NURSING DIAGNOSIS: Pain, acute May be related to Hyperperistalsis, prolonged diarrhea, skin/tissue irritation, perirectal excoriation, fissures, fistulas Possibly evidenced by Reports of colicky/cramping abdominal pain/referred pain Guarding/distraction behaviors, restlessness Facial mask of pain; self-focusing Desired Outcomes Pain Level (NOC) Report pain is relieved/controlled. Appear relaxed and able to sleep/rest appropriately. Nursing Interventions & Rationale Nursing Interventions Rationale  Encourage patient to [...]

NURSING DIAGNOSIS: Pain, acute May be related to Biological injuring agents: obstruction/ductal spasm, inflammatory process, tissue ischemia/necrosis Possibly evidenced by Reports of pain, biliary colic (waves of pain) Facial mask of pain; guarding behavior Autonomic responses (changes in BP, pulse) Self-focusing; narrowed focus Desired Outcomes Report pain is relieved/controlled. Demonstrate use of relaxation skills and diversional activities as indicated for [...]

Appendectomy is the surgical removal of the appendix. Here are 4 nursing care plans for appendectomy

Nursing Diagnosis: Acute Pain May be related to Muscle spasms Movement of bone fragments, edema, and injury to the soft tissue Traction/immobility device Stress, anxiety Possibly evidenced by Reports of pain Distraction; self-focusing/narrowed focus; facial mask of pain Guarding, protective behavior; alteration in muscle tone; autonomic responses Desired Outcomes Verbalize relief of pain. Display relaxed manner; able to participate in [...]

Nursing Diagnosis: Pain, acute May be related to Destruction of skin/tissues; edema formation Manipulation of injured tissues, e.g., wound debridement Possibly evidenced by Reports of pain Narrowed focus, facial mask of pain Alteration in muscle tone; autonomic responses Distraction/guarding behaviors; anxiety/fear, restlessness Desired Outcomes Report pain reduced/controlled. Display relaxed facial expressions/body posture. Participate in activities and sleep/rest appropriately. Nursing Interventions [...]

Nursing Diagnosis: Acute Pain May be related to Decreased myocardial blood flow Increased cardiac workload/oxygen consumption Possibly evidenced by Reports of pain varying in frequency, duration, and intensity (especially as condition worsens) Narrowed focus Distraction behaviors (moaning, crying, pacing, restlessness) Autonomic responses, e.g., diaphoresis, blood pressure and pulse rate changes, pupillary dilation, increased/decreased respiratory rate Desired Outcomes Pain Level (NOC) [...]

Nursing Diagnosis: Acute Pain May be related to Distension of intestinal tissues by inflammation Presence of surgical incision Possibly evidenced by Reports of pain Facial grimacing, muscle guarding; distraction behaviors Autonomic responses Desired Outcomes Report pain is relieved/controlled. Appear relaxed, able to sleep/rest appropriately. Nursing Interventions Rationale  Assess pain, noting location, characteristics, severity (0–10 scale). Investigate and report changes in [...]

Nursing Diagnosis: Acute Pain May be related to Mucosal irritation: bladder distension, renal colic; urinary infection; radiation therapy Possibly evidenced by Reports of pain (bladder/rectal spasm) Narrowed focus; altered muscle tone, grimacing; distraction behaviors, restlessness Autonomic responses Desired Outcomes Report pain relieved/controlled. Appear relaxed. Be able to sleep/rest appropriately. Nursing Interventions Rationale  Assess pain, noting location, intensity (scale of 0–10), [...]