Student Nurses Community

NURSING CARE PLAN - Hemorrhoids ASSESSMENT SUBJECTIVE: Masakit at nahihirapan ako dumumi (I've
been having trouble/pain pooping) as

DIAGNOSIS Acute pain may be related to inflammation and edema of prolapsed varices.

INFERENCE Hemorrhoids are vascular masses that protrude into the lumen of the lower rectum or perianal area. They result when increased intraabdominal pressure causes engorgement in the vascular tissue lining the anal canal. Loosening of vessels from surrounding connective tissue occurs with protrusion or prolapse into the anal canal. There are two types of hemorrhoids: external hemorrhoids appear outside the external sphincter, and internal hemorrhoids appear above the internal sphincter. When blood within the hemorrhoids becomes clotted because of obstruction, the

PLANNING After 8 hours of nursing interventions, the patient will report pain is relieved or controlled.

INTERVENTION Independent: Encourage patient to report pain. Assess reports of abdominal cramping or pain, noting location, duration, intensity (0-10 scale). Investigate and report changes in pain characteristics. Note nonverbal cues such as restlessness, reluctance to move and abdominal guarding.

RATIONALE May try to tolerate rather than request analgesics. Changes in pain characteristics may indicate spread of disease or developing complications. Body language/nonver bal cues may be both physiological and psychological and may be used in conjunction with verbal cues to determine the extent or severity of the problem. May pinpoint precipitating or aggravating factors such as stressful events, food intolerance or to identify developing complications. Reduces abdominal

EVALUATION After 8 hours of nursing interventions, the patient was able to report pain was relieved or controlled.

verbalized by the patient. OBJECTIVE: Guarding behavior Restlessness Facial mask of pain V/S taken as follows: T: 37.2 P: 90 R: 20 BP: 120/80

Review factors that aggravate or alleviate pain.

Encourage patient to assume

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hemorrhoids are referred to as being thrombosed. position of comfort. Provide comfort measures. tension and promotes sense of control. Promotes relaxation, refocuses attention, and may enhance coping abilities. Protects skin from bowel acids, preventing excoriation. Enhances cleanliness and comfort in the presence of inflammation of varices. For complete bowel rest and can reduce pain and cramping.

Cleanse rectal area with mild soap and water or wipes after each stool and provide skin care. Provide sitz bath as appropriate.

Collaborative: Implement prescribed dietary modifications.