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NURSING CARE PLAN ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION Subjective: Masakit ang tiyan ko as verbalized

by patient. Objective: Facial mask of pain. Guarding behavior. Rebound tenderness. V/S taken as follows: T: 37.3 P: 80 R: 18 Bp: 110/90 Acute pain related to inflammation of tissues. Appendicitis is inflammation of the vermiform appendix caused by an obstruction attributable to infection, stricture, fecal mass, foreign body or tumor. Appendicitis can affect either gender at any age, but is most common in males ages 10 to 30. Appendicitis is the most common disease requiring surgery. If left untreated, appendicitis may progress to abscess, perforation, subsequent peritonitis, and death. After 4 hours of nursing interventions, the patient will demonstrate use of relaxation skills, other methods to promote comfort. Independent: Investigate pain reports, noting location, duration, intensity (0-10 scale), and characteristics (dull, sharp, constant). Maintain semi-fowlers position. Move patient slowly and deliberately. Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Provide diversional activities. Provide frequent oral care. Remove noxious environmental stimuli. Changes in location or intensity are not uncommon but may reflect developing complications. Reduces abdominal distention, thereby reduces tension. Reduces muscle tension or guarding, which may help minimize pain of movement. Promotes relaxation and may enhance patients coping abilities by refocusing attention. Reduces nausea and vomiting, which can increase intra-abdominal pressure or After 4 hours of nursing interventions, the patient was able to demonstrate use of relaxation skills, other methods to promote comfort.

Collaborative: Administer analgesics as prescribed. pain. Reduce metabolic rate and aids in pain relief and promotes healing.

ASSESSME NT Subjective: Masakit ang tiyan ko as verbalized by patient. Objective: Facial mask of pain. Guarding behavior. Rebound tenderness. V/S taken as follows: T: 37.3 P: 80 R: 18 Bp: 110/90

DIAGNOSIS

INFERENCE

PLANNING

INTERVENTIO N Independent: Investigate pain reports, noting location, duration, intensity (010 scale), and characteristic s (dull, sharp, constant). Maintain semi-fowlers position. Move patient slowly and deliberately. Provide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Provide diversional activities. Provide frequent oral care. Remove noxious environment al stimuli. Collaborativ e:

RATIONALE

EVALUATIO N

Acute pain related to inflammati on of tissues.

Appendiciti s is inflammati on of the vermiform appendix caused by an obstruction attributabl e to infection, stricture, fecal mass, foreign body or tumor. Appendiciti s can affect either gender at any age, but is most common in males ages 10 to 30. Appendiciti s is the most common disease requiring surgery. If left untreated, appendiciti s may progress to abscess, perforation , subsequen t peritonitis,

After 4 hours of nursing interventio ns, the patient will demonstrat e use of relaxation skills, other methods to promote comfort.

Changes in location or intensity are not uncommon but may reflect developing complicatio ns. Reduces abdominal distention, thereby reduces tension. Reduces muscle tension or guarding, which may help minimize pain of movement. Promotes relaxation and may enhance patients coping abilities by refocusing attention. Reduces nausea and vomiting, which can increase intraabdominal

and death.

Administer analgesics as prescribed. pain. Reduce metabolic rate and aids in pain relief and promotes healing.

pressure or pain.