Renal calculi are made of minerals and acid salts that form in the kidney. This health condition is known as nephrolithiasis. These kidney stones can travel to the rest of the urinary tract such as the ureters, bladder, and urethra, and can result to urolithiasis.
Renal calculi begin to form when there is a high concentration of these crystal-forming substances than the fluid in the urine the kidneys can dilute.
Collections of these stones can cause obstruction and infection in severe cases. Although renal stones are commonly mild and can be treated symptomatically it accounts for 1 million emergency visits annually in the U.S.
Signs and Symptoms of Renal Calculi
The signs and symptoms of renal calculi may vary depending on the location of the kidney stone ranging from asymptomatic to severe infection or hemodynamic instability. These may include:
- Sudden or gradual onset of unilateral, abdominal/flank colicky pain
- Radiating pain in the back, lower abdomen, or groin with fluctuating intensity
- Pain or burning sensation upon urination
- Frequent urgency to urinate with small amounts of urine
- Nausea or vomiting
- Fever and chills
- Dark-color urine or blood in the urine (usually seen microscopically)
- Soft, non-distended abdomen
- Pediatric patients may be seen as restless, irritable, and crying
- In severe cases, the patient may present with mild confusion due to metabolic abnormalities.
Causes of Renal Calculi
There are different types of waste particles or crystal-forming substances that can cause the formation of kidney stones such as:
- Calcium Stones. These are composed of calcium oxalate, phosphate, or maleate. While it is true that calcium is the most abundant mineral in our body, consuming a diet high in calcium does not contribute to the formation of these stones but certain foods with high oxalates do such as spinach, beet, nuts, and chocolates. Certain medications like fish oil, vitamin C and high-dose vitamin D can cause calcium stone formation. Metabolic conditions such as type 2 diabetes mellitus, obesity, and hyperlipidemia are associated with calcium oxalate and uric acid stones. It is also the most common type of kidney stone that accounts for 80% of the cases.
- Struvite Stones. This is also called the infection stone as it is commonly formed secondary to a urinary tract infection. It is composed of magnesium ammonia phosphate from an elevated urine pH caused by Proteus or Klebsiella infections. This accounts for 10% of kidney stone cases.
- Uric Acid Stones. Certain metabolic disorders like diabetes, obesity, chronic diarrhea, or malabsorption can cause the formation of these stones. Diets high in animal protein can increase the uric acid level. 9% of kidney stone cases are uric acid stones.
- Cystine Stones. This is a rare type of kidney stone caused by a congenital disorder called cystinuria caused by a defective cystine metabolism and transport leading to stones. This rare type of kidney stone accounts for 1% of the cases.
Risk Factors to Renal Calculi
The risk of having renal calculi increases because of any condition that causes an obstruction or reduction in urinary flow. Certain risk factors increase the incidence of a stone formation such as:
- Gender. Men have a higher incidence in most cases, but women are more likely to have struvite stones because they tend to have urinary tract infections frequently.
- Race. White and non-Hispanic have high incidence than black people.
- Age. It is common among the ages 20 to 50 or the working-age population with rising incidence due to lifestyle and diet influences in the working environment.
- Family history. It is most likely to acquire kidney stones if it runs in the family or had it previously.
- Obesity. Associated with calcium oxalate and uric acid stone formation.
- Dehydration. Reduced body fluid affects the dilution of the urine by decreasing urine output and increasing urine pH leading to the formation of stones.
- Diet. High sodium, oxalate, fat, sugar, and animal protein diet contribute to different substances the kidney must filter leading to renal stone formation. High sodium intake also increases the amount of calcium in the urine.
- Medications. Diuretics, antacids, antiseizure, vitamin C, and a high dose of vitamin D increase the risk of kidney stone formation.
- Metabolic disorder. Diabetes, inflammatory bowel disease, or chronic diarrhea causes changes in the absorption of water increasing crystal-forming substances in the urine.
- Surgery and other medical conditions. Gastric bypass surgery, cystinuria, or repeated urinary tract infection increase the risk of kidney stones.
Complications of Renal Calculi
The presence of renal calculi can be asymptomatic until serious complications arise which commonly cause excruciating pain and serious medical emergency. This includes:
- Sepsis. Severe infections such as septicemia are one of the most common and most life-threatening complications of renal stones as they may block the urine flow causing urinary retention and septicemia. Sepsis or blood poisoning is the body’s deadly response to infection.
