ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS

Subjective data: Acute pain related Short term goals: Independent: Short term goals:
“I feel uneasy and to prolonged
uncomfortable.” diarrhea evidenced Within 8 hours of - Assess reports of - Assessment is the first After 8 hours of nursing
by cramping nursing interventions abdominal cramping or step in managing pain. It interventions and constant
Objective data: abdominal pain, and constant nurse- pain, noting location, helps ensure that the nurse-client interaction,
- weak, and pale guarding behavior, client interaction, duration, and intensity patient receives effective patient is able to:
looking restlessness, and patient will be able (such as 0–10 scale). pain relief. Changes in
facial mask of pain to: Investigate and pain - report pain is relieved or
- diarrhea report changes in pain characteristics may controlled.
- report pain is characteristics indicate spread of disease
- abdominal cramps relieved or or developing - displays improvement in
controlled. complications, such as mood, and coping
- abdominal pain bladder fistula,
- displays perforation, and - appear relaxed and able
- eyes were sunken improvement in toxic megacolon. to sleep and rest
and with observable mood, and coping appropriately
discomfort - Body language or
- appear relaxed and - Note nonverbal cues, nonverbal cues may be Long term goals:
- frequent watery able to sleep and rest such as restlessness, both physiological
stools appropriately reluctance to move, and psychological and After 3 days of nursing
abdominal guarding, may be used in interventions the patient is
-slight tachycardia Long term goals: withdrawal, and conjunction with able to:
depression. Investigate verbal cues to determine
- facial mask of pain Within 3 days of discrepancies between extent and severity of the - re-establish and maintain
nursing interventions verbal and nonverbal cues. problem normal pattern of bowel
- guarding and the patient will be functioning.
tenderness noted in the able to: - Review factors that - May pinpoint
left iliac fossa and aggravate or alleviate precipitating or - display improved well-
hypogastrium - re-establish and pain. aggravating factors (e.g., being such as baseline
maintain normal stressful events, food levels for pulse, BP,
- Vita Signs taken as pattern of bowel intolerance) or identify respirations, and relaxed
follows: functioning. developing muscle tone or body
BP: 90/50 complications posture
P: 122bpm - display improved
R: 28cpm well-being such as
baseline levels for - Encourage client to - Reduces abdominal
pulse, BP, assume position of tension and promotes
respirations, and comfort, such as knees sense of control.
relaxed muscle tone flexed.

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 or body posture.
-Demonstrate and
encourage use of stress
management behaviors,:
relaxation techniques,
guided imagery, slow/deep
breathing.
-Provide quiet and calm
environment. Review
reasons for limitation of
activities during acute
phase.
- Provide comfort
measures (e.g., back rub,
reposition) and diversional
activities
- Cleanse rectal area with
mild soap and water (or
wipes) after each stool and
provide skin care with a
moisture barrier ointment
(e.g., A&D ointment,
Sween ointment, karaya
gel, Desitin, petroleum
jelly, zinc oxide,
dimethicone).
- Provide sitz bath, as
appropriate.
- Observe for ischiorectal
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-Promotes patient
participation in exerting
some sense of control in a
stressful situation.
-Reduces stimulation and
release of stress-related
catecholamines, which can
cause or aggravate
dysrhythmias and
vasoconstriction,
increasing myocardial
workload.
- Promotes relaxation,
refocuses attention, and
may enhance
coping abilities.
- Protects skin from bowel
acids, preventing
excoriation.
- Enhances cleanliness and
comfort in the presence of
perianal irritation and
fissures
- Fistulas may develop
from erosion and
 and perianal fistulas.
- Observe and record
abdominal distension,
increased temperature, and
decreased BP
- Encourage patient to eat
fibre containing diets such
as cereal, grain, and
Metamucil.
- Encourage the patient to
remain in the supine
position and keep a warm
heating pad on the
abdomen.
Collaborative:
- Implement prescribed
dietary modifications, for
example, commence with
liquids and increase to
solid foods as tolerated
- Administer medications
as indicated, for example:
Analgesics
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weakening of intestinal
bowel wall.
- May indicate developing
intestinal obstruction from
inflammation, edema, and
scarring
- A fibre diet helps to
absorb the fluid and
thicken the stool.
- It promotes GI muscle
relaxation, thereby
reduces abdominal
cramps.
- Complete bowel rest can
reduce pain and cramping
- Pain varies from mild to
severe and necessitates
management to facilitate
adequate rest and
recovery. Note: Opiates
should be used with
caution because they may
precipitate
toxic megacolon.

- Anticholinergics
- Anodyne suppositories
- Refer to the primary care
provider if any
complications arise
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- Relieve spasms of GI
tract and resultant colicky
pain.
- Relax rectal muscle,
decreasing painful spasms.
- To provide immediate
medical intervention if
needed and possibly
prevent further
complications.