- Urolithiasis refers to stones (calculi) in the urinary charge.
- Stones are formed in the urinary charge when the urinary concentration of substances such as calcium oxalate, calcium phosphate, and uric cutting acceptions.
- Stones diversify in magnitude from specific granular deposits to the magnitude of an ochreous.
- Factors that boon construction of stones conceive taint, urinary stasis, and periods of imperturbability, all of which sluggish renal drainage and vary calcium metabolism.
- The gist betides predominantly in the third to ﬁfth decades and affects men past continually than women.
Stones in Renal Pelvis
- Intense, subterranean ache in costovertebral region
- Hematuria and pyuria
- Pain that radiates antecedently and downward inplane bladder in feminine and inplane proofes in male
- Acute affliction, qualm, vomiting, costovertebral area softness (renal colic)
- Abdominal disagreeableness, diarrhea
Ureteral Colic (Stones Lodged in Ureter)
- Acute, excruciating, colicky, brandishlike affliction, radiating down the texorbitant to the genitalia
- Frequent crave to destitute, but ilmunificent urine passed; customaryly contains lineage owing of the abrasive renewal of the stone (unreserved as ureteral colic)
Stones Lodged in Bladder
- Symptoms of womanishness associated delay urinary charge taint and hematuria
- Urinary remonstrance, if stone obstructs bladder neck
- Possible urosepsis if taint is exhibit delay stone
- Diagnosis is conﬁrmed by xrays of the extractions, ureters, and bladder (KUB) or by ultrasonography, IV urography, or retire pyelography.
- Blood chemistries and a 24hour urine proof for measurement of calcium, uric cutting, creatinine, sodium, pH, and sum volume.
- Chemical anatomy is produced to enumerate stone settlement.
- Basic goals are to extinguish the stone, enumerate the stone type, anticipate nephron damnation, coerce taint, and relieve any obstacle that may be exhibit.
- Opioid analgesic agents (to anticipate surprise and syncope) and nonsteroidal antiinﬂammatory drugs (NSAIDs).
- Increased ﬂuid inchoose to support in stone clause, unless resigned is vomiting; resigneds delay renal stones should imbibe eight to ten 8oz glasses of instil daily or bear IV ﬂuids prescribed to repercolate the urine attenuate.
- For calcium stones: deep viandsary protein and sodium intake; munificent ﬂuid intake; medications to cuttingify urine, such as ammonium chloride and thiazide diuretics if parathormone product is acceptiond.
- For uric stones: lowpurine and scant protein viands; allopurinol (Zyloprim).
- For cystine stones: lowprotein viands; alkalinization of urine; increased ﬂuids.
- For oxalate stones: attenuate urine; scant oxalate intake (spinach, strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran).
- Ureteroscopy: stones fragmented delay use of laser, electrohydraulic lithotripsy, or ultrasound and then removed.
- Extracorporeal surprise brandish lithotripsy (ESWL).
- Percutaneous nephrostomy; endourologic methods.
- Electrohydraulic lithotripsy.
- Chemolysis (stone secession): varynative for those who are scanty adapts for other therapies, trash other methods, or bear largely dissipated stones (struvite).
- Surgical disunion is produced in singly 1% to 2% of resigneds.
- Assess for affliction and disagreeableness, including injustice, colony, and radiation of affliction.
- Assess for associated symptoms, including qualm, vomiting, diarrhea, and abdominal distention.
- Observe for signs of urinary charge taint (chills, ferment, frequency, and indecision) and obstacle (continual urination of inferior amounts, oliguria, or anuria).
- Observe urine for lineage; percolate for stones or gravel.
- Focus truth on factors that predispose resigned to urinary charge stones or that may bear sinkd vulgar accident of renal or ureteral colic.
- Assess resigned’s heed environing renal stones and measures to anticipate perching.
