Student Nurses Community

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

DIAGNOSIS 5'ute pain ma! be related to distention o( intestinal tissue b! in(lammation and presen'e o( surgi'al in'ision#

IN ERENCE 5ppende'tom! is t"e removal o( t"e in(lamed appendi6# In an open7 'onventional7 and un'ompli'ated appende'tom!7 t"e surgeon removes t"e appendi6 t"roug" an in'ision appro6imatel! , in'"es long in t"e rig"t lo+er 8uadrant# T"e in'ision is larger i( t"e appendi6 is in a t!pi'al position or i( peritonitis is present#

PLANNING 5(ter 2 "our o( nursing interventions7 t"e 0atient +ill report pain is relieved or 'ontrolled and appear to be rela6ed7 able to sleep and rest appropriatel!#

INTER!ENTION Independent 5ssess pain7 noting lo'ations7 '"ara'teristi's7 and severit! (4 to 24 s'ale9# Investigate and report '"anges in pain7 as appropriate#

RATIONALE Use(ul in monitoring e((e'tiveness o( medi'ation and progression o( "ealing# C"anges in '"ara'teristi's o( pain ma! indi'ate developing abs'ess or peritonitis7 re8uiring prompt medi'al evaluation and intervention# Being in(ormed about t"e progress o( situation provides emotional support7 "elping to de'rease an6iet!# %ravit! lo'ali es in(lammator! e6udate into lo+er abdominal or pelvis7 relieving abdominal tension7 +"i'" is a''entuated b!

E!ALUATION 5(ter 2 "our o( nursing interventions7 t"e 0atient +as able to report pain is relieved or 'ontrolled and appear to be rela6ed7 able to sleep and rest appropriatel!#

verbali ed b! t"e patient#

$BJECTIVE: %uarding be"avior in t"e abdomen &a'ial mask o( pain )istra'tion be"aviors V*S taken as (ollo+s T: ,-#./C 0: ., 1: 23 B0: 224* .4

0rovide a''urate7 "onest in(ormation to patient or signi(i'ant ot"ers#

:eep at rest in semi;(o+lers position#

Student Nurses Community

supine position# 0romotes normali ation o( organ (un'tion? stimulates peristalsis and passing o( (latus7 redu'ing abdominal dis'om(ort# 1e(o'uses attention7 promotes rela6ation7 and ma! en"an'e 'oping abilities# )e'rease dis'om(ort o( earl! intestinal peristalsis and gastri' irritation and vomiting# 1elie( o( pain (a'ilitates 'ooperation +it" ot"er t"erapeuti' intervention su'" as ambulation and pulmonar! toilet# Soot"es and relieves pain t"roug" desensiti ation o( nerve endings#

En'ourage earl! ambulation#

0rovide diversional a'tivities#

Collaborative :eep <0$ and maintain nasogastri' su'tioning initiall!# 5dminister analgesi's as indi'ated#

0la'e i'e bag on abdomen periodi'all! during initial => to >. "ours as appropriate#