MAHAVIR COLLEGE OF NURSING

VATRAK

SUB : - ADVANCED NURSING PRACTICE

TOPIC : - CASE STUDY ON

APPENDICITIS

SUBMITTED TO, SUBMITTED BY,

Mr. Kaushal Patidar Ms. Snehal Parmar
[Link] , 1st year Msc nursing
M.C.O.N,Vatrak M.C.O.N,Vatrak
 DEMOGRAPHIC DATA:
NAME : Mr. Rajkumar Duryodhan bebra

AGE : 21 years

SEX : Male

ADDRESS : Jyotiba nagar near petrol pump kalewadi Pune

IP NUMBER : 11810

EDUCATION : 10std

OCCUPATION : Worker

INCOME : 8000/-month

MARITAL STATUS : Unmarried

RELIGION : Hindu

MOTHER TONGUE : Marathi

WARD : Surgery

DATE OF ADMISSION : 20/5/23

DIAGNOSIS : Appendicitis

CHIEF COMPLIANTS:-Pain in abdomen

Dyspepsia since 5 days
loose stool
Nausea
vomiting

PRESENT HISTORY OF ILLNESS:- Patient was alright 5 days back when he experienced
the symptom came to hospital with complaints of pain in abdomen with it was increased
progressively , dyspepsia and vomiting with loose stool.

PAST HISTORY OF ILLNESS:-

 MEDICAL HISTORY :-No any past medical history significant like TB, Asthma, HTN. etc
.
SURGICAL HISTORY:- No any past surgical history of the patient

MENSTRUAL HISTORY [FEMALE]- Nil

FAMILY HISTORY:-

NAME AGE/SEX QUALIFICATION/ RELATIONSHIP HEALTH

OCCUPATION STATUS
Mr. Rajkumar D 21y/M 10th /Worker Himself SICK

Mr. Durodhan 55Y/M 3rd /Farmer Father Healthy

Mrs. Sefla duryodhan 45Y /F House wife Mother Healthy

PERSONAL HISTORY:-

HABITS : No any bad habits

DIET : Veg and Non veg diet , non-veg twice a week.

SLEEPING HABITS : Patient sleep 2 hrs. at day time and 8 hrs. night time. but
now sleep pattern disturbance is there due to pain.

ALLERGY : No any allergic history of the patient

BOWEL AND BLADDER HABITS : Bowel and bladder movement is normal

SOCIO- ECONOMIC STATUS:-

CONDITION OF THE HOUSE : Pakka house and adequate ventilation 1room , and 2 window

WATER SUPPLY : Corporation water

DRAINAGE SYSTEM : Opened drainage

SURROUNDING ENVIRONMENT: The environment is clean around the house.

PHYSICAL EXAMINATION
GENERAL APPEARANCE:

CONSTITUTION : Thin

STATE OF NUTRITION : Under nourished

PERSONAL APPEARANCE : Good and maintained

POSTURE : Erect

SKIN AND HAIR : Normal texture , no any infection , lesion present

EMOTIONAL STATE : Anxious

CO-COOPERATIVENESS : Patient is co-operative

HEIGHT AND WEIGHT:

HEIGHT : 172cm

WEIGHT : 54kg

VITAL SIGNS:

TEMPERATURE : 98.6F

PULSE : 76 B/ MINUTE

RESPIRATION : 22/MINUTE

BLOOD PRESSURE : 110/70MM HG

HEAD AND FACE:

SKULL : Round in shape

SCALP : Clean, no dandruff, scar present

HAIR : Black color, and equally distributed

FACE : Symmetrical

NODE : Not palpable

EYES:
EYEBROWS : Symmetrical
EYELASHES : Equally distributed and there is no infection, lesion present.
EYELID : Intact , no discharge ,discoloration, and lids close symmentrically
EYEBALLS : Both eyes coordinated; move in unison with parallel alignment.
CONJUNCTIVA : No redness and lesion
SCLERA : White
PUPIL : Reactive to light
LENS : Dilated
VISION : Patient has good visual capacity , he can read and saw easily.

EARS:
EXTERNAL STRUCTURE : No any tenderness
CANAL : No any discharge from ears.
TYMPANIC MEMBRANE : Intact
HEARING : Weber test- patient hear equal in both ears.
Rinnus test- sound conducted by air is heard is more than
sound conducted by [Link] conduction is more than bone
conduction.

NOSE:-
EXTERNAL STRUCTURE – Symmetric and straight
SEPTUM - No deviated nasal septum
MUCOUS MEMBRANE -Moist
OLFACTORY SENSE -Present
PATENCY –Patent

MOUTH AND PHARYNX:

LIPS - Pink color
TEETH - No dental caries, shiny tooth enamel present.
GUMS - Healthy(no bleeding)
PALATES – Smooth and soft palate
VOICE –Soft and clear.
BREATH – No halitosis.
TASTE –Good

NECK:
LYMPH NODES - Not palpable

MUSCLES –Muscles are in equal in both size and head in centered.

TRACHEA -Centrally situated and space are equal in both side.

