Possibly evidenced by
Reports of colicky, cramping abdominal pain; referred pain
Guarding or distraction behaviors, restlessness
Facial mask of pain; self-focusing
Desired Outcomes/Evaluation Criteria—Client Will
Report pain is relieved or controlled.
Appear relaxed and able to sleep and rest appropriately.
Nursing intervention with rationale:
1. Encourage client to report pain.
Rationale: May try to tolerate pain rather than request analgesics.
2. Assess reports of abdominal cramping or pain, noting location, duration, and intensity (such as 0–10 scale). Investigate and report changes in pain characteristics.
Rationale: Colicky intermittent pain occurs with Crohn’s disease. Predefecation pain frequently occurs in UC with urgency, which may be severe and continuous. Changes in pain characteristics may indicate spread of disease or developing complications, such as bladder fistula, perforation, and toxic megacolon.
3. Note nonverbal cues, such as restlessness, reluctance to move, abdominal guarding, withdrawal, and depression. Investigate discrepancies between verbal and nonverbal cues.
Rationale: Body language or nonverbal cues may be both physiological and psychological and may be used in conjunction with verbal cues to determine extent and severity of the problem.
4. Review factors that aggravate or alleviate pain.
Rationale: May pinpoint precipitating or aggravating factors (e.g., stressful events, food intolerance) or identify developing complications.
5. Encourage client to assume position of comfort, such as knees flexed.
Rationale: Reduces abdominal tension and promotes sense of control.
6. Provide comfort measures (e.g., back rub, reposition) and diversional activities.
Rationale: Promotes relaxation, refocuses attention, and may enhance coping abilities.
7. Cleanse rectal area with mild soap and water (or wipes) after each stool and provide skin care with a moisture barrier ointment (e.g., A&D ointment, Sween ointment, karaya gel, Desitin, petroleum jelly, zinc oxide, dimethicone).
Rationale: Protects skin from bowel acids, preventing excoriation.
8. Implement prescribed dietary modifications, for example, commence with liquids and increase to solid foods as tolerated.
Rationale: Complete bowel rest can reduce pain and cramping.
9. Provide sitz bath, as appropriate.
Rationale: Enhances cleanliness and comfort in the presence of perianal irritation and fissures.
10. Observe and record abdominal distension, increased temperature, and decreased BP.
Rationale: May indicate developing intestinal obstruction from inflammation, edema, and scarring.