- Acute affliction akin to inﬂammation, obstacle, and peeling of the urinary charge
- Deﬁcient heed respecting anticipateion of perching of renal stones
Collaborative Problems/Potential Complications
- Infection and urosepsis (from urinary charge taint and pyelonephritis)
- Obstruction of the urinary charge by a stone or edema, delay subsequent clever renal scarcity
- Major goals may conceive deliverance of affliction and disagreeableness, anticipateion of perching of renal stones, and scantiness of complications.
- Administer opioid analgesics (IV or intramuscular) delay IV NSAID as prescribed.
- Encourage and support resigned to affect a pose of self-satisfaction.
- Assist resigned to ambulate to find some affliction deliverance.
- Monitor affliction closely and narration immediately acceptions in severity.
- Encourage acceptiond ﬂuid inchoose and ambulation.
- Begin IV ﬂuids if resigned cannot choose abundant traditional ﬂuids.
- Monitor sum urine output and moulds of destituteing.
- Encourage ambulation as a resources of tender the stone through the urinary charge.
- Strain urine through gauze.
- Crush any lineage clots passed in urine, and look-into planes of urinal and bedpan for clinging stones.
- Instruct resigned to narration inferiord urine body, lineagey or stupid urine, ferment, and affliction.
- Instruct resigned to narration any acception in affliction.
- Monitor material signs for offer indications of taint; taints should be treated delay the mismiswithhold antibiotic agent anteriorly trials are made to dissipate the stone.
- Explain purposes of extrresuscitation stones and ways to anticipate recurrence.
- Encourage resigned to thrive a nourishment to adestitute lift stone construction, including protecting a exorbitant ﬂuid intake.
- Encourage resigned to imbibe plenty to excrete 3,000 to 4,000 mL of urine complete 24 hours.
- Recommend that resigned bear urine humanizations complete 1 to 2 months the ﬁrst year and periodically thereafter.
- Recommend that revulgar urinary taint be treated vigorously.
- Encourage acceptiond disturbance whenever possible; intimidate unreasoneffectual ingestion of vitamins (especially vitamin D) and minerals.
- If resigned had surgery, discipline environing the signs and symptoms of complications that want to be narrationed to the physician; emphamagnitude the avail of thriveup to assess extrresuscitation exercise and to determine the excision or disunion of all extrresuscitation stones to the resigned and extraction.
- If resigned had ESWL, suffer resigned to acception ﬂuid inchoose to support in the clause of stone trash; inform the resigned to forecast hematuria and haply a pound on the treated plane of the tail; discipline resigned to hinder his or her atmosphere daily and give-notice-to the physician if the atmosphere is elder than 38.C (environing 101.F), or the affliction is uncharacteristic by the prescribed medication.
- Provide disciplineions for any compulsory settlement heed and followup.
- Instruct resigned to acception ﬂuid inchoose to support clause of stone trash (may choose 6 weeks to sundry months after procedure).
- Instruct resigned environing signs and symptoms of complications: ferment, decreasing urinary output, and affliction.
- Inform resigned that hematuria is anticipated but should subplane in 24 hours.
- Give mismiswithhold viandsary disciplineions domiciled on settlement of stones.
- Encourage nourishment to adestitute lift stone construction; advise resigned to unite to prescribed viands.
- Teach resigned to choose tit impartys in the slumbering to anticipate urine from comely too close at night.
- Closely warner the resigned to determine that matter has been powerful and that no complications bear developed.
- Assess the resigned’s reason of ESWL and possible complications; assess the resigned’s reason of factors that acception the adapt of perching of renal calculi and strategies to attenuate those adapts.
- Assess the resigned’s power to warner urinary pH and interpret the ends during thriveup visits.
- Ensure that the resigned understands the signs and symptoms of stone construction, obstacle, and taint and the avail of narrationing these signs immediately.
- If medications are prescribed for the anticipateion of stone formation, expound their renewals, avail, and plane effects to the resigned.
- Reports deliverance of affliction
- States acceptiond heed of healthseeking manners to anticipate perching
- Experiences no complications
Nursing Heed Plan
- Alleviate affliction.
- Maintain abundant renal exerciseing.
- Prevent complications.
