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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
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5. Impaired tissue integrity related to excess fluid volume secondary to vesicoureteral
reflux
Date/
Shift/
Time
Cues Needs Nursing diagnosis Objective of
care
Nursing Intervention Evaluation
January
8, 2010
11am
7-3
Subjective:
sakit kau akong
pantog as
verbalized by the
client.
Objective:
Grimace
face
C
O
G
N
I
T
I
V
E
Acute pain related
pain when urinating
secondary to
vesicourethro
reflux
Within our shift
the client will be
able to relieved
or decreased
from pain from
pain scale of 7
out of 10.
1. Assess for refered pain, as
appropriate
To help determine
possibility of underlying
condition or organ
dysfunction requiring
treatment
2. Administer analgesic, as
indicated, to maximum
GOAL MET!
After 8 hours
span of care
the client
was able to
reduce pain
from 7 out of
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Crying
Her hand
placed on
the pain
site
Irritable
Sleep
disturbance
Pain scale
of 7 out of
10
-
P
E
R
C
E
P
T
U
A
L
P
A
T
T
E
R
dosage, as needed
To maintain acceptable
level of pain. Notify
physician if regimen is
adequate to meet pain
control goal.
3. Monitor vital signs.
Vital signs are important
for baseline assessment and
to monitor patients
condition which evaluates
the whole treatment course.
.
4. Accept clients description
of pain. Acknowledge the
10 to 4 out
of 10 as
evidenced by
nga hinay
na xah ug
wala as
verbalizedby
the client.
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N pain experienceand convey
acceptance of clients
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
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To prevent fatigue
6. Note when pain occurs (eg.
Only with ambulation)
To medicate
prophylactically as
appropriate.
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Date &Time Cues Need Nursing Diagnosis Objectiveof care Nursing Interventions Evaluation
July
8,
2010
8:00AM
Subjective:
Galisod ug
pangihi ang
akong anak
mao
gipaoperahan
namo siya. as
verbalized by
the father.
Objective:
V/S:
Temp: 36.5 C
PR: 82 bpm
E
L
I
M
I
N
A
T
I
O
N
P
Impaired Urinary
Elimination related to
reimplantation of the
ureter into the bladder
secondary
to
Ureteroneocystostomy
Ureteroneocystostomy
is the reimplantation
of the ureter into the
bladder that is
necessary in cases of
Within 3
days span of
care and
effective
nursing
intervention,
patient will
display
continuous
flow of
urine with
output
adequate for
individual
Independent Nursing Action:
1.Establish rapport
Establishing rapport can gain trust
and cooperation
2. Monitor vital sign
Monitoring the vital signs serves
as the baseline data.
3. Monitor intake and output
Monitoring intake and output will
help us know the fluid balance of the
body
4. Record urinary output, investigate
sudden reduction/cessation of urine
flow.
After 3 days of
rendering effective
nursing intervention
the goal was
completely met as
evidenced by a
continuous flow of
urine with output
adequate for
individual situation.
.
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RR: 20 cpm
BP:110/80
mmHg
-loss of
continence
-changes in
amount,
character of
the urine.
-urinary
retention
-incision
noted at the
peritoneum
A
T
T
E
R
N
congenital anomaly or
damage to the ureter.
If there is total
obstruction of the
ureter, it will result an
abnormal flow of
urine that will cause a
problem on the
urinary elimination.
situation. Sudden decrease in urine flow may
indicate obstruction dysfunction or
dehydration.
5. Observe and record color of urine.
Note hematuria and/ or bleeding.
Urine may slightly pink, which
should clear up in 2-3 days after the
surgery.
6. Encourage patient to increase oral
fluid intake
Increasing oral fluid intake can
prevent dehydration and good urine
flow.
7. Assess peripheral pulses, skin
turgor, capillary refill and oral
mucosa. Weigh daily.
Indicators of fluid balance.
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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
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&
Time
Diagnosis
July
8,
2010
8am
S/O:
(+)nephrotic
syndrome
Increased RR
Intake
exceeds
output
N
U
T
R
I
T
I
O
N
A
L
M
E
T
A
Excess fluid
volume
related to
excess fluid
intake as
evidenced
by intake of
215cc and
output of
115cc
secondary to
vesicoureter
al reflux s/p
Ureteroneoc
ystostomy,
Right SSI
Within 3 days span
of care effective
nursing
intervention the
patient will be able
to:
a. stabilize
fluid
volume as
evidenced
by
balanced I
and O, vital
signs
within
clients
Independent:
1. Record accurate intake and output.
Include hidden fluids such as IV
antibiotics, liquid medications, frozen treats,
ice chips. Measure gastrointestinal losses
and estimate ensible losses, e.g., diaporesis
Low output (less than 400 mL/24hr) may
be first indicator of acute failure, especially
in a high- risk patient. Accurate I&O is
necessary for determining renal function
and fluid replacement needs and reducing
risk of fluid overload.
