticulum or an indwelling foreign body may impair drainage.
Systemic disease: Hyperparathyroidism, renal tubular acidosis, obesity, diabetes and some bowel disorders may alter urine chemistry.

Diet, lifestyle and environment

Regularly drinking too little, particularly during hot weather or strenuous work, reduces urine volume.
Excess dietary sodium can raise urinary calcium. Highly salted processed foods and adding large amounts of salt at the table may contribute.
Excess animal protein may lower urinary citrate and pH and raise uric acid excretion.
Very high intake of oxalate-rich foods can matter for a person with documented hyperoxaluria. Broad elimination of vegetables and other nutritious foods is not routinely appropriate.
Excessive use of vitamin supplements, particularly high-dose vitamin C, may be relevant for some calcium oxalate stone formers.
Repeated dehydration and excessive intake of sugar-sweetened drinks may increase risk in some people.

Medication and inherited factors

Some medicines can alter urinary pH, solute excretion or crystallisation. Examples include topiramate, acetazolamide and selected antiviral medicines; the risk depends on the medicine and patient. A family history, early onset, recurrent stones, cystinuria and primary hyperoxaluria suggest an inherited tendency. Nurses should record medication and family history and refer medication changes to the prescriber.

5. Clinical features and red flags

Common symptoms

Renal colic: Sudden severe pain, usually from the flank or costovertebral angle. It may come in waves and radiate to the lower abdomen, groin, testis or labium as the stone moves down the ureter. Patients with colic are often restless and unable to find a comfortable position.
Haematuria: Microscopic or visible blood may occur from urothelial irritation. Its absence does not exclude a stone, and visible blood may have other causes that require assessment.
Nausea and vomiting: Often accompany severe visceral pain. Persistent vomiting raises concern about dehydration and inability to take oral medicines.
Urinary frequency, urgency or dysuria: More likely when the stone is near the bladder or at the ureterovesical junction.
Flank tenderness: Costovertebral angle tenderness may be present. The abdomen may be soft, although tenderness can occur.
Asymptomatic presentation: A non-obstructing renal stone may be found incidentally on imaging.

Stone position	Possible presentation
Renal pelvis or upper ureter	Flank pain, costovertebral angle tenderness, nausea, vomiting and possible haematuria.
Mid or lower ureter	Pain may move toward the lower abdomen, groin or genital region. Urgency and frequency may occur as the stone approaches the bladder.
At the ureterovesical junction	Urgency, frequency, dysuria and suprapubic discomfort may be prominent.
Bladder	Suprapubic discomfort, dysuria, interrupted stream, urinary frequency, haematuria or acute retention, often with an underlying outlet problem.

Red flags requiring urgent assessment

Fever, rigors, confusion, hypotension, tachycardia or other signs of sepsis with suspected stone or obstruction.
Anuria, markedly reduced urine output, bilateral obstruction, or obstruction in a solitary functioning kidney or transplanted kidney.
Acute kidney injury, rising creatinine or rapidly deteriorating renal function.
Severe pain despite appropriate analgesia, repeated vomiting, inability to maintain oral intake or uncontrolled symptoms.
Pregnancy, immunosuppression, frailty, significant comorbidity or an uncertain diagnosis with severe abdominal symptoms.
Inability to void, a painful distended bladder, or a stone associated with urinary retention.

A patient with flank pain and fever should not simply be advised to drink more and wait for a stone to pass. Fever may indicate infection above an obstruction, where antibiotics alone may be insufficient without urgent drainage.

6. Assessment and diagnosis

History and physical assessment

Assess the onset, site, character, severity and radiation of pain; previous stone episodes; urinary symptoms; fever or rigors; nausea and vomiting; fluid intake and recent fluid losses; pregnancy possibility; medical and surgical history; family history; current medicines and supplements; and allergies. Ask about known bowel disease, gout, endocrine disorders, recurrent urinary infection and urinary procedures. Record what the patient has already taken for pain.

Check airway, breathing and circulation when the patient is acutely unwell. Record temperature, pulse, blood pressure, respiratory rate, oxygen saturation, pain score, hydration status and level of consciousness. Examine the abdomen and flank, assess costovertebral angle tenderness and check for bladder distension. Avoid assuming that all severe abdominal pain is renal colic; consider other urgent diagnoses.