THYROID GLAND- Not palpable

RANGE OF MOTION- Present

BREAST AND AREA NODES: -

INSPECTION:-Not applicable

PALPATION:-Not applicable

CHEST:
CHEST SHAPE : Symmetrical shape

TYPE OF RESPIRATION : Rhythmic and effortless respiration

EXPANSIONS -Chest is expanded during respiration.

INSPECTION - No any tender scar, mass, node present.

PALPATION -Bilateral symmentry and vocal fermitus present

PERCUSSION -No any dull sound present.

AUSCULTATION - During auscultation normal Biovesicular sound present

CARDIOVASCULAR SYSTEM:-

RATE AND RHYTHM : Regular

APICAL AND RADIAL: 76/m and regular

CAROTID PULSE : Full pulsation present and no bruit sound.

JUGULAR VENOUS DISTENSION:- Distended jugular vein

DESCRIPTION OF PERIPHERAL PULSES :-

BRACHIAL RADIAL FEMORAL POPLITEA DORSAL POST
L PEDIAL TIBIAL
RATE 72/m 76/m 78/m 74/m 70/m 68/m
RHYTHA Regular Regular Regular Regular Regular Regular
M

ABDOMEN AND INGUINAL AREAS :-

CONTOUR AND TONE : Flat or rounded (convex)

SCAR : No any scar present

LIVER : Not palpable and hepatomegaly

SPLEEN : Not palpable and spleenomegaly

KIDNEY : Not palpable

BLADDER : Audible bowel sound present

MASSES ; Not present

PALPATION : There is no tenderness, relax abdomen with consistent tension.

PERCUSSION :- Tympany sound present

AUSCULTATION :- Audible bowel sound present.

GENITALS AREA :

RECTAL EXAMINATION:- Its smooth and not tender.

MUSCULOSKELETAL SYSTEM:

UPPER EXTREMITIES : No any deformity normal ROM present

LOWER EXTREMITIES : No any deformity normal ROM present.

DEFORMITIES ; No tenderness or swelling

JOINT EVALUATION : No any swelling , tenderness, crepitation , nodules etc

MUSCLE STRENGTH:- According to grading system-

Grade 5---100% normal strength- normal full movement against gravity and against full
resistance.-PRSEENT

MUSCLE MASS :- Equal in both the side.

NODE :Not present

RANGE OF MOTION :Present

NERVOUS SYSTEM:-

MENTAL STATUS:- Patient is oriented to time , place and person.

He can calculate the normal value like 7+23=350
He has good judgment quality.
Patient has good immediate, recent and recall memory.
CRANIAL NERVES:- Present the sensory and motor response of the nerves.

DEEP TENDON REFLEX :- Deep tendon reflex present, bicep’s , triceps ,patellar,brachio-
Radialis And planter reflex etc.

SUPERFICIAL SENSORY REFLEX:-The reflex are reactive to light, pain, vibration, and touch.

MEDICATION

SR. MEDICATION ROUTE DOSE FREQUENCY

NO.
1 Inj.c-tri IV 1gm 10, 10

2 Inj. Emset IV 4mg 6,2,10

3 Inj. Pan IV 40mg 10,10

4 Inj. Morphine IV Sos ----

5 Tab. Vit-c Oral 500 9,3,9

 INVESTIGATION:-

TYPE PATIENT REPORT NORMAL VALUES IMPRESSION

25/3/15
BSL RANDOM 128 mg/dl Upto 150 mg/dl

HEMOGRAM 12.5% 13-18 mg/dl

WBC 26,500/cumm 4000-11000-cumm

LFT

SR. BILIRUBIN LEVEL 2.0mg/dl 0.2-1.0mg%

DIRECT 0.6mg/dl 0-0.3mg%

SGOT 12 5-40IU/L

RFT

BLOOD UREA 28mg% 10-45mg%

SR. CREATININE 1.4meq/l 0.9-1.2meq/l

SERUM
ELECTROLYTE
121Meq/l 135-145meq/l
Sr. SODIUM
2.6Meq/l 3.5-5.5 meq/l
SR. POTASSIUM

URINE ROUTINE
NORMAL

USG- APPENDICITIS
INFLAMMATION
SUGGEST
DRUG NAME ACTION DOSE /INDICATION CONTRA- SIDE-EFFECT NURSIN
INDICATION RESPO
1GM /IV MOA- - IT IS BROAD HYPERSENSITIVITY DIARRHEA SPECIFI
INJ CTRI BD SPECTRUM TO THIS DRUG NAUSEA PRECAU
CEPHALOSPORIN VOMITING HEPATI
(CEFIXIME ) GROUP. SKIN RASHES RENAL
URTICARIA IMPAIR
IT IS INHIBIT THE PAIN AT
BACTERIAL CELL WALL INJECTION SITE MAINTA
SYNTHESIS AND OF DRU
BACTERICIDAL. ADMIN

