TRINIDAD, ALYSSA ANGELA A.

ASSESSMENT NURSING DIAGNOSIS Acute pain related to inflamed tissues. INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Sumasakit po yung tiyan ko pag bumabangon po ako as verbalized by the patient while pointing at his incision site. Objective: Facial mask of pain Guarding behavior Pain scale of 5 out of 10 V/S taken as follows: Bp: 100/70 T: 37.8 P: 80 RR: 18

Inflammation of the appendix

Acute appendicitis

Appendectomy

After 8 hours of nursing intervention patient will report that pain is relieved and controlled, will appear relaxed and will be able to sleep and rest appropriately.

Independent 1. Assess the type of pain, noting location, characteristics and severity using the pain scale of 010. 1. Useful in monitoring effectiveness of medication, progression of healing and preventing complications. 2. Reduces abdominal distention, thereby reduces tension in the RLQ area 3. Helpful in keeping the patients tissue and muscles relaxed and relieved.

After 8 hours of nursing interventions, the patient was able to demonstrate use of relaxation skills and other methods to promote comfort. Patient was also seen andleft sleeping soundly after the shift.

Surgical wound will trigger activation of nociceptors from the tissues and will send impulses to the brain

2. Keep at rest in semi-fowlers position.

Pain will be perceived by the CNS causing

3. Provide comfort measures like back rubs and warm compress

ACUTE PAIN Dependent 4. Administer analgesics as ordered

4. Acts as a prophylactic in order to relieve pain

ASSESSMENT

NURSING DIAGNOSIS Risk for infection related to postoperative incision.

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Kanina pa po mainit tong anak ko nilalagnat po yata siya as verbalized by the patients mother. Objective: Skin is warm to touch Febrile General weakness and fatigue

Inflammation of the appendix

Acute Appendicitis

Appendectomy

V/S taken as follows: Bp: 100/70 T: 37.8 P: 80 RR: 18

Tissue trauma on RLQ abdomen may provide portal of entry for pathogens through: Unnecessary exposure of the surgical site Inadequate aseptic techniques especially in wound dressing Contact with patients SOs and visitors

After 8 hours of nursing intervention, the patient and his SOs will identify the risk factors that could be present and have partial understanding about its control and will finally be free from any signs and symptoms related to infection.

Independent: 1.Identify the risk factors for possible occurrence of infection in the incision 2. Render health teachings especially in identification of environmental risk factors that could add up on infection. 1. To help the patient identify the present risk factors that may cause infection 2. To help the client modify, change or avoid some of the environmental factors present which could reduce the incidence of infection. 3. Monitoring patients vital signs could detect any early signs of infection

After 8 hours of nursing intervention, the patient was able to meet the goals with an evidence of the absence of the signs and symptoms related to infection.

3. Monitor Vital Signs

Dependent 4. Administer antibiotics as ordered 4. Antibiotics will help kill and stop the proliferation and growth of the bacteria which could cause infection.

Collaborative 5. Assist client in early ambulation 5. Promotes normalization of organ function thus promote wound healing.

May result to infection

ASSESSMENT

NURSING DIAGNOSIS Impaired skin integrity related to post operative surgery evidenced by sutures in the abdominal area.

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Di pa po masyadong magaling ang sugat niya as verbalized by the patients mother. Objective: With surgical incision at right lower abdominal area With dry intact dressing on the surgical site Skin surrounding the area is warm to touch

Impaired skin integrity was due to the clients tissue trauma on the surgical incision site from his recent surgery caused by his acute appendicitis.

Within 8 hours of nursing intervention the patient will continue to manifest the following: Intact sutures Dry and intact wound dressing Participation in passive ROM exercises

Independent 1. Note skin color, texture, and turgor.

2. Determine degree or depth of injury or damage to skin.

The patient continued and maintained 1. To document status optimal conditions for and provide baseline wound healing as for future evidenced by intact comparisons. sutures, dry wound dressing and have 2. To monitor actively responded to progress of wound the mentioned healing. interventions.

3. Inspect surrounding 3. To protect the skin for erythema, wound and induration. surrounding tissues. 4. Inspect skin, describing wound characteristics and changes observed. 4. Promotes circulation and reduces risks associated with immobility.

