VENTILATORY ASSISTANCE (MECHANICAL)
Many patients on ventilators are now being transferred from the intensive care unit (ICU) to medical-surgical units with problems including (1) neuromuscular deficits, such as quadriplegia with phrenic nerve injury or high C-spine injuries, ¬Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS); (2) COPD with respiratory muscle atrophy and malnutrition (inability to wean); and (3) restrictive conditions of chest or lungs, such as kyphoscoliosis and interstitial fibrosis.
The expectation is that the majority of patients will be weaned before discharge. That is the focus of this plan of care. However, some patients are either unsuccessful at weaning or are not candidates for weaning. For those patients, portions of this plan of care would need to be modified for the discharge care setting, that is, an extended care facility or home.
Types of Ventilators
Volume-cycled ventilators are the primary choice for long-term ventilation of patients whose permanent changes in lung compliance and resistance require increased pressure to provide adequate ventilation (e.g., COPD).
Pressure-cycled ventilators are desirable for patients with relatively normal lung compliance who cannot initiate or sustain respiration because of muscular/phrenic nerve involvement (e.g., quadriplegics).
CARE SETTING
Patients on ventilators may be cared for in any setting; however, weaning is usually attempted/accomplished in the acute, subacute, or rehabilitation setting.
RELATED CONCERNS
Cardiac surgery: postoperative care
Chronic obstructive pulmonary disease (COPD) and asthma
Hemothorax/pneumothorax
Spinal cord injury (acute rehabilitative phase)
Total nutritional support: parenteral/enteral feeding
Psychosocial aspects of care
Patient Assessment Database
Gathered data depend on the underlying pathophysiology and/or reason for ventilatory support. Refer to the appropriate plan of care.
Discharge plan DRG projected mean length of inpatient stay: 9.5 days (or more)
considerations: If ventilator-dependent, may require changes in physical layout of home, acquisition of equipment/supplies, provision of a backup power source, instruction of SO/caregivers, provision for continuation of plan of care, assistance with transportation, and coordination of resources/support systems
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Pulmonary function studies: Determine the ability of the lungs to exchange oxygen and carbon dioxide, and include but are not limited to the following:
Vital capacity (VC): Is reduced in restrictive chest or lung conditions; normal or increased in COPD; normal to decreased in neuromuscular diseases (Guillain-Barré syndrome); and decreased in conditions limiting thoracic movement (kyphoscoliosis).
Forced vital capacity (FVC): Measured by spirometry, is reduced in restrictive conditions and in asthma, and is normal to reduced in COPD.
Tidal volume (VT): May be decreased in both restrictive and obstructive processes.
Negative inspiratory force (NIF): Can be substituted for vital capacity to help determine whether patient can initiate a breath.
Minute ventilation (VE): Measures volume of air inhaled and exhaled in 1 min of normal breathing. This reflects muscle endurance and is a major determinant of work of breathing.
Inspiratory pressure (Pimax): Measures respiratory muscle strength (less than -20 cm H2O is considered insufficient for weaning).
Forced expiratory volume (FEV): Usually decreased in COPD.
Flow-volume (F-V) loops: Abnormal loops are indicative of large and small airway obstructive disease and restrictive diseases, when far advanced.
ABGs: Assesses status of oxygenation, ventilation, and acid-base balance.
Chest x-ray: Monitors resolution/progression of underlying condition (e.g., adult respiratory distress syndrome [ARDS]) or complications (e.g., atelectasis, pneumonia).
Nutritional assessment: Done to identify nutritional and electrolyte imbalances that might interfere with successful weaning.
NURSING PRIORITIES
1. Promote adequate ventilation and oxygenation.
2. Prevent complications.
3. Provide emotional support for patient/SO.
4. Provide information about disease process/prognosis and treatment needs.
DISCHARGE GOALS
1. Respiratory function maximized/adequate to meet individual needs.
2. Complications prevented/minimized.
3. Effective means of communication established.
4. Disease process/prognosis and therapeutic regimen understood (including home ventilatory support if indicated).
5. Plan in place to meet needs after discharge.


NURSING DIAGNOSIS: Breathing Pattern, ineffective/Spontaneous Ventilation, impaired
May be related to
Respiratory center depression
Respiratory muscle weakness/paralysis
Noncompliant lung tissue (decreased lung expansion)
Alteration of patient’s usual O2/CO2 ratio
Possibly evidenced by
Changes in rate and depth of respirations
Dyspnea/increased work of breathing, use of accessory muscles
Reduced VC/total lung volume
Tachypnea/bradypnea or cessation of respirations when off the ventilator
Cyanosis
Decreased PO2 and SaO2; increased PCO2
Increased restlessness, apprehension, and metabolic rate
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Respiratory Status: Ventilation (NOC)
Reestablish/maintain effective respiratory pattern via ventilator with absence of retractions/use of accessory muscles, cyanosis, or other signs of hypoxia; ABGs/oxygen saturation within acceptable range.
Participate in efforts to wean (as appropriate) within individual ability.
CAREGIVER WILL:
Demonstrate behaviors necessary to maintain patient’s respiratory function.

ACTIONS/INTERVENTIONS
Mechanical Ventilation (NIC)
Independent
Investigate etiology of respiratory failure.




Observe overall breathing pattern. Note respiratory rate, distinguishing between spontaneous respirations and ventilator breaths.


Auscultate chest periodically, noting presence/absence and equality of breath sounds, adventitious breath sounds, and symmetry of chest movement.






Count patient’s respirations for one full minute and compare with desired/ventilator set rate.







Verify that patient’s respirations are in phase with the ventilator.



Elevate head of bed or place in orthopedic chair if possible.


Place in prone position when tolerated.


Inflate tracheal/ET cuff properly using minimal leak/occlusive technique. Check cuff inflation every 4–8 hr and whenever cuff is deflated/reinflated.


Check tubing for obstruction, e.g., kinking or accumulation of water. Drain tubing as indicated, avoiding draining toward patient or back into the reservoir.
RATIONALE



Understanding the underlying cause of patient’s particular ventilatory problem is essential to the care of patient, e.g., decisions about future patient capabilities/ventilation needs and most appropriate type of ventilatory support.

Patients on ventilators can experience hyperventilation/hypoventilation, or dyspnea/”air hunger,” and attempt to correct deficiency by overbreathing.

Provides information regarding airflow through the tracheobronchial tree and the presence/absence of fluid, mucus obstruction. Note: Frequent crackles or rhonchi that do not clear with coughing/suctioning may indicate developing complications (atelectasis, pneumonia, acute bronchospasm, pulmonary edema). Changes in chest symmetry may indicate improper placement of the ET, development of barotrauma.

Respirations vary, depending on problem requiring ventilatory assistance, e.g., patient may be totally ventilator-dependent, or be able to take breath(s) on own between ventilator-delivered breaths. Rapid patient respirations can produce respiratory alkalosis and/or prevent desired volume from being delivered by ventilator. Slow patient respirations/ hypoventilation increases PaCO2 levels and may cause acidosis.

Adjustments may be required in tidal volume, respiratory rate, and/or dead space of the ventilator, or patient may need sedation to synchronize respirations and reduce work of breathing/energy expenditure.

Elevation of patient’s head or getting out of bed while still on the ventilator is both physically and psychologically beneficial.

Prone position relaxes abdominal muscles, improving diaphragmatic excursion, increasing PaO2.

The cuff must be properly inflated to ensure adequate ventilation/delivery of desired tidal volume. Note: In long-term patients, the cuff may be deflated most of the time or a noncuffed tracheostomy tube used.

Kinks in tubing prevent adequate volume delivery and increase airway pressure. Water prevents proper gas distribution and predisposes to bacterial growth.



ACTIONS/INTERVENTIONS
Mechanical Ventilation (NIC)
Independent
Check ventilator alarms for proper functioning. Do not turn off alarms, even for suctioning. Remove from ventilator and ventilate manually if source of ventilator alarm cannot be quickly identified and rectified. Ascertain that alarms can be heard in the nurses’ station.

Keep resuscitation bag at bedside and ventilate manually whenever indicated.


Assist patient in “taking control” of breathing if weaning is attempted/ ventilatory support is interrupted during procedure/activity.


Collaborative
Assess ventilator settings routinely and readjust as indicated:


Note operating mode of ventilation, i.e., continuous mandatory ventilation (CMV), assist control (ACV), intermittent mandatory (IMV), pressure support (PSV), inverse ratio (IRV);








Observe oxygen concentration percentage (FIO2); verify that oxygen line is in proper outlet/tank; monitor in-line oxygen analyzer or perform periodic oxygen analysis;




Observe end-tidal CO2 (ETCO2) values.




RATIONALE



Ventilators have a series of visual and audible alarms, e.g., oxygen, low/high pressure, inspiratory:expiratory (I:E) ratio. Turning off/failure to reset alarms places patient at risk for unobserved ventilator failure or respiratory distress/arrest.

Provides/restores adequate ventilation when patient or equipment problems require patient to be temporarily removed from the ventilator.

Coaching patient to take slower, deeper breaths, practice abdominal/pursed-lip breathing, assume position of comfort, and use relaxation techniques can be helpful in maximizing respiratory function.



Controls/settings are adjusted according to patient’s primary disease and results of diagnostic testing to maintain parameters within appropriate limits.

Patient’s respiratory requirements, presence or absence of an underlying disease process, and the extent to which patient can participate in ventilatory effort determine parameters of each setting. PSV, a relatively new mode, has advantages for patients who are on long-term ventilation because it allows patient to strengthen pulmonary musculature without compromising oxygenation and ventilation during the weaning process. Research suggests that intermittent trials of unassisted breathing work faster (for weaning) than methods involving partial ventilatory support.

FIO2 is adjusted (21%–100%) to maintain an acceptable oxygen percentage and saturation (e.g., 90%) for patient’s condition. Because machine dials are not always accurate, an oxygen analyzer may be used to ascertain whether patient is receiving the desired concentration of oxygen. Note: FIO2 of 0.6 or below reduces risk of absorption atelectasis and surfactant inactivation.

Measures the amount of exhaled CO2 with each breath and is displayed graphically to spot CO2 exchange problems early before they show up on ABGs. Values are affected by matching of ventilation in lung with perfusion of pulmonary capillaries.




