Nursing Care Plan for Staghorn Renal Stone right Percutaneous Nephrolithotomy

Ø Staghorn renal stone right percutaneous Nephrolithonomy ( sudden onset of flank pain radiating laterally to the abdomen , the duration of pain is from 2 to 4 hours , severe , the relieving factors is taking NSAID.

Ø Diabetes Mellitus type 2 / Uretrorenoscopy ( left side ) on 23/9/2021 at 4:12.

Ø Diabetes Mellitus type 2 , Percutaneous Nephrolithotomy over 2 cm ( right ) has done on 4/11/2021 at 7:00

Ø Ibuprofen ( 400 mg ) every 6 hours by mouth ,TID,as needed for pain, for 7 days / Metformin ( 500 mg ) / Metformin ( 500 mg ) two times daily ,PC

Ø No family history items has been selected  

Ø Renal stone / Abdominal pain , constipation , Acute postoperative pain

Complete and accurate information

Accurate information but incomplete in one area

Accurate information but misses two or three details; Breaching patient confidentiality

Incomplete information

Complete and Accurate interpretation of the subjective and objective data of the 5 areas to include psychosocial

Adequate interpretation of the subjective and objective data of the five to include psychosocial but incomplete in one area

Adequate interpretation of the subjective and objective data but incomplete in more than one area; No psychosocial

Incomplete and inaccurate interpret information of the subjective and objective data

Complete and accurate details including but not limited to laboratory results interpretation, diagnostic results implications to nursing care, and nursing considerations in medication administration.

Accurate details including but not limited to laboratory results interpretation, diagnostic results implications to nursing care, and nursing considerations in medication administration but incomplete in one area.

Accurate details including but not limited to laboratory results interpretation, diagnostic results implications to nursing care, and nursing considerations in medication administration but missed more than one area.

Incomplete and inaccurate information.

Formulate and prioritize the highest (3) nursing diagnoses accurately per NANDA as applicable to patient condition

Formulate and prioritize the highest (3) nursing diagnoses but one is inaccurate per NANDA as applicable to patient condition

Formulate and prioritize the highest (3) nursing diagnoses but two are inaccurate per NANDA as applicable to patient condition

Unable to formulate and prioritize the highest (3) nursing diagnoses accurately per NANDA as applicable to patient condition

Diagnosis is appropriate for patient per NANDA; includes the three and/or two parts of diagnostic statement; subjective and objective data listed are correct

Diagnosis is appropriate for patient per NANDA; does not include all parts of diagnostic statement; subjective and objective data listed in the wrong part of diagnosis

Diagnosis is not appropriate for patient (one or two); NANDA is inaccurate; does not include the three parts of the diagnostic statement; subjective and objective data is inappropriate

Diagnosis portion is incomplete; Diagnostic statement is wrong; NANDA is inaccurate; subjective and objective data is inaccurate

Goal and outcomes are appropriate to the patient needs and contribute to the nursing diagnosis; Contains two or more measurable criteria and a target date & time.

Goal and outcomes are appropriate to the patient needs and contribute to the nursing diagnosis; Contains less than two measurable criteria and missing the target date or time.

Goal and outcomes are inaccurate for the patient needs and somehow contribute to the nursing diagnosis; Has no measurable criteria, target date or time.

Goal and outcomes are inappropriate, incomplete or inaccurate for the patient needs and does not contribute to the nursing diagnosis.

Interventions are appropriate to the patient's status and goal; Contribute to the nursing diagnosis with adequate number of assessment action, actual interventions, and health teaching that are   specific in action and frequency; Patient-centered interventions

Interventions are appropriate to the patient's status and goal; Contribute to the nursing diagnosis with adequate number of assessment action, actual interventions, and health teaching that are   specific in action and frequency; Interventions are not specific, and not patient-centered

Interventions are appropriate to the patient's status and goal; Does not contribute to the nursing diagnosis with inadequate number of interventions and are not specific in action and frequency.

Interventions are inappropriate to the patient's status, goal, and nursing diagnosis, with inadequate number of interventions that are not specific in action and frequency.

Each intervention has comprehensive scientific reasoning that identifies why the intervention was selected; with 2 or more references

Each intervention has an explanation of the intervention with adequately and justifies conclusion; with 1 or 2 references.

In appropriate use of rationale to the intervention; inadequately justifiable reasons; Some rationales are missing; no reference

Rationales are not included or when included doesn’t  attempt to explain the intervention; no reference

Evaluation statement is present; does support the goal statement with complete parameters

Evaluation statement is present; does support the goal statement with incomplete parameters

Evaluation statement is present; does not support the goal statement

Evaluations is incomplete; evaluation statement is inappropriate;

doesn’t support the goal statement

Sentences are well

Constructed with no errors in grammar, mechanics,

And/or spelling.

Sentences are well

Constructed with one to three errors in grammar, mechanics,

and/or spelling

Sentences are well

Constructed with four to six errors in grammar, mechanics, and/or spelling

Sentences sound awkward &

Incomplete, difficult to understand,

numerous errors in grammar,

mechanics, and/or spelling that interfere with understanding.