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NURSING CARE PLAN

ASSESSMENT
SUBJECTIVE
masuol la gehap an
akon tiyan. as
verbalized
OBJECTIVE

minimal movement
presence of penrose
drain
presence of
colostomy
incised wound at
RLQ of abdomen

Guarding the
abdominal incision
with right hand.

Pain at
periumbilical area
radiating to RLQ
region.

facial grimace
noted

NURSING
DIAGNOSIS
Acute pain
related to
presence of
incision RLQ of
abdomen
secondary to
acute appendicitis

SCIENTIFIC RATIONALE

OBJECTIVES/
PLANNING

NURSING
INTERVENTIONS

Tissue injury or infection


After a series of
Assess pain,
results to immediate vascular
nursing interventions
noting location,
response; transitory
the patient will be
characteristics,
vasoconstriction followed
able to:
severity (010
immediately by vasodilation
scale).
due to the release of
Verbalize feeling
histamine,bradykinin and
Investigate and
of relief or
prostaglandin which in turn
reduced sensation
report changes in
leads to increased capillary
from pain.
pain as
permeability, hyperemia and
appropriate.
cellular exudation that results The patient PRS
to edema and then pain caused
will reduce from
by compression of nerve
6 at least 2 out of
endings, release of pain
10.
>Keep at rest in
mediators bradykinin and
semi-Fowlers
prostaglandins and eventually
loss or impaired function.
position.
Reduce guarding
behavior
Reference: Josie QuiambaoUdan,Mastering Fundamentals
of Nursing 3rd edition, p. 156
Follow
prescribed
pharmacological
regimen

>Encourage early
ambulation.
Provide comfort
measures such as
repositioning
And fixing the bed sheets.

Monitor patients vital


signs (BP,HR,RR,Temp)

Encourage adequate
periods of rest and sleep.

Administer antibiotics

SCIENTIFIC RATIONALE

EVALUATION

Useful
in
monitoring
effectiveness
of
medication,
progression
of
healing. Changes in
characteristics
of
pain may indicate
developing abscess
or
peritonitis,
requiring
prompt
medical evaluation
and intervention.
>To
lessen
the
pain.
Gravity
localizes
inflammatory
exudate into lower
abdomen or pelvis,
relieving abdominal
tension, which is
accentuated
by
supine position.

>Patient will
verbalize feeling
of relief or
reduced
sensation of
pain.
The patient
PRS will
reduce from
6 at least 2
out of 10.

>

>Promotes

normalization
of
organ
function (stimulate
s peristalsis and
passing of flatus,
reducing
abdominal
discomfort)

To promote comfort and


alleviate pain.

Reduce
guarding
behavior

and analgesics as
prescribed such as
ketorolac

Provide
diversional
activities

Are usually altered when


there is pain as the body
is trying to fight and
compensate.
To maximize energy
available for healing and
meet comfort needs.
As
pharmacological
management for pain
and
infection
as
indicated
by
the
physician.

Watch closely for


Refocuses
possible surgical
attention,
complications.
promotes
relaxation,
and
may
enhance
coping abilities.
Continuing pain
and fever may
signal
an
abscess.

NURSING CARE PLAN

Assessment
S:
>makatol ak
tiyan

O:
>presence of
abdominal incision
at RLQ region, 4
inches.
> presence penrose
drain
>presence of
colostomy
>long untrimmed
nails
>itchiness at the
affected area

Diagnosis
Impaired skin and
tissue integrity related
to incised wound at
RLQ of the abdomen
secondary to post
appendectomy

Scientific Rationale
>state in which an individual
experience damage to
integumentary or
subcutaneous tissues. Break
in the skin wall has greater
possibility for sepsis and
damage to skin integrity.
Appendectomy is a surgical
operation done to remove
inflamed vernix appendix in
order to prevent further
damage to neighboring
tissues.

Planning
>after 8 hours of
nursing interventions
the pt will be able to:
>relieve timely wound
healing
>significant others will
verbalize
understanding
condition and its causes
>demonstrate lifestyle
changes to promote
healing and prevent
recurrence of
complications

Intervention
>Assess skin/tissue/pressure area and
wounds for any signs of infection
>. Provide routine incisional care, being
careful to keep dressing dry and sterile.
Assess and maintain patency of drains.

>assist with encouraged position changes


if tolerated

Quimbao, Basic nursing


skills; 5th edition, volume 2
>keep the bed linens dry and wrinkle free,
use pads under elbows for support and
proper positioning.
>Instruct patient the importance of proper
diet and food intake
>Educate the patient on the importance of
keeping the skin clean and dry

Scientific Rationale
>prevent infection

>Promotes healing.
Accumulation of
serosanguineous
drainage in
subcutaneous layers
increases tension on
suture line, may
delay wound healing
and serves as a
medium for bacteria
growth

>Reduces pressure
on skin, promoting
peripheral circulation
and reducing risk of
skin breakdown. Skin
barrier reduces risk
of shearing injury.

>reduces pressure
on susceptible areas
and risk of abrasions
breakdown

>nutrition is the
fundamental cellular
integrity and tissue
repair

>moisture softens
the skin and causes
a break in the skin

Assessment
S:
>di siya
nakakaturog kay
masuol ura-ura
verbalized by the
mother
O:
>yawning
>pain at RLQ scale
of 7 (1-10)
>fatigue scale rate
of 6(1-10)

Diagnosis
Fatigue related to
sleep deprivation
secondary to pain in
the right femoral
area radiating to the
tibia and ulna
region.

Scientific Rationale
> prostaglandin due to
inflammatory reaction as a
result from the wound, or
micro organism may result
to transmission of pain
thereby affects mobility,
mood, rest and
concentration.
Reference: Josie QuiambaoUdan,Mastering Fundamentals
of Nursing 3rd edition,

Planning
>after 8 hours of
nursing interventions
the pt will be able to:
>verbalize an
increase of energy
>fatigue scale from 6
will improve to 3

Intervention
>manipulated environment such as
cleaning the surroundings and
minimizing noise.
>encourage patient for adequate rest
periods to obtain rest and relieve
fatigue
>have patient in any comfortable
position as tolerated

Scientific Rationale
>to promote comfort

>adequate rest period


could prevent fatigue
and discomfort

> Clients
position may
aggravate pain felt.
Positioning properly
may promote comfort
and also ensure good
circulation.

> keep the bed linens dry and wrinkle


free to prevent discomforts
>instructed to:
-consume foods that are rich in
protein, vitamins and calcium which
can be a source of energy

>nutrition is the
fundamental
cellular integrity

-refrain from caffeine, alcohol and


other stimulating substances specially
during evening
-perform diversional activities such as
listening to music to diver attentions.

and tissue repair

>caffeine has
substances that i
known to disrupt
sleeping patterns

>Encourage deep breathing exercises

> Diversional
activities will help
the client focus o
other things
rather than the
pain felt

> To facilitate
expansion of
abdomen and to
decrease pain

NURSING CARE PLAN

ASSESSMENT
SUBJECTIVE
>inuuhaw ako
OBJECTIVE:
>post appendectomy
>400cc of urine output
per day
>dry lips
>poor skin turgor
>cool clammy skin

NURSING
DIAGNOSIS
>Fluid volume
deficit related to

decrease
absorption
of fluid
secondary
to bowel
perforation

OBJECTIVES/
PLANNING

SCIENTIFIC RATIONALE
Intestines functions not only as
a passage of chime but also for
digestion, intestine absorbs
water, vitamin B and
electrolytes. Perforations and
infection of bowel may
disrupts its normal function
causing a decrease in
absorption and fluid
imbalance.

Source: Stump,
Nutritional
foundations and
clinical
applications: a
nursing approach,

After a series of
nursing interventions
the patient will be
able to:
>

Demonstrate
adequate
fluid balance,
as evidenced
by normal
skin turgor,
moist
mucous
membranes,
and
individually
appropriate
urinary
output.

NURSING
INTERVENTIONS

SCIENTIFIC RATIONALE

> Measure and

>Accurate

record I&O
(including tubes
and drains).
Calculate urine
specific gravity as
appropriate.

documentation
helps identify fluid
losses
or
replacement needs
and
influences
choice
of
interventions.
>Indicators
of
adequacy
of
peripheral
circulation
and
cellular hydration.

>Inspect mucous
membranes; assess
skin turgor and
capillary refill.
> Provide voiding
assistance
measures as
needed: privacy,
sitting position,
running water in
sink, pouring warm
water over
perineum.
> Monitor skin
temperature,
palpate peripheral
pulses.

> Monitor
laboratory studies:
Hb/ Hct,
electrolytes.
Compare

>Promotes
relaxation
of
perineal
muscles
and may facilitate
voiding efforts.

> Cool or clammy


skin, weak pulses
indicate decreased
peripheral
circulation
and
need for additional
fluid replacement.
>
Indicators
of
hydration
and/or
circulating volume.
Preoperative
anemia and/or low

EVALUATIO

>Patient will hav


adequate fluid
balance.

Patient w
demonstra
adequate
fluid balan
as evidenc
by normal
skin turgor
moist
mucous
membrane
and
individuall
appropriat
urinary
output.
>

preoperative and
postoperative blood
studies.

> Give frequent


mouth care with
special attention to
protection of the
lips.
>Administer IV

fluids and
electrolytes.

Hct combined with


unreplaced
fluid
losses
intraoperatively will
further potentiate
deficit.
>
Dehydration
results in drying
and
painful
cracking of the lips
and mouth.
>The peritoneum
reacts
to
irritation and infecti
on by producing
large amounts of
intestinal
fluid,
possibly
reducing
the
circulating
blood
volume,
resulting
in
dehydration
and
relative electrolyte
imbalances.

NURSING CARE PLAN


Assessment
S:
O:
>wt loss noted
>wt less than 19kg

Diagnosis
Risk for Imbalanced
Nutrition: Less Than
Body Requirements
r/t inability to absorb
nutrients secondary
post revision of
colostomy

Scientific Rationale
> colostomy is a surgical
procedure in which an
opening (stoma) is formed
by drawing the healthy end
of the large intestine or
colon through an incision in
the anterior abdominal wall
and suturing it into place,
depending on the site, less
absorption of nutrients such
as vitamin B, water and
electrolytes due to the
presence of colostomy given
by its location.

Planning
>after 8 hours of
nursing interventions
the pt will be able to:

Intervention
> Auscultate bowel sounds,
noting absent or
hyperactive sounds.

>increase
weight from
<19kg to 22kg

> Measure abdominal girth.

Source: Stump,Nutritional
foundations and clinical
applications: a nursing
approach,
>Weigh regularly.

> Monitor BUN, protein,


prealbumin and albumin,
glucose, nitrogen balance as
indicated.
>Instruct to eat foods that

Scientific Rationale
> Although bowel
sounds are frequently
absent, inflammation
and irritation of the
intestine may be
accompanied by
intestinal hyperactivit
diminished water
absorption, and
diarrhea.
> Provides
quantitative
evidence of
changes in gastri
or intestinal
distension and/or
accumulation of
ascites.
> Initial losses or
gains reflect
changes in
hydration, but
sustained losses
suggest nutrition
deficit.
> Reflects organ
function and
nutritional status
and needs.
>Intake of Vitami
C may facilitate i
wound healing

are rich in vitamin C.


> Support family members to bring
the patient's favorite food from
home.

> Large portions of food offered


during the day when a high
appetite.

and nutrition.
> Patients feel

comfortable with food


brought from home an
can improve the
appetite of the patien

> By administering a
large portion can
maintain adequacy of
nutrition intake