CUES

NURSING
DIAGNOSIS

Rationale

GOAL &
OUTCOME
CRITERIA

NURSING ACTIONS &
NURSING ORDERS


RATIONALE


EVALUATION
Subjective:

"Masakit ang
tiyan ko as
verbalized by
patient.

bjective:

Oacial mask
of pain.

ORebound
tenderness.

OPain scale of 7/10

O \YS_`^U\SZ
cute pain
related to
inflammation
of tissues
secondary to
appendicitis.


ppendix is kinked or occluded
by a fecalith, tumor, or foreign
body

nflammation

ncrease intraluminal pressure

Pain localized at the right
lower quadrant of the
abdomen

ppendix is filled with pus
fter 4 hours of
nursing
interventions, the
patient will
demonstrate use of
relaxation skills,
other methods to
promote comfort.
Independent:
Onvestigate pain reports,
noting location, duration, and
intensity (0-10 scale).

OMaintain semi fowler's
position.


OMove patient slowly and
deliberately.

OProvide comfort measure
like back rubs and deep
breathing. Provide
diversional activities

ORemove noxious
Environmental stimuli.

4,-47,tive:
Odminister analgesics as
prescribed.

Ohanges in location or
intensity are not uncommon but
may reflect developing
complications.

OReduces abdominal distention
thereby reduces tension.

OReduces muscle tension or
guarding, which may help
minimize pain of movement.

OPromotes relaxation and may
enhance patient's coping
abilities by refocusing attention.

OReduces nausea and
vomiting, which can increase
intra-abdominal pressure or
pain.

OReduces metabolic rate and
aids in pain relief and promotes
healing.

fter 4 hours of
nursing
interventions,
the patient was
able to
demonstrate
use of
relaxation skills,
other methods
to promote
comfort.