Nursing Care Plan

Name of patient: Patient J.M. Age: 15 years old Sex: Male Civil Status: Single Room: Emergency Room
Nursing Diagnosis: Acute Pain related to Surgical Incision
Assessment Date: March 14, 2023 Intervention Date: N/A
Prepared by: Ma. Christina S. Mendoza Section/group no.: Sec 402, 3A CI/Supervisor: Mr. Vicente Baylon

Cues Nursing Analysis Goal Intervention Rationale Evaluation

Diagnosis
Subjective Cues Acute pain SCIENTIFIC Goal: Goal: Met
- Patient related to ANALYSIS:
stating a 7 out surgical incision Open After the 30
of 10 in pain secondary to appendectomy is After the 30 minutes shift,
scale post- a procedure minutes shift, the patient was
- Patient appendectomy done in the lower the patient will able to report a
characterize as evidence by right iliac, the be able to report relieve feeling
the sensation patient stating a surgeon makes a relieve feeling and a pain scale
of pain in the 7 out of 10 pain an incision and and a pain scale of 1.
incisional site scale while in the muscle layers of 1.
guarding is split to expose
Objective Cues position in the the peritoneum,
- One day post incisional site. after removing
apendectomy, the appendix and Objectives: Objectives:
with fresh whole procedure, 1. After nursing Independent Independent 1. MET. Patient
incisional the wound is intervention, Provide physical J.M. displayed
wound at the closed with patient J.M. will interventions Facial easiness, a
lower right stitches be able to - Massage Massage aid well relaxed and
quadrant of (Appendectomy: display facial (Effleurage) relaxation, comfortable
the iliac Procedure, easiness, hands, decrease muscle body, and his
region. preparation & relaxed arms, and tension, and vital signs were
- Facial risks comfortable feet. ease anxiety all in normal
Grimace 2018). Pain is a body, improved - Cold because the levels.
suggesting complex reaction well-being w/ compress physical contact
pain to tissue injury baseline level of around the related caring.
- Guarding during medical vital signs incisional (Berman et al.,
positioning in procedure that area, apply 2016)
the incisional invigorates 15 minutes
site to ease hypersensitivity at a time Reduces blood
pain of the central and do not flow to the
- Vital signs sensory system. apply ice specific area
shows: At the point directly on which can
BP: 140/100 when a patient the skin significantly
PR: 122 bpm goes through a reduce
RR: 28 bpm medical inflammation
procedure, and swelling
tissues and nerve that causes pain
endings are (John Hopkins
traumatized, Medicine, n.d.)
bringing an
incisional pain.
This trauma
overloads the
pain receptors
that send
messages to the 2. Patient J.M. Provide cognitive- Distraction 2. MET. Patient
spinal cord, and his guardian behavioral therapy makes the J.M. and his
which becomes will be able to (CBT) person unaware guardian
overwhelmed, demonstrates - Distraction. of the pain only demonstrated
(Post-surgical the use of Facilitating for the amount well the use of
pain, n.d.). appropriate and/or of time and to appropriate
SITUATIONAL diversional providing the extent that diversional
ANALYSIS: activities and reading the distracting activities and
Herewith, the relaxation skills. material, activity holds his relaxation skills.
patient was television or her
admitted to the show, etc. “undivided”
hospital for - Guided attention.
appendicitis and imagery. (Berman et al.,
underwent open Involves 2016)
appendectomy the use of
recently. After 2- mental Guided imagery
days, patient ASL pictures or decreases and
reports pain in guiding the counteracts
the lower right patient to harmful effects
quadrant of the imagine of stress (e.g.,
iliac region and event muscle tension,
where the to distract activating the
incision was from the sympathetic
made for the pain nervous system,
appendectomy. and putting the
He rated pain client at risk for
with a 7 out of stress-related
10. In addition types of pain)
to , patient ASL (Berman et al.,
he has elevated 2016)
level of BP, RR,
and PR upon
assessment.
Facial grimace
and guarding
position in the
LRQ was noted.
Dependent
Dependent Opioid 3. MET. Patient
3. Patient J.M. - Administer analgesics for J.M. completely
will be able to analgesia moderate pain verbalize his
verbalize his as ordered are controlled relieve from
relief by the substances that pain
physician must be ordered
assigned by the physician,
this includes
 drugs such as
codeine and
tramadol
(Berman et al.,
2016)

References:

Berman, A., Snyder, S. J., & Frandsen, G. (2016). Kozier & erb's fundamentals of Nursing: Concepts, processes and practice (10th ed.). Pearson
Australia.

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2013). Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales. Philadelphia,
PA: F.A. Davis

Franz, J. (n.d.). Post-surgical pain. Encyclopedia of Surgery. Retrieved September 14, 2021, from
https://www.surgeryencyclopedia.com/Pa-St/Post-Surgical-Pain.html.

John Hopkins Medicine. (n.d.). Ice packs vs. Warm Compresses for pain. Johns Hopkins Medicine. Retrieved September 20, 2021, from
https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/ice-packs-vs-warm-compresses-for-pain.

Stone, R. (2021, February 4). Appendectomy. Ramsey Stone, M.D. Retrieved September 20, 2021, from
https://www.ramseystonemd.com/appendectomy.

The Health Line Team. (2018, September 29). Appendectomy: Procedure, preparation & risks. Healthline. Retrieved September 14, 2021, from
https://www.healthline.com/health/appendectomy#:~:text=During%20an%20open%20appendectomy%2C%20a,if%20your%20 appendix
%20has%20burst.