What are the appropriate post-operative care instructions for a patient following laser cystolithopaxy?

Post-Operative SOAP Note for Laser Cystolithopaxy Patient

Subjective

• Patient underwent laser cystolithopaxy for bladder calculi
• Currently post-operative day #___
• Pain level: ___ /10 (assess location, character, and if adequately controlled)
• Voiding pattern: Document presence/absence of hematuria, dysuria, frequency, urgency
• Assess for fever, chills, nausea, or other systemic symptoms

Objective

• Vital signs: Temperature, heart rate, blood pressure, respiratory rate, oxygen saturation
• Physical examination:
  • Abdominal: Assess for distension, tenderness, suprapubic pain
  • Genitourinary: Evaluate catheter if present (color and character of urine output)
  • Incision site (if percutaneous approach was used): Check for signs of infection, bleeding, or drainage
• Laboratory results: CBC, electrolytes, creatinine (if obtained)
• Urine output: Volume, color, presence of clots
• Fluid balance: Intake and output

Assessment

• Status post laser cystolithopaxy for bladder calculi
• Patient is clinically stable with appropriate post-operative recovery without complications (modify based on actual findings)
• Stone-free status: Complete vs. residual fragments (based on intraoperative findings)
• Assess for any complications:
  • Hematuria (mild hematuria is expected)
  • Urinary tract infection
  • Urinary retention
  • Pain control issues

Plan

1. Monitoring and follow-up:

   • Continue monitoring vital signs per protocol
   • Assess urine output and character
   • Follow-up imaging if indicated based on intraoperative findings

2. Catheter management:

   • If urethral catheter present: Plan for removal on post-op day ___ if urine is clear
   • If suprapubic catheter present: Plan for clamping trial and removal after successful voiding 1

3. Medications:

   • Pain management: Continue as needed, transition to oral medications when appropriate
   • Proton pump inhibitor: Continue twice daily for 6-8 weeks 1
   • Antibiotics: Complete prescribed course if indicated

4. Diet and activity:

   • Advance diet from clear liquids to regular as tolerated 1
   • Encourage ambulation as tolerated
   • Avoid strenuous activity and heavy lifting for 2-4 weeks

5. Discharge planning:

   • Patient education on expected recovery course
   • Warning signs requiring immediate attention: severe pain, fever, inability to void, bright red bleeding
   • Schedule follow-up appointment in ___ weeks
   • Consider follow-up imaging to confirm stone-free status

6. Prevention of recurrence:

   • Address underlying causes of stone formation
   • Encourage adequate hydration
   • Consider metabolic evaluation if indicated

7. Anticoagulation management:

   • If applicable, resume anticoagulation/antiplatelet therapy after 48 hours if risk-benefit assessment allows 1