C.

Nursing care Plan Assessment Explanation of the problem Inflammation of the appendix Acute appendicitis Appendectomy Dissection of right lower abdominal tissue Disruption of skin surface and destruction of skin layers Activation of nociceptors in dermis and tissues Receptors send impulses to CNS for interpretation Pain perception Goal Interventions Rationale Evaluation

Subjective:  nasakit ditoy while pointing at RLQ of abdomen ,rated pain as 7/10, where 10 is the highest and 1 is the lowest, characterize d pain as pricking and aggravated when moving. Objective:  Grimaces.  Guarding behavior on affected site.  With dry intact dressing.

STO: After 8 hours of nursing interventions the patient will demonstrate use of relaxation skills and diversional activities as indicated.

Dx:  Monitor and record vital signs.

LTO: After 3 days of nursing interventions the patient will report that pain is control/relieve.

 Assess pain characterist ic including location, intensity, and frequency.

 Assess surgical site for swelling, redness or loose sutures.

 Elevation in rates suggests increased pain intensity and frequency.  Elevation in intensity and frequency may indicate worsening of condition.  Swelling, redness and loose sutures may contribute to the pain felt by pt. and are indicative of further

STO: After 8 hours of nursing interventions, goal met as evidenced by: -The patient demonstrated use of relaxation skills and diversional activities as indicated.

LTO: After 3 days of nursing interventions, goal met as evidenced by: -The patient reported that pain was controlled/relieved.

Dx: Acute pain related to tissue damage secondary to post appendectomy

management. Acute pain Tx:  Promote adequate rest periods by temporarily limiting activity.  Provide patient diversional activities such as socializatio n, reading news papers or magazines, and listening to music.  Administer pain medication as order.  To lessen pain felt aggravated by movements.

 To help patient divert his attention to other matters.

 To relieve or lessen pain by inhibition of prostagland in synthesis

Tx:  Encourage patient to verbalize pain perception.

 Encourage SO to continue provision on diversional activities and a quiet environment.  Encourage pt. to eat vitamin C rich foods.

 To allow further assessment of pain characteris tic and evaluation of treatment or interventio n.  To allow patient continue divert his attention.

 Vit. C helps in faster wound healing.

Assessment

Explanation of the problem Inflammation of the appendix Acute appendicitis Appendectomy Dissection in right lower abdominal tissues Disruption of skin and destruction of layers Impaired skin/tissue integrity

Planning

Interventions

Rationale

Evaluation

Subjective:  sariwa pa yung sugat ko  Grimaces.  Guarding behavior on operative site. Objective:  With surgical incision at right lower abdomen area.  With dry intact dressing on the surgical site.

STO: After 8 hours of nursing interventions the patient will be able to participate in prevention measures and treatment program.

Dx:  Monitor vital signs and record.

Dx: Impaired skin integrity related to skin/tissue trauma.

LTO: After 3 days of nursing interventions the patient will be able to display timely healing of skin lesions/wounds without complication.

 Assess operative site or redness, swelling, loose sutures, or soaked dressing. Tx:  Assist in passive movements such as bed turning and passive ROM exercises and active exercises.  Provide regular dressing care.

STO: After 8 hours of nursing  Serve as interventions baseline data to know goal met as evidenced by: the abnormalitie - The patient was able to s. participate in  To check prevention skin measures and integrity, treatment monitor program. process of healing and identify for further management. LTO: After 3 days of nursing interventions goal met as evidenced by: - The patient displayed timely healing of skin lesions/wounds without  To avoid accumulation complication. of moisture at the operative  To promote circulation to the surgical site or timely healing.

site which may lead to skin breakdown.  Administer antibiotic as ordered.  To prevent bacteria harbor in operative site.

Tx:  Encourage patient to support the incision when coughing and during movement.  Encourage to verbalize his any untoward feelings especially pain or discomfort.  Encourage pt. on early ambulation and have SO assist him  To reduce pressure on operative site.

 To allow continuous monitoring and assessment of pt. condition.

 To promote circulation to the surgical site or

in such activities.  Instruct pt. and SO to immediately report when dressing is soak.

timely healing.  To promote circulation to the surgical site or timely healing.

Assessment

Explanation of the problem Inflammation of the appendix Acute appendicitis Appendectomy Tissue trauma on RLQ of abdomen may provide portal of entry or pathogens through unnecessary exposure on surgical site, inadequate aseptic techniques especially in wound dressing and contact with patients , SOs and visitors hands or other parts. May result in

Planning

Interventions

Rationale

Evaluation

Objective:  With surgical incision at right lower abdomen area.  With dry intact dressing on the surgical site.  Weak in appearance.

STO: After 8 hours of nursing interventions the patient will be able to verbalize ways in preventing infection/ contamination.

Dx:  Monitor and record vital signs.  Assess for operative site for signs of infection.

 Elevation in rates may signal infection.  To provide baseline data or comparison and identify need for further management.  To prevent growth of microorgani sm on linens or beds.  To prevent unnecessary exposure and contaminati on on operative site which may delay

STO: After 8 hours of nursing interventions goal met as evidenced by: -The patient was able to verbalize ways in preventing infection.

Dx: Risk for infection related to surgical incision.

LTO: After 3 days of nursing interventions the patient will be free from any infections and achieve timely wound healing.

Tx:  Change linens as necessary.

 Provide regular dressing care.

LTO: After 3 days of nursing interventions the patients was free from any infections and achieve timely wound healing.

infection

wound healing.

 Administer antibiotic as order.

 Serve as prophylacti c treatment and prevent bacteria to harbor on operative site.  To prevent breakdown and contaminati on on operative site.  To allow continuous monitoring and assessment of pt. condition.  To promote circulation to the surgical site or

Tx:  Instruct pt and SO to refrain from touching/scratch ing the operative site.

 Encourage to verbalize his any untoward feelings especially pain or discomfort.

 Encourage pt. on early ambulation and have SO assist him in such activities.

timely healing.

 Instruct pt. and SO to immediately report when dressing is soak.

 To promote circulation to the surgical site or timely healing.