MASENO UNIVERSITY.

SCHOOL OF NURSING.
DEPARTMENT OF MEDICAL SURGICAL NURSING
COURSE: MEDICAL SURGICAL 1
MNS 206
LECTURER: DELVINE ADERO
INSTRUCTOR: SHIVACHI
ASSIGNMENT: CASE STUDY FOR APPENDICITIS
ADMISSION NUMBER: NUR/03002/021
SIGN:_________________________
DATE OF SUBMISSION:_____________________________
COMPREHENSIVE HISTORY

BIOGRAPHIC DATA.
NAME: JENNIFER ATIENO
AGE: 28 YEARS
GENDER: FEMALE
ADRESS: NYAMASARIA
IP NO.: 370842
MARITAL STATUS: MARRIED
OCCUPATION: HOUSE WIFE
NEXT OF KIN: DAVID OTIENO(HUSBAND)
TELPHONE NUMBER: 0703820190
MEDICAL DIAGNOSIS: APPENDICITIS
SOURCE OF HISTORY: JENNIFER ATIENO(PATIENT)
DATE OF INTERVIEW: 26/04/2023

[Link] PERCEPTION AND HEALTH

MANAGEMENT
CHIEF COMPLAINT:
Patient complains of lower abdominal pain that has lasted for
the past three weeks that is accompanied by nausea,vomiting
and [Link] patient also complains of muscle and joint
stiffness.

HISTORY OF PRESENTING ILLINESS

The patient reports of being well until three weeks ago when she
started experiencing a mild abdominal pain where she visited
Paga health centre where she was told to revisit but was given
tramadol 100mg and paracetamol 1g to manage the pain .She
also visited good neighbour medical centre with the complain of
abdominal pain where she was diagnosed of food [Link]
patient went home to nurse herself but a lot of pain was all over
the body that interrupted her daily activities when she decided to
visit Kisumu county hospital where she was referred to
Jaramogi Oginga Odinga Teaching and Referral hospital for
further management.
The manifestations were on and off and became very severe as
she was vomiting and had fever.
She reported no known drug allergies and also said maybe its
food that was affecting her since she took omena with ugali
before going to bed on the day of onset.
On admission to Jaramogi Oginga Odinga Teaching and
Referral hospital, IV Ceftriaxone 2g, IM morphine 20mg ,IV
Paracetamol 1g,normal saline and ringers lactate were
prescribed and administered after the patient was diagnosed of
appendicitis.
The patient was later transferred to female surgical ward for
further management and on admission to female surgical the
vital signs were;spo2 98%, pulse 102 beats/minute,blood
pressure 136/85mmHg, respiration 18 breaths per [Link]
patient reported trhat she used over the counter medication that
was paracetamol 1g per oral but never used any home or herbal
remedies

Past medical and surgical history

The patient had been hospitalized more than once;first was in
the year 2019 when she was diagnosed of intestinal obstruction.
Second was when she had severe malaria which was managed
after several admissions.
The patient has undergone major surgical operations;one was for
obstetric surgery for her second born and the other was to
correct the intestinal obstruction to relieve the blockage.
The patient has two children(one boy and one girl)who are of
good [Link] husband suffered from hypertension which was
also managed but is still under medication and reports of not
suffering any childhood infection.
The patient reports of history of chronic illness in her family
where her mother was diagnosed of diabetes mellitus and father
died two years ago of prostate [Link] patient reports that she
has never been transfused or donated any blood [Link] is
not allergic to any drug and has never suffered any accidents or
disabling injuries before.

CURRENT HEALTH STATUS

Patient reports that the current health is full of challenges and
has visited different hospitals for medical checkup.

LIFESTYLE HEALTH PROMOTING BEHAVIORS

The patient is fully immunized of polio,BCG and corona virus.I
was able to prove for BCG because of a scar on the lateral part
of the arm and corona virus vaccine through the ministry of
health message on her phone.

ALLERGIES
The patient is not allergic to any food or drug and she states that
she consumes edible food and diet with tolerance.

