Student Nurses’ Community NURSING CARE PLAN Appendectomy ─ ASSESSM ENT DIAGNO SIS INFERENC E PLANNI NG INTERVENT ION RATIONA LE EVALUATI ON SUBJECTIVE : “Sumasakit ang sugat ng opera ko.” (I feel pain aroun t!e in"ision site# as $er%ali&e %' t!e patient. BJECTIVE: • )uaring %e!a$ior in t!e a%omen • *a"ial mask of pain • +istra"tion %e!a$iors • V,S taken as follo-s: T : /.0 1C 2: 0 3: 45 B2: 446,06 7"ute pain ma ' %e relate to istention of intestinal ti ssue %' in8ammat ion an presen"e of surgi"al in"ision. Appendect omy is t!e remo$a l of t!e in8ame appe ni9. In an open "on$entional an un"ompli"at e appene"to m' t!e surgeon remo$es t!e appeni9 t!roug! an in"ision appro9imate l' in "!es long in t!e lo -er rig !t ;uarant. T!e in"ision is larger if t!e appe ni9 is in a t'pi "a l position or if peri tonit is is present. 7fter 4 !our of nursing inter$enti ons t!e patient -ill report pain is relie$e or "ontrolle an appear to %e rela9e a%le to sleep an rest appropriat el'. Inepenent • 7ssess pain noting lo"atiosn "!ara"terist i"s an se$eri t' (6 to 46 s"ale#. In$estigate an repor t "! anges in pain as appropriate. • 2ro$ie a""urate !onest information to patient or signi<"ant ot!ers. • =eep at rest in semi> *o-ler?s position. • Useful in monitorin g e@e"ti$en ess of mei"atio n an progressi on of !ealing. C!anges in "!ara"ter isti" of pain ma' ini"ate e$elopin g a%s"ess or peritoniti s re;uiring prompt mei"al e$aluatio n an inter$enti on. • Being informe a%out t!e progress of situation pro$ies emotiona l 7fter 4 !our of nursing inter$entio ns t!e patient -as a%le to report pain is rel ie$e or "ontrolle an appear to %e rela9e a%le to sleep an rest appropriate l' .