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Post-Op Care for Appendicitis

Patient X, a 30-year-old male, was diagnosed with acute appendicitis and underwent an appendectomy. The nursing assessment found the patient had an intact surgical incision with no signs of infection. The nursing plan was to monitor the patient's vital signs, intake and output, and inspect the wound regularly to ensure intact healing and prevent complications. After 8 hours of post-operative care, the patient's skin had healed without issues and his vital signs remained normal, indicating the goal of maintaining skin integrity was met.

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Nemo Del Rosario
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61 views2 pages

Post-Op Care for Appendicitis

Patient X, a 30-year-old male, was diagnosed with acute appendicitis and underwent an appendectomy. The nursing assessment found the patient had an intact surgical incision with no signs of infection. The nursing plan was to monitor the patient's vital signs, intake and output, and inspect the wound regularly to ensure intact healing and prevent complications. After 8 hours of post-operative care, the patient's skin had healed without issues and his vital signs remained normal, indicating the goal of maintaining skin integrity was met.

Uploaded by

Nemo Del Rosario
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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PATIENT NAME: PATIENT X

AGE: 30 y/o
CASE NO. : 21924
DIAGNOSIS: Acute Appendicitis

NURSING
ASSESSMENT PLANNING
DIAGNOSIS

Subjective Data: Impaired skin / tissue integrity Within 8 hours of our shift,
related to mechanical interrup- immediate post operative
tion of the skin (presence of nursing care, the client
surgical wound) will manifest intact skin
Objective Data: integrity as evidenced by:
T: 36.4oC
RR: 18 b/m 1.) absence of inflamma-
PR: 80b/m tion, redness, purulent
BP: 120/80mmHg discharges on skin or
operative site
(+) Surgical incision
2.) vital signs will remain
No exudates, itchiness, and in normal range
redness noted.
NURSING
RATIONALE EVALUATION
INTERVENTION
Goal Met
*Monitored vital signs. *To monitor patient's After 8 hours immediate post
progress. operative nursing care the
*Monitored intake and output. *To assess risk for hypo- client manifested intact
volemic shock. skin integrity as evidenced by:
*Inspected wound regularly, *Early recognition of
noting characteristics and delayed healing or deve- 1.) Absence of inflammation,
integrity. Note patients at loping complications may redness, purulent discharges
risk for delayed healing. prevent a more serious on skin or operative site
situation.
2.) Vital Signs remained in
normal range:
T: 37.1oC
RR: 18 b/m
PR: 99b/m
BP: 120/80mmHg

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