ACTIONS/INTERVENTIONS
Mechanical Ventilation (NIC)
Collaborative
Assess VE (respiratory rate and VT);




Assess VT (10–15 mL/kg). Verify proper function of spirometer, bellows, or computer readout of delivered volume. Note alterations from desired volume delivery;



Note airway pressure;











Monitor I:E ratio;



Check sigh rate intervals (usually 11⁄2 to 2 times VT);



Note inspired humidity and temperature. Use heat moisture exchanger (HME) as indicated. RATIONALE



Respiratory rate of 10–15/min may be appropriate except for patient with COPD and CO2 retention. In these patients, VE should be adjusted to achieve patient’s baseline PaCO2, not necessarily a “normal” PaCO2.

Monitors amount of air inspired and expired. Changes may indicate alteration in lung compliance or leakage through machine/around tube cuff (if used). Note: Smaller tidal volume may be required in patients with decreased lung compliance (e.g., ARDS).

Airway pressure should remain relatively constant. Increased pressure alarm reading reflects (1) increased airway resistance as may occur with bronchospasm; (2) retained secretions; and/or (3) decreased lung compliance as may occur with obstruction of the ET, development of atelectasis, ARDS, pulmonary edema, worsening COPD, or pneumothorax. Low airway pressure alarms may be triggered by pathophysiological conditions causing hypoventilation, e.g., disconnection from ventilator, low ET cuff pressure, ET displaced above the vocal cords, patient “overbreathing” or out of phase with the ventilator.

Expiratory phase is usually twice the length of the inspiratory rate, but may be longer to compensate for air-trapping to improve gas exchange in the COPD patient.

Sighing promotes maximal ventilation of alveoli to prevent/reduce atelectasis and enhances movement of secretions.

Usual warming and humidifying function of nasopharynx is bypassed with intubation. Dehydration can dry up normal pulmonary fluids, cause secretions to thicken, and increase risk of infection. Temperature should be maintained at about body temperature to reduce risk of damage to cilia and hyperthermia reactions. The introduction of a heated wire circuit to the traditional system significantly reduces the problem of “rainout” (condensation in the tubing).




NURSING DIAGNOSIS: Airway Clearance, ineffective
May be related to
Foreign body (artificial airway) in the trachea
Inability to cough/ineffective cough
Possibly evidenced by
Changes in rate or depth of respiration
Cyanosis
Abnormal breath sounds
Anxiety/restlessness
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Respiratory Status: Airway Patency (NOC)
Maintain patent airway with breath sounds clear.
Be free of aspiration.
CAREGIVER WILL:
Identify potential complications and initiate appropriate actions.


ACTIONS/INTERVENTIONS
Artificial Airway Management (NIC)
Independent
Assess airway patency.



Evaluate chest movement and auscultate for bilateral breath sounds.




Monitor ET placement. Note lip line marking and compare with desired placement. Secure tube carefully with tape or tube holder. Obtain assistance when retaping or repositioning tube.

Note excessive coughing, increased dyspnea (using a 0–10 scale), high-pressure alarm sounding on ventilator, visible secretions in endotracheal/tracheostomy tube, increased rhonchi. RATIONALE



Obstruction may be caused by accumulation of secretions, mucous plugs, hemorrhage, bronchospasm, and/or problems with the position of tracheostomy/ET.

Symmetrical chest movement with breath sounds throughout lung fields indicates proper tube placement/unobstructed airflow. Lower airway obstruction (e.g., pneumonia/atelectasis) produces changes in breath sounds such as rhonchi, wheezing.

The ET may slip into the right main-stem bronchus, thereby obstructing airflow to the left lung and putting patient at risk for a tension pneumothorax.


The intubated patient often has an ineffective cough reflex, or patient may have neuromuscular or neurosensory impairment, altering ability to cough. These patients are dependent on alternative means such as suctioning to remove secretions. Note: Research supports use of a dyspnea rating scale (like those used to measure pain) to more accurately quantify and measure changes in dyspnea as experienced by patient.




ACTIONS/INTERVENTIONS
Artificial Airway Management (NIC)
Independent
Suction as needed when patient is coughing or experiencing respiratory distress, limiting duration of suction to 15 sec or less. Choose appropriate suction catheter. Hyperventilate before and after each catheter pass, using 100% oxygen if appropriate (using vent rather than Ambu bag, which has an increased risk of barotrauma). Suction continuously or intermittently during withdrawal.




Use inline catheter suction when available.


Instruct patient in coughing techniques during suctioning, e.g., splinting, timing of breathing, and “quad cough” as indicated.

Reposition/turn periodically.


Encourage/provide fluids within individual capability.

Collaborative

Provide chest physiotherapy as indicated, e.g., postural drainage, percussion.

Administer IV and aerosol bronchodilators as indicated, e.g., aminophylline, metaproterenol sulfate (Alupent), isoetharine hydrochloride (Bronkosol).

Assist with fiberoptic broncoscopy, if indicated. RATIONALE



Suctioning should not be routine, and duration should be limited to reduce hazard of hypoxia. Suction catheter diameter should be less than 50% of the internal diameter of the endotracheal/tracheostomy tube for prevention of hypoxia. Hyperoxygenation with ventilator sigh on 100% oxygen may be desired to reduce atelectasis and to reduce accidental hypoxia. Note: Instilling normal saline (NS) is no longer recommended, because research reveals that the fluid pools at the distal end of the endotracheal/tracheal tube, impairing oxygenation and increaseing bronchospasm and the risk of infection.

Reduces risk of infection for healthcare workers and helps maintain oxygen saturation and PEEP, when used.

Enhances effectiveness of cough effort and secretion clearing.


Promotes drainage of secretions and ventilation to all lung segments, reducing risk of atelectasis.

Helps liquefy secretions, enhancing expectoration.





Promotes ventilation of all lung segments and aids drainage of secretions.

Promotes ventilation and removal of secretions by relaxation of smooth muscle/bronchospasm.


May be performed to remove secretions/mucous plugs.


NURSING DIAGNOSIS: Communication, impaired verbal
May be related to
Physical barrier, e.g., endotracheal/tracheostomy tube
Neuromuscular weakness/paralysis
Possibly evidenced by
Inability to speak
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Communication: Expressive Ability (NOC)
Establish method of communication in which needs can be understood.



ACTIONS/INTERVENTIONS
Communication Enhancement:
Speech Deficit (NIC)
Independent
Assess patient’s ability to communicate by alternative means.






Establish means of communication, e.g., maintain eye contact; ask yes/no questions; provide magic slate, paper/pencil, picture/alphabet board; use sign language as appropriate; validate meaning of attempted communications.






Consider form of communication when placing IV.


Place call light/bell within reach, making certain patient is alert and physically capable of using it. Answer call light/bell immediately. Anticipate needs. Tell patient that nurse is immediately available should assistance be required.

Place note at central call station informing staff that patient is unable to speak.

Encourage family/SO to talk with patient, providing information about family and daily happenings.




Collaborative

Evaluate need for/appropriateness of talking tracheostomy tube. RATIONALE




Reasons for long-term ventilatory support are various; patient may be alert and be adept at writing (e.g., chronic COPD with inability to be weaned) or may be lethargic, comatose, or paralyzed. Method of communicating with patient is therefore highly individualized. Note: The inability to talk while intubated is a primary cause of feelings of fear.

Eye contact assures patient of interest in communicating; if patient is able to move head, blink eyes, or is comfortable with simple gestures, a great deal can be done with yes/no questions. Pointing to letter boards or writing is often tiring to patients, who can then become frustrated with the effort needed to attempt conversations. Use of picture boards that express a concept or routine needs may simplify communication. Family members/other caregivers may be able to assist/interpret needs.

IV positioned in hand/wrist may limit ability to write or sign.

Ventilator-dependent patient may be better able to relax, feel safe (not abandoned), and breathe with the ventilator knowing that nurse is vigilant and needs will be met.



Alerts all staff members to respond to patient at the bedside instead of over the intercom.

SO may feel self-conscious in one-sided conversation, but knowledge that he or she is assisting patient to regain/maintain contact with reality and enabling patient to feel part of family unit can reduce feelings of awkwardness.



Patients with adequate cognitive/muscular skills may have the ability to manipulate talking tracheostomy tube.




NURSING DIAGNOSIS: Fear/Anxiety [specify level]
May be related to
Situational crises; threat to self-concept
Threat of death/dependency on mechanical support
Change in health/socioeconomic status/role functioning
Interpersonal transmission/contagion
Possibly evidenced by
Increased muscle/facial tension
Insomnia; restlessness
Hypervigilance
Feelings of inadequacy
Fearfulness, uncertainty, apprehension
Focus on self/negative self-talk
Expressed concern regarding changes in life events
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Fear Control/Anxiety Control (NOC)
Verbalize/communicate awareness of feelings and healthy ways to deal with them.
Demonstrate problem-solving skills/behaviors to cope with current situation.
Report anxiety/fear is reduced to manageable level.
Appear relaxed and sleeping/resting appropriately.


ACTIONS/INTERVENTIONS
Anxiety Reduction (NIC)
Independent
Identify patient’s perception of threat represented by situation. Determine current respiratory status/adequacy of ventilation.

Observe/monitor physical responses, e.g., restlessness, changes in vital signs, repetitive movements. Note congruency of verbal/nonverbal communication.

Encourage patient/SO to acknowledge and express fears.



Acknowledge the anxiety and fear of the situation. Avoid meaningless reassurance that everything will be all right.



Identify/review with patient/SO the safety precautions being taken, e.g., backup power and oxygen supplies, emergency equipment at hand for suction. Discuss/review the meanings of alarm system.
RATIONALE



Defines scope of individual problem, separate from physiological causes, and influences choice of interventions.

Useful in evaluating extent/degree of concerns, especially when compared with “verbal” comments.


Provides opportunity for dealing with concerns, clarifies reality of fears, and reduces anxiety to a more manageable level.

Validates the reality of the situation without minimizing the emotional impact. Provides opportunity for patient/SO to accept and begin to deal with what has happened, reducing anxiety.

Provides reassurance to help allay unnecessary anxiety, reduce concerns of the unknown, and preplan for response in emergency situation.
ACTIONS/INTERVENTIONS
Anxiety Reduction (NIC)
Independent
Note reactions of SO. Provide opportunity for discussion of personal feelings/concerns and future expectations.


Identify previous coping strengths of patient/SO and current areas of control/ability.

Demonstrate/encourage use of relaxation techniques, e.g., focused breathing, guided imagery, progressive relaxation. Provide music therapy, biofeedback as appropriate.

Provide/encourage sedentary diversional activities within individual capabilities, e.g., handicrafts, writing, television.

