Kidney stones or renal calculi are hard deposits formed from minerals and salts in the kidneys that cause pain and complications as they move through the urinary tract. The different types of kidney stones include:
- Calcium oxalate stones from hypercalciuria
- Struvite stones that form due to urinary tract infection
- Uric acid stones that form when the urine pH is acidic
- Cystine stones that form due to cystinuria
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Deficient Knowledge
- Imbalanced Nutrition: Less Than Body Requirements
- Impaired Urinary Elimination
- Ineffective Tissue Perfusion
Nursing Process
Treatment and management of kidney stones will depend on the type and size of the stone. Nursing care and interventions for patients with kidney stones include pain relief, preventing complications, and maintaining adequate renal function. Health teaching is essential in preventing the recurrence of kidney stones. The patient will need education regarding potential treatments, diet modifications, 24-hour urine testing, and surgical recovery.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to kidney stones.
Review of Health History
1. Determine the patient’s general symptoms.
Kidney stones cause the following symptoms:
- Severe and sharp pain to the side and flank area
- Pain that radiates to the lower abdomen and groin
- Pain that occurs in waves
- Dysuria
- Brown, pink, or red-colored urine
- Cloudy urine
- Foul-smelling urine
- Frequent urination
- Nausea and vomiting
- Fever and chills
2. Determine the patient’s risk factors.
Kidney stones form due to various reasons, such as:
- Excess body weight
- A diet rich in oxalates, sodium, or protein
- Certain supplements and medications
- Dehydration
- Gastric bypass surgery or inflammatory bowel disease
- Medical conditions affecting the urinary system
3. Review the patient’s medications.
The following medications can increase the risk of developing kidney stones:
- Diuretics
- Calcium-based antacids
- Antiviral medications
- Antiseizure drugs
- Antibiotics
4. Ask the patient to describe their urination experience and urine output.
Kidney stones may result in blood in the urine and pain during urination. Obvious hematuria, unrelenting pain, urinary retention, and an inability to pass the stone require medical attention.
5. Monitor pain frequently.
Renal calculi are extremely painful. The pain is often sudden, originating in the flank area. Assess the location of the pain, as it may change as the stone migrates through the urinary system.
Physical Assessment
1. Abdominal assessment is usually unremarkable.
Unlike with an acute abdomen, the patient with kidney stones won’t display abnormalities during an abdominal assessment, which helps in identifying this condition from other abdominal diagnoses.
2. Observe the patient for signs of infection.
Patients may experience fever, chills, or other symptoms of systemic infection (such as shock) if urosepsis occurs.
3. Strictly monitor the fluid intake and output.
Ask the patient about their fluid intake and any difficulty voiding. Closely monitor fluid balance. Kidney stone size and position can vary, resulting in urinary obstruction, causing infection, kidney damage, or urinary injury.
4. Monitor physical cues of pain intensity.
Patients with renal colic are often in intense pain and may move constantly to find a comfortable position. They may writhe in pain, pace, and display facial pain expressions.
Diagnostic Procedures
1. Examine the urine sample.
Examining the urine sample will help identify the type of stone the patient has. Urinalysis with microscopy identifies hematuria, leukocytes, crystals, and bacteria.
2. Obtain a sample for serum blood tests.
Blood tests may detect systemic infection or alterations in kidney function. Review the following:
- CBC with differential
- BUN and creatinine
- Serum electrolyte levels
- Parathyroid hormone
3. Prepare the patient for an imaging scan.
The following imaging procedures can detect calculi:
- Plain radiography (kidneys, ureters, bladder) can detect the size, shape, and location of urinary stones
- Computerized tomography (CT) is the most accurate modality to detect microscopic stones
- Ultrasound is used in pregnant patients but may not detect small stones
Note: When a kidney stone is suspected, contrast medium is avoided since it can mask stone findings.
4. Analyze the passed stone.
After the patient passes the stone, a lab analysis will reveal the stone’s chemical composition. These results will help develop the care plan to prevent further kidney stone production.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with kidney stones.
Relieve Symptoms and Promote Stone Passage
1. Remove the kidney stone according to its size and location.
The size and location of the stone determine treatment.
- The urinary tract may be able to pass small kidney stones without any medical intervention.
- Urgent treatment, including surgical intervention, may be required for larger kidney stones.
2. Administer antibiotics.
Antibiotics must be administered if the patient is diagnosed with a UTI.