Differential diagnosis

Depending on the presentation, differential diagnoses include pyelonephritis, urinary tract infection, appendicitis, biliary colic or cholecystitis, pancreatitis, bowel obstruction, diverticulitis, ectopic pregnancy, ovarian or testicular torsion, abdominal aortic aneurysm and musculoskeletal pain. Clinical assessment and appropriate investigations help distinguish these conditions.

Urine and blood investigations

Investigation	Purpose and nursing considerations
Urine dipstick and microscopy	Looks for red cells, white cells, nitrites, pH, protein and crystals. Haematuria supports but does not prove a stone; absence of blood does not rule it out.
Urine culture and sensitivity	Send when infection is suspected, especially with fever, pyuria or planned intervention. Obtain the specimen promptly, but do not delay emergency treatment in a septic patient.
Serum creatinine and electrolytes	Assess renal function and effects of obstruction, dehydration, vomiting or treatment. Compare with prior results if available.
Full blood count and inflammatory markers	May help assess infection, inflammation or anaemia. Interpret alongside the patient’s clinical condition.
Serum calcium and uric acid	May help identify metabolic or systemic contributors, particularly in recurrent or high-risk stone disease.
Pregnancy test when relevant	Helps guide safe imaging and treatment in patients who could be pregnant.
Stone analysis	Ask the patient to strain urine and retain any passed stone or fragment in a clean container for laboratory analysis. Stone analysis can guide recurrence prevention.
24-hour urine evaluation	Consider for recurrent, high-risk or selected first-time stone formers. It may measure urine volume, pH, calcium, oxalate, uric acid, citrate, sodium and other factors.

Imaging

Ultrasound: Avoids ionising radiation and can identify renal stones, urinary tract dilatation and some ureterovesical junction stones. It is commonly preferred initially for pregnancy and children, and is useful where CT access is limited. A negative ultrasound does not exclude a ureteric stone.
Low-dose non-contrast CT: Provides accurate information on stone location, size and burden and can identify alternative causes of acute flank pain. NICE recommends urgent low-dose non-contrast CT within 24 hours for adults with suspected renal colic, with ultrasound instead for pregnancy. The EAU recommends ultrasound as the initial imaging assessment followed by non-contrast CT to confirm suspected stones when appropriate. Local protocols, radiation exposure, age and clinical urgency guide the choice.
Plain KUB X-ray: May help identify radiopaque stones and support follow-up of a known visible stone, but it is less sensitive than CT and cannot identify all stone types.
MRI: May help assess obstruction during pregnancy when ultrasound is inconclusive. It is not generally the first test for detecting small stones.

Imaging is not a substitute for clinical assessment. Stabilisation, analgesia and urgent escalation should not be delayed when a patient is septic, anuric or otherwise unstable.

7. Medical and emergency management

Aims of treatment

Relieve pain and nausea.
Recognise and treat infection promptly.
Relieve dangerous obstruction and protect renal function.
Support safe passage of suitable stones or remove stones that are unlikely to pass or are causing complications.
Identify stone composition and reduce recurrence risk.

Initial care for acute renal colic

Triage and stabilise: Assess vital signs, pain, hydration, urine output and sepsis indicators. Establish intravenous access and monitoring when clinically indicated. Escalate early if the patient is unstable or has a red flag.
Provide analgesia as prescribed: An NSAID is recommended as first-line treatment for suspected renal colic when suitable for the patient. Check for renal impairment, dehydration, gastrointestinal bleeding or ulcer disease, anticoagulant use, allergy, pregnancy and cardiovascular risk. If NSAIDs are contraindicated or insufficient, intravenous paracetamol may be considered; an opioid may be needed when pain remains uncontrolled or other options are unsuitable. Follow local prescribing guidance and reassess the response.
Treat nausea and vomiting: Administer a prescribed antiemetic, provide oral care, and monitor intake and losses. Persistent vomiting may require intravenous fluid and medicine administration.
Use fluids appropriately: Correct dehydration and maintain safe hydration, but do not force large fluid volumes or use rapid diuresis to try to push a stone through an acute obstruction. Give oral or intravenous fluid according to the patient’s status, renal and cardiac function, orders and local protocol.
Monitor: Reassess pain, temperature, pulse, blood pressure, urine output, haematuria, vomiting and clinical response. Maintain accurate fluid balance when indicated. A sudden reduction or cessation in urine output requires prompt review.
Strain urine if requested: Provide a urine strainer and explain how to save a stone fragment for analysis. Document passage and the patient’s symptoms.
Review disposition and follow-up: Observation at home is suitable only when the patient is clinically stable, symptoms are controlled, renal function is acceptable, infection is absent or appropriately treated, and follow-up and return precautions are clear.

