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Published by Cathy Valeda

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Published by: Cathy Valeda on Jan 09, 2012
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ASSESSMENT Subjective: masakit yung parting inoperahan saakin as verbalized by the patient.

Objective: A mild painfelt in the right lower quadrant of the abdomen. Pain scale of 7 (from painscale of 0-10) is the highest

NURSING DIAGNOSIS Acute pain due to post operation (appendectomy)

PLANNING Within 1 hour of nursing intervention the patient will able to verbalize decrease in pain from pain scale of 7 to level 2.

INTERVENTION Independent: 1 .Assess location, character, onset/duration, frequency, quality, severity of pain. 2. Accept patients description of pain. 3. Observe non-verbal cues.4. Monitor vital signs. 4. Monitor vital signs.


EVALUATION The goal was met after 1 hour of nursing intervention the patient pain level decrease from pain scale of 7 to pain scale of 2. The patient falls asleep after intervention done.

1. Serves as baseline data.

2. Pain is subjective experience and cannot be felt by others. 3. Provide comparison of subjective data. 4. Usually altered in acute pain; to monitor progress of condition. 5. Provide relaxation technique. 6. Provide pharmacological management.

5. Provide quiet environment. Facial mask of pain. Guarding behavior. Discomfort in movement. 6. Provide comfort measures such as back rub, change in position and use of heat and cold. 7. Encourage deep breathing exercise. 8. Encourage diversional activities such as watching TV, listening to music. 9. Encourage adequate rests periods.

7. Aids in better tissue oxygenations thus reduce pain. 8. Diverts perception of pain.

9. To prevent fatigue.

ASSESSMENT Subjective: Pagising-gising ako sa pagtulog gawa ng opera ko as verbalized by the patient. INTERVENTION Independent: 1. PLANNING After 4 hours of nursing intervention the patient must able to learn some techniques of effective sleeping pattern. 2. 2. Health teaching to the patient. o 4. For the patient to understand the purpose of viral signs that causes him to be awake and why vital signs have to be done. NURSING DIAGNOSIS Sleep pattern disturbance related to pain due to post operation. 3. Back rub. For the client to help him more comfortable/relax on his bed . Ask the patient what is the reason why he cant sleep. the patient now understand all the techniques of sleeping pattern and can able to sleep comfortable. naiintindihan ko po. cleaning) in preparation for sleep 3. Objective: Dark circles under eyes. For the patient to feel at ease and comfortable . thus facilitating client-nurse interaction. Irritable o Explain necessity of disturbances for monitoring vital signs and or other care Provide quiet environment and comfort measures (eg. RATIONALE EVALUATION After doing the nursing interventions. washing hands/face. Establish rapport with the patient. Day 3 the patient verbalized sige. To have an idea on what and how to start the health teaching. ita try ko po 1.

3. 4. PLANNING Within 1hour of nursing intervention. 4. 2. Provide an environment that in conducive to learn 3.To prevent overload.Provide information about additional learning resources. 2.Provide written information/guidelines and self learning modules for client to refer to us for recovery.Helps to retain information what has been discussed. Discuss information relevant only to the situation. Objective: Always asks questions NURSING DIAGNOSIS Deficient knowledge related to lack of exposure and unfamiliarity of information resources. Provide active role for client in learning process. allows client to proceed at over pace. RATIONALE EVALUATION After 1 hour of nursing intervention the patient can now understand the nature of disorder.Reinforces learning process. INTERVENTION Independent: 1. 5 . 1. that client is assimilating /using new information. the patient will have sufficient knowledge about appendicitis.ASSESSMENT Subjective: Bakit ako nagkaroon ng appendicitis ? As verbalized by the patient. Promotes self of control over situation and is means for determining that.May assist with further learning/promote learning at own pace . 5 .

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