Ortiz, Sr. Jenny Lou T.

BSN-III BLOCK-1 Merilles, Kevin Kier BSN-III BLOCK-1

NURSING CARE PLAN

Patients Name: Pangalay, Benjamin Age: 36 Sex: Male Religion: Roman Catholic Status: Single Status: Single Complaints: Acute pain in right lower quadrant of the abdomen General Objective: After 3 days of nursing care, client comfort level increased, pain controlled with the expected outcome Diagnosis / Impression: Acute Appendicitis Date of Admission: July 03, 2013

CUES

NURSING DIAGNOSIS Acute Pain related to Surgical Incision

SCIENTIFIC ANALYSIS

OBJECTIVES

Subjective: *Verbal report of pain Objective: *Changes of appetite *Guarding behavior *Moaning

After 3 days of Pain is unpleasant nursing care, the sensory and patient will be able emotional to: experience report reduced arising from pain, pain scale 2-3 actual or gain calm facial potential tissue expression and can damage or rest, sleep. described in Have a normal terms of damage. limits of Vital signs It is a sudden or

NURSING INTERVENTIONS *Assess pain comprehensively including location, characteristics, duration, frequency, quality factor and precipitation. *Observation of nonverbal reactions inconvenience. *Provide a quiet environment

RATIONALE >To rule out worseningof underlying condition and developmetn of complications.

EVALUATION

>Observations may not be congruent with verbal reports or maybe only indicator present when client is unable to verbalize. >To provide comfort. >To distract attention and

Fully met

*Sleep disturbance *Restlessness

slow onset of any intensity from mild to severe with an anticipated or predictable end.

*Reduce pain precipitation factor. *Teach nonpharmacological techniques (relaxation, distraction, etc.) *Give analgesics *Monitor client's acceptance of pain management.

reduce tension >To promote Nonpharmacological pain management.

> To reduce pain. >Pain is subjective experience and cannot be felt by others.

Ortiz, Sr. Jenny Lou T. BSN-III BLOCK-1 Merilles, Kevin Kier BSN-III BLOCK-1

NURSING CARE PLAN

Patients Name: Pangalay, Benjamin Age: 36 Sex: Male Religion: Roman Catholic Status: Single Status: Single Complaints: Acute pain in right lower quadrant of the abdomen General Objective: After 3 days of nursing care, the patient will be able to demonstrate techniques in promoting safe environment. Diagnosis / Impression: Acute Appendicitis Date of Admission: July 03, 2013

CUES

NURSING DIAGNOSIS Risk for Infection related to surgical incision

SCIENTIFIC ANALYSIS Risk of infection is a nursing diagnosis which is defined as "the state in which an individual is at risk to be invaded by an opportunistic

OBJECTIVES

NURSING INTERVENTIONS *Stress proper hand hygiene to the patient and to those who are taking care of him. *Monitor clients visitors for respiratory illnesses. *Recommend routine body showers when

RATIONALE

EVALUATION

After 3 days of nursing interventions, the patient will be able to: *verbalize understanding of individual causative risk factors. *identify interventions

>A first line defense against infection is hand washing. >To limit exposures, thus reduce crosscontamination >to reduce bacterial

Partially met

or pathogenic agent (virus, fungus, bacteria, protozoa, or other parasite) from endogenous or exogenous sources. The
risk of infection depends on a number of endogenous sources. Risk factors includes decreased immune system secondary to disease, compromised circulation secondary to peripheral vascular disease, compromised

to prevent and reduce the risk of infection. *achieve timely wound healing and free from purulent drainage or erythema; afebrile.

indicated. *Cover perineal or pelvic region dressings with plastic when using bedpan. *Encourage early ambulation, deep breathing, coughing, and position changes. *Dress the wound as many times in a day.

colonization. *to prevent contamination.

>for mobilization of respiratory secretions and prevention of aspiration or respiratory infections. > to promote rapid healing.

skin integrity secondary to surgery, or repeated contact with contagious agents.