2.Weigh daily at the same time of the day,
on same scale, with same equipment and
clothing
daily body weight is best monitor of fluid
After 3 days of
rendering
effective
nursing
intervention
the goal was
completely met
as evidenced
by a stabilized
fluid volume as
evidenced by
balanced I and
O, vital signs
within clients
normal limits,
stable weight
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B
O
L
I
C
P
A
T
T
E
R
N
R: In VUR,
there is
inability of
the kidney
to absorb
and excrete
electrolytes.
(Medical
Surgical
Nursing,
third
edition,
Williams
and Hopper,
pg 799)
normal
limits,
stable
weight
b. demonstrat
e
dietary/flui
d
restrictions
and
monitor
fluid status
and
recurrence
of fluid
excess
status. A weight gain more than 0.5kg/day
suggest fluid retention
3. Assess skin, face, dependent areas for
edema. Evaluate degree of edema.
edema occurs primarily in dependent
tissues of the body(hands, feet, lumbosacral
area). Patient can gain up to 10lb(4.5kg) of
fluid before pitting edema is detected.
4. Monitor heart rate and BP
Tachycardia and hypertension can occur
because of (1)failure of the kidneys to
excrete urine, (2)excessive fluid
resuscitation during efforts to treat
hypovolemia/hypotension (3)changes in the
rennin-angiotensin system
5. Auscultate lung and heart sounds
fluid overload may lead to pulmonary
demonstrate
dietary/fluid
restrictions and
monitor fluid
status and
recurrence of
fluid excess.
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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
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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
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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 &
Time
Cues Need Nursing
Diagnosis
Objective of
care
Nursing Interventions Evaluation
July
9,
2010
Subjective:
Katol ug sakit
akong samad
as verbalized
N
U
Impaired skin
integrity related
to
inflammatory
Within a 3-
day nursing
intervention,
the client
Independent Nursing Action:
1. Establish rapport
Establishing rapport can gain trust
and cooperation
At the end of the 3-
daynursing
intervention, the
client was able to
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9:00AM by the patient.
Objective:
V/S:
Temp: 36.2 C
PR: 82 bpm
RR: 20 cpm
BP:110/80
mmHg
Disruption
of skin
surface at the
lower quadrant
of the
abdomen.
Wound
T
R
I
T
I
O
N
A
L
response
secondary
to infection
will be able
to display
improvement
in wound
healing as
evidenced
by:
Intact
skin or
minimized
presence of
wound.
Wound
is less than
10cm in
length.
2. Monitor vital sign
Monitoring the vital signs serves as
the baseline data.
3.Assessed skin. Noted color, turgor,
and sensation. Described and measured
wounds and observed changes.
Establishes comparative baseline
providing opportunity for timely
intervention.
4. Demonstrated good skin hygiene,
e.g.,wash thoroughly and pat dry
Carefully.
Maintaining clean, dry skin provides
display improvement
in wound healing
as evidenced by:
Minimized presence
of wounds.
Some parts of
wound
have dried up.
Minimized
erythema
Minimized purulent
discharge.
Wounds are still at
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10cm in
length.
Localized
erythema
Purulent
discharge
(+)
pruritus on the
site of the
wound.
(+) pain
M
E
T
A
B
O
L
Absence
of redness
or erythema.
Absence
of
purulent
discharge.
Absence
of
itchiness
a barrier to infection. Patting skin dry
instead of rubbing reduces 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 adequate
nutrition and fluid intake
Improved nutrition and hydration
will improve skin condition.
least 10cm in length.
(Continue cleaning
the wound with
disinfectant)
Presence of
Itchiness
(continue instructing
client to avoid
scratching the
wound)
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I
C
P
A
T
T
E
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.
8. Instructed family to clip and file
nails regularly.
Long and rough nails increase risk
of skin damage.
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R
N
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.
Date &
Time
Cues Need Nursing Diagnosis Objective of
care
Nursing Interventions Evaluation
July
8,
2010
8:00AM
S/Objective:
-damaged
tissue at the
suprapubic
N
U
T
R
I
Impaired tissue
integrity related to
knowledge deficit on
the infected site
secondary to
Within 3
days span of
care and
effective
nursing
Independent Nursing Action:
1. Establish rapport
Establishing rapport can gain trust
and cooperation
After 3 days of
rendering effective
nursing intervention
the goal was
completely met as
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area T
I
O
N
A
L
M
E
T
A
B
O
L
I
C
ureteroneocystostomy intervention,
patient will
be a able to
a.
demonstrate
behaviors or
lifestyle
changes to
promote
healing and
prevent
complication
or
recurrence.
b.
display
2. Monitor vital sign
Monitoring the vital signs serves
as the baseline data.
3.Assessed skin. Noted color, turgor,
and sensation. Described and
measured wounds and observed
changes.
Establishes comparative baseline
providing opportunity for timely
intervention.
4. Demonstrated good skin hygiene,
e.g.,wash thoroughly and pat dry
evidenced by a be a
able to
a. demonstrate
behaviors or lifestyle
changes to promote
healing and prevent
complication or
recurrence.
b.
display progressive
in wound healing
continuous flow of
urine with output
adequate for
individual situation.
.
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P
A
T
T
E
R
N
progressive
in wound
healing
Carefully.
Maintaining clean, dry skin
provides a barrier to infection. Patting
skin dry instead of rubbing reduces
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
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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.
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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