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ESTEBAN, JOYCE ANNE D

IV-Irregular student
Prof. Elvenia Q. Morgan

Nursing Care Plan

Nursing Goals and Nursing


Assessment Rationale Rationale Evaluation
Diagnosis Objectives Intervention
After 4 hours Independent: After 4 hours
Subjective: Acute pain Inflammation of nursing  Assess pain,  Useful in of nursing
“kumikirot-kirot related to of the intervention, noting monitoring intervention,
yung bandang presence Appendix the patient location, effectiveness of the patient
inoperahan” as of surgical I will be able characteristic medication, was able to
verbalized by incision as Acute to verbalize s, severity (0- progression of verbalize
the patient. manifested Appendicitis relief of pain 10). healing. Changes pain is
by facial I or at least Investigate in characteristics of reduced from
Objective: grimace Appendectomy pain is and report pain may indicate pain scale
 Observed and report I reduced changes in developing 5/10 to 3/10
evidence of of pain. Dissection of from pain pain as abscess/ and also the
pain; facial right lower scale 5/10 to appropriate. peritonitis, patient was
grimace abdominal 3/10 and requiring prompt able to
 Verbalized tissues also the medical evaluation appear
pain at the I patient will and intervention relaxed.
abdomen Disruption of be able to  Keep at rest  Gravity localizes
with a pain skin surface appear in semi- inflammatory
scale of and relaxed. Fowler’s exudates into lower
5/10 destruction of position. abdomen or pelvis,
 Guarding skin layers relieving abdominal
I
behaviour in Activation of tension, which is
the incision the accentuated by
site. nociceptors in supine position.
the dermis and  Encourage  Promotes
tissues early normalization of
I ambulation. organ function.
Receptors  Provide  Refocuses
send impulses diversional attention, promotes
to CNS for activities. relaxation, and
interpretation may enhance
I coping abilities.
Pain Collaborative:
Perception  Keep NPO/  Decreases
I maintain NG discomfort of early
Acute Pain suction intestinal peristalsis
initially. and gastric
irritation/vomiting.
 Administer  Relief of pain
analgesics as facilitates
indicated. cooperation with
other therapeutic
interventions.
 Place ice bag  Soothes and
on the relieve pain
abdomen through
periodically, desensitization of
during initial nerve endings.
24-48 hours Note: do not use
as heat because it
appropriate. may cause tissue
congestion/
increase edema
formation.