Antispasmodics are not routinely recommended for renal colic by NICE because they do not improve outcomes when added to analgesia. Do not use a medication simply because it was included in an older protocol without checking current local guidance.

Infected obstructed kidney: emergency pathway

When urinary infection or sepsis is present with an obstructing stone, the immediate priorities are sepsis care, antimicrobial treatment and urgent drainage of the obstructed collecting system.

Recognise sepsis or anuria and urgently notify the medical and urology teams; begin the facility’s sepsis response.
Obtain urine and blood cultures promptly where possible, without delaying antibiotics in a seriously unwell patient.
Start prescribed broad-spectrum antibiotics immediately and review them when culture and sensitivity results become available.
Prepare the patient for urgent decompression by ureteric stent or percutaneous nephrostomy. The choice depends on clinical circumstances, anatomy, expertise and availability.
Monitor vital signs, mental state, perfusion, renal function, urine output and response to treatment; escalate to higher-level care when required.
Definitive stone fragmentation or removal is usually delayed until infection and sepsis have resolved. Drainage relieves pressure but does not necessarily remove the stone.

Key exam point: Do not manage an infected obstructed system by observation alone. Antibiotics and urgent decompression are both important; definitive stone treatment is normally performed after the infection is controlled.

Conservative observation and spontaneous passage

Observation can be considered for selected patients with a ureteric stone likely to pass, controlled pain, no infection, stable renal function and no high-risk obstruction. Smaller stones, especially distal stones, are more likely to pass than larger or proximal stones, but passage is not guaranteed. The patient needs a clear review plan and instructions to return if fever, worsening pain, vomiting, reduced urine output or other red flags develop.

Medical expulsive therapy

An alpha-blocker such as tamsulosin may be offered as one treatment option for selected distal ureteric stones, particularly stones 5–10 mm, when conservative management is appropriate. This use is off-label in the EAU guideline and should be prescribed by a clinician after considering expected benefit, blood-pressure effects, dizziness, falls, drug interactions, patient preference and local policy. It is not appropriate when infection, refractory pain or worsening renal function means active intervention is needed. Stop and reassess if complications develop.

Chemolysis and stone-specific medicines

Selected uric acid stones may dissolve with clinician-supervised alkalinisation of urine, often using potassium citrate or another prescribed alkali. Urine pH must be monitored and the cause of the stone assessed; excessive alkalinisation can promote other stone types. Allopurinol may be considered for documented hyperuricosuria or another appropriate indication, but is not a universal stone treatment. Potassium citrate, thiazide diuretics and other preventive medicines should be guided by stone composition, biochemical results, comorbidities and prescriber review. Antibiotics are used for infection, not routinely for every stone.

8. Procedural and surgical treatment

Active removal may be considered when the stone is unlikely to pass, obstruction persists, renal function is threatened, infection requires drainage, symptoms remain uncontrolled, or the stone is growing or causing recurrent problems. The procedure depends on stone size, site, density and number; patient anatomy and comorbidities; pregnancy or bleeding risk; local expertise; and patient preference.

