NURSING CARE PLAN

Prioritization: Maslow’s Hierarchy of Needs

DIAGNOSIS DESIRED OUTCOME NURSING INTERVENTIONS

Acute pain related to an Within 8 hours of student Independent:

increase in ureteral nurse-patient interaction, the ● Determine and
contractions as evidenced by patient will be able to: note location,
facial grimacing. ● Report pain is relieved duration, and
and is able to relax. intensity of pain.
Scientific Basis: ● Reports signs and (To evaluate the
The majority of renal calculi symptoms of side site of obstruction
contain calcium. The pain effects and imply and progress of
generated by renal colic is manners to prevent calculi movement.)
primarily caused by dilation, additional problems. ● Implement comfort
stretching and spasm ● Establish realistic pain measures. (To
because of the acute relief goals. promote
ureteral obstruction. relaxation, reduces
muscle tension,
Chirag N Dave, MD. and enhances
“Nephrolithiasis.” Practice coping.)
Essentials, Background, ● Increase the fluid
Anatomy, Medscape, 28 intake of at least 3-
Feb. 2020, 4L a day. (To
emedicine.medscape.com/ar promote passing of
ticle/437096-overview. the stone and
prevent urinary
stasis.)
● Apply warm
compress to back.
(To relieve muscle
tension and reduce
reflex spasms.)
● Report an
increased in pain to
primary provider.
(May indicate
progression of the
obstruction and
may need acute
surgical
emergency.)
● Encourage the use
of focused
breathing and
diversional
activities. (To
 redirect attention
and help in muscle
relaxation.)
● Encourage and
assist in frequent
ambulation as
indicated and
tolerated. (Supine
position may
worsen signs and
symptoms.)
● Administer
medication for pain
relief as ordered.
(To reduce pain felt
by the patient.)
● Evaluate the
effectiveness of
analgesics as
ordered and
observe for any
signs and
symptoms of side
effects.
(Effectiveness of
pain medications
must be evaluated
individually since
they are absorbed
and metabolized
differently.)

Collaborative:
● Collaborated in
treatment of
underlying
conditions causing
pain and proactive
management such
as surgical
treatments. (To
have a successful
treatment of
underlying
conditions.)
● Identified specific
signs/symptoms

Impaired urinary elimination
related to renal obstruction
as evidenced by oliguria.
Scientific Basis:
If the blockage is only for a
short time, the kidneys can
usually recover completely.
However, if the blockage is
there for a long time (for
many days or weeks), it can
cause permanent kidney
damage.
“Obstruction and
Obstructive Nephropathy.”
Edrenorg,
edren.org/ren/edren-
info/obstruction-and-
obstructive-nephropathy/.
and changes in pain
characteristics
requiring medical
follow-up.
(Provides
opportunity to
modify pain
management
regimen.)
Within 8 hours of student Independent:
nurse-patient interaction, the ● Record input &
patient will be able to: output and
● Void in normal characteristics of
amounts and usual urine. (To pride
pattern. information about
Experience no signs of kidney function and
obstruction such as pain. presence of
complication.)
● Obtain urine
samples for culture
and sensitivities.
(Determine the
presence of
infection.)
● Encourage the
patient to walk. (To
facilitate
spontaneous
passage of stone.)
● Promote sufficient
intake of fluid.
(Increased
hydration flushes
bacteria, blood,
and debris and may
facilitate stone
passage.)
● Offer fruit juices,
particularly
cranberry juice. (To
help acidify urine.)
● Strain all urine.
Document any
stones expelled and
send to the
laboratory for
 analysis. (Retrieval
of calculi allows
identification of
type of stone and
influences choice of
therapy.)
● Check laboratory
studies such as
electrolytes, BUN,
Cr. (Elevated BUN,
Cr, and certain
electrolytes
indicate presence
and degree of
kidney
dysfunction.)
● Discuss possible
dietary restrictions
such as coffee,
carbonated drinks,
alcohol. (To
prevent further
stone formation.)
● Instruct the patient
to wipe the area
from front to back.
(Proper perineal
care helps in
minimizing the risk
of contamination
and re-infection.)

Collaborative:
● Assist with physical
assessment. (To
obtain data and
determine signs
and symptoms
notes.)
● Discuss possible
surgical procedures
and medical
regimen, as
indicated. (To treat
urinary retention.)

Hyperthermia related to Within 8 hours of student Independent:

urinary tract infection as
evidenced by temperature
of 38 degrees Celsius,
flushed skin and profuse
sweating
Scientific Basis:
The upper urinary tract is
composed of the kidneys
and ureters. Infection in the
upper urinary tract generally
affects the kidneys
(pyelonephritis), which can
cause fever, chills, nausea,
vomiting, and other severe
symptoms.
Jerry R. Balentine, D. (2019,
November 13). Urinary Tract
Infection (UTI) Symptoms,
Causes, Treatment & Home
Remedies. Retrieved
November 19, 2020, from
https://www.medicinenet.co
m/urinary_tract_infection/a
rticle.htm
nurse-patient interaction, the ● Assess patients’
patient will have: vital signs at least
● Stabilized temperature every 4 hours (To
within the normal monitor the
range effectiveness of
● Remain free from medical treatment
dehydration and fever reducing
● Remain free from drugs
infection administered.)
● Encourage to
increased oral fluid
intake to 2-3 liters
a day if no
contraindication.
(To reduce the risk
for dehydration
related to
hyperthermia
episodes.)
● Provide a tepid
sponge bath (To
facilitate the body
on cooling down
and provide
comfort.)
● Suggested drinking
of cranberry juice
(4-6oz per day).
(Cranberry juice
has been shown to
reduce adherence
of bacteria to the
uroepithelial cells
in the urinary
tract.)
● Eliminate excess
clothing and covers
(Exposing skin to
room air decreases
warmth and
increases
evaporative
cooling)
● Encourage the
patient to complete
the whole duration
of the antibiotic.
 (Client should finish
the prescribed
duration of the
antibiotics, even if
the symptoms
disappear, because
not finishing a
course of
antibiotics may
result in
reinfection.)
● Encourage to
maintain bedrest
(To reduce
metabolic
demands/oxygen
consumption)
● Administer the
prescribed anti-
pyretic as
indicated. (To
stimulate the
hypothalamus to
normalize the body
temperature.)
● Encourage patient
to maintain a
healthy diet. (To
meet metabolic
demands.)

