This patient presented with a one week history of progressive right lower abdominal pain rated 7/10, loss of appetite, and on and off nausea and vomiting. On examination, the patient displayed guarding behavior, difficulty walking upright, a flushed face, and was sighing. An ultrasound showed an inflamed appendix. The patient's care plan was to administer tramadol for pain relief, provide reassurance, and guided imagery. The patient would then undergo an appendectomy within 6 hours to remove the inflamed appendix and eliminate the risk of recurrence, restoring the patient's normal functioning.

1. ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATIONS
SUBJECTIVE
-Pt verbalizes Hx of
progressive pain-
(7/10 now) in the
right lower portion of
his abdomen for the
last one week
-Loss of appetite
-On and off N&V
OBJECTIVE
Guarding behavior
Difficulty walking
upright
Flushed face
Patient sighing
INVESTIGATIONS
USS = inflamed
appendix
Vitals
BP: 130/90mmHg
Temp. 35.8o
C
RR: 22 bpm
HR: 97 Bpm
Acute pain
related to
inflammatory
response of
the appendix
as evidenced
by patient
verbalizing
severe pain
8/10,
difficulty to
walk upright,
flushed face
and patient
sighing.
GOALS INTENTED OUTCOME INTERVENTION RATIONALE
Patient
verbalized great
relief from pain
to 1/10 and
verbalizes good
levels of physical
comfort after 2
hours.
XXXXXXXXX
XXXXXXX
Patient had
successful
surgery, well
managed
perioperatively,
remains
comfortable. To
be re-evaluated
in 2 weeks
SHORT TERM
Promote
patient
physical
comfort
MIDTERM
XXXXXXXX
LONG TERM
Restore
patient’s
normal
functioning
and wellness
(Surgery)
[] Patient will report
tolerable levels of
pain within 2 hours of
interventions
[] Patient will
demonstrate
satisfactory levels
comfort with in 3
hours of intervention
[] XXXXXXXXXXXXX
XXXXXXXXXXXXX
[] Patient will receive
interventions that will
provide permanent
solutions and patient
will be disease free
Pharmacological:
Administer
prescribed IM
Tramadol 150Mg
stat.
Non-pharm.
Reassure patient
and family.
Guided imagery
to destruct
patient
XXXXXX
XXXXXXXXXXX
Collaborative:
Patient will
undergo an
appendectomy
procedure within
the next 6 hours.
Tramadol will
provide good
level of
analgesia and
promote
patient
comfort to
allow other
planned
interventions
to follow
XXXXXX
XXXXXXXXXXX
Removing the
appendix
eliminates
chances of
recurrence
and promotes
long term
functioning of
the patient
Patient: J.K |35y/o |Male
IPNO. 0221 | DOA. 20/09/2022
Medical Dx: ACUTE APPENDICITIS
Prepared by: NAKADAMA, RN.
SAMPLE CARE PLAN