Collaborative

Refer to support groups and therapy as needed. RATIONALE



Family members have individual responses to what is happening, and their anxiety may be communicated to patient, intensifying these emotions.

Focuses attention on own capabilities, increasing sense of control.

Provides active management of situation to reduce feelings of helplessness.



Although handicapped by dependence on ventilator, activities that are normal/desired by the individual should be encouraged to enhance quality of life.



May be necessary to provide additional assistance if patient/SO are not managing anxiety or when patient is “identified with the machine.”






NURSING DIAGNOSIS: Oral Mucous Membrane, impaired
Risk factors may include
Inability to swallow oral fluids
Presence of tube in mouth
Lack of or decreased salivation
Ineffective oral hygiene
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Tissue Integrity: Skin and Mucous Membrane (NOC)
Report/demonstrate a decrease in symptoms.
CAREGIVER WILL:
Identify specific interventions to promote healthy oral mucosa as appropriate.




ACTIONS/INTERVENTIONS
Oral Health Maintenance (NIC)
Independent
Routinely inspect oral cavity, teeth, gums for sores, lesions, bleeding.

Administer mouth care routinely and as needed, especially in patient with an oral intubation tube, e.g., cleanse mouth with water, saline, or preferred mouthwash. Brush teeth with soft toothbrush, Waterpik, or moistened swab.

Change position of ET/airway on a regular/prn schedule as appropriate.

Apply lip balm; administer oral lubricant solution. RATIONALE



Early identification of problems provides opportunity for appropriate intervention/preventive measures.

Prevents drying/ulceration of mucous membrane and reduces medium for bacterial growth. Promotes comfort.




Reduces risk of lip and oral mucous membrane ulceration.


Maintains moisture, prevents drying.


NURSING DIAGNOSIS: Nutrition: imbalanced, less than body requirements
May be related to
Altered ability to ingest and properly digest food
Increased metabolic demands
Possibly evidenced by
Weight loss; poor muscle tone
Aversion to eating; reported altered taste sensation
Sore, inflamed buccal cavity
Absence of/hyperactive bowel sounds
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Nutritional Status (NOC)
Indicate understanding of individual dietary needs.
Demonstrate progressive weight gain toward goal with normalization of laboratory values.




ACTIONS/INTERVENTIONS
Nutrition Therapy (NIC)
Independent
Evaluate ability to eat.



Observe/monitor for generalized muscle wasting, loss of subcutaneous fat.

Weigh as indicated.




Document oral intake if/when resumed. Offer foods that patient enjoys.


Provide small frequent feedings of soft/easily digested foods if able to swallow.

Encourage/administer fluid intake of at least 2500 mL/day within cardiac tolerance.


Assess GI function: Presence/quality of bowel sounds; note changes in abdominal girth, nausea/vomiting. Observe/document changes in bowel movements, e.g., diarrhea/constipation. Test all stools for occult blood.

Collaborative

Adjust diet to meet respiratory needs as indicated.






Administer tube feeding/hyperalimentation as needed. (Refer to CP: Total Nutritional Support: Parenteral/Enteral Feeding.)

Monitor laboratory studies as indicated, e.g., prealbumin, serum transferrin, BUN/creatinine (Cr), glucose. RATIONALE



Patients with a tracheostomy tube may be able to eat, but patients with ETs must be tube fed or parenterally nourished.

These symptoms are indicative of depletion of muscle energy and can reduce respiratory muscle function.

Significant and recent weight loss (7%–10% body weight) and poor nutritional intake provide clues regarding catabolism, muscle glycogen stores, and ventilatory drive sensitivity.

Appetite is usually poor and intake of essential nutrients may be reduced. Offering favorite foods can enhance oral intake.

Prevents excessive fatigue, enhances intake, and reduces risk of gastric distress.

Prevents dehydration that can be exacerbated by increased insensible losses (e.g., ventilator/intubation) and reduces risk of constipation.

A functioning GI system is essential for the proper utilization of enteral feedings. Mechanically ventilated patients are at risk of developing abdominal distension (trapped air or ileus) and gastric bleeding (stress ulcers).



High intake of carbohydrates, protein, and calories may be desired/needed during ventilation to improve respiratory muscle function. Carbohydrates may be reduced and fat somewhat increased just before weaning attempts to prevent excessive CO2 production and reduced respiratory drive.

Provides adequate nutrients to meet individual needs when oral intake is insufficient/not appropriate.


Provides information about adequacy of nutritional support/need for change.




NURSING DIAGNOSIS: Infection, risk for
Risk factors may include
Inadequate primary defenses (traumatized lung tissue, decreased ciliary action, stasis of body fluids)
Inadequate secondary defenses (immunosuppression)
Chronic disease, malnutrition
Invasive procedure (intubation)
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT/CAREGIVER WILL:
Knowledge: Infection Control (NOC)
Indicate understanding of individual risk factors.
Identify interventions to prevent/reduce risk of infection.
Demonstrate techniques to promote safe environment.



ACTIONS/INTERVENTIONS
Infection Protection (NIC)
Independent
Note risk factors for occurrence of infection.







Observe color/odor/characteristics of sputum. Note drainage around tracheostomy tube.

Reduce nosocomial risk factors via proper handwashing by all caregivers, maintaining sterile suction techniques, reducing the number of times the ventilator tubes are open, and providing clean nebulizer/tubing changes.




Encourage deep breathing, coughing, and frequent position changes.


Auscultate breath sounds.


Monitor/screen visitors. Avoid contact with persons with URI. RATIONALE



Intubation, prolonged mechanical ventilation, trauma, general debilitation, malnutrition, age, and invasive procedures are factors that potentiate patient’s risk of acquiring infection and prolonging recovery. Awareness of individual risk factors provides opportunity to limit effects and help prevent ventilator-associated pneumonia (VAP).

Yellow/green, purulent odorous sputum is indicative of infection; thick, tenacious sputum suggests dehydration.

These factors may be the simplest but are the most important keys to prevention of hospital-acquired infection. Note: Centers for Disease Control and Prevention (CDC) guidelines recommend changing tubing no more often than every 48 hr. Research indicates that less frequent tubing changes (every 5–7 days) may even be acceptable.

Maximizes lung expansion and mobilization of secretions to prevent/reduce atelectasis and accumulation of sticky, thick secretions.

Presence of rhonchi/wheezes suggests retained secretions requiring expectoration/suctioning.

Individual is already compromised and is at increased risk for development of infections.


ACTIONS/INTERVENTIONS
Infection Protection (NIC)
Independent
Instruct patient/SO in proper secretion disposal, e.g., tissues, soiled tracheostomy dressings.

Provide respiratory isolation when indicated.



Maintain adequate hydration and nutrition. Encourage fluids to 2500 mL/day within cardiac tolerance.

Measure pH of gastric secretions, and monitor use of antacid medications as indicated.

Encourage self-care/activities to limit of tolerance. Assist with graded exercise program.

Collaborative

Obtain sputum cultures as indicated.


Administer antimicrobials as indicated. RATIONALE



Reduces transmission of fluid-borne organisms.


Depending on specific diagnosis, patient may require protection from others or must prevent transmission of infection to others (e.g., tuberculosis).

Helps improve general resistance to disease and reduces risk of infection from static secretions.

Maintaining acid level of stomach around 7.2 pH may help reduce risk of nosocomial infection and stress ulcers.

Improves general well-being and muscle strength and may stimulate immune system recovery.



May be needed to identify pathogens and appropriate antimicrobials.

If infection does occur, one or more agents may be used, depending on identified pathogen(s).




NURSING DIAGNOSIS: Ventilatory Weaning Response, risk for dysfunctional
Risk factors may include
Sleep disturbance
Limited/insufficient energy stores
Pain or discomfort
Adverse environment (e.g., inadequate monitoring/support)
Patient-perceived inability to wean; decreased motivation
History of extended weaning
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Respiratory Status: Ventilation (NOC)
Actively participate in the weaning process.
Reestablish independent respiration with ABGs within acceptable range and free of signs of respiratory failure.
Demonstrate increased tolerance for activity/participate in self-care within level of ability.



ACTIONS/INTERVENTIONS
Mechanical Ventilatory Weaning (NIC)
Independent
Assess physical factors involved in weaning, e.g.:
Stable heart rate/rhythm, BP, and clear breath sounds;



Fever;


Nutritional status and muscle strength;



Respiratory volumes.



Determine psychological readiness.



Explain weaning techniques, e.g., T-piece, spontaneous intermittent maximal ventilation (SIMV), continuous positive airway pressure (CPAP), or NIPPV. Discuss individual plan and expectations.







Provide undisturbed rest/sleep periods. Avoid stressful procedures/situations or nonessential activities.




Evaluate/document patient’s progress. Note restlessness; changes in BP, heart rate, respiratory rate; use of accessory muscles; discoordinated breathing with ventilator; increased concentration on breathing (mild dysfunction); patient’s concerns about possible machine malfunction; inability to cooperate/respond to coaching; color changes.
RATIONALE




The heart has to work harder to meet increased energy needs associated with weaning. Physician may defer weaning if tachycardia, pulmonary crackles, and/or hypertension are present.

Increase of 1°F (0.6°C) in body temperature raises metabolic rate and oxygen demands by 7%.

Weaning is hard work. Patient not only must be able to withstand the stress of weaning but also must have the stamina to breathe spontaneously for extended periods.

Predictors of readiness to wean include (NIP) ≤-220, (PEP) ≤+120, (STV) >5 mL/kg, (MC) >10–15 mL/kg, (MV) ≤10 L/min.

Weaning provokes anxiety for patient regarding concerns about ability to breathe on own and long-term need of ventilator.

Assists patient to prepare for weaning process, helps limit fear of unknown, promotes cooperation, and enhances likelihood of a successful outcome. Note: Pressure support ventilation unloads respiratory muscles, allowing patient to “set” rate and volume and decelerating flow pattern because breath can be shaped to simulate a more normal respiratory pattern with higher gas flow on inspiration then tapering off. This increases patient comfort and is especially beneficial for patients at high risk for DVWR.

Maximizes energy for weaning process; limits fatigue and oxygen consumption. Note: It takes approximately 12–14 hr of respiratory rest to rejuvenate tired respiratory muscles. For patients on assist/control, raising the rate to 20 breaths/min can also provide respiratory rest.

