ASSESSMENT

NURSING

SCIENTIFIC

S> mainit ang

DIAGNOSIS
Hypertherm

BACKGROUND
Entry of

pakiramdam

ia related to

ko

infection

PLANNING

NURSING

RATIONALE

EVALUATION

After 30

INTERVENTIONS
>Monitor vital

>serves as

After one

pathogens in

minutes to

signs and record

baseline data

hour of

systemic

one hour of

circulation

rendering

rendering

>Promote surface

>heat loss by

nursing

O> flushed

nursing

cooling such as

radiation and

interventions

skin

interventions

taking off extra

conduction

, the clients

Regulation of

, the clients

clothing.

toxins in the

temperature

body

will subside

>provide cool

>heat loss by

from 38.6C

from 38.6C

tepid sponge bath

evaporation

to 37.4C.

>skin warm to
touch
>irritable

subsided

to 37C.

and

Release of
>vital signs as

pyrogenic

follows:

cytokines

Temp= 38.3C

conduction
>maintain bed

>to reduce

rest

metabolic

PR=81
RR= 20
BP=120/90

temperature

demands and
Stimulation of

oxygen

the

consumption

hypothalamus
>administer

>vasodilation

antipyretic as

and

ordered:

increased

alteration of the

Paracetamol 1

peripheral

thermoregulatio

ampule PRN

blood flow in

Increase or

hypothalamu

s, which
dissipates
Increase in body

heat and

temperature

lowers body
temperature.

ASSESSMEN
T

NURSING

SCIENTIFIC

PLANNING

DIAGNOSIS BACKGROUND

NURSING

RATIONALE

EVALUATION

INTERVENTION

S> makirot

Pain

Pain is a very

After 30

S
>Monitor vital

yung tahi

related to

covert

minutes to

signs and record

tissue

condition in

one hour of

damage

which a range

rendering

>provide comfort

>to promote non

rendering

7/10 as 0 as

of unpleasant

nursing

measures such

pharmacological

nursing

the lowest

sensations and

interventions

as therapeutic

pain management

interventions,

and 10 as the

a wide variety

, the clients

touch,

the clients pain

highest

of upsetting

pain scale

repositioning,

scale decreased

factors may be

will decrease

and nurses

from 7/10 to

O> facial

experienced by

from 7/10 to

presence.

4/10.

grimaces

the patient.

3/10.

noted

Pain occurs in

>instruct to use

>to distract

the patient

relation

attention and

>guarding

because of

techniques such

reduce tension

behavior over

abdominal

as deep

the abdomen

incision

breathing

>pain scale of

>serves as

After 30

baseline data

minutes to one
hour of

noted
>irritable

sustained

exercise.

during

>encourage

>to distract

operation.

diversional

attention from

activities such as pain

>vital signs as

socialization

follows:

with others.

Temp= 38.3
PR= 81

>administer

>binds to opiate

RR= 20

analgesic as

receptors in CNS,

BP= 120/90

ordered:

inhibiting

Nalbuphine 5mg

ascending pain

IV q 60

pathways. This
inhibition alters
perception of and
response to
painful stimuli.

ASSESSMENT

NURSING
DIAGNOSIS

SCIENTIFIC
BACKGROUND

PLANNING

NURSING
INTERVENTION

RATIONALE

Objective:
Presence of
surgical
incisions
Staples or
sutures

Impaired
skin integrity
r/t
disruption of
skin integrity
by the
surgical
incision.

Inflammation of

After 12-24
hours of
appendix
rendering

nursing
interventions
Acute Appendicitis the patients
wound will

achieve
timely
Appendectomy
wound
healing and

absence of
Dissection of right any
lower abdominal complication
s.
tissues

Disruption of skin
surface and
destruction of
skin layers

Impaired
skin/Tissue
integrity

Monitor surgical site

and any drainage
tube insertion sites
for signs and
symptoms of
infection, such as
redness/discoloratio
n, swelling, purulent
drainage, poor
approximation, heat,
and increased pain.

Early
identification of
infection or poor
wound healing
can expedite
treatment and
prevent
irreparable
damage to site.

Encourage adequate
nutritional intake
with intake of
protein, vitamin C,
and iron.

Required for
healing and
tissue repair.

Teach the patient:

Care of the
incision or wound.
S/s of infection
Role of nutrition
in wound healing
Turn, cough, and
deep breathe
exercises.

The patient
needs to
understand how
to care for the
incision or
wound at home.
TCDB and IS are
required to open
airways, improve
oxygenation, and
prevent
atelectasis.

