Nursing Clinical Practice Guide
Clinical Scenario: You are caring for Mr. Johnson, a 45-year-old admitted with severe left flank pain rated 9/10, radiating to his groin. He is diaphoretic and nauseated. A CT scan confirms a 6mm calcium oxalate stone in the left mid-ureter. The provider's order set includes: IV fluids at 150 mL/hr, Ketorolac 30mg IV q6h PRN pain, Ondansetron 4mg IV PRN nausea, and "encourage PO fluids."
Nursing Intervention Strategy:1. Assessment & Pain Management: Immediately assess pain using PQRST, administer prescribed IV analgesic (Ketorolac), and antiemetic. Position for comfort (often side-lying with affected side up).2. Hydration Strategy: Initiate IV fluids as ordered. Simultaneously, provide a large water pitcher and set a goal with the patient: "Let's work on drinking this entire pitcher over the next 2 hours." Explain clearly: "The water will help push the stone along and is the best medicine we have right now."3. Monitoring & Specimen Collection: Provide a urine strainer and instruct to void all urine through it. Monitor I&O closely. Assess for stone passage (sudden relief of pain, finding stone in strainer).4. Complication Surveillance: Monitor vital signs, especially temperature, every 4 hours. Assess for signs of infection (fever, cloudy/foul-smelling urine) or worsening obstruction (decreased urine output, unrelenting pain).
Patient Safety and Precautions:
• Fluid Overload Risk: While encouraging fluids, assess for signs of fluid overload (crackles in lungs, shortness of breath, edema), especially in patients with a history of heart or kidney disease.• Medication Caution: NSAIDs like Ketorolac are contraindicated in patients with peptic ulcer disease or renal impairment. Monitor for GI upset or bleeding.• Infection Alert: Fever + obstruction = medical emergency (obstructive pyelonephritis). Report immediately.
Nursing Procedure & Medication Flow
Procedure: Assisting with Urine Straining
1. Provide a clean urine strainer (fine-mesh) and specimen cup.2. Instruct patient to void all urine directly through the strainer into the toilet or collection hat.3. After voiding, check the strainer for any particles or stones.4. If a stone is found, place it in the specimen cup, label it, and send to the lab for analysis.5. Document the event, stone appearance (if passed), and patient's pain level.
Medication: IV Ketorolac Administration
• Action: Nonsteroidal anti-inflammatory drug (NSAID). Provides analgesia and reduces ureteral inflammation.• Dose/Limits: Typical dose 15-30mg IV. Has a short-term use limit (usually 5 days) due to side effect risks.• Nursing Considerations: Administer over at least 15 seconds. Monitor for efficacy (pain relief). Assess for black/tarry stools (GI bleed) and monitor renal function (BUN, creatinine).
A Word from Your Senior Nurse
"Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! In clinical practice, the patient with a kidney stone is in some of the worst pain they'll ever experience. Your calm, efficient pain management and your persistent, encouraging coaching on fluid intake are what will get them through it. When studying for your boards, don't just memorize 'fluids for stones' — understand *why* it works (dilution, flow, passage) and what you're watching for (infection, obstruction). That mindset will not only earn you a great score on the NCLEX but will make you a truly confident, professional nurse who can turn a painful crisis into a manageable process for your patient."