Urolithiasis Nursing Care Plan

 

Nursing Priorities
  1. Alleviate pain.
  2. Maintain adequate renal functioning.
  3. Prevent complications.
  4. Provide information about disease process/prognosis and treatment needs.
Nursing Diagnosis: Pain, acute
May be related to
  • Increased frequency/force of ureteral contractions
  • Tissue trauma, edema formation; cellular ischemia
Possibly evidenced by
  • Reports of colicky pain
  • Guarding/distraction behaviors, restlessness, moaning, self-focusing, facial mask of pain, muscle tension
  • Autonomic responses
Desired outcomes/evaluation criteria—patient will:

Pain Level

  • Report pain is relieved with spasms controlled.
  • Appear relaxed, able to sleep/rest appropriately.
Nursing Interventions
Pain Management

Independent

  • Document location, duration, intensity (0–10 scale), and radiation. Note nonverbal signs, e.g., elevated BP and pulse, restlessness, moaning, thrashing about.
    • Rationale: Helps evaluate site of obstruction and progress of calculi movement. Flank pain suggests that stones are in the kidney area, upper ureter. Flank pain radiates to back, abdomen, groin, genitalia because of proximity of nerve plexus and blood vessels supplying other areas. Sudden, severe pain may precipitate apprehension, restlessness, severe anxiety.
  • Explain cause of pain and importance of notifying caregivers of changes in pain occurrence/characteristics.
    • Rationale: Provides opportunity for timely administration of analgesia (helpful in enhancing patient’s coping ability and may reduce anxiety) and alerts caregivers to possibility of passing of stone/developing complications. Sudden cessation of pain usually indicates stone passage.
  • Provide comfort measures, e.g., back rub, restful environment.
    • Rationale: Promotes relaxation, reduces muscle tension, and enhances coping.
  • Assist with/encourage use of focused breathing, guided imagery, diversional activities.
    • Rationale: Redirects attention and aids in muscle relaxation.
  • Encourage/assist with frequent ambulation as indicated and increased fluid intake of at least 3–4 L/day within cardiac tolerance.
    • Rationale: Renal colic can be worse in the supine position. Vigorous hydration promotes passing of stone, prevents urinary stasis, and aids in prevention of further stone formation.
  • Note reports of increased/persistent abdominal pain.
    • Rationale: Complete obstruction of ureter can cause perforation and extravasation of urine into perirenal space. This represents an acute surgical emergency.
  • Administer medications as indicated: Narcotics, e.g., meperidine (Demerol), morphine;
    • Rationale: Usually given during acute episode to decrease ureteral colic and promote muscle/mental relaxation.
  • Antispasmodics, e.g., flavoxate (Urispas) oxybutynin (Ditropan)
    • Rationale: Decreasing reflex spasm may decrease colic and pain.

Collaborative

  • Apply warm compresses to back.
    • Rationale: Relieves muscle tension and may reduce reflex spasms.
  • Maintain patency of catheters when used.
    • Rationale: Prevents urinary stasis/retention, reduces risk of increased renal pressure and infection.
Nursing Diagnosis: Urinary Elimination, impaired
May be related to
  • Stimulation of the bladder by calculi, renal or ureteral irritation
  • Mechanical obstruction, inflammation
Possibly evidenced by
  • Urgency and frequency; oliguria (retention)
  • Hematuria
Desired outcomes/evaluation criteria—patient will:

Urinary Elimination 

  • Void in normal amounts and usual pattern.
  • Experience no signs of obstruction.
Nursing Interventions
Urinary Elimination Enhancement

