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NURSING CARE

PLAN

Name of Patient: PATIENT A Agency/ Area: 5B WARD

Diagnosis: Acute Appendicitis________________________Rating:

ASSESSME

SUBECTI "BECTI

Nahihirapan akong dumumi.

!ga " #inggo na ang naka#ipas nunghu#i akong dumumi.

a$domina# cramping

pa##or

%& taken as 'o##o(s)BP) ""*+,*PR) ,-RR) *

T) /0.5

Im$a#anced Nutrition) 1ess than Bod2 Re3uirements re#ated to ina$i#it2 toprocess and digest nutrients as e4idenced $2 change in $o(e# 'unction.

Decrease $i#e acid s2nthesis

Increase cho#estero# s2nthesisin the #i4er

Bi#e supersaturated (ith cho#estero#

Precipitates out o' the $i#e

6orm stonesIn'#ammation o' the $#adder

Pain

A$domina# discom'ort

1ack o' interest to ingest '#uid+'ood

Inade3uate 'ood intake

Im$a#ance Nutrition) #ess than $od2 re3uirements

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L"NG%TERM S&"RT%TERM

The client will continue to:

Express feelings of comfort.Patients stool will be soft and will pass easily.

c. Express an understanding of the diseaseprocess and treatment regimen.

d. Bowel function will return to normal.

e. Express positive feelings about herself.Demonstrate adaptive coping behaviors.

The client will continue to:

Express feelings of comfort.Patients stool will be soft and will pass easily.

c. Express an understanding of the disease processand treatment regimen.

d. Bowel function will return to normal.

e. Express positive feelings about herself.Demonstrate adaptive coping behaviors.

NURSING

INTE RATI"NALE

". E4a#uate c#ient7s risk 'or ma#nutrition.

. Determine interest in eating and a$i#it2 to

che(8 s(a##o(8 and taste. Discuss eatingha$its8 inc#uding 'ood pre'erences8into#erances8 or a4ersions. Note a4ai#a$i#it2and use o' support s2stems./. Determine dietar2 intake and per'ormca#orie count i' c#ient is eating.9. Weigh8 as indicated. :ompare changes in'#uid status and recent (eight histor2.

5. Assist or encourage c#ient to eat; eC.,. Poor to#erance to #arger mea#s ma2 $e due to increasedintraa$domina# pressure or ascites.>. &a#t #imitations can he#p manage '#uid comp#ications in cirrhosis8

inc#uding ascites or tissue edema. &a#t su$stitutes enhance the'#a4or o' 'ood and aid in increasing appetite; ammonia potentiatesrisk o' encepha#opath2.-. Aids in reducing gastric irritation8 diarrhea8 and a$domina#discom'ort that ma2 impair ora# intake and digestion."*. :#ient is prone to sore and $#eeding gums and $ad taste inmouth8 (hich contri$utes to anore

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E$PECTED "UTC"ME/ E!ALUATI"Npatient will

. Express feelings of comfort.

. Patients stool will be soft and will pass easily.

. Express an understanding of the disease process and treatment regimen.

. Bowel function will return to normal.

. Express positive feelings about herself. Demonstrate adaptive coping behaviors

Pre'are()y: E*a+,ate( )y:

&tudent Nurse7s &ignature o4er PrintedName

DATE:

:#inica# Instructor7s &ignature o4er PrintedName

DATE:

Rating: P"INTS SC"RAssessment 5

Nursing Diagnosis "5

&cienti'ic E