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Data

:
Patient is crying and restless.
Stated “My stomach really
hurts”
Abdomen is tender to touch
Pulse – 105 beats/min
Pain 7/10

#1 Intervention
Administer
Acetaminophen 325mg
sup Q4H

#1 Nursing Diagnosis:
Acute Pain r/t inflammation of appendix

#2 Intervention
If Acetaminophen is ineffective,
administer 2-3mg Q4H IV/SQ as
needed for pain

#5 Intervention
Provide a calm and
restful environment
#3 Intervention
Allow child to
position herself
comfortably

Evaluation:
Goal Met:
At the end of the 2-hour
education session, the
patient and parent will
express their feelings of
anxiety towards upcoming
patient’s surgery and was
willing to use coping skills.

#6 Intervention
Educate parent on
observing cues for
pain

#2 Intervention
Assess for signs of
dehydration: skin tenting,
sunken eyes, dry mucous
membranes.

#3 Intervention
Monitor VS Q4H

Data:
Vomited X 1
NPO prior to
surgery

#3 Intervention
Give clear and
concise
explanations
regarding

Data:
RLQ pain
Temperature: 38.7
C
Vomited X 1
WBC 15000

#2 Nursing Diagnosis:
Risk for infection related to impending rupture of
appendix
Goal: The patient will not exhibit any signs of infection
and will be able to proceed with surgery with no
#3 Intervention
Administer
Dimenhydrinate 25 mg
Q4H IV/SQ for nausea

#4 Intervention #5 Intervention
Maintain adequate Administer
hydration. Acetaminophen 325
mg sup Q4H for relief
from fever.

#5
Intervention
Monitor
intake and
output.

#4 Intervention
Administer
Dimehydrinate 25 mg
Q4H IV/SQ as needed.
Data:
Patient’s first hospitalization
Patient verbalized, “Will they put me to sleep when I have the
operation?”
#5 Intervention
Patient’s mom stated, “The doctor told us, that she might have
Identify and reinforce
appendicitis and may require an operation. He said, he wanted to
coping strategies.
admit her and keep an eye on her for a while. When will the doctor
Evaluation:
know if Marcy will need operation?”
Goal Met: At the end of my 2-hour shift,
No prior health problems
the client will verbalize understanding
of the surgical procedure, pre-operative
and post- operative care.

#4 Nursing Diagnosis:
Anxiety (mild) related to upcoming surgery.
Goal: At the end of my shift, the patient and parent will
acknowledge their feelings of anxiety and verbalize relief from
anxiety.
#1 Intervention
Discuss alternate
strategies for handling
anxiety.

Evaluation: Goal Met
1 hour prior to surgery.
Patient’s fever was resolved,
temperature 36.8C. Vital
Signs remained within
normal limits. No emesis

#2 Intervention
Administer
prophylactic
antibiotics as

#3 Nursing Diagnosis:
#4 Intervention
Risksmall
for deficient fluid volume related to decreased fluid intake
Provide a stuffed animal,
and loss
pillow or blanket to aid in
Goal: At the end of my shift, the patient will not exhibit signs of
splinting the area
dehydration.

#1 Intervention
Maintain NPO
status

#2 Intervention
Encourage client to
acknowledge and
express feelings of
anxiety.

#1 Intervention
Assess patient’s Vital Signs
Q4H

#7 Intervention
Provide
distractions such
as books, puzzles,
TV and games

Goal: The patient will demonstrate relief from pain by the end of my
shift

Data:
Pulse – 105 beats/min
First Hospitalization
Patient stated, “Will they
put me to sleep when I
have the operation?”
Restlessness

Evaluation: Goal
Met
2 hours preoperative, client
was observed to
have adequate skin

Evaluation: Goal
Met
20 mins after the
first dose of
Morphine, patient
states relief from

#5 Nursing Diagnosis:
#1 Intervention
Deficient Knowledge related to lack of information regarding surgery
Perform pre-op and post-op
and post-operative care.
education.
Goal: At the end of my shift, the patient and parent will acknowledge
their feelings of anxiety and verbalize relief from anxiety.

#4 intervention
Provide distractions
such as books, games
and television.

#2 Intervention
Assess barriers and readiness to
learn and response to teaching
education.