Independent

  • Monitor I&O and characteristics of urine.
    • Rationale: Provides information about kidney function and presence of complications, e.g., infection and hemorrhage. Bleeding may indicate increased obstruction or irritation of ureter. Note: Hemorrhage due to ureteral ulceration is rare.
  • Determine patient’s normal voiding pattern and note variations.
    • Rationale: Calculi may cause nerve excitability, which causes sensations of urgent need to void. Usually frequency and urgency increase as calculus nears ureterovesical junction.
  • Encourage increased fluid intake.
    • Rationale: Increased hydration flushes bacteria, blood, and debris and may facilitate stone passage.
  • Strain all urine. Document any stones expelled and send to laboratory for analysis
    • Rationale: Retrieval of calculi allows identification of type of stone and influences choice of therapy.
  • Investigate reports of bladder fullness; palpate for suprapubic distension. Note decreased urine output, presence of periorbital/dependent edema.
    • Rationale: Urinary retention may develop, causing tissue distension (bladder/kidney), and potentiates risk of infection, renal failure.
  • Observe for changes in mental status, behavior, or level of consciousness.
    • Rationale: Accumulation of uremic wastes and electrolyte imbalances can be toxic to the CNS.

Collaborative

  • Monitor laboratory studies, e.g., electrolytes, BUN, Cr.
    • Rationale: Elevated BUN, Cr, and certain electrolytes indicate presence/degree of kidney dysfunction.
  • Obtain urine for culture and sensitivities.
    • Rationale: Determines presence of UTI, which may be causing/complicating symptoms.
  • Administer medications as indicated, e.g.: Acetazolamide (Diamox), allopurinol (Zyloprim)
    • Rationale: Increases urine pH (alkalinity) to reduce formation of acid stones. Antigout agents such as allopurinol (Zyloprim) also lower uric acid production and potential of stone formation.
  • Hydrochlorothiazide (Esidrix, HydroDIURIL), chlorthalidone (Hygroton)
    • Rationale: May be used to prevent urinary stasis and decrease calcium stone formation if not caused by underlying disease process such as primary hyperthyroidism or vitamin D abnormalities.
  • Ammonium chloride; potassium or sodium phosphate
    • Rationale: Reduces phosphate stone formation.
  • Antibiotics
    • Rationale: Presence of UTI/alkaline urine potentiates stone formation.
  • Sodium bicarbonate
    • Rationale: Replaces losses incurred during bicarbonate wasting and/or alkalinization of urine; may reduce/prevent formation of some calculi.
  • Ascorbic acid.
    • Rationale: Acidifies urine to prevent recurrence of alkaline stone formation.
Nursing Diagnosis: Fluid Volume, risk for deficient
Risk factors may include
  • Nausea/vomiting (generalized abdominal and pelvic nerve irritation from renal or ureteral colic)
  • Postobstructive diuresis
Possibly evidenced by
  • [Not applicable; presence of signs or symptoms establishes an actual]
Desired outcomes/evaluation criteria—patient will:

Hydration 

  • Maintain adequate fluid balance as evidenced by vital signs and weight within patient’s normal range, palpable peripheral pulses, moist mucous membranes, good skin turgor.
Nursing Interventions
Fluid/Electrolyte Management

Independent

  • Monitor I&O.
    • Rationale: Comparing actual and anticipated output may aid in evaluating presence/degree of renal stasis/impairment.Note: Impaired kidney functioning and decreased urinary output can result in higher circulating volumes with signs/symptoms of HF.
  • Document incidence and note characteristics and frequency of vomiting and diarrhea, as well as accompanying or precipitating events.
    • Rationale: Nausea/vomiting and diarrhea are commonly associated with renal colic because celiac ganglion serves both kidneys and stomach. Documentation may help rule out other abdominal occurrences as a cause for pain or pinpoint calculi.
  • Increase fluid intake to 3–4 L/day within cardiac tolerance.
    • Rationale: Maintains fluid balance for homeostasis and “washing” action that may flush the stone(s) out. Dehydration and electrolyte imbalance may occur secondary to excessive fluid loss (vomiting and diarrhea).
  • Monitor vital signs. Evaluate pulses, capillary refill, skin turgor, and mucous membranes.
    • Rationale: Indicators of hydration/circulating volume and need for intervention. Note: Decreased GFR stimulates production of renin, which acts to raise BP in an effort to increase renal blood flow.
  • Weigh daily.
    • Rationale: Rapid weight gain may be related to water retention.

