App.docx

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Assessment

Scientific Basis

Nursing Diagnosis

Nursing Goal Plan

Nursing Intervention

Subjective: “Sakitakoang kilid”, as patient verbalized.

Due to the presence of inflammation and mass on the RLQ of the abdomen, it causes some obstruction in the lumen of the appendix in turn causes s sharp acute pain in the Right Lower Quadrant part of the abdomen.

Acute pain related to inflammation of the appendix.

Within our 8 hour span of care, patient will be alleviated from pain.

 Establish rapport.

Objective:  Conscious  Grimaced face noted  Weakness noted  Guarded behavior noted  Pain scale: 7/10  Pale looking

 V/S taken and recorded.

Rationale

 To gain trust and cooperation.  Serves as baseline data.  To assess the level of pain.

 Encourage verbalization of feelings about pain.  Encourage patient to have diversional activities such as mobile internet and watching TV.  Encourage patient to use relaxation techniques such as deep breathing.  Provide comfort measures such as touch, repositioning, quiet environment and calm activities.  Encourage adequate rest periods.  Observe and document 2

 To alleviate pain.

 Distract attention and reduce tension.

 To promote nonpharmacologic pain management.

 To promote wellness and prevent fatigue.  To get a baseline data of pain scale.

severity (1-10 scale) and character of pain (steady, intermittent, colicky). 

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Assessment

Scientific Basis

Subjective: “Worried kosaakong situationbasig operahan man gudko”, as verbalized by the patient.

Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a Objective: feeling of apprehension Irritability caused by noted anticipation of Anxious danger it is an looking alerting signal Discomfort that warns of noted impending Restlessnes danger and s noted enables the individual to take measures to deal with the threat. (Gulanick/Myers Nursing Care Plans, 6th Edition)

Nursing Diagnosis Anxiety related to possible surgery secondary to Acute Appendicitis.

Nursing Goal Plan

Nursing Intervention

Within our 8  Establish rapport. hour span of care, patient will be able to understand and  V/S taken and recorded. demonstrat e positive coping  Assess awareness of mechanism patient about anxiety. and describe a reduction in the level of anxiety.  Provide accurate information to the client.  Provide comfort measures.  Provide and maintain quiet environment.

 Encourage patient to talk about anxious feelings.

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Rationale

 To gain trust and cooperation.  Serves as baseline data.  Validate the feeling and communicate acceptance of the feelings.  Helps the client to identify what is reality based.  To help the patient relax.  Anxiety may escalate with excessive conversation, noise and equipment about the patient.  Talking about anxiety producing situations and anxious feelings can help the person perceive the situation in less threatening manner.

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