Nursing Care Plan Cues

Nursing Diagnosis Subjective: Acute pain related to ang sakit kai irritation and gasugod sa likod spasm of paingon sa ako stone paa as verbalized movement in by the patient. the urinary tract With a pain scale of 8/10 Objective: Facial mask of pain Appears restless Vital Signs: BP 130/90 mmHg, Pulse 110 bpm, Respiration 23 cpm, temperatur e - 38c

Objectives Short term: At the end of 30 minutes client will be able to a. report pain is relieved and spasm is controlled b. appear relaxed Long term

Intervention Independent: 1. Provide comfort measures, e.g., back rub, restful environment. -

Rationale

Evaluation At the end of 30 minutes patient was able to verbalized reduce of pain felt with a scale of 5/10

Promotes relaxation, reduces muscle tension, and enhances coping Redirects attention and aids in muscle relaxation.

2. Assist with/encourage use of focused breathing, guided imagery, diversional activities. 3. Encourage/assist with frequent ambulation as indicated and increased fluid intake of at least 3 4 L/day within cardiac tolerance.

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 4. Apply warm compresses to back Relieves muscle tension and may reduce reflex spasms.

Dependent: 5. Administer medications as indicated: Narcotics, e.g., meperidine (Demerol), morphine;

Usually given during acute episode to decrease ureteral colic and promote muscle Decreasing reflex spasm may decrease colic and pain. May be used to reduce tissue edema to facilitate movement of stone.

Antispasmodics, e.g., flavoxate (Urispas), oxybutynin (Ditropan);

Corticosteroids.

Cues Subjective: sakit kayo pag mag-ihi ko, dayon cge ko ihi-ihi pero ginagmay ra as stated by the patient Objective Hematuria Oliguria

Nursing Diagnosis Impaired urinary elimination related to mechanical obstruction

Objectives Short term At the end of 8 hours client will be able to void in normal amounts and without pain in urination. Long term: At the end of 2 days client will be able to experience no signs of obstruction.

Interventions Independent 1. Monitor I&O and characteristics of urine. -

Rationale

Evaluation At the end of 8 hours patient was able to urinate without pain

Provides information about kidney function and presence of complication. Bleeding may indicate increased obstruction or irritation of ureter. Increased hydration flushes bacteria, blood, and debris and may facilitate stone passage.

2. Encourage increased fluid intake.

3. Strain all urine. Document any stones expelled and send to

Retrieval of calculi allows identification of type of

laboratory for analysis.

stone and influences choice of therapy

Dependent: 4. Administer medications as ordered May be used to prevent urinary stasis and decrease calcium Hydrochlorothiazide stone formation if (Esidrix, not caused by HydroDIURIL), underlying disease chlorthalidone process such as (Hygroton); primary hyperthyroidism or vitamin D abnormalities.

Cues Subjective: sakit kayo pag mag-ihi ko, dayon cge ko ihi-ihi pero ginagmay ra as stated by the patient

Nursing Diagnosis Infection related to stasis

Objectives Short term At the end of 8 hours client will be pain free during urination

Intervention Independent
1. Encourage

Rationale

Evaluation At the end of 8 hours client was able to relieve from pain during urination

the patient to drink extra fluid

Long term Objective: Hematuria Elevated WBCs Low back pain Bacteriuria Temperature: 38C (fever) At the end of 3 days client will be able to have normal WBCs count and absence of blood and bacteria in urine
2. Instruct the

Fluid promotes renal blood flow and flushes bacteria from the urinary tract. This enhances bacterial clearance, reduces urine stasis, and prevents reinfection. To acidify urine

patient to void often (every 2 to 3 hours during the day) and to empty bladder completely.
3. Suggest intake of

vitamin C contaning juice Dependent

4. Administer

antibiotics as prescribed

To eliminate infection

Cues Subjective three days naman ko gahilanat as verbalized by the patient

Nursing Diagnosis Hyperthermia related to illness

Objectives Short term At the end of 30 minutes client will be able to maintain body temperature below 38C Long term Be free of seizure activity

Intervention Independent 1. Maintain bed rest -

Rationale

Evaluation

At the end of 30 minutes patient was To reduce metabolic demands/ able to lower body oxygen temperature consumption to 36.8C

Objective Flushed skin, warm to touch Increased heart rate: pulse 110 bpm Temperature 38C

2. Remove excess clothing and covers

This decreases warmth and increases evaporative cooling

3. Perform tepid sponge bath Dependent 4. Administer antipyretic as ordered 5. Administer replacement fluids and electrolytes

To promote cooling

Aids to lower body temperature

To support circulating volume and tissue perfusion

Cues Risk factors may include Nausea/vomiting (generalized abdominal and pelvic nerve irritation from renal or ureteral colic) Postobstructive diuresis

Nursing Diagnosis Risk for fluid volume deficit

Objectives Short term Long term At the end of 2 days client will be able to Maintain adequate fluid balance as evidenced by vital signs and weight within patients normal range, palpable peripheral pulses, moist mucous membranes, good skin turgor.

Intervention Independent 1. Monitor I&O. -

Rationale

Evaluation At the end of 2 days patient was able to maintain adequate fluid balance

Comparing actual and anticipated output may aid in evaluating presence/degree of renal stasis/impairment. 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. 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

2. Document incidence and note characteristic s and frequency of vomiting and diarrhea, as well as accompanyin g or precipitating events.

3. Increase fluid intake to 34 L/day within cardiac tolerance.

(vomiting and diarrhea). 4. Monitor vital signs. Evaluate pulses, capillary refill, skin turgor, and mucous membranes. Dependent 5. Administer IV fluids. Maintains circulating volume (if oral intake is insufficient), promoting renal function. Reduces nausea/vomiting. Indicators of hydration/circulating volume and need for intervention.

6. Administer medications as indicated: antiemetics, e.g., prochlorperaz ine (Compazine).