NURSING CARE PLAN

1. Acute pain related to inflammationfected secondary to status post

Ureteroneocystostomy

2. Impaired Urinary Elimination related to reimplantation of the ureter into the

bladder secondary to Ureteroneocystostomy

3. Excess fluid volume related to excess fluid intake as evidenced by intake of 215cc

and output of 115cc secondary to vesicoureteral reflux s/p Ureteroneocystostomy,

Right SSI

4. Impaired skin integrity related to inflammatory response secondary to infection

78
 5. Impaired tissue integrity related to excess fluid volume secondary to vesicoureteral

reflux

Date/ Cues Needs Nursing diagnosis Objective of Nursing Intervention Evaluation

Shift/ care

Time
January Subjective: C Acute pain related Within our shift 1. Assess for refered pain, as

8, 2010 “sakit kau akong O pain when urinating the client will be appropriate GOAL MET!

11am pantog” as G secondary to able to relieved

 To help determine
7-3 verbalized by the N vesicourethro or decreased After 8 hours
possibility of underlying
client. I reflux from pain from span of care
condition or organ
T pain scale of 7 the client
dysfunction requiring
Objective: I out of 10. was able to
treatment
• Grimace V reduce pain
2. Administer analgesic, as
face E from 7 out of
indicated, to maximum

79
• Crying - dosage, as needed 10 to 4 out

P of 10 as
• Her hand  To maintain acceptable
E evidenced by
placed on level of pain. Notify
R
the pain physician if regimen is
C “ nga hinay
site adequate to meet pain
E na xah ug
control goal.
• Irritable P wala” as
3. Monitor vital signs.
T verbalizedby
• Sleep
U  Vital signs are important the client.
disturbance
A for baseline assessment and
• Pain scale
L to monitor patient’s
of 7 out of
P condition which evaluates
10
A the whole treatment course.
T
.
T
4. Accept client’s description
E
of pain. Acknowledge the
R

80
N pain experienceand convey

acceptance of client’s

response to pain.

 Pain is subjective

experience and cannot be

felt by others.

5. Provide comfort measures

(eg. Touch, repositioning),

quiet environment, and

calm activities

 To promote

nonpharmacological pain

management.

5.encourage adequate rest

periods

81
 To prevent fatigue

6. Note when pain occurs (eg.

Only with ambulation)

 To medicate

prophylactically as

appropriate.

82
Date & Cues Need Nursing Diagnosis Objective Nursing Interventions Evaluation
Time of care
July Subjective: E Impaired Urinary Within 3 Independent Nursing Action: After 3 days of

8, “Galisod ug L Elimination related to days span of 1.Establish rapport rendering effective

2010 pangihi ang I reimplantation of the care and ® Establishing rapport can gain trust nursing intervention

akong anak M ureter into the bladder effective and cooperation the goal was

8:00AM mao I secondary nursing 2. Monitor vital sign completely met as

gipaoperahan N to intervention, ® Monitoring the vital signs serves evidenced by a

namo siya.” as A Ureteroneocystostomy patient will as the baseline data. continuous flow of

verbalized by T display 3. Monitor intake and output urine with output

the father. I ® continuous ® Monitoring intake and output will adequate for

O Ureteroneocystostomy flow of help us know the fluid balance of the individual situation.

Objective: N is the reimplantation urine with body .

V/S: of the ureter into the output 4. Record urinary output, investigate

Temp: 36.5 °C bladder that is adequate for sudden reduction/cessation of urine

PR: 82 bpm P necessary in cases of individual flow.

83
RR: 20 cpm congenital anomaly or situation. ®Sudden decrease in urine flow may
A
BP:110/80 damage to the ureter. indicate obstruction dysfunction or
T
mmHg T If there is total dehydration.

E obstruction of the 5. Observe and record color of urine.

-loss of
R ureter, it will result an Note hematuria and/ or bleeding.
continence
N abnormal flow of ® Urine may slightly pink, which
-changes in
urine that will cause a should clear up in 2-3 days after the
amount,
problem on the surgery.
character of
urinary elimination. 6. Encourage patient to increase oral
the urine.
fluid intake

® Increasing oral fluid intake can

-urinary
prevent dehydration and good urine
retention
flow.

7. Assess peripheral pulses, skin

-incision
turgor, capillary refill and oral
noted at the
mucosa. Weigh daily.
peritoneum
® Indicators of fluid balance.

84
 Reflects level of hydration and

effectiveness of fluid therapy

replacement.

