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Published by deric

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Published by: deric on Sep 21, 2011
Copyright:Attribution Non-commercial


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SUBJECTIVE:“ Madalassumakit angtiyan ko atmadalas angpagdumi ko” (
I'mhaving frequent abdominal pain and diarrhea
) asverbalized by thepatient.OBJECTIVE:
Reluctanceto move
V/S taken asfollowsT: 37.1˚CP: 75R: 18BP: 110/ 80Acute pain maybe related tohyperperistalsis,prolongeddiarrhea, skinand tissueirritation,perirectalexcoriation,fissures, andfistulas.Crohn’s diseaseis an idiopathicinflammatorydisease of thesmall intestine(60%), the colon(20%), or both. Itinvolves all layersof the bowel butmost commonlyinvolves theterminal ileum. Itis slowlyprogressive andrecurrent diseasewith predominantinvolvement of multiple regionsof the intestinewith normalsections between.Chronic,nonspecificinflammation of the entireintestinal tractcharacterizes thedisease, with theterminal ileum thesite mostaffected.Eventually deepfissures andulcerationsdevelop and oftenextend through allbowel layersAfter 4 hours of nursinginterventions, thePatient will reportpain is relieved or controlled andappear to berelaxed and ableto sleep and restappropriately.Independent
Encourage client toreport pain.
Assess reports of abdominalcramping or pain,noting location,duration, andintensity.
Review factors thataggravate or alleviate pain.
Encourage patientto assume positionof comfort, such asknees flexed.
Provide comfortmeasures anddiversionalactivities.
Cleanse rectal areawith mild soap andwater after eachstool and provideskin care with
May try to toleratepain rather thanrequestanalgesics.
Changes in paincharacteristicsmay indicatespread of diseaseor developingcomplications.
May pinpointprecipitating or aggravatingfactors such asstressful events,food intolerance,or identifydevelopingfactors.
Reducesabdominaltension andpromotes senseof control.
Promotesrelaxation,refocusesattention, andmay enhancecoping abilities.
Protects skin frombowel acids,preventingexcoriation.After 4 hours of nursinginterventions, thePatient was able toreport pain isrelieved or controlled andappear to berelaxed and ableto sleep and restappropriately.

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