For nursing students

1. NEPHROLITHIASIS
By Dr. KRISHNA GHARTI

2. Introduction
 Nephrolithiasis is a formation of stone in the
kidney. Kidney stones are small deposit that build
up in the kidney made of calcium, phosphate and
other components.
 Nephrolithiasis represent one of the 3 common
emergency admissions seen on urology wards (the
other 2 being acute urinary retention and
haematuria).
 Approximately 50% of patients present between
the ages of 30 and 50 years.
 There is a slight male preponderance.

3. Factors responsible for stone formation
 Crystalloid colloid imbalance.
 Infection.
 Parathyroid tumour.
 Diminished excretion citrate in urine.
 Prolonged immobilization.
 Climate factor.
 Dietary factor.

4. Types of urinary stones
 According to site
a. Renal stone.
b. Ureteric stone.
c. Bladder stone.
d. Urethral stone.
 According to
composition
a. Phosphate stone.
b. Oxalate stone.
c. Uric acid stone.
d. Cysteine stone.
e. Xanthine stone.

5. Typical features of some stones
 Phosphate stone
 Also known as triple phosphate stones or struvite
stones or staghorn stone.
 They tends to grow in alkaline urine especially
with infection caused by urea splitting bacteria
(proteus, pseudomonas, staphylococcus).
 They are soft stones with smooth surface. So,
they causes less pain and presentation will be
late.
• Oxalate stone
 Irregular sharp projections which cause bleeding.
Presentation will be early with heamaturia and
pain.
 Very hard stones.

6.  Uric acid stone
 Multiple, may be hard or soft. Present in late stage.
 They are radiolucent that is they are not seen on
plain xray KUB.
 Uric acid, cysteine and xanthine stones are known
as metabolic stones.

7. Symptoms
 Pain (Unilateral or bilateral flank pain).
 Nausea.
 Vomiting.
 Urinary frequency.
 Haematuria.
 Abdominal pain.
 Dysuria.
 Nocturia.
 Fever / Chills.
 Abnormal urine color or smell

8. Investigations
 Laboratory
a. Blood: CBC, Na+, K+, Creatinine
b. Urine: urine routine and microscopic
examination
 X Ray (KUB)
 USG abdomen
 Intravenous urography (IVU)
 CT scan of abdomen

9. Management of stones
 Indication of active removal of stone
1. Size (when stone is of the size 5-8mm or more).
Stones <5mm size should wait for natural
expulsion).
2. Repeated colicky pain.
3. Repeated haematuria.
4. When straight X ray shows stone is increasing in
size.
5. If stone is present in the plviureteric junction or
vesicoureteric junction.

10. Modalities of management
 Conservative  Surgical
1. Non-invasive
2. Minimally invasive
3. Invasive or open
surgery

11. Conservative
 Wait and watch if asymptomatic stones, stones ≤ 5
mm in size and no associated complications.
 Drink plenty of water, do exercise and jogging.
 On acute presentation give analgesics (diclofenac
100 mg or other higher grade analgesics like
morphine, pethedine), anti-emetics (ondem,
perinorm), antispasmodics (buscopan).
 Depending on the type of stone such medication
are given to reduce further stone formation or
dissolve the material forming the stone such as
diuretics, phosphate solution,
allopurinol,antibiotics, sodium bicarbonate or
sodium citrate.

12. Surgical
 Non-invasive
1. ESWL (Extracorporeal shock wave lithotripsy)
 Minimally invasive
1. Percutaneous nephrolithotomy (PCN)
2. Uretero Renoscopic lithotripsy (URSL)
 Invasive or open surgery
1. Open pyelolithotomy
2. Extended pyelolithotomy
3. Nephrolithotomy

13. A: Extracorporeal
shock wave lithotripsy
(ESWL)
for renal calculi
dissolution.
B: A percutaneous
nephrostomy tract
permits access to the
collecting system of the
kidney for removal of
renal calculi under
direct vision via a
nephroscope. (PCNL)

14. Complications of renal stones
 Infection (Pyelonephritis, Pyonephrosis).
 Obstruction (Hydronephrosis).
 Persistent haematuria leading to anemia.
 Chronic renal failure.

15. Nursing management
 Nursing Assessment
1. Obtain history focusing on family history of calculi,
episodes of dehydration, prolonged immobility, UTI, dietary,
bleeding history, and medication history.
2. Assess pain location and radiation; assess level of pain
using a scale of 1 to 10. Observe for presence of associated
symptoms: nausea, vomiting, diarrhea, abdominal
distention.
3. Monitor for signs and symptoms of UTI, such as chills,
fever, dysuria, frequency. Examine urine for hematuria.
4. Observe for signs and symptoms of obstruction, such as
frequent urination of small amounts, oliguria, anuria.

16.  Nursing Diagnosis
1. Acute Pain related to inflammation, obstruction, and
abrasion of urinary tract by migration of stones.
2. Impaired Urinary Elimination related to blockage of
urine flow by stones.
3. Risk for Infection related to obstruction of urine flow
and instrumentation during treatment

17.  Nursing Interventions
Controlling Pain
1. Give prescribed NSAID or opioid analgesic (usually I.V. ) until
cause of pain can be removed.
2. Encourage patient to assume position that brings some relief.
3. Administer anti-emetics as indicated for nausea.
Maintaining Urine Flow
1. Administer fluids orally or I.V. (if vomiting) to reduce
concentration of urinary crystalloids and ensure adequate
urine output.
2. Monitor total urine output and patterns of voiding. Report
oliguria or anuria.
3. Help patient to walk, if possible, because ambulation may
help move the stone through the urinary tract.

18. Controlling Infection
1. Administer parenteral or oral antibiotics, as
prescribed
during treatment, and monitor for adverse effects.
2. Assess urine for color, cloudiness, and odor.
3. Obtain vital signs, and monitor for fever and
symptoms of impending sepsis (tachycardia,
hypotension).