No.	Procedure	What it involves and nursing considerations
1	Extracorporeal shock-wave lithotripsy (SWL/ESWL)	Shock waves are focused on a suitable stone from outside the body to fragment it. Fragments pass in urine. Check pre-procedure instructions and contraindications; after treatment monitor pain, urine colour, fever, and passage of fragments. Follow-up imaging may be required. It may require repeat treatment and is less effective for some hard, dense, large or poorly targeted stones.
2	Ureteroscopy (URS)	A small endoscope is passed through the urethra and bladder into the ureter, where the stone may be fragmented with a laser and fragments removed. A temporary ureteric stent may be placed. Teach the patient that frequency, urgency, mild haematuria or discomfort can occur with a stent, but fever, inability to void, severe pain or heavy bleeding needs review.
3	Percutaneous nephrolithotomy (PCNL)	A tract is created through the skin into the kidney so that larger renal stones can be fragmented and removed. It is commonly considered for large renal stones, including many stones over 20 mm and staghorn calculi. Postoperative nursing includes monitoring bleeding, pain, fever, urine output, renal function and nephrostomy drainage if present.
4	Temporary ureteric stent or nephrostomy	These procedures drain urine around an obstruction and are used urgently for infected obstruction or as a temporary measure. They may not remove the stone. Observe drainage, securement, pain, infection signs, output and follow-up plans.
5	Open or laparoscopic stone surgery	Rarely required today; reserved for selected complex cases when endoscopic or other less invasive options are unsuitable or unsuccessful.

No single size cut-off determines treatment for every patient. Procedure choice is individualised. For example, SWL has lower procedural morbidity but may need repeat treatment, while ureteroscopy often achieves earlier stone-free status for ureteric stones but is more invasive. PCNL is often considered for large renal stone burden. Explain that the treating urologist weighs benefits and risks for the individual patient.

9. Nursing management

Assessment and ongoing monitoring

Use a structured assessment: pain location, severity, radiation and response to treatment; urinary symptoms; fever or chills; nausea and vomiting; fluid intake and losses; and relevant history.
Record and trend temperature, pulse, blood pressure, respiratory rate, oxygen saturation, mental state and pain score. Report deteriorating observations promptly.
Measure intake and output when indicated. Note urine volume, colour, visible blood, clots and ability to void. Report anuria, oliguria, retention or a sudden decline in output.
Review laboratory results and report rising creatinine, electrolyte abnormalities, leukocytosis or positive cultures to the responsible clinician.
Assess hydration and avoid both untreated dehydration and unnecessary forced fluid loading. Follow fluid restrictions for heart failure, kidney failure or other conditions.
Observe for sepsis, obstruction, uncontrolled pain, adverse drug effects, falls, bleeding and complications of a stent, nephrostomy or procedure.
Document assessments, interventions, response, escalation and patient understanding.

Pain, nausea and comfort

Administer prescribed analgesia promptly and reassess at the time specified by local protocol. Monitor for adverse effects such as gastrointestinal symptoms or renal risk with NSAIDs, sedation or respiratory depression with opioids, and hypotension or dizziness with alpha-blockers. Provide an emesis bowl, mouth care, a calm environment and assistance with position changes or mobility. Offer heat only if permitted by local practice and comfortable for the patient; it does not replace analgesia or urgent treatment.

Pre-procedure and postoperative care

Explain the planned investigation or procedure in clear language and refer questions about consent, risks and alternatives to the clinician performing it.
Check identity, allergies, prescribed fasting, medications, anticoagulants and required investigations according to local checklist. Do not independently stop anticoagulants or other medicines.
After SWL, URS or PCNL, monitor observations, pain, haematuria, urine output and signs of infection or bleeding. Follow the operation-specific monitoring chart.
If a nephrostomy is present, maintain a closed drainage system, secure the tube, keep the bag below kidney level, measure output and report leakage, dislodgement, blockage or sudden cessation of drainage.
If a ureteric stent is present, explain the removal or exchange plan and the expected symptoms. Ensure the patient knows where and when to seek help for fever, severe pain, inability to void, heavy haematuria or catheter/stent concerns.
Encourage mobilisation when safe and support gradual resumption of oral intake after anaesthesia according to orders.

Discharge planning

Before discharge, confirm that the patient has a medication plan, follow-up date, instructions for any stent or nephrostomy, access to review if symptoms worsen and understands how to strain urine if requested. Reinforce hydration for recurrence prevention after the acute obstruction has been assessed; this advice is different from forcing fluids during uncontrolled acute colic.

