ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUA

Subjective: Acute pain related to Ulcerative colitis is a
“Sobrang sakit po ng prolonged diarrhea. chronic, or long lasting,
tiyan ko kanina pa disease that causes
po ako labas masok inflammation—irritation
sa CR”. or swelling—and sores
called ulcers on the inner
Objective: lining of the large
Short Term Goal INDEPENDENT NURSING After 8 hours o
ACTION: intervention the
After 8 hours of  May try to tolerate pain rather was able to rela
nursing intervention  Encourage patient to report than request analgesics. rest appropriate
the patient will be pain.
able to relaxed and
rest appropriately

 Fatigue intestine.  Assess reports of abdominal

cramping or pain, noting  To measure the intensity of
 Weight loss Ulcerative colitis shows location, duration, intensity pain and to know what
intestinal and extra (0–10 scale). Investigate and management should be given.
 Hyperactive intestinal findings on report changes in pain
Bowel Sounds physical examination. characteristics
These include abdominal  Body language or nonverbal
Vital signs:  Note nonverbal cues
tenderness, fever, pallor, cues may be both physiological
HR: 110 bpm inflammation of the iris (restlessness, reluctance to and psychological and may be
and uvea, skin rash, move, abdominal guarding, used in conjunction with verbal
RR: 19 BPM inflammation of the joints, withdrawal, and depression). cues to determine extent and
aphthous ulcers and Investigate discrepancies severity of the problem.
BP: 90/60 mmhg
clubbing of the fingers. between verbal and
Temperature: 38.1°C nonverbal cues.

Physical  Review factors that  May pinpoint precipitating or

Assessment: aggravate or alleviate pain. aggravating factors (such as
stressful events, food
 Pallor
 Abdominal intolerance) or identify developing
Tenderness complications.

 Panniculitis
 Encourage patient to assume
position of comfort (knees  Reduces abdominal tension and
flexed). promotes sense of control.

 Provide comfort measures

(back rub, reposition) and
diversional activities.  Promotes relaxation, refocuses
attention, and may enhance
 Observe and record coping abilities.
abdominal distension,
increased temperature,  May indicate developing
decreased BP. intestinal obstruction from
inflammation, edema, and
scarring.

DEPENDENT NURSING
ACTION

 Provide additional fluids via

IV as ordered by the
physician.  Maintenance of bowel rest
requires alternative fluid
 replacement to correct losses
and anemia. Note: Fluids
containing sodium may be
restricted in presence of
regional enteritis. Total
Parenteral Nutrition is given.

 Administer medication like

acetaminophen as ordered by
the physician  A better choice for pain relief is
acetaminophen for ulcerative
colitis.

 COLLABORATIVE
NURSING ACTION

 Coordinate with a dietary

counselor for meal planning  To prevent imbalance nutrition
and to regain the loss nutrients
modifications due to diarrhea.