Indicators that patient may require slower weaning/opportunity to stabilize or may need to stop program. Note: Moving from pressure/volume (e.g., assist/control) ventilator to T-piece may precipitate a “flash” form of heart failure requiring prompt intervention.



ACTIONS/INTERVENTIONS
Mechanical Ventilatory Weaning (NIC)
Independent
Recognize/provide encouragement for patient’s efforts.


Monitor response to activity.


Collaborative

Consult with dietitian, nutritional support team for adjustments in composition of diet.


Monitor CBC, serum albumin and prealbumin, transferrin, total iron-binding capacity, and electrolytes (especially potassium, calcium, and phosphorus).

Review chest x-ray and ABGs. RATIONALE



Positive feedback provides reassurance and support for continuation of weaning process.

Excessive oxygen consumption/demand increases the possibility of failure.



Reduction of carbohydrates/fats may be required to prevent excessive production of CO2, which could alter respiratory drive.

Verifies that nutrition is adequate to meet energy requirements for weaning.


Chest x-rays should show clear lungs or marked improvement in pulmonary congestion or infiltrates. ABGs should document satisfactory oxygenation on an FIO2 of 40% or less.




NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis and therapy, self-care and discharge needs
May be related to
Lack of exposure/recall
Misinterpretation of information; unfamiliarity with information resources
Stress of situational crisis
Possibly evidenced by
Questions about care, request for information
Reluctance to learn new skills
Inaccurate follow-through of instructions
Development of preventable complications
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT/SO/CAREGIVER WILL:
Health-Seeking Behavior (NOC)
Participate in learning process.
Exhibit increased interest, shown by verbal/nonverbal cues.
Assume responsibility for own learning and begin to look for information and to ask questions.
Knowledge: Treatment Regimen (NOC)
Indicate understanding of mechanical ventilation therapy.
Demonstrate behaviors/new skills to meet individual needs/prevent complications.




ACTIONS/INTERVENTIONS
Learning Facilitation (NIC)
Independent
Determine ability and willingness to learn.




Schedule teaching sessions for quiet, nonstressful times when all participants are well rested.

Arrange information in logical sequence, progressing from simple to more complex material at learners’ pace.

Knowledge: Disease Process (NIC)

Provide material in multiple formats, (e.g., books/pamphlets, audiovisuals, hands-ondemonstrations) and take-home instruction sheets as appropriate.

Discuss specific condition requiring ventilatory support, what measures are being tried for weaning, short- and long-term goals of treatment.




Encourage patient/SO to evaluate impact of ventilatory dependence on their lifestyle and what changes they are willing or unwilling to make. Problem-solve solutions to issues raised.

Promote participation in self-care/diversional activities and socialization as appropriate.

Review issues of general well-being: role of nutrition, assistance with feeding/meal preparation, graded exercise/specific restrictions, rest periods alternated with activity.

Recommend that SO/caregivers learn CPR.



Schedule team conference. Establish in-hospital training for caregivers if patient is to be discharged home on ventilator.

Instruct caregiver and patient in handwashing techniques, use of sterile technique for suctioning, tracheostomy/stoma care, and chest physiotherapy.
RATIONALE



Physical condition may preclude patient involvement in care before and after discharge. SO/caregiver may feel inadequate and afraid of machinery and have reservations about ability to learn or deal with overall situation.

Enhances learners’ ability to focus on and absorb content provided.

Allows learner to build on information learned in previous sessions, is less threatening/overwhelming.



Uses multiple senses to stimulate learning/ retention of information. Provides resources for review following discharge.

Provides knowledge base to aid patient/SO in making informed decisions. Weaning efforts may continue for several weeks (extended period of time). Dependence is evidenced by repeatedly increased Pco2 and/or decline in PaO2 during weaning attempts, presence of dypsnea, anxiety, tachycardia, perspiration, cyanosis.

Quality of life must be resolved by the ventilator-dependent patient and caregivers who need to understand that home ventilatory support is a 24-hr job that affects everyone.

Refocuses attention toward more normal life activities, increases endurance, and helps prevent depersonalization.

Enhances recuperation and ensures that individual needs will be met.



Provides sense of security about ability to handle emergency situations that might arise until help can be obtained.

Team approach is needed to coordinate patient’s care and teaching program to meet individual needs.


Reduces risk of infection and promotes optimal respiratory function.
ACTIONS/INTERVENTIONS
Knowledge: Disease Process (NIC)
Independent
Provide both demonstration and “hands-on” sessions, as well as written material, about specific type of ventilator to be used, function, and care of equipment.

Discuss what/when to report to the healthcare provider, e.g., signs of respiratory distress, infection.


Ascertain that all needed equipment is in place and that safety concerns have been addressed, e.g., alternative power source (generator, batteries); backup equipment; patient call/alarm system.

Contact community/hospital-based services.




Refer to vocational/occupational therapist. RATIONALE



Enhances familiarity, reducing anxiety and promoting confidence in implementation of new tasks/skills.


Helps reduce general anxiety while promoting timely/appropriate evaluation and intervention to prevent complications.

Predischarge preparations can ease the transfer process. Planning for potential problems increases sense of security for patient/SO.


Suppliers of home equipment, physical therapy, care providers, emergency power provider, social services; financial assistance, aid in procuring equipment/personnel, and facilitating transition to home.

Some ventilator-dependent patients are able to resume vocations, either while on the ventilator or during the day (while ventilator-dependent at night).


POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patient’s age, physical condition/presence of complications, personal resources, and life responsibilities)
If patient is discharged on ventilator, the patient’s needs/concerns remain the same as noted in this plan of care, in addition to:
Self-Care deficit—decreased strength/endurance, inability to perform ADLs, depression, restrictions imposed by therapeutic intervention.
Family Processes, interrupted—situational crisis.
Caregiver Role Strain, risk for—severity of illness of care receiver, discharge of family member with significant home care needs, presence of situational stressors (economic vulnerability, changes in roles/responsibilities), duration of caregiving required, inexperience in caregiving.

UROLITHIASIS (RENAL CALCULI)
Kidney stones (calculi) are formed of mineral deposits, most commonly calcium oxalate and calcium phosphate; however, uric acid, struvite, and cystine are also calculus formers. Although renal calculi can form anywhere in the urinary tract, they are most commonly found in the renal pelvis and calyces. Renal calculi can remain asymptomatic until passed into a ureter and/or urine flow is obstructed, when the potential for renal damage is acute.
CARE SETTING
Acute episodes may require inpatient treatment on a medical or surgical unit.
RELATED CONCERNS
Fluid and electrolyte imbalances
Metabolic acidosis (primary base bicarbonate deficiency)
Metabolic alkalosis (primary base bicarbonate excess)
Psychosocial aspects of care
Renal failure: acute
Patient Assessment Database
Dependent on size, location, and etiology of calculi.
ACTIVITY/REST
May report: Sedentary occupation or occupation in which patient is exposed to high environmental temperatures
Activity restrictions/immobility due to a preexisting condition (e.g., debilitating disease, spinal cord injury)
CIRCULATION
May exhibit: Elevated BP/pulse (pain, anxiety, kidney failure)
Warm, flushed skin; pallor
ELIMINATION
May report: History of recent/chronic UTI; previous obstruction (calculi)
Decreased urinary output, bladder fullness
Burning, urgency with urination
Diarrhea
May exhibit: Oliguria, hematuria, pyuria
Alterations in voiding pattern
FOOD/FLUID
May report: Nausea/vomiting, abdominal tenderness
Diet high in purines, calcium oxalate, and/or phosphates
Insufficient fluid intake; does not drink fluids well
May exhibit: Abdominal distension; decreased/absent bowel sounds
Vomiting
PAIN/DISCOMFORT
May report: Acute episode of excruciating, colicky pain with location depending on stone location, e.g., in the flank in the region of the costovertebral angle; may radiate to back, abdomen, and down to the groin/genitalia. Constant dull pain suggests calculi located in the renal pelvis or calyces.
Pain may be described as acute, severe, not relieved by positioning or any other measures
May exhibit: Guarding; distraction behaviors; self-focusing
Tenderness in renal areas on palpation
SAFETY
May report: Use of alcohol
Fever; chills
TEACHING/LEARNING
May report: Family history of calculi, kidney disease, hypertension, gout, chronic UTI
History of small-bowel disease, previous abdominal surgery, hyperparathyroidism
Use of antibiotics, antihypertensives, sodium bicarbonate, allopurinol, phosphates, thiazides, excessive intake of calcium or vitamin D
Discharge plan DRG projected mean length of inpatient stay: 2.9 days
considerations:
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Urinalysis: Color may be yellow, dark brown, bloody. Commonly shows RBCs, WBCs, crystals (cystine, uric acid, calcium oxalate), casts, minerals, bacteria, pus; pH may be less than 5 (promotes cystine and uric acid stones) or higher than 7.5 (promotes magnesium, struvite, phosphate, or calcium phosphate stones).
Urine (24-hr): Cr, uric acid, calcium, phosphorus, oxalate, or cystine may be elevated.
Urine culture: May reveal UTI (Staphylococcus aureus, Proteus, Klebsiella, Pseudomonas).
Biochemical survey: Elevated levels of magnesium, calcium, uric acid, phosphates, protein, electrolytes.
Serum and urine BUN/Cr: Abnormal (high in serum/low in urine) secondary to high obstructive stone in kidney causing
ischemia/necrosis.
Serum chloride and bicarbonate levels: Elevation of chloride and decreased levels of bicarbonate suggest developing renal tubular acidosis.
CBC:
Hb/Hct: Abnormal if patient is severely dehydrated or polycythemia is present (encourages precipitation of solids), or patient is anemic (hemorrhage, kidney dysfunction/failure).
RBCs: Usually normal.
WBCs: May be increased, indicating infection/septicemia.
Parathyroid hormone (PTH): May be increased if kidney failure present. (PTH stimulates reabsorption of calcium from bones, increasing circulating serum and urine calcium levels.)
KUB x-ray: Shows presence of calculi and/or anatomical changes in the area of the kidneys or along the course of the ureter.
IVP: Provides rapid confirmation of urolithiasis as a cause of abdominal or flank pain. Shows abnormalities in anatomical structures (distended ureter) and outline of calculi.
Cystoureteroscopy: Direct visualization of bladder and ureter may reveal stone and/or obstructive effects.
CT scan: Identifies/delineates calculi and other masses; kidney, ureteral, and bladder distension.
Ultrasound of kidney: To determine obstructive changes, location of stone; without the risk of failure induced by contrast medium.
NURSING PRIORITIES
1. Alleviate pain.
2. Maintain adequate renal functioning.
3. Prevent complications.
4. Provide information about disease process/prognosis and treatment needs.
DISCHARGE GOALS
1. Pain relieved/controlled.
2. Fluid/electrolyte balance maintained.
3. Complications prevented/minimized.
4. Disease process/prognosis and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.


