nephrolithiasis - ncp
DESCRIPTION
DDDTRANSCRIPT
Cues/clues Nursing
Diagnosis
Plan Nursing Interventions Rationale Evaluation
S> “masakit ang
likod ko” as
verbalized
O> with facial
grimace
Irritable at times
Slightly weak in
appearance
With guarding
behavior
Pain scale=8/10
BP=110/80
Alteration in
comfort; flank pain
secondary to
disease condition
At the end of nursing
intervention the
patient will be able
to demonstrate ways
and technique on
how to reduce pain
to a tolerable level
Assessed severity of pain using pain
scale
Monitor VS esp. BP
Provided comfort measures such as
positioning
Provided diversional activities such as
listening to music or talking to S.O.
Instructed S.O. not to leave the patient
alone
Provided therapeutic touch
Demonstrated and encouraged to do
deep breathing exercise
Encouraged back tapping
Avoid abrupt movements
Provided adequate rest and sleep
periods
Administered analgesics as ordered
For baseline data
For baseline data
To promote comfort and
relaxation
To divert focus of attention
to pain
To prevent pain stimulation
To promote comfort and
relaxation
For pharmacologic
intervention
“Medyo nawala na ung sakit
ng likod ko”as verbalized
Pain scale= 6/10
BP=90/60
Cues/clues Nursing Nursing Plan Nursing Interventions Rationale Evaluation
Diagnosis
O>BP =
150/90mmHg
>PR = 89bpm
>episodes of
dizziness
>slightly pale nail
beds; capillary refill
time of 2-3 seconds
Decrease cardiac
output related to
increase peripheral
vasoconstriction as
evidenced by
elevated blood
pressure
At the end of
nursing
interventions, patient
with the help of SO
will be able to
demonstrate ways
and techniques on
how to normalize
cardiac output and
maintain blood
pressure within
normal range
assess contributing factors
assess general appearance
monitor v/s esp. blood pressure
instruct to move gradually and have a
gradual increase in activities
encourage to avoid strenuous activities
assist in moderate high back rest
encourage to limit intake of salty and
fatty foods
instruct the SO not to leave the patient
alone
PRN meds given
serves as baseline data
serves as baseline
data
serves as baseline data
to prevent dizziness
to prevent dizziness
to promote relaxation and
comfort
to prevent water retention
to prevent injury through
proper supervision
for pharmacological
purposes
Seen pt in semi-fowler’s
position
Seen SO always on bedside
Seen pt moving gradually
BP=130/90
Cues/ Clues Nursing Plan/Goal Nursing Interventions Rationale Evaluation
Diagnosis
O
Weak in
appearance
With assistance
in doin activities
With dry
slightly skin
With easy
fatigability
With long nails
Self-care deficit
related to decrease
strength and
endurance
secondary to
disease condition
At the end of the
nursing interventions
the patient with the
help of the S.O, will
be able to identify
ways on how to
enhance proper
hygiene
Assess capability to do activities
Discuss the importance of hygiene
Instruct SO to clean and cut long
fingernails
Instruct SO to do sponge bath
Encourage the patient to take a bath
Encourage to do oral hygiene
Encourage SO to be involve in giving
patient proper hygiene
Instruct SO to provide non-constricting
clothes
Encourage patient to splash a little
baby cologne after bath
To identify the patient’s
status
To educate the patient
about the importance of
hygiene
For proper personal
hygiene
For proper personal
hygiene
For proper personal
hygiene
For proper personal
hygiene
For the SO will be able to
apply the procedures at
home
To make the patient feel
comfortable
For the patient to feel
fresh
Seen S.O. wiping patients
extremities
Seen S.O. assisting patient
in changing of clothes and
doing some activities
Cues/ Clues Nursing
Diagnosis
Plan/Goal Nursing Interventions Rationale Evaluation
O
With edema on
the feet +1
Fluid volume
excess related to
compromised
regulatory
mechanism
secondary to
disease condition
At the end of the
nursing intervention
the patient will be
able to identify ways
on how to lessen
fluid volume excess
Assess general condition
Assess contributing factors
Assess the characteristic of edema
Monitor VS esp. BP
Instructed to limit fluid intake to less
than 1L a day
Put pillows under both legs
Instructed to turn side to side at least
every 2 hours
Advised to eat foods rich in albumin
such as egg white
Regulate IVF properly
Emphasized the importance of
furosemide treatment
Encouraged to have adequate rest and
sleep
Emphasized the importance of strict
adherence to treatment regimen
For baseline data
For baseline data
For baseline data
For baseline data
To avoid fluid
accumulation in the body
To increase venous return
To help in fluid shift
To help in lessen the
edema
For rehydration
To help in the disease
condition
To regain body strength
For faster prognosis
Seen with pillows under the
legs
Seen drinking ample
amount of water
Cues/ Clues Nursing Plan/Goal Nursing Interventions Rationale Evaluation
Diagnosis
S> “Wala kaming
pera, naghahanap
ng pa kami ng
pagkukunan para
makabili ng
pangsalin ng dugo”
O> still for blood
transfusion
>without any
contraptions
Noncompliance to
treatment regimen
r/t lack of
involvement
financial problems
At the end of
nursing intervention
the S.O. with the
patient will be able
to realize the
importance of
compliance to
treatment regimen
Identified strategies most effective for
S.O.
