ASSESSMEN T

NURSING DIAGNO SIS

Subjective: Acute Pain related to Client verbalized inflammati on of , masakit tissues po yung ditto ko, (pointing on the right lower part of his abdomen) Rated pain of where 1 as the lowest and 10 as the highest.

Objective: Facial mask of

ANALYSIS AND INTERPRETAT ION 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

PLANNING Goal: Within 6-8 hours of nursing intervention, the patient will be able to manifest ability to cope with incompletely relieved pain as evidenced by verbalization of decrease pain form 6/10 to 2/10 Objectives: After 10 minutes of

NURSING INTERVENTI ONS

RATIONALE

EVALUATI ON Was the client able to manifest ability to cope with incompletel y relieved pain? ____ Yes ____ No

Monitor

Elevation in rates suggest

pain Measureme nts: T: 37.2 P: 86 R: 27

surgery. If left untreated, appendicitis may progress to abscess, perforation, subsequent peritonitis, and death.

nursing interventio n, the client will be able to determine precipitatin g contributor y factors. After 10 minutes of nursing interventio n, the nurse will be able to evaluate clients response to pain.

V/S and record

increased pain intensity and frequency

Assess pain characteristi cs including location, intensity, and frequency Perform pain assessment each time

Elevation in intensity and frequency may indicate worsening condition

To rule out worsening of underlying condition/devel opment of complications.

 After 20 minutes of nursing interventio n, the client will be able to explore methods for alleviation/ control of pain.

pain occurs. Note and investigate changes from previous reports. Accept clients description of pain

Pain is a subjective experience and cannot be felt by others. Observation s may/may not be congruent with verbal reports indicating need for further evaluation. Reduce stimuli

Observe non-verbal cues and other objective.

Provide quite

environmen t Provide comfort measures (e.g., back rub, change of position.)

To provide nonpharmacolo gic pain management

After 20 minutes of nursing interventio n, the client will be able to promote wellness.

To prevent fatigue

Encoura ge adequate rest periods. Review ways to lessen pain, including techniques such as, relaxation techniques.

 Identify specific signs/sympt oms and changes in pain requiring medical follow up.