NCP for Appendectomy

7/24/2019 NCP for Appendectomy

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GANIH, FATIMA SHANGRILA

NURSING CARE PLAN Name of Patient: M.C.T. Patient’s Health Pofile:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!A"e: #$ %eas ol& Se': Male !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!())*+ation:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!ate of A&mission: !!!!!!!!!!!!!!!!!! Initial Com+laint:!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Stat*s: Maie& Reli"ion: Roman Catholi) ia"nosis: !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Needs/NursingDiagnosis/Cues

Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation

PH-SI(L(GIC

Acute Pain related to tissue

trauma and reflex muscle

spasms secondary to

appendectomy

C*es:

S*/e)ti0e

“Nagasakit akong tinay-an”

as verbalized by client

(/e)ti0e

Diaphoresis

Pupil Dilation

hang e inrespiratory rate

hanges in blood

pressure or pulse

!uarding behavior

!rimacing

A highly sub"ective state

in #hich a variety of

unpleasant sensations and

#ide range of distressing

factors may be experienced

by the sufferer$ Pain may

be acute% a symptom of

in"ury or illness$ Pain may

also arise from emotional%

psychological% cultural or

spiritual distress% Pain can

be very difficult to explain%

because it is uni&ue to the

individual' pain should be

accepted as described by

the sufferer$

(n the case of my client%

having an Appendectomy is

a procedure that has the

need to cause the tissue tobe traumatized% #hich

leads to the inflammatory

process characterized by

pain% redness% s#elling and

loss of function of some

Afte )hours of )oo+eatin" a

1$$2 3ith the )ae +lan

&esi"ne& 3ith him, the

+atient 3ill e ale to:

(dentify factors that

aggravate pain

*erbalize ade&uate

relief of pain$

Demonstrate non-

pharmacological

distraction

techni&ues and

relaxation measures$

INEPENENT

Asses pain

characteristics

+ncourage ade&uate

rest periods

+valuate patient,s

response to pain and

medications or

therapeutics aimed at

abolishingrelieving

pain$ +valuate #hat the

patient means to the

individual$

Assess patients past

coping mechanisms$

Assess patient,s

expectations for pain

relief$

INEPENENT

.o include location%

characteristics%

duration fre&uency%

severity /0 to 10 or face

scale2 and precipitating

aggravating factors$

.o facilitate comfort

and relaxation$ (t is important to help

patients express as

factually as possible the

effect of pain relief

measures$

.he meaning of pain

#ill directly influence

patient,s response$

.o determine #hat

measures #orked best in

the past$ 3ome patients may be

content to have pain

decreased' others #ill

expect complete

elimination of pain$ .his

After ) hours

cooperating 1004

the client'

1-!oal 5et lient #as abl

identify factors

aggravate pain

moving rigorously$

6-!oal 5et lient verbalized re

pain and absence

grimacing and guar

behavior$

7-!oal 5et lient #as able

demonstrate relaxa

and distraction techni

like deep breath

soothing massage ataffected area

imagery$

N*sin" Cae Plans4 G*lani)5, 6lo++4 7& E&.4 8199 % Mos%;-ea <oo5 = Han&oo5 of N*sin" ia"nosis4 Ca+enito;Mo%et, L%n&a >*all4 17th E&.4 8?$1$4 Li++in)ott @illiams an& @il5ins = Pe+ae& %: FSANAGANIH