Key:
Nursing Diagnosis
Outcomes
Subjective/ Objective
Data
Interventions
Evaluations

#4 Intervention
Offer emotional support allow
time to discuss concerns and
possibilities.
#3 Intervention
Explain the rationale for
surgery.

Patient: Marcy Lane
Nursing Diagnoses

Goal

Interventions

Evaluation

#5 Intervention
Review discharge
instructions and follow up
with written copy for
patient.

“Will they put me to sleep when I have the operation?”  Restlessness 5. Explain the rationale for surgery. 2. Provide distractions such as books. Perform pre-op and post-op education. small pillow or blanket to aid in splinting the area.7 C  Vomited X 1  WBC 15000 cells/cu mm The patient will not exhibit any signs of infection and will be able to proceed with surgery with no complications. Give clear and concise explanations regarding impending procedures. Monitor intake and output. Goal Met: At the end of the 2 hour education session. preoperative and postoperative care. 1. 5. Maintain NPO status 2. Encourage client to acknowledge and express feelings for anxiety. Monitor VS Q4H 4. 2.  Abdomen is tender to touch  Pulse – 105 beats/min The patient will demonstrate relief from pain by the end of shift on June 5 2016 2. Goal Met: At the end of my 2 hour shift. “Will they put me to sleep when I have the operation?”  Patient’s mom stated. Goal Met: 2 hours pre-operative. Signs and Symptoms:  Vomited X 1  NPO prior to surgery At the end of my shift. Administer Acetaminophen 325mg sup Q4H. puzzles. the patient will not exhibit signs of dehydration. Goal Met: 20 mins after the first dose of Morphine. the patient and parent will acknowledge their feelings of anxiety and verbalize relief from anxiety. No emesis reported for the remainder of the shift. Deficient Knowledge related to lack of information regarding surgery and post-operative care. administer 23mg Q4H IV/SQ as needed 3. Administer prophylactic antibiotics as ordered. 3. Administer Dimehydrinate 25 mg Q4H IV/SQ as needed. client was observed to have adequate skin turgor and moist mucous membranes.  Stated “My stomach really hurts”. that she might At the end of my shift. At the end of my shift. Patient’s fever was resolved. 5. Educate parent on observing cues for pain. Acute Pain related inflammation of the appendix Signs and Symptoms:  Patient is crying and restless. 6. 1. 3. the patient and the parent will understand the rationale for the surgery and learn about the importance of adhering to postoperative care. Allow child to position herself comfortably. 7. Anxiety (mild) related to upcoming surgery. Administer Dimenhydrinate 25 mg Q4H IV/SQ for nausea 4. 5. Risk for deficient fluid volume related to decreased fluid intake and loss. 5. “The doctor told us. 4. Assess barriers and readiness to learn and response to teaching. 2. games and television. 4. 3. Discuss alternate strategies for handling anxiety.  Pain Scale 7/10. Risk for infection related to impending rupture of appendix Signs and Symptoms:  RLQ pain  Temperature: 38. Review discharge instructions and follow up with written copy for patient. Provide a calm and restful environment. If Acetaminophen is ineffective. Signs and Symptoms:  Patient’s first hospitalization  Patient verbalized. Goal Met: 1 hour prior to surgery. . 1. Vital Signs remained within normal limits. the patient and parent will express their feelings of anxiety towards upcoming patient’s surgery and was willing to use coping skills. Signs and Symptoms:  Pulse – 105 beats/min  First Hospitalization  Patient stated. temperature 36. Identify and reinforce coping strategies. Offer emotional support allow time to discuss concerns and possibilities. Assess patient’s Vital Signs Q4H 2. Provide a stuffed animal. Administer Acetaminophen 325 mg sup Q4H for relief from fever.1. 3. dry mucous membranes. 3. TV and games 1. 4. sunken eyes. Assess for signs of dehydration: skin tenting. 5. Maintain adequate hydration.8C. the client will verbalize understanding of the surgical procedure. Provide distractions such as books. 4. 1. patient states relief from pain 3/10 .

  have appendicitis and may require an operation. He said. he wanted to admit her and keep an eye on her for a while. When will the doctor know if Marcy will need operation?” No prior health problems Restlessness .