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Student Nurses Community

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

DIAGNOSIS Acute pain may be related to distention of intestinal tissue by inflammation and presence of surgical incision.

INFERENCE Appendectomy is the removal of the inflamed appendix. In an open, conventional, and uncomplicated appendectomy, the surgeon removes the appendix through an incision approximately 3 inches long in the right lower quadrant. The incision is larger if the appendix is in a typical position or if peritonitis is present.

PLANNING After 1 hour of nursing interventions, the Patient will report pain is relieved or controlled and appear to be relaxed, able to sleep and rest appropriately.

INTERVENTION Independent Assess pain, noting locations, characteristics, and severity (0 to 10 scale). Investigate and report changes in pain, as appropriate.

RATIONALE Useful in monitoring effectiveness of medication and progression of healing. Changes in characteristics of pain may indicate developing abscess or peritonitis, requiring prompt medical evaluation and intervention. Being informed about the progress of situation provides emotional support, helping to decrease anxiety. Gravity localizes inflammatory exudate into lower abdominal or pelvis, relieving abdominal tension, which is accentuated by supine position.

EVALUATION After 1 hour of nursing interventions, the Patient was able to report pain is relieved or controlled and appear to be relaxed, able to sleep and rest appropriately.

verbalized by the patient.

OBJECTIVE: Guarding behavior in the abdomen Facial mask of pain Distraction behaviors V/S taken as follows T: 36.8C P: 83 R: 17 BP: 110/ 80

Provide accurate, honest information to patient or significant others.

Keep at rest in semi-fowlers position.

Student Nurses Community

Encourage early ambulation. Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort. Refocuses attention, promotes relaxation, and may enhance coping abilities. Decrease discomfort of early intestinal peristalsis and gastric irritation and vomiting. Relief of pain facilitates cooperation with other therapeutic intervention such as ambulation and pulmonary toilet. Soothes and relieves pain through desensitization of nerve endings.

Provide diversional activities.

Collaborative Keep NPO and maintain nasogastric suctioning initially. Administer analgesics as indicated.

Place ice bag on abdomen periodically during initial 24 to 48 hours as appropriate.