IV. PATHOPHYSIOLOGY

Predisposing Factors:
>age (20yrs old)
>gender (female)
>diet (fond eating guava)

Occlusion of appendix by
fecalith
Decreased flow/drainage of
mucosal secretions
Increased intraluminal
pressure
vasocongestion

Decreased blood supply in the

appendix
Decreased oxygen supply in the
appendix
Bacteria invade the
appendix
Disruption of cell membrane of
appendix

Start of inflammatory
process

Release of chemical mediators

Inflammation of appendix

appendectomy
Prostaglandin, bradykinin

Interlukin-I
Tissue trauma

Pain in the RLQ of abdomen

Increase WBC
Disruption of cell membrane

Acute pain
Start of
inflammatory
process

Open wound

Impaired skin
integrity

Infection

Release of
prostaglandin and
bradykinins

Pain on surgical site

Hyperthermi
a
Acute Pain

IX. DRUG STUDY

GENERIC NAME: paracetamol
BRAND NAME: Sinomol
CLASSIFICATION: Antipyretic
DOSAGE: 1 ampule
INDICATION: For fever
MODE OF ACTION
Vasodilation and
increased
peripheral blood
flow in
hypothalamus,
which dissipates
heat and lowers
body temperature.

SIDE EFFECTS

Nausea
Vomiting

CONTRAINDICATION

Hypersensitivity
to drug

ADVERSE
REACTIONS
Hema:
thrombocytopenia,
hemolytic anemia,
neutropenia
Hepatic: jaundice,
hepatotoxicity
Metabolic:
hypoglycemic coma

NURSING
CONSIDERATIONS
>inform patient
about the drug
>disinfect the
medication port
using cotton balls
with alcohol before
administering the
drug.
>slowly push the
drug to reduce
pain.
>Observe for acute
toxicity and
overdose.
>Tell patients
significant other
not to use drug
concurrently with
other
acetaminophen

containing
products
>as appropriate,
review all other
significant and lifethreatening
adverse reaction
and interactions,
especially those
related to the
drugs, test and
other behaviors
mentioned.

GENERIC NAME: nalbuphine hydrochloride

BRAND NAME: Endurpin
CLASSIFICATION: analgesic
DOSAGE: 5mg IV every 6 hours
INDICATION: For moderate to severe pain
MODE OF ACTION
Binds to opiate
receptors in CNS,
inhibiting
ascending pain
pathways. This
inhibition alters
perception of and
response to painful
stimuli.

SIDE EFFECTS

Dizziness
Headache
Nausea
Vomiting
Sweating
Dry mouth

CONTRAINDICATION

Hypersensitivity
to drug.

ADVERSE
REACTIONS
CNS: sedation,
vertigo
CV: hypertension,
hypotension
EENT: myosis
Respiratory:
respiratory
depression

NURSING
CONSIDERATIONS
>watch out for
respiratory
depression and
heart rate changes
>instruct patient to
change position
slowly and
carefully to avoid
dizziness from
sudden blood
pressure decrease
>wet lips of the
patient to prevent
dry mouth

GENERIC NAME: metronidazole

BRAND NAME: Euromet
CLASSIFICATION: antiprotozoal
DOSAGE: 500mg IV every 8 hours
INDICATION: bacterial infection
MODE OF ACTION
Disturbs DNA
synthesis in
susceptible
bacterial
organisms.

SIDE EFFECTS

Dizziness
Headache
Nausea
Vomiting
Diarrhea

CONTRAINDICATION

Hypersensitivity
to drug, other
nitroimidazole
derivatives or
parabens

ADVERSE
REACTIONS
CNS: ataxia,
incoordination,
insomnia
EENT: rhinitis,
pharyngitis
GI: furry tongue,
glossitis, anoresia
GU: incontinence
Hema: leucopenia
Skin: burning
Other: unpleasant
or metallic taste,
phlebitis at IV site

NURSING
CONSIDERATIONS
>monitor IV site
>advise patient to
report fever, sore
throat, bleeding or
bruising
>inform patient
that drug may
discoloration of
urine

XII. ONGOING APPRAISAL

The patient shows progressive recovery and is responding well to both medical and nursing interventions.

XIII. DISCHARGE PLAN (HEALTH TEACHINGS)

Medication: Instruct patient to continue to give the medications and take medications on time.
Treatment: Instruct patient to continue the prescribed medications.
Clinical Follow-up: Instruct patient to have her follow-up check- up after one week.
Diet: Emphasized the importance of green leafy vegetables, rich in Vitamin C and protein for immunity and
tissue formation
Health Teachings:

Emphasized proper wound cleaning

Emphasized the importance of green leafy vegetables, rich in Vitamin C and protein for immunity and
tissue formation

Advised patient to avoid lifting heavy object, extreme activities

Encourage patient to do deep breathing exercise to promote muscles relax

Advised patient to put a pillow on surgical area when coughing to prevent opening of incision