INDICATION – WBC CO
 MENINGITIS SHOUL
 THYROID MONITO
 SEPTISEMIA
 UTI GIVE SL
 LRTI OTHER
 PNEUMONIA OTHER
 PROPHYLASXIS IN PATIEN
SURGICAL ASEPSIS NAUSE
Drug name Action Dose /indication Contra-indication Side-effect Nursi
respo
INJ PAN IT IS VERY 40 MG HYPERSENSITIVIT CNS- MAIN
PATENT Y TO THIS DRUGS. IRRITATION RIGH
INHIBITOR INDICATION – DIZZINESS ADM
PHARMACOLOGICA OF GASTRIC ULCER HEADCHE .
L NAME – GASTRIC
PANTAPROZOLE ACID GERD CVS- CHEC
OUTPUT. PALPITATION ANY
ULCERATIVE SEEN
EXECT ITS OESOPHAGITIE SKIN-
ACTION BY S SKIN RASH GIVE
SPECIFIC Z-E SYNDROM PRURITIS BEFO
INHIBITION MEA
OF H+/K+ NSAIDS INDUCED GI-
ATPASE ULCER NAUSEA MON
ENZYME VOMITING COUN
SYSTEM AT CONSTIPATION
THE
SECRETOR RESP-
Y SURFACE DISCOMFORT
OF
GASTRIC OTHER –
PARIETAL THROMBOCYTOPENI
CELL. A
IT BLOCKS LEUCOPENIA
THE FINAL
STEPS OF
ACID
PRODUCTS.
 DISEASE CONDITION
APPENDICITIS

INTRODUCTION

THE APPENDIX IS A SMALL, FINGER-LIKE TUBE ABOUT 10 CM (4 IN) LONG

THAT IS ATTACHED TO THE CECUM JUST BELOW THE ILEOCECAL VALVE.
THE APPENDIX FILLS WITH FOOD AND EMPTIES REGULARLY INTO THE
CECUM. BECAUSE IT EMPTIES INEFFICIENTLY AND ITS LUMEN IS SMALL,
THE APPENDIX IS PRONE TO OBSTRUCTION AND IS PARTICULARLY
VULNERABLE TO INFECTION (IE, APPENDICITIS).

ANATOMY AND PHYSIOLOGY OF THE APPENDIX-

IT IS EXTENDING FROM THE INFERIOR END OF THE LARGE INTESTINE’S

CECUM, THE HUMAN APPENDIX IS A NARROW POUCH OF TISSUE WHOSE
RESEMBLANCE TO A WORM INSPIRED ITS ALTERNATE NAME, VERMIFORM
(WORM-LIKE) APPENDIX. IT IS LOCATED IN THE RIGHT ILIAC REGION OF
THE ABDOMEN (IN THE LOWER RIGHT-HAND ABDOMINAL AREA),
MEASURING ABOUT FOUR INCHES LONG AND ROUGHLY A QUARTER OF
AN INCH IN DIAMETER.

DEFINITION –IT IS DEFINED AS THE INFLAMMATION OF THE APPENDIX IS

KNOWN AS APPENDICITIS.
 CAUSES- CAUSES OF APPENDICITIS IS-

BOOK PICTURE PATIENT PICTURE

APPENDIX BECOMES BLOCKED, ABSENT
OFTEN BY STOOL, A FOREIGN
BODY, OR CANCER.
BLOCKAGE MAY ALSO OCCUR PRESENT
FROM INFECTION

PATHOPHYSIOLOGY

DUE TO ETIOLOGICAL FACTORS

APPENDIX BECOME OBSTRUCTED

INCREASE INTRALUMINAL PRESSURE

DECREASE VENOUS DRAINAGE,THROMBOSIS, EDEMA, AND BACTERIAL

INVASION OF BOWEL WALL

APPENDIX BECOME INCREASINGLY HYPEREMIC, WARM AND COVER WITH

EXUDATES

PERFORATION AND GANGRENE

APPENDICITIS
CLINICAL MANIFESTATION

BOOK PICTURE PATIENT PICTURE

MC BURNEY’S POINT WHEN PRESSURE PRESENT
IS APPLIED
REBOUND TENDERNESS (IE, PRESENT
PRODUCTION OR INTENSIFICATION OF
PAIN WHEN PRESSURE IS RELEASED)
ROVSING’S SIGN MAY BE ELICITED BY PRESENT
PALPATING THE LEFT LOWER
QUADRANT; THIS CAUSES PAIN TO BE
FELT IN THE RIGHT LOWER
QUADRANT.

LOW-GRADE FEVER PRESENT

NAUSEA AND SOMETIMES VOMITING PRESENT
CONSTIPATION ABSENT

DIAGNOSTIC FINDINGS

1. COMPLETE PHYSICAL EXAMINATION

2. LABORATORY TSETS - THE COMPLETE BLOOD CELL COUNT
DEMONSTRATES AN ELEVATED WHITE BLOOD CELL COUNT. I THIS THE
WHITE BLOOD CELL COUNTS IS 26,500/CUMM
3. X-RAY ABDOMEN - NOT DONE
4. USG-IMPRESSION SHOWS INFLAMMATION OF APPENDIX SEEN

MEDICAL MANAGEMENT-

 THE GOAL OF MEDICAL MANAGEMENT ARE –

 TO CORRECT OR PREVENT FLUID AND ELECTROLYTE IMBALANCE.
(NORMAL SALINE , RINGER LACTATE)
 ANTIBIOTICS (CEFIXIME 1 gm) AND INTRAVENOUS FLUIDS ARE
ADMINISTERED UNTIL SURGERY IS PERFORMED.
 ANALGESICS CAN BE ADMINISTERED AFTER THE DIAGNOSIS IS MADE. IF
PATIENT HAS MORE PAIN, INJ MORPHINE SOS

SURGICAL MANAGEMENT – IT IS DONE IN MY PATIENT.

