Data:

Patient is crying and restless.

Stated My stomach really
hurts
Abdomen is tender to touch
Pulse 105 beats/min
Pain 7/10

#1 Intervention
Administer
Acetaminophen 325mg
sup Q4H

#1 Nursing Diagnosis:
Acute Pain r/t inflammation of appendix

#2 Intervention
If Acetaminophen is ineffective,
administer 2-3mg Q4H IV/SQ as
needed for pain

#5 Intervention
Provide a calm and
restful environment
#3 Intervention
Allow child to
position herself
comfortably

Evaluation:
Goal Met:
At the end of the 2-hour
education session, the
patient and parent will
express their feelings of
anxiety towards upcoming
patients surgery and was
willing to use coping skills.

#6 Intervention
Educate parent on
observing cues for
pain

#2 Intervention
Assess for signs of
dehydration: skin tenting,
sunken eyes, dry mucous
membranes.

#3 Intervention
Monitor VS Q4H

Data:
Vomited X 1
NPO prior to
surgery

#3 Intervention
Give clear and
concise
explanations
regarding

Data:
RLQ pain
Temperature: 38.7
C
Vomited X 1
WBC 15000

#2 Nursing Diagnosis:
Risk for infection related to impending rupture of
appendix
Goal: The patient will not exhibit any signs of infection
and will be able to proceed with surgery with no
#3 Intervention
Administer
Dimenhydrinate 25 mg
Q4H IV/SQ for nausea

#4 Intervention #5 Intervention
Maintain adequate Administer
hydration. Acetaminophen 325
mg sup Q4H for relief
from fever.

#5
Intervention
Monitor
intake and
output.

#4 Intervention
Administer
Dimehydrinate 25 mg
Q4H IV/SQ as needed.
Data:
Patients first hospitalization
Patient verbalized, Will they put me to sleep when I have the
operation?
#5 Intervention
Patients mom stated, The doctor told us, that she might have
Identify and reinforce
appendicitis and may require an operation. He said, he wanted to
coping strategies.
admit her and keep an eye on her for a while. When will the doctor
Evaluation:
know if Marcy will need operation?
Goal Met: At the end of my 2-hour shift,
No prior health problems
the client will verbalize understanding
of the surgical procedure, pre-operative
and post- operative care.

#4 Nursing Diagnosis:
Anxiety (mild) related to upcoming surgery.
Goal: At the end of my shift, the patient and parent will
acknowledge their feelings of anxiety and verbalize relief from
anxiety.
#1 Intervention
Discuss alternate
strategies for handling
anxiety.

Evaluation: Goal Met

1 hour prior to surgery.
Patients fever was resolved,
temperature 36.8C. Vital
Signs remained within
normal limits. No emesis

#2 Intervention
Administer
prophylactic
antibiotics as

#3 Nursing Diagnosis:
#4 Intervention
Risksmall
for deficient fluid volume related to decreased fluid intake
Provide a stuffed animal,
and loss
pillow or blanket to aid in
Goal: At the end of my shift, the patient will not exhibit signs of
splinting the area
dehydration.

#1 Intervention
Maintain NPO
status

#2 Intervention
Encourage client to
acknowledge and
express feelings of
anxiety.

#1 Intervention
Assess patients Vital Signs
Q4H

#7 Intervention
Provide
distractions such
as books, puzzles,
TV and games

Goal: The patient will demonstrate relief from pain by the end of my
shift

Data:
Pulse 105 beats/min
First Hospitalization
Patient stated, Will they
put me to sleep when I
have the operation?
Restlessness

Evaluation: Goal
Met
2 hours preoperative, client
was observed to
have adequate skin

Evaluation: Goal
Met
20 mins after the
first dose of
Morphine, patient
states relief from

#5 Nursing Diagnosis:
#1 Intervention
Deficient Knowledge related to lack of information regarding surgery
Perform pre-op and post-op
and post-operative care.
education.
Goal: At the end of my shift, the patient and parent will acknowledge
their feelings of anxiety and verbalize relief from anxiety.

#4 intervention
Provide distractions
such as books, games
and television.

#2 Intervention
Assess barriers and readiness to
learn and response to teaching
education.

