Subjective	Objective
Verbalization of sensation of bladder fullness	Bladder distention; small, frequent voiding or absence of urine output; dysuria; dribbling of urine; residual urine; overflow incontinence

RISK FACTORS:

• Surgery

• Preoperative poor bladder tone

DESIRED OUTCOMES: The client will not experience urinary retention as evidenced by:

a. No reports of bladder fullness and suprapubic discomfort

b. Absence of bladder distention and dribbling of urine

c. Balanced intake and output 48 hours after surgery

d. Voiding adequate amounts at expected intervals after removal of the catheter(s)

NOC OUTCOMES: Urinary retention care; tube care: urinary; urinary catheterization: intermittent

NIC INTERVENTIONS: Urinary elimination

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis RISK FOR CONSTIPATION NDx

Definition: A decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool.

• Reluctance to defecate associated with fear of pain and possible disruption of sutures

CLINICAL MANIFESTATIONS:

Subjective

Objective

Verbalization of straining with defecation; feeling of rectal fullness or pressure; abdominal pain inability to pass stool; headache; indigestion nausea; abdominal tenderness

Change in bowel pattern; bright red blood with stool; presence of soft, pastelike stool in rectum; distended abdomen; dark, black, or tarry stool; increased abdominal pressure; percussed abdominal dullness; pain with defecation; decreased volume of stool; decreased frequency; dry, hard, formed stool; palpable rectal mass; anorexia; change in abdominal growling (borborygmi); atypical presentation in older adults (e.g., change in mental status, urinary incontinence, unexplained falls, elevated body temperature); severe flatus; hypoactive or hyperactive bowel sounds; palpable abdominal mass; abdominal tenderness with or without palpable muscle resistance; vomiting; oozing liquid stool

RISK FACTORS:

• Immobility

• Lack of fiber in pre-operative diet

• Inadequate fluid replacement

DESIRED OUTCOMES: The client will maintain usual bowel elimination pattern as evidenced by:

a. Usual frequency of bowel movements

b. Passage of soft, formed stool

c. Absence of abdominal distention and pain, feeling of rectal fullness or pressure, and straining during defecation

NOC OUTCOMES: Bowel elimination; gastrointestinal function; hydration; symptom control

NIC INTERVENTIONS: Constipation/impaction management

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Collaborative Diagnosis RISK FOR BLADDER, URETHRAL, OR URETERAL INJURY

Definition: Surgery-related bladder injury

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbalization of back pain	Hematuria; significantly increased urine output

RISK FACTOR:

• Surgical procedure

DESIRED OUTCOMES: The client will experience healing of bladder, urethral, or ureteral injury if it occurs as evidenced by:

a. Gradual resolution of hematuria and backache

b. Urine output greater than 200 mL within 6 to 8 hours after surgery

NURSING ASSESSMENT

	RATIONALE
Assess for and report signs and symptoms of bladder, urethral, or ureteral injury (e.g., persistent or increasing hematuria or backache, urine output less than 200 mL in first 6-8 hours after surgery).	Early recognition of signs and symptoms of urinary tract injury allows for prompt intervention.

THERAPEUTIC INTERVENTIONS

Collaborative Diagnosis RISK FOR URINARY TRACT INFECTION; WOUND INFECTION

Definition: At risk for invasion of the body by pathogenic organisms

Urinary tract infection

• Introduction of pathogens associated with the presence of urethral and/or suprapubic catheters and performance of intermittent catheterizations if being done

Wound infection

• Decreased resistance to infection associated with factors such as diminished blood flow to wound area or an inadequate nutritional status

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbalization of frequency, urgency, and burning upon urination; chills	Elevated temperature; urinalysis—increased white blood cells (WBCs) and presence of bacteria; positive urine cultures

RISK FACTORS:

• Poor surgical hygiene

• Surgical procedure

DESIRED OUTCOMES: The client will remain free of urinary tract and/or infection as evidenced by:

a. Clear urine

b. Absence of frequency, urgency, and burning on urination

c. Absence of chills and fever

d. Urinalysis slowing fewer than 5 WBCs, negative leukocyte esterase and nitrates, and absence of bacteria

e. No redness, swelling or drainage from surgical site

f. Negative urine cultures

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

DISCHARGE TEACHING/CONTINUED CARE

Nursing Diagnosis DEFICIENT KNOWLEDGE NDx; INEFFECTIVE FAMILY THERAPEUTIC REGIMEN MAINTENANCE NDx; or INEFFECTIVE SELF-HEALTH MANAGEMENT^* NDx