3. Relieve the pain.
Renal calculi are said to be one of the most painful medical conditions. Administer NSAIDs for mild pain and narcotic analgesics for more severe pain.
4. Treat nausea and vomiting.
Nausea and vomiting occur in 50% of patients with kidney stones and may exacerbate electrolyte abnormalities and dehydration if untreated. Administer antiemetics to relieve these symptoms.
5. Promote kidney stone passage.
Administer medications as ordered to assist in the passing of a kidney stone. Alpha-blockers relax the ureter’s muscles to aid kidney stone passage. Combining an alpha-blocker such as tamsulosin with an analgesic like ibuprofen has been shown to improve the passage of stones while addressing pain and reducing the need for surgery.
6. Don’t forget to strain the urine.
Keep a hat in the toilet so that the patient’s urine is strained so that the stones can be analyzed to determine their composition.
7. Anticipate more extensive treatment for large stones.
Larger kidney stones that cannot dissolve or pass naturally or that result in bleeding or kidney damage may need more intensive care. Stones larger than 8mm are likely to require intervention, such as:
- Extracorporeal shock wave lithotripsy (ESWL)
- Percutaneous nephrolithotomy
- Stent placement
- Ureteroscopy
Prevent Kidney Stone Recurrence
1. Encourage fluid intake.
Hydration is considered the most important intervention to prevent future stone formation. The patient should be instructed to consume enough fluid to produce at least 2.5 L of urine per day.
2. Advise on recommended medications.
Medications can regulate the amount of salts and minerals in the urine and may be beneficial for those who develop certain types of stones. The healthcare provider may recommend the following medications if the patient frequently develops these types of stones:
- Calcium oxalate stones: thiazide diuretics
- Uric acid stones: allopurinol and an alkalizing agent
- Struvite stones: acetohydroxamic acid
- Cystine stones: tiopronin or penicillamine
3. Encourage the patient to achieve the desired weight.
There is a high prevalence of kidney stones in obese patients due to multiple comorbidities. Advise the patient to avoid using the following weight-loss medications that were found to increase the risk of developing kidney stones:
- Orlistat (lipase inhibitor) increases oxalate stone formation
- Topiramate (carbonic anhydrase inhibitor) increases urine pH and decreases urinary citrate excretion
4. Educate on performing a 24-hour urine study.
If the patient is motivated to learn about what is causing recurrent stones, have them measure their urine in a 24-hour period for lab analysis of the chemical makeup of their urine.
5. Instruct on diet modifications.
Patients should limit sodium and eat protein in moderation. Uric acid stones are caused by high levels of purines found in animal protein. Decrease urine acidity to prevent uric acid stones by limiting alcohol, red meat, shellfish, and high fructose corn syrup.
6. Calcium restriction isn’t necessary.
Though calcium-oxalate stones are the most common type of stone, they aren’t necessarily caused by too much calcium. Reducing calcium may lead to more stones as more oxalate is absorbed since there isn’t enough calcium to bind with it. Instead, the patient should consume oxalate-rich foods (fruits, vegetables, grains, chocolate, spinach) with calcium-rich foods such as milk, yogurt, and cheese.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for kidney stones, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for kidney stones.
Acute Pain
Urolithiasis is an extremely painful medical condition. Controlling pain is a nursing priority.
Nursing Diagnosis: Acute Pain
Related to:
- Kidney stones
- Spasms
- Inflammation of the kidney
- Urinary system obstruction
- Decreased oxygenated blood supply to the kidney
- Ureter tissue trauma
As evidenced by:
- Reports of colicky pain
- Complaint of sharp and severe pain on the side or back (flank), radiating to the groin and lower abdomen
- Dysuria
- Distraction behavior
- Guarding behavior
- Positioning to ease pain
- Facial grimacing
Expected outcomes:
- Patient will report pain relief or a decrease in pain using a numeric pain scale.
- Patient will appear relaxed without facial grimacing or crying.
- Patient will verbalize the absence of pain and burning during urination.
Assessment:
1. Ask the patient to describe the pain.
Kidney stone pain is described as acute, severe pain. Renal colic typically presents with severe, steady pain followed by waves of excruciating pain. This may last for hours, followed by mild relief, with pain fluctuations.
2. Ask the patient to rate the pain.
A numerical rating scale of 0-10 is used to assess the patient’s subjective pain. Most patients with kidney stones have moderate to severe (4-10) pain.
