Republic of the Philippines

UNIVERSITY OF EASTERN PHILIPPINES

University Town, Northern Samar
COLLEGE of NURSING and ALLIED HEALTH SCIENCES
NURSING CARE PLAN

Date
Name of Patient: M.D Admitted: 1-30-23 Chief Complaint: LRQ PAIN Case Number:
Age 41y/ Address
: o Gender: F Civil Status: : Ward:

NURSING SCIENTIFIC OBJECTIVES/ NURSING SCIENTIFIC

ASSESSMENT EVALUATION
DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE
.  The patient will
Subjective data: Acute pain maybe Effects of be able to  Assess pain,  .useful in After an eight
“nagsusuol ak related to stimulated report pain is noting location, monitoring hours of nursing
tinahian pag presence of nociceptors, local relieved/control characteristics, effectiveness intervention the
naubo ak” as surgical incision inflammation, led severity (0-10 of medication, patient appears
verbalized. possibly systemic stress  Appear scale. progression of relaxed, able to
evidenced by response relaxed, able Investigate and healing. sleep/rest
reports of pain. mediators, and to sleep/rest report pain as Changes in appropriately
psychological appropriately appropriate characteristics
Objective data: factors. of pain may
>Guarding indicate
behavior developing
abscess or
>BP: 140/90 peritonitis,
requiring
prompt
medical
evaluation
 Provide intervention
accurate,  Being informed
honest about progress
information to of situation
patient and SO provides
emotional
 support,
helping to
decrease
 Keep at rest in anxiety
semi-Fowler’s  To lessen the
position pain. Gravity
localizes
inflammatory
exudate into
lower or pelvis,
relieving
abdominal
tension, which
is accentuated
 Encourage by supine
early position
ambulation  Promotes
normalization
 Provide of organ
diversional function
activities  Refocuses
attention,
promotes
relaxation, and
 Keep NPO may enhance
coping abilities
 Decrease
discomfort of
early intestinal
 Administer peristalsis
analgesics as gastric irritation
indicated and vomiting
 Relief of pain
facilitates
cooperation
 Place ice bag with other
on abdomen therapeutic
periodically interventions.
 during initial 24-  Soothes and
48 hr, as relieves pain
appropriate through
 Never apply desensitization
heat to the right of nerve
lower abdomen endings
 This may
 Watch closely cause the
for possible appendix to
surgical rupture
complications  Continuing
pain and fever
may signal an
abscess.
STUDENT NURSE: BRIA M. HERMOSA CLINICAL INSTRUCTOR: EVELYN BALANQUIT, MAN
 Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
COLLEGE of NURSING and ALLIED HEALTH SCIENCES
NURSING CARE PLAN

Date
Name of Patient: M.D Admitted: 1-30-23 Chief Complaint: LRQ PAIN Case Number:
Age 41y/ Address
: o Gender: F Civil Status: : Ward:

NURSING SCIENTIFIC OBJECTIVES/ NURSING SCIENTIFIC

ASSESSMENT EVALUATION
DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE
.
Subjective data:  Risk Fluid volume  Maintain  Monitor BP and  Variations help After an eight hour
“nauuhaw ak” as for Deficient deficient can be a adequate fluid pulse. identify shift the patient
verbalized Fluid Volume common balance as  Inspect mucous fluctuating was able to
occurrence. evidenced by membranes; intravascular maintain adequate
Objective data: Dehydration ids moist mucous assess skin volumes fluid balance as
>thirst when there is a membranes, turgor and  Indicators of evidenced by
>decrease skin loss of too much good skin capillary refill. adequacy of moist mucous
turgor fluid from the body turgor, stable  Monitor I&O; peripheral membranes, good
vital signs, and note urine color circulation and skin turgor, stable
individually and cellular vital signs, and
adequate concentration, hydration. individually
urinary output specific gravity.  Decreasing adequate urinary
 Auscultate and output of output
document concentrated
bowel sounds. urine with
Note passing of increasing
flatus, bowel specific gravity
movement. suggests
 Provide clear dehydration and
liquids in small need for
amounts when increased fluids.
oral intake is Indicators of
resumed, and return of
progress diet peristalsis,
 as tolerated. readiness to
 Give frequent begin oral
mouth care with intake. Note:
special This may not
attention to occur in the
protection of hospital if
the lips. patient has had
 Administer IV a laparoscopic
fluids and procedure and
electrolytes. been
 Never discharged in
administer less than 24 hr
cathartics or  Reduces risk of
enemas. gastric irritation
 Give the patient and vomiting to
nothing by minimize fluid
mouth, and loss.
administer  Dehydration
analgesics results in drying
judiciously. and painful
cracking of the
lips and mouth.
 The peritoneum
reacts to
irritation and
infection by
producing large
amounts of
intestinal fluid,
possibly
reducing the
circulating blood
volume,
resulting in
dehydration and
relative
electrolyte
imbalances.
 Cathartics and
 enemas may
rupture the
appendix.
This may mask
symptoms.
STUDENT NURSE: BRIA M. HERMOSA CLINICAL INSTRUCTOR: EVELYN BALANQUIT, MAN
 Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
COLLEGE of NURSING and ALLIED HEALTH SCIENCES
NURSING CARE PLAN

Date
Name of Patient: M.D Admitted: 1-30-23 Chief Complaint: LRQ PAIN Case Number:
Age 41y/ Address
: o Gender: F Civil Status: : Ward:

NURSING SCIENTIFIC OBJECTIVES/ NURSING SCIENTIFIC

ASSESSMENT EVALUATION
DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE
. Achieve timely wound
Subjective Risk for The state in healing; free of signs  Practice and  Reduces risk of After an eight
data: infection which an of instruct in good spread of hours of nursing
“dre pa individual is at infection/inflammation handwashing and bacteria. intervention the
nababahaw ak Possibly risk to be , purulent drainage, aseptic wound  Provides for early patient was able
samad” evidenced by invaded by erythema, and fever care. Encourage detection of to achieve timely
risk factors of opportunistic or and provide developing wound healing;
Objective data: breach of pathogenic perineal care infectious free of signs of
>T- 36.7 C primary agent from  Inspect incision and process and infection/inflam
>Weak in defenses endogenous or dressings. Note monitors mation, purulent
appearance (surgical exogenous characteristics of resolution of drainage,
>Clean and incision), stasis sources drainage from preexisting erythema, and
intact abdominal of body fluids at wound (if inserted), peritonitis. fever
dressing operative site, presence of  Suggestive of
and altered erythema. presence of
inflammatory  Monitor vital signs. infection or
response. Note onset of fever, developing sepsi
chills, diaphoresis, s, abscess,
changes in peritonitis.
mentation, reports  Gram’s stain,
of increasing culture, and
abdominal pain. sensitivity testing
 Obtain drainage is useful in
specimens if identifying
indicated. causative
  Administer antibioti organism and
cs as appropriate. choice of therapy.
 Prepare and assist  Antibiotics given
with incision and before
drainage (I&D) if appendectomy
indicated. are primarily for
 Watch closely for prophylaxis of
possible surgical wound infection
complications. and are not
continued
postoperatively.
Therapeutic
antibiotics are
administered if
the appendix is
ruptured or
abscessed or
peritonitis has
developed.
 May be
necessary to
drain contents of
localized
abscess.
 Continuing pain
and fever may
signal an
abscess.
STUDENT BRIA M. HERMOSA CLINICAL INSTRUCTOR: EVELYN BALANQUIT, MAN
NURSE:
 Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
COLLEGE of NURSING and ALLIED HEALTH SCIENCES
NURSING CARE PLAN

Date
Name of Patient: M.D Admitted: 1-30-23 Chief Complaint: LRQ PAIN Case Number:
Age 41y/ Address
: o Gender: F Civil Status: : Ward:

NURSING SCIENTIFIC OBJECTIVES/ NURSING SCIENTIFIC

ASSESSMENT EVALUATION
DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE
.
Subjective data: Deficient A knowledge  Verbalize  Identify symptoms  .Prompt After eight hours
“d ko aram pan o knowledge deficit in relation understandi requiring medical intervention of nursing
ak nagkayaon sin possibly to healthcare is ng of evaluation (increas reduces risk of intervension the
basta tigda nala evidenced by lack of information disease ing pain; edema or serious patient was able
na ko na naiilob development of needed for a process and erythema of complications to verbalized
an suol” preventable thorough potential wound; presence (delayed wound understanding of
complications understanding of complicatio of drainage, fever) healing, disease process
Objective data: a disease process ns. . peritonitis). and potential
>History of past and  Verbalize  Review  Provides complications.
illness: abdominal recommended understandi postoperative information for
pain treatment and the ng of activity patient to plan for
ability to make therapeutic restrictions (heavy return to usual
>The educational informed choices needs. lifting, exercise, routines without
level of the to carry out task in  Participate sex, sports, untoward
patient: alignment with in treatment driving). incidents.
highschool health regimen.  Encourage  Prevents fatigue,
graduate. maintainance. progressive promotes healing
activities as and feeling of
tolerated with well-being, and
periodic rest facilitates
periods. resumption of
normal activities.
 Recommend use  Assists with return
of to usual bowel
 mild laxative or sto function; prevents
ol softeners as undue straining for
necessary and defecation.
avoidance of
enemas.  Understanding
 Discuss care of promotes
incision, including cooperation with
dressing changes, therapeutic
bathing regimen,
restrictions, and enhancing healing
return to physician and recovery
for suture and process.
staple removal.

 Encourage the  To prevent

patient to cough, pulmonary
breathe deeply, complication
and and turn
frequently.
STUDENT NURSE: BRIA M. HERMOSA CLINICAL INSTRUCTOR: EVELYN BALANQUIT, MAN
 Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
COLLEGE of NURSING and ALLIED HEALTH SCIENCES
NURSING CARE PLAN

Date
Name of Patient: M.D Admitted: 1-30-23 Chief Complaint: LRQ PAIN Case Number:
Age 41y/ Address
: o Gender: F Civil Status: : Ward:

NURSING SCIENTIFIC OBJECTIVES/ NURSING SCIENTIFIC

ASSESSMENT EVALUATION
DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE
.
Subjective data: Impaired skin Conversely, Achieve timely  Reinforce initial  Protects wound After few days of
“halaba ak integrity may be impaired skin wound healing dressing and from nursing intervention
tinahian sa tiyan” related to integrity is change as mechanical the patient was able
mechanical defined as an Demonstrate indicated. Use injury and to demonstrate
Objective data: interruption of “altered behaviors/techniques strict aseptic contamination. behaviors/techniques
skin and tissues epidermis and/or to promote healing techniques  Reduce risk of to promote healing
>dressing dry dermis and prevent  Gently remove skin trauma and prevent
and intact Possibly destruction of complications tape (in direction and disruption complications.
evidenced by skin layers of hair growth) of wound
disruption skin (dermis), and and dressings  Reduces of
surface/layers disruption of skin when changing. potential for
and tissue. surface  Apply skin skin trauma
(epidermis) sealants or and/or
barriers before abrasions and
tape if needed. provides
 Check tension additional
of dressings. protection for
Apply tape at delicate skin or
center of tissues.
incision to outer  Can impair or
margin of occlude
dressing. Avoid circulation to
wrapping tape wound and to
around the distal portion of
 extremity. extremity
 Inspect wound  Early
regularly, recognition of
nothing delayed
characteristics healing or
and integrity. developing
 Assess amount complications
and may prevent
characteristics more serious
of drainage situation.
 Caution patient  Dressing
not to touch the drainage
wound suggests
 Use abdominal evolution of
binder as healing
possible. process,
whereas
continued
drainage or
presence or
bloody or
odoriferous
exudate
suggest
complications.
 Prevents
contamination
of wound
 Provides
additional
support for high
risks incision.
STUDENT BRIA M. HERMOSA CLINICAL INSTRUCTOR: EVELYN BALANQUIT, MAN
NURSE: