![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](https://image.slidesharecdn.com/patientcareplan-220918073329-79306cc3/85/Patient-care-plan-pdf-1-320.jpg)
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Patient care plan.pdf
- 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