N512-19A Module Five: Disorders of the Urinary System Across the Life Span

Nephrolithiasis or renal colic is caused by calculi or stones to large pass through the structures of the renal system. These stones are formed primarily in the medulla of the kidney by crystallization of compounds due to abnormal urine pH that is either too alkaline or too acidic. (Dlugasch, & Story, 2019). The resulting stones will attempt to pass from the renal pelvis through the calyx and the ureter to the bladder and finally out the urethra where if the calculi are too large they will obstruct the passage ways causing damage, pain, inflammation and possibly infection (Dlugasch & Story, 2019).

Calcium, Uric Acid, Cystine and Struvite are the 4 major types of kidney stones, with calcium containing stones being the most common (Perlman & Heung, 2019) and the most likely culprit behind L.J.’s renal calculi. Where it was once thought that reducing dietary calcium intake would benefit patients prone to nephrolithiasis, Perlman & Heung (2019) explain how a diet high in animal protein and salt intake produces the environment that encourages calcium-type stone creation. Dehydration is also thought to contribute to the stone formation due to slow passage of the solute through the renal structures and the resulting calcification of the same solute (Perlman & Heung, 2019).

While many patients can pass stones without surgical intervention, there are other non-invasive or minimally invasive procedures available to facilitate the passage of the offending calculi to minimize further damage (Dlugash & Story, 2019). The size of the obstruction would be the major factor in determining which procedure or intervention would be the most beneficial for L.J. as stones greater than 4 mm will be difficult for the patient to pass (Dlugash & Story, 2019). Dlugash & Story (2019) recommend that all stones be identified at least once to ensure appropriate follow-up. Dave (2019) further recommends follow-up with a qualified health-care provider (HCP) if the stone has not passed within a month due to the increased likelihood of renal structural injury. At this point, radiologic or ultrasound imaging of the abdominal and pelvic structures should be used to determine size and site of nephrolithiasis and the complications from the same (Dlugash & Story, 2019). Furthermore, a metabolic and hematology panel and a urinalysis with a reflex culture if indicated should also be completed in determining the extent of the inflammation or infection (Dave, 2019).

A possible plan of care for L.J. if his stone was small enough and not causing an obstruction would have him sent home with a urine strainer and specimen cup with instructions to follow up with his primary HCP to have the stone elements identified (Dave, 2019). For those first two weeks following discharge, L.J. would be encouraged to increase his fluid intake by 2-3 L to facilitate stone passage, reduce his salt and animal protein intake to reduce stone reoccurrence, and have both rest and activity periods to ensure adequate urination (Dlugash & Story, 2019). He would also be given prescriptions for pain control, likely a non-steroidal anti-inflammatory (if his kidney function values were sufficient), an anti-emetic for nausea associated with his flank pain, an alpha blocker to relax his ureters and an antibiotic if indicated (Dave, 2020).

If L.J. was unable to pass his stone due to size or obstruction, he would then be admitted for interventional stone removal. The intervention would depend on his stone size and whether it was obstructing major renal structures, for simplicity, his HCP decided on a Ureteroscopy with complete stone removal. The ureteroscope is used to visualize the stone and if it is to large to be retrieved intact, the stone would be split by a fragmentation device, laser, or shockwave and then retrieved with the stone basket to ensure complete removal (Dave, 2020). Recovery would be similar to the first scenario, in terms of dietary changes, increased fluid intake, pain control and rest. He would also require follow-up with his HCP to discuss measures to avoid future occurrences. 

Dave, C.N. (13 January 2020). Nephrolithiasis: Treatment & management. Retrieved 13 August 2020 from 

Dlugasch, L., & Story, L. (2019). Applied pathophysiology for the advanced practice nurse (1st ed.). Jones & Bartlett Learning, LLC.

Perlman, R.L. & Heung, M. (2019). Renal Disease. In McPhee, S. J., & Hammer, G. D. (Eds.), Pathophysiology of disease: An introduction to clinical medicine (8th ed. pp.667-703). McGraw-Hill Education LLC.