NDx: Acute pain RT irritation of the parietal peritoneum AEB guarding behavior, tenderness upon palpation in right loin
and right iliac fossa, and rebound tenderness
in right iliac fossa
Nursing Goals and
Cues Analysis Intervention Rationale Evaluation
Diagnosis Objectives
Subjective Acute pain RT Appendicitis Goal
Client irritation of the occurs due to the After 5 hours of
verbalized parietal obstruction of the nursing intervention,
“Sobrang peritoneum lumen of the the client must be able
sakit ng AEB guarding vermiform report that pain has
tiyan ko, behavior, appendix. been controlled.
dito sa tenderness Intraluminal
baba, sa upon palpation pressure builds Objective
bandang in right loin up, causing After 1 hour of nursing
kanan.” and right iliac ischemic injury intervention, the client
fossa, and and encouraging must be able to:
Objective rebound bacterial Effectiveness
Guarding tenderness in overgrowth and Identify the Independent Independent Was the client able to
behavior is right iliac fossa eliciting an cause 1. Conduct health 1. Provides knowledge. identify the cause of the
evident. inflammatory (appendicitis) of teaching on the presence of pain through
Tenderness response. the presence of underlying verbalization?
is elicited pain through cause of pain, _Met
upon As the which is _Partially Met
verbalization.
palpation of appendiceal wall appendicitis. _Unmet
the right becomes
inflamed, the Verbalize at least 2. Assess the scale 2. Useful in the Did the client verbalize at
lower
visceral afferent 2 of pain supervision and least 2 nonpharmacological
quadrant of
fibers surrounding nonpharmacologi location, pain efficient medicine, methods that provide relief?
the
abdomen. the organ are cal methods that characteristics healing progress, _Met
Rebound stimulated. These provide relief. and report changes, and _Partially Met
tenderness fibers enter the change characteristics of _Unmet
is present. spinal cord at T9- Verbalize sense pain.
accordingly.
T10, producing of control of Did the client verbalize
the classic diffuse response to acute sense of control of response
periumbilical pain 3. Assess severity 3. Provides baseline to the acute situation and had
situation and
seen at the outset of pain on the foundation. a positive outlook for the
positive outlook
of appendicitis. for the future. pain scale. future?
As the _Met
inflammation Demonstrate use 4. Observe 4. Observations may _Partially Met
progresses over of relaxation nonverbal cues not be congruent _Unmet
the course of a skills and and pain with verbal reports
few days, the diversional behaviors. or may be only Did the client demonstrate
parietal activities, indicator present the use of relaxation skills
peritoneum is as indicated. when client is unable and diversional activities as
irritated, thereby to verbalize. indicated?
stimulating _Met
somatic nerve 5. Increased HR, _Partially Met
fibers and 5. Monitor vital Respiration, _Unmet
producing more signs. Temperature, and
localized pain. status of abdominal Efficiency
Localization of pain (very intense) Were the nursing
the pain depends interventions efficient in
and abdominal
on the position of improving the client’s
distention/bloating
the tip of the condition?
appendix. Two may be signs of a __ Met
classic findings ruptured appendix __ Partially Met
known as the leading to __ Unmet
“psoas sign”, peritonitis.
which is pain
produced by 6. Reduces abdominal Appropriateness
stretching the 6. Position client Were all the nursing
distention, thereby
iliopsoas muscle in a semi- interventions appropriate to
reducing tension.
through hip fowler’s the client’s condition?
Gravity localizes
extension while position. __ Met
inflammatory
the patient is in exudate into lower __ Partially Met
the left lateral __ Unmet
abdomen or pelvis,
decubitus position
relieving abdominal
and the Adequacy
McBurney’s sign, tension, which is Were the number of nursing
which is pain accentuated by interventions enough to
elicited upon supine position. answer the problem of the
palpation of the client?
abdominal wall at __ Met
the McBurney's 7. Gives client more __ Partially Met
point (two-thirds 7. Review __ Unmet
options to choose
the distance from nonpharmacolo
from in the
the umbilicus to gical ways to Acceptability
management of
the right anterior lessen pain, Were the nursing
his/her pain.
superior iliac including interventions acceptable to
spine). techniques such the client?
as Therapeutic __ Met
References: Touch (TT), __ Partially Met
Hodge, B. D., & self-hypnosis, __ Unmet
Khorasani-Zadeh, and relaxation
A. (2017). skills.
Anatomy,
Abdomen and 8. Promotes relaxation
Pelvis, Appendix. 8. Provide and may enhance
diversional patient’s coping
activities. abilities by
refocusing attention.
Dependent
Dependent 1. Decreases
1. Keep client discomfort of early
NPO as intestinal peristalsis,
prescribed by gastric irritation and
the physician. vomiting.
2. Soothes and relieves
2. Place ice bag pain through
on abdomen desensitization of
periodically, as nerve endings
appropriate
Collaborative
Collaborative 1. Confirms causative
1. Review factors of the
laboratory proliferation of the
results pertinent pain and serves as
to causative baseline foundation
factors. for the condition of
the client.
2. Addresses
2. Collaborate in underlying cause of
treatment of pain.
underlying
cause
(appendectomy
).
References:
Appendicitis NCLEX Review.
(2017, March 7). Registered
Nurse RN.
https://www.registerednursern.
com/appendicitis-nclex-
review/
Appendicitis Nursing Care
Plan & Management. (n.d.).
RNpedia. Retrieved October
22, 2020, from
https://www.rnpedia.com/nursi
ng-notes/medical-surgical-
nursing-notes/appendicitis/
Belleza, R. M. N. (2017,
September 26). Appendicitis.
Nurseslabs.
https://nurseslabs.com/appendi
citis/#diagnosis
Doenges, M. E., Moorhouse,
M. F., & Murr, A. C. (2019).
Nurses pocket guide:
diagnoses, prioritized
interventions, and rationales.
Philadelphia: F.A. Davis
Company.
