Last edited: 6/21/2023

RENAL CALCULI
Renal Calculi Medical Editor: Aldrich Christiandy

OUTLINE
I) PATHOPHYSIOLOGY IV) SIGNS & SYMPTOMS VII) NURSING
II) CAUSES AND RISK V) DIAGNOSTIC INTERVENTIONS
FACTORS VI) PROCEDURES (A) INCREASE FLUIDS
(B) STRAIN THE URINE
III) TYPES OF STONES (A) EXTRACORPOREAL SHOCKWAVE
LITHOTRIPSY (ESWL) (C) ENCOURAGE AMBULATION
(A) CALCIUM OXALATE (MOST COMMON)
(B) PERCUTANEOUS NEPHROLITHOTOMY (D) MEDICATIONS
(B) URIC ACID
(E) ALTER DIET
(C) STRUVITE STONE
(D) CALCIUM PHOSPHATE VIII) APPENDIX
(E) CYSTINE STONE IX) REVIEW QUESTIONS
X) REFERENCES

I) PATHOPHYSIOLOGY II) CAUSES AND RISK FACTORS

Some of these cause increased concentration.

(1) Dehydration
The kidney is trying to make filtrate, → becomes urine
that we urinate out Not drinking enough water
o Creating a balance of filtering out things that we don’t Sweating a lot
and keeping what we do need On diuretic → urinating a lot
o So within our urine, there is a certain amount of
concentration of substances (2) Alteration in medications

When we eat food or take medications, and we have

any comorbidities or imbalances within our body (3) Absorption problem
o The balance of electrolytes, nutrients, and fluids is
In patients that have irritable bowel diseases like
going to change
o Crohn’s disease
→ alter the concentration in the urine
o Ulcerative colitis
o When the concentration is too rich →, form crystal →
form stone (4) Hyperparathyroidism
Stone location Causing hypercalcemia
Kidney (5) Neurogenic bladder
Ureter
Opening into the bladder (vesicoureteral junction)
(6) Frequent urinary tract infection (UTI)
Introduction of the stone
Stone in the kidney may have no problem
o When the kidney starts to “move,” → start to (7) Hereditary
experience pain
o Think about a jagged stone → trying to push through
(8) Male
the tube
Depending on the size of the stone Males are more likely to form a kidney stone
o If it’s a tight fit →, creating some tear or damage
along
o As it does, the patient starts to experience pain
Stone physically gets stuck → not going down through
into the bladder
o Can’t urinate it out → start to have to build up of
urine into the kidney

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 III) TYPES OF STONES

Not necessarily important for NCLEX

o But important to understand there are different ones
o Because that could also indicate a different type of treatment/care that we give to our patients

(A) CALCIUM OXALATE (MOST COMMON) (C) STRUVITE STONE

Increased calcium and oxalate in the urine More alkaline in the environment
Due to Related to bacteria
o Hyperparathyroidism So, think about patients that have
o Hypercalcemia o Chronic UTI
o Hypercalciuria o Neurogenic bladder
o Dehydration  Not able to empty their bladder as often
o IBD (Crohn’s disease)  Build up of bacteria → Creating an alkaline
Different ways we can help this patient environment
o Changing the amount of Ca2+ and oxalate intake
(D) CALCIUM PHOSPHATE
o Changing medications
Different from calcium oxalate
(B) URIC ACID Found in alkaline urine
Increased uric acid in the urine → creates crystal → o Hyperparathyroidism
create stone o Renal tubular acidosis
Treat their gout → better outcome of decreased Less common
occurrence of uric acid stone
(E) CYSTINE STONE
Rarest
Increase in cysteine → crystal → stone
Hereditary

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 IV) SIGNS & SYMPTOMS

Despite all the different types of stones

o There are symptoms and clinical manifestations of the patients that are relatively similar
Stones not trying to advance anywhere through the kidney → ureter → bladder causing no symptoms
When the stone starts moving, that’s when we could have the symptoms.

(1) Flank pain (6) Elevated heart rate and blood pressure due to pain
If the stone drops on the
o Right side → Right-sided flank pain (7) Septic → blood pressure is starting to drop
o The same goes for the left side
So, start thinking about what their vital signs are looking
The pain is severe and stabbing
like
They may not think it’s their flank
o They may say, “You know, for a day or so, I’ve been (8) Difficulty going to the bathroom
having like this. I don’t know, like discomfort, and I
Having urgency and frequency
thought I threw my back out a little bit. But now, it’s
Less urine output
not getting any better. It’s getting worse. It almost
o Due to the stone partially blocking the flow of urine
feels like I’m getting stabbed back there.”
Assess the patient (9) Hematuria
o Do light tap on both sides on the costovertebral angle The patient might also complain, “Yeah, my urine looks a
o Generally, they’re going jolt because that’s painful little bloody. I can’t really tell, but it’s getting a little
and tender back there darker and red.”
That’s when we’re going to think that’s blood in the urine
(2) Abdominal distention/discomfort and pain
o Remember, as the stone progresses, it can scrape
Pain may radiate around to the front down the sides
→ little breakage of the vessels
(3) Nausea, vomiting
→ blood appears in the urine
Mainly look for these symptoms
(4) Diaphoretic, sweating
Very severe flank pain
o Stabbing pain
(5) Fever Hematuria
Remember, the stone is trying to progress through
If they start developing fever and the stone is possibly lodged
o There could be an infection going on

