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Appendicitis, Miss Kornkanok Jaiwong 61010158, Miss Nattida Kantawong…

- - - - S: The patient reported having severe abdominal pain on the right side for 20 hours.
      - O: Physical examination found tenderness at RLQ
    - - The patient pain decreased.
    - - No of signs of infection include pain, swelling, redness, warmth in the abdomen
      - Pain score < 3
      - Normal Laboratory result especially WBC.
    - - Assess and monitor symptoms Signs of infection include pain, swelling, redness, warmth in the abdomen, abdominal pain, and abdominal tenderness.
      - Assess vital sign and pain score every 4 hours.
      - Administered Metronidazole 500 mg IV as an antibiotic medication and Plasil 10 mg IV to prevent nausea and vomiting follow doctor order.
      - Follow up lab result and assess the risk of appendicitis and abdominal infections.
    - - 21/03/2022
        
        Patient complains pain score = 2
      - The patient no signs of infection include pain, swelling, redness, warmth in the abdomen
      - Laboratory result is normal.
  - - - S: The patient said “I feel a little bit pain.
      - O: Pain score = 4, Patient has a frowning face expression.
    - - To reduce pain of the patient.
      - To promote patient comfortable.
    - - The patient no pain.
      - Patient look comfortable
    - - Assess pain score use numeric rating scales (0-10 point).
      - Assess surgical wound that has any discharge, bleeding, swollen, redness, or painful.
      - Explain the mechanism of pain due to the skin on stomach area was cut during operation and sutures, the tissue was injured so that is the cause of pain.
      - Keep the environment calm for the patient to rest.
      - Teach patient about relaxation techniques, as.
        
        Breathing technique: Take a deep breathe when pain and flow out by mouth.
        
        Massage technique: Massage at the hip of patient for pain relief.
      - Provide Pethidine 35 mg inj q 4 hrs prn. and observe side effect such as drowsiness, dizziness, tiredness, constipation, headache, nausea, vomiting, sweating.
      - Encourage patients to perform early ambulation, to assist in turning every 2 hours, to encourage sitting up and getting out of bed 24 hours after surgery, if assessed to be no risk or no contraindications.
    - - 21/03/2022
        
        Patient complains pain score = 2
        
        Patient has a comfort face
      - 22/03/2022
        
        Patient complains pain score = 0
        
        Patient has a comfort face
      - 23/03/2022
        
        Patient complains pain score = 0
        
        Patient has a comfort face
  - - - O: The patient received spinal block L3-L4 with double ligate stump.
      - S: -.
    - - Patient safe from complications of spinal block.
    - - The patient had no symptoms indicating a complication as cannot voiding, headache, brain hernia, and other.
      - Vital signs in normal range as: T 36.0-37.0 oC, BP 120-80/90-60 mmHg, PR 80-100 bpm, RR 16-20 bpm.
    - - Keep patient lying on the bed 8 hours to prevent postural hypotension.
      - Assess symptoms and manifestations respiration characteristics, skin color, vital sign every 15 minutes, 4 times, every 30 minutes, 2 times, every 1 hour until symptoms stabilize.
      - Assess about mental state, the patient's mood because in the preoperative period patients will have anxiety and fear about surgery.
      - Arrange a sleeping position that is suitable for the patient according to the level of consciousness. To make the patient breathe easier by laying down.
      - Evaluate urinary excretion, encourage the patient to excrete urine within 6-8 hours after surgery.
      - Lift the bed rails every time and adjust the bed in lower level to prevent falling.
    - - 21/03/2022
        -V/S: BT=36.0oC, BP 113/67 mmHg, PR 62 bpm, RR 18 bpm, O2 Sat 98%
        -Patient can voiding and can move.
  - - - S: Patient said that “I don’t know how to take care myself after come back home”
      - O: Patient cannot answer the question about how to take care herself after discharge.
    - - Patient has knowledge about self-care.
    - - Patient can answer the questions about self-care correctly more than 80%.
      - Patient understand how to take care herself discharge.
    - - Explain the patient need to keep the surgical wound clean and dry.
      - Teach the patient to observe the wound and report to the physician any increased swelling, redness, drainage, odor, or separation of the wound edges.
      - Explain that the patient should avoid heavy lifting and should question the physician about when lifting can be resumed.
      - Instruct the patient that a possible complication of appendicitis is peritonitis.
      - Teach the patient about symptoms that indicate peritonitis, including sharp abdominal pains, fever, nausea and vomiting, and increased pulse and respiration, The patient must know to seek medical attention immediately should these symptoms occur.
      - Instruct the patient that diet can be advanced to her or his normal food pattern if no gastrointestinal distress is experienced.
      - Come to follow up as doctor make an appointment on 28 March 2022.
      - Take home medication as Levofloxacin 500 mg 1-tab po pc as antibiotics and paracetamol 500 mg 1-tab prn for pain relievers.
    - - 23/03/2022
        -The patient can answer the questions about self-care correctly more than 80%.
        -Patient understand how to take care herself discharge.