ASSESSMENT NURSING GOAL OF CARE OUTCOME NURSING INTERVENTIONS AND RATIONALE EVALUATION

DIAGNOSIS CRITERIA
Subjective Cues: Acute Pain Short Term: Patient will report Independent: Short Term:
Patient reports related a decrease of  Monitor vital signs – Fever, chills and
abdominal pain with Inflammation After 8 hours of pain score of 8/10 diaphoresis are signs of infection, developing After 8 hours of nursing
nursing intervention, to 3/10 by sepsis, abscess or peritonitis. Hypotension intervention, the patient was
a pain scale of 8/10. Secondary to
the patient will be able discharge. with tachycardia may indicate dehydration if able to:
Acute to:  Report pain is
vomiting or diarrhea is severe.
Appendicitis  Report pain is Patient will relieved/control ed
relieved/control display signs of  Monitor Labs – Very high levels of CRP may after carrying out
Objective Cues: ed after carrying comfort as interventions.
indicate gangrene.
out evidenced by  Patient is relaxed,
 Facial interventions. resting with eyes able to sleep/rest
 Place in semi- Fowler’s position – This
Grimace Scientific Basis:  Patient is closed and vital
position allows gravity to assist by reducing appropriately within
 Limited Acute signs within
relaxed, able to abdominal stress and relieves discomfort. the shift.
appendicitis is a normal limits.
movement sleep/rest  Demonstrate use of
severe and
 Body sudden case of appropriately  Place ice bag on abdomen periodically during relaxation skills and
Weakness appendicitis. The within the shift. initial 24–48 hr, as appropriate – Soothes and diversional activities,
symptoms tend to  Demonstrate relieves pain through desensitization of nerve as indicates, for
 V/S: develop quickly use of endings. Do not use heat because it may individual situation
T: 36.2 over the course relaxation skills cause tissue congestion. after health teaching.
PR:80 of one to two and diversional
days. The activities, as  Educate patient and her family about
RR: 20
opening of the indicates, for appendectomy. – More knowledge about Long Term:
BP:120/90 appendix is surgery will ease anxiety and help prepare
individual After 3 days of nursing
blocked therefore situation after patient and her family.
interventions the patient is
allowing bacteria health teaching. Dependent: free from any pain.
to multiply rapidly
irritating the lining  Administer medications such as analgesics,
of the appendix. Long Term: antipyretics, and antibiotics as ordered. –
This infection Analgesics aid to relieve pain while
causes the After 3 days of nursing antipyretics regulate body temperature, and
patient to be interventions the antibiotics will help fight off the infection.
febrile, unable to patient will be free
eat, in pain, and from any pain.
vomiting.