Nurseslabs For All Your Nursing Needs
Urolithiasis may form anywhere in the urinary tract but usually develop in the renal pelvis or the calyces of the kidneys.
Nursing Diagnosis
Contents
- Acute Pain
- Increased frequency/force of ureteral contractions
- Tissue trauma, edema formation; cellular ischemia
- Possibly evidenced by
- Reports of colicky pain
- Guarding/distraction behaviors, restlessness, moaning, self-focusing, facial mask of pain, muscle tension
- Autonomic responses
Desired Outcomes
- Report pain is relieved with spasms controlled.
- Appear relaxed, able to sleep/rest appropriately.
Acute Pain Nursing Interventions for Urolithiasis with Rationale
| Nursing Intervention | Rationale |
| Document location, duration, intensity (0–10 scale), and radiation. Note nonverbal signs, e.g., elevated BP and pulse, restlessness, moaning, thrashing about. | Helps evaluate site of obstruction and progress of calculi movement. Flank pain suggests that stones are in the kidney area, upper ureter. Flank pain radiates to back, abdomen, groin, genitalia because of proximity of nerve plexus and blood vessels supplying other areas. Sudden, severe pain may precipitate apprehension, restlessness, severe anxiety. |
| Explain cause of pain and importance of notifying caregivers of changes in pain occurrence/characteristics. | Provides opportunity for timely administration of analgesia (helpful in enhancing patient’s coping ability and may reduce anxiety) and alerts caregivers to possibility of passing of stone/developing complications. Sudden cessation of pain usually indicates stone passage. |
| Provide comfort measures, e.g., back rub, restful environment. | Promotes relaxation, reduces muscle tension, and enhances coping. |
| Assist with/encourage use of focused breathing, guided imagery, diversional activities. | Redirects attention and aids in muscle relaxation. |
| Encourage/assist with frequent ambulation as indicated and increased fluid intake of at least 3–4 L/day within cardiac tolerance. | Renal colic can be worse in the supine position. Vigorous hydration promotes passing of stone, prevents urinary stasis, and aids in prevention of further stone formation. |
| Note reports of increased/persistent abdominal pain. | Complete obstruction of ureter can cause perforation and extravasation of urine into perirenal space. This represents an acute surgical emergency. |
| Apply warm compresses to back. | Relieves muscle tension and may reduce reflex spasms. |
| Maintain patency of catheters when used. | Prevents urinary stasis/retention, reduces risk of increased renal pressure and infection. |
