Question

GU Unit – Chapter 55

Student Readiness Activity

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

Nursing care plan for patients with nephrolithiasis.

Nephrolithiasis is a condition characterized by stone formation in kidney. Care plan include

1)acute pain related to obstruction, inflammation and migration of stone as evidenced by pain scale score rating is 10/10,verbalization of pain and patient expressions.

Outcome

Patient verbalize reliving of pain

Intervention

:assess the charecterestics ,location, duration and nature of pain.

:administer analgesics to relieve pain.

:encourage ambulation and assisting them with ambulation .Ambulation help to remove stone via urine.

:provide comfortable position to the patient.

2)impaired urinary elimination related to mechanical obstruction and inflammation as evidenced by hematuria and dysuria

Outcome

Void in normal amount and  correct pattern with out any obstruction

Intervention

:maintain strict intake and out put chart

:advice to take 3 to 4 L of fluid in a day

:advice to take fruit juices especially cranberry juice

:encourage ambulation

3)hyperthermia related to inflammatory process as evidenced by temperature 101.5 degree Fahrenheit .

Outcome

The patient temperature become normal limit.

Intervention

:monitor vital signs frequently

:administer antipyretics such as paracetamol.

:provide tepid sponge

:provide well ventilated environment.

:encourage to take more amount of fluid to prevent dehydration.