NURSING CARE PLAN
NAME OF PATIENT: Patricia WARD: _______________________________________
DIAGNOSIS: Acute Appendicitis DATE: March 18, 2020
ASSESSMENT BACKGROUND NURSING OBJECTIVES NURSING RATIONALE EVALUATION
KNOWLEDGE DIAGNOSIS INTERVENTION
Subjective Data: Acute Acute Pain RT - Report pain is Independent: 1. Patient will
Patient appendicitis is a Inflammation relieved/controll - Monitor vital signs - Fever, chills and verbalize pain scale
reports severe and Secondary to ed after carrying diaphoresis are signs of rating decrease of at
abdominal pain sudden case of Acute out infection, developing least 5/10 after
with a pain appendicitis. Appendicitis interventions sepsis, abscess or interventions are
scale of 8/10 The symptoms peritonitis. Hypotension carried out.
Nausea tend to develop - Patient is with tachycardia may
Patient quickly over the relaxed, able to indicate dehydration if 2. Patient is able to
states she is course of one sleep/rest vomiting or diarrhea is sleep / verbalize a
unable to eat to two days. appropriately severe feeling of comfort
The opening of within the shift. after interventions
Objective Data: the appendix is - Monitor Labs Very high levels of CRP are carried out.
• Febrile (38 blocked - Demonstrate may indicate gangrene.
degrees celsius) therefore use of relaxation 3. Patient and family
• RR 21 allowing skills and - Place in semi- - This position allows will be able to state
• PR 102 bacteria to diversional Fowler’s position gravity to assist by at least 3 ways of
Vomiting multiply rapidly activities, as reducing abdominal pain relieving
Fetal position irritating the indicates, for stress and relieves methods after health
to reduce pain lining of the individual discomfort teachings are done
Rebound appendix. This situation after by the student nurse.
tenderness at infection health teaching. - Place ice bag on - Soothes and relieves
McBurney’s causes the abdomen pain through
Point patient to be periodically during desensitization of nerve
Abnormal labs febrile, unable initial 24–48 hr, as endings. Do not use
o ↑ WBC to eat, in pain, appropriate. heat because it may
o ↑ CRP and vomiting. cause tissue congestion.
- Maintain NPO diet - avoids intestinal
irritation
Dependent:
- Administer - Analgesics aid to
medications such as relieve pain while
analgesics, antipyretics regulate
antipyretics, and body temperature, and
antibiotics as antibiotics will help
ordered. fight off the infection.
Collaborative:
- Educate patient - more knowledge
and her family about surgery will ease
about anxiety and help
appendectomy prepare patient and her
family
- Educate the
patient on ways to - this will aid in pain
protect abdomen management and
before and after prevent dehiscence of
surgery by splinting incision.
with a pillow