 APPENDECTOMY DONE IN MY PATIENT

 IT IS THE SURGICAL PROCEDURE IN THIS THE REMOVAL OF APPENDIX IS
DONE IN MY PATIENT
 THE PROCEDURE WAS DONE UNDER GENERAL ANESTHESIA.

NURSING MANAGEMENT

 ASSESSMENT
 ASSESS VITAL SIGNS.
 ASSESS THE SIGN AND SYMPTOMS OF PATIENT WITH APPENDICITIS.
 ASSESS FLUID STATUS.
 ASK TO PATIENT RELATED PRESENT COMPLAINT.
 ASSESS THE CAUSE OF APPENDICITIS
 ASSESS PATIENT'S AND FAMILY'S RESPONSES REGARDING APPENDICITIS
 IF PATIENT HAS PAIN THEN ASSESS THE SITE , NATURE AND SEVERITY OF
PAIN.
 ASK THE PATIENT ANY MEDICAL TREATMENT IS TAKEN BY
HERSELF/HIMSELF FOR THE APPENDICITIS.
PRE OPERATIVE NURSING CARE

1. PERFORM A PREOPERATIVE PHYSICAL ASSESSMENT,

2. DISCUSS THE LEGAL ASPECTS OF INFORMED CONSENT.
3. CORRECTLY PREPARE A PATIENT FOR TRANSFER TO THE OPERATING
ROOM,
4. GIVE PRE MEDICATION TO THE PATIENT, AVIL, EFFCORLIN AND CTRI
1GM
5. SHAVE THE AREA IF NECESSARY.
6. PSYCHOLOGICALLY PREPARE THE PATIENT
7. EXPLAIN THE PROCEDURE TO THE PATIENT ,
8. KEEP PATIENT NBM IF ORDER.
9. GIVE FLUID IF PATIENT IS NBM , BY ORDER
10. MONITOR THE PATIENT VITAL SIGN
11. AND SHIFT THE PATIENT IN OT

POST OPERATIVE MANAGEMENT

 VITAL SIGNS, RESPIRATORY STATUS, PAIN STATUS, THE INCISION, AND

ANY DRAINAGE TUBES SHOULD BE MONITORED EVERY ONE TO TWO
HOURS FOR AT LEAST THE FIRST EIGHT HOURS.
 BODY TEMPERATURE MUST BE MONITORED, SINCE PATIENTS ARE OFTEN
HYPOTHERMIC AFTER SURGERY, AND MAY NEED A WARMING BLANKET.
 RESPIRATORY STATUS SHOULD BE ASSESSED FREQUENTLY, INCLUDING
ASSESSMENT OF LUNG SOUNDS (AUSCULTATION) AND CHEST EXCURSION,
AND PRESENCE OF AN ADEQUATE COUGH.
 FLUID INTAKE AND URINE OUTPUT SHOULD BE MONITORED EVERY ONE
TO TWO HOURS. IF THE PATIENT DOES NOT HAVE A URINARY CATHETER,
THE BLADDER SHOULD BE ASSESSED FOR DISTENSION, AND THE PATIENT
MONITORED FOR INABILITY TO URINATE. THE PHYSICIAN SHOULD BE
NOTIFIED IF THE PATIENT HAS NOT URINATED SIX TO EIGHT HOURS
AFTER SURGERY.
 ASSESSES PATIENT’S PAIN LEVEL AND ADMINISTERS APPROPRIATE PAIN
RELIEF
 MAINTAINS PATIENT’S SAFETY (AIRWAY, CIRCULATION, PREVENTION OF
INJURY)
 ADMINISTERS MEDICATIONS, flUID, AND BLOOD COMPONENT THERAPY,
 ASSISTS PATIENT IN RECOVERY AND PREPARATION FOR DISCHARGE
HOME
NURSING DIAGNOSIS

1. DISCOMFORT RELATED TO PAIN SECONDARY TO SURGICAL

INTERVENTION.(APPENDECTOMY)

2. SLEEP PATTERN DISTURBANCE RELATED TO PAIN SECONDARY TO

DISEASE CONDITION.

3. IMBALANCED NUTRITION LESS THAN BODY REQUIREMENT RELATED TO

LOSS OF APPETITE AND VOMITING SECONDARY TO DISEASE CONDITION

4. RISK FOR INFECTION RELATED TO INVASIVE PROCEDURE AND TUBINGS

SECONDARY TO DISEASE CONDITION..

