HEMORRHOIDS
_____________
A Nursing Care Plan Presented To
The Faculty of the Nursing Department
MRS. MONICA AGUIRRE, RN
_____________
In Partial Fulfillment of
The Requirements in NCM-216 RLE
By:
Keyna Juliet N. Dizon, St.N.
January 30, 2021
NAME: Patient X AGE/ GENDER: 28 years old/ female ROOM#: San Lorenzo 301-1
CC: rectal pain DIAGNOSIS: Grade 2 internal and external hemorrhoids AP: Dr. Uy
D/ CUES NEED NSG DIAGNOSIS PT OUTCOME NSG INTERVENTION IMPLEMEN EVALUATION
T TATION
J Subjective:` C Acute pain:severe Within the span of 3 1. Assess the 1 January 25,2021 @ 10
O related to hours of giving patient’s vital AM
Pain scale of G inflammation of the nursing signs.
A 3/3 with the GOAL MET.
N external sphincter interventions, the
following I as evidenced by patient will be able R: To create a
N indication: T facial grimacing, to demonstrate baseline set of
0 - no pain I irritability, behaviors of observations for the
1 - mild V restlessness diminished pain as patient. Vital signs are
U
2 - moderate E evidenced by: affected when pain is
3 - severe present.
A P Rationale: a. displays
Objective: E improved vital
R A thrombosed signs within 2
R Restlessness 2. Use
C external hemorrhoid the normal
is a painful swelling nonpharmacolo
Irritable E ranges: gical pain relief
Y in the anal tissues
P methods such
Facial caused by a clot (or
T a1. blood as relaxation
grimace “thrombus”) in one
2 U pressure of exercises,
Vital signs of or more of the small
A 110-170- breathing
L veins in the anal 120/80mmHg
5 Temp: 37.5°C exercises and
skin. This may occur
P in conjunction with music therapy.
(normal: 36.5 °C- [Link] Keyna Juliet Dizon, St. N
A prolonged sitting or Also give
, 37.5°C) of 36.5 °C-
T constipation, but diversional
37.5°C activities such
T can also occur
2 E spontaneously for as watching
R no apparent reason. television and
RR: 24 cpm N The swollen tissues b. absence of socialization
0
(normal: 16-20 are quite tender and grimaced face; with other
cpm) painful and often people.
2 have a c. demonstration
characteristic bluish of R:
color, because of nonpharmacolo Nonpharmacological
1 CR: 98 bpm pain relief methods
the underlying clot. gical pain-relief
Although very strategies such works by increasing
8:0 (normal: 80-90 the release of
bpm) painful, the as:
endorphins, boosting
0 condition is not relaxation
PR: 95 bpm serious and the therapeutic effects
exercises
A resolves without of pain relief
(normal: 80-90 breathing
specific treatment medcations.
bpm) exercises
M over several days to music
a week or two. therapy.
Rarely, if the 3. Provide a quiet 3
BP:130/ 100 thrombosed environment.
mmhg hemorrhoid is very
R: Additional stressors
(normal: 110- large, your doctor
can intensify the
170- may remove some
patient’s perception
120/80mmHg ) of the clot under
and tolerance of pain.
local anesthesia.
This is called
‘incision and
FHT: 120 bpm 4. Provide rest
drainage’ of
thrombosed periods to 4
(normal: 120-160
hemorrhoid. The facilitate
bpm) area will continue to comfort, sleep
be painful even after and relaxation.
this since this
treatment is yet R: Rest periods can
Has a reduce inflammation
unclear if it is helpful
Thrombus and assist with
external in any way.
healing.
hemorrhoid
Reference:
measuring
1cm X 2 cm
Burney, R. (2018). 5. Administer 5
resistance
behavior of Thrombosed Analgesic with
the affected External antipyretic and
area upon Hemorrhoids. Preparation- H
palpation Retrieved January ointment as
21, 2021, from
pescribed.
[Link]
[Link]/1libr/Sur R: To provide pain
gery/GenSurgery/T
[Link] relief to the patient.
f
6. Ask the patient
6
to re-rate her
acute pain 30
minutes after
administering
medication.
R: To assess the
effectiveness of
treatment.
7. Assist in gentle 7
handling and
supporting of
body parts
especially in
sitting.
R: Prevents extra pain
to affected parts.
8. Provide hot sitz 8
bath as ordered
by the
physician.
R: Hot sitz bath is
performed because it
helps ease pain and
itching
from hemorrhoids.
9
9. Instruct patient
to immediately
report presence
of pain.
R: To provide instant
nursing intervention to
relieve pain.
10. Provide a high- 10
fiber diet.
R: Improves peristalsis
and promotes
elimination which helps
lessen the pain during
deffecation.
References:
Burney, R. (2018). Thrombosed External Hemorrhoids. Retrieved January 21, 2021, from
[Link]
Lynda Juall Carpenito-Moyet (2015). Nursing Care Plans & Documentation Nursing Diagnoses and Collaborative Problems. Wolters Kluwer Health |
Lippincott Williams & Wilkins
Wayne, G. (2020). Acute pain nursing care plan. Retrieved December 4, 2020, from [Link]