NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
Subjective: • Acute pain • Appendicitis is • After 4 hours • Investigate pain • Changes in • After 4
related to inflammation of of nursing reports, noting location or hours of
“Masakit ang inflammation interventions location, duration, intensity are not nursing
the vermiform
tiyan ko” as of tissues. , the patient intensity (0-10 uncommon but intervention
verbalized by appendix will scale), and may reflect s, the
patient. caused by an demonstrate characteristics developing patient was
obstruction use of (dull, sharp, complications. able to
Objective: attributable to relaxation constant). demonstrate
infection, skills, other • Maintain semi- • Reduces use of
• Facial mask stricture, fecal methods to fowler’s position. abdominal relaxation
of pain. mass, foreign promote distention, skills, other
body or tumor. comfort. thereby methods to
• Guarding Appendicitis reduces promote
behavior. can affect tension. comfort.
either gender • Move patient • Reduces
• Rebound at any age, but slowly and muscle tension
tenderness. deliberately. or guarding,
is most
which may help
• V/S taken as
common in minimize pain
follows: males ages 10 of movement.
to 30. • Provide comfort • Promotes
T: 37.3 Appendicitis is measure like relaxation and
P: 80 the most back rubs, deep may enhance
R: 18 common breathing. patient’s coping
Bp: 110/90 disease Instruct in abilities by
requiring relaxation or refocusing
surgery. If left visualization attention.
untreated, exercises.
Provide
appendicitis
diversional
may progress activities.
to abscess, • Provide frequent • Reduces
perforation, oral care. nausea and
subsequent Remove noxious vomiting, which
peritonitis, and environmental can increase
death. stimuli. intra-abdominal
pressure or
 pain.

Collaborative:
• Administer • Reduce
analgesics as metabolic rate
prescribed. and aids in pain
relief and
promotes
healing.