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    NCP Appendectomy

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    100l
    The patient complained of pain in the right lower quadrant of the abdomen, rating it 5 out of 10. Vital signs were taken and the patient had a temperature of 37.0 C, respiratory rate of 21, pulse rate of 64, and blood pressure of 120/70. The patient recently had an appendectomy. Nursing interventions included monitoring vital signs, assessing pain characteristics and surgical site, providing diversional activities, encouraging verbalization of pain, and administering the analgesic Toradol as ordered. The objective was for the patient to demonstrate ability to cope with pain rated 2 out of 10 or less within 6-8 hours.

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    NCP Appendectomy

    Uploaded by

    100l
    323 views10 pages
    The patient complained of pain in the right lower quadrant of the abdomen, rating it 5 out of 10. Vital signs were taken and the patient had a temperature of 37.0 C, respiratory rate of 21, pulse rate of 64, and blood pressure of 120/70. The patient recently had an appendectomy. Nursing interventions included monitoring vital signs, assessing pain characteristics and surgical site, providing diversional activities, encouraging verbalization of pain, and administering the analgesic Toradol as ordered. The objective was for the patient to demonstrate ability to cope with pain rated 2 out of 10 or less within 6-8 hours.

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    25847042 NCP Appendectomy

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    The patient complained of pain in the right lower quadrant of the abdomen, rating it 5 out of 10. Vital signs were taken and the patient had a temperature of 37.0 C, respiratory rate of 21, pulse rate of 64, and blood pressure of 120/70. The patient recently had an appendectomy. Nursing interventions included monitoring vital signs, assessing pain characteristics and surgical site, providing diversional activities, encouraging verbalization of pain, and administering the analgesic Toradol as ordered. The objective was for the patient to demonstrate ability to cope with pain rated 2 out of 10 or less within 6-8 hours.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as TXT, PDF, TXT or read online from Scribd
    Download as txt, pdf, or txt
    323 views10 pages

    NCP Appendectomy

    Uploaded by

    100l
    The patient complained of pain in the right lower quadrant of the abdomen, rating it 5 out of 10. Vital signs were taken and the patient had a temperature of 37.0 C, respiratory rate of 21, pulse rate of 64, and blood pressure of 120/70. The patient recently had an appendectomy. Nursing interventions included monitoring vital signs, assessing pain characteristics and surgical site, providing diversional activities, encouraging verbalization of pain, and administering the analgesic Toradol as ordered. The objective was for the patient to demonstrate ability to cope with pain rated 2 out of 10 or less within 6-8 hours.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as TXT, PDF, TXT or read online from Scribd
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    of 10

    Cues

    Nursing Diagnosis

    Scientific Explanation

    Objectives/Plan of Care

    Nursing Interventions

    Rationale

    Evaluation

    S> “ Hindi pa masyado magaling ang sugat ko” as verbalized by the patient

    Impaired Skin Integrity related to skin/tissue trauma

    Inflammation of the appendix ↓ Acute Appendicitis ↓

    Within 8 hours >Assess operative site for of nursing redness, swelling, loose
    intervention the sutures, or soaked dressing pt will be able to manifest the
    following: a.) intact sutures b.) dry and intact wound dressing c.) participation
    in passive ROM exercises >Monitor Vital Signs

    >to check skin integrity, monitor progress of healing and identify need for
    further

    Within 8 hours of nursing intervention the pt be able manifest the following:

    O> S/P Appendecto my >with surgical incision at right lower


    abdominal area >with dry intact dressing on the surgical site

    Appendectomy ↓ Dissection if right lower abdominal tissues ↓ Disruption of skin


    surface and destruction of skin layers ↓

    >Assist in passive movements(while 8hrs. flat on bed) such as bed turning


    circulation to the and passive ROM exercise surgical site for and active exercise
    thereafter timely healing movements such as bed position, sitting, standing,
    walking

    a.) intact > Serve as baseline sutures data b.) dry and intact wound dressing >to
    promote c.) participation in passive ROM exercises

    > Support incision as in splinting when coughing and during movement

    >to reduce pressure on the

    >Evaluation was not carried out due to time constraints. Pt was endorsed to
    succeeding
    Impaired skin/tissue integrity

    operative site >Encourage pt to verbalized his for any untoward feelings


    especially pain, discomfort as well as changes noted on operative site

    >Encourage pt to engage early ambulation and have SO’s assist him in such
    activities

    >to allow continuous monitoring and assessment of pt. condition

    members of the health team for further management and evaluation

    >to promote circulation to the surgical site for timely healing

    >Instruct pt and SO’s to immediately report when dressing are soaked >to promote
    circulation to the surgical site for timely healing

    >Instruct pt and SO’s to refrain from touching/scratching operative site

    >for immediate replacement to


    prevent skin breakdown and contamination of operative site

    >Provide regular dressing care

    >to avoid accumulation of moisture at the operative site which may lead to skin
    breakdown