V) DIAGNOSTIC

(2) Imaging
Goal
o Verify that there’s a stone
o Where is the stone?
o What size of the stone?
Modalities
o X-ray KUB
o CT scan
o Ultrasound
The location and size of the stone are important
Blood work → nondescript for this patient because there’s a certain threshold where patients
typically pass stones
(1) Urinalysis
o And there’s a threshold where they’re not going to pass the stone
Blood? o We have to do something more to get the stone out
White blood cells?
Size → 4-6mm (depending upon the facility we work at)
< 4mm → The stone may pass
> 6 mm → The stone may not pass

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 VI) PROCEDURES

(A) EXTRACORPOREAL SHOCKWAVE (B) PERCUTANEOUS

LITHOTRIPSY (ESWL) NEPHROLITHOTOMY
Shockwave (sound or laser) goes in and If the stone is too big or something that we
busts the stone into little pieces can’t really bust-up with the waves
Similar to recovery, somebody who’s Put a small incision → go in and grab out
allowing the stone to pass the stone
o But they’re going to have the presence o Potentially have a nephrotomy tube
of a lot more little stones where they’re going to have some
o May have a little more blood within drainage
the urine for the first 24 hours Very common → blood in the urine for the
 Because we busted the stone → a first 24 hours
little more damage to the area o It should be progressively getting clearer,
not darker

VII) NURSING INTERVENTIONS

Focusing on passing their stone without getting some procedure

When we’re hoping that our patients can pass this stone on their own
o The biggest thing we want to think about is dehydration
o High concentrations of crystals cause stones

(A) INCREASE FLUIDS (D) MEDICATIONS

Drink (1) NSAIDS and opioids
If they can’t drink, give IV fluids
As we increase the fluids Get these patients comfortable
o Hopefully, it’s going to be able to perfuse those o Within patient-centered care, we want to start thinking
kidneys → push the stone out. about their comfort.
One of their biggest complaints is pain
(B) STRAIN THE URINE o Make sure we’re taking care of pain
So that we know when the stone comes out NSAID → ketorolac (Toradol) IV
o Physically see the stone o Decrease inflammation and help the patient have a
Take the stone and send it off to the lab to analyze it little more comfort
o That’s going to indicate to us what our patient's care If NSAID is not working
should be further o Move to opiates, e.g., morphine or other
o To prevent other stones just like it medications depending on what the doctor orders.
 Alter the diet
(2) Antibiotics
 Change the medication
Treat the infection
(C) ENCOURAGE AMBULATION
(3) Antiemetics → Ondansetron (Zofran)
Promote our patients to be able to get rid of and pass the
stone For nausea and vomiting
We want our patients to walk The first time they’re getting opiates (they might
o Hopefully, we will get the stone moving experience nausea)

(4) Alpha-blocker → Tamsulosin (Flomax)

Dilate the diameter of the ureter → creating a bigger

passage for the stone to come through.

(E) ALTER DIET

Depending upon the type of stone
o Decrease protein
o Decrease purine
Not particularly the same for every single patient

These are the biggest nursing interventions we want along with I/Os
o The medications that we’re giving
o Increasing fluids
o Strain the urine
o Getting them to ambulate
Also, making sure that their vitals are stable

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 VIII) APPENDIX

IX) REVIEW QUESTIONS X) REFERENCES

1) Increased concentration of calcium and oxalate intake ● Hoffman, B. L., Casey, B. M., & Spong, C. Y. (2018). Williams
Obstetrics (25th ed.). New York: McGraw-Hill Education.
with dehydration increases the chance of forming
calcium oxalate stones.
a) True
b) False

2) Which findings below that may be found in patients

with renal calculi, EXCEPT?
a) Red blood cells
b) Crystals
c) White blood cells
d) Glucose

3) Extracorporeal shock wave lithotripsy is a suitable

treatment for patients with relatively large renal
calculi.
a) True
b) False

4) Urine straining is important to help us on deciding the

proper treatment plan for the patients in order to treat
the patient and prevent the recurrence of the renal
calculi.
a) True
b) False

5) Alpha-blockers are mainly used to contract the

ureters in order to expulse the stones.
a) True
b) False

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