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