Name: C.C. Neil Abraham M.Lalap BSN3-E Group21 Age / Sex: 15 years old/ male Ms. Jovita L R.N.

Medical Diagnosis: Ruptured appendicitis with localized peritonitis Nursing Diagnosis: Acute Pain related to distention of intestinal tissues by inflammation as evidenced by facial grimace and guarding behavior. Short Term Goal: at the end of my 8hours shift the patient will report pain is alleviated from pain scale of 10/10 to 7/10 Long Term Goal: at the end of the hospitalization the patient report pain is relieved and able to sleep/rest appropriately Date Cues tyan ko as verbalized by the patient
O: > (+) facial grimace > (+) guarding behavior > pain scale of 10/10

Problem
Acute Pain

Scientific Rationale

Nursing Intervention

Rationale

Evaluation

03/11/ 11 S: >ansakit ng

Unpleasant sensory and emotional INDEPENDENT: experience arising from actual or potential tissue damage, sudden or -assess pain, note location, slow onset of any intensity from characteristics and severity mild to severe wit anticipated or predictable end and a duration of less than 6months. -keep at rest in semi fowlers position

-useful in monitoring effectiveness of medicines given and pregression of healing. -gravity localizes inflammatory exudate in lower abdomen or pelvis, relieving abdominal tension. -promotes normalization of organ function and stimulates peristalsis. -refocus attention and promotes relaxation -relief of pain facilitates cooperation with other therapeutic regimens.

-encourage early ambulation -provide diversional activities -administer analgesics as prescribed