- Renal scarring. It is the kidney’s response to injury which reduce its ability to filter waste products leading to progressive renal failure. Frequent urinary tract infections and renal calculi can cause this injury. This condition doesn’t have a cure and is considered irreversible.
- Obstruction. This is the latest and most painful manifestation of renal calculi. The obstruction may lead to the dilation of the ureter and hydronephrosis which eventually lead to renal failure. Unilateral obstruction can be asymptomatic but bilateral obstruction usually present with renal failure and requires prompt treatment.
- Anuria. This is also called anuresis, defined as non-passage of at least 100mL of urine per day where the kidney cannot produce urine. This is usually caused by a large kidney stone stuck in the urethra leading to complete bladder blockage and urinary retention.
- Urinary Tract Infection. Recurrent infection related to kidney stones can cause damage over time through inflammation and scarring of kidney tissues.
- Renal failure. Severe blockage and untreated renal obstruction will eventually cause kidney atrophy and loss of function. Although this rarely happens this can lead to a serious medical condition and lifetime treatment.
Diagnosis of Renal Calculi
Early detection can help prevent the development of complications of renal calculi. The diagnostic tests usually include:
- Urinalysis. This is the primary test used to detect the presence of blood in the urine (hematuria), leukocytes, bacteria, crystals, increased WBC, and pH level of the urine.
- Blood tests. Complete blood count detects elevated white blood cell count that signifies an infection. Basic Metabolic Panel (BMP) can also be used to measure the level of glucose and electrolytes such as calcium, sodium, and potassium which are indicators of kidney dysfunction.
- Physical assessment. A thorough physical assessment along with the signs and symptoms can help in determining the location of the stones.
- Patient history. Complete medical history should include family history, previous surgery, diet, and medical conditions.
- Imaging. List all commonly used imaging tests for the disease example for cancer:
- CT Scan. An abdominal or pelvic CT scan is the ideal diagnostic test to use as it can detect renal calculi as small as 3mm in size.
- KUB Ultrasound. This is a non-invasive procedure ideal for pediatric and pregnant patients that can quickly measure and detect renal stone location.
- MRI. This can be used adjunctively with ultrasound as it provides 3-dimension imaging without radiation and is reliable in determining hydronephrosis.
- X-ray. This is commonly used in monitoring stone growth for radiopaque stones such as calcium oxalate and phosphate.
- Kidney stone analysis. This test is used to determine the composition of the stone to determine the cause and appropriate treatment.
Treatment for Renal Calculi
Treatment of patients with renal calculi may vary depending on the present condition and complications associated which includes conservative and surgical interventions such as:
- Medications. The initial treatment goal is to relieve symptoms and the underlying conditions.
- Analgesics. NSAIDs are the first choice of treatment for pain. Opioids are used for severe refractory pain.
- Antiemetics. Used to relieve nausea and vomiting.
- Antibiotics. Management of urinary tract infections that can cause struvite stones.
- Diuretics. Help prevent calcium stones from forming.
- Alpha-blocker. Muscle relaxant that facilitates passage of stones by relaxing the muscles in the ureter.
- IV Fluids. Help the patient stay hydrated and act as natural diuretics that may help in flushing out kidney stones.
- Procedures. Patients with larger kidney stones may benefit from the following acute urologic interventions:
- Extracorporeal shockwave lithotripsy (ESWL). This procedure uses shockwave to break the stones into smaller pieces that can be passed into the urine. A follow-up ureteral stent placement may be done to facilitate the passage of the stones.
- Flexible ureteroscopy (URS). This method uses an endoscopic approach to remove blocked stones in the lower urinary tract or ureter.
- Indwelling urinary catheter. This is used as an urgent management for patients with acute renal obstruction to decompress the bladder.
- Surgery. For larger stones that do not pass spontaneously, surgical management must be done to prevent permanent renal damage such as:
- Percutaneous nephrolithotomy (PCNL). This is used for stones greater than 20mm in size located in the upper urinary tract such as kidneys and proximal ureter. A ureteroscope is also used over a small incision at the back to remove the stones.
- Nephrostomy tube. This is an emergent, minimally invasive procedure that is used to bypass the obstruction and drain urine from the body to prevent permanent renal damage.