10. Nursing care plans

Care plan 1: Acute pain related to ureteric obstruction

Goal: The patient reports reduced pain to a tolerable level, demonstrates improved comfort and has stable observations after interventions.

Nursing intervention	Rationale
Assess pain score, location, radiation, onset and pattern; reassess after each intervention.	Establishes a baseline, detects change and evaluates whether treatment is effective.
Administer prescribed analgesia promptly; check contraindications and monitor adverse effects.	Timely analgesia reduces distress while safety checks reduce avoidable harm.
Monitor vital signs and urine output, and report fever, hypotension, anuria or uncontrolled pain.	Deterioration may indicate infection, worsening obstruction or renal compromise.
Provide a calm environment, explain care and assist the patient to a comfortable position.	Reduces anxiety and supports coping while medical treatment takes effect.

Care plan 2: Nausea and vomiting related to severe visceral pain

Goal: The patient experiences reduced nausea, has fewer vomiting episodes and can tolerate prescribed oral fluids and medicines when safe.

Nursing intervention	Rationale
Assess nausea, vomiting frequency, abdominal symptoms and oral intake.	Identifies severity, fluid loss and need for further review.
Administer prescribed antiemetic and reassess the response.	Relief of nausea may improve comfort and allow oral treatment.
Provide mouth care and keep emesis equipment accessible.	Supports comfort and dignity during vomiting.
Monitor hydration, urine output and electrolytes when ordered; report persistent vomiting.	Vomiting can cause fluid and electrolyte loss and may make outpatient management unsafe.

Care plan 3: Risk of deficient fluid volume related to vomiting and reduced intake

Goal: The patient maintains an appropriate fluid balance and urine output for their clinical condition without signs of dehydration or fluid overload.

Nursing intervention	Rationale
Assess mucous membranes, thirst, perfusion, vital signs, intake, output and recent losses.	Helps identify dehydration and establish the patient’s fluid status.
Give oral or IV fluids only as prescribed and according to renal, cardiac and obstruction status.	Corrects deficit safely; indiscriminate high-volume fluids do not reliably force an obstructing stone to pass.
Maintain accurate fluid balance in patients who are acutely unwell or at risk.	Supports early recognition of oliguria, anuria or fluid overload.
Encourage the patient to follow an individualised fluid plan after acute symptoms settle.	Long-term prevention usually relies on maintaining adequate urine volume, with adjustment for comorbidities.

Care plan 4: Impaired urinary elimination related to obstruction

Goal: Urine drains as expected for the patient’s condition, and any obstruction or retention is escalated promptly.

Nursing intervention	Rationale
Measure urine output when indicated and assess colour, clots, dysuria, urgency and ability to void.	Identifies haematuria, retention, reduced drainage and change in obstruction.
Report anuria, declining output, new retention or a painful distended bladder immediately.	These may indicate significant obstruction or worsening renal function.
Strain urine if ordered and save any stone fragment in a clean container.	Stone analysis can identify composition and direct recurrence prevention.
Monitor any nephrostomy or urinary catheter using the relevant device-care procedure.	Maintaining a patent drainage system reduces the risk of blockage and supports accurate output measurement.

Care plan 5: Risk of infection related to urinary stasis or instrumentation

Goal: The patient remains free of sepsis and receives timely assessment and treatment if infection is suspected.

Nursing intervention	Rationale
Monitor temperature, pulse, blood pressure, mental status, urine symptoms and sepsis indicators.	Infection behind an obstruction can deteriorate rapidly.
Collect ordered urine and blood cultures promptly and label specimens correctly.	Accurate samples help identify the organism and guide antimicrobial treatment.
Administer prescribed antibiotics promptly and observe for allergy or adverse reactions.	Timely antimicrobial therapy is important in suspected complicated infection.
Escalate suspected infected obstruction for urgent urological review and preparation for drainage.	Antibiotics may not adequately control infection until the obstructed system is decompressed.