USE OF ILLEGAL SUBSTANCES

She reports that she has never used any illegal substances i.e
cigarette and other narcotics for which I was able to confirm for
he had no signs of use of illegal drugs like darkened tongue and
lips.
NEEDS
Abdominal pain
Intestinal obstruction
Inability to excrete stool normally

2. NUTRITION/METABOLIC PATTERN
Patient reports that since he began with the illness her weight
has been progressively decreasing for she used to weigh 64kg
and now she weighs [Link] reports that she drinks water
more than four times a day and always drinks at least 2 glasses
of water anytime she has the urge to atleast after every three
[Link] majorly takes vegetables with ugali and sometimes
omena and fish.
Patient reports that since she became ill her appetite has greatly
decreased and reports of nausea and vomiting after taking her
[Link] are no records of fluid or food input and [Link]
has no history of skin disease though she has signs of
malnutrition on the skin. The skin is dry and the lips are also
[Link] patient reports she has no difficulty in
swallowing and does not experience any cultural practice that
has negative impact on her health such as food restrictions.
She is not on medication that hinder food digestion,absorption
and metabolism e.g laxatives and warfarin.
NEEDS
Reduced body weight and muscle mass
Reduced appetite
Nausea and vomiting
Abdominal pain
DIAGNOSIS
Imbalanced nutritional status less than body requirement related
to inadequate food intake as evidenced by reduced body
weight,loss of appetite, nausea and vomiting.

[Link] PATTERN.
She visits the toilet for excretion of faeces though she
experiences [Link] experiences diarrhoea and the fecal
color is yellow..She reports that she visits the toilet at least three
times a day to urinate and does not use any assistive device for
urination such as catheter.
NEEDS
Diarrhoea
Constipation
Diagnosis:Bowel incontinence related to blocking of some
fecal matter as evidenced by constipation.

[Link]/EXERCISE PATTERN.
The patient is able to perform self care activities of daily living
though weakly and some times needs assistance such as
[Link] has no problem with bones and joints though he has
a problem with abdominal [Link] patient complains of
fatigue when all the symptoms started to [Link]
experiences while walking and even when exercising that have
resulted to her resting on the bed [Link] is no cyanosis or
pallor on the mucous membrane and palmar surfaces of the
[Link] patient cannot do activities like digging like she used
to do before .
NEED
Fatiue
Inability to perform activities requiring consumption of high
amount of energy.
Diagnosis:Acute pain related to bowel obstruction as evidenced
by patient verbalization of pain,facial grimacing and pain when
walking or moving the limbs.

[Link]/REST PATTERN
The patient reports no unusual sleeping [Link] always feel
rested after sleep and does not have any sleep disturbances e,g
nightmares though the abdominal pain has made it difficult for
her to have enough [Link] the illness she was not using
any medication to fall asleep but currently sheis injected with
analgesics such as tramadol that helps he [Link] patient is
tired but has no loss of concentration or disturbed
[Link] the day because of more bed rest she
sleeps most of the time as compared to before illness when she
used to work on her farm and not sleeping during the day.

NEEDS
Difficulty sleeping
Tiredness
Swollen and red eyes
 Diagnosis:Disturbed sleeping pattern related to pain in the
abdomen as evidenced by patient verbalization on difficult to
falling asleep.

[Link]/PERCEPTUAL PATTERN
The patient has no history of nose [Link] is well oriented
to time,place,person and [Link] is aware she is in the hospital
and can guess time as [Link] does not have any slurred
speech,her short,intermediate and long term memories are
intact.,he can remember something and even my name as I had
told her and also the current outbreak of cholera in Kisumu.
She can remember about the post-election violence that occurred
in [Link] has no changes in sense of
hearing,smell,eyesight,touch and [Link] can smell the scent of
alcohol sanitizer even when both eyes are [Link] can also
differentiate sweet and sour taste though she is experiencing
abdominal pain.

NEEDS
No needs identified

Diagnosis:No priority nursing diagnosis because there is no

need.

[Link] PERCEPTION -SELF CONCEPT PATTERN

The patient is not calm due to abdominal pain and looks anxious
because of the current health status wheather he will have her
normal [Link] is very assertive ,she can express herself very
well and believes that one day things will be okay and that she
will be able to have her life [Link] patient has no redded
eyes,no signs of volume changes as the muscles are not tensed
or [Link] does not have any weird behavior.

NEED
Anxiety
Low self esteem

Diagnosis:Acute confusion related to underlying medical

condition as evidenced by restlessness and patient having low
self esteem.

