ncp for appendectomy
TRANSCRIPT
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
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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
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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
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
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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
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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$
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
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Needs/Nursing
Diagnosis/Cues
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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$
(n the case of my client%
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
+atient 3ill e ale to:
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
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$4 Li++in)ott @illiams an& @il5ins = Pe+ae& %: FSANAGANIH
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+ncourage intake of
protein- and calorie-
rich foods .each patient to #ash
hands fre&uently%
especially after
toileting% before meals%
and before and after
administering self-care$
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
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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%
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$4 Li++in)ott @illiams an& @il5ins = Pe+ae& %: FSANAGANIH
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/antibiotic2 drug as
ordered$
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
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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$
(n the case of my client%
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
+atient 3ill e ale to:
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
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$4 Li++in)ott @illiams an& @il5ins = Pe+ae& %: FSANAGANIH
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mani sa akoa” as verbalized
by client
(/e)ti0e
Buestions meaning of
suffering
Appears anxious and
fearful 3ho#s emotional
detachment from self
and others
=eels a sense of
spiritual emptiness
course of his life$ 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
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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$
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
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Needs/Nursing
Diagnosis/Cues
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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
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Needs/Nursing
Diagnosis/Cues
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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
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Needs/Nursing
Diagnosis/Cues
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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
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Needs/Nursing
Diagnosis/Cues
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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
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Needs/Nursing
Diagnosis/Cues
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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
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Needs/Nursing
Diagnosis/Cues
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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
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Needs/Nursing
Diagnosis/Cues
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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
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Needs/Nursing
Diagnosis/Cues
Scientific Analysis Objectives Nursing Problem/Intervention Rationale Evaluation
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
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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