LESSON PLAN ON RENAL CALCULI

TOPIC- Renal calculi

NAME OF STUDENT TEACHERS- Amrita,
CLASS/SECTION- B.sc (N) 2nd YEAR.
NO. OF STUDENTMEDIUM OF INSTRUCTION- English
DATE- 20-4-2015
TIME- 12:30 pm 2 pm
PLACE- Class Room
METHOD OF TEACHING- Lecture cum discussion
A.V. AIDS- Whiteboard, transparency, chart, LCD.
NAME OF SUPERVISOR TEACHERGENERAL OBJECTIVES- After the completion of the class the students will be able
to explain about renal calculi.
PREVIOUS KNOWLEDGE- The students have some knowledge about anatomy and
physiology of kidney.
SPECIFIC KNOWLEDGE

S.

Define Renal calculi.

Enlist Types of renal calculi.
Incidence of disease.
Enlist its risk factor.
Describe its etiology.
Explain the pathophisiology of renal calculi.
Describe the clinical manifestation of renal calculi.
Explain the diagnostic evaluation of renal calculi.
What are its complication.
Discuss its medical management.
Describe the surgical management of renal calculi
Discuss its nursing management.
List down the related diagnosis with the disease condition.

TEACHIN

TIM

SPECIFI

CONTENT

A.V.

METHO

EVALUATI

N
O

G
POINT

C
OBJECTI
VE

AID
S

D OF
TEACHI
NG

LC
D

Lecture

LC
D

Lecture

LC
D

Lecture

LC

Lecture

ON

1
Definition:-

DEFINIT
ON

2
Min

Definiti
on of
Renal
calculi

TYPES

2
Min

Enlist
Types
of renal
calculi

INCIDEN
CE

3
Min

Inciden
ce of
disease

RISK

Enlist

Urolithiasis refers to
stones (calculi) in the
urinary tract. Stones
are formed in the
urinary tract when
urinary
concentrations of
substances such as
calcium oxalate,
calcium phosphate,
and uric acid
increase.

Types:

Define
Renal
calculi?

Calcium stone
Uric acid stone
Oxalate stone

Incidence:Kidney stones are

one of the most
common urologic
problems. In the
United States, ~13%
of men and 7% of
women will develop a
kidney stone during
their lifetimes, and
the prevalence is
increasing
throughout the
industrialized world.

Enlist
Types of
renal
calculi?

Enlist its

FACTOR

Min

its risk
factor

Predisposing Factors:

ETIOLOG
Y

5
Min

Describ
e its
etiology

PATHOPHYSIOL
OGY

10
Min

Explain
the
pathop
hisiolog
y of
Heart

cum
discussi
on

risk
factor?

LC
D

Lecture
cum
discussi
on

Describe
its
etiology?

Lecture
cum
discussi
on

Explain
the
pathophis
iology of
renal
calculi?

Family history
of stones,
the presence
of cancer or
bone marrow
disorders
The use of
chemotherapeu
tic agents,
Inflammatory
bowel disease,
A diet high in
calcium or
purines

Etiology:

Idiopathic
hypercalciuria
Hyperuricosuria
Primary
hyperparathyro
idism
Distal renal
tubular acidosis
Dietary
hyperxaluria
Gout
Dehydration
Lesch- nyhan
syndrome
Neurogenic
bladder
Foreign bodies
Recurrent uti

Pathophysiology:Stones can also form

when there is a
deficiency of

cha
rt

failiure

CLINICAL
MANIFES
TATION

3
Min

Describ
e the
clinical

substances that
normally prevent
crystallization in the
urine, such as citrate,
magnesium,
nephrocalcin, and
uropontin. The fluid
volume status of the
patient (stones tend
to occur more often
in dehydrated
patients) is another
factor playing a key
role in stone
development.
Calculi may be found
anywhere from the
kidney to the bladder.
They vary in size
from minute granular
deposits, called sand
or gravel, to bladder
stones as large as an
orange. Certain
factors favor the
formation of stones,
including infection,
urinary stasis, and
periods of immobility
(slows renal
drainage and alters
calcium metabolism).
In addition, increased
calcium
concentrations in
blood and urine
promote precipitation
of calcium and
formation of stones.

Clinical manifestation:-

LC
D

Lecture
cum
discussi

Describe
the
clinical

manifes
tation
of renal
calculi.