V/S taken as follows: Bp: 100/70 T: 37.8 P: 80 RR: 18

Collaborative 5. Encourage early ROM exercises. 5. Promotes normalization of organ function thus promote wound healing.

ASSESSMENT

NURSING DIAGNOSIS Ineffective Breathing Pattern related to Decreased Lung Volume Capacity as evidenced by tachypnea and crackles on both lungs

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective:

Objective: Presence of crackles upon auscultation Use of accessory muscles Tachypnea: RR of 28 Pale skin Orthopnea

VS taken as follows: BP: 100/70 PR. 110 RR: 28 T: 35.9

Ineffective breathing pattern occurs when inspiration and expiration does not provide adequate ventilation. Pleural inflammation causes sharp localized pain that increases deep of breathing, coughing and movement. This can result to shallow and rapid breathing pattern. Distal airways and alveoli may not expand optimally with each breath, increasing the possibility of atelectasis and impaired gas exchange.

Short Term: After 8 hours of nursing interventions, the patient will demonstrate appropriate coping behaviors and methods to improve breathing pattern. Long term: After 1 to 2 days of nursing interventions, the patient would be able to apply techniques that would improve breathing pattern and be free from signs and symptoms of respiratory distress.

Independent 1. Monitor and record vital signs 2. Assess breath sounds, respiratory rate, depth and rhythm 3. Elevate head of the patient Collaborative 4. Administer supplemental oxygen as ordered 5. Administer prescribed medications as ordered Dependent 6. Assist client in the use of relaxation technique 7. Maximize respiratory efforts with good posture and effective use if accessory muscles.

1. To obtain baseline data 2. Note for any respiratory abnormalities

3. Promote lung expansion and easier breathing 4. Maximizes oxygen available for the body to use 5. To provide relief from pharmacological management of the patients condition

The patient have somehow demonstrated appropriate coping behaviors and methods to improve breathing pattern and have applied techniques that improved breathing pattern and be free from signs and symptoms of respiratory distress AEB respiratory rate within normal range, absence of cyanosis, effective breathing and minimal use of accessory muscles during breathing.

6. To encourage wellness

7. Promote adequate rest periods to limit fatigue

NURSING DIAGNOSIS generalized weakness Activity intolerance limited range of related to insufficient motion as observed oxygen for activities of use of accessory daily living muscles during breathing (+) DOB

ASSESSMENT

INFERENCE

PLANNING After 3-4 hours of nursing interventions, the patient will use identified techniques to improve activity intolerance Long Term: After 2-3 days of nursing interventions, the patient will report measurable increase in activity intolerance.

INTERVENTION Monitor and record Vital Signs Assess patients general condition Adjust clients daily activities and reduce intensity of level. Discontinue activities that cause undesired psychological changes Instruct client in unfamiliar activities and in alternate ways of conserve energy Encourage patient to have adequate bed rest and sleep Provide the patient with a calm and quiet environment Assist the client in ambulation Note presence of factors that could contribute to fatigue Ascertain clients ability to stand and move about and degree of assistance needed or use of equipment Give client information

RATIONALE To obtain baseline data To note for any abnormalities and deformities present within the body To prevent strain and overexertion To conserve energy and promote safety to relax the body to provide relaxation to prevent risk for falls that could lead to injury fatigue affects both the clients actual and perceived ability to participate in activities to determine current status and needs associated with participation in needed or desired activities to sustain motivation of client to enhance sense of well being to promote easy breathing to maintain an open airway

EVALUATION The patient shall have used identified techniques to improve activity intolerance Long Term: The patient shall have reported measurable increase in activity intolerance.

that provides evidence of daily or weekly progress Encourage the client to maintain a positive attitude Assist the client in a semi-fowlers position Elevate the head of the bed Assist the client in learning and demonstrating appropriate safety measures Instruct the SO not to leave the client unattended Provide client with a positive atmosphere Instruct the SO to monitor response of patient to an activity and recognize the signs and symptoms

to prevent injuries to avoid risk for falls to help minimize frustration and rechannel energy to indicate need to alter activity level