Student Nurses’ Community NURSING CARE PLAN – Crohn’s Disease ASSESSMENT
SUBJECTIVE: “ Madalas sumakit ang tiyan ko at madalas ang pagdumi ko” (I'm having frequent abdominal pain and diarrhea) as
verbalized by the patient.
OBJECTIVE: Reluctance to move Abdominal guarding Restlessness •
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V/S taken as follows T: 37.1˚C P: 75 R: 18 BP: 110/ 80
DIAGNOSIS
INFERENCE
Acute pain may be related to hyperperistalsis, prolonged diarrhea, skin and tissue irritation, perirectal excoriation, fissures, and fistulas.
Crohn’s disease is an idiopathic inflammatory disease of the small intestine (60%), the colon (20%), or both. It involves all layers of the bowel but most commonly involves the terminal ileum. It is slowly progressive and recurrent disease with predominant involvement of multiple regions of the intestine with normal sections between. Chronic, nonspecific inflammation of the entire intestinal tract characterizes the disease, with the terminal ileum the site most affected. Eventually deep fissures and ulcerations develop and often extend through all bowel layers
PLANNING
INTERVENTION
After 4 hours of Independent nursing Encourage client to interventions, the report pain. Patient will report pain is relieved or controlled and Assess reports of appear to be abdominal relaxed and able cramping or pain, to sleep and rest noting location, appropriately. duration, and intensity. Review factors that aggravate or alleviate pain.
RATIONALE
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Encourage patient to assume position of comfort, such as knees flexed. Provide comfort measures and diversional activities.
Cleanse rectal area with mild soap and water after each stool and provide skin care with
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May try to tolerate pain rather than request analgesics. Changes in pain characteristics may indicate spread of disease or developing complications. May pinpoint precipitating or aggravating factors such as stressful events, food intolerance, or identify developing factors. Reduces abdominal tension and promotes sense of control. Promotes relaxation, refocuses attention, and may enhance coping abilities. Protects skin from bowel acids, preventing excoriation.
EVALUATION
After 4 hours of nursing interventions, the Patient was able to report pain is relieved or controlled and appear to be relaxed and able to sleep and rest appropriately.
Student Nurses’ Community fistulas. •
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moisture barrier ointment. Provide sitz bath, as appropriate.
Observe and record abdominal distention.
Collaborative Implement prescribed dietary modifications such as commence with liquids and increase to solid foods as tolerated. Administer analgesics as indicated.
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Enhances cleanliness and comfort in the presence of perianal irritation and fissures. May indicate developing intestinal obstruction from inflammation, edema, and scarring.
Complete bowel rest can reduce pain and cramping.
Pain varies from mild to severe and necessitates management to facilitate adequate rest and recovery.
