A client who has been diagnosed with calculi reports that the pain is intermittent and less colicky. Which of the following nursing actions is most important at this time?
A. Report hematuria to the physician.
B. Strain the urine carefully.
C. Administer meperidine (Demerol) every 3 hours.
D. Apply warm compresses to the flank area.
Correct Answer: B. Strain the urine carefully
Intermittent pain that is less colicky indicates that the calculi may be moving along the urinary tract. Fluids should be encouraged to promote movement, and the urine should be strained to detect the passage of the stone. Strain all urine. Document any stones expelled and sent to the laboratory for analysis. Retrieval of calculi allows identification of the type of stone and influences choice of therapy.
Option A: Hematuria is to be expected from the irritation of the stone. Assist with frequent ambulation as indicated and increased fluid intake of at least 3–4 L a day within cardiac tolerance. Renal colic can be worse in the supine position. Vigorous hydration promotes the passing of stone, prevents urinary stasis, and aids in the prevention of further stone formation.
Option C: Analgesics should be administered when the client needs them, not routinely. Implement comfort measures (back rub, restful environment). Promotes relaxation, reduces muscle tension and enhances coping. Encourage use of focused breathing, guided imagery, diversional activities. Redirects attention and helps in muscle relaxation.
Option D: Moist heat to the flank area is helpful when renal colic occurs, but it is less necessary as pain is lessened. Apply warm compresses to the back. Relieves muscle tension and may reduce reflex spasms. Document reports of increased and persistent abdominal pain. Complete obstruction of the ureter can cause perforation and extravasation of urine into perirenal space. This represents an acute surgical emergency.
No comments:
Post a Comment