5. KNOWLEDGE DEFICIT RELATED TO DISEASE CONDITION.

6. ANXIETY RELATED TO HOSPITALIZATION AND SURGERY SECONDARY TO

DISEASE CONDITION

7. INEFFECTIVE FAMILY COPING RELATED TO THE STRESS OF , LOSS OF

INDEPENDENCE
 APPLICATION OF ROYS ADAPTATION THEORY-

DISCOMFORT RELATED TO
PHYSIOLOGICA PAIN
L SLEEP PATTERN
FUNCTION DISTRUBANCE
FOCAL IMBALANCED NUTRITION
MC BURNEY’S POINT
WHEN PRESSURE IS
APPLIED, SELF- KNOWLEDGE DEFICIT
REBOUND CONCEPT ANXIETY
INTERVENTI
TENDERNESS ,
ONS
NAUSEA
AND ,VOMITING
LOW-GRADE FEVER ROLE-
ROVSING’S SIGN FUNCTION

INEFFECTIVE FAMILY
RESIDUAL
COPING
AGE-21YEARS
GENDER-MALE INTERDEPEND
EDUCATION-10th ENCE
 NURSING CARE PLAN-1
ASSESSMENT NURSING GOAL NURSING PLANING NURSING RATIONAL EVALUATION
DIAGNOSIS INTERVENTION
SUBJECTIVE DISCOMFORT THE ASSESS THE GENERAL ASSESSED THE GENERAL TO PLAN FOR THE EOC IS
DATA – RELATED TO PATIENT CONDITION OF THE CONDITION OF THE FURTHER CARE MET
THE PATIENT PAIN WILL HAVE PATIENT PATIENT PAIN LEVEL IS PARTIALLY
SAYS THAT HE SECONDARY REDUCE (LEVEL OF PAIN SCORE) 06 AS
HAVING PAIN ON TO THE PAIN TO REDUCE EVIDENCED
RIGHT SIDE . DISTENSION AS GIVE COMFORTABLE COMFORTABLE POSITION THE PAIN BY REDUCED
SURGICAL OF EVIDENCE POSITION TO THE GIVEN TO THE PATIENT PAIN
PROCEDURE INTESTINAL BY PATIENT (FOWLER POSITION) PAIN SCORE
SIDE. TISSUES BY NORMAL IS
INFLAMMATI PAIN GIVE COMFORT DEVICES NOT DONE =03
ON AND SCORE 3 TO THE PATIENT TO REDUCE
OBJECTIVE PRESENCE OF DIVERSIONAL THERAPY THE PAIN
DATA:-PATIENT SURGICAL GIVE DIVERSIONAL GIVEN. ALLOW RELATIVE
FACIAL INCISION THERAPY TO TALK WITH PATIENT
EXPRESSION TO THE PATIENT TO REDUCE
SHOWS THAT HE ANALGESIC GIVEN TO PAIN
IS HAVING PAIN THE PATIENT
IN ABDOMEN GIVE ANALGESIC TO
PATIENT VITAL SIGN CHECKED VITALS ARE
PAIN SCALE WITHIN
RATE IS =7 NORMAL
MONITOR THE VITAL RANGE
PATIENT LOOK SIGN OF THE PATIENT
WEAK AND
RESTLESSNESS
 NURSING CARE PLAN-2
ASSESSMENT NURSING GOAL NURSING PLANING NURSING RATIONAL EVALUATION
DIAGNOSIS INTERVENTION
SUBJECTIVE SLEEP THE ASSESS THE GENERAL ASSESSED THE GENERAL TO PLAN FOR THE EOC
DATA- PATTERN PATIENT CONDITION OF THE CONDITION OF THE FURTHER CARE PARTIALLY MET
DISTURBANC WILL HAVE PATIENT PATIENT. AS EVIDENCE BY
THE PATIENT E RELATED ADEQUATE ADEQUATE
SAID THAT HE TO SLEEP ASSESS THE SLEEP ASSESS THE SLEEP SLEEP.
NOT SLEPT AT (DISCOMFORT PATTERN PATTERN OF THE PATTERN OF THE
LAST NIGHT )PAIN AS PATIENT. PATIENT. TEMP.
BECAUSE OF SECONDARY EVIDENCE INCREASED
PAIN. TO DISEASE BY ASSESS THE VITAL SIGN VITAL SIGN CHECKED
CONDITION. NORMAL OF THE PATIENT. TEMP 99.6F TO REDUCE
OBJECTIVE REDUCE TEMP.
DATA- PAIN GIVE COMFORTABLE COMFORTABLE POSITION
FACIAL POSITION TO THE GIVEN TO THE
EXPRESSION PATIENT. PATIENT(SEMI-FOWLER FOR
SHOWS THAT HE POSITION) ADEQUATE
WERE NOT SLEEP
SLEPT AT LAST GIVE CALM AND QUITE CALM AND QUITE ENVT.
NIGHT. AND ENVT. TO THE PATIENT. GIVEN TO THE PATIENT FOR PROPER
LOOK WEAK AND NIGHT
RESTLESSNESS. TELL TO PATIENT AVOID TOLD TO PATIENT AVOID SLEEPING
DAY TIME SLEEPING DAY TIME SLEEPING
TO TAKE
SCHEDULE ACTIVITY OF SCHEDULED ACTIVITY OF PROPER REST
PATIENT AND SLEEPING THE PATIENT.
HOURS.
FOR PROPER
PROVIDE NOISE FREE PROVIDED NOISE FREE SLEEP
ENVT. TO THE PATIENT. ENVT. TO THE PATIENT.
TO REDUCE
GIVE ANALGESIC TO THE ANALGESIC GIVEN TO PAIN
PATIENT. THE PATIENT(INJ.
 MORPHINE)