Signs and
symptoms of
stones in the
urinary tract
depend on
obstruction,
infection, and
edema.
When the
stones block
the flow of
urine,
obstruction
develops,
producing an
increase in
hydrostatic
pressure and
distending the
renal pelvis and
proximal ureter.
Infection
(pyelonephritis
and cystitis
with chills,
fever, and
dysuria) can
occur from
constant
irritation by the
stone.
Some stones
cause few, if
any, symptoms
while slowly
destroying the
functional units
(nephrons) of
the kidney;
others cause
excruciating
pain and
discomfort.

on

manifesta
tion of
renal
calculi?

Stones in the
renal pelvis
may be
associated with
an intense,
deep ache in
the
costovertebral
region.
Hematuria is
often present;
pyuria may also
be noted.
Pain originating
in the renal
area radiates
anteriorly and
downward
toward the
bladder in the
female and
toward the
testis in the
male.
If the pain
suddenly
becomes acute,
with tenderness
over the
costovertebral
area, and
nausea and
vomiting
appear, the
patient is
having an
episode of renal
colic.
Diarrhea and
abdominal
discomfort may
occur.
These GI

DIAGNO
SIS

10
Min

Explain
the
diagnos
tic
evaluati
on of

symptoms are
due to
renointestinal
reflexes and
the anatomic
proximity of the
kidneys to the
stomach,
pancreas, and
large intestine.
Stones lodged
in the ureter
(ureteral
obstruction)
cause acute,
excruciating,
colicky,
wavelike pain,
radiating down
the thigh and to
the genitalia.
Often, the
patient has a
desire to void,
but little urine
is passed, and
it usually
contains blood
because of the
abrasive action
of the stone.
This group of
symptoms is
called ureteral
colic.
Urinary
retention

Diagnosis: x-ray films of

the kidneys,
ureter, and
bladder (KUB)

LC
D

Lecture
cum
discussi
on

Explain
the
diagnostic
evaluatio
n of renal
calculi?

renal
calculi

10

COMPLIC
ATION

5
Min

What
are its
complic
ation.

ultrasonograph
y, intravenous
urography,
retrograde
pyelography.
Blood
chemistries
24-hour urine
test for
measurement
of calcium, uric
acid, creatinine,
sodium, pH,
and total
volume are part
of the
diagnostic
workup.
Dietary and
medication
histories and
family history
of renal stones
are obtained to
identify factors
predisposing
the patient to
the formation
of stones.
chemical
analysis is
carried out to
determine their
composition.

Complication:Based on assessment
data, potential
complications that
may develop
include the following:

LC
D

Lecture

What are
its
complicati
on?

 Infection and sepsis

(from UTI and
pyelonephritis)
Obstruction of the
urinary tract by a
stone or edema with
subsequent acute
renal failure.
11

MEDICAL
MANAGE
MENT

3
Min

Discuss
its
medical
manage
ment.

Medical management:The basic goals of

management are
to eradicate the
stone,
to determine
the stone type
to prevent
nephron
destruction,
to control
infection,
to relieve any
obstruction
that may be
present.

The immediate
objective of
treatment of
renal or
ureteral colic is
to relieve the
pain until its
cause can be
eliminated.
Opioid
analgesics are
administered to
prevent shock
and syncope
that may result
from the
excruciating

tra
ncp
era
ncy

Lecture
cum
discussi
on

Discuss
its
medical
managem
ent?

pain. NSAIDs
may be as
effective as
other
analgesics in
treating renal
stone pain.
They provide
specific pain
relief because
they inhibit the
synthesis of
prostaglandin
E.
Hot baths or
moist heat to
the flank areas
may also be
useful.
Unless the
patient is
vomiting or has
heart failure or
any other
condition
requiring fluid
restriction,
fluids are
encouraged.
This increases
the hydrostatic
pressure
behind the
stone, assisting
it in its
downward
passage.
A high, aroundthe-clock fluid
intake reduces
the
concentration
of urinary
crystalloids,

dilutes the
urine, and
ensures a high
urine output.
Nutritional
therapy plays
an important
role in
preventing
renal stones.
Fluid intake is
the mainstay of
most medical
therapy for
renal stones.
Unless
contraindicated
, any patient
with renal
stones should
drink at least
eight 8-ounce
glasses of
water daily to
keep the urine
dilute.
A urine output
exceeding 2 L a
day is advisable
.

