Nursing Diagnosis: impaired Urinary Elimination related to stimulation of the bladder by calculi, renal or ureteral irritation, mechanical obstruction, inflammation
Possibly evidenced by
Urgency and frequency, oliguria
Desired Outcomes/Evaluation Criteria—Client Will
Void in normal amounts of greater than or equal to 30 mL/hour, and usual pattern.
Experience no signs of obstruction.
Nursing intervention with rationale:
1. Monitor intake and output (I&O) and characteristics of urine.
Rationale: Provides information about kidney function and presence of complications—infection and hemorrhage. Bleeding may also indicate increased obstruction or irritation of ureter.
2. Determine client’s normal voiding pattern and note variations.
Rationale: Calculi may cause urinary tract nerve excitability, which causes sensations of urgent need to void. Frequency and urgency usually increase as calculus nears the ureterovesical junction.
3. Encourage increased fluid intake, if nausea is not present.
Rationale: Increased hydration dilutes urine and flushes bacteria, blood, and debris and may facilitate stone passage—especially small stones.
4. Strain all urine. Document any stones expelled and send to laboratory for analysis.
Rationale: Retrieval of calculi allows identification of type of stone and influences choice of therapy.
5. Investigate reports of bladder fullness; palpate for suprapubic distention. Note decreased urine output and presence of periorbital or dependent edema.
Rationale: Urinary retention may develop, causing bladder, ureteral, and kidney distention, potentiating risk of infection and renal failure.
6. Observe for changes in mental status, behavior, or level of consciousness (LOC).
Rationale: Accumulation of uremic wastes and electrolyte imbalances can be toxic to the central nervous system (CNS).
7. Maintain patency of indwelling catheters—ureteral, urethral, or nephrostomy—when used.
Rationale: May be required to facilitate urine flow, preventing retention and corresponding complications. Catheters are positioned above the stone to promote urethral dilation and stone passage. Continuous or intermittent irrigation can be carried out to flush kidneys and ureters and adjust pH of urine to permit dissolution of stone fragments following lithotripsy.
8. Administer medications, as indicated, for example: Acetazolamide (Diamox) and allopurinol (Zyloprim)
Rationale: Increases urine pH (alkalinity) to reduce formation of acid stones. Antigout agents such as allopurinol also lower uric acid production and potential of uric acid stone formation.
9. Monitor laboratory studies, for example: Electrolytes, BUN, and Cr
Rationale: Elevated BUN, Cr, and certain electrolytes indicate presence and degree of kidney dysfunction.
10. Prepare client for and assist with endoscopic procedures, such as the following: Basket procedure, percutaneous ultrasonic lithotripsy, and stent placement
Rationale: Calculi in the distal and midureter may be removed by fiber-optic ureteroscope, which shatters the stone with a shock wave and captures it in a basket catheter.