3. Assess costovertebral angle (CVA) tenderness.
CVA tenderness is pain in the region of the 12th rib and the spine. Pain when palpating this region can signal urolithiasis or a kidney infection.
Interventions:
1. Promote pain relief.
Kidney stones are often extremely painful, and the patient may require NSAIDs or opioid medications for relief.
2. Use OTC pain relievers.
The healthcare provider may prescribe ibuprofen or naproxen sodium to treat minor pain from kidney stones in the outpatient setting.
3. Treat the underlying cause.
Determine if stones are caused by infection, obstruction, diet, or another cause to treat and prevent further stone formation effectively.
4. Allow passage of the stone.
Alpha-blockers or calcium channel blockers may also be prescribed to help pass a kidney stone more easily by relaxing the ureters.
Deficient Knowledge
Deficient knowledge can be caused by misconceptions and inadequate information about kidney stones and their management.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Misinformation about kidney stones
- Unfamiliarity with kidney stones
- Inability to access available resources
- Inadequate commitment to learning
- Misconceptions about preventing kidney stones
- Inadequate participation in care planning
As evidenced by:
- Inquiries about kidney stones and management
- Inaccurate follow-through of instructions
- Inaccurate statements about kidney stones
- Nonadherence to treatment
- Development of recurrent kidney stones
Expected outcomes:
- Patient will verbalize two strategies to prevent kidney stones.
- Patient will adhere to dietary recommendations to prevent kidney stones.
- Patient will be able to identify signs of kidney stones and when to seek treatment.
Assessment:
1. Review the patient’s diet.
Diets high in protein, oxalates, sodium, and purines can contribute to stone formation. A lack of water intake allows minerals and salts to bind together to form stones.
2. Review medications.
Medications such as antacids, diuretics, vitamin C supplements, and some antibiotics increase the risk of developing kidney stones.
3. Assess the lab analysis of stones.
The kidney stones’ composition via laboratory analysis is used to identify the cause of the kidney stones. Knowing the type of stone can guide interventions.
Interventions:
1. Identify signs of poor hydration and increase water intake.
Ensure the patient recognizes headaches, a dry mouth, an increased heart rate, and fatigue as signs of thirst and dehydration. Remind them also to assess the color of their urine. Urine should be straw-colored. If it is dark/amber-colored, the patient needs to drink more water.
2. Instruct on expectations after surgery.
Remind the patient that their urine may be pink or have small clots following lithotripsy or surgery. Stone fragments will pass over the next days and weeks. If fever, chills, heavy bleeding, or an inability to urinate occur, the patient should seek medical attention.
3. Refer the patient to a dietitian.
A dietician can assist the patient in creating a diet that can lower the risk of kidney stones.
- High oxalates- avoid this with patients at risk for calcium oxalate stones. Foods include rhubarb, spinach, soy products, beets, okra, sweet potatoes, almonds, tea, and chocolate.
- High sodium- calcium, and excess salt are eliminated proportionately in the urine. The more salt consumed, the more calcium there is, which can lead to new stones.
- Adequate calcium- calcium is necessary for healthy bones and teeth. Calcium actually binds to oxalate to remove it. Getting the right amount of calcium is recommended.
- High purines- can build up in the joints, resulting in gout, or travel to the kidneys, forming kidney stones. High-purine foods like alcohol, soda, sardines, mussels, scallops, bacon, and organ meats should be avoided.
4. Instruct the patient when to seek medical attention.
To prevent complications, advise the patient to seek urgent medical attention when the following signs are present in a patient with kidney stones:
- Uncontrollable pain from the stone
- Severe nausea or vomiting
- Fever and/or chills
- Complete blockage of urine flow
Imbalanced Nutrition: Less Than Body Requirements
A high sodium diet can cause calcium leakage in the urine and increase the chance of kidney stone formation. Diets high in oxalates and purines also lead to stone formation.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Poor water intake
- Inadequate knowledge of nutrient requirements
- Large intake of dietary proteins
- Excessive salt intake
- Low calcium intake
- High oxalate intake
As evidenced by:
- Recurrent kidney stone formation
- Inappropriate dietary choices
- Concentrated urine
- Difficulty urinating
- Hematuria
- Dysuria
Expected outcomes:
- Patient will not experience recurrent kidney stones.
- Patient will report three foods to avoid to prevent kidney stone formation.
Assessment:
1. Assess the patient’s diet.
Understanding the patient’s current dietary intake, including fluids, can help identify necessary modifications to prevent future stone formation.
2. Assess laboratory studies.
A microscopic urinalysis can help confirm the diagnosis of kidney stones and determine the type of stone, which allows for the most appropriate treatment regimen and dietary modifications to prevent recurrences.
3. Assess and monitor the patient’s hydration status.
Poor hydration can contribute to kidney stone formation through reduced diuresis and concentrated urine.
Interventions:
1. Encourage increased fluid intake.
Proper hydration is the most vital intervention to prevent kidney stones. Instruct patients to consume at least 2-3 L of fluid per day.
2. Encourage dietary modifications depending on the type of kidney stone.
For calcium oxalate stones, instruct on reducing sodium intake and eating oxalate-rich and calcium-rich foods together. For uric acid stones, high-purine foods like organ meats, shellfish, and alcohol should be reduced.
3. Refer the patient to a dietitian for nutritional counseling.
In cases of recurrent kidney stones, a carefully planned dietary regimen is necessary to ensure the patient can meet recommended nutritional requirements to prevent malnutrition while reducing stone formation.
4. Instruct on limiting or discontinuing supplements.
Calcium supplements may contribute to calcium oxalate stones. Excessive vitamin C supplementation may produce more oxalate in the body.
Impaired Urinary Elimination
Impaired urinary elimination related to kidney stones can be caused by stones blocking the ureters, causing urine backflow into the bladder, kidney swelling, and spasms.
Nursing Diagnosis: Impaired Urinary Elimination
Related to:
- Bladder stimulation due to calculi
- Urinary tract obstruction
- Scarring
- Spasms
- Inflammation
As evidenced by:
- Dysuria
- Nocturia
- Frequent voiding
- Urinary incontinence
- Urinary hesitancy
- Urinary urgency
- Hematuria
- Urinary retention
Expected outcomes:
- Patient will manifest urine output within the expected limits.
- Patient will demonstrate urination without difficulty, urgency, or frequency.
- Patient will display clear and yellow urine with little to no odor.
Assessment:
1. Check the urine’s characteristics.
Urine may appear red, pink, or brown in color, cloudy, and foul-smelling. Hematuria is present in 85% of patients.
2. Obtain a sample for urinalysis.
Typically, urinalysis may appear to have blood in the urine (hematuria). Also, nitrites, leukocytes, and bacteria indicate infection.
3. Review the KUB report.
A KUB can be obtained to check for blockage and measure the resistive index, which may indicate a ureteral blockage. KUB can detect larger stones.
4. Review CT scan results.
A non-contrast abdominal and pelvic CT scan is the most accurate and sensitive technique to identify kidney stones. It can also reveal a blockage or infection.
Interventions:
1. Encourage adequate fluid intake.
Adequate hydration helps promote urine production, flush out bacteria, and facilitate the passage of kidney stones.
2. Allow small stones to pass if possible.
A kidney stone might take one to four weeks to pass. The size of the stone and its location in the urinary system will determine how long it takes to pass.
3. Anticipate surgical interventions.
Larger kidney stones need a more intensive approach if they cannot pass naturally. Treatments such as:
- Extracorporeal shock wave lithotripsy (ESWL) employs soundwaves to break up kidney stones
- Ureteroscopy surgically removes the stone through the urethra
- Percutaneous nephrolithotomy surgically removes large stones through the kidney
4. Encourage the patient to ambulate as tolerated.
Ambulation promotes the spontaneous movement and passage of kidney stones.
Ineffective Tissue Perfusion
Kidney stones, when left untreated, can cause serious complications that affect renal tissue perfusion, including urinary tract infection, abscess formation, urinary fistula formation, ureteral scarring, stenosis, perforation, sepsis, and renal failure.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Disease process
- Urinary tract obstruction
- Inflammatory process
- Infection
As evidenced by:
- Severe flank pain
- Renal colic
- Dysuria
- Hematuria
- Urinary retention
- Fever/chills
- Poor urine output
- Altered kidney function
Expected outcomes:
- Patient will maintain adequate renal perfusion as evidenced by normal elimination patterns without retention, pain, or hematuria.
- Patient will exhibit adequate renal perfusion as evidenced by urine output of at least 0.5mL/kg/hr.
Assessment:
1. Assess the patient’s urinary elimination patterns and urine characteristics.
Patients with kidney stones often have problems with urinary elimination, like hematuria, dysuria, and retention, and stones can cause obstruction and lead to decreased renal perfusion.
2. Assess diagnostic studies.
Diagnostic tests like a renal CT scan can detect obstruction, abscesses, or hydronephrosis.
3. Assess the patient’s kidney function.
BUN, creatinine, and glomerular filtration rate tests can check how well the kidneys are functioning and if there are any problems associated with decreased renal perfusion. A urinalysis can also help confirm the presence of bacteria, crystals, hematuria, protein, and more.
Interventions:
1. Encourage increased fluid intake.
Adequate hydration can promote the natural passing of kidney stones, preventing urinary tract obstruction and renal hypoperfusion. It also ensures adequate circulating volume toward the kidneys and other vital organs.
2. Administer medications as indicated.
Medications like alpha-adrenergic blockers are administered to help relax the smooth muscles of the ureters, allowing easy stone passage. Antibiotics may be given if infection is present.
3. Monitor intake and output.
Urine output declines with poor kidney function. Measure urine to ensure the patient is exhibiting at least 0.5mL/kg/hr of urine.
4. Assist in the surgical removal of kidney stones as indicated.
Extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy, or stent placement may be indicated in patients with large kidney stones preventing spontaneous passage to reduce the risk of urinary tract injury, obstruction, and impaired renal perfusion.
References
- Asadi-Pooya, A. A., & Sperling, M. R. (2022, September). Antiseizure medications in patients with renal disease. OUP Academic. Retrieved September 2023, from https://academic.oup.com/book/44298/chapter-abstract/373616782
- Burns, S. (2014). AACN essentials of critical care nursing (3rd ed.). McGraw-Hill Education / Medical.
- Cleveland Clinic. (2021, May 3). Kidney stones: Symptoms, causes, diagnosis, treatment & prevention. Retrieved February 2023, from https://my.clevelandclinic.org/health/diseases/15604-kidney-stones
- Dave, C. N. (2023, July 28). Nephrolithiasis: Practice essentials, background, anatomy. Diseases & Conditions – Medscape Reference. Retrieved September 2023, from https://emedicine.medscape.com/article/437096-overview
- Harding, M. M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2019). Lewis’s medical-surgical nursing E-book: Assessment and management of clinical problems, single volume (11th ed.). Elsevier Health Sciences.
- Manzo, B. O., Cabrera, J. D., Emiliani, E., Sánchez, H. M., Eisner, B. H., & Torres, J. E. (2021). Impact of the adherence to medical treatment on the main urinary metabolic disorders in patients with kidney stones. Asian Journal of Urology, 8(3), 275-279. https://doi.org/10.1016/j.ajur.2020.07.002
- Mayo Clinic. (2022, June 3). Kidney stones – Symptoms and causes. Retrieved September 2023, from https://www.mayoclinic.org/diseases-conditions/kidney-stones/symptoms-causes/syc-20355755
- Mayo Clinic. (2022, June 3). Kidney stones – Diagnosis and treatment – Mayo Clinic. Retrieved September 2023, from https://www.mayoclinic.org/diseases-conditions/kidney-stones/diagnosis-treatment/drc-20355759
- National Kidney Foundation. (2022, November 3). Kidney stones. Retrieved February 2023, from https://www.kidney.org/atoz/content/kidneystones
- National Institute of Diabetes and Digestive and Kidney Diseases. (2017, May 1). Treatment for kidney stones. Retrieved September 2023, from https://www.niddk.nih.gov/health-information/urologic-diseases/kidney-stones/treatment
- Nojaba, L., & Guzman, N. (2022, August 8). Nephrolithiasis – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved September 2023, from https://www.ncbi.nlm.nih.gov/books/NBK559227/
- Poore, W., Boyd, C. J., Singh, N. P., Wood, K., Gower, B., & Assimos, D. G. (2020). Obesity and Its Impact on Kidney Stone Formation. Rev Urol, 22(1), 17-23. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265184/
- Prochaska, M., & Worcester, E. (2020). Risk factors for kidney stone formation following bariatric surgery. Kidney360, 1(12), 1456-1461. https://doi.org/10.34067/kid.0004982020
- Urology Care Foundation. (n.d.). Kidney stones. Retrieved February 2023, from https://www.urologyhealth.org/urology-a-z/k/kidney-stones
