Nursing Care Plan (NCP) for Renal Calculi

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Outline

Pathophysiology

Renal calculi, commonly known as kidney stones, are crystallized minerals, typically calcium or uric acid,  in your urine that stick together and form stones. These stones may pass through the urinary tract and be expelled in the urine, or may be large enough to require surgical intervention.

Etiology

Stones form when urine is concentrated and contains  more mineral deposits than fluid. These substances crystallize and stick together forming stones. Dehydration is a major risk factor for developing renal calculi. Other factors include infection, diet and heredity. Most stones will pass through the urinary tract without intervention, however some may require medication or surgery.

Desired Outcome

Normal voiding of urine without pain. Passing of the kidney stones without traumatic injury.

Renal Calculi Nursing Care Plan

Subjective Data:

  • Severe pain of back and side
  • Radiating pain to lower abdomen and groin
  • Nausea
  • Dysuria
  • Urinary urgency
  • Urinary frequency

Objective Data:

  • Hematuria
  • Cloudy / foul-smelling urine
  • Fever (with infection)

Nursing Interventions and Rationales

  • Assess for and manage pain
    • Administer medications for pain relief, may include opioids
    • Assist in positioning patient for comfort
    • Assist with ambulation for pain relief

 

The primary symptom of renal stones is excruciating pain. Monitor for location and character of pain to determine if stone is moving. Nausea and vomiting may occur due to intense pain.

 

  • Assess for signs/symptoms of infection
    • Fever / chills
    • Oliguria
    • Hematuria
    • Administer antibiotics as necessary

 

Monitor for signs and symptoms of infection such as malodorous urine, fever and chills. Hematuria may be  a sign of infection or movement of a renal calculi.

 

  • Monitor for dehydration
    • Dry mucous membranes
    • Skin turgor / tenting

 

Nausea and vomiting as well as high levels of pain may prevent the patient from eating or drinking.

 

  • Encourage intake of fluids

 

Encourage oral fluids and initiate IV fluids if necessary. Optimal hydration may help the movement of the stone and prevent further complications..

 

  • Monitor urine output for evidence of stones

 

Provide urinary basin (hat) for toilet to measure urinary output. Inspect urine and any blood clots for possible stones.

 

  • Monitor diagnostic tests
    • Labs
      • Serum
      • Urinalysis
      • Urine Culture
    • Radiology (KUB, CT, Ultrasound)

 

  • BUN/Cr will be elevated in serum, but decreased in urine levels due to the kidneys impaired ability to filter waste
  • Urine– may be dark yellow or brown and bloody. Urinalysis will help determine if infection is present and the overall health of the kidneys.
  • Hgb/Hct (CBC) may be abnormal if dehydration is an issue
  • KUB x-rays, ultrasound and CT can show the presence of and location of calculi as well as other masses or abnormalities.

 

  • Prepare patient for and assist with procedures for removing or managing renal stones
    • Extracorporeal shock wave lithotripsy (ESWL)
    • Percutaneous nephrolithotomy
    • Ureteroscopy

 

Depending on the size and location of the stone, surgical intervention may be necessary.

  • ESWL- is strong sound waves that are used to break the stone into smaller pieces under anesthesia or sedation.
  • Nephrolithotomy- Patient will require general anesthesia for an incision made in the back to remove large stones and place stents
  • Ureteroscopy- Done under general or local anesthesia using a scope through the ureters and bladder to find and break the stones.

 

  • Provide nutrition education depending on type of calculi:
    • Calcium stones
    • Uric stones
    • Cystine stones
    • Oxalate stones

 

  • Calcium stones:  Reduce dietary protein and sodium intake, increase fluid intake
  • Uric stones:  Low purine diet (organ meats such as liver), limited protein
  • Cystine stones:  Low protein diet and increase fluids
  • Oxalate stones:  Increase fluid intake to dilute urine, reduce intake of oxalate (found in strawberries, spinach, chocolate, tea, peanuts and wheat bran)

Writing a Nursing Care Plan (NCP) for Renal Calculi

A Nursing Care Plan (NCP) for Renal Calculi starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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Transcript

Hey guys, in this care plan, we are going to discuss the basics of providing care to a patient who has a renal calculi. Specifically what we’re going to look at is a description of this diagnosis. We’re going to look at subjective and objective data, and then your nursing interventions with rationales. 

 

Renal calculi are more commonly known as kidney stones and these kidney stones actually form when crystallized minerals like calcium or uric acid get built up and stick together in the urinary tract. So, when this happens, this can cause a problem and create a blockage in the urinary tract. Sometimes, if they’re small enough, these stones may pass through the urinary tract, or again, if they’re large, they may get stuck and require surgical intervention. There are some important risk factors to be aware of for developing kidney stones.

