Hemoroid_case Study.pdf

Scenario: A 26 year old female is in day 3 of postpartum care from delivering a healthy baby girl via c-section. She reports to you she is experiencing constipation and has been unable to have a bowel movement for 5 days. She says she has been “straining” and she is having difficulty passing stool and when she does it is a very hard small “ball”. In addition, she say she feels ” a lot of pressure” in her rectum and she is having pain from hemorrhoids she developed in the last trimester of her pregnancy. She says she is afraid to have a bowel movement because of the pain caused by the hemorrhoids The patient received many narcotics during and after the delivery. Nursing Diagnosis:

-Constipation related to pain on defecation secondary to hemorrhoids as evidence by the patient reporting she has not had a bowel movement for 5 days, hard stool, rectum pressure, and painful hemorrhoids. Subjective Data: -The patient states she is experiencing constipation and has been unable to have a bowel movement for 5 days. She says she has been “straining” and she is having difficulty passing stool and when she does it is a very hard small “ball”. In addition, she say she feels ” a lot of pressure” in her rectum and she is having pain from hemorrhoids she developed in the last trimester of her pregnancy. She says she is afraid to have a bowel movement because of the pain caused by the hemorrhoids. Objective Data: A 26 year old female is in day 3 of postpartum care from delivering a healthy baby girl via c-section. The patient received many narcotics during and after the delivery. Nursing Outcomes: -The patient will have a bowel movement before discharge.-The patient will report decreased pain in rectum from hemorrhoids. -The patient will verbalize 3 techniques on how to keep bowel movements regular. -The patient will verbalize how to take prescribed medication regime to prevent constipation. Nursing Interventions: -The nurse administer per MD orders Miralax and Colace as prescribed to help assist patient with bowel movement.-The nurse assess and document when patient has had a bowel movement daily. -The nurse will provide the patient with a sitz bath and hemorrhoid cream as prescribed to help with hemorrhoid pain. -The nurse will educate the patient on 3 techniques on how to keep bowl movements regular by discharge. -The nurse will educate the patient how to take prescribed medications to prevent constipation by discharge.