ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Acute pain Due to the Within our 8 hour Establish rapport. To gain trust and Within our 8 hour span of care,
“Sakit akoang related to presence of span of care, cooperation. patient was alleviated from
kilid”, as patient inflammation inflammation patient will be pain.
verbalized. of the appendix and mass on the alleviated from V/S taken and recorded. Serves as baseline data. Goal partially met
Objective: RLQ of the pain.
 Conscious abdomen, it Encourage verbalization To assess the level of
 Grimaced causes some of feelings about pain. pain.
face noted obstruction in the
 Weakness lumen of the Encourage patient to To alleviate pain.
noted appendix in turn have diversional
 Guarded causes s sharp activities such as mobile
behavior noted acute pain in the internet and watching
 Pain scale: Right Lower TV.
7/10 Quadrant part of
 Pale looking the abdomen. Encourage patient to use Distract attention and
relaxation techniques reduce tension.
such as deep breathing.

Provide comfort To promote non-

measures such as touch, pharmacologic pain
repositioning, quiet management.
environment and calm
activities.

Encourage adequate rest To promote wellness and

periods. prevent fatigue.

Observe and document To get a baseline data of

severity (1-10 scale) and pain scale.
character of pain
(steady, intermittent,
colicky).
ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective: Anxiety related Vague uneasy Within our 8 hour  Establish rapport  To gain trust and Within our 8 hour
“Worried ko sa to possible feeling of span of care, cooperation. span of care,
akong situation surgery discomfort or patient will be patient was able to
basig operahan secondary to dread able to  V/S taken and recorded.  Serves as baseline data. understand and
man gud ko”, as Acute accompanied by understand and demonstrate
verbalized by the Appendicitis. an autonomic demonstrate  Assess awareness of  Validate the feeling and positive coping
patient. response (the positive coping patient about anxiety. communicate acceptance of mechanism and
Objective: source often mechanism and the feelings. describe a
 Irritability nonspecific or describe a reduction in the
noted unknown to the reduction in the  Provide accurate  Helps the client to identify level of anxiety.
 Anxious individual); a level of anxiety. information to the client. what is reality based. Goal Met.
looking feeling of
 Discomfort apprehension  Provide comfort  To help the patient relax.
noted caused by measures.
 Restlessness anticipation of
noted danger it is an  Provide and maintain  Anxiety may escalate with
alerting signal quiet environment. excessive conversation,
that warns of noise and equipment about
impending the patient.
danger and
enables the
 Encourage patient to talk  Talking about anxiety
individual to take
about anxious feelings. producing situations and
measures to deal
anxious feelings can help the
with the threat.
person perceive the situation
(Gulanick/Myers
in less threatening manner.
Nursing Care
Plans, 6th
Edition)
ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Limited Having an After 8 hours of INDEPENDENT: After 8 hours of
“Anay, hinay movement Appendectomy is nursing  Instruct the client to  Activity that require nursing
hinay la ke ma ol- related to pain a procedure that interventions, the minimize activities that holding the breath and interventions the
ol tak samad” as as manifested has the need to patient will be will put pressure on his bearing down can result in patient is able to
verbalized by the by incision on cause the tissue able to regain / abdomen. pain to surgical site in Rest quietly Sit in
patient. RLQ. to be maintain mobility RLQ, bradycardia and a high-fowlers
traumatized, at the higher rebound tachycardia with position from
Objective: which leads to possible level, elevated BP. lying in bed, and
Temp - 36.6 oC the inflammatory Demonstrate  Reposition periodically know the proper
PR - 53 bpm process techniques that and slowly and encourage  Prevent / reduces way in seating
RR - 26 cpm characterized by enable deep breathing exercises. incidence of skin and from a supine
BP-110/70mmhg pain, redness, resumption of respiratory complications. position.
 weakness swelling and loss activities, and therefore:
 facial of function of Increase strength/  Encourage rest. GOAL MET
grimace some part, it is function of  Reduces myocardial
 guarding effective in the affected and workload / oxygen
behavior treatment of compensatory consumption, reducing
 incision on appendicitis with body parts. risk of complication.
RLQ perforation,  Move patient slowly and
surgery leaves deliberately.  Reduces muscle tension or
tissue damage guarding, which may help
that causes the minimize pain of
release of movement.
chemical
mediators, and  Administer analgesics as
WBC’s which ordered  To maintain “acceptable”
causes to form level in pain. Notify
exudates then physician if regimen is
this exudates inadequate to meet pain
causes the nerve control goal.
endings to be
compressed thus
making pain and
this pain makes a
person to have
limited
movement.

Reference:
Medical Surgical
nursing by
Brunner and
Suddarth 11th
edition; Vol.2
pages 1240-
1242