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CUES

NURSING SCIENTIF GOAL OF NURSING RATIONA COMPET OUTCOM DIAGNOS IC CARE INTERVE LE ENCIES E IS EXPLANA NTIONS TION Acut pain related to distention of intestinal tissue(app endix) by inflammati on Causes: Renal calculi & fecalith Short term: After 2 hours of nursing Obstructio interventio n in ns patient appendice will be al lumen able to: Engorged vein Stasis Arterial Occlusion Increases Intalumina l pressure NIC-Pain Managem ent INDEPEN DENT: - Changes Safe and in Quality characteri Care stics of pain may indicate abscess and complicati on such as peritonitis -This is also useful in monitoring the effectiven ess of medicatio ns (analgesia ) Safe and -To relax Quality abdominal Care muscle and to reduce abdominal distention there by reduce SHORT TERM: Goal met. After 2 hours of nursing interventio ns patient was able to demostrat e the proper use of relaxation technique such as deep breathing exercises and diversiona l activities to relieve pain. LONG TERM: Goal met after 8 hours of of nursing interventio n patient was able to demostrat e and use properly the relaxation

S=Masak it ang tiyan koas verbalized by the patient. With pain scale of 8/10 O=restles s -irritable -facial grimacing -anorexia abdominal muscle guarding Signs -rebound tendernes s noted -(+) Rovsing's sign -(+) Obturator sign Laborator y test a. Urinalysis -(+) RBC,WBC ,Bacteria

a. Assessed pain location, Demonstr characteri ate stic and relaxation severity skills and other methods to promote comfort

Distention of appendix (causing pain) Long term: decreases After 8 venous hours of drainage nursing interventio Blood flow ns patient and O2 will be restriction able to: in the appendix Demonstr are Bacterial realxation invasion in skill and blood wall other

b. Maintaine d patient at bedrest and at semi fowlers position

and renal calculi b. Abdominal x-ray (+) fecalith Vital signs Temp:38 C RR: 16 cpm PR:67 bpm BP: 100/80 mmHg

methods Inflammati to on/Infetion promote comfort Necrosis Perforatio n of appendix Acute appendicit is -Decrease sensation of pain and free from signs and symptoms of complicati ons

ension c. Monitored body temperatu re, blood pressure pulse and respiration q1 -To have a baseline data - Increase in body temperatu re, tachycardi a, hypotensi on and other symptoms such as diaphoresi s, abdominal distention, N/V, and d. pain may Diversiona indicate l activities peritonitis. provided -to refocusse s attention and promote relaxation -To e. Comfort enhance measures also provided coping such as abilities back rubs -To f. Health promote teachings relaxation imparted such as: importanc - to relax e of deep abdominal breathing muscle exercises and to

technique s such as deep breathing exercises and the use of diversiona l activities to relieve pain -Patient also reported decrease sensation of pain from 8/10 to 4/10 during nursing interventio ns and health teachings imparted ( deep breathing exercises and applying icebag) - patient also was free from any signs and symptoms of complicati on ( peritoniti s ) at the end of the shift due

provide relaxation COLLABO also to RATIVE patient a. Administer analgesic as prescribed and indicated - To relief pain and fascilitate cooperatio b. Place n of icebag on patient the with other abdomen therapeuti c interventio ns - It soothes and relief pain through desentizat ion of nerve endings NOTE! Do not use heat it may cayse tissue congestio n that will result to rupture that will c. Keep at increases NPO the mortality and morbidity

to nursing interventio ns done.

and it will prolong the hospitaliza tion of patient. -To decrease discomfort and gastric irritation ( vommitin g)