Definition: Absence or deficiency of cognitive information related to specific topic (lack of specific information necessary for clients/significant others) to make informed choices regarding condition/treatment/lifestyle changes; Pattern of regulating and integrating into daily living and family processes a therapeutic regimen for treatment of illness and the sequelae of illness that is unsatisfactory for meeting specific health goals

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbalizes inability to manage illness; verbalizes inability to follow prescribed regimen	Inaccurate follow through with instructions; inappropriate behaviors; experience of preventable complications of following surgery.

RISK FACTORS:

• Cognitive deficit

• Financial concerns

• Failure to take action to reduce risk factors for posts operative complications

• Inability to care for oneself

• Difficulty in modifying personal habits and integrating treatments into lifestyle

NOC OUTCOMES: Knowledge: treatment regimen

NIC INTERVENTIONS: Health system guidance; teaching: individual; teaching: psychomotor skill; teaching: disease process

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

CYSTECTOMY WITH URINARY DIVERSION

Cystectomy is the removal of the bladder and is accompanied by a procedure to divert urinary flow. It may be performed to treat a malignancy of the bladder, congenital bladder anomalies, neurogenic bladder, and irreparable bladder trauma. A cystectomy may also be performed to prevent further deterioration of renal function associated with chronic bladder infection. In some cases, the surgery includes removal of just the bladder (simple cystectomy), but when there is an invasive malignancy, a more radical procedure is performed. In men, a radical cystectomy usually includes removal of the bladder, prostate, seminal vesicles, a portion of the vas deferens, and some or all of the pelvic lymph nodes. In women, a radical cystectomy usually includes removal of the bladder, urethra, uterus, fallopian tubes, ovaries, a portion of the anterior vaginal wall, and some or all of the pelvic lymph nodes.

There are several ways to accomplish urinary diversion. The most common surgical method is the conventional conduit (incontinent urinary diversion). In this procedure, the ureters are implanted in a portion of a resected segment of intestine and then the end of the segment is brought through the abdominal wall to create a stoma. Because no valves are incorporated into the construction of the conventional conduit, drops of urine usually flow from the stoma every few seconds, resulting in the client’s need to wear a urinary collection appliance at all times.

The second most common surgical method to accomplish urinary diversion is the continent internal reservoir (e.g., Kock pouch, Mainz pouch, Indiana pouch). In this method, the ureters are implanted in a resected portion of intestine that has been remodeled to create a reservoir. Another segment of the reservoir is used to create the stoma that is brought out through the abdominal wall. The reflux of urine from the reservoir back through the ureters and the uncontrolled flow of urine from the reservoir through the stoma are prevented by the surgical positioning of the ureters, reservoir, and stoma or by the construction of one-way valves at these sites. After healing occurs, a catheter is inserted into the stoma at regularly scheduled intervals (usually every 4-6 hours once the reservoir stretches to its full capacity) to drain the reservoir. If the system functions properly, the client does not need to wear a urinary collection appliance over the stoma.

Two less commonly used methods of urinary diversion are cutaneous ureterostomy (direct implantation of the ureters into the abdominal wall) and nephrostomy (insertion of catheters into the kidneys via flank incisions). These methods are usually reserved for clients who cannot tolerate lengthy surgery and/or have a short life expectancy.

The type of urinary diversion selected depends on many factors including the client’s preference, age, body build, ability to learn about and participate in care of the urinary diversion, prognosis, and ability to tolerate lengthy surgery; the integrity of the client’s ureters, kidneys, and intestinal tract; the advice of the enterostomal therapy nurse; and the expertise of the surgeon.

This care plan focuses on the adult client hospitalized for a cystectomy with urinary diversion by means of a conventional conduit. Some additional nursing interventions are also included for the client with a continent internal reservoir. Much of the postoperative information is applicable to clients receiving follow-up care in an extended care facility or home setting.