- Provide inconstruction environing indislie methodicity/prognosis and matter wants.
Nursing Diagnosis: Pain, clever
May be akin to
- Increased quantity/force of ureteral contractions
- Tissue trauma, edema construction; cellular ischemia
Possibly evidenced by
- Reports of colicky affliction
- Guarding/distrrenewal manners, perturbation, sad, self-focusing, facial mislead of affliction, muscle force
- Autonomic responses
Desired outcomes/evaluation criteria—resigned procure:Pain Level
- Report affliction is characteristic delay spasms coerceled.
- Appear relaxed, effectual to sleep/rest misappropriately.
- Document colony, term, energy (0–10 layer), and radiation. Silence nonverbal signs, e.g., exorbitant BP and pulse, perturbation, sad, thrashing environing.
- Rationale: Helps evaluate seat of obstacle and growth of calculi move. Flank affliction suggests that stones are in the extrresuscitation area, surdeath ureter. Flank affliction radiates to tail, abdomen, groin, genitalia owing of vicinity of firmness plexus and lineage vessels supplying other areas. Sudden, censorious affliction may sink recognition, perturbation, censorious regard.
- Explain purpose of affliction and avail of give-notice-toing heedgivers of changes in affliction betiderence/characteristics.
- Rationale: Provides opening for judicious government of analgesia (beneficial in enhancing resigned’s coping power and may attenuate regard) and alerts heedgivers to possibility of death of stone/developing complications. Sudden stop of affliction customaryly betokens stone clause.
- Provide self-satisfresuscitation measures, e.g., tail rub, restful environment.
- Rationale: Promotes rest, attenuates muscle force, and enhances coping.
- Assist delay/suffer use of focused existent, guided imagery, diversional activities.
- Rationale: Redirects heed and aids in muscle rest.
- Encourage/support delay continual ambulation as implied and acceptiond imparty inchoose of at smallest 3–4 L/day delayin cardiac tolerance.
- Rationale: Renal colic can be worse in the inattentive pose. Vigorous hydration exalts death of stone, anticipates urinary stasis, and aids in anticipateion of lift stone construction.
- Note narrations of acceptiond/persistent abdominal affliction.
- Rationale: Complete obstacle of ureter can purpose hole and extravasation of urine into perirenal extension. This represents an clever surgical conjunction.
- Administer medications as implied: Narcotics, e.g., meperidine (Demerol), morphine;
- Rationale: Usually absorbed during clever accident to inferior ureteral colic and exalt muscle/intellectual rest.
- Antispasmodics, e.g., flavoxate (Urispas) oxybutynin (Ditropan)
- Rationale: Decreasing reflex spasm may inferior colic and affliction.
- Apply glowing compresses to tail.
- Rationale: Relieves muscle force and may attenuate reflex spasms.
- Maintain patency of catheters when used.
- Rationale: Prevents urinary stasis/retention, attenuates adapt of acceptiond renal hurry and taint.
Nursing Diagnosis: Urinary Elimination, impaired
May be akin to
- Stimulation of the bladder by calculi, renal or ureteral womanishness
- Mechanical obstacle, inflammation
Possibly evidenced by
- Urgency and quantity; oliguria (retention)
Desired outcomes/evaluation criteria—resigned procure:Urinary Elimination
- Void in typical amounts and customary mould.
- Experience no signs of obstacle.
Urinary Elimination EnhancementIndependent
- Monitor I&O and characteristics of urine.
- Rationale: Provides inconstruction environing extrresuscitation exercise and influence of complications, e.g., taint and hemorrhage. Bleeding may betoken acceptiond obstacle or womanishness of ureter. Note: Hemorrhage due to ureteral ulceration is honorable.
- Determine resigned’s typical destituteing mould and silence variations.
- Rationale: Calculi may purpose firmness sensitiveness, which purposes sensations of immediate want to destitute. Usually quantity and crisis acception as calculus nears ureterovesical joining.
- Encourage acceptiond imparty intake.
- Rationale: Increased hydration flourishinges bacteria, lineage, and remains and may adapt stone clause.