NURSING CARE PLAN-3

ASSESSMENT NURSING GOAL NURSING PLANING NURSING RATIONAL EVALUATION
DIAGNOSIS INTERVENTION
SUBJECTIVE IMBALANCED THE ASSESS THE GENERAL ASSESS THE GENERAL TO PLAN FOR THE EOC NOT
DATA- NUTRITION PATIENT CONDITION OF THE CONDITION OF THE FURTHER CARE MET
PATIENT SAYS LESS THAN WILL HAVE PATIENT PATIENT
THAT HIS BODY RELIEVE (T98.6F,P-86/M,RR22/
APPETITE IS REQUIREMEN SIGN AND M,BP-110/70MM OF HG,
DECREASED T RELATED TO SYMPTOM AS HT-172CM,WT 48 KG,
NAUSEA AND LOSS OF EVIDENCE BMI- )
VOMITING APPETITE BY TO KNOW THE
PRESENT AND INCREASED CHECK DAILY WEIGHT DAILY WEIGHT OF THE DAILY
VOMITING WEIGHT 56 OF THE PATIENT PATIENT CHECKED 54 KG IMPROVEMENT
OBJECTIVE SECONDARY KG , TO INCREASED
DATA- TO DISEASE HEMOGLOBI GIVE LIQUID AND SOFT LIQUID AND SOFT DIET THE APPETITE
PATIENT LOOKS CONDITION N DIET TO THE PATIENT GIVEN (HIGH
WEAK AND 15MG/DL CALORIES2400,PROTEIN-
FATIGUE 44GM/DAY,CHO, FAT-
25GM/DAY)
PATIENT’S TO KNOW THE
WEIGHT 54 KG MONITOR THE INTAKE MONITOR THE INTAKE DAILY
HB-12.5MG/DL OUTPUT OF THE OUTPUT OF THE MONITORING
PATIENT. PATIENT(950/600)
ELECTROLYTE- TO KNOW THE
[Link] -- PATIENT
121MEQ/L GIVE FOOD ACCORDING FOOD GIVEN(GREEN STATUS
TO PATIENT LIKE AND LEAFY ,SOYA, JUICE, ETC)
SR.K+-2.6MEQ/L DISLIKE TO MAINTAIN
ADMINISTERED FLUID BODY
ADMINISTER FLUID AND AND ELECTROLYTE(NS FUNCTION
 ELECTROLYTE TO THE AND RL 2 LTR.)
PATIENT

NURSING CARE PLAN-4

ASSESSMENT NURSING GOAL NURSING PLANING NURSING RATIONAL EVALUATION
DIAGNOSIS INTERVENTION
OBJECTIVE THE ASSESS THE GENERAL ASSESS THE GENERAL TO PLAN FOR THE EOC
DATA- RISK FOR PATIENT CONDITION OF THE CONDITION OF THE FURTHER PARTIALLY MET
INFECTION WILL PATIENT PATIENT. CARE AS EVIDENCED
PATIENT HAD RELATED TO HAVE NO REDUCED
FEVER-98.6F INVASIVE ANY SIGN MONITOR THE VITAL MONITORED THE VITAL ITS WITHIN WBC COUNT
PROCEDURES, AND SIGN OF THE PATIENT. SIGN OF THE PATIENT. NORMAL 20,000/CMM
WBC COUNT- SURGICAL SYMPTOM RANGE
26,500/CUMM S AS MONITOR THE WBC MONITOR THE WBC
INCISION
EVIDENCE COUNT OF THE PATIENT. COUNT OF THE WBC COUNT
SECONDARY BY PATIENT ,22,000/CMM INCREASED
TO DISEASE NORMAL MAINTAIN ASEPTIC
CONDITION WBC TECHNIQUE DURING MAINTAINED ASEPTIC TO REDUCE
COUNT PROCEDURE TECHNIQUE DURING INFECTION
4000- PROCEDURE
11000/CU
M
ANTIBIOTIC HAS TO BE ANTIBIOTIC GIVEN TO TO REDUCE
GIVE. THE PATIENT. INJ C-TRI INFECTION.
1GM
PATIENT NAME:- Mr. Rajkumar D NURSE’S NOTE DIAGNOSIS:-Appendicitis

AGE:- 21 year D.O.A:-20/3/15

SEX:- Male SURGERY:-Appendectomy

WARD:- Male Surgery ward STUDENT NAME-Ganesh

DATE DIET MEDICATION TIME NURSING OBSERVATION NURSING CARE REMARK SIGN.

