ASSESSMENT

EXPLANATION OF
THE PROBLEM

OBJECTIVES

NSG.
INTERVENTION

P>PYELOLITHOTOM
Y

Pyelolithotomy is a
surgical incision of
the renal pelvis of a
kidney for removal
of a kidney stone.
This operative
removal, causes
tissue trauma.
Distraction of
tissues, activates
inflammatory
response, It starts
with the
destruction of
phospholipid
membrane of the
cell, in which break
down of archidonic
acid paves way to
the cyclooxygenase
pathway and as its
end product the
production of
prostagaldin.
Prostaglandins, are
like hormones in
that they act as
chemical
messengers. When
prostaglandin is
released, the nerve
endings respond to
it by picking up and
transmitting the

STO:
After 2 hours of
nursing
intervention patient
will have decreased
pain as manifested
by pain rated as
less than 5/10

Dx:
>Assess changes in
vital signs

SMasakit parang
mainit na
mahapdi,nakakatul
og pa naman ako
ng maayos, tsaka
may appetite pa
ako rated pain as
5/10, non radiating,
localized at the
right flank area.
Aggravated by
sudden movement,
pressure, DBE.
Alleviated by rest
and analgesic
medication.
O>guarding over
the area noted
>no grimacing
>needs assistance
with ADLs and
positioning
A>acute pain
related to tissue
trauma secondary
to pyelolithotomy
right

LTO:
After 3 days of
nursing
interventions
patient will be free
from pain as
manifested by pain
rating of 0/10 and
no non-verbal cues
indicative of pain

>Assess pain
characteristics (hx,
location, quality,
radiation, intensity,
duration,
aggravating and
alleviating)
>Assess non verbal
cues that indicate
pain like grimacing
and guarding

>Assess for
changes in appetite
and sleep pattern

Tx;
>Provide rest and
comfort by
maintaining quiet
enviroment

RATIONALE

> Pain affects vital

signs. May increase
BP, HR

>Pain
characteristics
provide data on
which intervention
and management is
and will be
effective. It also
indicate the
progression of pain
felt
> Verbalizations do
not alone convey
patients feelings.
54% of
communication is
done non- verbally.
Grimacing and
guarding are signs
that pain is present
> Pain may disrupt
eating and sleeping
pattern. This may
hinder patients
recovery

CRITERIA FOR
EVALUATION
STO: Fully met if
after nursing
intervention
patient rates pain
less than 5/10
Partially met if
rating is 5/10
Not met if patient
rated pain greater
than 5/10

LTO : Fully met if

after nursing
intervention patient
will be free of pain
as pain rating of
0/10
Not met if patient is
still with pain as
manisfested by
pain rating of
greater than 0/10

pain and injury

messages through
the nervous system
to the brain. Thus
there is acute pain
is felt by patient.
Reference:
Merriam-Webster
Dictionary., (2014)
Porth, C. M., (2005).
Pathophysiology:
Concepts of Altered
Health States

>Assist in moving
and ambulating

> Providing
divertional
activities such as
listening to music,
watching tv and
reading

>Administer
Analgesic
medications as
ordered such as:
Tramadol

Ketorolac

>Relaxation
releases
endorphins, that
lessen pain
sensation felt.
Noise may also
irritate patient
increasing
discomfort
>Assistance helps
limit exhaustion
that may aggravate
pain.
>Helps to divert
attention and not to
concentrate on pain

>Analgesic provide
parin relief
>central nervous
system agent,
opioid analgesic

Edx:
>Advise to perform
movement and
ambulation
gradually as
tolerated

>Ketorolac is an
NSAID, which
inhibit
prostaglandin
sythesis

>Encourage to
verbalize of
worsening of pain

>Exertion and
sudden movement
may induce or

worsen pain

>Instructed on how
to do divertional
activities

> This may indicate

worsening of
condition. Also, to
give prompt
interventions to
reduce pain
>This will enable
patient do
divertional
activities without
health workers