COLEGIO SAN AGUSTIN BACOLOD

COLLEGE OF HEALTH AND ALLIED PROFESSIONS

NURSING PROGRAM
B.S. Aquino Drive, Bacolod City
Contact Number: (034) 434 – 24 71 Local 162
Email Address: csab.chap@gmail.com

NURSING CARE PLAN

Patient’s Name: J.R Chief Complaint/s: Pain at the incision site

Room/ Bed#: Rm 317 Diagnosis/ Impression: Perforated Appendicitis
Age: 16 y.o. Attending Physician: Dr. X

General Objective: To facilitate maintenance of energy conservation.

CUES NURSING RATIONALE SPECIFIC OBJECTIVE INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective: Acute pain related Acute pain related to the presence of Independent: After 8 hours of
“Kasakit sng akon to presence of surgical wound has a distinct Within 8 hours of nursing nursing intervention,
tinahi-an.” surgical wound as pathophysiology that reflects intervention the patient will be  Establish rapport  To promote the patient felt
evidenced by peripheral and central sensitization as able to show signs of through the use of cooperation and comfort and relieved
patient's well as humoral factors contributing improvement and relief from therapeutic improve patient from pain as
verbalization and to pain. communication
“Nakulbaan ko. pain scale of 5/10. pain at rest and during movement. care evidenced by:

Kasakit! Basi ano This can impair functionality and often  Assess patient’s
 To describe pain The patient
matabo sakon mag culminates in delayed recovery. pain using PQRST
to help determine verbalized
sige sige ni." method
the best “Nagbahar na ang
intervention sakit.”
Verbalized pain on The most common risks factors that  Monitor vital signs  To have a -Pain scale of 3/10
his incision site when can contribute to the occurrence of changes in the baseline data and
he moves. acute pain are anxiety, surgical data to monitor for
approach with risk of nerve damage, any deviation. -The patient
depression, and catastrophizing and improved his
Objective: radiation therapy to that area where  Provide non-  To help ease post- strength and mood.
-Pain Scale the surgery is done. surgical pain.
pharmacologic
Pre-op: 9/10 pain (Cold packs,
management. meditation or -There is no evidence
Post-op: 5/10 In our patient, due to an injury made other of facial grimace or
to a major peripheral nerve during a distractions) flinch when moving;
-Facial grimace
surgical procedure which is cutting of absence of guarding
-Guarding behavior tissues and nerves acute pain was felt,  To allow proper behavior is noted.
 Encourage use of
then this activate the body's O2 supply in the
-Restlessness deep breathing
automatic injury responses such as body, client tend
technique and
-Irritability inflammation on incision site when to stop breathing -The patient was able
relaxation
surgical intervention was done. during pain. to rest appropriately
technique
without complaint.
V/S:
Reference:  To ensure the
-BP 130/90  Educate adequate patient gets
Post-operative pain management, rest periods Vital signs:
enough rest
-RR 23cpm Health & Medicine. April 9, 2016 from which is vital BP- 120/80mmHg
-HR 99 https://www.slideshare.net/.../ post- in their RR- 19cpm
operative-pain... recovery and
to promote PR- 90cpm
Special Procedures
-Appendectomy comfort
Goal met.
 To promote
 Advise and recovery and
encourage healing on the
patient, after 24 incision site
hours, to
ambulate
 Advise the client  To aid in
to eat plenty of strengthening of
nutritious food having a good
and vegetables immune system
and drink plenty against infection
of water

 Provide  To decrease
information and patient’s anxiety
anticipatory and to encourage
guidance the patient to
regarding causes participate with
of discomfort their plan of care

 Provide health  To divert the

teaching and patient’s
encourage attention from
distraction pain and relieve
techniques for anxiety
pain and anxiety
(music and
therapy, board
games if able, and
etc.)

 Move patient  Reduces muscles

slowly and tension or
deliberately guarding which
may help
minimize pain
 Note: If there are  To assess
risk factors for causative /
occurrence of contributing
infection (eg: skin factors.
/tissue wounds

 Keep area of  To assess body’s

incision clean/dry natural process
and carefully repair.
dress wounds,
support incision.

 Inspect incision
 Provide early
site. Note
detection of
characteristics of
drainage from infection and any
wound discharges may
help to identify
whether there is
an infection

Dependent:
 Administer  To relieve the
analgesic as patient from
ordered by the feeling pain as
physician resulted by
surgical wound

 Provide  To keep the

supplemental patient from
fluids being dehydrated
by acting as a
 secondary source
of hydration.

 Administer
 To prevent
antibiotics (if
further and stop
there is infection)
as prescribed bacterial
[IND. Provide infection; to
then after patient prevent antibiotic
teaching to take resistance.
antibiotics as
scheduled and do
not skip a dose]

Collaborative:
 Schedule for
 To know any
follow up check
other
up
complications
 Encourage patient
to follow  To aid in
recommended strengthening
meal plan of the of having a
dietician as good immune
possible system
against
infection and
aid in fast
wound
healing.