ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING IMPLEMENTATIO RATIONALE EVALUATION

EXPLANATION N

SUBJECTIVE: ACUTE PAIN Ruptured/perforated DISCHARGED 1.Accept client’s 1.Pain was a PLAN
related to post appendix OUTCOME: description of pain. subjective ACHIEVED!!
“Ang lakas talaga surgical incision Acknowledge the experience and
ng iyak niya pag as evidenced by ↓ After 4 days of pain experience cannot be felt by DISCHARGED
gumagalaw at pain scale of nursing and convey others. OUTCOME:
nahihipo ang 10/10, 10as the Appendicitis intervention the acceptance of After 1 week of
sugat niya” as highest, facial client will be able client’s response to nursing
verbalized by the grimace and ↓ to be free of pain. pain. intervention the
support person. muscle guarding. client had been
Surgery 2.Observe 2.Observations free of pain.
SHORT TERM: nonverbal may be congruent
↓ cues/pain with verbal
After 8hrs of behaviors and other reports.
Wound nursing objectives defining
intervention the characteristics, as SHORT TERM:
↓ client will be able noted, especially in
OBJECTIVE: to: persons, who can’t After 2 hours of
Post surgical incision communicate. nursing
The patient a) reduce pain 3.To promote non intervention the
manifested: ↓ from a grade of 3.Provide comfort pharmacologic client had been
*pain scale of 10/10 to 5/10, 10 measures: touch, pain management. able to:
10/10 Local effect: as the highest. repositioning, nurse a.)reduce pain
*grimace PAIN presence. fom a grade of
*muscle guarding b) verbalize non 4.To distract 7/10 to 3/10, 10 as
*post surgical pharmacologic 4.Encourage attention. the highest
incision methods to diversional
*RR=22cpm -pathophysiology provide relief. activities : TV/radio, b.)verbalize
gould page 234. socialization of nonpharmacologic
others. methods to
5.To reduce provide relief.
5.Encourage use of tension.
relaxation
techniques:
focused breathing,
imaging, CD/tapes.

COLLABORATIVE:
6.To reduce pain.
6.Instruct to take
dolax 100mg/5ml
1tsp BID for pain,
as prescribe by the
physician.
7.To be able to
7.Cooperate with follow up the
the family of the situation of the
client to document patient.
the health of the
patient.