NURSING DIAGNOSIS: Pain, acute
May be related to
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/EVALUATION CRITERIA—PATIENT WILL:
Pain Level (NOC)
Report pain is relieved with spasms controlled.
Appear relaxed, able to sleep/rest appropriately.

ACTIONS/INTERVENTIONS
Pain Management (NIC)
Independent
Document location, duration, intensity (0–10 scale), and radiation. Note nonverbal signs, e.g., elevated BP and pulse, restlessness, moaning, thrashing about.





Explain cause of pain and importance of notifying caregivers of changes in pain occurrence/characteristics.




Provide comfort measures, e.g., back rub, restful environment.

Assist with/encourage use of focused breathing, guided imagery, diversional activities.

Encourage/assist with frequent ambulation as indicated and increased fluid intake of at least 3–4 L/day within cardiac tolerance.

Note reports of increased/persistent abdominal pain.


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, genitalia because of proximity of nerve plexus and blood vessels supplying other areas. Sudden, severe pain may precipitate apprehension, restlessness, severe anxiety.

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.

Promotes relaxation, reduces muscle tension, and enhances coping.

Redirects attention and aids in muscle relaxation.


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.

Complete obstruction of ureter can cause perforation and extravasation of urine into perirenal space. This represents an acute surgical emergency.




ACTIONS/INTERVENTIONS
Pain Management (NIC)
Independent
Administer medications as indicated:
Narcotics, e.g., meperidine (Demerol), morphine;


Antispasmodics, e.g., flavoxate (Urispas), oxybutynin (Ditropan);

Corticosteroids.


Collaborative

Apply warm compresses to back.

Maintain patency of catheters when used. RATIONALE




Usually given during acute episode to decrease ureteral colic and promote muscle/mental relaxation.

Decreasing reflex spasm may decrease colic and pain.


May be used to reduce tissue edema to facilitate movement of stone.



Relieves muscle tension and may reduce reflex spasms.

Prevents urinary stasis/retention, reduces risk of increased renal pressure and infection.




NURSING DIAGNOSIS: Urinary Elimination, impaired
May be related to
Stimulation of the bladder by calculi, renal or ureteral irritation
Mechanical obstruction, inflammation
Possibly evidenced by
Urgency and frequency; oliguria (retention)
Hematuria
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Urinary Elimination (NOC)
Void in normal amounts and usual pattern.
Experience no signs of obstruction.

ACTIONS/INTERVENTIONS
Urinary Elimination Enhancement (NIC)
Independent
Monitor I&O and characteristics of urine. RATIONALE



Provides information about kidney function and presence of complications, e.g., infection and hemorrhage. Bleeding may indicate increased obstruction or irritation of ureter. Note: Hemorrhage due to ureteral ulceration is rare.


ACTIONS/INTERVENTIONS
Urinary Elimination Enhancement (NIC)
Independent
Determine patient’s normal voiding pattern and note variations.


Encourage increased fluid intake.


Strain all urine. Document any stones expelled and send to laboratory for analysis.

Investigate reports of bladder fullness; palpate for suprapubic distension. Note decreased urine output, presence of periorbital/dependent edema.

Observe for changes in mental status, behavior, or level of consciousness.

Collaborative

Monitor laboratory studies, e.g., electrolytes, BUN, Cr.


Obtain urine for culture and sensitivities.


Administer medications as indicated, e.g.:
Acetazolamide (Diamox), allopurinol (Zyloprim);




Hydrochlorothiazide (Esidrix, HydroDIURIL), chlorthalidone (Hygroton);



Ammonium chloride; potassium or sodium phosphate;

Antibiotics;


Sodium bicarbonate;



Ascorbic acid.


ACTIONS/INTERVENTIONS
Urinary Elimination Enhancement (NIC)
Independent

Maintain patency of indwelling catheters (ureteral, urethral, or nephrostomy) when used.


Irrigate with acid or alkaline solutions as indicated.


Prepare patient for/assist with endoscopic procedures, e.g.:
Basket procedure;



Ureteral stents;





Percutaneous or open pyelolithotomy, nephrolithotomy, ureterolithotomy;

Percutaneous ultrasonic lithotripsy;


Extracorporeal shockwave lithotripsy (ESWL). RATIONALE



Calculi may cause nerve excitability, which causes sensations of urgent need to void. Usually frequency and urgency increase as calculus nears ureterovesical junction.

Increased hydration flushes bacteria, blood, and debris and may facilitate stone passage.

Retrieval of calculi allows identification of type of stone and influences choice of therapy.

Urinary retention may develop, causing tissue distension (bladder/kidney), and potentiates risk of infection, renal failure.

Accumulation of uremic wastes and electrolyte imbalances can be toxic to the CNS.



Elevated BUN, Cr, and certain electrolytes indicate presence/degree of kidney dysfunction.

Determines presence of UTI, which may be causing/complicating symptoms.


Increases urine pH (alkalinity) to reduce formation of acid stones. Antigout agents such as allopurinol (Zyloprim) also lower uric acid production and potential of stone formation.

May be used to prevent urinary stasis and decrease calcium stone formation if not caused by underlying disease process such as primary hyperthyroidism or vitamin D abnormalities.

Reduces phosphate stone formation.


Presence of UTI/alkaline urine potentiates stone formation.

Replaces losses incurred during bicarbonate wasting and/or alkalinization of urine; may reduce/prevent formation of some calculi.

Acidifies urine to prevent recurrence of alkaline stone formation.

RATIONALE




May be required to facilitate urine flow/prevent retention and corresponding complications. Note: Tubes may be occluded by stone fragments.

Changing urine pH may help dissolve stones and prevent further stone formation.



Calculi in the distal and midureter may be removed by endoscopic cystoscope with capture of the stone in a basketing catheter.

Catheters are positioned above the stone to promote urethraldilation/stone passage. Continuous or intermittent irrigation can be carried out to flush kidneys/ureters and adjust pH of urine to permit dissolution of stone fragments following lithotripsy.

Surgery may be necessary to remove stone that is too large to pass through ureters.

Invasive shock wave treatment for stones in renal pelvis/calyx or upper ureters.

Noninvasive procedure in which kidney stones are pulverized by shock waves delivered from outside the body.






NURSING DIAGNOSIS: Fluid Volume, risk for deficient
Risk factors may include
Nausea/vomiting (generalized abdominal and pelvic nerve irritation from renal or ureteral colic)
Postobstructive diuresis
Possibly evidenced by
[Not applicable; presence of signs or symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Hydration (NOC)
Maintain adequate fluid balance as evidenced by vital signs and weight within patient’s normal range, palpable peripheral pulses, moist mucous membranes, good skin turgor.



ACTIONS/INTERVENTIONS
Fluid/Electrolyte Management (NIC)
Independent
Monitor I&O.






Document incidence and note characteristics and frequency of vomiting and diarrhea, as well as accompanying or precipitating events.



Increase fluid intake to 3–4 L/day within cardiac tolerance.



Monitor vital signs. Evaluate pulses, capillary refill, skin turgor, and mucous membranes.



Weigh daily.

Collaborative

Monitor Hb/Hct, electrolytes.


Administer IV fluids.


Provide appropriate diet, clear liquids, bland foods as tolerated.

Administer medications as indicated: antiemetics, e.g., prochlorperazine (Compazine).
RATIONALE



Comparing actual and anticipated output may aid in evaluating presence/degree of renal stasis/impairment. Note: Impaired kidney functioning and decreased urinary output can result in higher circulating volumes with signs/symptoms of HF.


Nausea/vomiting and diarrhea are commonly associated with renal colic because celiac ganglion serves both kidneys and stomach. Documentation may help rule out other abdominal occurrences as a cause for pain or pinpoint calculi.

Maintains fluid balance for homeostasis and “washing” action that may flush the stone(s) out. Dehydration and electrolyte imbalance may occur secondary to excessive fluid loss (vomiting and diarrhea).

Indicators of hydration/circulating volume and need for intervention. Note: Decreased GFR stimulates production of renin, which acts to raise BP in an effort to increase renal blood flow.

Rapid weight gain may be related to water retention.



Assesses hydration and effectiveness of/need for interventions.

Maintains circulating volume (if oral intake is insufficient), promoting renal function.

Easily digested foods decrease GI activity/irritation and help maintain fluid and nutritional balance.

Reduces nausea/vomiting.




NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May be related to
Lack of exposure/recall; information misinterpretation
Unfamiliarity with information resources
Possibly evidenced by
Questions; request for information; statement of misconception
Inaccurate follow-through of instructions, development of preventable complications
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Knowledge: Illness Care (NOC)
Verbalize understanding of disease process and potential complications.
Correlate symptoms with causative factors.
Verbalize understanding of therapeutic needs.
Initiate necessary lifestyle changes and participate in treatment regimen.

ACTIONS/INTERVENTIONS
Teaching: Disease Process (NIC)
Independent
Review disease process and future expectations.


Stress importance of increased fluid intake, e.g., 3–4L/day or as much as 6–8 L/day. Encourage patient to notice dry mouth and excessive diuresis/diaphoresis and to increase fluid intake whether or not feeling thirsty.

Review dietary regimen, as individually appropriate:




Low-purine diet, e.g., limited lean meat, turkey, legumes, whole grains, alcohol;

Low-calcium diet, e.g., limited milk, cheese, green leafy vegetables, yogurt;




Low-oxalate diet, e.g., restrict chocolate, caffeine-containing beverages, beets, spinach.
RATIONALE



Provides knowledge base from which patient can make informed choices.

Flushes renal system, decreasing opportunity for urinary stasis and stone formation. Increased fluid losses/dehydration require additional intake beyond usual daily needs.

Diet depends on the type of stone. Understanding reason for restrictions provides opportunity for patient to make informed choices, increases cooperation with regimen, and may prevent recurrence.

Decreases oral intake of uric acid precursors.


Reduces risk of calcium stone formation. Note: Research suggests that restricting dietary calcium is not helpful in reducing calcium-stone formation, and researchers, although not advocating high-calcium diets, are urging that calcium limitation be reexamined.

Reduces calcium oxalate stone formation.

