Cues Nursing Diagnosis Scientific Explanation Objective
s> (-) Acute pain related to Appendicitis is the
inflammation of the inflammation of the
o> vermiform appendix appendix. Inflammation
(+) facial grimace occurs when the opening
the appendix to the large
(+) rebound tenderness on intestine is blocked. This
right lower quadrant will cause the stretching of
the appendix resulting to
(+) guarding behavior on epigastric or periumbilical
right lower quadrant pain. When the
inflammatory process has
Irritable extended to involve the
serosal layer of the
Increase RR appendix and the
peritoneum, pain becomes
localized to lower right
quadrant, which is called
as McBurney’s pain
Destura Noel T. N308 Dx: CVA 76yo female c/c chest pain and body weakness.
Nursing Intervention
After 1 hour of nursing
intervention, the patient
will be able to report or
verbalize relief from pain.
Rationale Expected Outcome
>Provide comfort >To provide non- The patient will verbalize
measures such as pharmacological pain control of pain as
change position management. evidenced by absence of
facial grimace, moaning
>Perform pain >To rule out worsening of and decrease RR, PR, BP,
assessment each time underlying condition or through patient’s change
pain occur development of of position, the use of
complication relaxation exercises such
>Instruct patient to as deep breathing,
report pain >so that relief diversional activities such
measurement may be as watching TV or Board
>Instruct use of instituted games, and last but not
relaxation exercises least his/her adequate rest
such as deep breathing >To assist patient in period.
controlling his/her pain
>Encourage diversional
activities such as >To divert the clients
talking with their attention from his pain to
significant others, other productive or
watching TV, or recreational activities.
playing board games.
>to prevent fatigue
>Encourage adequate
rest periods >To relieve pain through
removal of the
>Surgical management contributory factor which
as ordered by the is the inflamed infected
physician apendix