Patient D, age 32, was admitted post-appendectomy with a diagnosis of acute appendicitis. He reported pain rated 6/10 at the right lower quadrant surgical incision that worsened with movement. Nursing interventions included monitoring vital signs, assessing pain characteristics and surgical site, providing diversional activities, and administering Toradol as needed. Objectives were for the patient to demonstrate ability to cope with pain and engage in activities within 8 hours. Evaluation found intact sutures, dry wound dressing, and participation in passive range of motion exercises.
Patient D, age 32, was admitted post-appendectomy with a diagnosis of acute appendicitis. He reported pain rated 6/10 at the right lower quadrant surgical incision that worsened with movement. Nursing interventions included monitoring vital signs, assessing pain characteristics and surgical site, providing diversional activities, and administering Toradol as needed. Objectives were for the patient to demonstrate ability to cope with pain and engage in activities within 8 hours. Evaluation found intact sutures, dry wound dressing, and participation in passive range of motion exercises.
Patient D, age 32, was admitted post-appendectomy with a diagnosis of acute appendicitis. He reported pain rated 6/10 at the right lower quadrant surgical incision that worsened with movement. Nursing interventions included monitoring vital signs, assessing pain characteristics and surgical site, providing diversional activities, and administering Toradol as needed. Objectives were for the patient to demonstrate ability to cope with pain and engage in activities within 8 hours. Evaluation found intact sutures, dry wound dressing, and participation in passive range of motion exercises.
Nursing Assessment Explanation of the Objectives Nursing Interventions Rationale Evaluation
Problem S:> “ Masakit dito sa Inflammation of the STO:> Within 8 hours of Dx:> Monitor v/s and > Elevation in rates suggest > The Pt. manifested baba”, while pointing at appendix nursing intervention, the record. increased pain intensity ability to cope with RLQ of abdomen. Pt. will manifest ability and frequency. incompletely relieved > rated pain as 6 on a to cope with > Assess pain > Elevation in intensity and pain as evidenced by: scale of 10, where 1 as Acute Appendicitis incompletely relieved characteristics including frequency may indicate a a.) verbalization of the lowest and 10 as the pain as evidenced by: location, intensity, and worsening condition. decrease in pain from highest. a.) verbalization of frequency. 6/10 to 4/10 > characterized pain as Appendectomy decrease in pain from > Assess surgical site > Swelling, redness, and b.) decreased RR from 23 pricking 6/10 to 2/10 for swelling, redness, or loose sutures may to 19 breaths per minute, > reported that pain b.) RR will be decreased loose sutures. contribute to the pain felt while other v/s remained occurs every time Pt. from 23 to 19 breaths per by the Pt, and are within normal range moves or is moved Dissection of right minute, while other v/s indicative of further c.) engagement in lower abdominal remain within normal management. diversional activities such O:> v/s taken as follows: tissues range as socialization, watching T= 37.0 C c.) engagement in Tx: > Provide Pt. with > To help Pt. divert his TV game shows, and PR= 83 bpm diversional activities diversional activities attention to other matters listening to mellow music RR= 23 breaths/min Disruption of skin such as socialization, such as socialization and other than the pain felt. BP= 110/70 mmHg surface and destruction watching TV game watching TV game > S/P appendectomy of skin layers shows, and listening to shows. > with surgical incision mellow music > Promote adequate > To lessen pain felt on RLQ of abdomen rest periods by aggravated by movements. > Evaluation was not > facial grimacing Activation of temporarily limiting carried out due to time upon movement nociceptors in the activity. constraints. Pt. was > guarding behavior dermis and tissues > Administer Toradol > To relieve or lessen pain endorsed to succeeding over surgical site LTO:> Within 3 days of (analgesic), as ordered. by inhibiting prostaglandin members of the health nursing intervention, the synthesis. team for further A:> Acute pain r/t Receptors send Pt. will manifest signs of management and skin/tissue trauma impulses to CNS for completely relieved pain Edx:> Encourage Pt. to > To allow further evaluation. interpretation as evidenced by: verbalize pain. assessment of pain > verbal report that pain characteristics and is completely relieved evaluation of treatment/ Pain perception > absence of facial interventions. grimacing upon > Encourage SOs to > To allow Pt. to continue performance of activities continue provision of to divert his attention to Acute Pain such as changing diversional activities and other matters other than position, sitting, a quiet environment. felt pain. standing, and walking > absence of guarding behavior over surgical site Name: Patient D Date: June 28, 2008 Age: 32 Gender: Male Shift: 3-11 Diagnosis: S/P Appendectomy Ward: Private Room N3302
Nursing Assessment Explanation of the Objectives Nursing Interventions Rationale Evaluation