ACTIONS/INTERVENTIONS
Teaching: Disease Process (NIC)
Independent
Shorr regimen: low-calcium/phosphorus diet with aluminum carbonate gel 30–40 mL, 30 min pc/hs.



Discuss medication regimen; avoidance of OTC drugs, and reading all product/food ingredient labels.




Encourage regular activity/exercise program.


Active-listen concerns about therapeutic regimen/lifestyle changes.

Identify signs/symptoms requiring medical evaluation, e.g., recurrent pain, hematuria, oliguria.

Demonstrate proper care of incisions/catheters if present. RATIONALE



Prevents phosphatic calculi by forming an insoluble precipitate in the GI tract, reducing the load to the kidney nephron. Also effective against other forms of calcium calculi. Note: May cause constipation.

Drugs will be given to acidify or alkalize urine, depending on underlying cause of stone formation. Ingestion of products containing individually contraindicated ingredients (e.g., calcium, phosphorus) potentiates recurrence of stones.

Inactivity contributes to stone formation through calcium shifts and urinary stasis.

Helps patient work through feelings and gain a sense of control over what is happening.

With increased probability of recurrence of stones, prompt interventions may prevent serious complications.

Promotes competent self-care and independence.


POTENTIAL CONSIDERATIONS following acute hospitalizations (dependent on patient’s age, physical condition/presence of complications, personal resources, and life responsibilities)
Urinary Elimination, impaired—recurrence of calculi.

URINARY DIVERSIONS/UROSTOMY (POSTOPERATIVE CARE)
Incontinent urinary diversions: These ostomies require permanent stoma care and external collecting devices.
Ileal conduit: Ureters are anastomosed to a segment of ileum, resected with the blood supply intact (usually 15–20 cm long). The proximal section is closed, and the distal end brought to skin opening to form a stoma (a passageway, not a storage reservoir).
Colonic conduit: This is a similar procedure using a segment of colon.
Ureterostomy: The ureter(s) is brought directly through the abdominal wall to form its own stoma.
Continent urinary diversions: Continent urinary reservoirs (CURs) have become one of the major options for patients to improve their quality of life regarding stoma care and the ability to sleep and travel.
Kock reservoir or Indiana (ileocecal) pouch: A section of intestine is used to form a pouch inside the patient’s abdomen, creating a reservoir that the patient periodically drains by inserting a catheter through the stoma, thus negating the need for an external collecting device.
CARE SETTING
Inpatient acute surgical unit.
RELATED CONCERNS
Cancer
Peritonitis
Psychosocial aspects of care
Surgical intervention
Patient Assessment Database
Data depend on underlying problem, duration, and severity, e.g., malignant bladder tumor, congenital malformations, trauma, chronic infections, or intractable incontinence due to injury/disease of other body systems (e.g., multiple sclerosis). (Refer to appropriate CP.)
TEACHING/LEARNING
Discharge plan DRG projected mean length of inpatient stay: 5.5 days
considerations: May require assistance with management of ostomy and acquisition of supplies.
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Intravenous pyelogram (IVP): Visualizes size/location of kidneys and ureters and rules out presence of tumors elsewhere in urinary tract.
Cystoscopy with biopsy: Determines tumor location/stage of malignancy. Ultraviolet cystoscopy outlines bladder lesion.
Bone scan: Determines presence of metastatic disease.
Bilateral pedal lymphangiogram: Determines involvement of pelvic nodes, where bladder tumor easily seeds because of close proximity.
CT scan: Defines size of tumor mass, degree of pelvic spread.
Urine cystoscopy: Detects tumor cells in urine (for determining presence and type of tumor).
Endoscopy: Evaluates intestines for use as conduit.
Conduitogram: Assesses length and emptying ability of the conduit and presence of stricture, obstruction, reflux, angulation, calculi, or tumor (may complicate or contraindicate use as a urinary diversion).
NURSING PRIORITIES
1. Prevent complications.
2. Assist patient/SO in physical and psychosocial adjustment.
3. Support independence in self-care.
4. Provide information about procedure/prognosis, treatment needs, potential complications, and resources.
DISCHARGE GOALS
1. Complications prevented/minimized.
2. Adjusting to perceived/actual changes.
3. Self-care needs met by self/with assistance as necessary.
4. Procedure/prognosis, therapeutic regimen, potential complications understood and sources of support identified.
5. Plan in place to meet needs after discharge.



NURSING DIAGNOSIS: Skin Integrity, risk for impaired
Risk factors may include
Absence of sphincter at stoma [actual] with continuous flow of urine
Character/flow of urine from stoma
Reaction to product/chemicals; improper fitting of appliance or removal of adhesive
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Tissue Integrity: Skin and Mucous Membranes (NOC)
Maintain skin integrity.
Risk Control (NOC)
Identify individual risk factors.
Demonstrate behaviors/techniques to promote healing/prevent skin breakdown.

ACTIONS/INTERVENTIONS
Ostomy Care (NIC)
Independent
Inspect stoma/peristomal skin. Note irritation, bruises (dark, bluish color), rashes, status of sutures.







Clean with water and pat dry (or use hair dryer on cool setting).

Handle stoma gently to prevent irritation.


Measure stoma periodically, e.g., each appliance change for first 6 wk, then monthly times six.



Apply effective sealant barrier, e.g., Skin Prep or similar product. RATIONALE



Monitors healing process/effectiveness of appliance and identifies areas of concern, need for further evaluation/intervention. Stoma should be pink or reddish, similar to mucous membranes. Color changes may be temporary, but persistent changes may require surgical intervention. Early identification of stomal necrosis/ischemia or fungal infection provides for timely interventions to prevent skin necrosis.

Maintaining a clean/dry area helps prevent skin breakdown.

Mucosa has good blood supply and bleeds easily with rubbing or trauma.

As postoperative edema resolves (during first 6 wk), size of appliance must be altered to ensure proper fit so that urine is collected as it flows from the stoma and contact with the skin is prevented.

Protects skin from pouch adhesive, enhances adhesiveness of pouch, and facilitates removal of pouch when necessary.


ACTIONS/INTERVENTIONS
Ostomy Care (NIC)
Independent
Make sure opening for adhesive backing of pouch is at least 1⁄16 in larger than the base of the stoma (Wound, Ostomy and Continence Nursing Society [WOCN] standard), with adequate adhesiveness left to apply pouch.

Use a transparent, odor-proof drainable pouch. Keep gauze square/wick over stoma while cleansing area, and have patient cough or strain before applying pouch.





Avoid use of karaya-type appliances.

Apply waterproof tape around pouch edges if desired.

Connect collecting pouch to continuous bedside drainage system, when necessary.



Cleanse ostomy pouch on a routine basis, using vinegar solution.



Change pouch every 3–5 days or as needed for leakage. Remove appliance gently while supporting skin. Use adhesive removers as indicated and wash off completely.

Investigate reports of burning/itching around stoma.




Evaluate adhesive product and appliance fit on ongoing basis.

Monitor for distension of lower abdomen (with ileal conduit); assess bowel sounds.
RATIONALE



Prevents trauma to the stoma tissue and protects the peristomal skin. Adequate adhesive area is important to maintain a seal. Note: Too tight a fit may cause stomal edema or stenosis.

A transparent appliance during first 4–6 wk allows easy observation of stoma and stents (when used) without necessity of removing pouch and irritating skin. Covering stoma prevents urine from wetting the peristomal area during pouch changes. Coughing empties distal portion of conduit, followed by a brief pause in drainage to facilitate application of pouch.

Will not protect skin because urine melts karaya.

Reinforces anchoring.

May be needed during times when rate of urine formation is increased, e.g., while IV fluids are administered. Weight of the urine can cause pouch to pull loose/leak when pouch becomes more than half full.

Frequent pouch changes are irritating to the skin and should be avoided. Emptying and rinsing the pouch with vinegar not only removes bacteria but also deodorizes the pouch.

Prevents tissue irritation/destruction associated with “pulling” pouch off.


Suggests peristomal irritation or possibly Candida infections, both requiring intervention. Note: Continuous exposure of skin to urine can cause hyperplasia around stoma, affecting pouch fit and increasing risk of infection.

Provides opportunity for problem solving. Determines need for further intervention.

Intestinal distension can cause tension on new suture lines with possibility of rupture.




ACTIONS/INTERVENTIONS
Ostomy Care (NIC)
Collaborative
Consult with enterostomal nurse.









Apply antifungal spray or powder, as indicated. RATIONALE



Helpful in problem solving and choosing products appropriate for patient needs, considering stoma characteristics, patient’s physical/mental status, and financial resources. In the presence of persistent or recurring problems, the ostomy nurse has a wider range of knowledge and resources. Note: WOCN standards mandate that patient be capable of changing an ostomy appliance before discharge, or receive home care until such time as patient or caregivers are competent.

Assists in healing if peristomal irritation is caused by fungal infection. Note: These products can have potent side effects and should be used sparingly. Creams/ointments are to be avoided, because they interfere with adhesion of the appliance.



NURSING DIAGNOSIS: Body Image, disturbed
May be related to
Biophysical: presence of stoma; loss of control of urine elimination
Psychosocial: altered body structure
Disease process and associated treatment regimen, e.g., cancer
Possibly evidenced by
Verbalization of change in body image, fear of rejection/reaction of others, and negative feelings about body
Actual change in structure and/or function (ostomy)
Not touching/looking at stoma, refusal to participate in care
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Body Image (NOC)
Demonstrate beginning acceptance by viewing/touching stoma and participating in self-care.
Verbalize feelings about stoma/illness; begin to deal constructively with situation.
Verbalize acceptance of self in situation, incorporating change into self-concept without negating self-esteem.


ACTIONS/INTERVENTIONS
Body Image Enhancement (NIC)
Independent
Review reason for surgery and future expectations. RATIONALE



Patient may find it easier to accept/deal with an ostomy done for chronic/long-term disease (e.g., intractable incontinence, infections) than for traumatic injury.




ACTIONS/INTERVENTIONS
Body Image Enhancement (NIC)
Independent
Ascertain whether counseling was initiated when the possibility and/or necessity of urinary diversion was first discussed.

Answer all questions concerning urostomy and its function.


Encourage patient/SO to verbalize feelings. Acknowledge normality of feelings of anger, depression, and grief over loss. Discuss daily “ups and downs” that can occur after discharge.


Note behaviors of withdrawal, increased dependency, manipulation, or noninvolvement in care.




