Faith Marfil

BSN 2-2

MATERNAL AND CHILD NURSING II (LAB)

NURSING CARE PLAN FOR HEMORROID

Name of the Patient: D.A.S

G4P3
Age: 30 years old
Date of Birth: 02/22/1990
LMP: May 18, 2019
Height: 160 centimeters
Weight: 81 kg
BMI: 31.6 (Obese)

PLANNING,
ASSESSMENT NURSING INFERENCE CLIENT GOAL, NURSING RATIONALE EVALUATION
DIAGNOSIS DESIRED INTERVENTION
OUTCOMES
Subjective Data: Acute Pain Pregnancy, Short term: Independent: Short term:
“Namamaga yung related to obesity and
puwet ko, parang may inflammation as repeated heavy After 4 hours of  Assess vital  Changes in pain After 4 hours of
maliliit na bukol tapos evidenced by lifting effective nursing signs and reports characteristics effective
masakit kapag pain scale of ↓ interventions, of abdominal may indicate nursing
umuupo at 7/10 and facial Veins below the patient will cramping or spread of
interventions,
dumudumi” grimace. dentate line experience pain, noting disease or
covered by lesser pain and location, developing
the patient was
Objective Data: anoderm above a duration, complications. able to
 Facial become tolerable level as intensity (0-10 experience
Grimacing distended manifested by: scale). lesser pain and
 Restlessness ↓ - Pain scale of at above a
 Guarding Clot forms in least 5/10  Note nonverbal  Nonverbal cues tolerable level
Behavior distended veins. - No facial cues such as may be both as manifested
Vital signs taken as Blood supply to grimace restlessness, physiological by:
follows: vein is impaired reluctance to and - Pain scale of
 T: 36.8 ↓ Long term: move and psychological 3/10
 P: 85 Thrombosed abdominal and may be used - No facial
 R: 18 external After 7 days of guarding. in conjunction grimace noted
 BP: 120/80 hemorrhoid effective nursing with verbal cues
Pain Assessment: ↓ intervention, the to determine the
Acute patient will extent or Long term:
 P: Relieved by
hot bath. exquisite pain report a decrease severity of the
in the size of the problem. After 7 days of
Aggravated
hemorrhoid effective nursing
during sitting
from the initial intervention, the
and excretion
3cm. patient reported a
 Q: Sharp and
decreased in the
intense pain
 R: Localized  Encourage  Reduces size of the
patient to abdominal hemorrhoid as
in the anal manifested by
area assume position tension and
of comfort. promotes sense 1cm hemorrhoid
 S: 7/10 from the initial
of control.
 T: Painful 3cm.
sharp
 Instruct patient  Helps patient to
sensation
in deep focus less on
when doing
breathing, pain, and may Therefore the
various
activities
relaxation improve goal was fully
techniques, efficacy of met.
Review of Systems:
guided imagery, analgesics by
 3 cm.
massage and decreasing
thrombosed
other non- muscle tension.
external
pharmacologic
hemorrhoid
aids.
 Difficulty in
passing of
 Cleanse rectal  Protects skin
stools
area with mild from bowel
 Small blood
soap and water acids,
clots in stools or wipes after preventing
 Pain around each stool and excoriation.
the anus
 Itching around provide skin
the anus or care.
rectal area
 Educate patient  Fiber helps to
about lifestyle soften the stool
changes such as which makes it
eating a high- easier to pass.
fiber diet and Proper lifting
proper lifting prevents
techniques. excessive
pressure on the
abdomen.
Dependent:

 Administer  Pharmacologic
analgesics as therapy to
ordered. control pain and
aches by
inhibiting brain
prostaglandin
synthesis.

 Provide sitz bath  Enhances

as appropriate. cleanliness and
comfort in the
presence of
inflammation of
hemorrhoids.

Collaborative:
 Implement  For complete
prescribed bowel rest and
dietary to reduce pain
modifications. and cramping.