Scribd Logo
Upload

Welcome to Scribd!

  • 1K views

    Appendectomy NCP

    Uploaded by

    Christian Karl B. Llanes
    The patient reported a 7/10 pricking pain in their right lower abdomen that worsened with movement. Vital signs were taken. The nursing diagnosis was acute pain related to post-appendectomy tissue damage. The plan was to provide interventions within 6-8 hours to help the patient cope with pain rated 3/10 or lower and engage in activities. Interventions included rest, distraction activities, splinting of the wound, clear liquids and ambulation. The long-term goal was for the patient to display continuous progress and no pain within 2-3 days.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Appendectomy NCP

    Uploaded by

    Christian Karl B. Llanes
    1K views3 pages
    The patient reported a 7/10 pricking pain in their right lower abdomen that worsened with movement. Vital signs were taken. The nursing diagnosis was acute pain related to post-appendectomy tissue damage. The plan was to provide interventions within 6-8 hours to help the patient cope with pain rated 3/10 or lower and engage in activities. Interventions included rest, distraction activities, splinting of the wound, clear liquids and ambulation. The long-term goal was for the patient to display continuous progress and no pain within 2-3 days.

    Original Title

    61753063 Appendectomy Ncp

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The patient reported a 7/10 pricking pain in their right lower abdomen that worsened with movement. Vital signs were taken. The nursing diagnosis was acute pain related to post-appendectomy tissue damage. The plan was to provide interventions within 6-8 hours to help the patient cope with pain rated 3/10 or lower and engage in activities. Interventions included rest, distraction activities, splinting of the wound, clear liquids and ambulation. The long-term goal was for the patient to display continuous progress and no pain within 2-3 days.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views3 pages

    Appendectomy NCP

    Uploaded by

    Christian Karl B. Llanes
    The patient reported a 7/10 pricking pain in their right lower abdomen that worsened with movement. Vital signs were taken. The nursing diagnosis was acute pain related to post-appendectomy tissue damage. The plan was to provide interventions within 6-8 hours to help the patient cope with pain rated 3/10 or lower and engage in activities. Interventions included rest, distraction activities, splinting of the wound, clear liquids and ambulation. The long-term goal was for the patient to display continuous progress and no pain within 2-3 days.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Assessment Nursing Diagnosis Scientific

    Explanation
    Objectives/Plan of
    Care
    Nursing
    Interventions
    Rationale Evaluation

    S> S> Masakit tong
    sugat ko pag
    gumagalaw ako at
    lalo na kung
    nawawala na yung
    eefect nung pain
    killer ko while
    pointing at RLQ of
    abdomen.
    >rated pain as 7 on a
    scale of 10, where 1 as
    the lowest and 10 as
    the highest
    >characterized pain as
    pricking
    >reported that pain
    occurs everytime
    when pt moves or
    moved

    O> v/s taken as
    follow:

    BP:90/60 mmHg
    RR:21 cpm
    PR:60 bpm
    T: 37.0 C

    >with dry intact

    Acute pain related to
    tissue damage
    secondary to post
    appendectomy

    Inflammation of the
    appendix

    Acute Appendicitis

    Appendectomy

    Dissection if right
    lower abdominal
    tissues

    Disruption of skin
    surface and
    destruction of skin
    layers

    Activation of
    nociceptors in dermis
    and tissues

    Receptors send
    impulses to CNS for
    interpretation

    Pain Perception

    Acute Pain


    STO: Within 6-8 hours
    of comprehensive
    nursing intervention,
    the patient will be
    able to manifest ability
    to cope with
    incompletely relieved
    pain as evidenced by
    a. ) verbalization of
    decrease pain form
    7/10 to 3/10
    b.) engagement in
    diversional activities
    such as socialization,
    texting, and listening
    mellow music















    DX>Monitored V/S and
    record



    >Assessed pain
    characteristics
    including location,
    intensity, and
    frequency

    >Assessed surgical site
    for swelling, redness
    or loose sutures




    TX>Promoted
    adequate rest periods
    by temporarily limiting
    activity



    >Provided patient with
    diversional activities
    such as socialization,
    watching TV, and
    listening mellow music

    >Elevation in rates
    suggest increased
    pain intensity and
    frequency

    >Elevation in intensity
    and frequency may
    indicate worsening
    condition

    >Swelling, redness ,
    and loose sutures may
    contribute to the pain
    felt by pt. and are
    indicative of further
    management


    >to lessen pain felt
    aggravated by
    movements




    >to help pt divert his
    attention to other
    matters than pain felt



    STO:Goal met if within
    6-8 hours of nursing
    intervention, the
    patient will be able to
    manifest ability to
    cope with
    incompletely relieved
    pain as evidenced by
    a. ) verbalization of
    decrease pain form
    7/10 to 3/10
    b.) engagement in
    diversional activities
    such as socialization,
    watching TV, and
    listening mellow music
    >verbal report that
    pain is completely
    relieved
    >absence of facial
    grimacing upon
    performance of
    activities such as
    changing position,
    sitting ,standing and
    walking
    > absence of guarding
    behavior over surgical
    site

    dressing on the
    surgical site
    >grimacing noted
    >irritable
    >with guarding
    behavior at the wound
    site
    >weak in appearance
    >moaning noted


    Reference: Brunner
    and Suddharts

    LTO: Within 2-3 days
    of comprehensive
    nursing intervention,
    the patient will be able
    to display continuous
    progress and changes
    of condition and will
    be able to display no
    signs of pain.

    >Administered Toradol
    (analgesic)as ordered


    >Assisted in early
    ambulation


    EDX> Emphasized the
    importance of clear
    liquid diet.

    >Instructed to do DBE

    >Instructed to splint
    wound site upon
    coughing



    >Instructed to
    continue provision of
    diversional activities
    and a quiet
    environment




    >Encouraged patient
    to verbalize pain
    perception


    >to relieved or lessen
    pain by inhibiting
    prostaglandin
    synthesis
    >to promote normal
    peristaltic movement


    >To prevent further
    complications.


    >To lessen pain

    >To prevent the
    wound site to open.




    >to allow patient
    continue divert his
    attention






    >to allow further
    assessment of pain
    characteristics and
    evaluation of

    LTO: Goal met if
    Within 2-3 days of
    comprehensive
    nursing intervention,
    the patient will be able
    to display continuous
    progress and changes
    of condition and will
    be able to display no
    signs of pain.

    *Evaluation was not
    carried out due to
    time constraints. Pt
    was endorsed to
    succeeding members
    of the health team
    for further
    management and
    evaluation



    >Encouraged early
    ambulation



    treatment /
    intervention

    >to promote normal
    peristaltic movement.

    You might also like