Key:
Nursing Diagnosis
Outcomes
Subjective/ Objective
Data
Interventions
Evaluations

#4 Intervention
Offer emotional support allow
time to discuss concerns and
possibilities.
#3 Intervention
Explain the rationale for
surgery.

Patient: Marcy Lane

Nursing Diagnoses

Goal

Interventions

Evaluation

#5 Intervention
Review discharge
instructions and follow up
with written copy for
patient.

1. Acute Pain related inflammation

of the appendix
Signs and Symptoms:
Patient is crying and restless.
Stated My stomach really
hurts.
Pain Scale 7/10.
Abdomen is tender to touch
Pulse 105 beats/min

The patient will

demonstrate relief
from pain by the
end of shift on
June 5 2016

2. Risk for infection related to

impending rupture of appendix
Signs and Symptoms:
RLQ pain
Temperature: 38.7 C
Vomited X 1
WBC 15000 cells/cu mm

The patient will

not exhibit any
signs of infection
and will be able to
proceed with
surgery with no
complications.

3. Risk for deficient fluid volume

related to decreased fluid
intake and loss.
Signs and Symptoms:
Vomited X 1
NPO prior to surgery

At the end of my
shift, the patient
will not exhibit
signs of
dehydration.

4. Anxiety (mild) related to

upcoming surgery.
Signs and Symptoms:
Pulse 105 beats/min
First Hospitalization
Patient stated, Will they put
me to sleep when I have the
operation?
Restlessness
5. Deficient Knowledge related to
lack of information regarding
surgery and post-operative
care.
Signs and Symptoms:
Patients first hospitalization
Patient verbalized, Will they
put me to sleep when I have
the operation?
Patients mom stated, The
doctor told us, that she might

At the end of my
shift, the patient
and parent will
acknowledge their
feelings of anxiety
and verbalize
relief from anxiety.

At the end of my
shift, the patient
and the parent will
understand the
rationale for the
surgery and learn
about the
importance of
adhering to postoperative care.

1. Administer Acetaminophen 325mg sup Q4H.

2. If Acetaminophen is ineffective, administer 23mg Q4H IV/SQ as needed
3. Allow child to position herself comfortably.
4. Provide a stuffed animal, small pillow or blanket
to aid in splinting the area.
5. Provide a calm and restful environment.
6. Educate parent on observing cues for pain.
7. Provide distractions such as books, puzzles, TV
and games
1. Assess patients Vital Signs Q4H
2. Administer prophylactic antibiotics as ordered.
3. Administer Dimenhydrinate 25 mg Q4H IV/SQ
for nausea
4. Maintain adequate hydration.
5. Administer Acetaminophen 325 mg sup Q4H for
relief from fever.
1. Maintain NPO status
2. Assess for signs of dehydration: skin tenting,
sunken eyes, dry mucous membranes.
3. Monitor VS Q4H
4. Administer Dimehydrinate 25 mg Q4H IV/SQ as
needed.
5. Monitor intake and output.
1. Discuss alternate strategies for handling
anxiety.
2. Encourage client to acknowledge and express
feelings for anxiety.
3. Give clear and concise explanations regarding
impending procedures.
4. Provide distractions such as books, games and
television.
5. Identify and reinforce coping strategies.
1. Perform pre-op and post-op education.
2. Assess barriers and readiness to learn and
response to teaching.
3. Explain the rationale for surgery.
4. Offer emotional support allow time to discuss
concerns and possibilities.
5. Review discharge instructions and follow up
with written copy for patient.

Goal Met:
20 mins after the first dose
of Morphine, patient states
relief from pain 3/10 .

Goal Met:
1 hour prior to surgery.
Patients fever was
resolved, temperature
36.8C. Vital Signs remained
within normal limits. No
emesis reported for the
remainder of the shift.
Goal Met:
2 hours pre-operative,
client was observed to
have adequate skin turgor
and moist mucous
membranes.
Goal Met:
At the end of the 2 hour
education session, the
patient and parent will
express their feelings of
anxiety towards upcoming
patients surgery and was
willing to use coping skills.
Goal Met:
At the end of my 2 hour
shift, the client will
verbalize understanding of
the surgical procedure, preoperative and postoperative care.

have appendicitis and may

require an operation. He said,
he wanted to admit her and
keep an eye on her for a while.
When will the doctor know if
Marcy will need operation?
No prior health problems
Restlessness