Hannah N.

Lopez Name of Patient: Fredie De Guzman Male, 14 y/o Diagnosis: Acute Appendicitis; S/P Appendectomy ASSESSMENT Subjective: NURSING DIAGNOSIS PLANNING After 8 hours of nursing intervention, the patient will be relieved from pain as manifested by: a. pt. performs ADL independently b. pain scale of 3 from 7 c. pt. assumes different position Date of Admission: 04-16-12

April 15, 2012

INTERVENTION Assess V/S and record Evaluate clients actual and perceived limitations/degree of deficit in light of usual status Note client reports of weakness, fatigue, pain, difficulty of accomplishing tasks Adjust activities

RATIONALE Serves as baseline data Provides comparative baseline and provides information about needed education/ interventions regarding quality of life Symptoms may be result of/or contribute to intolerance of activity

EVALUATION Patient was relieved from pain as evidenced by: a. pt. performs ADL independently b. pain scale of 3 from 7 c. pt. assumes different position

Activity Intolerance Masakitpoangs r/t pain ugatkonahihirap secondary to anakokumilos presence of as verbalized by surgical the patient. procedure A score of 7 in a pain scale of 110 where 1 is the lowest and 10 as the highest score. Objective: Inability to perform ADLs Weak in appeara nce Loss of

To prevent overexertion

Increase activities/exercise levels gradually Provide positive atmosphere while acknowledging difficulty of situation for client

To conserve energy

Helps minimize frustration

interest to particip ate in desired activitie s Patient prefers to assume lying position most of the time

physical therapy Plan care to carefully balance rest periods with activities Assist client with daily activities Promote comfort measures Encourage to increase intake of nutritious foods To prevent fatigue

To protect client from injury To enhance ability to participate in activities To increase immune system/ increase body resistance To enhance sense of well-being To decrease stretching of the affected muscles thereby reducing pain

Encourage participation/ social activities Provide splint/perform splinting on the surgical incision site during activities Administer prescribed medications

For fast recovery

Hannah N. Lopez Nurse Trainee Noted by: Ms. Liza Mamaril, RN, MAN OIC Asst. Chief Nurse for Training

Mrs.ErlindaMamayson Senior Nurse, Surgical Ward

Mr.RosauroCatabay, RN, MAN OIC Chief Nurse RIMC

LIBERTY G. NARAG Name of Patient: CrispinaManaois 76 y/o, Female Diagnosis: CalculousCholecystitis; S/P Cholecystectomy ASSESSMENT Subjective: Masakitpoiyongsa may operasyonkoyungsa may tahi at patiungditosakinalal agyannitongtubo A score of 7 in a pain scale of 1-10 where 1 is the lowest score and 10 as the highest score. Objective: Weak in appearance Guarded/dist raction behaviour NURSING DIAGNOSIS Acute pain r/t interruption in skin/tissue layers with mechanical closure (sutures/staples) and invasive procedures (Ttube) PLANNING After 8 hours of nursing intervention, the patient will be able to: Report that pain is relieved/ controlled. To assist client to explore methods for alleviation/ control of pain Determine clients acceptable level of pain on a 0 to 10 or faces scale Providecomfort measures (backrub, change of position) Instruct in/ encourage use of relaxation exercises such as focused breathing Provides comparative baseline

APRIL 15, 2012

Date of Admission: 4/11/2012 INTERVENTION RATIONALE EVALUATION The patient has reported that pain is relieved/ controlled. With a pain scale of 3 from 7.

To provide nonpharmacologic pain management

Facial grimace Irritable Vital signs:

Identify ways of avoiding/ minimizing pain (splinting incision, good body mechanics) Administer analgesics as indicated to maximal dosage as needed

To decrease stretching of the affected muscles thereby reducing pain To maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal To medicate prophylactically as appropriate Usually altered in acute pain To conserve energy

BP 140/80 mmHg RR- 28 cpm PR- 99 bpm Temperature 36.4 degree Celsius

Note when pain occurs

Monitor vital signs

Provide quiet environment/ calm activities Encourage adequate rest periods Mrs.ErlindaMamayson Senior Nurse, Surgical Ward

To prevent fatigue

Liberty G. Narag Nurse Trainee Noted by: Ms. Liza Mamaril, RN, MAN OIC Asst. Chief Nurse for Training

Mr.RosauroCatabay, RN, MAN OIC Chief Nurse RIMC