Encouraged S.O. on verbalization of
feelings
Helped S.O. in understanding the need
for the following treatment and
consequences of non-compliance
Emphasized the importance of
adherence to treatment regimen
Provided emotional support to S.O.
For S.O. to easily complete
with the treatment
To asses emotional
response that interfere
with compliance
For the S.O. to realize the
importance of the
treatment
For the S.O. to understand
the need for the following
the prescribed treatment
To help S.O. cope up with
the problem
Tranfused 1 “U” of FWB
Cues/ Clues Nursing Plan/Goal Nursing Interventions Rationale Evaluation
Diagnosis
O
Hgb=9gm/dl
Hct= 29.6
Poor skin turgor
Pale
conjusctivae
With Pale and
slightly dry lips
Pale nailbeds,
2-3upon
blanching
Slightly pale in
appearance
For BT
Altered tissue
perfusion related
to decreased O2
carrying capacity
of the blood as
revealed in the
laboratory results
At the end of
nursing intervention
the patient will
demonstrate ways
and technique on
how to improve
arterial circulation
Assessed causative factors such as
bleeding
Monitored V/S esp. PR
Assessed capillary refill time
Monitored and reviewed findings
Encouraged to eat Iron-rich foods like
green leafy vegetables like malunggay
Encouraged to increase intake of Vit. C
Regulated IVF properly
Encouraged to turn from side to side
Instructed to increase fluid intake
Encouraged to do O2 conservation
techniques such as sitting and sleeping
Watched out for any sign of bleeding
Provided safety measures
Advised to avoid strenuous activities
Provided bed exercises with proper
instruction to S.O.
To see cause of decreased
in Hgb in the blood
To identify any alteration
To assess for tissue
perfusion
To identify progression of
dse.
To facilitate adequate
tissue perfusion
For better absorption and
increase resistance of
body to infection
To maintain hydration
To improve circulation
To support circulating
volume and tissue
perfusion
To conserve O2 of body
To prevent further damage
Hgb=11.3
Hct=35%
With pinkish nailbeds
With pinkish conjunctiva
FWB transfused
To prevent further injury
To promote wellness,
provide optimum health
and improve blood count
levels
Too improve circulation
Cues/ Clues Nursing
Diagnosis
Plan/Goal Nursing Interventions Rationale Evaluation
O>with yellow to
brownish colored urine
No crystals or blood
observed
Goes to comfort room
twice per shift
Impaired urinary
elimination related
to decreased renal
perfusion
secondary to
disease condition;
nephrolithiasis
At the end of the
nursing intervention
the patient will vid
in normal amounts
and usual pattern
Monitored Intake and output and
characteristic of urine
Encourage oral fluid intake
Investigate reports of bladder fullness
or palpate suprapubic distention
Document any stone expelled and send
laboratory for analysis
For baseline data
To lessen concentration of
the urine
For hydration
To eliminate bladder
distention
With slightly colored urine
Cues/ Clues Nursing
Diagnosis
Plan/Goal Nursing Interventions Rationale Evaluation
S “Ano bang nagyayari
kapag nagkakabato” as
verbalized.
O>asking questions
about his health
problem
>Asks regarding the
food he can eat
>Unfamiliar with the
things that contributes
to his health problem
like eating salty foods
Knowledge deficit
related to lack of
information
regarding current
health condition
At the end of the
shift the patient will
be able to verbalize
understanding of his
disease process and
potential
complications
Reviewed disease process and potential
complications
Stressed the importance of increased
fluid intake (3-4 L/day)
Encouraged to notice dry mouth and
excessive diaphoresis and to increase fluid
intake whether or not feeling thirsty
Encourage to eat low salt low fat foods
Discussed medication regimen
For baseline data
To impart knowledge
To help avoid foods that
may complicate condition
To avoid dehydration
Seen drinking plenty of
water. Seen eating citrus foods
Cues/ Clues Nursing
Diagnosis
Plan/Goal Nursing Interventions Rationale Evaluation
S> “hindi ako
madumi”as verbalized.
O>hypoactive bowel
sounds upon
auscultation, 3bpm
>with negative bowel
movement for 1 week
Constipation
related to
insufficient
physical activity
At the end of the
nursing intervention
the patient will
demonstrate
behaviors to relieve
constipation
Monitored input and output
Auscultated for bowel sounds
Instructed to increase oral fluid intake
at least 6-8 glasses per day
Instructed to eat high in fiber foods
such as oranges.
Encourage to increase mobility or
exercise such as walking
For baseline data
to help stimulate bowel
movement and for hydration
to help stimulate bowel
movement
still with negative bowel
movement