Nursing Care Plan

(NCP)

NAME/ INITIALS OF PATIENT: R.O. AGE:____16__ SEX: __Female STATUS: _Single

ADDRESS: ____unindicated (rural area)
PRINCIPAL MEDICAL DIAGNOSIS:________Appendicitis.
NURSING CARE PLAN DEVSED BY:__ENRIQUEZ, Angelique Jade C._____________________YEAR AND SECTION:__BSN 3C_ GROUP__C14

Date and Time Nursing Diagnosis Short Term and Long Term Outcomes
November17, 2020 Acute Pain related to distention and Afterthree hours of nursing interventions, After series of nursing interventions, will be able
8:00am tenderness in abdomen the patient will verbalize adequate pain to return to preoperative activities.
relief.

Assessment Parameters Implementation

Subjective:
 Pain is rated 10/10
 Patient stated, “hurts all
over my whole
stomach.”
Objective:
 Pale and listless
 Bowel sounds are absent
 Abdomen is distended
 Abdomen is tender to
touch
 NGT is draining in an
increased amount of
dark, greenish black
fluid.
Nursing Orders/ Approaches
Dx:
Asses level of pain at leasthourly during the initial
postoperative then at least every 4 hours or whenever
vital signs are obtained. Have patient describe pain on a
scale of 0 to 10 (where 0 is no pain and 10 is worst
pain)
Note response of patient to medication, and report to
physician if pain is not being relieved.
Ascertain client’s understanding of individual
nutritional needs and ways client is meeting those
needs.
Monitor Vital Signs, including temperature, at least
every 4 hours
Tx:
Place patient in a Fowler’s position.
Promote bedrest.
Initiate non-pharmacologic approaches to pain
management such as relaxation, distraction, and
imagery techniques.
Make time to listen to and maintain frequent contact
with patient.
Administer analgesics, as ordered.
Rationale
Controlling postoperative pain not only promotes comfort but also facilitates
coughing, turning, deep breathing exercises, early ambulation, and healing.
Rating the pain provides a more objective description and helps the
nurse/physician to choose pain medication appropriate to severity of pain.
Severe pain not relieved by routine measures may indicate developing
complications or need for further intervention.
To determine informational needs of client.
Bacterial Infection often is present in acute cholecystitis, and may cause an
elevated temperature and respiratory rate
Fowler’s position decreases pressure on the inflamed gallbladder.
Allowing patient to assume position of comfort.
These techniques complement pain medication.
Helpful in alleviating anxiety and refocusing attention, which can relieve
pain.
Medication helps in maintaining comfort and enhance mobility.It allows the
client to rest. Regular analgesic administration maintains a therapeutic

Evaluate effectiveness of pain medicationwithin 30 to
45 minutes of administration.
Edx
Discuss abdominal splinting during coughing, turning,
or ambulating as needed.
Teach home care of incision.
Discuss activity limitations, as needed.
Discuss with SO(s) ways in which they can assist client
with pain management.
ACTUAL OUTCOME:Goal met. After three hours of
nursing interventions, the patient verbalized an adequate pain
relief from 10/10 to 6/10.
blood level for more effective pain relief.
Effectiveness may indicate a need for change of dosage or medication.
Teaching the patient on how to properly care for the wound would facilitate
a good and faster healing of the wound.
Family members/SOs may provide assistance to the client by helping on the
client's strenuous chores, supporting timely pain control, and providing
gentle massage to reduce muscle tension (as indicated).
DATE& TIME RESOLVED
November17, 2020
12:00pm

References:
Le Mone, P. & Burke, K. (2007) Principles of Medical-Surgical Nursing. Volume 1. 4th Edition. Philippines. Pearson Education Inc., Prentice Hall. ISBN 978-
981-06-9815-
Vera, M. (2019) Cholecystitis and Cholelithiasis. Retrieved November 21, 2020 from https://nurseslabs.com/4-cholecystitis-cholelithiasis-nursing-care-
plans/2/