CAPITOL UNIVERSITY

College of Nursing
Cagayan de Oro City

Name: Salaguste, Cherry Phine Date: 10/1/2021

Section/ CN: RLE112 NCP #: 1

NURSING CARE PLAN

SUBJECTIVE OBJECTIVE

Patient verbalized intense fear Looks anxious

regarding the surgical procedure. Sad

Crying
Unfamiliar with surgical procedure
and environment.
Temperature: 104 ℉
BP: 80/60 mm Hg
HR: 135 bpm
RR: 23 bpm
ASSESSMEN
T
Presence of rebound tenderness
Increased Pain score of 10 out of 10 in McBurney’s
point when pressure is released
Presence of inflamed appendix with CT scan

Laboratoy findings:
WBC 14,000

DIAGNOSIS Fear / Anxiety related to surgical intervention, Appendectomy.

(P&E/P.E.S
FORMAT)

SHORT TERM LONG TERM

After 1 hour of nursing intervention, Within 6 hours, the patient is able to cope up with
PLANNING patients report a decrease in fear and the surgical interventions
anxiety with the use of effective coping
(Goals and strategies.
Objective)

Intervention INTERVENTION RATIONALE

MEDICAL-SURGICAL NURSING NCM 112

NURSING CARE PLAN (NCP) FORMAT Professor: Xerczhiel Faye C. Rio, R.N.
 Independent:
Assess the level of Anxiety of the To provide intervention according to anxiety level
patient.

Provide psychological support by

explaining the procedure.
Patient gains knowledge and confidence regarding
Do not leave client alone and if the surgical procedure.
possible allow near relative to be with
client.
(With
Rationale) To support patient and relieve fear and anxiety.
Orient the patient regarding the
environment in the operating room.

Administer Diazepam (Sedatives) as To promote confidence and hope.

prescribed.

To relieve fear and induce sleep.

After 1 hour of nursing intervention, the client's anxiety was decreased and the goal was met.

After 6 hours of nursing intervention, the patient was able to cope up with the surgical
EVALUATION interventions and the goal was met.

MEDICAL-SURGICAL NURSING NCM 112

NURSING CARE PLAN (NCP) FORMAT Professor: Xerczhiel Faye C. Rio, R.N.