[Link]-RELATIONSHIP PATTERN
The patient is married to David Otieno and are blessed with two
kids(a boy and a girl).Her next of kin is her husband and he is a
[Link] is sometimes the provider of the family and has
good interaction with the husband and other relatives and they
do visit her in the hospital.

NEEDS
Inability to provide for the family
Diagnosis:Impaired parenting related to prolonged
hospitalization and underlying of her inability to provide for the
family.

[Link]-REPRODUCTIVE HEALTH PATTERN

She has no history with the [Link] has no history of vaginal
discharge,bleeding and [Link] has no history of sexually
transmitted infections and had done her breast examination three
weeks [Link] uses no implants but her husband uses condoms
as the [Link] has no problem with sexual
functioning and she does not have any sexual concern as at now.

NEED
No need identified
Diagnosis:No nursing diagnosis because no need has been
identified.

[Link] STRESS AND TOLERANCE.

The patient’s major stressor is to be able to resume her normal
[Link] normally handles her stress by repressing
everything and imagining everything is just [Link] condition
has made the client sad and is disturbed [Link]
does not have any medical condition that has resulted from
stress.
NEEDs
Pain in abdomen
Saddness
Diagnosis:Ineffective coping related to stressful situations
and medical conditions as evidenced by the patient having
frown face and being sad.

[Link]/BELIEF PATTERN
The patient is a christian who goes to catholic church. She has
no religious restrictions or practices that may hinder her health-
seeking [Link] main concern is inability to attend the
church as usual every Sunday and also to [Link] the church she
is a choir member of which he is unable to train with the other
choir members because of [Link] patient has no
signs of religious conflict with the heath state.

NEED
Inability to attend church
Inability to pray
Inability to attend choir training

REFERENCES
[Link] C. Smelter Brunner and Suddarth’s textbook of
medical surgical nursing.
[Link] textbook of medical surgical nursing 10th edition.
3.A. Berman Singder Kezier and Erb’s Fundamentals of nursing
10th edition.
[Link] council of Kenya procedure manual 4th edition.
PHYSICAL EXAM
HEAD
Inspection:hair is dark,evenly distributed on the head and there
are no lesions on the head.
Head is symmetrical and uniform in relation to other body
[Link] signs of infestation,no signs of dandruff and the scalp
is clean.
Palpation:the hair texture is rough,she reports of tenderness
around the occipital region,temporal artery pulsable and the
temporal mandibular joint intact and movable with the
movement of the mouth.

FACE
Inspection:facial features present and symmetrical,dark facial
colour that is uniform to other body [Link] abnormal
twitches,no lesions,no [Link] are facuial around the
eyes and face.

EYES
There is reddening and swelling of eyes with no [Link]
eyes are normal in size and not bulging,there are no signs of
strained [Link] does not use glasses.
There is uniform distribution of the hairs of the eye
brows,properly aligned [Link] are no swellings on the
eyebrows but there are lesions around the eyebrows.
Eyelashes are evenly distributed and are curled upwards.
Eyelids are properly positioned in relation to cornea and the
patient is able to blink.
Conjunctiva is pink and no lesions in [Link] sclera is white with
no [Link] lacrimal glands are not swollen and there is no
excessive lacrimation.
Pupils are dark,equal,round and responsive to light and
[Link] is able to move the eyes through all the six
cardinal points of gauze,She has reduced visual acuity for she is
unable to read values or letters slightly far [Link] temporal
visual fields diminished for there is delay in ability to see
objects introduced from behind.

EAR
Inspection:ears are of normal size,shape and position.
There is no discharge from the ear or any lesions or
redness,there is no deformity.
Palpation:there is no tenderness,tympanic and nit red and the
patient can hear normal voice.

NOSE
Inspection:the nose is midline with both cavities [Link]
abnormal dicharge from the nose,there is no [Link]
mucosal membrane is pink and moist as the internal nose is
darkened and the patient reports no altered smell.
Palpation:the nose is patent,there is no tenderness and no
swelling on the nose.

MOUTH AND THROAT

The mouth is present and midline,colour of external lips is dark
with rough [Link] patient is able to purse the lips,the lips
are dry. Inner lips are pinkish in colour,moist with no [Link]
teeth are present and are white in [Link] are no gum
retractions or bleeding and reports of no toothache and no
lesions on the [Link] tongue is centrally placed and the
patient can roll the tongue in the [Link] tongue is pink in
colour with a smooth [Link] is no lesions or ulcerations
on the [Link] hard and soft palate are pinkish in colour,no
exudates draining and the uvula is centrally placed and mobile
with vocalization.

