Nursing Care Plan Nursing Diagnosis: Acute pain related to build up of material in ureter as evidenced by patient report pain

of 6 out of 10. Long Term Goal: Patient will be free of renal and ureteral calculi prior to discharge. Intervention Assess for pain q4h Rationale Use OLDCARTS method to assess for pain. Ureteral calculi are often painful. Frequent assessment will allow for early intervention. Pain management is a priority focus in patients with calculi. (Ackley, 604) Non-pharmalogical interventions for pain are a first line of defense when patient expresses discomfort. Hot flashes and sweating often occur in conjunction with nausea and pain. A cool cloth can ease headache, nausea, and pain associated with ureteral calculi. (Ackley, 605) Renal and ureteral calculi cause acute pain. Administration of analgesia will help to increase patient comfort. Pain management is a priority focus in patients with calculi. (Ackley, 606) Renal and ureteral calculi cause acute pain. K-pads administer either heat or cold therapy to areas of identified pain which should improve patient comfort. (Ackley, 605) Frequent assessment of vital signs will allow for early detection of complications related to ureteral calculi. Increased heart rate and BP are indicative of increased pain. Fever is an early indicator of infection caused by invasive procedure or urinary retention. (Ackley, 866) Ureteroscopy is an invasive procedure which eliminates ureteral calculi. The RN should review the preoperative checklist and ensure that all steps are complete and signed off prior to transport to the OR. (Ackley, 868) Outcome Criteria Patient will report decreased pain prior to discharge due to pain management interventions. Patient will report decreased symptoms of nausea or pain within 1 hour of use of cool cloth. Patient will report no pain prior to discharge with the use of medication as needed to treat pain resulting from invasive procedure. Patient will report decreased pain after use of k-pad. All vitals will remain stable both preoperatively and postoperatively. Evaluation Patient reports no pain and is ready for discharge. Patient reports decreased nausea after operation with use of cool cloth. Patient reports no pain and has not taken medication.

Apply cool cloth to head PRN for nausea or pain

Administer opiod and non-opiod analgesics as prescribed PRN for pain. Apply k-pad PRN for pain Assess vital signs q4h.

Patient reports reduced pain with use of k-pad. Blood pressure was slightly elevated. All other vitals remained stable. Patient explains procedure well and pre-operative checklist was complete.

Prepare for ureteroscopy as ordered by MD.

Pre-operative checklist will be completed and patient will report an understanding of the procedure.

Ackley B.J., Ladwig G.B. (2011) Nursing Diagnosis Handbook. St. Louis, MO