Care plan 6: Knowledge deficit about treatment and recurrence prevention

Goal: Before discharge, the patient explains their follow-up plan, identifies danger signs and describes prevention advice relevant to their own stone type and health status.

Nursing intervention	Rationale
Assess what the patient understands about the stone, medicines, procedures and previous episodes.	Teaching can be tailored to the patient’s knowledge, language and concerns.
Explain the purpose and safe use of each prescribed medicine, including when to seek help for adverse effects.	Promotes adherence and timely recognition of medicine-related problems.
Teach red flags: fever or rigors, worsening pain, repeated vomiting, reduced urine, inability to void or feeling faint or confused.	Encourages rapid review for obstruction, infection or deterioration.
Discuss stone analysis, follow-up imaging and any planned metabolic evaluation.	Determining stone composition and recurrence risk supports targeted prevention.
Use teach-back and give written instructions where available.	Confirms understanding and makes instructions easier to follow at home.

11. Complications

Ureteric obstruction and hydronephrosis: Impaired drainage causes dilatation above the stone. Persistent obstruction may impair renal function.
Acute kidney injury: Risk is higher with bilateral obstruction, obstruction of a solitary kidney, severe dehydration, infection or pre-existing renal disease.
Pyelonephritis and urosepsis: Infection behind an obstructing stone can progress to sepsis and septic shock.
Renal damage and chronic kidney disease: Recurrent infections, prolonged obstruction, underlying metabolic disease or repeated stone events may compromise renal health.
Recurrent stones: A prior stone episode increases the chance of future episodes, particularly when an underlying risk factor is not addressed.
Haematuria and urothelial injury: Irritation can cause blood in urine. Persistent haematuria needs assessment for other causes.
Procedure-related problems: Bleeding, infection, ureteric injury, residual fragments, stent symptoms, nephrostomy blockage or need for repeat treatment may occur.

Existing media image: possible complications associated with kidney stones.

12. Prevention and follow-up

General measures after the acute episode

Prevention should begin with the patient’s stone type, clinical history, kidney function, medications, fluid losses, diet and recurrence risk. General measures are useful for many patients, but recurrent or high-risk stone formers often need a targeted plan.

Maintain adequate fluid intake: For many adults, EAU guidance advises fluid intake around 2.5–3.0 litres per day to achieve urine output around 2.0–2.5 litres per day; the recommendation is to maintain a generous fluid intake, preferably water, with urine output above 2.5 litres per day when appropriate. Needs vary with climate, activity, pregnancy, age, kidney and heart function, and fluid restrictions. Do not give a universal target to someone with a prescribed fluid restriction.
Keep normal dietary calcium: Do not routinely restrict food calcium. EAU guidance describes normal calcium intake of about 1.0–1.2 g daily for adults. Calcium with meals binds dietary oxalate in the gut. Supplements should be reviewed with a clinician and taken only when indicated.
Reduce excess salt: Limit highly salted foods and avoid adding excessive salt. The EAU general target is about 4–5 g of salt (NaCl) per day; follow local dietary advice and consider other medical conditions.
Moderate animal protein: Avoid excessive portions of meat and other animal protein. The EAU gives a general adult reference of about 0.8–1.0 g/kg/day; protein needs differ with age, pregnancy, illness and nutritional status, so children and malnourished patients require individual advice.
Choose a balanced diet: Include vegetables, fruit and fibre. Avoid excessive sugar-sweetened drinks and excessive vitamin supplements.
Personalise oxalate advice: Restricting all oxalate-containing foods is not routine. Specific restriction may be advised for documented hyperoxaluria or enteric hyperoxaluria; preserve adequate nutrition and normal dietary calcium.
Manage heat and fluid loss: Replace fluid losses during heavy sweating, fever, vomiting or diarrhoea when medically safe. People working in hot environments may need a deliberate hydration plan.
Address underlying conditions: Treat urinary infection, bowel malabsorption, hyperparathyroidism, gout, renal tubular acidosis or urinary stasis as directed by the relevant clinician.

