acute Pain

May be related to
Increased frequency and force of ureteral contractions Tissue trauma, edema formation, cellular ischemia

Possibly evidenced by
Reports of colicky pain Guarding or distraction behaviors, restlessness, moaning, self-focusing, facial mask of pain, muscle tension Autonomic responses

Note reports of increased or persistent abdominal pain. RATIONALE: Complete obstruction of ureter can cause perforation and extravasation of urine into perirenal space. This represents an acute surgical emergency.

7.

Collaborative
1. Administer medications, as indicated, for example: Opioids, such as morphine sulfate (Astramorph, Duramorph);oral opioid combination analgesics, such as oxycodone and acetaminophen (Percocet); and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ketorolac (Toradol) RATIONAL: Opioid and NSAID combination is often given intravenously (IV) during acute episode to quickly decrease ureteral colic and promote muscle and mental relaxation. Antispasmodics, such as flavoxate (Urispas) and oxybutynin (Ditropan); calcium channel blocker, such as nifedipine (Adalat); and alpha-adrenergic blockers, such as tamsulosin (Flomax) RATIONALE: Decreases reflex spasm and relaxes ureteral smooth muscle,which facilitates stone passage. Note: Oral analgesics,NSAIDs, and alpha-adrenergic blockers help facilitate stone passage after acute attack 3. Corticosteroids, such as prednisone (Deltasone) RATIONALE: May be used short-term to reduce tissue edema to facilitate movement of stone. 4. Maintain patency of catheters when used RATIONALE: Prevents urinary stasis or retention, reduces risk of increased renal pressure and infection. 2.

ACTIONS/INTERVENTIONS
Pain Management Independent
Document location, duration, intensity (0 to 10 scale), and radiation. Note nonverbal signselevated BP and pulse, restlessness, moaning, and thrashing about. Rationale: Helps evaluate site of obstruction and progress of calculimovement. Flank pain suggests that stones are in the kidney area, upper ureter. Flank pain radiates to back, abdomen, groin, and genitalia because of proximity of nerve plexus and blood vessels supplying these areas. Sudden, severe pain may precipitate apprehension, restlessness, and severe anxiety. Explain cause of pain and importance of notifying caregivers of changes in pain occurrence or characteristics. Provide such comfort measures as back rub and restful environment. Rationale: Provides opportunity for timely administration of analgesia and alerts caregivers to possibility of passing of stone or developing complications. Sudden cessation of pain usually indicates stone passage. Provide such comfort measures as back rub and restful environment. Rationale: Promotes relaxation, reduces muscle tension, and enhances Coping. 4. Apply warm compresses to back. Rationale: Relieves muscle tension and may reduce reflex spasms. Assist with and encourage use of focused breathing, guided imagery, and diversional activities. RATIONALE: Redirects attention and aids in muscle relaxation. Encourage and assist with frequent ambulation as indicated; increase fluid intake to at least 3 to 4 L/day within cardiac tolerance. RATIONALE: Renal colic can be worse in the supine position. Vigorous hydration promotes passing of stone, prevents urinarystasis, and aids in prevention of further stone formation. 6. 5. 3. 2. 1.

impaired Urinary Elimination

May be related to
Stimulation of the bladder by calculi, renal or ureteral irritation Mechanical obstruction, inflammation

Possibly evidenced by
Urgency and frequency, oliguria Hematuria

Desired Outcomes/Evaluation Criteria Client Will

Urinary Elimination
Void in normal amounts of greater than or equal to 30 mL/hour, and usual pattern. Experience no signs of obstruction.

ACTIONS/INTERVENTIONS
Independent
1. Monitor intake and output (I&O) and characteristics of urine. RATIONALE: Provides information about kidney function and presence of complicationsinfection and hemorrhage. Bleeding may also indicate increased obstruction or irritation of ureter.

Determine clients normal voiding pattern and note variations RATIONALE: Calculi may cause urinary tract nerve excitability, which causes sensations of urgent need to void. Frequency and urgency usually increase as calculus nears the ureterovesical junction. 2. 3. Encourage increased fluid intake, if nausea is not present. RATIONALE: Increased hydration dilutes urine and flushes bacteria, blood, and debris and may facilitate stone passageespecially small stones. 4. Strain all urine. Document any stones expelled and send to laboratory for analysis. RATIONALE: Retrieval of calculi allows identification of type of stone and influences choice of therapy. 5. Investigate reports of bladder fullness; palpate for suprapubic distention. Note decreased urine output and presence of periorbital or dependent edema. RATIONALE: Urinary retention may develop, causing bladder, ureteral, and kidney distention, potentiating risk of infection and renal failure. 6. Observe for changes in mental status, behavior, or level of consciousness (LOC). RATIONALE: Accumulation of uremic wastes and electrolyte imbalances can be toxic to the central nervous system (CNS).

Collaborative
1. Maintain patency of indwelling cathetersureteral, urethral, or nephrostomywhen used. RATIONALE: May be required to facilitate urine flow, preventing retention and corresponding complications. Catheters are positioned above the stone to promote urethral dilation and stone passage. Continuous or intermittent irrigation can be carried out to flush kidneys and ureters and adjust pH of urine to permit dissolution of stone fragments following lithotripsy. 2. Administer medications, as indicated, for example: Acetazolamide (Diamox) and allopurinol (Zyloprim) RATIONALE: Increases urine pH (alkalinity) to reduce formation of acid stones. Antigout agents such as allopurinol also lower uric acid production and potential of uric acid stone formation.