NURSING CARE PLAN

NURSING
CUES ANALYSIS GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

.
Subjective: Acute Appendicitis, one Goal: Independent:
Abdominal Pain of the most
“Sobrang sakit at Right Lower common diseases (1) After 8 (1) Assess the Pain is a subjective After 8 hours of
talaga banda dito Quadrant (RLQ) requiring hours of patient’s pain noting experience and nursing
(points RLQ), hindi r/t to emergency nursing location, cannot be felt by intervention,
ako makakain nang Inflammation of abdominal surgery, intervention, characteristics, others. For this patient’s pain
maayos at di ‘rin the Appendix as is inflammation of patient’s pain onset, duration, reason, obtaining reduced from 10 to
makatayo basta evidenced by the vermiform will reduce frequency, information 5 as evidenced by
sobrang sakit patient’s report appendix caused by from 10 to 5 as quality, intensity. regarding the patient’s report of
talaga niya. Di of pain intensity an obstruction evidenced by Identify precipitating patient’s pain decreased
nawawala tapos eh of 10/10 with a attributed to patient’s report or aggravating and should come from sensation of pain,
bigla bigla,” as characteristic of infection, stricture, of decreases relieving factors. him alone and if not felt relieved, and
verbalized by the sudden, sharp fecalith, foreign sensation of Document available, his able to
patient pain, guarding body or tumor. It pain, feeling and investigate significant others. control/manage his
behavior, facial affects either relieved, and/or changes from As a healthcare pain unlike before.
“Hindi sa OA pero grimacing, and gender at any age, able to previous reports and provider, accept the
10/10 talaga siya, distracted but its incidence is control/manage evaluate patient’s The goal has been
halata naman behavior higher among the pain unlike results of pain description of pain met.
siguro at inda ako males and there is a before. interventions to investigate
nang inda kanina familial changes and After 8 hours of
pa,” patient predisposition. (2) After 8 demonstrate nursing
answered when When there’s an hours of improvement intervention, the
asked about the obstruction in the nursing in status or to patient showed no
severity of the pain lumen of the intervention, identify worsening signs of
from pain scale of appendix, bacteria the patient will of underlying abdominal
0-10 (0 indicating multiplies quickly show no signs condition. guarding behavior
no pain and 10 as and may result in of abdominal and rebound
the highest) irritation of the guarding For elderly, they tenderness upon
organ. As the behavior and often experience physical
Objective: disease progresses, rebound reduction in examination.
it will affect the tenderness perception
 Abdominal lining of the upon physical of pain or have The goal has been
muscle abdominal wall, or examination. difficulty localizing met.
guarding peritoneum. With or describing
 Facial this, it causes (3) After 8 pain, and pain may After 8 hours of
grimacing sudden, sharp pain hours of be manifested as a nursing
 Distracted in the right lower nursing change in behavior intervention, the
behavior quadrant of the intervention, such as restlessness, patient appeared
 (+) abdomen.  If left the patient will increased relaxed and
Rebound untreated, appear relaxed confusion, focused.
tenderness appendicitis may and focused. distracted behavior.
lead to abscess, The goal has been
perforation, met.
subsequent Objective (2) Keep at rest in To lessen the pain.
peritonitis, and semi-Fowler’s Gravity localizes After 15 minutes
worst, death. Knowledge position inflammatory of health teaching,
exudate into lower the patient was
Based on the (1) After 15 abdomen or pelvis, able to identify
International minutes of relieving both three contributing
Association health teaching, abdominal factors that causes
for the Study of the patient will distension and pain in his
Pain, acute pain is be able to tension, which is abdomen.
an unpleasant identify three accentuated by
sensory and contributing supine position. The goal has been
emotional factors that met.
experience causes pain in
associated with his abdomen.
actual or potential After 15 minutes
tissue damage, (3) Move patient Likewise, to lessen of health teaching,
or described in (2) After 15 slowly. the pain because as the patient was
terms of such minutes of mentioned, the able to give three
damage; sudden or health teaching, patient has an interventions to
slow onset of the patient will abdominal guarding manage the disease
any intensity from be able to give behavior and it will per se.
mild to severe with three be of great of
an anticipated or interventions to importance because The goal has been
predictable end. manage the it minimizes pain met.
disease per se. upon movement.
Reference: After 15 minutes
Attitude of health teaching,
Hinkle, J. L. the patient was
Cheever, K. H., (1) After 15 (4) Encourage early To promote able to demonstrate
Brunner, L. S., & minutes of ambulation. normalization of behavior to
Suddarth, D. S. health teaching, organ monitor and
(2014). Brunner & the patient will function (stimulates promote alleviation
Suddarth's demonstrate peristalsis and of his disease.
Textbook Of behavior to passing of flatus,
Medical-Surgical monitor and reducing abdominal The goal has been
Nursing. promote discomfort). met.
Philadelphia: alleviation of
Wolters Kluwer his disease. (5) Place ice bag on To soothe and After 15 minutes
Health, Lippincott abdomen relieve pain through of health teaching,
Williams & (2) After 15 periodically during desensitization of the patient was
Wilkins. minutes of initial 24–48 hr, as nerve endings. The able to demonstrate
health teaching, appropriate. use of heat may use of relaxation
National Institute of the patient will cause tissue skills and
Diabetes and be able to Notes: Do not apply congestion and diversional
Digestive and demonstrate hot compress or hot applying direct activities.
Kidney Diseases use of shower. Avoid direct pressure on the The goal has been
(NIDDK). (2014). relaxation skills pressure on the abdomen met.
Appendicitis. and diversional abdomen. precipitates the
Retrieved from activities rupture of the
https://www.niddk. appendix.
nih.gov/health-
information/digesti
ve- (6) Provide comfort To promote
diseases/appendiciti measure like back relaxation and may
s rubs and deep enhance patient’s
breathing. Provide coping abilities by
Doenges, diversional refocusing
Moorhouse & activities. attention.
Murr. (2016).
Nurse’s Pocket
Guide: Diagnoses, (7) Keep NPO and To decrease
Prioritize maintain NG suction discomfort of early
Interventions, and initially. intestinal
Rationales 14th peristalsis, gastric
edition, p. 600 irritation and
vomiting.

Dependent:

(1) Maintain IV
fluids and
administer
antibiotic ordered by
physician.
Collaborative:

(1) Monitor To determine

hematologic test and indications of
other pertinent lab infections and such
records. to give an
immediate
intervention and
prevent further
complications.

(2) Administer Relief of pain

analgesic and other facilitates
medications as cooperation with
prescribed. other therapeutic
interventions
(ambulation).

Cefuroxime 750 mg Antibiotic

IVTT Q8 ANST prescribed for the
treatment of
infection.

Ranitidine 50 mg To reduce the

IVTT Q8 amount of acid
produced to prevent
further
complications.
Paracetamol 300 mg To relieve pain.
IVTT Q4

(3) Discuss with the Being informed

patient and his about progress of
significant others situation provides
about his condition emotional support,
with an accurate and helping to decrease
honest information. anxiety.

Reference:
Doenges,
Moorhouse &
Murr. (2016).
. Nurse’s Pocket
Guide: Diagnoses,
Prioritized
Interventions, and
Rationales 14th
edition, pp. 600 –
605