, Vardeleon, Hazel O.

BSN003- Group 12 Patients Name: Santos Banares Age: 40room 3 bed 11 Dx: S/P Appendectomy

Far Eastern University Institute of Nursing NURSING CARE PLAN Cues INTERACTION: Masakit padin ang tahi ko sa may bandang tagiliran OBSERVATION: -irritable -facial grimacing/ facial mask of pain -guarded movements/ behavior MEASUREMENT : -VS: BP-110/70 mmHg Temp- 36.8 PR- 77 bpm RR-21 bpm Pain scale : 7 out of 10 Nursing Diagnosis Acute Pain related to post surgical incision Situational Analysis: Appendicitis is the most common disease requiring emergency surgery. It is the inflammation and obstruction of the vermiform appendix. Appendectomy is the best treatment for this and this will leave a surgical incision in the right lower portion of the abdomen or the McBurneys point. Health Implication: If appendicitis is untreated, this is Objectives Short Term: After one hour of nursing intervention, the client will be able to have a pain scale from 7 to 5 out of 10. Long Term: After the end of shift, the client will be able to verbalize relief from pain and states level of pain as tolerable. Interventions INDEPENDENT: Monitor and record vital signs Monitor and record Intake and output Assess for pain scale Assess incision site and change dressing as needed To obtain baseline data. To check for signs of infection and wound dehiscence. Changing the soiled dressing will prevent infection and discomfort. In a patient whose nausea and abdominal rigidity have subsided, these signs indicate readiness to resume oral fluids To reduce pain To obtain baseline data. To obtain baseline data. Rationale Evaluation GOAL MET As evidenced by the following: Interaction: hindi na gaano masakit yung tahi ko Observation: -the patient looks comfortable and less irritable -no facial grimacing when moving Measurement: -VS: BP-110/70 mmHg Temp- 36.8 PR- 77 bpm RR-21 bpm Pain scale : 5 out of 10

Document bowel sounds, passing of flatus and bowel movements

Place client in semifowlers to fowlers position Place an ice bag

invariably fatal. Pain in the incision site will be uncomfortable for the patient, there is also a chance to develop complications such as infection. Lippincot Manual of Nursing Practice Series, Pathophysiology pg. 190-191.

Watch closely for possible surgical complications Encourage deep breathing and frequent turning DEPENDENT: Give analgesia as ordered Assist with medication regimen as necessary, noting potential presence of side effects COLLABORATIVE: Assist/support family with care of the patient

Never apply heat to the site because it will cause pain, ice bag can relief the pain Fever and continuing pain would indicate abscess To prevent pulmonary complications

Analgesics reduces pain To aid in fast recovery of the patient and to prevent complications

Enhance likelihood to finding individually appropriate situation to meet clients needs.