Student Nurses Community

NURSING CARE PLAN Appendectomy

ASSESSM
ENT

DIAGNO
SIS

INFERENC
E

SUBJECTIVE
:

Acute
pain may
be related
to
distention
of
intestinal
tissue by
inflammat
ion
and
presence
of surgical
incision.

Appendect
omy is the
removal of
the inflamed
appendix. In
an
open,
conventional
,
and
uncomplicat
ed
appendecto
my,
the
surgeon
removes the
appendix
through an
incision
approximate
ly 3 inches
long in the
lower right
quadrant.
The incision
is larger if
the
appendix is
in a typical
position or if
peritonitis is
present.

Sumasakit
ang sugat
ng opera
ko. (I feel
pain around
the incision
site) as
verbalized
by the
patient.
OBJECTIVE:
Guarding
behavior
in the
abdomen
Facial mask
of pain
Distraction
behaviors
V/S taken
as follows:
T: 36.8 C
P: 83
R: 17
BP:
110/80

PLANNI
NG

INTERVENT
ION

RATIONA
LE

EVALUATI
ON

After 1
Independent Useful in
hour of
Assess pain,
monitorin
nursing
noting
g
interventi
locatiosn,
effectiven
ons, the
characterist
ess of
patient
ics,
and
medicatio
will report
severity (0
n and
pain is
to
10
progressi
relieved
scale).
on of
or
Investigate
healing.
controlled
and report
Changes
and
changes in
in
appear to
pain,
as
character
be
appropriate.
istic of
relaxed,
Provide
pain may
able to
accurate,
indicate
sleep and
honest
developin
rest
information
g abscess
appropriat
to
patient
or
ely.
or
peritoniti
significant
s,
others.
requiring
Keep at rest
prompt
in
semimedical
Fowlers
evaluatio
position.
n and
interventi
on.
Being
informed
about the
progress
of
situation
provides
emotiona
l

After
1
hour
of
nursing
interventio
ns,
the
patient was
able
to
report pain
is relieved
or
controlled
and appear
to
be
relaxed,
able
to
sleep and
rest
appropriate
ly.

support ,
helping
to
decrease
anxiety.
Gravity
localizes
inflamma
tory
exudates
into lower
abdomina
l tension.
g