Cues Nursing Scientific Objectives/Plan Nursing Interventions Rationale Evaluation

Diagnosis Explanation of Care

S> “ Hindi pa Impaired Inflammation of Within 8 hours >Assess operative site for >to check skin Within 8 hours
masyado Skin Integrity the appendix of nursing redness, swelling, loose integrity, monitor of nursing
magaling ang related to intervention the sutures, or soaked dressing progress of healing intervention the
↓
sugat ko” as skin/tissue pt will be able and identify need pt be able
verbalized by trauma Acute to manifest the for further manifest the
the patient Appendicitis following: following:

↓ a.) intact >Monitor Vital Signs a.) intact

> Serve as baseline
sutures sutures
O> S/P Appendectomy data
Appendecto b.) dry and b.) dry and
my ↓ intact wound >Assist in passive intact wound
dressing movements(while 8hrs. flat dressing
Dissection if >to promote
>with on bed) such as bed turning
right lower circulation to the
surgical c.) participation and passive ROM exercise c.) participation
abdominal surgical site for
incision at in passive ROM and active exercise thereafter in passive ROM
tissues timely healing
right lower exercises movements such as bed exercises
abdominal position, sitting, standing,
area
↓
walking
>with dry
Disruption of >Evaluation
intact dressing
skin surface and was not carried
on the
destruction of out due to time
surgical site > Support incision as in
skin layers constraints. Pt
splinting when coughing and
during movement was endorsed
↓ >to reduce
to succeeding
pressure on the
 Impaired operative site members of the
skin/tissue health team for
>Encourage pt to verbalized
integrity further
his for any untoward feelings
management
especially pain, discomfort as
and evaluation
well as changes noted on >to allow
operative site continuous
monitoring and
assessment of pt.
>Encourage pt to engage condition
early ambulation and have
SO’s assist him in such
activities >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
>for immediate
site
replacement to
 prevent skin
breakdown and
contamination of
operative site

>Provide regular dressing >to avoid

care accumulation of
moisture at the
operative site

which may lead to

skin breakdown

>to prevent
bacteria harbor in
>Administer Chlorampenicol operative site
Sodium(antibiotic) as ordered
Cues Nursing Scientific Objectives/Plan of Nursing Rationale Evaluation
Diagnosis Explanation Care Interventions

S>”Hindi namn Risk for Inflammation of Within 8 hours of >Monitor v/s >Elevation in Within 8 hours of
ako nilalagnat” infection the appendix nursing and record rates may nursing
verbalized by related to intervention the pt signal infection intervention the pt
↓
the patient tissue trauma will be able will be able
Acute verbalize ways in verbalize ways in
Appendicitis preventing >to provide preventing
infection/contamin >assess infection/contamin
baseline data
↓ ation specifically operative site ation specifically
for comparison
O> v/s taken as proper hand for signs of proper hand
Appendectomy and identify
follow: washing, and infection washing, and
need for further
↓ proper wound care management proper wound care
as evidenced by: as evidenced by:
Tissue trauma
BP:110/80
on RLQ >maintain stable >maintain stable
mmHg
abdomen v/s >to prevent v/s
RR:22 cpm growth of
May provide >good skin >change linens microorganisms >good skin
PR:68 bpm portal of entry integrity as necessary on linens and integrity
for pathogens beds
T: 37.0 C >absence of >absence of
through:
swelling redness swelling redness
 >unnecessary and pain on and pain on
exposure of operative site operative site
> S/P >Provide regular > to prevent
surgical site
Appendectomy dressing care unnecessary >Evaluation was
>inadequate exposure and not carried out due
>with dry intact
aseptic contamination to time constraints.
dressing on the
techniques of operative site Pt was endorsed to
surgical site
especially in succeeding
which may
wound dressing members of the
delay wound
health team for
>contract with healing
further
pt’s, SO’s and
management and
visitors hands
evaluation
or other parts >for immediate
replacement to
↓ >Instruct pt and
prevent skin
SO’s to refrain
May result to breakdown and
from
infection contamination
touching/scratch
of operative site
ing operative
site

>to allow
continuous
monitoring and
assessment of
pt. condition
>Encourage pt
to verbalized
any changes
noted on
operative site
such as redness,
swelling and
unusual/odorous
drainage
>to promote
circulation to
the surgical site
for timely
>Encourage pt
healing
to engage early
ambulation and
have SO’s assist
him in such
activities
>serve as
prophylactic
treatment and
>Administer prevent
Penicillin G bacteria to
Sodium(antibioti harbor on
c) as ordered operative site
Kenneth Antonio B. Bacani, SN Group 1 Nursing Care Plan Callang General Hospital, Santiago City

Cues Nursing Scientific Objectives/Plan Nursing Rationale Evaluation

Diagnosis Explanation of Care Interventions

S> “Masakit ditto Acute pain related Within 6-8 hours >Monitor V/S and >Elevation in Within 6-8 hours
sa baba”, while to tissue damage Inflammation of of nursing record of nursing
rates suggest
pointing at RLQ of 2nd to post the appendix intervention, the intervention, the
increased pain
abdomen. appendectomy pt will be able to intensity and pt will be able to
>rated pain as 5
↓ manifest ability to manifest ability to
frequency
on a scale of 10, cope with >Assess pain cope with
Acute
where 1 as the incompletely characteristics incompletely
Appendicitis
lowest and 10 as relieved pain as including location, relieved pain as
the highest ↓ evidenced by intensity, and >Elevation in evidenced by
>characterized a. ) verbalization frequency intensity and a. ) verbalization
pain as pricking Appendectomy of decrease pain frequency may of decrease pain
>reported that form 5/10 to 2/10 >Assess surgical indicate form 5/10 to 0/10
pain occurs ↓ b.) engagement in site for swelling, worsening b.) engagement in
everytime when diversional redness or loose condition diversional
Dissection if
pt moves or activities such as sutures activities such as
moved right lower socialization, >Swelling, socialization,
abdominal watching TV, and redness , and watching TV, and
O> v/s taken as tissues listening mellow loose sutures may listening mellow
follows music >Promote contribute to the music
T: 37.0 C ↓ adequate rest pain felt by pt. >verbal report
RR: 21 cpm periods by and are indicative that pain is
Disruption of
PR: 64 bpm temporarily of further completely
skin surface and
BP: 120/70 mmHg limiting activity management releived
destruction of >absence of facial
 skin layers >Encourage pt to >to lessen pain grimacing upon
verbalize pain felt aggravated by performance of
> S/P ↓ perception movements activities such as
Appendectomy changing position,
Activation of
sitting ,standing
>with dry intact nociceptors in
>to allow further and walking
dressing on the dermis and tissues
assessment of > absence of
surgical site >Provide pt with pain guarding behavior
>with guarding ↓
diversional characteristics over surgical site
behavior over the activities such as and evaluation of
Receptors send
site
impulses to CNS socialization, treatment / >Evaluation was
>facial grimacing watching TV, and intervention
for interpretation not carried out
listening mellow due to time
↓ music >to help pt divert constraints. Pt
his attention to
Pain Perception was endorsed to
other matters
succeeding
>Encourage SO’s than pain felt
↓ members of the
to continue
provision of health team for
Acute Pain
diversional further
activities and a management
quiet environment >to allow pt and evaluation
continue divert his
>Administer attention
Toradol
(analgesic)as
ordered

>to relieved or
lessen pain by
inhibiting
prostaglandin
synthesis