ASSESSME EXPLANATIO PLANNING INTERVEN RATIONALE EVALUATI

NT N OF THE TION ON
PROBLEM
Subjective: Patient have STO: Diagnostic: Short term
“Masakit po confirmed Within 4 hour Assess To be able to goal met if
ang tiyan ko appendicitis and of effective palliative, plan effective patient
lalo nap pag had gone for nursing quality, treatment and verbalizes
gumagalaw” appendectomy, intervention region, to provide reduce pain
as verbalized therefore there the client severity and comfort for scale from
by the patient may be pain on would be able time of pain. patient 8/10 to 5/10
the incision site. to report that
Objective: pain is
-Pain scale relieved or Because if there Long term
rated as 8/10 controlled, Monitor vital is pain the vital goal met if
-facial from pain signs BP, sign usually patient
grimace scale of 8/10 PR, RR increase. demonstrates:
noted to 5/10. Deep
-Guarding breathing
behaviors To be able to exercises to
noted LTO: Monitor and plan effective relive pain
-Patient is After 2-3 days document the treatment and
irritable of effective location, to provide
-diaphoresis nursing severity, and comfort for
noted intervention character of patient
the patient pain -Perform
Nursing will be able to pain
Diagnosis demonstrate assessment May be altered
Acute Pain pain each time pain by acute pain
related to management occurs
presence of techniques.
surgical Monitor skin
incision color and
temperature,
as well as vital
signs (e.g.,
heart rate, Gravity
blood localizes
pressure, inflammatory
respirations). exudate into
lower abdomen
Therapeutic: or pelvis,
Independent relieving
Keep at rest in abdominal
semi-Fowler’s tension, which
position. is accentuated
by supine
position

Refocuses
attention; may
enhance coping
Provide abilities
diversional
activities,
such as Promotes
reading, relaxation and
visiting, decreases
music, and tension
television.
Decreases
Perform discomfort of
palliative early intestinal
measures, peristalsis and
such as gastric irritation
repositioning or vomiting.

Keep NPO
and maintain To relieve pain
NG suction felt by client
initially

Dependent
-Give Non-
Ketorolac pharmacologic
30mg IV pain
every 6 hours management
as ordered by
medical
doctor Prevents
fatigue,
Educative: promotes
Instruct and healing and
demonstrated feeling of well-
deep breathing being, and
exercises facilitates
resumption of
Encourage normal
progressive activities.
activities as
tolerated with Assists with
periodic rest return to usual
periods. bowel function;
prevents undue
straining for
defecation.
Recommend
use of mild Understanding
laxative or promotes
stool softeners cooperation
as necessary with therapeutic
and avoidance regimen,
of enemas. enhancing
healing and
Discuss care recovery
of incision, process.
including
dressing To prevent the
changes, spread of
bathing bacteria
restrictions,
and return to -Decreases
physician for susceptibility to
suture and infection.
staple
removal.

Practice good
hand hygiene

Encourage
increased fluid
intake, good
nutrition, and
adequate rest.