 

So the major one is going to be dehydration, but you also want to think about things like infection, diet, and sometimes, they’re just hereditary. Your desired outcomes for patients who have kidney stones are number one, to try and promote normal voiding of urine, and what we mean by normal, is really that they experienced as little pain as possible. Then, we really need them to pass that kidney stone without experiencing traumatic injury. 

 

Let’s take a look at the care plan. Your subjective data for renal calculi are first and foremost, severe pain of back and side. You may hear this called blink pain, and then you may also have patients that complain of pain that radiates from the lower abdomen into the groin. Nausea is common as well as pain with urination, urinary frequency and urinary urgency. 

 

Your objective data here are hematuria, so, if you notice that there are any red blood cells in the urine, cloudy/ foul smelling urine and fever, if they have an infection. So, like we said, kidney stones can cause severe, severe pain. It’s very important that we go ahead and get a baseline pain assessment so that we can monitor the effectiveness of our treatment. To help us do that, we need to assess pain, and then go along with our interventions to relieve that. Now, the top ways that we can help relieve pain are first and foremost, to help with positioning. Get the patient in positions that are comfortable. We need to then assist them with ambulation and offer any medications that may be helpful. Now, one additional thing about pain that’s really, really important is to pay attention to the location of the pain and the character of the pain. This can sometimes help us know if the stone is moving. Now, when the pain is really severe, it’s not uncommon for patients to also experience nausea and vomiting, so we may need to treat that as well. Next in your assessment, you want to be looking for signs and symptoms of infection. We’re assessing the patient and looking for things like malodorous urine, fever, chills, and hematuria. Next we need to be monitoring for dehydration. Remember, that dehydration is one of our risk factors for developing renal calculi. It can make things a lot more complicated, so we need to assess the patient’s hydration status, and make sure that we’re paying attention to things like their nausea and their vomiting, because that could make things worse as well. 

 

Next, if we know that dehydration is a problem, we want to hydrate the patient by encouraging intake of fluids. It’s going to help with some of their symptoms and it’s also going to possibly help move that stone along, so it’s very, very important that we make sure the patient’s getting plenty of fluids. Now, as we are increasing the patient’s fluid intake, hopefully the patient’s going to be going to the toilet a lot more frequently, and hopefully moving that stone along their urinary tract and out of the body. It’s really important that during this process, we monitor the urine output very, very closely, first to see how much they’re having, and then secondly, we’re going to be looking for evidence of stones in the urine. This means that every time the patient voids, we need to be in there assessing that to see if there is any evidence that stones have been passed. The patient’s going to need a urinary hat in the toilet with something in there that’s going to catch those stones, so that we can assess and see if that’s happening. 

 

In some cases, diagnostic tests may need to be done to help us monitor kidney function and to assess the location of the stone. The common tests that you’re going to see are potentially serum BUN and creatinine, urinalysis, hemoglobin, hematocrit and CBC, KUB x-rays, which is just look at the abdomen, an ultrasound and possibly even a CT scan. Now there’s a lot you could look into, but the main thing to be aware of with these diagnostic tests is to just know that with your BUN and creatinine, you’re going to see those levels elevated in the serum, and they’re going to be decreased in the urine. 

 

Now, if the patient isn’t able to pass the stone on their own with their increased hydration, they may actually need to have surgery or a procedure of some kind to remove them, so we definitely need to prepare them for this possibility. Your common procedures for this are an ESWL, which stands for extra corporeal shockwave lithotripsy, and then you might have enough nephrolithotomy or a ureteroscopy, so those are three things that you may see. The ESWL sends shockwaves through the kidneys to break up the stones, and then the other two procedures are actually surgical to go in and remove them. The thing with this procedure here is that the patient’s still going to have to pass those stones that have been broken up, whereas with the two surgical procedures, they’re going to go ahead and remove them. 

 

Once we get those stones out and the patient’s not having those problems anymore, it’s important to educate them on their diet to help prevent the future development of stones. We’re going to provide some nutritional education, and the types of foods they need to avoid may vary based on the type of stone that they have.You can get calcium stones, Uric stones, Cystine stones, or oxalate stones, but the main dietary items that come into play with the stones are having too much protein, too much sodium, too many purines in the diet and too much oxalate in the diet, so you want to think about educating them on those different elements. Foods that are high in oxalate are things like strawberries, spinach, chocolate, tea, peanuts. Things that are high in purines are organ meats, which is probably the most common one. Those are the kinds of things you want to make sure that patients are aware of. 

 

Okay guys, that’s it for our care plan on renal calculi. Remember, we love you guys. Now, go out and be your very, very best self today and as always, happy nursing!

 

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