Romar Rico H.

Arcega
BSN- III
NCP(Ulcerative Colitis & Crohn's Disease)
Assessment
Assessment Diagnosis
Diagnosis Planning
Planning Implementation
Implementation Rationale
Rationale Evaluation
Evaluation
May nasakit sa aking tiyan Acute Pain After 8 hours of nursing >Assess pt’s >To know what problem After a series of nursing
May nasakit sa aking tiyan Hyperthermia After 8 hours of nursing >Establish rapport >To get the cooperation After a series of nursing
”as verbalized by the interventions, the general condition >Provides information to intervention, the goal was
”as verbalized by the intervention, the patient >Monitor & record vital of the patient intervention, the goal was
patients' patient’s pain >Assess pain,noting aid in determining choice met.
patients' will achieve timely signs >To obtain baseline data met.
(+)anorexia will be relieved or location,intensity (scale of or effectiveness of
(+)irritability resolution of current >Monitor hematologic >Indicates presence
(+)anal abscesses controlled 0–10), duration interventions  The patient’s
(+)dry lips infection without test & other pertinent lab of infection &  Client's response
(+)abdominal tenderness >Monitored vital signs >Provide baseline data pain will be
(+)facial grimace connotes complication records dehydration to intervention,
(+)irritability
pain and recorded
>Determine clients
>Increased hydration
>To assess degree of
relieved or
teaching and
(+)dry lips
(+)pallor >Encourage increased flushes bacteria and controlled
(+)facial grimace connotes pattern of elimination interference actions
(+)restlessness fluid intake toxins  Client's response
pain >Provide TSB >Indicates presence performed
(+)diarrhea >Provide comfort >To promote non- to intervention,
(+)pallor >Encourage increased of infection &  Attainment or
(+)rebound tenderness in measures, quiet pharmacological pain teaching and
(+)restlessness fluid intake dehydration progress toward
right lower quadrant environment and calm management actions
(+)diarrhea >Assess fluid loss & >Increased hydration desired
>P:when? no specific time activities. >To maintain acceptable performed
>P:when? no specific time facilitate oral intake flushes bacteria and outcomes
on and off the pain >Administered pain relief level of pain  Attainment or
on and off the pain >Promote bed rest toxins  Response to
>Q:stabbing pain as ordered by the >Promotes progress toward
>Q:stabbing pain >Provide cool circulation >To assess degree of medications
>R:lower left quadrant
>R:lower right quadrant physician. muscle desired
abdominal pain air using a fan interference administered
abdominal pain >Encourage use relaxation outcomes
>S:6/10 moderate pain >Assiss patient in >Enhances heat loss by
>S:6/10 moderate pain Of sitz baths, warm >Stimulants may increase  Response to
>T:frequently changing into dry clothing evaporation & conduction
>T:frequently soaks to the perineum gastrointestinal motility medications
T-38 >Provide oral hygiene >Increases metabolic rate
T-37 >Limit ingestion of and worsen diarrhea. administered
RR-20 >Monitor vital signs & diaphoresis
RR-23 alcohol, coffee, >To assess level of
PR-90 >Maintain IV fluid as >Reduce body heat
PR-80 >Note condition of skin hydration
BP-120/90 ordered by the physician production
BP-130/90 and mucous membranes, >To assess degree of
O2sat-96% >Administer antipyretic as >Dissipates heat by
O2sat-95% color of urine. interference
ordered convection
>Determine clients >Pain can be a great
>Administer antibiotic as >Increases comfort
pattern of elimination source of embarrassment
ordered >Prevent herpetic lesions
>Provide emotional to the elderly and can
of the mouth
support for patients who lead to social isolation
>Notes progress &
are having trouble and a feeling of
changes of condition
>Prevents dehydration
>Reduces fever
>Treats underlying cause
controlling unpredictable powerlessness.
episodes of pain