8. Provide safe & quite environment

® Providing a safe & quite

environment can offer conducive

place to rest

Dependent nursing intervention:

1.Administer IV fluids as indicated.

® Assissts in maintaining

hydration/adequate circulating

volume and urinary flow.

Date Cues Need Nursing Objective of care Nursing Interventions Evaluation

85
 & Diagnosis
Time
July S/O: N Excess fluid Within 3 days span Independent: After 3 days of

8, • (+)nephrotic U volume of care effective 1. Record accurate intake and output. rendering

2010 syndrome T related to nursing Include “hidden” fluids such as IV effective

• Increased RR R excess fluid intervention the antibiotics, liquid medications, frozen treats, nursing

8am • Intake I intake as patient will be able ice chips. Measure gastrointestinal losses intervention

exceeds T evidenced to: and estimate ensible losses, e.g., diaporesis the goal was

output I by intake of a. stabilize ®Low output (less than 400 mL/24hr) may completely met

O 215cc and fluid be first indicator of acute failure, especially as evidenced

N output of volume as in a high- risk patient. Accurate I&O is by a stabilized

A 115cc evidenced necessary for determining renal function fluid volume as

L secondary to by and fluid replacement needs and reducing evidenced by

vesicoureter balanced I risk of fluid overload. balanced I and

M al reflux s/p and O, vital 2.Weigh daily at the same time of the day, O, vital signs

E Ureteroneoc signs on same scale, with same equipment and within client’s

T ystostomy, within clothing normal limits,

A Right SSI client’s ® daily body weight is best monitor of fluid stable weight

86
B normal status. A weight gain more than 0.5kg/day demonstrate

O R: In VUR, limits, suggest fluid retention dietary/fluid

L there is stable 3. Assess skin, face, dependent areas for restrictions and

I inability of weight edema. Evaluate degree of edema. monitor fluid

C the kidney b. demonstrat ®edema occurs primarily in dependent status and

to absorb e tissues of the body(hands, feet, lumbosacral recurrence of

P and excrete dietary/flui area). Patient can gain up to 10lb(4.5kg) of fluid excess.

A electrolytes. d fluid before pitting edema is detected.

T (Medical restrictions 4. Monitor heart rate and BP

T Surgical and ® Tachycardia and hypertension can occur

E Nursing, monitor because of (1)failure of the kidneys to

R third fluid status excrete urine, (2)excessive fluid

N edition, and resuscitation during efforts to treat

Williams recurrence hypovolemia/hypotension (3)changes in the

and Hopper, of fluid rennin-angiotensin system

pg 799) excess 5. Auscultate lung and heart sounds

®fluid overload may lead to pulmonary

87
edema and HF evidenced by development

of adventitious breath sounds, extra sounds

6. Assess level of consciousness; investigate

changes in mentation, presence of

restlessness

®may reflect fluid shifts, accumulation of

toxins, acidosis, electrolyte imbalances, or

developing hypoxia

Collaborative:

1. Monitor laboratory/ diagnostic studies:

a. BUN, Cr

® assess progression and management of

renal function. Cr is a better indictor of

renal function because it is not affected by

hydration, diet, and tissue catabolism

b. Serum sodium

® hyponatremia may result from fluid

88
overload. Hypernatremia indicates total

body water defecit

c. Serum potassium

®lack of renal excretion or retention of

potassium to excrete excess hydrogen ions

leads to hyperkalemia, requiring prompt

intervention

d. Hb/Hct

®decreased values may indicate

hemodilution (hypervolemia); howver,

during prolonged failure, anemia frequently

develops as a result of RBC loss/ decreased

production.

e. serial chest x-rays

®increased cardiac size, prominent

pulmonary vascular markings, pleural

effusion, infiltrates / congestion indicate

89
 acute responses to fluid overload

2. Administer medications as indicated

3.Maintain indwelling catheter as indicated

® Catheterization excludes lower tract

obstruction and provides means of accurate

monitoring of urine output

Date & Cues Need Nursing Objective of Nursing Interventions Evaluation

Time Diagnosis care
July Subjective: N Impaired skin Within a 3- Independent Nursing Action: At the end of the 3-

9, “Katol ug sakit integrity related day nursing 1. Establish rapport daynursing

2010 akong samad” U to ® Establishing rapport can gain trust

intervention, intervention, the
as verbalized inflammatory and cooperation
the client client was able to

