Kidney stones or Renal calculi are hard masses formed in the different sites of the urinary tract. The process of stone formation is called urolithiasis, renal lithiasis or nephrolithiasis.
The most common mineral deposits are calcium oxalate and calcium phosphate and it is commonly found in the renal pelvis and calyces.
Stones are more common to people with underlying diseases like hypertension and short bowel syndrome and those persons with diet high in protein or those who do not consume enough water. Sometimes the formation of stones can be caused by urinary tract infection, which can be evidenced by struvite stones or also known as infection stones.
A renal calculus is asymptomatic until it passes through the ureter. Obstruction of urine flow becomes the triggering indicator for renal damage which is then considered acute. An excruciating pain is the main basis for the diagnosis of renal calculi. It is accompanied by tenderness over the back and groin and urinalysis may show the presence of blood or pus in the urine.
Nursing Diagnosis: ACUTE PAIN
Possible Etiologies: (Related to)
- Increased frequency or force or ureteral contractions
- Tissue trauma
- Edema formation
- Cellular ischemia
Defining Characteristics: (Evidenced by)
“This pain is bothering me a lot.”
Cries or moans frequently
Rates pain as 7/10 when asked to rate pain in a scale of 1 to 10, with 10 as the highest.
- Guarding behavior/ protective
- Creasing eyebrows
- Tensed muscles
- Frequent grimacing
- Autonomic responses:
-Blood pressure, pulse and respiratory rates changes
Blood pressure ranging from 140/90 – 130/ 100
Pulse rate ranging from 95 – 105 beats per minute
Respiratory rate ranging from 18 – 22 breaths per minute
Short term goal:
Client will be able to report and demonstrate behaviors signalling a relief or control of pain.
Long term goal:
Client will be able to know and perform activities that do not only provide relief from pain but helpful in dealing the disease condition.
Client will be able to report that the pain is relieved or controlled and demonstrates behaviors like decrease in frequency of guarding behavior, restlessness and grimacing; also present vital signs to be stable with BP of 110/70mmHg – 120/80mmHg, pulse rate of 60 – 75 beats per minute and respiratory rate of 16 – 20 breaths per minute within 3 days of nursing intervention.
Client will be able to learn and perform relaxation skills like deep breathing exercises and diversional activities like guided imagery etc. for pain relief; as well as other activities like proper diet planning, BP monitoring, and compliance to medications and treatment regimen.
|Document the pain in terms of location, duration, intensity (1-10 pain scale), and radiation. Also, observe for nonverbal cues like BP and pulse rate elevation, restlessness, crying or moaning.||-This would aid you in assessing and evaluating the effectivity of treatment; it can also reflect the progress of calculi movement because a flank pain means the stones are still in the kidney area and upper ureter; severe pain may result to severe anxiety and restlessness.|
|Encourage to verbalize pain noting also for the pain threshold of the client; let client explain how the pain occur or for any changes in characteristics.||-It will provide an avenue for timely administration of pain medication.|
|Educate and encourage client in diversional activities like focused breathing and guided imagery.||-It will help client in diverting pain and coping with disease condition.|
|Provide scheduled resting periods for client and also provide a peaceful environment.||-It can promote relaxation and reduces muscle tension.|
|Assist client in daily ambulation and encourage increasing fluid intake of at least 3 L per day as tolerated.||-Supine position could be worse for renal colic while an increased fluid intake promotes the passing of the stone and prevents further stone formation.|
|Instruct client to report for persistent or increased abdominal pain.||-Complete obstruction of the ureter can cause the perforation of urine into the perirenal space making it a surgical emergency.|
|Administer medications like narcotics, antispasmodic and corticosteroid as prescribed by the physician.||– Narcotics are given during acute periods of pain; antispasmodic is used to decrease spasm preventing colic and pain; corticosteroid is given to reduce edema, facilitating the movement of stone.|
|If indicated, a warm compress may be applied to the back.||-It reduces muscle tension and spasms.|
|Insert and maintain the patency of urinary catheter.||– To determine and prevent urinary retention and it can also help in lessening renal pressure and infection.|
Originally posted 2016-12-25 14:21:04. Republished by Blog Post Promoter