Collaborative:
● Assist with medical
procedures as
indicated. (To
prevent recurrent
infection.)

Risk for deficient fluid Within 8 hours of student Independent:

volume as evidenced by the nurse-patient interaction, the ● Assess skin turgor
client being nauseous patient will be able to: and oral mucous
● Maintain adequate membranes for
Scientific basis: fluid balance signs of
Fluid volume deficit ● Maintain moist dehydration. (To
describes the loss of mucous membrane determine any
extracellular fluid from the and good skin turgor signs of
body. Major causes of dehydration)
deficient fluid volume ● Monitor and
include blood loss, vomiting, document I&O and
diarrhea, and bleeding daily weight. (To
disorders. The fluids in the aid in evaluating
body also constantly need to presence and
be replenished. Patients can degree of renal
experience deficient fluid stasis or
volume if they aren’t taking impairment.)
enough fluids. ● Review laboratory
data such as
hemoglobin,
McCammon, E. (n.d.). How osmolality,
to Diagnose Fluid Volume electrolytes. (To
Deficit: Signs and Care Plan. evaluate
Retrieved November 19, electrolyte and
2020, from fluid status.)
https://blog.prepscholar.co ● Promote fluid
m/fluid-volume-deficit-signs- intake to3-4L a day
care-plan within cardiac
tolerance. (To flush
stones out.)
● Encourage
appropriate diet,
clear liquids, bland
foods as tolerated.
(To maintain fluid
and nutritional
balance.)
● Administer
medications as
appropriate.
(Reduces nausea
and vomiting.)
● Discuss individual
risk factors,
potential problems,
and specific
interventions. (To
reduce the increase
of complications
and symptoms.)
● Enumerate
interventions to
prevent episodes of
dehydration. (To
understand the
importance of
 drinking extra
fluids with
conditions causing
fluid deficits.)
● Emphasize the
relevance of
maintaining proper
nutrition and
hydration.
(Increasing the
patient’s
knowledge level
will assist in
preventing and
managing the
problem.)

Collaborative:
● Provide
supplemental IV
fluids as indicated.
(Maintains
circulating volume
if oral intake is
insufficient,
promoting renal
function.)

Deficient Knowledge related Within 8 hours of student Independent:

to unfamiliarity with the
dietary regimen and its
relationship to calculi
formation
Scientific Basis:
Kidney stone prevention
should be individualized in
both its medical and dietary
management, keeping in
mind the specific risks
involved for each type of
stone. Recognition of these
risk factors and
development of long-term
management strategies for
dealing with them are the
most effective ways to
nurse-patient interaction, the ● Determine the
patient will be able to: client’s ability,
● Verbalize the readiness, and
understanding and barriers to learning.
knowledge about the (To ensure that the
foods and liquids to patient is ready to
limit in order to learn and retain
prevent stone information.)
formation ● Teach the patient
● Create a meal plan to to maintain
exclude or limit food adequate hydration
intake of at least 2-3L/day,
especially after
meals and heavy
activities. (Good
hydration after
meals and exercise
is important
prevent recurrence of kidney because a person’s
stones. solute load is
highest at these
Han, H., Segal, A., Seifter, J., times)
& Dwyer, J. (2015, July ● Limit the intake of
31). Nutritional foods such as milk,
Management of Kidney cheese, green leafy
Stones (Nephrolithiasis). vegetables, yoghurt
Retrieved November 19, (These foods are
2020, from high in calcium
https://www.ncbi.nlm.nih.g content)
ov/pmc/articles/PMC452513 ● Limit sodium intake
0/ (A low-sodium diet
helps reduce
intestinal
absorption of
calcium)
● Limit intake of
refined
carbohydrates and
animal proteins
(These foods can
cause
hypercalciuria)
● Encourage foods
high in natural fiber
content like bran,
prunes and apples
(These foods
provide phytic acid,
which binds dietary
calcium)
● Explain that sodium
cellulose
phosphate, 5 g,
may be given three
times a day before
each meal (Sodium
cellulose
phosphate, when
used with calcium-
restricted diet,
reduces risk of
stone formation by
binding with
intestinal calcium
and thus increasing
 excretion of
calcium. It should
be used cautiously
in postmenopausal
women at risk for
osteoporosis)
● Explain that
orthophosphates
like potassium acid
phosphate and
disodium and
dipotassium
phosphates or
thiazides also may
be given for
calcium stones
(These agents
decrease urinary
excretion of citrate
and pyrophosphate
and thus inhibit
stone formation)
● Provide positive
reinforcement. (To
encourage
continuation of
efforts.)

Collaborative:
● Provide access to
information. (To
answer questions
and validate
information.)