NURSING CARE PLAN ACUTE PAIN NURSING CUES Subjective: Masakit yung almunaras ko Pain scale of 8/10 DIAGNOSIS

OSIS Acute pain related to irritation, pressure and rectal sensitivity in the area / anal and anorectal disease secondary to postoperative spasm of the sphincter. SCIENTIFIC EXPLANATION When blood within the hemorrhoids becomes clotted because of obstruction, the hemorrhoids are referred to as being thrombosed. When thrombosed, hemorrhoids may become very painful due unpleasant sensory Encourage patient to assume position of comfort. Reduces abdominal tension and promotes sense Did patient felt relief? OBJECTIVE NURSING INTERVENTION After 6 hours Assess reports of nursing interventions, the patient will report pain is relieved or controlled. of abdominal cramping or pain, noting location, duration, intensity (0-10 scale). Investigate and report changes in pain characteristics Assess reports of abdominal cramping or pain, noting location, duration, intensity (010scale). Investigate and report changes in pain characteristics. What is the pain scale of the patient? RATIONALE EVALUATION

Objective: c facial grimace of frowning c rectal plug in rectal area c dressing over rectal area

 Vital sign as follows:

experience, either physical or emotional, associated with actual or potential tissue damage. Provide comfort measures.

of control. Promotes relaxation, refocuses attention, and may enhance coping abilities. Cleanse rectal area with mild soap and water or wipes after each stool and provide skin care. Provide sitz bath as appropriate. To provide a quick relief from the swelling and pain of Did patient felt of pain? Enhances cleanliness and comfort in the presence of inflammation of varices Did patient felt comfort? Did patient pain reduced?

hemorrhoids Administer analgesics such as diclofenac for moderate to severe pain and celecoxib for acute pain. To decrease the pain. What is the patients therapeutic response upon administrati on of medication?

IMPAIRED SKIN INTEGRITY NURSING SCIENTIFIC OBJECTIVE NURSING INTERVENTION After 6 hours of nursing procedures, the patient will: 1. Verbalize understanding of causes of hemorrhoids, methods controlling hemorrhoids and comfort measures to employ if hemorrhoids is present. 2. Patient will have less rectal bleeding. Assess patient for presence of hemorrhoids, discomfort associated with hemorrhoids, diet fluid intake and presence of constipation. Provides information as to type of hemorrhoids ( external versus internal), degree of venous thrombosis, presences of complications including bleeding and risk factors that preclude to hemorrhoids to able to initiation of care plan What are the risk factor the preclude to hemmorhoid s? RATIONALE EVALUATION

CUES Subjective: Pain scale of 8/10

DIAGNOSIS EXPLANATION Surgery itself is a kind of anal skin integrity trauma, because anorectal nerve related to dense, very rich hemorrhoidal in blood vessels, nerves, muscles surgery and closely linked to hemorrhoidal the surgery damage the procedures. integrity of the skin, thus, pain is inevitable. Impaired

Objective: c rectal plug in anal area c dressing over rectal area

appropriate for the patient. Administer stool softeners like phosphosoda as ordered. Helps to prevent further straining and increased pressure that may cause clotted vessel to rupture or cause further hemorrhoids to develop. Helps to relieve pain by avoiding passage of hard fecal material. Instruct patient regarding cause of Hemorrhoids are caused by heavy lifting, Did patient understand the What is the client response?

hemorrhoids, methods of avoiding hemorrhoids, and treatments that can be performed.

straining, obesity, pregnancy, and any activity that distends rectal veins and causes them to prolapse.

instructions given to her?

Instruct patient/family in dietary management

Increasing bulk, fiber, fluids, and eating fruits and vegetables can help by maintaining soft stools to avoid straining bowel movements.

What did the client ate?

 Instruct patient/family in comfort measures like warm sitz bath.

Warm sitz baths can help to alleviate pain temporarily.

Did it alleviate the patients pain?

RISK FOR INFECTION NURSING SCIENTIFIC OBJECTIVE NURSING INTERVENTION After 6 hours of nursing intervention the patient will not have any sign and symptoms of anal infection such as foul smelling drainage and pain. Stress proper hand hygiene and wear gloves especially when changing the wound dressing. To avoid the spread of microorganism and to prevent infection. Did the patient stress the properly hand washing? Check for signs and symptoms of anal infection such as increased pain and foul smelling drainage. For early prevention of progression to more serious complications. Did patient manifest any signs and symptom of anal infection? RATIONALE EVALUATION

CUES Subjective:

DIAGNOSIS EXPLANATION Risk for infection related to Infection is a risk after hemorrhoid treatment due to the location of the treatment. Stool can come into contact with the site where the hemorrhoid was removed, and can contribute to an infection.

Objective: c rectal plug in anal area c dressing over rectal area

normal bacterial flora at the surgical site

 Use warm water and a mild soap to clean the perinial area Provide sitz bath as indicated.

To prevent infection and irritation.

Did patient felt relief from irritation?

To provide a quick relief from the swelling and pain Did patient felt relief from swelling and pain? Did patient felt comfort?

Provide wound care and change wound dressing at incision site Administer antibiotics such as clindamycin.

To keep the anal area clean and dry

To stop the growth of bacteria in hemorrhoids

Did patient manifest any side effects?