Collaborative

  • Monitor Hb/Hct, electrolytes.
    • Rationale: Assesses hydration and effectiveness of/need for interventions.
  • Administer IV fluids.
    • Rationale: Maintains circulating volume (if oral intake is insufficient), promoting renal function.
  • Provide appropriate diet, clear liquids, bland foods as tolerated.
    • Rationale: Easily digested foods decrease GI activity/irritation and help maintain fluid and nutritional balance.
  • Administer medications as indicated: antiemetics, e.g., prochlorperazine (Compazine).
    • Rationale: Reduces nausea/vomiting.
Nursing Diagnosis: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs.
May be related to
  • Lack of exposure/recall; information misinterpretation
  • Unfamiliarity with information resources
Possibly evidenced by
  • Questions; request for information; statement of misconception
  • Inaccurate follow-through of instructions, development of preventable complications
Desired outcomes/evaluation criteria—patient will:

Knowledge: Illness Care 

  • Verbalize understanding of disease process and potential complications.
  • Correlate symptoms with causative factors.
  • Verbalize understanding of therapeutic needs.
  • Initiate necessary lifestyle changes and participate in treatment regimen.
Nursing Interventions
Teaching: Disease Process

Independent

  • Review disease process and future expectations.
    • Rationale: Provides knowledge base from which patient can make informed choices.
  • Stress importance of increased fluid intake, e.g., 3–4L/day or as much as 6–8 L/day. Encourage patient to notice dry mouth and excessive diuresis/diaphoresis and to increase fluid intake whether or not feeling thirsty.
    • Rationale: Flushes renal system, decreasing opportunity for urinary stasis and stone formation. Increased fluid losses/dehydration require additional intake beyond usual daily needs.
  • Review dietary regimen, as individually appropriate:
    • Rationale: Diet depends on the type of stone. Understanding reason for restrictions provides opportunity for patient to make informed choices, increases cooperation with regimen, and may prevent recurrence.
  • Low-purine diet, e.g., limited lean meat, turkey, legumes, whole grains, alcohol
    • Rationale: Decreases oral intake of uric acid precursors.
  • Low-calcium diet, e.g., limited milk, cheese, green leafy vegetables, yogurt
    • Rationale: Reduces risk of calcium stone formation. Note:Research suggests that restricting dietary calcium is not helpful in reducing calcium-stone formation, and researchers, although not advocating high-calcium diets, are urging that calcium limitation be reexamined.
  • Low-oxalate diet, e.g., restrict chocolate, caffeine-containing beverages, beets, spinach.
    • Rationale: Reduces calcium oxalate stone formation.
  • Short regimen: low-calcium/phosphorus diet with aluminum carbonate gel 30–40 mL, 30 min pc/hs.
    • Rationale: Prevents phosphatic calculi by forming an insoluble precipitate in the GI tract, reducing the load to the kidney nephron. Also effective against other forms of calcium calculi. Note: May cause constipation.
  • Discuss medication regimen; avoidance of OTC drugs, and reading all product/food ingredient labels.
    • Rationale: Drugs will be given to acidify or alkalize urine, depending on underlying cause of stone formation. Ingestion of products containing individually contraindicated ingredients (e.g., calcium, phosphorus) potentiates recurrence of stones.
  • Encourage regular activity/exercise program.
    • Rationale: Inactivity contributes to stone formation through calcium shifts and urinary stasis.
  • Active-listen concerns about therapeutic regimen/lifestyle changes.
    • Rationale: Helps patient work through feelings and gain a sense of control over what is happening.
  • Identify signs/symptoms requiring medical evaluation, e.g., recurrent pain, hematuria, oliguria.
    • Rationale: With increased probability of recurrence of stones, prompt interventions may prevent serious complications.
  • Demonstrate proper care of incisions/catheters if present.
    • Rationale: Promotes competent self-care and independence.