NURSING PROCESS: THE PATIENT WITH KIDNEY STONES
The patient with suspected renal stones is assessed for pain and discomfort as well as associated symptoms, such as nausea, vom-iting, diarrhea, and abdominal distention. The severity and loca-tion of pain are determined, along with any radiation of the pain. Nursing assessment also includes observing for signs and symp-toms of UTI (chills, fever, dysuria, frequency, and hesitancy) and obstruction (frequent urination of small amounts, oliguria, or anuria). The urine is inspected for blood and is strained for stones or gravel.
The history focuses on factors that predispose the patient to urinary tract stones or that may have precipitated the current episode of renal or ureteral colic. Predisposing factors include family history of stones, the presence of cancer or bone marrow disorders or the use of chemotherapeutic agents, inflammatory bowel disease, or a diet high in calcium or purines. Factors that may precipitate stone formation in the patient predisposed to renal calculi include episodes of dehydration, prolonged immo-bilization, and infection. The patient’s knowledge about renal stones and measures to prevent their occurrence or recurrence is also assessed.
Based on the assessment data, the nursing diagnoses in the patient with renal stones may include the following:
· Acute pain related to inflammation, obstruction, and abra-sion of the urinary tract
· Deficient knowledge regarding prevention of recurrence of renal stones
Based on assessment data, potential complications that may de-velop include the following:
· Infection and sepsis (from UTI and pyelonephritis)
· Obstruction of the urinary tract by a stone or edema with subsequent acute renal failure
The major goals for the patient may include relief of pain and dis-comfort, prevention of recurrence of renal stones, and absence of complications.
Immediate relief of the severe pain from renal or ureteral colic is accomplished with the administration of opioid analgesic agents (intravenous or intramuscular administration may be prescribed to provide rapid relief) or NSAIDs (ie, ketorolac). The patient is encouraged and assisted to assume a position of comfort. If ac-tivity brings some pain relief, the patient is assisted to ambulate. The pain level is monitored closely, and increases in severity are reported promptly to the physician so that relief can be provided and additional treatment initiated. The patient is prepared for other treatment (eg, lithotripsy, percutaneous stone removal, ureteroscopy, or surgery) if severe pain is unrelieved and the stone is not passed spontaneously.
Because renal stones increase the risk for infection, sepsis, and ob-struction of the urinary tract, the patient is instructed to report decreased urine volume and bloody or cloudy urine. The total urine output and patterns of voiding are monitored. Increased fluid intake is encouraged to prevent dehydration and increase hydrostatic pressure within the urinary tract to promote passage of the stone. If the patient cannot take adequate fluids orally, in-travenous fluids are prescribed. Ambulation is encouraged as a means of moving the stone through the urinary tract.
Patients with calculi require frequent nursing observation to detect the spontaneous passage of a stone. All urine is strained through gauze because uric acid stones may crumble. Any blood clots passed in the urine should be crushed and the sides of the urinal and bedpan inspected for clinging stones. The patient is instructed to report any sudden increases in pain immediately be-cause of the possibility of a stone fragment obstructing a ureter. Analgesic medications are administered as prescribed for the re-lief of pain and discomfort.Vital signs, including temperature, are monitored closely to detect early signs of infection. UTIs may be associated with renal stones due to an obstruction from the stone or from the stone it-self. All infections should be treated with the appropriate anti-biotic agent before efforts are made to dissolve the stone (DeLeskey & Massi-Ventura, 2000).
Because the risk of recurring renal stones is high, the nurse pro-vides education about the causes of kidney stones and ways to prevent their recurrence (Chart 45-12). The patient is encour-aged to follow a regimen to avoid further stone formation. One facet of prevention is to maintain a high fluid intake because stones form more readily in concentrated urine. A patient who has shown a tendency to form stones should drink enough fluid to excrete greater than 2,000 mL of urine every 24 hours (prefer-ably 3,000 to 4,000 mL), should adhere to the prescribed diet, and should avoid sudden increases in environmental tempera-tures, which may cause a fall in urinary volume. Occupations and activities that produce excessive sweating can lead to severe tem-porary dehydration; therefore, fluid intake should be increased. Sufficient fluids should be taken in the evening to prevent urine from becoming too concentrated at night.
Urine cultures may be performed every 1 to 2 months the first year and periodically thereafter. Recurrent UTI is treated vigor-ously. Because prolonged immobilization slows renal drainage and alters calcium metabolism, increased mobility is encouraged whenever possible. In addition, excessive ingestion of vitamins (especially vitamin D) and minerals is discouraged.
If lithotripsy, percutaneous stone removal, ureteroscopy, or other surgical procedures for stone removal have been performed, the patient is instructed about the signs and symptoms of com-plications that need to be reported to the physician. The impor-tance of follow-up to assess kidney function and to ensure the eradication or removal of all kidney stones is emphasized to the patient and family.
If the patient underwent ESWL, the nurse must provide in-structions for home care and necessary follow-up. The patient is encouraged to increase fluid intake to assist in the passage of stone fragments, which may occur for 6 weeks to several months after the procedure. The patient and family are instructed about signs and symptoms that indicate complications, such as fever, decreasing urine output, and pain.
It is also important to tell the patient to expect hematuria (it is anticipated in all patients), but it should disappear within 4 to 5 days. If the patient has a stent in the ureter, hematuria may be expected until it is removed. The patient is in-structed to notify the physician if nausea or vomiting, a tempera-ture greater than 38°C (about 101°F), or pain unrelieved by the prescribed medication occurs. The patient is also informed that a bruise may be observed on the treated side of the back.
The patient is monitored closely in follow-up care to ensure that treatment has been effective and that no complications, such as obstruction, infection, renal hematoma, or hypertension, have developed. During the patient’s visits to the clinic or physician’s office, the nurse has the opportunity to assess the patient’s un-derstanding of ESWL and possible complications. Additionally, the nurse has the opportunity to assess the patient’s understand-ing of factors that increase the risk for recurrence of renal calculi and strategies to reduce those risks.
The patient’s ability to monitor urinary pH and interpret the results is assessed during follow-up visits to the clinic or physi-cian’s office. Because of the high risk for recurrence, the patient with renal stones needs to understand the signs and symptoms of stone formation, obstruction, and infection and the importance of reporting these signs promptly. If medications are prescribed for the prevention of stone formation, the actions and importance of the medications are explained to the patient.
Expected patient outcomes may include:
1) Reports relief of pain
2) States increased knowledge of health-seeking behaviors to prevent recurrence
a) Consumes increased fluid intake (at least eight 8-ounce glasses of fluid per day)
b) Participates in appropriate activity
c) Consumes diet prescribed to reduce dietary factors pre-disposing to stone formation
d) Recognizes symptoms to be reported to health care provider (fever, chills, flank pain, hematuria)
e) Monitors urinary pH as directed
f) Takes prescribed medication as directed to reduce stone formation
3) Experiences no complications
a) Reports no signs or symptoms of sepsis or infection
b) Voids 200 to 400 mL per voiding of clear urine with-out evidence of bleeding
c) Experiences absence of dysuria, frequency, and hesi-tancy
d) Maintains normal body temperature