JUICE 100 INJ.C-TRI 1GM 9AM MR. RAJKUMAR WAS ASSESSED THE PATIENT WAS Ganesh
ML IVBD ADMITTED IN THE HOSPITAL GENERAL CO-OPERATIVE
9AM 10, 10 WITH COMPLAINTS OF PAIN CONDITION OF
INJ. PAN 40MG IV IN ABDOMEN AND THE PATIENT
POHA-1/2 BD VOMITING, AND PATIENT
PLATE 10,10 DIAGNOSED AS PAIN REDUCED
INJ. EMSET 4 MG APPENDICITIS PATIENT
IV BD 6, 2 ,10 HAVING PAIN ,
PATIENT WAS NOT SLEPT AT ANALGESIC
INJ. MORPHINE LIGHT BECAUSE OF PAIN IN GIVEN BY
SOS OPERATED SITE. ADVICED, INJ
MORPHINE
TAB. VIT. C 500 PATIENT ACTIVITY IS
MG NORMAL
ORAL , TDS 9, 3, 9
PATIENT HIS APPETITE IS THERE IS NO
DECREASED DUE TO PAIN REDNESS AND
INFECTION
PATIENT BOWEL AND Ganesh
BLADEER MOVEMENT IS BED LOOKS
NORMAL. CLEAN AND
TIDY.
INTRACATH WAS PRESENT BED MAKING ITS WITHIN
ON LEFT HAND DONE NORMAL
RANGE
PATIENT BED LOOKS
UNCLEAN AND UNTIDY
VITAL SIGNS Ganesh
CHECKED THERE IS NO
T -98.6F, BP- ANY SIDE
VITAL SIGN HAS TO BE 110/70 EFFECT OF THE
CHECK P -76/M ,RR-22/M DRUGS SEEN.

NO ANY
MEDICATION INFECTION
GIVEN TO THE PRESENT.
PATIENT.
MEDICATION HAS TO BE
GIVE
ASSESSED THE FOR BLOOD
PHYSICIAN IN VALUES.
DOING
DRESSING OF
THE PATIENT.

SAMPLE
COLLECTED
FOR
INVESTIGATION

HEALTH
EDUCATION
GIVEN TO THE
PATIENT
REGARDING
MEDICATION
AND FOLLOW
UP.
 RECORDING AND
REPORTING

PATIENT NAME:- Mr. Rajkumar D NURSE’S NOTE DIAGNOSIS:-Appendicitis

AGE:- 21 year D.O.A:-20/3/15

SEX:- Male SURGERY:-Appendectomy

WARD:- Male Surgery ward STUDENT NAME-Ganesh

DATE DIET MEDICATION TIME NURSING OBSERVATION NURSING CARE REMARK SIGN.
INJ.C-TRI 1GM IVBD 9AM MR. RAJKUMAR WAS ASSESSED THE PATIENT GANESH
10, 10 ADMITTED IN THE GENERAL WAS CO-
UPMA -1/2 INJ. PAN 40MG IV BD HOSPITAL WITH CONDITION OF OPERATIVE
PLATE, 10,10 COMPLAINTS OF PAIN IN THE PATIENT
LUNCH- INJ. EMSET 4 MG IV ABDOMEN AND VOMITING,
CHAPATTI- BD 6, 2 ,10 AND PATIENT DIAGNOSED
1, SBJI -1/2 AS APPENDICITIS
PLATE INJ. MORPHINE SOS
PATIENT WAS SLEPT WELL
TAB. VIT. C 500 MG AT LAST NIGHT
ORAL , TDS 9, 3, 9
PATIENT ACTIVITY IS
NORMAL

PATIENT HIS APPETITE IS

DECREASED DUE TO PAIN
GANESH
PATIENT BOWEL AND
BLADDER MOVEMENT IS
NORMAL. THERE IS
NO
INTRACATH WAS PRESENT REDNESS
ON LEFT HAND AND
BED MAKING INFECTION
PATIENT BED LOOKS DONE
UNCLEAN AND UNTIDY BED LOOKS
CLEAN AND
VITAL SIGNS TIDY.
VITAL SIGN HAS TO BE CHECKED ITS WITHIN
CHECK T -98.6F, BP- NORMAL
110/70 RANGE
P -76/M ,RR-22/M GANESH

MEDICATION THERE IS
GIVEN TO THE NO ANY
MEDICATION HAS TO BE PATIENT. SIDE
GIVE EFFECT OF
THE DRUGS
ASSESSED THE SEEN.
PHYSICIAN IN
DOING NO ANY
DRESSING OF INFECTION
THE PATIENT. PRESENT.
 VITAL SIGN ITS WITHIN
CHECKED NORMAL
VITAL SIGN HAS TO BE RANGE
CHECK HEALTH
EDUCATION
GIVEN TO THE
PATIENT
REGARDING
MEDICATION
AND FOLLOW
UP.

RECORDING AND
REPORTING

PATIENT NAME:- Mr. Rajkumar D NURSE’S NOTE DIAGNOSIS:-Appendicitis

AGE:- 21 year D.O.A:-20/3/15

SEX:- Male SURGERY:-Appendectomy

WARD:- Male Surgery ward STUDENT NAME-Ganesh

DATE DIET MEDICATION TIME NURSING NURSING CARE REMARK SIGN
OBSERVATION
 INJ.C-TRI 1GM 9AM MR. RAJKUMAR WAS ASSESSED THE PATIENT WAS Ganesh
IVBD ADMITTED IN THE GENERAL CO-
UPMA -1/2 10, 10 HOSPITAL WITH CONDITION OF OPERATIVE
PLATE, INJ. PAN 40MG COMPLAINTS OF PAIN IN THE PATIENT
LUNCH- IV BD ABDOMEN AND
CHAPATTI- 10,10 VOMITING, AND PATIENT
1, SBJI -1/2 INJ. EMSET 4 DIAGNOSED AS
PLATE MG IV BD 6, APPENDICITIS
2 ,10
PATIENT WAS SLEPT
INJ. WELL AT LAST NIGHT
MORPHINE
SOS PATIENT ACTIVITY IS
NORMAL
TAB. VIT. C
500 MG PATIENT HIS APPETITE Ganesh
ORAL , TDS 9, IS DECREASED DUE TO
3, 9 PAIN