NECK
Inspection:There are no abrasions and the neck is dark in colour
that is uniform to other body parts. Sternocleinomastoid muscle
present and patient able to rotate,flex and extend the [Link]
trachea is present and midline,there are no swellings on the
trachea and the patient is able to perform range of motion of the
[Link] is no jugular vein distention or thyroid gland
enlargement.
Palpation:There is tenderness on the neck,the pre auricular,post
auricular,submental,supraclavicular and and subclavicular
lymph nodes are not [Link] thyroid gland is not tender
and the carotid pulses present;strong with regular rhythm.
Auscultation:There are no carotid and thyroid bruits.

CHEST
Inspection:the chest is dark in colour that is uniform to the other
body parts,there is simultaneous rising of chest during breathing
and there is no evident use of accessory muscles for
[Link] is longer than inspiration,the shape of the
chest is normal and [Link] is no abnormal chest
retractions in the intercostal spaces,sub sternal and suprasternal
[Link] is apical pulsation present.

Palpation:There is no tenderness,no pain and bruising on the

[Link] fremitus equal down the chest aortic and pulmonic
pulsations are palpable though diminished.

Percussion:There is resonance all over the [Link] are no

regions of hyper resonance.

Auscultation:There are harsh sounds when auscultating over the

apex of the lungs. S1 and S2 sounds are heard on the aortic and
pulmonic area. S1 is heard on the tricuspid area and the mitral
[Link] are no murmurs heard at the Erb’s point.

BACK
Inspection:the back is symmetrical and dark in colour that is
uniform to other body parts with normal skin integrity.
The skin is well moisturized. The spine is continuous and
slightly curved as you move [Link] is no scapulae
bone prominence.
Palpation:There is no tenderness and no [Link] tactile
fremitus increases as you move down the back.

Percussion:There is resonance which increases down the back.

Auscultation:There are no abnormal breath or lung sounds on

the back.

UPPER EXTREMITIES
Inspection: there are symmetrical and of the same size and
[Link] skin is dark in colour which is symmetrical to other
body [Link] joints are dark and have a reduced range of
[Link] shoulders are symmetrical, the size of the joints
equal with a hyper pigmentation on the right [Link] are
no deformities on the shoulders with no signs of swelling or
muscle atrophy.

Palpation:there are no muscle spasms on the shoulders, no

atrophy swelling, temperatures are uniform to the other body
[Link] patient is able to perform active range of motion
though [Link] is bilateral reduction of the shoulder
strength.
The patient can flex the elbow against mild resistance hence can
perform range of motion with the elbows.
Wrist and hand have normal size and shape,properly positioned
with no [Link] can flex the wrist joint [Link]
fingers align straight in the same axis as the forearm but there is
a scar on the hand that resulted from her fall while walking.
The skin on the hand is smooth on [Link] is no
tenderness but has a limited range of motion.

ABDOMEN
Inspection:the skin has a scars on the lower right and left
[Link] is no striae and there are some [Link]
umbilicus is inverted,centrally placed with no signs of
inflammation.
The abdomen is scaphoid shaped and symmetrical and there is
no bulging around the flanks or visible organs.
The temperature is warmer compared to other parts of the body
with normal integrity.
There is no visible peristalsis,aortic pulsation present on the
epigastric region.
There is symmetrical movement of the abdomen and there is no
visible vesicular pattern on the abdomen.

Auscultation:there are two bowel sounds auscultated on the

RLQ,2 on the RUQ, 2 on the LUQ and 1 one the LLQ for a
complete 4 [Link] patient has hypo active bowel sounds
indicating reduced gastrointestinal mobility due to
inflammation. Bruits are heard on the abdominal aorta on the
epigastrium and the renal arteries.
There is no peritoneal friction rubs over the liver and the spleen.

Percussion: The patient reports pain on percussion hence

percussion was impossible.

Palpation:Patient reports pain on light palpation on the lower

left and right [Link] palpation is impossible due to the
discomfort caused to the patient due to [Link] liver and the
spleen are not palpable on light palpation .Both kidneys cannot
be palpated indicating no enlargement of the kidneys or urine
retention.

