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Name: Malana, Joseph P. Year/Section: BSN 4-F Assessment Nursing Diagnosis Area:UPHMC Clinical Instructor: Ms.Maricel Datoy RN, MAN Scientific Explanation of the Problem Planning Interventions Rationale Date: Jan, 20, 2012 Group No.: 4 Evaluation
“Masakit at nahihirapan ako dumumi” as verbalized by the patient.
Acute pain may be related to inflammation.
Guarding behavior Restlessness Facial grimace of pain V/S taken as follows: T: 37.2 P: 90 R: 20 BP: 120/80
Hemorrhoids are enlarged or swollen veins in the lower rectum. The most common symptoms of hemorrhoids are rectal bleeding, itching, and pain. You may be able to see or feel hemorrhoids around the outside of the anus, or they may be hidden from view, inside the rectum
After 8 hours of nursing interventions, the patient will report pain is relieved or controlled.
Encourage patient to report pain. Assess reports of abdominal cramping or pain, intensity (0-10 scale). Investigate and report changes in pain characteristics. Review factors that aggravate or alleviate pain.
May try to tolerate rather than request analgesics. Changes in pain characteristics may indicate spread of disease or developing complications.
After 8 hours of nursing interventions, the patient was able to report pain was relieved or controlled.
May pinpoint precipitating or aggravating factors such as stressful events, food intolerance or to identify developing complications. Reduces abdominal tension and promotes sense of control.
Encourage patient to assume position of comfort.
• Provide comfort measures. • • Enhances cleanliness and comfort in the presence of inflammation of varices. . • • Cleanse rectal area with mild soap and water or wipes after each stool and provide skin care. • Promotes relaxation. refocuses attention. and may enhance coping abilities. For complete bowel rest and can reduce pain and cramping. Protects skin from bowel acids. preventing excoriation. Provide hot sit bath as appropriate. Collaborative: Implement prescribed dietary modifications.