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NCP Appendicitis

NCP Appendicitis

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Published by Arnel Luces Beato

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Categories:Types, School Work
Published by: Arnel Luces Beato on Sep 12, 2010
Copyright:Attribution Non-commercial

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05/12/2014

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ASSESSMENT NURSING
DIAGNOSIS
INFERENCE PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective:

Ang sakit ng
tiyan ko, as
verbalized by
the patient

Objective:
-Guarding
behavior
- Protective
gestures
- Positioning
to avoid
pain
- Facial Mask
of Pain
- V/S taken as
follows:
y
T: 37.3
y
P: 80
y
R: 18
y
Bp:
110/90
y
Pain:
6/10
y

Acute pain
related to
inflammati
on of
tissues

(Appendicitis)
Stimuli
Sensory
Stimuli
Dorsal Horn
Medulla
Interpretation
Acute Pain

After the
intervention, the
patient will:

- Demonstrate
use of
relaxation

technique or
methods to
promote
comfort

- Report pain
is relieved/
controlled
Independent

· Investigate pain
reports, noting
location, duration,
intensity (0-10

scale), and
characteristics
(dull, sharp,
constant)

· Maintain
semifowlers
Position

· Move patient
slowly and
deliberately

· Provide comfort
measure like
back rubs, deep
breathing.

· Changes in
location or
intensity are

not
uncommon but

may reflect
developing
complications

·Reduces
abdominal
distention,
thereby
reduces
tension

·Reduces
muscle tension
or guarding,
which may help
minimize pain
of movement

· Promotes
relaxation and
may enhance
patients coping

After the
intervention, the
goal has partially
met as manifested
by:

- Demonstrated
use of
relaxation

technique or
methods to
promote
comfort

-Reported pain
is relieved/
controlled

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