Problem S:> “Hindi pa Inflammation of the STO: Dx: > Assess operative > To check for skin > The patient manifested masyadong magaling appendix > Within 8 hours of site for redness, swelling, integrity, monitor progress the following: tong sugat ko” as nursing intervention, the loose sutures, or soaked of healing, and identify a.) intact sutures verbalized by the patient Pt. will manifest the dressings. need for further b.) dry and intact wound Acute Appendicitis following: management. dressing O: > S/P appendectomy a.) intact sutures Tx: > Provide regular > To avoid accumulation c.) participation in > with surgical incision b.) dry and intact wound wound dressing. of moisture at the operative passive ROM exercises at right lower abdominal Appendectomy dressing site that may lead to skin area c.) participation in breakdown. > with dry and intact passive ROM exercises > Assist in passive > To promote circulation to dressing on the surgical movements (while flat on the surgical site for timely site Dissection of right LTO: bed for 8 hours) such as healing. > Evaluation was not lower abdominal > Within 3 days of bed turning and passive carried out due to time A:> Impaired skin/tissue tissues nursing intervention the ROM exercises, and constraints. Pt. was integrity related to Pt. and SOs will active (thereafter) endorsed to succeeding skin/tissue trauma demonstrate: movements such as members of the health Disruption of skin a.) proper aseptic wound changing bed position, team for further surface and destruction care technique sitting, standing, and management and of skin layers b.) proper supporting of walking. evaluation. incision such as splinting > Support incision, > To reduce pressure on c.) engagement in active as in splinting when the operative site. Impaired skin/tissue movements such as coughing, and during integrity sitting, standing, and movement. walking > Administer > To prevent bacteria to Zefocent (antibiotic), as harbor in the operative site ordered. and hinder tissue/skin healing, by inhibiting bacterial cell wall synthesis. Edx:> Encourage Pt. to > To allow continuous verbalize any untoward monitoring and assessment feelings, esp. discomfort of Pt. condition. or pain, as well as changes noted on operative site. > Instruct Pt. and SOs > To prevent unnecessary to refrain from exposure and touching/scratching contamination of the operative site. operative site which may delay healing. > Instruct Pt and SOs > For immediate to immediately report replacement to prevent skin when dressings are breakdown and soaked. contamination of operative site. > Demonstrate to Pt. > To promote healing and and SOs the proper way emphasize the importance of giving wound care of aseptic techniques in with emphasis on proper preventing handwashing and aseptic infection/contamination of techniques. operative site. > Encourage Pt. to > To promote circulation at engage in early operative site for timely ambulation and have his healing. SOs assist him in such activities. Name: Patient D Date: June 28, 2008 Age: 32 Gender: Male Shift: 3-11 Diagnosis: S/P Appendectomy Ward: Private Room N3302
Nursing Assessment Explanation of the Objectives Nursing Interventions Rationale Evaluation
Problem O:> v/s taken as Inflammation of the STO: >Within 8 hours Dx:> Monitor v/s and > Elevation in rates may > The Pt. and SOs follows: appendix of nursing intervention, record. signal infection. verbalized ways in T= 37.0 C the Pt. and SOs will > Assess operative site > To provide baseline data preventing infection/ PR= 81 bpm verbalize ways in for signs of infection. for comparison. contamination, RR= 23 breaths/min Acute Appendicitis preventing infection/ > To check for skin specifically proper BP= 110/70 mmHg contamination, integrity and identify need handwashing, and proper > S/P appendectomy specifically proper for further management. wound care. > with dry and intact Appendectomy handwashing, and dressing on RLQ of proper wound care. Tx: > Provide regular > To prevent growth of abdomen wound dressing MOs on dressings. Tissue trauma on RLQ aseptically. LTO:> Within 3 days of > Change linens and > To prevent growth of > Evaluation was not A:> Risk for infection nursing intervention, the Pt’s robes, as necessary. MOs on linens and robes. carried out due to time r/t tissue trauma May provide portal of Pt. will maintain stable > Administer Zefocent > To prevent bacteria to constraints. Pt. was entry for pathogens v/s and good skin (antibiotic), as ordered. harbor in the operative site endorsed to succeeding through: integrity, characterized and hinder tissue/skin members of the health > unnecessary exposure by absence of swelling, healing, by inhibiting team for further of surgical site redness and pain on bacterial cell wall management and > inadequate aseptic operative site. synthesis. evaluation. techniques especially in wound dressing Edx:> Encourage Pt. to > To allow continuous > contact with Pt.’s, verbalize any changes monitoring and assessment SOs’, and visitors’ hands noted on operative site of Pt. for signs of or other body parts such as redness, swelling, infection. and unusual/odorous drainage on operative site. May result to infection > Instruct Pt. and SOs > To prevent to refrain from contamination of operative touching/scratching site. operative site. > Instruct Pt and SOs > To prevent growth of to immediately report MOs on dressings that when dressings are may cause contamination soaked. of operative site. > Demonstrate to Pt. > To emphasize and SOs the proper way importance of aseptic of giving wound care techniques in preventing with emphasis on proper infection/contamination of handwashing. operative site. > Inform Pt. and SOs > To prevent growth of of the importance of MOs especially on following the prescribed operative site. drug regimen. > Advise Pt. to engage in > To promote circulation early ambulation and at operative site for timely have his SOs assist him in healing. such activities.