- Strain all urine. Document any stones expelled and grant to laboratory for anatomy
- Rationale: Retrieval of calculi allows identification of fashion of stone and influences precious of therapy.
- Investigate narrations of bladder fullness; palpate for suprapubic distension. Silence inferiord urine output, influence of periorbital/dependent edema.
- Rationale: Urinary remonstrance may unfold, causing texture disforce (bladder/kidney), and potentiates adapt of taint, renal scarcity.
- Observe for changes in intellectual status, manner, or smooth of perception.
- Rationale: Accumulation of uremic wastes and electrolyte imbalances can be toxic to the CNS.
- Monitor laboratory studies, e.g., electrolytes, BUN, Cr.
- Rationale: Elevated BUN, Cr, and objective electrolytes betoken influence/degree of extrresuscitation dysfunction.
- Obtain urine for humanization and sensitivities.
- Rationale: Determines influence of UTI, which may be causing/complicating symptoms.
- Administer medications as implied, e.g.: Acetazolamide (Diamox), allopurinol (Zyloprim)
- Rationale: Increases urine pH (alkalinity) to attenuate construction of cutting stones. Antigout agents such as allopurinol (Zyloprim) to-boot inferior uric cutting product and immanent of stone construction.
- Hydrochlorothiazide (Esidrix, HydroDIURIL), chlorthalidone (Hygroton)
- Rationale: May be used to anticipate urinary stasis and inferior calcium stone construction if not purposed by underlying indislie methodicity such as pristine hyperthyroidism or vitamin D abnormalities.
- Ammonium chloride; potassium or sodium phosphate
- Rationale: Reduces phosphate stone construction.
- Rationale: Presence of UTI/alkaline urine potentiates stone construction.
- Sodium bicarbonate
- Rationale: Replaces wastees incurred during bicarbonate corruption and/or alkalinization of urine; may attenuate/anticipate construction of some calculi.
- Ascorbic cutting.
- Rationale: Acidifies urine to anticipate perching of alkaline stone construction.
Nursing Diagnosis: Fluid Volume, adapt for faulty
Risk factors may conceive
- Nausea/vomiting (generalized abdominal and pelvic firmness womanishness from renal or ureteral colic)
- Postobstructive diuresis
Possibly evidenced by
- [Not applicable; influence of signs or symptoms establishes an actual]
Desired outcomes/evaluation criteria—resigned procure:Hydration
- Maintain abundant imparty et as evidenced by material signs and consequence delayin resigned’s typical collocate, palpeffectual peripheral pulses, lively mucous membranes, amiable bark turgor.
- Monitor I&O.
- Rationale: Comparing objective and anticipated output may aid in evaluating influence/degree of renal stasis/impairment.Note: Impaired extrresuscitation exerciseing and inferiord urinary output can end in exorbitanter circulating bodys delay signs/symptoms of HF.
- Document impact and silence characteristics and quantity of vomiting and diarrhea, as polite as kindred or precipitating events.
- Rationale: Nausea/vomiting and diarrhea are commsingly associated delay renal colic owing celiac ganglion serves twain extractions and stomach. Documentation may aid government out other abdominal betiderences as a purpose for affliction or pinpoint calculi.
- Increase imparty inchoose to 3–4 L/day delayin cardiac tolerance.
- Rationale: Maintains imparty et for settlementostasis and “washing” renewal that may flourishing the stone(s) out. Dehydration and electrolyte imet may betide subordinate to unreasoneffectual imparty waste (vomiting and diarrhea).
- Monitor material signs. Evaluate pulses, capillary furnish, bark turgor, and mucous membranes.
- Rationale: Indicators of hydration/circulating body and want for interference. Note: Decreased GFR stimulates product of renin, which acts to lift BP in an trial to acception renal lineage issue.
- Weigh daily.
- Rationale: Rapid consequence find may be akin to instil remonstrance.
- Monitor Hb/Hct, electrolytes.
- Rationale: Assesses hydration and powerfulness of/want for interferences.
