NURSING CARE PLAN ASSESSMENT DIAGNOSIS PLANNING Short term: After 1 hour of nursing intervention the patient pain

will relieve as evidenced by patient verbalize of decrease in pain from 6/10 to 2/10 INTERVENTION Independent: Assess client perception, level of understanding and needs Monitor vital Signs Performed a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity of pain Encouraged verbalized of feelings about the pain Provide calm activities

RATIONALE To assess the different intervention to be done To obtain baseline data To have necessary information about the case of the patient To lessen the pain of the patient To lessen the pain To prevent fatigue To promote circulation To relax and provide comfort measure

EVALUATION After 1 hour of nursing intervention the patient pain relieved as evidenced by patient verbalize of decrease in pain from 6/10 to 2/10

Subjective: Acute pain Hindi ako related to masyadong post op makagalaw ng incision as maayos,sumasakit evidenced by ang tahi ko as a pain scale verbalized by the of 6/10 patient Objective: P-pain occurs every time he moves q-stabbing r- increased right lower quadrant (RLQ) pain with extension of right leg s-6/10 t-last for 2 mins vital signs taken as follows: BP:120/70mmhg RR:26cpm PR:74bpm temp:37.7 c -restlessness -pale skin

Long term: After 8 hours the patient will be able to know the different techniques to prevent pain

Encouraged adequate rest period Instructed to do activities such as deep breathing exercise and changing position Dependent: Provide nonpharmacological therapies

To decrease level of pain

Long term: After 8 hours of nursing intervention the patient able to know the different techniques to prevent pain

 Administration of analgesics as ordered

ASSESSMAENT Subjective: nandito ang tahi ko sa may tagiliran ko as verbalized the patient

Objective: Dry skin Decreased sensation Disruption of skin surface Observed scratching of the operative site With Surgical incision at right lower abdominal area

DIAGNOSIS Impaired skin integrity related to post operative incision as manifested by observed scratching of the operative site

PLANNING After 2 hours of nursing intervention the patient will Understand the importance of caring the incision site

INTERVENTION Independent: Used appropriate wound dressing Evaluate for use of specialty bed mattresses Remove the once it soiled Assess patient nutritional status

RATIONALE To protect the wound and surrounding tissues To reduce shearing forces on the skin. It can be a portal entry of microorganism Inadequate nutritional intake places individual at risk for skin breakdown and it compromise healing To promote circulation To decrease risk for infection To avoid accumulation of moisture at the operative site To prevent bacteria harbor in operative site

Long term: After 3 weeks the patient will shows signs of wound healing such as dry and intact wound

EVALUATION After 2 hours of nursing intervention the patient understand the importance of caring the incision site

Long term: After 3 weeks the patient shows signs of wound healing such as dry and intact wound

Instructed to do activities such as deep breathing exercise and changing position Maintain infection controlled standards Provide regular dressing care Dependent Administer drug as prescribe

ASSESSMENT Subjective: nagkaapendiks ako mula nung tumatalon ako ng mataas pag nagbabasketball ako as verbalized the patient Objective: . Dry skin Lack of integration of treatment plans into daily activities. Verbalizes a deficiency in knowledge about appendicitis Expresses and inaccurate perception of health status

DIAGNOSIS PLANNING Knowledge Short term: deficit After 2 hours of related to nursing lack of intervention the information patient will be able to describe the factors contributing to the symptoms Long term: After 1 week the patient will identifies perceive learning needs

INTERVENTION Independent: Provide a quiet atmosphere without interruption. Determine patient ability to learn Assess the level of patient capabilities Motivate patient y providing information relevant to the situation

RATIONALE

To concentrate more completely

To know the level of learning To know patient coping ability towards to the situation To help patient acquired relevant information

EVALUATION Short term: After 2 hours of nursing intervention the patient able to describe the factors contributing to the symptoms Long term:

Provide active role for patient in learning process Assist patient to incorporate activity regimen into daily routine

After 1 week the patient identifies perceived learning needs

To promote sense of control over the situation To properly alternate period of rest and activity