5oaning% rying

8estlessness

part% it is effective in the

treatment of appendicitis

#ith perforation% surgery

leaves tissue in"ury that

#ill impact on their

perception of the

effectiveness of the

Needs/Nursing

Diagnosis/Cues


causes the release of chemical mediators% and

9:,s #hich causes to

form exudates then this

exudates causes the nerve

endings to be compressed

thus making the client feel

pain$

Anticipate need for

analgesics or additional

methods of pain relief$

8espond immediately to

complaint of pain$

(nstruct on relaxation

techni&ues to reduce

skeletal muscle tensionlike deep breathing$

Provide back rub%

massage or #arm bath

.each method of

distraction /(magery%

.reatment modality and their #illingness to participate in

further treatments$

;ne can most effectively

deal #ith pain by

preventing it$ +arly

intervention may

decrease the total

amount of analgesic

re&uired$

Prompt responses to

complaints may result indecrease anxiety in

patient$ Demonstrated

concern for patient,s

#elfare and comfort

fosters the development

of a trusting

relationship$

.o reduce the intensity

of pain$

.o promote relaxation$

<eightening one,s

concentration upon

non-painful stimuli to

decrease one,s




ount 3ilently to self%

breathe rhythmically%

ount anything in the

room% think of happy

memories% listen to

music2

a#areness and

experience of pain$

Needs/Nursing

Diagnosis/Cues


EPENENT

!ive analgesics as

ordered% evaluating

ef fectiveness and

observing for any signs

and symptoms of

unto#ard effects$

Apply heat or cold

compresses% as ordered$

EPENENT

Pain medications are

absorbed and

metabolized differently

by patients% so their

effectiveness must be

evaluated form patient

to patient$ Analgesics

may cause side effectsthat range from mild to

life threatening$

<ot moist compresses

have a penetrating

effect$ .he #armth

rushes blood to the

affected area to promote

healing$ old

compresses may reduce

local edema and

promote some numbing%

thereby promoting

comfort$




Needs/Nursing

Diagnosis/Cues


P(TENTIAL

8isk for (nfection related to a

site for organism invasion

secondary to appendectomy

MANIFESTATI(NS

3P Appendectomy

Dry intact dressing

on surgical site

8isk for infection

describe a situation #hen

host defenses are

compromised% making the

host more susceptible to

environmental pathogens$

Nursing interventions

focus in minimizing

introduction of organisms

or increasing resistance to

infection$


he is high risk for infection

because of the presence of

surgical #ound after

appendectomy that is only

protected by a #ound

dressing that should be

change fre&uently as it

may harbor organism from

time to time$

Afte )hours of )oo+eatin" a

1$$2 3ith the )ae +lan

&esi"ne& 3ith him, the


8emain free of

infections% as

evidenced by normal vital signs% absence

of purulent drainage

from #ounds

8ecognize early

infection to allo# for

prompt treatment$

Demonstrate

meticulous hand

#ashing techni&ue

by the time of

discharge

Asses for presence of

risk factors for

occurrence of infection 5onitor for signs of

infection$

-8edness% s#elling% increased

pain% purulent drainage$

-+levated temperature$

• Assess nutritional

status$

.o assess causative or

contributing factors$

Any suspicious

drainage should be

cultured' antibiotictherapy is determined

by pathogens identified

at cultured$

=ever of up to 7>

degrees for )> hours

after surgery is related

to surgical stress' after

)> hours% fever above

7?$@ degrees suggests

infection' fever spikes

that occur and subside

are indicative of #ound

infection$

Patients #ith poor

nutritional status

maybe anergic% or




+ncourage intake of

protein- and calorie-

rich foods .each patient to #ash

hands fre&uently%

especially after

toileting% before meals%

and before and after

administering self-care$

unable to muster a

cellular immune

response to pathogens

and are therefore more

susceptible to infection$ .o maintain optimal

nutritional status$

Patients can spread

infection from one part

of the body to another%

as #ell as pick up

surface pathogens

Needs/Nursing

Diagnosis/Cues


hange linens as

necessary$

C(LLA<(RATIE

5onitor #hite blood

count

Administer

antimicrobial

hand #ashing reduces these

risks$

.o prevent gro#th of

microorganisms on

linens and beds$

C(LLA<(RATIE

8ising 9: indicates

body,s efforts to combat

pathogens$ *ery lo#

9: indicates severe

risk for infect ionbecause patient does

not have sufficient

9:s to fight infection$

Antimicrobial drugs

include antibacterial%




/antibiotic2 drug as

ordered$

antifungal% anti-

parasitic% and antiviral

agents$ All of these

agents are either toxic

to the pathogen or

retard the pathogen,s

gro#th$

Needs/Nursing

Diagnosis/Cues


SPIRITUAL

3piritual Distress related

to separation from spiritual

ties secondary to pain$

C*es:

S*/e)ti0e

“9ala man koy dako nga sala

sa ginoo nganung nahitabo

An experience of

profound disharmony inthe client,s belief or value

system that threatens the

meaning of the client,s life$

During spiritual distress

the client% loses hope%

&uestion his belief system%

feels separated from his

personal source of comfort

and strength$


due to feeling tremendous

amount of pain% client

&uestions belief as it #as

not #hat he expected to

happened through the

Afte 6hours of )oo+eatin" a

1$$2 3ith the )ae +lan&esi"ne& 3ith him, the


ontinue spiritual

practices not

detrimental to health$

3ho# decrease

feelings of anxiety.

+xpress hope in and

value of his o#n

belief system

Assess history of formal

religious affiliation$

Assess other significant

beliefs

Assess spiritual meaning of illness or

treatment$

Assess #hether patients

have any unfinished

(nformation regarding

specific religion and

importance of rituals or

practices may improve

understanding of

patient,s need #hile

hospitalized$ (ndividuals may have

other important beliefs

besides religion that

provide strength and

inspiration$

.o provide a basis for future care planning$

Patients may not find

peace or harmony until

business is resolved$

.o encourage




mani sa akoa” as verbalized

by client

(/e)ti0e

Buestions meaning of

suffering

Appears anxious and

fearful 3ho#s emotional

detachment from self

and others

=eels a sense of

spiritual emptiness

course of his life$ business$

Display an

understanding and

accepting attitude$

3tructure interventions

in terms of patient,s

belief system

(f re&uested% pray #ith

patient$ Ackno#ledge and

support patient,s hopes

verbalization of

feelings% anger or

loneliness$

Patients have a right to

their beliefs% even if they

conflict #ith the nurse,s

beliefs$ .his provides a sense of

connectedness to others

$<opes are different

from denial or

delusions$ 3upporting a

hope for discharge does

not mean supporting a

denial of the

seriousness of the

patient,s condition$

<ope allo#s the patient

to face the seriousness

of the situation$

Needs/Nursing

Diagnosis/Cues


Do not provide logical

solutions for spiritual

dilemmas Provide information in

a #ay that does not

interfere #ith patient,s

beliefs% faith% or hopes$

3piritual beliefs are

based on faith and are

independent of logic$ .his demonstrates

respect for patient,s

individuality$




Needs/Nursing

Diagnosis/Cues



NCP for Appendectomy

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