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 stones from calcium oxalate, struvite stones that form due to urinary tract infection, uric acid stones that form when the pH is below 5.0 or with a high intake of purine foods, and cystine stones that form due to cystinuria.
Kidney stones form due to various reasons:
- Excess body weight
- Diet
- Use of supplements and medications
- Dehydration
- Certain medical conditions that affect the urinary tract
Kidney stones cause the following symptoms:
- Severe and sharp pain to the side and flank area, radiating 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
Kidney stones may be diagnosed through urine testing to assess the presence of specific crystals and minerals. A KUB (kidneys, ureters, bladder) scan can detect larger stones, while CT scans are the most sensitive imaging tool for diagnosing kidney stones.
Nursing Process
Treatment and management of kidney stones will depend on the type of stone and the cause. Nursing care and interventions for patients with kidney stones includes pain relief, preventing complications, and maintaining adequate renal function.
Health teaching is essential in preventing the development of kidney stones. The patient will also need education regarding potential treatments, 24-hour urine testing, and surgical recovery.
Nursing Care Plans Related to 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.
If possible, nonpharmacologic therapies for pain management of kidney stones should be tried first, then nonopioid medications, and lastly, opioids.
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.
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.
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
References
- 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
- 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.
- National Kidney Foundation. (2022, November 3). Kidney stones. Retrieved February 2023, from https://www.kidney.org/atoz/content/kidneystones
- Urology Care Foundation. (n.d.). Kidney stones. Retrieved February 2023, from https://www.urologyhealth.org/urology-a-z/k/kidney-stones