PATIENT BOWEL AND

BLADDER MOVEMENT IS
NORMAL. THERE IS NO
REDNESS AND
INTRACATH WAS INFECTION
PRESENT ON LEFT HAND BED MAKING
DONE BED LOOKS
PATIENT BED LOOKS CLEAN AND
UNCLEAN AND UNTIDY VITAL SIGNS TIDY.
CHECKED ITS WITHIN
VITAL SIGN HAS TO BE T -98.6F, BP-110/70 NORMAL
CHECK P -76/M ,RR-22/M RANGE

MEDICATION THERE IS NO
MEDICATION HAS TO BE GIVEN TO THE ANY SIDE
GIVE PATIENT. EFFECT OF
THE DRUGS
SAMPLE SEEN.
COLLECTED
FROM THE
PATIENT

ASSESSED THE NO ANY

PHYSICIAN IN INFECTION
DOING DRESSING PRESENT.
VITAL SIGN HAS TO BE OF THE PATIENT.
CHECK ITS WITHIN
VITAL SIGN NORMAL
CHECKED RANGE

HEALTH
EDUCATION
GIVEN TO THE
RECORDING AND PATIENT
REPORTING REGARDING
MEDICATION
AND FOLLOW UP.
PROGRESS NOTE:-
FIRST DAY-

MY PATIENT MR. RAJKUMAR DURYODHAN WAS ADMITTED IN MALE SURGERY

WARD BECAUSE PAIN IN ABDOMEN, VOMITING , LOOSE STOOL AND DYSPEPSIS,
AND PATIENT IS DIAGNOSED AS APPENDICITIS AND APPENDECTOMY DONE IN
HOSPITAL .
 PATIENT VITALS SIGN CHECKED. AND ITS NORMAL IN RANGE
 MEDICATION GIVEN TO THE PATIENT. FOR TEMP. TAB PCM
 PATIENT IS CO-OPERATIVE , HISTORY TAKEN FROM THE PATIENT.
 PATIENT PREPARE FOR THE SURGERY,
 PRE MEDICATION GIVEN TO THE PATIENT.
 CONSENT TAKEN FROM THE PATIENT
 PROCEDURE EXPLAIN TO THE PATIENT AND HIS RELATIVE.

SECOND DAY
 PATIENT VITAL SIGN CHECKED , AND ITS NORMAL IN RANGE
 PATIENT HAVING PAIN SO DIVERSIONAL THERAPY GIVEN TO THE
PATIENT.
 DRESSING DONE UNDER ASEPTIC TECHNIQUE.
 FOR PAIN RELIEVE ANALGESIC GIVEN, INJ MORPHINE

THIRD DAY
 IN PATIENT CONDITION IMPROVEMENT IS THERE .
 THE VITAL SIGN ARE NORMAL IN RANGE.
 MEDICATION GIVEN TO THE PATIENT.
 DRESSING DONE UNDER ASEPTIC TECHNIQUE.
 PAIN IS REDUCED

HEALTH EDUCATION-

MEDICATION- HEALTH EDUCATION GIVEN ABOUT THE MEDICATION, WHAT IS

THE ACTION, HOW IT IS EFFECT
, SIDE EFFECT AND AT HOME HOW TO TAKE AND TIMING OF THE
MEDICATION.

PERSONAL HYGIENE- TOLD TO PATIENT TO MAINTAIN PERSONAL HYGIENE

DAILY. TAKE CARE OF DRESSING WHILE GOING AT HOME.

DIET- TOLD TO PATIENT TO TAKE HIGH PROTEIN 60GM /DAY,LIKE GREEN LEAFY
VEGETABLES , MILK, EGG, SOYA ETC.

EXERCISE- TOLD TO PATIENT DO EXERCISE REGULARLY, AND DO NOT LIFT

HEAVY WEIGHT AFTER GOING TO HOME .

TOLD TO PATIENT COME FOR FOLLOW UP ACCORDING TO ADVICED

REFERANCES

 BRUNNER AND SUDDHARTH, TEXTBOOK O MEDICAL SURGICAL

NURSING,11TH EDITION, PAGE NO.1034-1039
 JOYCE M BLACK, TEXTBOOK OF MEDICAL SURGICAL NURSING, VOL-2ND
EDITION, PAGE NO1131-1165
 TAYLOR CAROL etal, FUNDAMENTAL OF NURSING, 2ND EDTION , VOL 2 ,2009
PAGE NO. 1407-1425
 LIPPINCOTT NURSING DRUG GUIDE ,5TH EDITION ,PP 127,420
 [Link] .com
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