Student Nurses Community

NURSING CARE PLAN Appendicitis

ASSESSMENT

DIAGNOSIS

SUBJECTIVE:
Nasusuka at
nauuhaw ako palagi
(I always feel
naseous and
thirsty) , as
verbalized by the
patient

Fluid Volume Deficit

related to loss of
fluids secondary to
nausea, vomiting

OBJECTIVES:
Poor skin turgor
Chapped and
dry lips
VS as taken

INFERENCE

Blockage of lumen
of appendix

mucus produced by
mucous appendix
suffer dam

Increased
intraluminal
pressure

Inflammation
T 36.8
P 103
R 17
BP 80/50

PLANNING
After 8 hours or
nursing
intervention, the
patient will be able
to maintain body
fluid balance by
having:
Normal BP
Normal pulse
rate
Do not complain
of thirst
Balance
between intake
and output

INTERVENTION

EVALUATION

To serve as a
basis to monitor
the balance of
fluids in the
body that are
needed for daily
metabolism

After 8 hours of
nursing
intervention, goal
met.
Patients BP and
pulse rate are in
normal range
(BP 110/80 P89);

To find out the

less interstitial
fluid / loss can
lead to loss of
skin elasticity.

The output is
balanced with
the patients
fluid intake in 24
hours

A dry mucous
membrane is an
indication of
dehydration

The patient does

not complain of
thirst.

Independent:
Record intake
and output

Monitor skin
turgor

Observe for dry

mucous
membranes

Edema and
ulceration

Pain in the
epigastrium
radiating to the

RATIONALE

Give fluid little

by little but
often, as
appropriate
Monitor urine

To minimize loss
of fluids

Reduced amount

Student Nurses Community

lower right
abdomen

Pain
stimulus/irritant is
sent to enteric
plexuses

Nausea and
vomiting
Are induced

output
Per hour and
shift

Dependent:
Establish IV
access and
replace GI
losses,
volume/volume

of urine and its

concentration
indicate reduced
fluid in the body.

To restore fluids
and electrolytes
lost via IV since
oral intake is
limited due to
nausea and
vomiting

Loss of body fluid

Dehydration

Give antiemetics
as ordered

To reduce
vomiting