Provide opportunities for patient/SO to view and touch stoma, using the moment to point out positive signs of healing, normal appearance, and so forth.




Provide opportunity for patient to deal with ostomy through participation in self-care.


Maintain positive approach during care activities, avoiding expressions of disdain or revulsion. Do not take patient’s angry expressions personally.


Plan/schedule care activities with patient.


Discuss possibility of contacting ostomy/urostomy visitor and make arrangements for visit if desired. RATIONALE



Provides information about patient’s/SO’s level of knowledge about individual situation and process of acceptance.

Establishes rapport and conveys interest/concern of caregiver. Provides additional information for patient to consider.

Provides opportunity to deal with issues/misconceptions. Helps patient/SO to realize that feelings experienced are not unusual and that feeling guilty for them is not necessary/helpful. Patient needs to recognize feelings before they can be dealt with effectively.

Suggestive of problems in adjustment that may require further evaluation and more extensive therapy. May reflect grief response to loss of body part/function and worry over acceptance by others and fear of further disability/loss of life from cancer.

Although integration of stoma into body image can take months or even years, looking at the stoma and hearing comments (made in a normal, matter-of-fact manner) can help patient with this acceptance. Touching stoma reassures patient/SO that it is not fragile and that slight movements of stoma actually reflect normal peristalsis.

Independence in self-care helps improve self-esteem. In the case of a continent diversion, patient needs the energy, ability, and time to intubate the stoma four times a day.

Assists patient/SO to accept body changes and feel all right about self. Anger is most often directed at the situation and lack of control individual has over what has happened (powerlessness), not the individual caregiver.

Promotes sense of control and gives message that patient can handle this situation, enhancing self-esteem.

Can provide a good support system. Helps reinforce teaching (shared experiences) and facilitates acceptance of change as patient realizes “life does go on” and can be relatively normal.




ACTIONS/INTERVENTIONS
Body Image Enhancement (NIC)
Independent
Discuss sexual functioning, medications that promote erection, and penile implant, if applicable, and alternative ways for sexual pleasuring. (Refer to ND: Sexual Dysfunction, risk for.)
RATIONALE



Patient may experience anticipatory anxiety, fear of failure in relation to sex after surgery, usually because of ignorance, lack of knowledge. Surgery that removes the bladder and prostate (removed with the bladder) may disrupt parasympathetic nerve fibers that control erection in men, although newer techniques are available that may be used in individual cases to preserve nerve function.




NURSING DIAGNOSIS: Pain, acute
May be related to
Physical factors, e.g., disruption of skin/tissues (incisions/drains)
Biological: activity of disease process (cancer, trauma)
Psychological factors, e.g., fear, anxiety
Possibly evidenced by
Reports of pain
Guarding/distraction behaviors, restlessness
Self-focusing
Autonomic responses, e.g., changes in vital signs
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Pain Level (NOC)
Verbalize relief/control of pain.
Appear relaxed, able to sleep/rest appropriately.
Pain Control (NOC)
Perform general comfort measures.

ACTIONS/INTERVENTIONS
Pain Management (NIC)
Independent
Assess pain, noting location, characteristics, intensity(0–10 scale). RATIONALE



Helps evaluate degree of discomfort and effectiveness of analgesia or may reveal developing complications, e.g., because abdominal pain usually subsides gradually by the third or fourth postoperative day, continued or increasing pain may reflect delayed healing, peristomal skin irritation, infection, intestinal obstruction.




ACTIONS/INTERVENTIONS
Pain Management (NIC)
Independent
Auscultate bowel sounds; note passage of flatus.




Note urine flow and characteristics.





Encourage patient to verbalize concerns. Active-listen these concerns and provide support by acceptance, remaining with patient and giving appropriate information.

Provide comfort measures, e.g., back rub, repositioning(using body support measures as needed). Assure patient that position change will not injure stoma.

Encourage use of relaxation techniques, e.g., guided imagery, visualization, diversional activities.


Assist with ROM exercises and encourage early ambulation.



Investigate and report abdominal muscle rigidity, involuntary guarding, and rebound tenderness.

Collaborative

Administer medications as indicated, e.g., narcotics, analgesics; patient-controlled analgesia (PCA).


Provide sitz baths, if indicated.



Apply/monitor effects of transcutaneous electrical nerve stimulator (TENS) unit.

Maintain patency of NG tube. RATIONALE



Indicates reestablishment of bowel function. Lack of return of bowel sounds/function within 72 hr may indicate presence of complication, e.g., peritonitis, hypokalemia, mechanical obstruction.

Decreased flow may reflect urinary retention (due to edema) with increased pressure in upper urinary tract or leakage into peritoneal cavity (failure of anastomosis). Cloudy urine may be normal (presence of mucus) or indicate infectious process.

Reduction of anxiety/fear can promote relaxation and comfort.



Reduces muscle tension, promotes relaxation, and may enhance coping abilities.


Helps patient rest more effectively and refocuses attention, which may enhance coping ability, reducing pain and discomfort.

Reduces muscle/joint stiffness. Ambulation returns organs to normal position and promotes return of peristalsis/passage of flatus and feelings of general well-being.

Suggestive of peritoneal inflammation, requiring prompt medical intervention.



Relieves pain, enhances comfort, and promotes rest. PCA may be more beneficial than intermittent analgesia, especially following radical resection.

Relieves local discomfort, reduces edema, and promotes healing of perineal wound associated with radical procedure.

Cutaneous stimulation may be used to block transmission of pain stimulus.

Decompresses stomach/intestines; prevents abdominal distension when intestinal function is impaired.




NURSING DIAGNOSIS: Infection, risk for
Risk factors may include
Inadequate primary defenses (e.g., break in skin/incision; reflux of urine into urinary tract)
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Immune Status (NOC)
Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.
Knowledge: Infection Control (NOC)
Verbalize understanding of individual causative/risk factors.
Demonstrate techniques, lifestyle changes to reduce risk.


ACTIONS/INTERVENTIONS
Infection Protection (NIC)
Independent
Empty ostomy pouch when it becomes one-third full, once IV fluids and continuous pouch drainage have been discontinued.

Document urine characteristics, and note whether changes are associated with reports of flank pain.


Test urine pH with Nitrazine paper (use fresh specimen, not from pouch); notify physician if greater than 6.5.



Report sudden cessation of urethral drainage.



Note red rash around stoma.



Inspect incision line around stoma. Observe and document wound drainage, signs of incisional inflammation, systemic indicators of sepsis.


Change dressings as indicated when used.


Assess skin-fold areas in groin, perineum, under arms and breasts. RATIONALE



Reduces risk of urinary reflux and maintains integrity of appliance seal if pouch does not have an antireflux valve.


Cloudy odorous urine indicates infection (possibly pyelonephritis); however, urine normally contains mucus after a conduit procedure.

Urine is normally acidic, which discourages bacterial growth/UTIs. Note: Presence of alkaline urine also creates favorable environment for stone formation in presence of hypercalciuria.

Constant drainage usually subsides within 10 days; however, abrupt cessation may indicate plugging and lead to abscess formation.

Rash is most commonly caused by yeast. Urine leakage or allergy to appliance or products may also cause red, irritated areas.

Provides baseline/comparative reference. Complications may include interrupted anastomosis of intestine/bowel or ureteral conduit, with leakage of bowel contents into abdomen or urine into peritoneal cavity.

Moist dressings act as a wick to the wound and provide media for bacterial growth.

Use of antibiotics and trapping of moisture in skin-fold areas increases risk of Candida infections.


ACTIONS/INTERVENTIONS
Infection Protection (NIC)
Independent
Monitor vital signs.


Auscultate breath sounds.







Collaborative

Use pouch with antireflux valve, if available.


Obtain specimens of exudates, urine, sputum, blood as indicated.



Administer medications as indicated, e.g.:
Cephalosporins, e.g., cefoxitin (Mefoxin), cefazolin (Ancef);


Antifungal powder;

Ascorbic acid/vitamin C.



Assist with injection of IV methylene blue. RATIONALE



An elevated temperature suggests incisional infection or UTI and/or respiratory complications.

Patient is at high risk for development of respiratory complications because of length of time under anesthesia. Often this patient is older and may already have a compromised immune system. Also, painful abdominal incisions cause patient to breathe more shallowly than normal and to limit coughing effort. Accumulation of secretions in respiratorytract predisposes to atelectasis and infections.


Prevents backflow of urine into stoma, reducing risk of infection.

Identifies source of infection/most effective treatment. Infected urine may cause pyelonephritis. Note: Urine specimen must be obtained from the conduit because the pouch is considered contaminated.


Given to treat identified infection or may be given prophylactically, especially with history of recurrent pyelonephritis.

Used to treat yeast infections around stoma.

Given to acidify urine, reduce bacterial growth/risk of infection. Note: Large doses of vitamin C can impair GI absorption of vitamin B12, potentiating pernicious anemia.

Dye appearing in wound drainage signifies urine leakage into peritoneal cavity and need for surgical repair.




NURSING DIAGNOSIS: Urinary Elimination, impaired
May be related to
Surgical diversion; tissue trauma, postoperative edema
Possibly evidenced by
Loss of continence
Changes in amount, character of urine; urinary retention
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Urinary Elimination (NOC)
Display continuous flow of urine, with output adequate for individual situation.

ACTIONS/INTERVENTIONS
Urinary Elimination Management (NIC)
Independent
Note presence of stents/ureteral catheters. Label “right” and “left” and observe urine flow through each.


Record urinary output; investigate sudden reduction/cessation of urine flow.






Observe and record color of urine. Note hematuria and/or bleeding from stoma.




Position tubing and drainage pouch so that it allows unimpeded flow of urine. Monitor/protect placement of stents.



Demonstrate self-catheterization techniques and reservoir irrigations as appropriate. RATIONALE



Use of stents/ureteral catheters assists in healing of anastomosis by keeping it urine-free. It is necessary to verify that both kidneys/ureters are functional.

Sudden decrease in urine flow may indicate obstruction/dysfunction (e.g., blockage by edema or mucus) or dehydration. Note: Reduced urinary output (not related to hypovolemia) associated with abdominal distension, fever, and clear/watery discharge from incision suggests urinary fistula, also requiring prompt intervention.

Urine may be slightly pink, which should clear up in 2–3 days. Rubbing/washing stoma may cause temporary oozing because of vascular nature of tissues. Continued bleeding, frank blood in the pouch, or oozing around the base of stoma requires medical evaluation/intervention.

