Care Plan 3:21 - careplans nursing PDF

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Summary

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Description

NURSING CARE PLAN TEMPLATE

NANDA-I Dx

Goal

P: Acute pain Decreased pain E: r/t Physical injury Removal of appendix Abdominal surgery

S: (AEB) 18yr old female P/O Appendectomy for ruptured appendix. Pt reports abdominal pain at the surgical site 6/10. Sharp, constant. Surgical abdominal incision, dressing dry and intact. JP was D/C Hurts to take a deep breath, hurts to cough, r/r 21 HR 100 BP 140/80

Notify health care team when pain is present to reduce pain intensity.

Expected Outcome(s)

Nsg Interventions

Assessments: - Assess pain intensity, location, type, every Q4hours, PN The patient will use - Assess Vital signs, B/P the pain tool to rate and HR Q4hrs pain from 1-10 to - Assess the Abdomen, identify the pain surgical site intensity and level >5. - Assess labs, WBC This will allow the patient to establish a Activities: comfort goal to - Administer pain meds reduce intense pain. as prescribed. - Massage and Pt will report pain < distraction 3 with pain meds in 8 - Positioning to relieve hours. pain Patient will describe 2 nonpharmacological methods to reduce pain, before D/C.

Education: - Teach about pain med administration before pain get to >5 - Teach comfort positions (semi-fowlers) - Use pillow to splint the surgical incision, hold pillow to reduce pain during movement.

Rationales (citation required)

Eval. N/A

Increased pain may indicate injury, or infection at surgical site (McCaffery, 1968; Drew & Peltier, 2018). Increased BP and Pulse, may indicate increased pain, physiological response. increased inflammation, drainage, signs and symptoms of infection, (Drew & Peltier, 2018).

Willingness of patient to report pain by self-report, when pain is present before intensity occurs (Drew & Peltier, 2018)

PATHOPHYSIOLOGY Describe the pathophysiology as it relates to the nursing diagnosis. Cite your references using APA 6th ed. Post op management, surgical incision and pain involved, pain relief measures, management, nursing care. Appendectomy secondary to appendicitis. The exact mechanism of the cause of appendicitis is not well understood. Obstruction of the lumen with stool, tumors, or foreign bodies, with consequent bacterial infection, is the most common theory. The obstructed lumen does not allow drainage of the appendix, and as mucosal secretion continues, intraluminal pressure increases. The increased pressure decreases mucosal blood flow, and the appendix becomes hypoxic. The mucosa ulcerates, promoting bacterial or other microbial invasion, with further inflammation and edema. Inflammation may involve the distal or entire appendix. Gangrene develops from thrombosis of the luminal blood vessels, followed by perforation in complex cases. Bhangu A, et al. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015;386(10000):1278–1287._ Epigastric or periumbilical pain is the typical symptom of an inflamed appendix. The pain may be vague at first and in the periumbilical area, increasing in intensity over 3 to 4 hours. It may subside and then migrate to the right lower quadrant, indicating extension of the inflammation to the surrounding tissues. Nausea, vomiting, and anorexia follow the onset of pain, and a low-grade fever is common. Diarrhea occurs in some individuals, particularly children; others have constipation. Perforation, peritonitis, and abscess formation are the most serious complications of appendicitis. Bhangu A, et al. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet. 2015;386(10000):1278–1287._

In addition to clinical manifestations, there is pain with abdominal palpation and rebound tenderness, usually referred to the right lower quadrant. The white blood cell count is greater than 10,000 cells/mm3, with increased neutrophils and C-reactive protein. Abdominal ultrasound, CT scans, and magnetic resonance imaging (MRI) (particularly for pregnant women and children) assist with diagnostic accuracy and help rule out nonappendicular disease. Antibiotics or antibiotics and appendectomy are treatments for simple appendicitis. Complicated appendicitis (perforation, abscess formation, peritonitis) usually requires both antibiotics and surgery. 4141. Wagner M, Tubre DJ, Asensio JA. Evolution and current trends in the management of acute appendicitis. Surg Clin North Am. 2018;98(5):1005–1023

References

1. B.J. Ackley G.B. Ladwig : Nursing diagnosis handbook 10th ed.; Retrieved from https://evolve.elsevier.com , 2014. 2. Centers for Disease Control and Prevention (CDC) : Core elements of hospital antibiotic stewardship programs CDC/IHI antibiotic stewardship drivers and change package , 2017. 3. Centers for Disease Control and Prevention (CDC) : Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force , MMWR. Recommendations and Reports: Morbidity and Mortality Weekly Report. Recommendations and Reports 51: (RR–16): 1- 45 , 2011. Retrieved from http://www.cdc.gov/handhygiene/Guidelines.html updated 2014) 4.

Huether, S. E., & McCance, K. L. (2020). Understanding pathophysiology (7th ed). St. Louis, MO: Elsevier.

5. Perry P. Potter W. Ostendurr : Measuring body temperature Clinical nursing skills and techniques 9th ed. , 2014. Retrieved from https://www.elsevier.com...