Stone-specific prevention

Calcium stones: Maintain normal dietary calcium, reduce excess sodium and avoid excessive animal protein. If recurrent or high-risk, test for urinary abnormalities; citrate or a thiazide may be prescribed for selected patients based on results and comorbidities.
Uric acid stones: Adequate fluid, clinician-directed urinary alkalinisation and management of relevant metabolic factors are central. Allopurinol is reserved for appropriate hyperuricosuria or another clinical indication.
Infection stones: Address the infection and aim for complete removal when indicated. Antibiotics are guided by culture and the persistence of bacteriuria, not prescribed automatically for every patient long term.
Cystine stones: Specialist-led care may include very high fluid intake, sodium reduction, urine alkalinisation and medicines that reduce cystine concentration.

Follow-up and recurrence evaluation

Follow-up confirms that the stone has passed or has been treated and that obstruction has resolved. Imaging, renal function tests and timing of review depend on stone location, treatment, symptoms and local specialist guidance. Retrieve and analyse passed stones where possible. People with recurrent stones, childhood onset, a solitary kidney, infection stones, chronic kidney disease, a strong family history or suspected metabolic disease may need a more detailed metabolic assessment and specialist review.

13. Patient and family education

Take prescribed pain relief, antiemetics, antibiotics or preventive medicines exactly as directed; do not share medicines or change a dose without advice.
Return urgently for fever, chills, worsening or uncontrolled pain, persistent vomiting, faintness, confusion, inability to urinate or markedly reduced urine output.
Do not try to force a stone out by rapidly drinking large volumes during an acute attack.
Use a urine strainer if advised and bring any passed stone or fragment for analysis.
Keep the follow-up appointment even if pain improves; symptoms may settle before obstruction has fully resolved.
Attend planned stent removal or exchange and follow nephrostomy care instructions.
Use prevention advice suited to the stone type and personal health. Maintain a balanced diet rather than adopting an extreme food restriction.
Ask the care team how much fluid is safe if living with heart failure, kidney failure, pregnancy or a prescribed fluid restriction.

14. Revision questions and answers

Short-answer questions

What is renal colic?
Severe, often wave-like pain caused by a stone obstructing or irritating the ureter and increasing pressure in the urinary tract.
Why is fever with an obstructing stone an emergency?
It may indicate infection trapped above an obstruction. The patient may need immediate antibiotics and urgent decompression by stent or nephrostomy.
Does absence of haematuria exclude a stone?
No. Haematuria is common but may be absent.
What is the purpose of straining urine?
To retrieve a stone fragment for laboratory composition analysis, which can guide prevention.
Why should nurses avoid encouraging forced fluid loading during acute colic?
Rapid high-volume fluid loading does not reliably push a stone through an obstruction and may worsen discomfort or fluid overload. Correct dehydration and follow the individual plan.
Which procedures can urgently drain an infected obstructed kidney?
Ureteric stenting or percutaneous nephrostomy. The choice depends on the patient, anatomy and local expertise.
Name two factors that guide procedure selection.
Stone size and location; other factors include density, number, obstruction, anatomy, renal function, comorbidities and patient preference.

Clinical scenario

A patient presents with sudden right flank pain, vomiting and visible blood in urine. Their temperature is 39°C, pulse 122 beats/minute and urine output has fallen. Priority: assess for sepsis and obstruction, escalate immediately, obtain cultures promptly if this does not delay treatment, prepare for prescribed antibiotics and urgent urological drainage, and monitor observations, urine output and response closely. Pain relief remains important but must occur alongside management of the emergency.

15. References

European Association of Urology (EAU). EAU Guidelines on Urolithiasis, 2026: assessment, renal colic, infected obstruction, medical expulsive therapy, stone treatment and follow-up. Read the guideline.
European Association of Urology (EAU). Metabolic Evaluation and Recurrence Prevention, 2026: fluid intake, dietary advice, stone analysis and targeted prevention. Read the guideline chapter.
National Institute for Health and Care Excellence (NICE). Renal and ureteric stones: assessment and management, guideline NG118: imaging, pain relief, medical expulsive therapy and prevention recommendations. Read NICE recommendations.

Educational note: This article is for nursing education. Clinical decisions, prescriptions and emergency management must follow current national and facility protocols and be made by the responsible healthcare team.