Blocked drainage allows pressure to build within urinary tract, risking anastomosis leakage and damage to renal parenchyma. Note: Stents inserted to maintain patency of ureters during period of postoperative edema may be inadvertently dislodged, compromising urine flow.

Patients with continent diversions do not require an external collection device. Periodic catheterization empties the internal reservoir and reduces risk of injury from overdistension. Daily irrigations remove accumulated mucus from the reservoir. Note: Patients with Kock pouches connected to the urethra are instructed to void every 2 hr during the day and every 3 hr during the night. This is done by bearing down and applying hand pressure on the lower abdomen to aid in emptying the reservoir.


ACTIONS/INTERVENTIONS
Urinary Elimination Management (NIC)
Independent
Encourage increased fluids and maintain accurate intake.

Monitor vital signs. Assess peripheral pulses, skin turgor, capillary refill, and oral mucosa. Weigh daily.

Collaborative

Administer IV fluids as indicated.


Monitor electrolytes, ABGs, calcium.





Prepare for diagnostic testing, procedures as indicated. RATIONALE



Maintains hydration and good urine flow.

Indicators of fluid balance. Reflects level of hydration and effectiveness of fluid replacement therapy.



Assists in maintaining hydration/adequate circulating volume and urinary flow.

Impaired renal function in patient with intestinal conduit increases risk of severe electrolyte and/or acid-base problems, e.g., hyperchloremic acidosis. Elevated calcium levels increase risk of crystal/stone formation, affecting both urinary flow and tissue integrity.

Retrograde ileogram may be done to evaluate patency of conduit; nephrostomy tube or stents may be inserted to maintain urine flow until edema/obstruction is resolved.










NURSING DIAGNOSIS: Sexual Dysfunction, risk for
Risk factors may include
Altered body structure/function; radical resection/treatment procedures
Vulnerability/psychological concern about response of SO
Disruption of sexual response pattern, e.g., erection difficulty
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Sexual Functioning (NOC)
Verbalize understanding of relationship of physical condition to sexual problems.
Identify satisfying/acceptable sexual practices and explore alternative methods.
Resume sexual relationship as appropriate.



ACTIONS/INTERVENTIONS
Sexual Counseling (NIC)
Independent
Ascertain patient’s/SO’s sexual relationship before the disease and/or surgery. Identify future expectations and desires.





Review with patient/SO anatomy and physiology of sexual functioning in relation to own situation.


Reinforce information given by the physician. Encourage questions. Provide additional information as needed.





Discuss resumption of sexual activity approximately 6 wk after discharge, beginning slowly and progressing (e.g., cuddling/caressing until both partners are comfortable with body image/function changes). Include alternative methods of stimulation as appropriate.


Encourage dialogue between patient/SO. Suggest wearing pouch cover, T-shirt, or shortie nightgown.


Stress awareness of factors that might be distracting (e.g., unpleasant odors and pouch leakage).

Encourage use of sense of humor.



Problem-solve alternative positions for coitus.


Discuss/role-play possible interactions or approaches when dealing with new sexual partners.


Provide birth control information as appropriate and stress that impotence does not mean patient is necessarily sterile.
RATIONALE



Mutilation and loss of privacy/control of a bodily function can affect patient’s view of personal sexuality. When coupled with the fear of rejection by SO, the desired level of intimacy can be greatly impaired. Sexual needs are very basic, and patient will be rehabilitated more successfully when a satisfying sexual relationship is continued/developed.

Understanding normal physiology helps patient/SO understand the mechanisms of nerve damage and need for exploring alternative methods of satisfaction.

Reiteration of previously given information assists patient/SO to hear and process the knowledge again, moving toward acceptance of individual limitations/restrictions and prognosis (e.g., that it may take up to 2 yr to regain potency after a radical procedure or that a penile prosthesis may be necessary).

Knowing what to expect in progress of recovery helps patient avoid performance anxiety/reduce risk of “failure.” If the couple is willing to try new ideas, this can assist with adjustment and may help achieve sexual fulfillment.


Disguising urostomy appliance may aid in reducing feelings of self-consciousness, embarrassment during sexual activity.

Promotes resolution of solvable problems.


Laughter can help individuals deal more effectively with difficult situation and promote a positive sexual experience.

Minimizing awkwardness of appliance and physical discomfort can enhance satisfaction.

Rehearsal helps deal with actual situations when they arise, preventing self-consciousness about “different” body image.

Confusion about impotency and sterility can lead to an unwanted pregnancy.

ACTIONS/INTERVENTIONS
Sexual Counseling (NIC)
Collaborative
Arrange meeting with an ostomy visitor if appropriate.


Refer to counseling/sex therapy as indicated. RATIONALE



Sharing of how these problems have been resolved by others can be helpful and reduce sense of isolation.

If problems persist longer than several months after surgery, a trained therapist may be required to facilitate communication between patient and SO.




NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis, treatment, self-care, and discharge needs
May be related to
Lack of exposure/recall; information misinterpretation
Unfamiliarity with information resources
Possibly evidenced by
Questions; statement of misconception/misinformation
Inaccurate follow-through of instruction/performance of urostomy care
Inappropriate or exaggerated behaviors (e.g., hostile, agitated, apathetic, withdrawn)
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Knowledge: Disease Process (NOC)
Verbalize understanding of condition/disease process, prognosis, and potential complications.
Knowledge: Treatment Regimen (NOC)
Verbalize understanding of therapeutic needs.
Correctly perform necessary procedures, explain reasons for the action.
Initiate necessary lifestyle changes.

ACTIONS/INTERVENTIONS
Teaching: Disease Process (NIC)
Independent
Evaluate patient’s emotional and physical capabilities.


Review anatomy, physiology, and implications of surgical intervention. Discuss future expectations.


Include written/picture resources. RATIONALE



These factors affect patient’s ability to master tasks and willingness to assume responsibility for ostomy care.

Provides knowledge base from which patient can make informed choices and an opportunity to clarify misconceptions regarding individual situation.

Provides references after discharge to support patient efforts for independence in self-care.




ACTIONS/INTERVENTIONS
Teaching: Disease Process (NIC)
Independent
Instruct patient/SO in stomal care as appropriate. Allot time for return demonstrations and provide positive feedback for efforts.

Ensure that stoma and appliance are odorless, nonleaking.


Demonstrate padding to absorb urethral drainage; ask patient to report changes in amount, odor, character.


Recommend routine clipping/trimming of hair around stoma to edges of pouch adhesive.


Encourage patients with Kock pouch to lengthen voiding interval by 1 hr each week unless discomfort noted.


Instruct patient in a progressive exercise program to include Kegel exercises and stop/start of urinary stream.


Encourage optimal nutrition.




Discuss use of acid-ash diet (e.g., cranberries, prunes, plums, cereals, rice, peanuts, noodles, cheese, poultry, fish); avoidance of salt substitutes, sodium bicarbonate, and antacids; and cautious use of products containing calcium.



Discuss importance of maintaining normal weight.



Stress necessity of increased fluid intake of at least2–3 L/day; of cranberry juice or ascorbic acid/vitamin C tablets; avoidance of citrus fruits as indicated. RATIONALE



Promotes positive management and reduces risk of improper ostomy care.


When patient feels confident about urostomy, energy/attention can be focused on other tasks.

Small amount of leakage may continue for several weeks after prostate surgery with bladder left in place (temporary diversion procedure).

Hair can be pulled out when the pouch is changed, causing irritation of hair follicles and increasing risk of local infection.

Increases capacity of reservoir to achieve a more normal voiding pattern. Presence of discomfort suggests reservoir is full, necessitating prompt emptying.

Improves tone of pelvic muscles and the external sphincter to enhance continence when patient voids through urethra.

Promotes wound healing, increases utilization of energy to facilitate tissue repair. Anorexia may be present for several months postoperatively, requiring conscious effort to meet nutritional needs.

May be useful in acidifying urine to decrease risk of infection and crystal/stone formation. Products containing bicarbonate/calcium potentiate risk of crystal/stone formation affecting both urinary flow and tissue integrity Note: Use of sulfa drugs requires alkaline urine for optimal absorption, so acid-ash diet/vitamin C supplements should be withheld.

Changes in weight can affect size of stoma/appliance fit. Note: Weight loss of 10–20 lb is not uncommon because of intestinal involvement and anorexia.

Maintains urinary output and promotes acidic urine to reduce risk of infection and stone formation. Note: Oranges/citrus fruits make urine alkaline and are therefore contraindicated. Large doses of vitamin C can inhibit vitamin B12 absorption, requiring periodic monitoring of vitamin B12 levels.




ACTIONS/INTERVENTIONS
Teaching: Disease Process (NIC)
Independent
Discuss resumption of presurgery level of activity and possibility of sleep disturbance, anorexia, loss of interest in usual activities.



Encourage regular activity/exercise program.



Identify signs/symptoms requiring medical evaluation, e.g., changes in character, amount and flow of urine, unusual drainage from wound; fatigue/muscle weakness, anorexia, abdominal distension, confusion.



Stress importance of follow-up appointments.





Identify community resources, e.g., United Ostomy Association and local ostomy support group, enterostomal therapist, visiting nurse, pharmacy/medical supply house. RATIONALE



Patient should be able to manage same degree of activity as previously enjoyed and in some cases increase activity level except for contact sports. “Homecoming depression” may occur, lasting for up to 3 mo after surgery, requiring patience/support and ongoing evaluation.

Immobility/inactivity increases urinary stasis and calcium shift out of bones, potentiating risk of stone formation and resultant urinary obstruction, infection.

Early detection and prompt intervention of developing problems such as UTI, stricture, intestinal fistula may prevent more serious complications. Urinary electrolytes (especially chloride) are resorbed in the intestinal conduit, which leads to compensatory bicarbonate loss, lowered serum pH (metabolic acidosis), and potassium deficit.

Monitors healing, disease process; provides opportunity for discussion of appliance fitting problems, generalized health, and adaptation to condition. Note: Extensive surgery requires prolonged recuperation for regaining strength and endurance.

Continued support after discharge is essential to facilitate the recovery process and patient’s independence in care. Enterostomal nurse can be very helpful in solving appliance problems and identifying alternatives to meet individual patient needs.


POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patient’s age, physical condition/presence of complications, personal resources, and life responsibilities)
In addition to postsurgical concerns:
Urinary Elimination, impaired—anatomical diversion.
Self-Esteem, situational low—loss of/altered control of body function.