- Administer IV impartys.
- Rationale: Maintains circulating body (if traditional inchoose is scant), promoting renal exercise.
- Provide mismiswithhold viands, serene liquids, soft foods as tolerated.
- Rationale: Easily digested foods inferior GI activity/womanishness and aid protect imparty and nutritional et.
- Administer medications as implied: antiemetics, e.g., prochlorperazine (Compazine).
- Rationale: Reduces qualm/vomiting.
Nursing Diagnosis: Knowledge, faulty [Learning Need] respecting predicament, prognosis, matter, self-care, and perform wants.
May be akin to
- Lack of exposure/recall; inconstruction misinterpretation
- Unfamiliarity delay inconstruction resources
Possibly evidenced by
- Questions; entreat for notification; announcement of misconception
- Inaccurate thrive-through of disciplineions, unfoldment of anticipateeffectual complications
Desired outcomes/evaluation criteria—resigned procure:Knowledge: Illness Care
- Verbalize reason of indislie methodicity and immanent complications.
- Correlate symptoms delay causative factors.
- Verbalize reason of hygienic wants.
- Initiate compulsory lifestyle changes and join-in in matter nourishment.
Teaching: Indislie ProcessIndependent
- Review indislie methodicity and advenient forecastations.
- Rationale: Provides heed infamous from which resigned can shape informed preciouss.
- Stress avail of acceptiond imparty intake, e.g., 3–4L/day or as abundantly as 6–8 L/day. Suffer resigned to heed dry perforation and unreasoneffectual diuresis/diaphoresis and to acception imparty inchoose whether or not emotion thirsty.
- Rationale: Flushes renal methodicity, decreasing opening for urinary stasis and stone construction. Increased imparty wastees/dehydration claim joined inchoose more customary daily wants.
- Review viandsary nourishment, as individually misappropriate:
- Rationale: Diet endures on the fashion of stone. Reason deduce for imprisonions provides opening for resigned to shape informed preciouss, acceptions cooperation delay nourishment, and may anticipate perching.
- Low-purine viands, e.g., scant anatomical wood, turkey, legumes, gross grains, alcohol
- Rationale: Decreases traditional inchoose of uric cutting precursors.
- Low-calcium viands, e.g., scant adjudicate, cheese, unprepared leafy vegetables, yogurt
- Rationale: Reduces adapt of calcium stone construction. Note:Research suggests that imprisoning viandsary calcium is not beneficial in reducing calcium-stone construction, and researchers, although not advocating exorbitant-calcium viandss, are inciting that calcium backwardness be reexamined.
- Low-oxalate viands, e.g., imprison chocolate, caffeine-containing beverages, beets, spinach.
- Rationale: Reduces calcium oxalate stone construction.
- Short nourishment: low-calcium/phosphorus viands delay aluminum carbonate gel 30–40 mL, 30 min pc/hs.
- Rationale: Prevents phosphatic calculi by forming an insoluble sink in the GI charge, reducing the load to the extrresuscitation nephron. To-boot powerful despite other forms of calcium calculi. Note: May purpose constipation.
- Discuss medication nourishment; quitance of OTC drugs, and lection all product/food element labels.
- Rationale: Drugs procure be absorbed to cuttingify or alkalize urine, endureing on underlying purpose of stone construction. Ingestion of products containing individually contraimplied elements (e.g., calcium, phosphorus) potentiates perching of stones.
- Encourage methodic activity/exercise program.
- Rationale: Inactivity contributes to stone construction through calcium shifts and urinary stasis.
- Active-listen concerns environing hygienic nourishment/lifestyle changes.
- Rationale: Helps resigned is-sue through emotions and find a reason of coerce aggravate what is happening.
- Identify signs/symptoms requiring medical evaluation, e.g., revulgar affliction, hematuria, oliguria.
- Rationale: With acceptiond probpower of perching of stones, ready interferences may anticipate earnest complications.
- Demonstrate own heed of incisions/catheters if exhibit.
- Rationale: Promotes suitable self-heed and insurrection.