Question

You receive a 56 year old male patient newly admitted to your general medical floor who presented to the ED with complaints of severe right flank pain (rated 10/10 on numeric pain scale), nausea & vomiting for the past 36 hours, fever of 101.5 degrees, hematuria, & dysuria. This patient was diagnosed with a 0.7cm nephrolithiasis in the right kidney, seen on renal ultrasound.

1. Write out 3 nursing diagnoses (include ‘related to’ and ‘as evidenced by’ (AEB) statements) that are appropriate for this patient. Remember you do not need to include AEB statements for ‘risk for’ nursing diagnoses.
2. Identify a patient outcome for each of your nursing diagnoses.
3. Identify 2 nursing interventions for each nursing diagnoses (minimum 6 nursing interventions total) that you would include in your care plan to help the patient achieve their outcomes.

Answer 1

1) Nursing diagnosis: Acute pain related to patient condition as evidenced by verbalization

Goal : reduce the client pain

Nursing interventions - rationale:

Assess the patient pain by pain scoring scale - to know about the patient condition.

Implement comfort measures back rub, restful environment.- Promotes relaxation, and enhances coping.

Assist with frequent ambulation as indicated and - Renal colic can be worse in the supine position.

Increase fluid intake- Vigorous hydration promotes passing of stone, prevents urinary stasis, and aids in prevention of further stone formation.

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

Administer the medication as per physician order to treat the condition of patient.

Evaluation:the client pain may reduce by proper implementation of interventions.

2) nursing diagnosis:

Risk for Deficient Fluid Volume related to
Nausea/vomiting as Evidenced by patient condition.

Goal: Maintain adequate fluid balance

Nursing interventions and rationale:

Monitor and document I&O and daily weight. To know the condition.

Administer medications as indicated-Reduces nausea and vomiting.

Promote fluid intake to 3–4 L a day helps for homeostasis and “washing” action that may flush the stones out.

supplemental Iv fluids may be given.-Maintains circulating volume promoting renal function.

Evaluation: the client fluid volume is maintained by implementation

Nursing diagnosis:

Impaired Urinary Elimination related Mechanical obstruction as evidenced by Hematuria

Goals:

Void in normal amounts and usual pattern.

Nursing interventions and rationale:

Determine patient’s normal voiding pattern and note variations. - Usually frequency and urgency increase as calculus nears ureterovesical junction.

Encourage the patient to walk if possible.-To facilitate spontaneous passage.

Promote sufficient intake of fluids.- Increased hydration flushes bacteria, blood, and debris and may facilitate stone passage

Offer fruit juices ,particularly cranberry juice.- To help acidify urine

Irrigate with acid or alkaline solutions as indicated.-Changing urine ph may help dissolve stones and prevent further stone formation