Nursing diagnosis: acute Pain 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
Desired Outcomes/Evaluation Criteria—Client Will
Report pain is relieved, with spasms controlled.
Appear relaxed and be able to sleep and rest appropriately.
Nursing intervention with rationale:
1. Document location, duration, intensity (0 to 10 scale), and radiation. Note nonverbal signs—elevated BP and pulse, restlessness, moaning, and thrashing about.
Rationale: 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, and genitalia because of proximity of nerve plexus and blood vessels supplying these areas. Sudden, severe pain may precipitate apprehension, restlessness, and severe anxiety.
2. Explain cause of pain and importance of notifying caregivers of changes in pain occurrence or characteristics.
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.
3. 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.
5. Assist with and encourage use of focused breathing, guided imagery, and diversional activities.
Rationale: Redirects attention and aids in muscle relaxation.
6. 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 urinary stasis, and aids in prevention of further stone formation.
7. 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.
8. 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 antiinflammatory drugs (NSAIDs), such as ketorolac (Toradol)
Rationale: Opioid and NSAID combination is often given intravenously (IV) during acute episode to quickly decrease ureteral colic and promote muscle and mental relaxation.
9. Administer 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
10. Maintain patency of catheters when used.
Rationale: Prevents urinary stasis or retention, reduces risk of increased renal pressure and infection.