SY 2021-2022

COLLEGE OF NURSING
Silliman University
Dumaguete City

NURSING CARE PLAN FOR APPENDECTOMY

Submitted to:
Asst. Prof. Veveca V. Bustamante R.N. M.N

Submitted by:
Garganian, Ma. Therese H.

BSN III-D3

May 17,2022
 Immediate preop (one hour before transporting to OR)

CUES/EVIDENCES DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective Data Acute pain related to At the end of 1-hour INDEPENDENT: At the end of
● Complains of obstructed appendix pre-op care, patient’s 1-hour pre-op care,
the right lower as evidenced by pain will be ● Assess ● Useful in patient’s pain was
quadrant reports of right lower relieved/controlled as pain, noting monitoring relieved/controlled
(RLQ) abdominal pain evidenced by: location, effectivenes as evidenced by:
abdominal pain characterist s of
for 2 days. ics, severity medication, ● States
● Gain and state (0–10 progression knowledge
● experiencing a knowledge scale). of healing. about the
sudden loss of about the Investigate Changes in importance
appetite, importance and report characteristi of pain relief
unexplained of pain relief changes in cs of pain measures.
vomiting, and measures. pain as may
nausea. appropriate indicate ● Demonstrate
● Demonstrate . developing s the use of
● Pain in the the use of abscess or relaxation
McBurney’ s relaxation peritonitis, skills, and
point. skills and requiring other
other methods prompt methods to
● Pain was rated that promote medical promote
8 on a scale of comfort. evaluation comfort.
1-10 on the and
Wong Bakers intervention. ● Verbalized
scale. ● Verbalize that that pain
pain is ● Assess and ● Changes in was reduced
relieved and monitor these vital and relieved
Objective Data reduced. V/S. signs often
● The patient indicate ● Appears to
looks ill, lying ● Appear to be pain and be relaxed.
 uncomfortably, relaxed. discomfort.
grasping on his
clothes, and a
febrile ● Assess the ● Patients
patient with feelings
● Facial expectation of pain may
grimacing of the not expect
noted course of a complete
pain absence of
● Restlessness treatment. pain but
may be
● Moaning and satisfied
crying with the
decreasing
severity.
● Irritability
noted ● Educate ● Promotes
and provide relaxation
● Vital signs: the patient and may
○ T = 37.5 about enhance
○ CPR= noninvasive patient's
70 bpm /diversional coping
○ BP = activities. abilities by
120 / 80 refocusing
mmHg attention.
RR= 18
cpm ● Move ● Reduces
○ O2=98 patient muscle
% slowly and tension on
deliberately guarding
. which may
help
minimize
 pain
movement.

● Reduces
● Maintain abdominal
Semi- distention
Fowler's there by
position. reducing
tension.

● Provide ● Reduces
frequent nausea and
oral care. vomiting
which can
increase
intra
abdominal
pressure.
 Intra-op

CUES/EVIDENCES DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective Data Ineffective breathing At the end of 1-hour INDEPENDENT At the end of
pattern related to intra-op care, patient 1-hour intra-op
decreased lung will maintain an ● Administer ● For care, patient was
Objective Data expansion secondary effective breathing oxygen at managemen able to maintain
● Decreased to surgery as pattern as evidenced lowest t of effective breathing
respiratory manifested by by: concentrati underlying pattern as
depth decreased respiratory on pulmonary evidenced by:
(Bradypnea) depth indicated condition,
● Establish a and respiratory ● Established
● Decreased normal prescribed distress, or normal
inspiratory/ effective respiratory cyanosis effective
expiratory respiratory medication respiratory
pressure pattern. s. pattern

● Tachypnea is ● Absence of ● Monitor ● Increased ● No presence

observed cyanosis and vital signs respirations, of cyanosis
tachypnea. continuousl tachycardia
● Patient is y. ,and/or
cyanotic bradycardia
● Increase of suggests ● Free of signs
respiratory hypoxia and
depth , symptoms of
inspiratory and ● Educate ● To maximize respiratory
expiratory the respiratory distress after
pressure. importance effort surgery.
of good
● Free of signs posture for ● Increased
and symptoms effective respiratory
of hypoxia use of depth,
after surgery. accessory inspiratory
muscles. and
expiratory
● Provide ● Depending pressure.
and on cause o f
maintain respiratory
ventilator depression
assistance. or type of
surgery
endotrachea
l tube ( E T )
may be left
in place and
mechanical
ventilation
maintained
for a time.
 Immediate postop/PACU (one hour postop).

CUES/EVIDENCES DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective Data Risk for infection At the end of 1-hour INDEPENDENT At the end of
● Patient related to surgical post-op care the 1-hour post-op care
verbalized “di incision in the right patient will be free ● Note risk ● To assess the patient was free
lang ba ko ani lower abdominal area from infection as factors for causative/ from infection as
magka evidenced by: the contributing evidenced by:
impeksyon agi occurrence factors
sa samad?” ● Identify of infection ● Identify
interventions interventions
Objective Data to prevent or ● Assess and ● Provides for to prevent or
● Surgical reduce the risk document early reduce the
incision of infection skin detection of risk of
present at the conditions, developing infection
right lower noting infection
quadrant as a ● Vital signs inflammatio process ● Have vital
result of within normal n and signs within
surgical range drainage normal
appendectomy range
● Administer ● To
● No signs of or monitor determine ● No possible
infection medication the signs of
regimen effectivenes infection
s of
● State the therapy/pres ● Knows the
possible signs ence of side possible sign
and symptoms effects and
of infection symptoms of
● Check for ● Elevated infection
elevated temperature
temperatur can be a
 e sign of
infection

● Maintain ● The aseptic

strict technique
asepsis of decreases
wound the chances
care , of
dressing transmitting
changes or spreading
pathogens
to or
between
patients