General Objective: To recognize the physiological responses of the body to disease conditions- pathological, physiological, and compensatory.

Assessment

Subjective Cues:
As verbalized by the
client:
Tulo na ka adlaw
gasakit.
Ga balik-balik lang
ang sakit.
Murag gidunggab sa
kasakit.

Objective Cues:
Facial grimace
noted
Guarding
behavior noted
Pain scale of
7/10 noted
(+) Rovsings
sign
(+) Rebound
tenderness

Nursing
Diagnosis
.
Severe pain at right
lower quadrant
related to
appendeceal
swelling secondary
to Acute
Appendicitis.

Rationale

It is caused by an
obstruction attributed
to infection, stricture,
fecalith, foreign body
or tumor. Appendicitis
can affect either
gender at any age, but
is most common in
male ages 10-30.
Appendicitis is the
most common disease
requiring surgery and
one of the most
commonly
misdiagnosed
diseases.
When theres an
obstruction in the
appendix, bacteria can
multiply quickly
inside the organ. This
causes the appendix to
become irritated and
swollen. As the
appendix becomes

Specific
Objectives
After 8 hours of
rendering effective
nursing care the client
will be able to:
Demonstrate
use of
relaxation
skills and other
methods to
promote
comfort and
alleviate pain
Reduce pain
level

Nursing
Intervention

Rationale

Independent:

Investigate pain
reports, noting
location,
duration,
intensity (0-10 scale),
and characteristics (dull,
sharp, constant).
Maintain semifowlers
position.

-Changes in location or
intensity are not
uncommon but may
reflect developing
complications.

Reduces abdominal
distention, thereby
reduces tension.

Assess for rigid

board-like
abdomen.

-This is a sign of
Peritonitis

Move patient
slowly.

Reduces muscle tension

or guarding,
which may help
minimize pain of
movement.

Assess pain
regularly.

There is pain
cessation when
the appendix

Evaluation

After 8 hours of rendering

effective nursing
interventions, the patient
was able to:
Demonstrate use of
relaxation skills,
other methods to
promote comfort
such as deep
breathing exercise
Verbalized pain
scale of 5/10

(+) Psoas sign

(+) Obturator
sign
Vital signs are
as follows:

BP: 110/70
mmHg
Temp: 36.5 C
Pulse rate: 86
bpm
Respiratory rate:
21 cpm
Others:
With IVF PLR
1L 120cc/hr
Hematology
Result:
Eosinophils: 5%
(1-3%)
Given
Paracetamol
300 mg IVTT
Q4 as ordered
by the
physician

more swollen and

inflamed, it will
irritate the lining of
the abdominal wall,
known as the
peritoneum. This
causes localized, sharp
pain in the right lower
part of the abdomen.
Client J.J., a 17 yearold male, complains of
right lower quadrant
pain. Upon physical
assessment he was
positive for Rovsings
sign, Psoas sign,
Obturator sign and
rebound tenderness.

ruptures.

No hot compress
or hot shower.
No direct
pressure on the
abdomen. There
should be no
enema. Patient
should be on
NPO.

Provide comfort
measure like
back rubs and
deep breathing.
Provide
diversional
activities
Remove noxious
environmental
stimuli.

Collaborative:
Administer analgesic
and other medications as

This precipitates
the rupture of the
appendix

Promotes relaxation and

may enhance patients
coping abilities by
refocusing attention.

Reduces nausea and

vomiting, which can
increase intra-abdominal
pressure or pain.

prescribed.

cefuroxime 750
mg IVTT Q8
ANST

ranitidine 50 mg
mg IVTT Q8

paracetamol 300
mg IVTT Q4

Antibiotic
prescribed for the
treatment of
infection

To reduce the
amount of acid
produced to
prevent further
complications

Used to treat pain

and fever

Exertional
dyspnea noted
RBS: 147 mg/dL