LOWER EXTREMITIES
Hip:the hip joint is stable and [Link] is no crepitation
on moving of the [Link] patient reports pain and tenderness
on palpation.

Knee:the knee is rough and dark .the knees are properly aligned
and can extend and flex with [Link] is no swelling on
the knees and the range of motion is diminished.

Ankle and feet: the feet is properly positioned in relation to the

lower [Link] are no bony prominences present,the skin is
rough with no lesions.
There is limited range of motion due to pain on movement. The
patient cannot flex and straighten the toes,turn the sole of feet
out and in indicating reduced range of motion.
All the pulses on the lower extremities are present with regular
rhythm though they are weak such as the femoral,tibia,popliteal
and dorsalis.

GENITOURINARY SYSTEM
Patient reports of reduced frequency of urination and urgency.
She reports that the colour of the urine is dark and reports of no
pain during urination.
The vagina has no lesions and has no abnormal discharge.

NERVOUS SYSTEM

1. CRANIAL NERVES

The patient is able to distinguish different smells from different

substances(olfactory nerve)

The patient is able to see objects though the visual acuity is

reduced for objects slightly far for she cannot read the word box
when placed far away at the farthest corner of the room(optic
nerve)

The patient is able to move eyes through the six cardinal

positions of gauze without necessarily moving the
head(oculomotor,trochlear and abducens nerves)

The patient clenches the jaw weakly and can feel the light touch
on the ophthalmic ,maxillary and the mandibular
region(trigerminal nerve).

The patient can frown the face and can smile(facial nerve)

The patient can hear(auditory nerve)

The gag reflex present and can taste using the posterior
tongue(glossopharyngeal)

She has no hoarseness of the voice and can properly articulate

words.(vagus)

She can rotate the head and flex the sternocleidomastoid muscle
and and also shrug the shoulder though weakly.(accessory
nerve)

She can pull the tongue out of the mouth and also move it
sideways in the mouth.(hypoglossal nerve)

2. MENTAL STATUS

The patient is alert and well oriented to person,place and

[Link] has no difficulty in articulating words or following
instructions for she obeys [Link] cognitive functions
are intact for she has a realistic view of herself and she is aware
of her illness and has no hallucination or delusions.
She does not show signs of memory loss for she can account for
the events that have occurred since admission to that facility.

3. MOTOR FUNCTION
The patient has normal muscle tone,the gait is impaired for the
patient cannot stand without support and the muscle strength is
reduced due to pain and muscle stiffness.
There are no involuntary movements on the muscles
fasciculating ,tremors and twitches.
4. REFLEXES

For the plantar reflex using the tip of the pen, there is no
Babinski reflex for there is plantar flexion when the pen is
stroked slowly from the lateral aspect of the patient’s sole from
the heel of the great toe.

5. SENSORY FUNCTION
The patient able to discern light touch with the eyes closed, she
can feel the pain when the tip of a sharp pointed pen is pressed
on the skin,she can differentiate cold and warm temperatures
and also feel vibrations.
She can correctly tell the direction where her big toe is pulled
with her eyes closed and the big toe not touching the other toes.

Medical and Nursing management in the hospital

a)medication since administration
Ceftriaxone IV 2g BD- ceftriaxone inhibits the cross linking and
assembly of bacterial cell wall by preventing peptidoglycan
synthesis.
IM morphine 20 mg- morphine binds to opioid receptors in the
brain thereby preventing transmission of pain impulses and pain
perception
IV paracetamol 1g- analgesic for relief of pain.
Intravenous fluids.
Normal saline alternating with rangers lactate-maintain
appropriate urine outline and replaces the lost fluids from the
body.
To prevent correct fluid and electrolyte imbalance, dehydration
and sepsis
Treatment / special procedure
Laparoscopic surgery- the laparoscope is inserted through a 1
cm umbilical incision with additional trocans used for
visualization and assistance.
Appendectomy-removing the appendix when it is infected.
Admission of fluids and antibiotics to prevent /correct fluids and
electrolyte imbalance dehydration and sepsis
Nursing theory
Theory of self care by Dorothea Orem
The nurse to assist clients in acting,teaching on how the disease
affects the body.
The nurse to perform total care that educates the patient and
family to do the same.
Patient to take responsibility to nurse and monitor her health
after discharge.
Patient to observe hygiene measures to avoid being contacted
with diseases.
The nurse to educate family and patient on how to administer
some drugs and on how to take care of herself without any
assistance.
The patient to learn how to manage her lifestyle after an
ambulatory surgical procedures.
Anatomy ,physiology and pathophysiology
(a) Draw the organ
(b) physiology- Function of the organ involved.
Appendix- helps in maturation of B lymphocytes and production
of IgA [Link] is involved in production of molecules that
help in movement of lymphocytes to other parts of the body.
Appendicitis- inflammation of appendix due to inflammation
caused by infection.
Pathophysiology
Appendix is inflammed or becomes edematous due to occlusion
by hardened stool or foreign bodies and rumors. This increases
intraluminal pressure causing edema and obstruction of orifice
causing ischemia of appendix and bacterial growth. Eventually
gangrene or perforation occurs.
Clinical manifestation
Vague periumbilical pain
Anorexia
Nausea
Low grade fever
Rebound tenderness
Abdominal detention
Constipation
Vomiting
Loss of appetite
Complications
Gangrene of appendix- It occurs when blood flow to internal an
organ is blocked.
Perforation of the appendix- appendix becomes
inflamed ,swollen and filled with pussy and can rupture.
Abscess formation- Inflammation of the appendix leads to
formation of absence.
Peritonitis- Bacteria enters the lining of the gastrointestinal tract
and forms a hole that burst appendix.

LAB INVESTIGATIONS

2. ELECTROLYTE ANALYSIS

TEST RESULT FLAG NORMAL

RANGES
Sodium 129mmol/l Low 135-
145mmol/l
Potassium 2.9mmol/l Low 3.5-5.5mmol/l

Sodium levels are low because of reduced sodium in the renal

[Link] may also result from shift of sodium from
extracellular space to intracellular compartments.
Potassium levels are low due to alkalosis increasing shift of
potassium from interstitial space to intracellular space.

2. Full hemogram

parameter Data flag Normal ranges

WBC 9.04X10^3 high 4.0-9.0x10^3
RBC 3.55x10^6 Iow 3.76-
5.70x10^3
HGB 8.86g/dl low 12.0-18.0g/dl
HCT 27.0% low 33.5-52.0%
MCV 76.1fl low 80.0-100fl
MCH 25.0 low 28.0-32.0
RDWSD 37.0 normal 37.0-39.0
PCT 0.23 normal 0.16-0.33
MPV 8.1 normal 8.0-11.0

Wbc are high as an indication of infection at the site of

appendectomy.

HGB are low because of reduced iron intake and increased loss
of blood in the inflamed appendix.
MCV levels are low due to decrease in HGB levels as a result of
iron deficiency and increased blood loss.
MCH is low due to decrease in levels of circulating Hb levels in
blood due to reduced synthesis.

BIOGRAPHIC DATA.
NAME: JENNIFER ATIENO
AGE: 28 YEARS
GENDER: FEMALE
ADRESS: NYAMASARIA
IP NO.: 370842
MARITAL STATUS: MARRIED
OCCUPATION: HOUSE WIFE
 NEXT OF KIN: DAVID OTIENO(HUSBAND)
TELPHONE NUMBER: 0703820190
MEDICAL DIAGNOSIS: APPENDICITIS

ASSESSMENT NURSING PLANNING INTERVENTIO RATIONALE EVALUATIO

DIAGNOSIS N N
SUBJECTIVE Acute pain GOAL 1. The nurse to 1. Analgesics act By the end of
DATA related to The patient to administer by relieving pain 30 minutes:
Headache abdominal report relieve of analgesics such 2. Bed rest 1. The patient
Patient distention as pain from a scale of as paracetamol initiates muscle reports no
verbalization of evidenced by 8/10 to 3/10 by the iv 1g relaxation by headache
pain on the headache,patien end of thirty 2. The nurse to reducing their 2. The patient
lower abdomen t verbalization minutes encourage the activity hence verbalizes
Muscle and joint of pain on the Expected patient to have reducing reduced pain to
stiffness around lower outcomes. enough bed rest demands a scale of 4/10
the abdomen abdomen,muscl 1. Patient to 3. The nurse to 3. Accessing 3. There was
OBJECTIVE e and joint verbalize reduced re-access the level of pain reduced muscle
DATA stiffness,facial pain level of pain helps evaluate and joint
Facial grimacing grimacing,restl 2. Patient to report after every thirty whether the pain stiffness around
to touch on the essness and no headache minutes noting has been relieved the abdomen.
abdomen tenderness to 3. Patient to report the location by the 4. there is still
Restlessness touch. reduced muscle and character and interventions facial
Tenderness on joints stiffness intensity initiated grimacing to
the abdomen around the 4. The nurse to 4. Health touch
abdomen provide health education helps 5. There is
4. There will e no education to the the patient to be reduced
facial grimace to patient reassured and be restlessness
touch pertaining her well educated on 6. There is still
5. The patient will condition to her condition tenderness of
have no alleviate there by reducing the abdomen
restlessness restlessness restlessness
6. Patient to have Hence goals
no tenderness on partially met
the abdomen
ASSESMENT DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALUATIO
NS N
SUBJECTIVE Imbalanced GOAL The nurse to 1. Ondansentron Patient still
DATA nutrition less To improved administer anti- blocks serotonin reports fatigue
Patient reports than body nutritional status of emetics and drug receptors in the and body
of reduced body requirements the patient by the for nausea eg brain hence weakness
weight related to poor end treatment in the Ondansentron iv prevent vomiting. The patient
Loss of appetite absorption of ward . 1. The nurse to 2. Measurement muscle mass
Constipation food in the EXPECTED routinely of weight will and body
gastrointestinal OUTCOMES measure the determine an weight have not
OBJECTIVE tract as 1. Patient will patients weight increase or improved to
DATA evidenced by report enhanced 2. The nurse reduction of expectation
Muscle wasting general body appetite will administer weight pr The patient
Fatigue and weakness, 2. Patient will multivitamins whether the reports no
general body muscle report reduced 3. The nurse to weight is constant nausea and
weakness wasting,fatigue constipation implement 3. Multi- vomiting
Nausea and and general 3. Patient will parenteral vitamins will The patient still
vomiting body weakness, report improved feeding eg increase the reports
nausea and body weight by 6kg nutriflex appetite hence constipation
vomiting, on discharge from perilipid increasing the The patient
reduced body the hospital. 4. The nurse to desire to eat. reports
weight and 4. Patient will encourage the 4. Parenteral increased
Loss of appetite report no nausea patient to eat feeds are directly appetite
and vomiting small amounts of absorbed into the Hence goal
5. Patient will food. blood stream partial
report reduced 5. The nurse to without being
fatigue and general implement diet transported to the
body weakness rich in fiber I.e ileum for
kales, cassava absorption
5. Fibers contain
roughage that
help in softening
the stool hence
prevent
constipation

ASSESMENT NURSING GOALS AND NURSING RATIONALE EVALUATION

DIAGNOSIS EXPECTED INTERVENTIONS
OUTCOMES
 SUBJECTIVE Deficient fluid GOAL 1. The nurse will 1. Fluids helps to The patient
DATA volume related To achieve administer isotonic replace the lost reports no
The patient to inadequate efficient fluid solutions such as fluid from the vomiting
reports vomiting fluid intake as volume during Normal saline body The patient still
and diarrhoea evidenced by discharge from alternating with 2. Anti emetics reports diarrhoea
vomiting and the ward. ringers lactate as prevents The patient has
OBJECTIVE diarrhoea, EXPECTED prescribed stimulation of normal skin tugor
DATA Dehydration, OUTCOMES 2. The nurse will vomiting hence but still had dry
Dehydration Hypokalemia, 1. Patient will administer anti- reducing vomiting lips
Dry lips Hyponatremia report no emetics such as 3. Input and The patient serum
Dry skin vomiting Ondansentron output charts helps sodium level is
Poor skin tugor 2. Patient will 3. The nurse to evaluate the 137 mmol/l
Lab findings: report no or maintain input- volume within normal
Hypokalemia reduced diarrhoea output charts for administered and range 135-145
2.9mmols/liter 3. Patient will fluids administered ones eliminated to mmol/l
Hyponatremia- have normal skin 4. The nurse will assess for excess The patient serum
129mmol/l tugor and monitor the patient fluid lost potassium level is
hydrated lips for signs of fluid 4. Symptoms eg within normal
4. Patient will overload using dry lips indicated range 3.5-
have serum input and output dehydration which 5mmol/l
sodium levels chart. indicated fluid Hence goal
ranging 135- 145 5. The nurse to loss partially met
mmol/l monitor the 5. Routine
5. Patient will laboratory studies monitoring of
have serum electrolytes laboratory values
potassium levels replacement based helps evaluate
of 3.5-5mmol/l on laboratory fluid loss since
findings fluid loss is mostly
accompanied by
water loss

ASSESSMENT NURSING PLANING INTERVENTIO RATIONALE EVALUATION

DIAGNOSIS N
SUBJECTIVE Impaired physical GOALS [Link] nurse will 1. Monitoring By the end of
DATA mobility related to To attain monitor the help in assessing 48 hours:
Patient reports pain on movement effective physical patients for ischaemia or The patient
pain on and decreased mobility after 48 sensation and edema reports no pain
movement strength as hours motion after 2. To promote to movements
Inability to move evidenced by 1hour. functional The patient can
the lower limbs inability to move EXPECTED 2. The nurse to positioning of slightly move
the limbs, Limited OUTCOMES maintain proper extremities the affected
OBJECTIVE range of motion 1. The patient to body alignment 3. To prevent limbs
DATA Decreased report no pain on along the joints progressive The patient has
Limited range of muscles strength movement 3. the nurse to stiffness and passive range of
motion Reluctance to 2. The patient to perform range of maintain the motion
Decreased move slightly move the motion and function of The patient has
muscles strength Muscle and joint limbs exercise to the muscles and a muscles
Reluctance to stiffness 3. The patient to patient joints by strength of 4/5
move have an active 4. The nurse to preventing The patient is
Muscle and joint range of motion assist in paralysis still reluctant to
stiffness on the 4. The patient activities of 4. To prevent movements
affected parts will not be normal day such over straining of The patient has
reluctant to as ambulation the patient to reduced
movement 5. The nurse to enhance stiffness on the
encourage the cooperation and affected
patient to recovery muscles and
participate in 5. To promote joints
activities she can independence
engage to best. and enhance self Hence goals
esteem and to partially met
facilitate
recovery
ASSESSME NURSING PLANING INTERVENTIO RATIONALE EVALUATIO
NT DIAGNOSIS N N

SUBJECTI Risk for infection GOALS 1. The 1. Tetanus The patient

VE DATA related to loss of The patient will nurse to vaccine blocks the reports no
Feeling pain skin integrity as have no risk for administer GABBA pain on
on the evidenced by infection at the end tetanus toxoid neurotransmitters injured areas
affected area impaired defence of hospitalization vaccine released by the tetanus The skin still
after surgery mechanisms in the hospital. 2. The virus thereby exposed and
was done reducing defence EXPECTED nurse to inhibiting the impulse integrity
against OUTCOMES administer 2. Ceftriaxone impaired
OBJECTIV pathogens. 1. The patient antibiotics such inhibiting the cross There are no
E DATA to report no pain as Ceftriaxone linking and assembly blisters
Loss of skin on the affected IV 2g for of bacterial cell wall around the
integrity area after surgery. prophylaxis by preventing burned areas
Blisters 2. The 3. The peptidoglycan there is small
around the integrity of the nurse to initiate synthesis reddening of
affected area skin will be two hourly 3. Turning burned areas
after increased. turning and prevents formations of There is
surgery. 3. There will changing the pressure sores due to warmth over
Warmth be no blisters position of the prolonged immobility burned areas
over the around the wound patient. and exertion to the Hence goal
surgical after surgery. 4. Nurse to muscle partially met
wound that 4. There will use aseptic 4. Aseptic
is not be normal techniques while techniques prevent
uniform to temperatures over performing introduction of
other body the affected area. wound cleaning bacteria and microbes
parts. and debridement to the wound
5. Nurse to 5. Sterile dressing
use sterile prevent inoculation of
dressing to cover bacteria and pathogens
the wound. preventing bacterial
6. Nurse to growth in the wounds
dress the wound 6. Sulphadiazine
with topical prevents processing of
antibiotics such paraaminobenzoic acid
as sulfadiazine. needed by bacteria
thereby initiating
healing and preventing
infection
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