Nursing Diagnosis for Renal Calculi
Nursing Care Plan for Renal Calculi 1
Nursing Diagnosis: Acute Pain related to tissue trauma secondary to the excretion of renal calculi as evidenced by hematuria and burning pain with urination.
Desired Outcomes:
- The patient will be able to urinate normally without any pain and discomfort.
- The patient will be able to perform activities that provide relief and control of pain.
| Renal Calculi Nursing Interventions | Rationale |
| Document the patient’s characteristics and level of pain (pain scale 1-10). Note for signs such as blood pressure elevation, rapid pulsation, and blood in the urine. Observe for nonverbal cues such as facial grimaces, irritability, or restlessness. | Documentation will help in determining the effectiveness of the treatment and monitoring of progress. Pain can cause blood pressure and pulse rate to increase. Blood in the urine suggests the passage of stones. Restlessness and irritability are due to severe pain. |
| Encourage and increase fluid intake up to 3-4 liters a day as tolerated. | An increase in fluid intake promotes frequent urination and passing of stones preventing further stone formation. |
| Educate the patient about sitz bath and apply a warm compress to the lower abdomen. | Sitz bath is proven to be effective in relaxing urinary muscles, reducing edema, promoting comfort and pain relief. |
| Assist the patient with frequent ambulation. | Ambulation can aid in the passage of kidney stones via gravity while renal colic tends to worsen when lying. |
| Educate patient about diversional activities such as focused breathing and guided imagery. | This facilitates control of attention from pain and relaxation of muscles. |
| Provide rest in between activities and a peaceful environment. | This promotes relaxation reducing muscle tension. |
| Encourage verbalization of feelings and notify the caregiver of any changes in pain. | Change in characteristics of pain may signify a passage of stone which may aid in timely administration of pain medication. |
Nursing Care Plan for Renal Calculi 2
Nursing Diagnosis: Impaired Urinary Elimination related to mechanical obstruction secondary to renal calculi formation s evidenced by oliguria and distended bladder.
Desired Outcomes:
- The patient will be able to achieve a normal elimination amount and pattern.
- The patient will verbalize techniques to prevent urinary retention.
| Renal Calculi Nursing Interventions | Rationale |
| Assess the patient’s current elimination pattern and compare it with the patient’s normal elimination pattern before the manifestation of symptoms. | This will serve as baseline data to compare with the present condition of the urinary elimination pattern. |
| Monitor patient’s intake and output | This will determine the patient’s hydration status and check for urinary retention. |
| Palpate the bladder. | To check for bladder distention and fluid retention. |
| Encourage an increase in water intake. | Adequate fluid intake increases urine production, flushing out renal stones and preventing further formation of stones. |
| Assist the patient with frequent ambulation. | Ambulation facilitates the passage of kidney stones spontaneously. |
| Encourage the patient to void every 2 to 3 hours. | This will relieve bladder distention and avoid urine accumulation. |
| Instruct the patient to strain every urine voided and document the characteristics of the stones and urine. | This may help the primary care provider to plan appropriate treatment and preventive measures needed to prevent further renal damage. |
| Insert an indwelling catheter as ordered. | This will facilitate the draining of the bladder relieving the distention. This may also help in evacuating renal stones and debris that may have caused the blockage. |
| Educate on bladder training and pelvic floor exercises. | Catheter insertion may affect the integrity of the pelvic muscles. Kegel exercises help strengthen the pelvic muscles. Bladder training prevents urinary retention relieving bladder distention. |
Nursing Care Plan for Renal Calculi 3
Risk for Deficient Fluid Volume
Nursing Diagnosis: Risk for Deficient Fluid Volume related to vomiting secondary to the presence of renal calculi.
Desired Outcomes:
- The patient will be able to tolerate fluids without vomiting within 24 hours.
- The patient will have an adequate and equal amount of intake and output within 24 hours.
| Renal Calculi Nursing Interventions | Rationale |
| Document the frequency and the characteristic of the patient’s vomitus as well as precipitating factors or events. | Vomiting is commonly associated with renal calculi. Documenting may help in monitoring the effectiveness of treatment. |
| Monitor intake and output along with the patient’s daily weight. | Adequate intake and output mean adequate kidney function and hydration status of the patient. Determining the amount of fluid loss can aid in the adequate amount of fluids to be replaced. Decreasing weight may signify dehydration. |
| Assess the patient’s mental status and skin integrity every 2 hours. | Dehydration and electrolyte imbalance from vomiting may affect the patient’s mental state and skin integrity with decreased perfusion. |
| Monitor vital signs frequently. | Vital sign changes such as decreased blood pressure and increased heart rate may indicate hypovolemia. |
| Assess the patient’s readiness for clear liquids within 4 hours. | Oral intake after vomiting can cause GI irritation and further vomiting. |
| Administer intravenous fluid as ordered. | Maintains fluid balance and prevents dehydration while the patient cannot tolerate oral fluids due to vomiting. |
| Instruct the patient on gradual oral intake as tolerated. | To replace lost volume from vomiting and maintain homeostasis. |
| Educate the patient about fluid replacement therapy. | Electrolyte-rich oral fluids such as sports drinks can help replace fluid loss. |
| Administer antiemetics as ordered. | Resolve vomiting and prevent electrolyte imbalance. |
Nursing Care Plan for Renal Calculi 4
Nursing Diagnosis: Deficient Knowledge related to unfamiliarity with information resources about renal calculi as evidenced by frequent questions and clarification
Desired Outcomes:
- The patient will verbalize understanding of the disease process and potential complications of having renal calculi.
- The patient will participate and comply with the treatment plan.
| Renal Calculi Nursing Interventions | Rationale |
| Assess the patient’s level of knowledge and understanding. | This will determine the patient’s cognitive level to properly plan for an effective teaching approach about renal calculi and the appropriate management. |
| Assess the patient’s beliefs and willingness to learn. | Certain beliefs may block the patient from accepting information from another person. Being open-minded promotes good learning outcomes and better understanding. |
| Educate the patient about his/her condition and treatment plans in a language that the patient can easily understand. | Detailed information about the condition will help the patient accept and trust the treatment plan. Avoid using medical jargon as this may cause confusion and further questions from the patient and significant others. |
| Educate the patient and significant others using visualization materials such as structural models, images, or videos. | This will provide a clear and detailed picture of the patient’s condition without confusing the patient. |
| Encourage lifestyle modification such as proper diet and regular exercise. | High sodium and animal protein food have increased renal stone formation. Inactivity also contributes to stone formation caused by urinary stasis. |
| Instruct the patient to repeat the given information about his/her condition. | This will determine the patient’s comprehension of the information given. |
| Encourage verbalization of feelings and active listening with the patient. | Promote a trusting environment with positive outcomes. |
| Encourage the patient to report any concerns or problems that may arise during the treatment. | Building trust is important, as it increases promotes cooperation and compliance with the treatment plan. |
Nursing Care Plan for Renal Calculi 5
Nursing Diagnosis: Hyperthermia related to urinary tract infection secondary to renal calculi as evidenced by high body temperature and flushed skin.
Desired Outcome: The patient will be able to maintain a normal body temperature after 4 hours of intervention and treatment.
| Renal Calculi Nursing Interventions | Rationale |
| Assess and monitor vital signs frequently along with other signs and symptoms that can be associated with hyperthermia. | This will serve as baseline data to monitor progress and the patient’s response to treatment. |
| Assess the patient for any signs of dehydration such as dry mucous, decrease perfusion, or decrease urine output. | Hyperthermia can cause dehydration and early detection may help prevent further complications and problems. |
| Instruct the patient to remove unnecessary clothing and regulate room temperature and humidity. | Excessive and constricting clothing may cause the body temperature to elevation the same as hot and humid environment. |
| Assist the patient in a tepid sponge bath or an ice bath as tolerated. Place an ice pack on the groin area, axilla, and neck. | This can quickly drop the body temperature and must be discontinued once the patient’s core temperature lowers down to less than 38 degrees Celsius. |
| Provide the patient with a cooling blanket or hypothermal blanket. | This will quickly drop the body temperature while providing comfort to the patient. |
| Encourage an increase in fluid intake and start an IV infusion as ordered. | Adequate fluid intake increases urine production, flushing out renal stones. This may also help lower the body temperature and prevent dehydration from hyperthermia. |
| Administer antipyretics and antibiotics as ordered. | This will quickly lower the body temperature and resolve the ongoing infection that causes hyperthermia. |
| Educate the patient and significant others about signs of hypothermia. | The goal is to normalize the patient’s body temperature, cooling interventions should be discontinued once the core body temperature reaches 38 degrees Celsius or below. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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