Nursing Care Plan for Urinary Diversion

Nursing diagnosis: risk for infection

Risk factors may include
Inadequate primary defenses—break in skin or incision, reflux of urine into urinary tract

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Immune Status
Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.
Knowledge: Infection Control
Verbalize understanding of individual causative or risk factors.
Demonstrate techniques or lifestyle changes to reduce risk.

Nursing intervention with rationale:
1. Empty ostomy pouch when it becomes one-third full, once continuous pouch drainage is discontinued.
Rationale: Reduces risk of urinary reflux and maintains integrity of appliance seal if pouch does not have an antireflux valve.

2. Document urine characteristics and note whether changes are associated with reports of flank pain.
Rationale: Cloudy, odorous urine indicates infection, possibly pyelonephritis; however, urine normally contains mucus after a conduit procedure because of normal secretions of the intestine.

3. Report sudden cessation of urethral drainage.
Rationale: Constant drainage usually subsides within 10 days; however, abrupt cessation may indicate plugging and lead to abscess formation.

4. Note red rash around stoma.
Rationale: Rash is most commonly caused by yeast. Urine leakage or allergy to appliance or products may also cause red, irritated areas.

5. Inspect incision line around stoma. Observe and document wound drainage, signs of incisional inflammation, and systemic indicators of sepsis.
Rationale: Provides baseline and comparative reference. Complications may include interrupted anastomosis of intestine or ureteral conduit, with leakage of bowel contents into abdomen or urine into peritoneal cavity.

6. Change dressings, as indicated, when used.
Rationale: Moist dressings act as a wick to the wound and provide media for bacterial growth.

7. Assess skinfold areas in groin, perineum, and under arms and breasts.
Rationale: Use of antibiotics and trapping of moisture in skinfold areas increases risk of Candida infections.

8. Monitor vital signs.
Rationale: An elevated temperature suggests incisional infection, urinary tract infection (UTI), or respiratory complications.

9. Auscultate breath sounds.
Rationale: Client is at high risk for development of respiratory complications because of length of time under anesthesia. Often this client is older and may already have a compromised immune system. Also, painful abdominal incisions cause client to breathe more shallowly than normal and to limit coughing effort. Accumulation of secretions in respiratory tract predisposes to atelectasis and infections.

10. Obtain specimens of exudates, urine, sputum, and blood, as indicated.
Rationale: Identifies source of infection and most effective treatment. Infected urine may cause pyelonephritis. Note: Urine specimen must be obtained from the conduit because the pouch is considered contaminated.


Post a Comment