90
9:00AM by the patient. T response display improvement
will be able
secondary 2. Monitor vital sign in wound healing
to display
Objective: R to infection ® Monitoring the vital signs serves as
improvement as evidenced by:
V/S: the baseline data.
in wound •Minimized presence
Temp: 36.2 °C I
healing as
PR: 82 bpm 3.Assessed skin. Noted color, turgor, of wounds.
evidenced
RR: 20 cpm T
by: and sensation. Described and measured •Some parts of
BP:110/80
wounds and observed changes.
mmHg I • Intact wound

®Establishes comparative baseline

• Disruption skin or have dried up.
providing opportunity for timely
of skin O minimized
intervention. •Minimized
surface at the presence of

lower quadrant N wound. 4. Demonstrated good skin hygiene, erythema

of the • Wound e.g.,wash thoroughly and pat dry Minimized purulent

abdomen. A is less than
Carefully. discharge.
10cm in

• Wound L length. ® Maintaining clean, dry skin provides •Wounds are still at

91
10cm in • Absence a barrier to infection. Patting skin dry least 10cm in length.

length. of redness instead of rubbing reduces risk of

(Continue cleaning
or erythema. dermal trauma to fragile skin.
the wound with
• Absence
• Localized disinfectant)
M of
erythema 5. Instructed family to maintain clean,
•Presence of
purulent
• Purulent dry clothes, preferably cotton fabric
E discharge. Itchiness
discharge (any T- shirt).
• Absence
• (+) (continue instructing
.
T of
pruritus on the client to avoid
® Skin friction caused by stiff or rough
A itchiness
scratching the
clothes leads to irritation of fragile skin
site of the
wound)
and increases risk for infection.
wound. B

• (+) pain 6. Emphasized importance of adequate

O nutrition and fluid intake

® Improved nutrition and hydration

L
will improve skin condition.

92
I

7. Demonstrated to the family

C members on how to make a guava

decoction to apply to the wound as

alternative

disinfectant

® Providing the family with alternative

P Solution assists them in optimal

healing with less expensive resources.

8. Instructed family to clip and file

T
nails regularly.

T ®Long and rough nails increase risk

of skin damage.
E

93
 9. Provided and applied wound

R dressings carefully.

® Wound dressings protect the wound

N
and the surrounding tissues.

10. Provide safe & quite environment

® Providing a safe & quite

environment can offer conducive place

to rest.

Date & Cues Need Nursing Diagnosis Objective of Nursing Interventions Evaluation
Time care
July S/Objective: N Impaired tissue Within 3 After 3 days of

8, U integrity related to days span of Independent Nursing Action: rendering effective

2010 -damaged T knowledge deficit on care and 1. Establish rapport nursing intervention

tissue at the R the infected site effective ® Establishing rapport can gain trust the goal was

8:00AM suprapubic I secondary to nursing and cooperation completely met as

94
area T ureteroneocystostomy intervention, evidenced by a be a

I patient will 2. Monitor vital sign able to

O be a able to ® Monitoring the vital signs serves a. demonstrate

N a. as the baseline data. behaviors or lifestyle

A demonstrate changes to promote

L behaviors or 3.Assessed skin. Noted color, turgor, healing and prevent

lifestyle complication or
and sensation. Described and
M changes to recurrence.
measured wounds and observed
E promote
changes.
T healing and b.
®Establishes comparative baseline
A prevent display progressive
providing opportunity for timely
B complication in wound healing
intervention.
O or continuous flow of

L recurrence. urine with output

I adequate for
4. Demonstrated good skin hygiene,
C b. individual situation.
e.g.,wash thoroughly and pat dry
display .

95
P progressive Carefully.

A in wound
® Maintaining clean, dry skin
T healing
T provides a barrier to infection. Patting

E skin dry instead of rubbing reduces

R risk of dermal trauma to fragile skin.

5. Instructed family to maintain

clean, dry clothes, preferably cotton

fabric (any T- shirt).

® Skin friction caused by stiff or

rough clothes leads to irritation of

fragile skin and increases risk for

infection.

6. Emphasized importance of

96
adequate nutrition and fluid intake

® Improved nutrition and hydration

will improve skin condition.

7. Demonstrated to the family

members on how to make a guava

decoction to apply to the wound as

alternative

disinfectant

® Providing the family with

alternative

Solution assists them in optimal

healing with less expensive

resources.

97
8. Instructed family to clip and file

nails regularly.

®Long and rough nails increase risk

of skin damage.

9. Provided and applied wound

dressings carefully.

® Wound dressings protect the

wound

and the surrounding tissues.

10. Provide safe & quite environment

® Providing a safe & quite

environment can offer conducive

place to rest.

98