Inaia Medical College (IMC) Critical health nursing/practice, 2019/2020

(Nur 458 )

Nursing care plan

Patient's name:
Medical diagnosis: pneumonia

Nursing diagnosis Expected outcomes Implementation Rationale Evaluation

1. Acute Pain Report pain is 1. Determine and 2. Aids Goal is met
R/ T Increased relieved with note location, duration, to evaluate
frequency/force spasms intensity (0–10 scale), and site of
of ureteral controlled radiation. obstruction
contractions and progress
of calculi
movement.
Flank pain
suggests that
stones are in
the kidney
area, upper
ureter..
1. Justify and clarify cause of Provides opportunity Goal is met
pain and the need of for timely
notifying caregivers of administration of
changes in pain occurrence analgesia (helpful in
Inaia Medical College (IMC) Critical health nursing/practice, 2019/2020
(Nur 458 )
and characteristics. enhancing patient’s
coping ability and
may reduce anxiety)
and alerts caregivers
to possibility of
passing of
stone and developin
g complications
Implement comfort Promotes relaxation,
measures (back rub, restful reduces muscle
environment). tension, and
enhances coping
ADVERTISEMENTS
 Void in normal Record I&O and characteristics of
 Impaired Provides information
amounts and urine.
Urinary about kidney
usual pattern.
Elimination R/T function and
Stimulation of presence of
the bladder by complications
calculi, renal or (infection and
ureteral hemorrhage)..
irritation

1. Determine patient’s Calculi may cause GAOL IS MET

normal voiding nerve excitability,
Inaia Medical College (IMC) Critical health nursing/practice, 2019/2020
(Nur 458 )
pattern and note which causes
variations. sensations of urgent
need to void.
 Risk for Deficient  peripheral 2. Monitor and document I&O and daily weight. Comparing
Fluid Volume R/T pulses, moist actual and
Nausea/vomiting mucous anticipated
(generalized membranes, output may aid
abdominal and good skin turgor. in evaluating
pelvic nerve presence and
irritation degree of renal
 stasis or
impairment. 

Promote fluid intake to 3–4 L a day within cardiac Maintains fluid

tolerance. balance for
homeostasis
and “washing”
action that may
flush the
stone(s) out.
 Deficient  Verbalize 1. Recall and analyze disease process and Provides knowledge base
Knowledge R/T understanding of future expectations. . from which patient can make
Lack of disease process informed choices.
exposure/recall; and potential
Inaia Medical College (IMC) Critical health nursing/practice, 2019/2020
(Nur 458 )
information complications. 1.

misinterpretation

Emphasize importance of increased fluid intake of 3–4L 2. Flushes renal
a day or as much as 6–8 L a day. Encourage patient to system,
notice dry mouth and excessive diuresis and decreasing
diaphoresis and to increase fluid intake whether or not opportunity for
feeling thirsty. urinary stasis and
stone formation.
Increased fluid
losses or
dehydration
require
additional intake
beyond usual
daily needs.

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