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Appendectomy - NCP

The patient, Ricardo Denoso, 49 years old, presented with right lower quadrant pain and fever and was diagnosed with an abdominal wall abscess after an appendectomy. The nursing care plan focused on monitoring and managing his acute pain, providing wound care to prevent infection at the surgical site, and observing for signs of complications as he recovered from surgery. After 4 hours of nursing interventions including relaxation techniques and analgesics, the patient was able to rest comfortably and appropriately while continuing to closely monitor for infection or other issues.

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Rhenzes Hara
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0% found this document useful (0 votes)
133 views6 pages

Appendectomy - NCP

The patient, Ricardo Denoso, 49 years old, presented with right lower quadrant pain and fever and was diagnosed with an abdominal wall abscess after an appendectomy. The nursing care plan focused on monitoring and managing his acute pain, providing wound care to prevent infection at the surgical site, and observing for signs of complications as he recovered from surgery. After 4 hours of nursing interventions including relaxation techniques and analgesics, the patient was able to rest comfortably and appropriately while continuing to closely monitor for infection or other issues.

Uploaded by

Rhenzes Hara
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Tanutan, Rhenzes Hara R.

BSN – 3B

NURSING CARE PLAN


Name of Patient: Denoso, Ricardo S. Room and Bed Number: Aircon Ward (Adult Room 210 – 1) Room 210
Age: 49 yrs. old Physician: Gerardo S. Hernandez
ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC BASIS OBJECTIVE NURSING RATIONALE EVALUATION
INTERVENTIONS
Chief Complain: RLQ pain and Fever Diagnosis: Abscess-Abdominal Wall (Fascia)
Subjective:
“Sakit japun Acute Pain Related to Appendectomy is a surgery After 4 hours of nursing Independent: After 4 hours of
ma’am tungod sa Distention of Intestinal to remove the appendix interventions, the patient 1. Assess pain, noting 1. Useful in monitoring nursing
tahi.” As Tissue by Inflammation and when it is infected. This will demonstrate use of location, characteristics effectiveness of interventions, the
verbalized by the Presence of Surgical relaxation skills, other (dull, sharp, and constant), medication, patient was able to
condition is
patient. Incision methods to promote and severity (0–10 scale). progression of demonstrate use of
called appendicitis. The comfort and appear to Investigate and report relaxation skills,
healing. Changes in
Objective: appendix is a thin pouch be relaxed, able to sleep changes in pain as characteristics of other methods to
- Grimace face that is attached to the large and rest appropriately. appropriate. pain may indicate promote comfort,
- Pain scale: intestine and sits in the developing abscess and appeared to be
7/10 lower right part of the belly. or peritonitis, relaxed, able to
- Guarding requiring prompt sleep and rest
In Laparoscopic
behavior medical evaluation a appropriately.
appendectomy, 1 to 3 tiny
nd intervention.
V/S taken as cuts will be made and a 2. Provide accurate, honest 2. Being informed
follows: long, thin tube called a information to patient and about progress of
Temp: 36.9*C laparoscope is put into one SO. situation provides
RR: 16 of the incisions that have a emotional support,
BP: 110/80 tiny video camera and helping to
PR: 75 decrease anxiety.
surgical tools which helps
3. Keep at rest in semi- 3. To lessen the pain.
the surgeon look at a TV
Fowler’s position. Gravity localizes
monitor to see inside your
inflammatory
abdomen and guide the exudate into lower
tools. Then, appendix is abdomen or pelvis,
Tanutan, Rhenzes Hara R. BSN – 3B

removed through one of the relieving abdominal


incisions. (Appendectomy, tension, which is
n.d.) accentuated
4. Watch closely for possible by supine position.
surgical complications. 4. Continuing pain
and fever may signal
an abscess.
Collaborative:
5. Administer analgesics as
indicated. 5. For Relief of pain
and promote healing
which facilitates
cooperation with
other therapeutic
interventions
(ambulation,
pulmonary toilet).

ASSESSMENT NURSING DIAGNOSIS INTERVENTION


Tanutan, Rhenzes Hara R. BSN – 3B

Objective: Risk for Infection SCIENTIFIC BASIS GOAL Independent:


- Dressing on the related to incision/suture 1. Practice and instruct in EVALUATION
surgical site in the Right Lower  Skin is a natural barrier Short Term Goal: At good hand washing and RATIONALE
- Pallor Quadrant area against infection. Even with the end of the shift, the aseptic wound care. At the end of the shift
- Capillary refill: many precautions and patient will identify 2. Inspect incision and the client was able to
protocols to prevent interventions to prevent 1. Reduces risk of identify interventions
3 seconds dressings. Note
infection in place, any or reduce risk of spread of bacteria. to prevent or reduce
V/S taken as characteristics of drainage
follows: surgery that causes a break infection. from wound (if inserted), risk of infection like
in the skin can lead to an 2. Provides for early initiating change of
Temp: 36.9*C presence of erythema.
infection. Infections after detection of dressing on surgical
RR: 16
surgery are caused by developing site and verbalizing the
BP: 110/80
germs. Germs can infect a Long Term Goal: infectious process importance of daily
PR: 75
surgical wound through Within hospitalization, 3. Monitor vital signs. Note and monitors hand washing.
various forms of contact, the patient will achieve onset of fever, chills, resolution of
such as from the touch of a timely wound healing; diaphoresis, changes in preexisting Within hospitalization
contaminated caregiver or be free of purulent mentation, and reports of peritonitis. the client will achieve
surgical instrument, through drainage increasing abdominal 3. Suggestive of timely wound healing
germs in the air, or through pain. presence of infection as marked by absence
germs that are already on or 4. Watch closely for possible or developing sepsis, of secretions in the
in your body and then surgical complications. abscess, peritonitis. dressing and
spread into the wound verbalizing of the
(Hopkins, 2019). healing wound
Collaborative: 4. Continuing pain and
5.  Administer or monitor fever may signal an
medication regimen abscess.

5. To determine
effectiveness of ther
apy/presence of side
effects.
Tanutan, Rhenzes Hara R. BSN – 3B
Tanutan, Rhenzes Hara R. BSN – 3B
Tanutan, Rhenzes Hara R. BSN – 3B

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