HASHHASH,BASEMA

BSN4-2C

ASSESSMENT EXPLANATION OF OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM

Subjective: The patient was STO: Dx: STO/ DESIRED

hospitalized to receive OUTCOME:
"Feeling ko po treatment post-operatively Within 8 hours of effective  Monitor vital signs. Note onset  Suggestive of presence of
lalagnatin ako" as after having nursing interventions, the of fever, chills, diaphoresis, infection or developing (Goal Met)
verbalized by the appendectomy. patient will be able to: changes in mentation, reports sepsis, abscess, peritonitis.
patient. of increasing abdominal pain. Within 8 hours of
Appendicitis is a medical a) Able to demonstrate effective nursing
“namumula at mahapdi condition that occurs effective hand washing interventions,
daw sa sugat niya” as when there is an and aseptic techniques in  Inspect incision and dressings. patient is seen
verbalized by the legal inflammation of the cleaning the dressing. Note characteristics of demonstrating
 Provides for early detection
guardian. finger-shaped pouch near drainage from wound (if correct
b) Comply to the treatment of developing infectious
the colon called appendix. inserted), presence of handwashing
Objective: regimen. process and monitors
erythema. resolution of preexisting procedure with his
Appendectomy is the SO, able to
 Skin Flushed and
surgical removal of the comply to
 warm to touch appendix. An inflamed
 Dry and Intact appendix may be removed
dressing at RLQ using a laparoscopic
 Rales in lungs approach with laser.
present However, the presence of
 Redness around multiple adhesions,
the wound site. retroperitoneal positioning
of the appendix, or the
likelihood of rupture
necessitates an open
Intact NGT @ low
(traditional) procedure.
suction and Foley
Catheter
SOURCE/S:
IVF: D5 LR at  Matt Vera, BSN,
75cc/hr. R.N.”Appendectomy”.
Retrieved October
VITAL SIGNS as
26,2020 from
follows:
https://nurseslabs.com/4-
T: 37.6 C appendectomy-nursing-
care-plans/3/
LAB RESULTS:
https://nursestudy.net/
WBC: 16.3
appendicitis-nursing-care-
plans/
Nursing Diagnosis:
Risk for Infection
related to related to
peritonitis. treatment regimen
comfortably.
 Observed changes in skin color
and warmth at insertion sites of
invasive lines, sutures, surgical  could be signs of LTO/DESIRED
incisions, and wounds developing localized OUTCOME:
LTO: infection
(Goal Met)
Within 24-48 hours of
effective nursing Within 24-48
Tx:
interventions, the patient hours of effective
will:  Cleanse incisions and nursing
insertion sites per facility interventions, the
protocol with appropriate patient maintained
antimicrobial topical or comfortablity with
a) free of signs of  To reduce the
solution potential for catheter- no signs of
infection/inflammation
related bloodstream infection to his
including redness around
infections, and surgical incision.
the incision site.
to prevent the growth of The patient is seen
 Administer or assist with self bacteria. walking, giving
administration of vasodilators, signs of good
as ordered. healing, and is
 The vasodilator
ready to be
nitroglycerin enhances
discharged.
blood flow to the
myocardium. It reduces the
amount of blood returning
to the heart, decreasing
preload which in turn
decreases the workload of
the heart.
post-surgical incision  Administer antibiotics as
appropriate.
 Antibiotics given before
appendectomy are primarily
for prophylaxis of wound
infection and are not
continued postoperatively.
Therapeutic antibiotics are
administered if the
appendix is ruptured or
abscessed or peritonitis has
developed.

 Provide regular urinary

catheter and perineal care
 This reduces the risk of
ascending urinary tract
infection.

Edx:

 Encourage family/SO(s) to
participate cleaning the
dressing using aseptic  To Ensure continuity of
technique. care even if patient is
 Instruct patient and SO in good discharged
handwashing and aseptic
wound care and provide
perineal care.  To reduce risk spread of
bacteria

 Encourage patient and SO to

report any untoward signs and
symptoms.
 To improve efficiency of
care and prevent occurrence
of infection.