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DE RAMOS, Karen R.

07-12-10

BSN III –A1 / Group CA1


MCP – OR

Ma’am Nenita Orobia

Nursing Care Plan

Priority Problem for Post – op Appendectomy

Cues Nursing Rationale Goals and Nursing Rationale Evaluation


Diagnosis Objectives Intervention
Subjective: Acute pain Unpleasant After 4 hours Independent: After 4 hours
“kumikirot-kirot related to sensory and of nursing  Assess pain,  Useful in monitoring of nursing
yung bandang presence of experience intervention, noting effectiveness of intervention,
inoperahan” as surgical arising from the patient location, medication, the patient
verbalized by incision as actual or will be able to characteristics progression of was able to
the patient. manifested potential tissue verbalize , severity (0- healing. Changes in verbalize pain
by facial damage or relief of pain 10). characteristics of is reduced
Objective: grimace described in or at least Investigate pain may indicate from pain
 Observed and report terms of pain is and report developing abscess/ scale 5/10 to
evidence of of pain. damage; reduced from changes in peritonitis, requiring 3/10 and also
pain; facial sudden or slow pain scale pain as prompt medical the patient
grimace onset of any 5/10 to 3/10 appropriate. evaluation and was able to
 Verbalized intensity from and also the intervention appear
pain at the mild to severe patient will relaxed.
abdomen with an be able to  Gravity localizes
with a pain anticipated or appear  Keep at rest in inflammatory
scale of predictable end relaxed. semi-Fowler’s exudates into lower
5/10 and a duration position. abdomen or pelvis,
 Guarding of less than 6 relieving abdominal
behaviour in moths. tension, which is
the incision accentuated by
site. Reference: supine position.
 Positioning page 498
to avoid pain Nurse’s Pocket  Encourage  Promotes
Guide early normalization of
Diagnoses, ambulation. organ function.
prioritized
interventions  Provide  Refocuses attention,
and rationale diversional promotes relaxation,
11th edition by activities. and may enhance
Doenges, coping abilities.
Moorhouse and
Murr
Collaborative:
 Keep NPO/  Decreases
maintain NG discomfort of early
suction intestinal peristalsis
initially. and gastric
irritation/vomiting.

 Administer  Relief of pain


analgesics as facilitates
indicated. cooperation with
other therapeutic
 Place ice bag interventions.
on the
abdomen  Soothes and relieve
periodically, pain through
during initial desensitization of
24-48 hours nerve endings. Note:
as do not use heat
appropriate. because it may
cause tissue
congestion/ increase
edema formation.
Reference:
Page 354
Nursing Care Plan
Guidelines for
individualizing client
care across the life span
Edition 7 by Doenges,
Moorhouse and Murr