OUTCOME/DISCHARGE CRITERIA

The client will:

1. Maintain an adequate urine output via the urinary diversion

2. Have surgical pain controlled

3. Have evidence of normal healing of surgical wound

4. Have a medium pink to red, moist stoma and intact peristomal skin

5. Have no signs and symptoms of postoperative complications

6. Verbalize a basic understanding of the anatomical changes that have occurred as a result of the surgery

7. Demonstrate the ability to change the urostomy appliance and maintain stomal and peristomal skin integrity

8. Demonstrate the ability to properly clean reusable urostomy equipment

9. Demonstrate the ability to drain and irrigate a continent internal reservoir if present

10. Identify ways to control odor of the urostomy drainage and appliance

11. Identify ways to prevent urinary tract infection

12. State signs and symptoms to report to the health care provider

13. Share thoughts and feelings about altered urinary elimination and its effect on body image and lifestyle

14. Identify appropriate community resources that can assist with home management and adjustment to changes resulting from the urinary diversion

15. Verbalize an understanding of and a plan for adhering to recommended follow-up care including future appointments with health care provider, wound care, activity level, and medications prescribed

For a full, detailed care plan on this topic, go to http://evolve.elsevier.com/Haugen/careplanning/.

NEPHRECTOMY

Nephrectomy is the surgical removal of the kidney. Conditions that are commonly treated by nephrectomy include renal carcinoma, massive traumatic injury to the kidney, polycystic kidney disease (especially if the kidney is bleeding or severely infected), calculi, renal tuberculosis, pyelonephritis, glomerulonephritis, and renal sclerosis resulting from hypertension. The kidney may also be removed for the purpose of donation.

The surgical approach used to perform a nephrectomy depends on the extensiveness of the planned surgery; the client’s age, body build, and physiological status; the underlying pathology; and prior surgical incisions. The approach commonly used for a simple nephrectomy (removal of just the kidney) is the subcostal flank approach. Other approaches (e.g., thoracoabdominal, transabdominal, dorsolumbar) may be necessary when greater visualization, improved access, or a radical nephrectomy (removal of the kidney, renal artery and vein, adrenal gland, proximal ureter, regional lymph nodes, and surrounding fat and fascia) is necessary. Although it is most often necessary to remove the entire kidney, advances in renal imaging, earlier diagnosis of renal disease, and improved surgical techniques have provided surgeons with an option of performing a partial nephrectomy (nephron-sparing nephrectomy) in some instances. In these situations, a laparoscopic rather than an open approach is often feasible.

This care plan focuses on the adult client hospitalized for a simple unilateral nephrectomy. Much of the postoperative information is applicable to clients receiving follow-up care in an extended care facility or home setting. The care plan will need to be individualized according to the client’s diagnosis, prognosis, and plans for subsequent treatment.

OUTCOME/DISCHARGE CRITERIA

The client will:

1. Have evidence of normal healing of the surgical wound

2. Have adequate functioning of the remaining kidney

3. Have clear, audible breath sounds throughout lungs

4. Have no signs and symptoms of postoperative complications

5. Verbalize ways to maintain health of the remaining kidney

6. State signs and symptoms to report to the health care provider

7. Share thoughts and feelings about the loss of the kidney

See Standardized Preoperative and Postoperative Care Plans for additional diagnoses.

Nursing Diagnosis INEFFECTIVE BREATHING PATTERN NDx

Definition: Inspiration and/or expiration that does not provide adequate ventilation

• Decreased rate of respirations associated with the depressant effect of anesthesia and some medications (e.g., narcotic [opioid] analgesics, some antiemetics)

• Decreased depth of respirations associated with:

• Depressant effect of anesthesia and some medications (e.g., narcotic [opioid] analgesics, some antiemetics)

• Reluctance to breathe deeply resulting from incisional pain and fear of dislodging chest tube if present (a chest tube is usually inserted after a thoracoabdominal approach and may be needed after a flank approach)

• Positioning, weakness, fatigue, and elevation of the diaphragm (can occur if abdominal distention is present)

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbal report of shortness of breath and difficulty breathing	Alterations in depth of breathing; altered chest excursion; bradypnea; decreased minute ventilation; use of accessory muscles to breathe

RISK FACTORS: