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NURSING CARE PLAN Appendectomy ASSESSMENT SUBJECTIVE: Sumasakit and sugat ng opera ko (I feel pain
around the incision site) as

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

INFERENCE Appendectomy is the removal of the inflamed appendix. In an open, conventional, and uncomplicated appendectomy, the surgeon removes the appendix through an incision approximately 3 inches long in the right lower quadrant. The incision is larger if the appendix is in a typical position or if peritonitis is present.

PLANNING After 1 hour of nursing interventions, the Patient will report pain is relieved or controlled and appear to be relaxed, able to sleep and rest appropriately.

INTERVENTION Independent Assess pain, noting locations, characteristics, and severity (0 to 10 scale). Investigate and report changes in pain, as appropriate.

RATIONALE Useful in monitoring effectiveness of medication and progression of healing. Changes in characteristics of pain may indicate developing abscess or peritonitis, requiring prompt medical evaluation and intervention. Being informed about the progress of situation provides emotional support, helping to decrease anxiety. Gravity localizes inflammatory exudate into lower abdominal or pelvis, relieving abdominal tension, which is accentuated by supine position.

EVALUATION After 1 hour of nursing interventions, the Patient was able to report pain is relieved or controlled and appear to be relaxed, able to sleep and rest appropriately.

verbalized by the patient.

OBJECTIVE:

Guarding behavior in the abdomen Facial mask of pain Distraction behaviors V/S taken as follows T: 36.8C P: 83 R: 17 BP: 110/ 80

Provide accurate, honest information to patient or significant others.

Keep at rest in semi-fowlers position.

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Encourage early ambulation. Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort. Refocuses attention, promotes relaxation, and may enhance coping abilities. Decrease discomfort of early intestinal peristalsis and gastric irritation and vomiting. Relief of pain facilitates cooperation with other therapeutic intervention such as ambulation and pulmonary toilet. Soothes and relieves pain through desensitization of nerve endings.

Provide diversional activities.

Collaborative Keep NPO and maintain nasogastric suctioning initially. Administer analgesics as indicated.

Place ice bag on abdomen periodically during initial 24 to 48 hours as appropriate.

Problem

Nursing Diagnosis

Background Knowledge

Goal and Objectives

Nursing Intervention

Rationale

Evaluation

Open wound

Student Nurses Community High risk for Trauma on After 2 hours of infection d/t skin at left nursing inadequate anterior intervention the primary patient will gain defense as knowledge in manifested by Broken skin infection control broken skin as evidenced by discussing the Open wound wound care. Risk for infection

Independent 1. Establish rappoirt

2. Teach patient to wash hands often, especially before toileting, before meals and before and after administering self-care 3. Discuss to patients the following signs of infection redness, swelling, increased pain, or purulent drainage on the site and fever 4. Demonstrate and allow return demonstration of wound care

To gain trust and cooperation of the patient Hand washing reduces the risks for infection

After 2 hours of nursing intervention the patient will be able to gain knowledge in infection control as evidenced by his discussion in wound care. Therefore, the goal was met

To impart to the patient when the wound become infected and when to sought medical care To know if the patient really understand the principle of proper wound care

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