A client with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the client's postprocedural care?

A. Morse Scale:

The Morse Scale, also known as the Morse Fall Scale, is used to assess a patient's risk of falling. It evaluates various factors such as history of falling, secondary diagnosis, ambulatory aids, IV therapy, gait, and mental status. It is primarily focused on assessing the risk of falls, not pressure ulcers.
B. Braden Scale:

As previously mentioned, the Braden Scale assesses a patient's risk for developing pressure ulcers. It takes into account sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The scale helps healthcare providers determine the level of risk a patient has for developing pressure sores and guides interventions to prevent them.

C. Bristol Scale:

The Bristol Stool Scale is used to classify the form of human feces into seven categories. It is a medical aid designed to classify the form of human feces into seven categories. This scale is primarily used to assess bowel movements and is unrelated to pressure ulcers.
D. Hendrich II Scale:

The Hendrich II Fall Risk Model is a tool designed to identify patients at risk for falls. It includes factors such as confusion, symptomatic depression, altered elimination, dizziness, male gender, and the use of antiepileptics, benzodiazepines, or non-opioid analgesics. Similar to the Morse Scale, it focuses on assessing the risk of falls, not pressure ulcers.

A. Apply cold compress to the client's flank area - Applying a warm compress, not a cold one, to the flank area can help alleviate pain associated with urolithiasis. Heat can promote muscle relaxation and increase blood flow to the area, potentially easing discomfort.

B. Restrict protein intake to 2 servings per day - There is no direct connection between protein intake and urolithiasis. However, specific dietary recommendations may vary based on the type of kidney stones a person has. For example, individuals with certain types of stones might be advised to limit oxalate-rich foods. It's essential to tailor dietary advice based on the composition of the stones.

C. Encourage intake of at least 3 L of fluids per day - Adequate fluid intake, particularly water, is crucial for preventing the formation of kidney stones. Increased fluid intake can help dilute substances in the urine that contribute to stone formation, reducing the risk of stone recurrence.

D. Discourage ambulation - Encouraging ambulation and movement is generally beneficial for patients with urolithiasis. Movement can help alleviate discomfort, prevent complications such as blood clots, and promote overall well-being. Restricting movement unnecessarily is not advisable.