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Nursing Care Plan (NCP) Renal Calculi

Kidney stones (calculi) are formed of mineral deposits, most commonly calcium oxalate and calcium phosphate; however, uric acid, struvite, and cystine are also calculus formers. Renal calculi vary in size, with 90% of them smaller than 5 mm in diameter; some, however, grow large enough to prevent the natural passage of urine through the ureter. Calculi may be solitary or multiple. Approximately 80% of these stones are composed of calcium salts. Other types are the struvite stones (which contain magnesium, ammonium, and phosphate), uric acid stones, and cystine stones. If the calculi remain in the renal pelvis or enter the ureter, they can damage renal parenchyma (functional tissue). Larger calculi can cause pressure necrosis. In certain locations, calculi cause obstruction, lead to hydronephrosis, and tend to recur. Although renal calculi can form anywhere in the urinary tract, they are most commonly found in the renal pelvis and calyces. Renal calculi can remain asymptomatic until passed into a ureter and/or urine flow is obstructed, when the potential for renal damage is acute.

The precise cause of renal calculi is unknown, although they are associated with dehydration, urinary obstruction, calcium levels, and other factors. Patients who are dehydrated have decreased urine, with heavy concentrations of calculus-forming substances. Urinary obstruction leads to urinary stasis, a condition that contributes to calculus formation. Any condition that increases serum calcium levels and calcium excretion predisposes people to renal calculi. These conditions include an excessive intake of vitamin D or dietary calcium, hyperparathyroidism,
heredity factors, and immobility. Metabolic conditions such as renal tubular acidosis, elevated serum uric acid levels, and urinary tract infections associated with alkaline urine have been linked with calculus formation. Cystine stones are associated with hereditary renal disease.

Physical Assessment of this nursing care plan

Symptoms of renal calculi usually appear when a stone dislodges and begins to travel down the urinary tract and enters the ureter. Establish a history of pain, and determine the intensity, duration, and location of the pain. The location of the pain varies according to the placement of the stone. The pain usually begins in the flank area but later may radiate into the lower abdomen and the groin. Ask if the pain had a sudden onset. Patients may relate a recent history of hematuria, nausea, vomiting, and anorexia. In cases in which a urinary tract infection is also present, the patient may report chills and fever. Determine the patient’s history to identify risk factors.

Inspection reveals a patient in intense pain who is unable to maintain a comfortable position. Assess the patient for bladder distension. Monitor the patient for signs of an infection such as fever, chills, and increased white blood cell counts. Assess the urine for hematuria. Auscultate the patient’s abdomen for normal bowel sounds. Palpate the patient’s flank area for tenderness. Percussion of the abdominal area is normal, but percussion of the costovertebral angle elicits severe pain.

Patients with renal calculi may be extremely anxious because of the sudden onset of severe pain of unknown origin. Assess the level of the pain, as well as the patient’s ability to cope. Since diet and lifestyle may contribute to the formation of calculi, the patient may face lifestyle changes. Assess the patient’s ability to handle such changes.

Diagnostic Studies
  1. Urinalysis: Color may be yellow, dark brown, bloody. Commonly shows RBCs, WBCs, crystals (cystine, uric acid, calcium oxalate), casts, minerals, bacteria, pus; pH may be less than 5 (promotes cystine and uric acid stones) or higher than 7.5 (promotes magnesium, struvite, phosphate, or calcium phosphate stones).
  2. Urine (24-hr): Cr, uric acid, calcium, phosphorus, oxalate, or cystine may be elevated.
  3. Urine culture: May reveal UTI (Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas).
  4. Biochemical survey: Elevated levels of magnesium, calcium, uric acid, phosphates, protein, electrolytes.
  5. Serum and urine BUN/Cr: Abnormal (high in serum/low in urine) secondary to high obstructive stone in kidney causing ischemia/necrosis.
  6. Serum chloride and bicarbonate levels: Elevation of chloride and decreased levels of bicarbonate suggest developing renal tubular acidosis.
  7. CBC: Hb/Hct: Abnormal if patient is severely dehydrated or polycythemia is present (encourages precipitation of solids), or patient is anemic (hemorrhage, kidney dysfunction/failure). RBCs: Usually normal. WBCs: May be increased, indicating infection/septicemia.
  8. Parathyroid hormone (PTH): May be increased if kidney failure present. (PTH stimulates reabsorption of calcium from bones, increasing circulating serum and urine calcium levels.)
  9. KUB x-ray: Shows presence of calculi and/or anatomical changes in the area of the kidneys or along the course of the ureter.
  10. IVP: Provides rapid confirmation of urolithiasis as a cause of abdominal or flank pain. Shows abnormalities in anatomical structures (distended ureter) and outline of calculi.
  11. Cystoureteroscopy: Direct visualization of bladder and ureter may reveal stone and/or obstructive effects.
  12. CT scan: Identifies/delineates calculi and other masses; kidney, ureteral, and bladder distension.
  13. Ultrasound of kidney: To determine obstructive changes, location of stone; without the risk of failure induced by contrast medium.
Nursing Priorities
  1. Alleviate pain.
  2. Maintain adequate renal functioning.
  3. Prevent complications.
  4. Provide information about disease process/prognosis and treatment needs.
Primary Nursing Diagnosis: Altered urinary elimination related to the blockage of ureter with a calculus.

Nursing Care Plan/Intervention
In about 80% of cases, renal calculi of 5 mm or less are treated conservatively with vigorous hydration, which results in the stone passing spontaneously. Increased fluid intake is ordered orally or intravenously (IV) to flush the stone through the urinary tract. Unless contraindicated, maintain hydration at 200 mL per hour of IV or orally. Strain the patient’s urine to detect stones that are passed so they can be analyzed.

For calculi that are larger than 5 mm or that cannot be passed with conservative treatment, surgical removal is performed. Percutaneous ultrasonic lithotripsy or extracorporeal shock wave lithotripsy (ESWL) uses sound waves to shatter calculi for later removal by suction or natural passage. Calculi in the ureter may be removed with catheters and a cystoscope (ureteroscopy), while a flank or lower abdominal surgical approach may be needed to remove calculi from the kidney calyx or renal pelvis.

Initially, the most important nursing interventions concentrate on pain management. Teach relaxation techniques, diversional activities, and position changes. Help promote the passage of renal calculi. Encourage the patient to walk, if possible. Offer the patient fruit juices to help acidify the urine. Teach the patient the importance of proper diet to help avoid a recurrence of the renal calculi, with particular emphasis on adequate hydration and avoiding excessive salt and protein intake.

To reduce anxiety, give the patient and family all pertinent information concerning the treatment plan and any diagnostic tests. Preoperatively, explain the procedure and what to expect afterward. For patients who are undergoing a flank or abdominal incision, teach deep breathing and coughing exercises. Give postoperative care and monitor for signs of infection or pneumonia. Do not irrigate urinary drainage systems without consulting with the physician.

Health Teaching
Instruct the patient to increase fluid intake to enhance the passage of the stone. Instruct the patient to strain all urine, and, if a stone is obtained, emphasize the importance of returning the stone to the physician for analysis. If the patient has passed the stone and it has been analyzed, teach the necessary dietary changes, fluid intake requirements, and exercise regimen to prevent future stone formation. Patient should drink at least 2.5 L a day of fluid to prevent recurrences.
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