NURSING CARE PLAN

Name of the Patient: Mr. M Age: 52 y/o Sex: M Name of Student: PENGSON,ANGELA N.
Civil Status: Religion: ______________ Rm/Bed No. _________________ Area: __________________________ Level/ Block: III-B
Address : _________________________________________________________________ Date Submitted: October 26, 2022
Date of Admission: _____________________ Diagnosis: ____________________________ Rating: ___________________________________________________

CUES Nursing Diagnosis Nursing Objectives Nursing Interventions Rationale Expected Outcomes

Subjective/ Objective

Subjective cues: Acute pain related to a After 8 hours of GOALS WERE

● Severe right pain scale of 8/10 as nursing interventions, Independent interventions: MET.
flank pain evidenced by severe the client will be able
radiating to right flank pain to: 1. Establish trust and 1. To relieve their After 8 hours of
the right radiating to the lower rapport with the client. anxiety and elicit nursing interventions,
lower quadrant. ● Verbalize accurate the client was able to:
quadrant relief from 2. Monitor vital signs and information.
severe pain observe for nonverbal ● Verbalize
as evidenced cues such as facial 2. To have a baseline relief from
Objective cues: by decrease grimace, restlessness, & data since pain can severe pain as
● Pain scale of Scientific Definition: pain score irritability. increase blood evidenced by
8/10 Unpleasant sensory from 8/10 pressure and pulse decrease pain
● CT scan and to 4/10 3. Assess and determine the rate. Also, signs of score from
emotional experience pain (location, duration, nonverbal cues 8/10 to 4/10
showing a 7mm
associated with actual ● Enumerate at indicate severe pain.
calcific density intensity (0–10 scale),&
or least 3 signs ● Enumerate at least
in the right potential tissue radiation).
and symptoms 3. To formulate 3 signs and
proximal ureter damage, or of urolithiasis 4. Monitor for signs & effective pain control symptoms of
described in terms of
 such symptoms of infection urolithiasis
damage (International such as fever/chills, management and
Association for the oliguria, & hematuria. aids to evaluate site
Study of of obstruction and
Pain); sudden or slow 5. Apply warm progress of calculi
onset compresses to the movement.
of any intensity location of pain.
4. To have early
from mild to
6. Provide and assist in a detection and proper
severe with an
comfortable position, treatment if
anticipated or
environment, and other complications occur.
predictable end,
and with a comfort measures. 5. To relieve muscle
duration of tension.
less than 3 months. 7. Educate the patient
about the condition 6. To promote
Reference: like factors and signs relaxation and
NANDA International and symptoms. reduce muscle
Nursing Diagnoses: tension which
8. Promote proper, enhances coping.
Definitions &
balanced, and healthy
Classification (11th diet. 7. Increasing the
Edition) Page 495 patient’s
9. Encourage increased knowledge
fluid intake at least about the
drink eight to ten 8oz condition will
glasses of water daily if assist in
not contraindicated. preventing
and managing
Dependent interventions: the problem.
10. Administer
medications such as 8. To prevent formation
Ketorolac (Toradol) of stones and
10 mg IV and improve overall
 Morphine 10 mg IV as health.
ordered.
9. To assist
11. Explain about the passage/movement of
interventional the stone and prevent
procedures and further
prepare patients for complications.
and assist with
procedures for 10. To relieve moderate to
removing or managing severe pain and
renal stones as provide comfort.
prescribed.
11. To enhance patient
understanding of his
Collaborative intervention: medical procedure
and to provide
12. Collaborate with a clarity which reduces
dietician. fear. Also, ensure
and encourage
compliance.

12. To meet the patient’s

nutritional needs.
 NURSING CARE PLAN

Name of the Patient: Mr. M Age: 52 y/o Sex: M Name of Student: PENGSON,ANGELA N.
Civil Status: Religion: ______________ Rm/Bed No. _________________ Area: __________________________ Level/ Block: III-B
Address : _________________________________________________________________ Date Submitted: October 26, 2022
Date of Admission: _____________________ Diagnosis: ____________________________ Rating: ___________________________________________________

RISK Nursing Diagnosis Nursing Objectives Nursing Interventions Rationale Expected Outcomes

FACTORS

● ANXIETY/ Risk for Anxiety After 1 hour and 30 Independent: 1. To gain cooperation GOALS WERE MET.
FEAR Related to Deficient minutes of nursing 1.Establish rapport with and trust of then
patient. After 1 hour and 30
Knowledge about Self- intervention, the patient. minutes of nursing
Care Management of patient will be able to: intervention, the patient
2. Open communication
Ureteric Stent ● Verbalize 2.Acknowledge the feeling that will be able to:
and active listening
Placement understanding the patient is experiencing.
address the problem
about the and question of the
Scientific Definition: 3.Teach patient relaxation ● Verbalize
expected patient. Thus,
techniques like deep understanding
Risk for Anxiety : The discomforts, anxiousness is
breathings. about the expected
state in which an side effects, lessened. discomforts, side
individual or group and possible
experiences feelings of effects, and
complications 4.Reinforce and reiterate to
uneasiness or 3. This helps patient possible
of the device patient and their family
apprehension and focus not on the fear, complications of
placement and about the expected
activation of the the device
dietary changes, discomfort and side effects but on the
autonomic nervous placement and
system in response to a including oral of the stent that he may understanding of the
dietary changes,
vague, nonspecific fluid intake treatment. including oral fluid
threat. experience while at home,
intake
such as: 4. Rationale/s:
References:
NANDA International, • Urinary urgency, ● The effects are
Inc. nursing diagnoses: frequency, pain in passing possibly due to
definitions and urine, and sensation of pressure of the stent
classification (12th ed.) incomplete emptying of inside, causing
the bladder. mechanical irritation.
• Intermittent presence of Thus, patient must be
blood in the urine. mindful of their
• Flank pain and pelvic proximity to the
pain where the stent is. bathroom.
● Blood in urine on
5. Advise patient to increase some occasion is
oral fluid intake at about 1.5- made worse by some
2L/day unless physical activity.
contraindicated. Even if urine
contains blood, as
6. Advise patient to limit foods long as urine is
rich in calcium, such milk, passing, this is fine.
cheese, dairy products, and It may be clearer by
green leafy vegetables and drinking plenty of
limit Protein rich foods, such water.
as red meat, shellfish, and ● This is common and
alcoholic beverages. minor that can be
tolerated.
7. Remind patient to take the
5. To help prevent stone
prescribed medications,
formation by diluting
 especially for pain. urine concentration,
decreasing urine
acidity, and taking
8. Inform patient to expect urine away excess salt. It
of becoming bright orange or also reduces the risk
red in color. If symptoms of getting infection
persist, consult the doctor. and the amount of
blood in the urine.
9. Advise patient to sleep on the
opposite side where the stent
6. To prevent the
is placed,
formation of renal
10. Make patient aware calculi, as well as
about the occurrence of uric acid stones.
complications, such as:

a. Displacement or 7. Alpha-blockers and

fall out of stent anticholinergic,
b. Blockage of the antiinflammation and
stent. narcotics are likely the
c. Fever, increased most effective pain
pain, discomfort reliever.
in the kidney or
bladder, burning 8. Change in color of
sensation while urine may be due to
passing urine, side effects of
heavy blood in prescribed
the urine, pus in medications.
the urine, and
 generally feeling
unwell.
9. This is the single
11. Advise patient to attend all best position for
their appointments and be in reducing stent
contact with doctor/nurse related discomforts
call line if he has any while sleeping.
problem.
10. To help the patient
12. Encourage family members determine when to
to support the patient with report and go to the
the therapeutic alternative hospital promptly for
therapy and include them in doctor’s management
the discharge planning. and medication.

• This is unusual to
happen because the
stent is designed with
coils in both ends that
precents it form
displacement and are
flexible enough to
withstand various body
movement. Yet it needs
to be treated
immediately in case.
• Stent may develop a
crystal coating on its
 surface, leaving in
place for too long can
lead to blockage. As a
standard, stent needs
to be replaced every 3-
6 months.

• Having stent is most

likely to develop UTI
that requires
treatment.

11. Follow-up care is the

key part of treatment
and safety.

12. Family members

can provide
valuable
information about
the patient’s
functioning at
home and can help
patient comply
with treatments.
This may reduce
the patient’s
anxiety because it
helps him realize
that he is not on his
own and has a
family to rely on.