Acute Pain
related to
- distended colon tissue,
- inflammation,
- operation wound
Outcomes:
- patients seemed relaxed,
- able to sleep or rest
Interventions:
- Assess pain, note the location, severity characteristics.
- Keep the rest, with the rest to maintain a semi-Fowler position.
- Give entertainment activities.
- Teach relaxation techniques with a deep breath.
- Collaboration in analgesic administration.
- To determine the level of pain.
- This position reduces the strain on the incision and abdominal organs.
- Distract the patient from pain.
- Reduce tension.
- To reduce / eliminate pain.
Risk of Infection
related to
- perforation or rupture of the appendix,
- peritonitis,
- abscess formation
characterized by:
- encountered no signs of infection, inflammation, purulent drainage, erythema and fever
Interventions:
- Monitor and record vital signs, notice if there is fever sweating, mental changes, increased abdominal pain.
- Do a good hand washing and wound care septic appropriate work procedures.
- Monitor the incision wound and bandage, wound drainage characteristics notes / erythema.
- Provide accurate and honest information on the client or the client's closest people about the condition.
- Collaboration in the administration of antibiotic drugs.
Rational:
- Soon the alleged onset of infection or sepsis, peritonitis, abscess making it easier for nurses and nursing action plan early.
- Can reduce or prevent the occurrence of infections.
- Provide early detection of the infection or control the situation healing process.
- An accurate information provides knowledge about the progress of the situation so as to provide emotional support, help reduce anxiety.
- Allows a reduction in the number of organisms, especially on pre-existing infections.