Anda di halaman 1dari 3

Assessment Nursing Diagnosis Scientific

Explanation
Objectives/Plan of
Care
Nursing
Interventions
Rationale Evaluation

S> S> Masakit tong
sugat ko pag
gumagalaw ako at
lalo na kung
nawawala na yung
eefect nung pain
killer ko while
pointing at RLQ of
abdomen.
>rated pain as 7 on a
scale of 10, where 1 as
the lowest and 10 as
the highest
>characterized pain as
pricking
>reported that pain
occurs everytime
when pt moves or
moved

O> v/s taken as
follow:

BP:90/60 mmHg
RR:21 cpm
PR:60 bpm
T: 37.0 C

>with dry intact

Acute pain related to
tissue damage
secondary to post
appendectomy

Inflammation of the
appendix

Acute Appendicitis

Appendectomy

Dissection if right
lower abdominal
tissues

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

Acute Pain


STO: Within 6-8 hours
of comprehensive
nursing intervention,
the patient will be
able to manifest ability
to cope with
incompletely relieved
pain as evidenced by
a. ) verbalization of
decrease pain form
7/10 to 3/10
b.) engagement in
diversional activities
such as socialization,
texting, and listening
mellow music















DX>Monitored V/S and
record



>Assessed pain
characteristics
including location,
intensity, and
frequency

>Assessed surgical site
for swelling, redness
or loose sutures




TX>Promoted
adequate rest periods
by temporarily limiting
activity



>Provided patient with
diversional activities
such as socialization,
watching TV, and
listening mellow music

>Elevation in rates
suggest increased
pain intensity and
frequency

>Elevation in intensity
and frequency may
indicate worsening
condition

>Swelling, redness ,
and loose sutures may
contribute to the pain
felt by pt. and are
indicative of further
management


>to lessen pain felt
aggravated by
movements




>to help pt divert his
attention to other
matters than pain felt



STO:Goal met if within
6-8 hours of nursing
intervention, the
patient will be able to
manifest ability to
cope with
incompletely relieved
pain as evidenced by
a. ) verbalization of
decrease pain form
7/10 to 3/10
b.) engagement in
diversional activities
such as socialization,
watching TV, and
listening mellow music
>verbal report that
pain is completely
relieved
>absence of facial
grimacing upon
performance of
activities such as
changing position,
sitting ,standing and
walking
> absence of guarding
behavior over surgical
site

dressing on the
surgical site
>grimacing noted
>irritable
>with guarding
behavior at the wound
site
>weak in appearance
>moaning noted


Reference: Brunner
and Suddharts

LTO: Within 2-3 days
of comprehensive
nursing intervention,
the patient will be able
to display continuous
progress and changes
of condition and will
be able to display no
signs of pain.

>Administered Toradol
(analgesic)as ordered


>Assisted in early
ambulation


EDX> Emphasized the
importance of clear
liquid diet.

>Instructed to do DBE

>Instructed to splint
wound site upon
coughing



>Instructed to
continue provision of
diversional activities
and a quiet
environment




>Encouraged patient
to verbalize pain
perception


>to relieved or lessen
pain by inhibiting
prostaglandin
synthesis
>to promote normal
peristaltic movement


>To prevent further
complications.


>To lessen pain

>To prevent the
wound site to open.




>to allow patient
continue divert his
attention






>to allow further
assessment of pain
characteristics and
evaluation of

LTO: Goal met if
Within 2-3 days of
comprehensive
nursing intervention,
the patient will be able
to display continuous
progress and changes
of condition and will
be able to display no
signs of pain.

*Evaluation was not
carried out due to
time constraints. Pt
was endorsed to
succeeding members
of the health team
for further
management and
evaluation



>Encouraged early
ambulation



treatment /
intervention

>to promote normal
peristaltic movement.