Student Nurses’ Community

NURSING CARE PLAN - Hemorrhoids

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Independent:
SUBJECTIVE: Acute pain may After 8 hours of • Encourage patient • May try to After 8 hours of
be related to Hemorrhoids are nursing nursing
to report pain. tolerate rather
“Masakit at inflammation vascular masses interventions, the interventions, the
than request
nahihirapan ako and edema of that protrude into patient will report patient was able
analgesics.
dumumi” (I've prolapsed the lumen of the pain is relieved or to report pain
lower rectum or • Assess reports of • Changes in pain
been having varices. controlled. was relieved or
trouble/pain perianal area. They abdominal characteristics
cramping or pain, may indicate controlled.
pooping) as result when
verbalized by the increased intra- noting location, spread of
patient. abdominal pressure duration, intensity disease or
causes (0-10 scale). developing
OBJECTIVE: engorgement in the Investigate and complications.
vascular tissue report changes in
lining the anal pain
 Guarding
behavior canal. Loosening of characteristics. • Body
vessels from • Note nonverbal language/nonver
 Restlessness
surrounding cues such as bal cues may be
 Facial mask
connective tissue restlessness, both
of pain
occurs with reluctance to physiological and
 V/S taken as
protrusion or move and psychological
follows:
prolapse into the abdominal and may be used
anal canal. There guarding. in conjunction
T: 37.2
are two types of with verbal cues
P: 90
hemorrhoids: to determine the
R: 20
external extent or severity
BP: 120/80
hemorrhoids of the problem.
appear outside the • Review factors • May pinpoint
external sphincter, that aggravate or precipitating or
and internal alleviate pain. aggravating
hemorrhoids factors such as
appear above the stressful events,
internal sphincter. food intolerance
When blood within or to identify
the hemorrhoids developing
becomes clotted complications.
because of • Encourage patient • Reduces
obstruction, the to assume abdominal
Student Nurses’ Community
hemorrhoids are position of tension and
referred to as being comfort. promotes sense
thrombosed. of control.
• Provide comfort • Promotes
measures. relaxation,
refocuses
attention, and
may enhance
coping abilities.
• Cleanse rectal • Protects skin
area with mild from bowel
soap and water or acids, preventing
wipes after each excoriation.
stool and provide
skin care.
• Provide sitz bath • Enhances
as appropriate. cleanliness and
comfort in the
presence of
inflammation of
varices.

Collaborative:
• Implement • For complete
prescribed dietary bowel rest and
modifications. can reduce pain
and cramping.