Cues Nursing Scientific Objectives/Plan of Nursing Interventions Rationale Evaluation

Diagnosis Explanation Care

S> Hindi pa Impaired Skin Inflammation of the Within 8 hours of >Assess operative site for redness, >to check skin integrity, Within 8 hours of
masyado Integrity related appendix nursing swelling, loose sutures, or soaked monitor progress of nursing
magaling ang to skin/tissue intervention the pt dressing healing and identify intervention the pt
sugat ko as trauma Acute Appendicitis will be able to need for further be able manifest
verbalized by manifest the the following:
the patient Appendectomy following: >Monitor Vital Signs > Serve as baseline data a.) intact sutures
a.) intact sutures b.) dry and intact
O> S/P Dissection if right b.) dry and intact >Assist in passive movements(while >to promote circulation wound dressing
Appendectomy lower abdominal wound dressing 8hrs. flat on bed) such as bed turning to the surgical site for c.) participation in
>with surgical tissues c.) participation in and passive ROM exercise and active timely healing passive ROM
incision at right passive ROM exercise thereafter movements such exercises
lower abdominal Disruption of skin exercises as bed position, sitting, standing,
area surface and walking >Evaluation was
>with dry intact destruction of skin not carried out due
dressing on the layers > Support incision as in splinting >to reduce pressure on to time constraints.
surgical site when coughing and during the operative site Pt was endorsed to
Impaired skin/tissue movement succeeding
integrity members of the
>Encourage pt to verbalized his for >to allow continuous health team for
any untoward feelings especially monitoring and further
pain, discomfort as well as changes assessment of pt. management and
noted on operative site condition evaluation

>Encourage pt to engage early >to promote circulation

ambulation and have SOs assist him to the surgical site for
in such activities timely healing
>Instruct pt and SOs to immediately >to promote circulation
report when dressing are soaked to the surgical site for
timely healing

>Instruct pt and SOs to refrain from >for immediate

touching/scratching operative site replacement to prevent
skin breakdown and
contamination of
operative site

>Provide regular dressing care >to avoid accumulation

of moisture at the
operative site
which may lead to skin
breakdown

>Administer Chlorampenicol >to prevent bacteria

Sodium(antibiotic) as ordered harbor in operative site
Cues Nursing Diagnosis Scientific Objectives/Plan of Care Nursing Rationale Evaluation
Explanation Interventions

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

>Encourage pt to >to promote

engage early circulation to the
ambulation and surgical site for
have SOs assist him timely healing
in such activities

>Administer >serve as
Penicillin G prophylactic
Sodium(antibiotic) treatment and
as ordered prevent bacteria to
harbor on operative
site
Kenneth Antonio B. Bacani, SN Group 1 Nursing Care Plan Callang General Hospital, Santiago City

Cues Nursing Diagnosis Scientific Objectives/Plan of Nursing Rationale Evaluation

Explanation Care Interventions

S> Masakit ditto sa Acute pain related to Inflammation of the Within 6-8 hours of >Monitor V/S and >Elevation in rates Within 6-8 hours of
baba, while pointing tissue damage 2nd to appendix nursing intervention, record suggest increased nursing intervention,
at RLQ of abdomen. post appendectomy the pt will be able to pain intensity and the pt will be able to
>rated pain as 5 on a Acute Appendicitis manifest ability to frequency manifest ability to
scale of 10, where 1 as cope with cope with

the lowest and 10 as incompletely relieved >Assess pain incompletely relieved
Appendectomy >Elevation in intensity
the highest pain as evidenced by characteristics pain as evidenced by
and frequency may
>characterized pain as a. ) verbalization of including location, a. ) verbalization of
Dissection if right indicate worsening
pricking decrease pain form intensity, and decrease pain form
lower abdominal condition
>reported that pain 5/10 to 2/10 frequency 5/10 to 0/10
occurs everytime tissues b.) engagement in b.) engagement in
>Swelling, redness ,
when pt moves or diversional activities >Assess surgical site diversional activities
and loose sutures may
moved Disruption of skin such as socialization, for swelling, redness such as socialization,
contribute to the pain
surface and watching TV, and or loose sutures watching TV, and
felt by pt. and are
O> v/s taken as follows destruction of skin listening mellow music listening mellow music
indicative of further
T: 37.0 C layers >verbal report that
management
RR: 21 cpm pain is completely

PR: 64 bpm >Promote adequate releived
Activation of >to lessen pain felt
BP: 120/70 mmHg rest periods by >absence of facial
nociceptors in dermis aggravated by
temporarily limiting grimacing upon
and tissues movements
> S/P Appendectomy activity performance of

>with dry intact activities such as
Receptors send >Encourage pt to changing position,
dressing on the >to allow further
impulses to CNS for verbalize pain sitting ,standing and
surgical site assessment of pain
>with guarding interpretation perception walking
characteristics and
behavior over the site > absence of guarding
evaluation of
>facial grimacing Pain Perception behavior over surgical
treatment /
site
intervention
Acute Pain
>Provide pt with >to help pt divert his >Evaluation was not
diversional activities attention to other carried out due to
such as socialization, matters than pain felt time constraints. Pt
watching TV, and was endorsed to
listening mellow music
succeeding members
of the health team
>Encourage SOs to >to allow pt continue for further
continue provision of divert his attention management and
diversional activities evaluation
and a quiet
environment

>Administer Toradol >to relieved or lessen

(analgesic)as ordered pain by inhibiting
prostaglandin
synthesis