    >Administer Chlorampenicol Sodium(antibiotic) as ordered

    >to prevent bacteria harbor in operative site


    Cues

    Nursing Diagnosis

    Scientific Explanation

    Objectives/Plan of Care

    Nursing Interventions

    Rationale

    Evaluation

    S>”Hindi namn ako nilalagnat” verbalized by the patient

    Risk for infection related to tissue trauma

    Inflammation of the appendix ↓ Acute Appendicitis ↓

    O> v/s taken as follow:

    Appendectomy ↓

    BP:110/80 mmHg RR:22 cpm PR:68 bpm T: 37.0 C

    Tissue trauma on RLQ abdomen May provide portal of entry for pathogens through:

    Within 8 hours of nursing intervention the pt will be able verbalize ways in


    preventing infection/contamin ation specifically proper hand washing, and proper
    wound care as evidenced by: >maintain stable v/s >good skin integrity >absence of
    swelling redness

    >Monitor v/s and record

    >Elevation in rates may signal infection

    >assess operative site for signs of infection

    >to provide baseline data for comparison and identify need for further management

    Within 8 hours of nursing intervention the pt will be able verbalize ways in


    preventing infection/contamin ation specifically proper hand washing, and proper
    wound care as evidenced by: >maintain stable v/s >good skin integrity >absence of
    swelling redness

    >change linens as necessary

    >to prevent growth of microorganisms on linens and beds


    > S/P Appendectomy
    >with dry intact dressing on the surgical site

    >unnecessary exposure of surgical site >inadequate aseptic techniques especially


    in wound dressing >contract with pt’s, SO’s and visitors hands or other parts ↓
    May result to infection

    and pain on operative site

    >Provide regular > to prevent dressing care unnecessary exposure and contamination
    of operative site which may delay wound healing

    and pain on operative site >Evaluation was not carried out due to time
    constraints. Pt was endorsed to succeeding members of the health team for further
    management and evaluation

    >Instruct pt and SO’s to refrain from touching/scratch ing operative site

    >for immediate replacement to prevent skin breakdown and contamination of


    operative site

    >Encourage pt to verbalized any changes

    >to allow continuous monitoring and assessment of pt. condition


    noted on operative site such as redness, swelling and unusual/odorous drainage >to
    promote circulation to the surgical site for timely healing

    >Encourage pt to engage early ambulation and have SO’s assist him in such
    activities

    >Administer Penicillin G Sodium(antibioti c) as ordered

    >serve as prophylactic treatment and prevent bacteria to harbor on operative site


    Kenneth Antonio B. Bacani, SN

    Group 1

    Nursing Care Plan

    Callang General Hospital, Santiago City

    Cues

    Nursing Diagnosis
    Acute pain related to tissue damage 2nd to post appendectomy

    Scientific Explanation

    Objectives/Plan of Care
    Within 6-8 hours of nursing intervention, the pt will be able to manifest ability
    to cope with incompletely relieved pain as evidenced by a. ) verbalization of
    decrease pain form 5/10 to 2/10 b.) engagement in diversional activities such as
    socialization, watching TV, and listening mellow music

    Nursing Interventions
    >Monitor V/S and record

    Rationale

    Evaluation

    S> “Masakit ditto sa baba”, while pointing at RLQ of abdomen. >rated pain as 5 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 follows T: 37.0 C RR: 21 cpm PR: 64 bpm BP: 120/70 mmHg

    Inflammation of the appendix ↓ Acute Appendicitis ↓ Appendectomy ↓ Dissection if


    right lower abdominal tissues ↓ Disruption of skin surface and destruction of

    >Assess pain characteristics including location, intensity, and frequency >Assess


    surgical site for swelling, redness or loose sutures

    >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

    >Promote adequate rest periods by temporarily limiting activity

    Within 6-8 hours of nursing intervention, the pt will be able to manifest ability
    to cope with incompletely relieved pain as evidenced by a. ) verbalization of
    decrease pain form 5/10 to 0/10 b.) engagement in diversional activities such as
    socialization, watching TV, and listening mellow music >verbal report that pain is
    completely releived >absence of facial
    skin layers > S/P Appendectomy
    >with dry intact dressing on the surgical site >with guarding behavior over the
    site >facial grimacing

    ↓
    Activation of nociceptors in dermis and tissues

    >Encourage pt to verbalize pain perception

    >to lessen pain felt aggravated by movements

    ↓ Receptors send impulses to CNS for interpretation ↓ Pain Perception ↓ Acute Pain

    >Provide pt with diversional activities such as socialization, watching TV, and


    listening mellow music

    >to allow further assessment of pain characteristics and evaluation of treatment /


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

    grimacing upon performance of activities such as changing position, sitting


    ,standing and walking > absence of guarding behavior over surgical site

    >Encourage SO’s to continue provision of diversional activities and a quiet


    environment >Administer Toradol (analgesic)as ordered

    >to allow pt continue divert his attention

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

    >to relieved or lessen pain by inhibiting


    prostaglandin synthesis

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