Calcium Stones.
Historically, patients
with calcium-based
renal stones were
advised to restrict
calcium in their diet.
Recent evidence,
however, has
questioned the
advisability of this
practice, except for
patients with type II

absorptive
hypercalciuria (half
of all patients with
calcium stones), in
whom stones are
clearly due to excess
dietary calcium.
Current research
supports a liberal
fluid intake along
with dietary
restriction of protein
and sodium. It is
thought that a highprotein diet is
associated with
increased urinary
excretion of calcium
and uric acid, thereby
causing a
supersaturation of
these substances in
the urine. Similarly, a
high sodium intake
has been shown in
some studies to
increase the amount
of calcium in the
urine. The urine may
be acidified by use of
medications such as
ammonium chloride
or acetohydroxamic
acid (Lithostat)
(Trinchieri, Zanetti,
Curro & Lizzano,
Cellulose sodium
phosphate (Calcibind)
may be effective in
preventing calcium
stones. It binds
calcium from food in
the intestinal tract,

reducing the amount

of calcium absorbed
into the circulation. If
increased
parathormone
production (resulting
in increased serum
calcium levels in
blood and urine) is a
factor in the
formation of stones,
therapy with thiazide
diuretics may be
beneficial in reducing
the calcium loss in
the urine and
lowering the elevated
parathormone levels.

Uric Acid Stones.

For uric acid stones,
the patient is placed
on a low-purine diet
to reduce the
excretion of uric acid
in the urine. Foods
high in purine
(shellfish, anchovies,
asparagus,
mushrooms, and
organ meats) are
avoided, and other
proteins may be
limited. Allopurinol
(Zyloprim) may be
prescribed to reduce
serum uric acid levels
and urinary uric acid
excretion. The urine
is alkalinized. For
cystine stones, a lowprotein diet is
prescribed, the urine

is alkalinized, and
penicillamine is
administered to
reduce the amount of
cystine in the urine.

Oxalate Stones.
For oxalate stones, a
dilute urine is
maintained and the
intake of oxalate is
limited. Many foods
contain oxalate;
however, only certain
foods have been
proved to increase
the urinary excretion
of oxalate
significantly. These
include spinach,
strawberries,
rhubarb, chocolate,
tea, peanuts, and
wheat bran.
13

SURGICA
L
MANAGE
MENT

5
min

Describ
e its
surgical
manage
ment

Surgical management:If the stone is not

passed
spontaneously or if
complications occur,
treatment modalities
may include surgical,
endoscopic,
ureteroscopy,
extracorporeal
shock wave
lithotripsy
(ESWL),
endourologic
(percutaneous)
stone removal.
Ureteroscopy

LC
D

Lecture
cum
discussi
on

Describe
the
surgical
managem
ent?

14

NURSIN
G
MANAGE
MENT

5
Min

Discuss
its
nursing
manage
ment.

Nursing management:-

Assessment
The patient with
suspected renal
stones is assessed
for pain and
discomfort as well as
associated
symptoms, such as
nausea, vomiting,
diarrhea, and
abdominal distention.
The severity and
location
of pain are
determined, along
with any radiation of
the pain. Nursing
assessment also
includes observing
for signs and
symptoms 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.

RELIEVING PAIN
Immediate relief of
the severe pain from
renal or ureteral colic
is accomplished with
the administration of
opioid analgesic

tra
ns
per
anc
y

Lecture
cum
discussi
on

Discuss
its
nursing
managem
ent?

agents (intravenous
or intramuscular
administration may
be prescribed to
provide rapid relief)
or NSAIDs (ie,
ketorolac).

MONITORING AND
MANAGING
POTENTIAL
COMPLICATIONS
Because renal stones
increase the risk for
infection, sepsis, and
obstruction 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, intravenous
fluids are prescribed.
Ambulation is
encouraged as a
means of moving the
stone through the

urinary tract.
15

17

NURSIN
G
DIAGNO
SIS

5
Min

summari
zation

2
min

list
down
the
related
diagnos
is with
the
disease
conditio
n

Summa
rise the
topic

Nursing diagnosis: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
abrasion
of the urinary tract
Deficient
knowledge regarding
prevention of
recurrence of
renal stones
Urolithiasis refers to
stones (calculi) in the
urinary tract. These
are of three types,
calcium stone , uric
acid stone, and
oxalate stone. Risk
factors include
Family history of
stones,the presence
of cancer or bone
marrow disorders. Its
etiology has been
enlisted.
Pathophysiology ,
clinical manifestation
, medical and nursing
management has
been discussed in
details.

tra
ns
per
anc
y

Lecture
cum
discussi
on

list down
the
related
diagnosis
with the
disease
condition?

Wh
ite
bo
ard

lecture

Summaris
e the
topic