Acute Pain | Nursing Diagnosis for Appendectomy

Nursing diagnosis: acute Pain related to Distention 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/Evaluation Criteria—Client Will
Pain Level
Report pain is relieved or controlled.
Appear relaxed, able to sleep and rest appropriately.

Nursing intervention with rationale:
1. Assess pain, noting location, characteristics, and severity (0 to 10 scale). Investigate and report changes in pain, as appropriate.
Rationale: Useful in monitoring effectiveness of medication and progression of healing. Changes in characteristics of pain may indicate developing abscess or peritonitis, requiring prompt medical evaluation and intervention.

2. Provide accurate, honest information to client/ significant other (SO).
Rationale: Being informed about progress of situation provides emotional support, helping to decrease anxiety.

3. Keep at rest in semi-Fowler’s position.
Rationale: Gravity localizes inflammatory exudate into lower abdomen or pelvis, relieving abdominal tension, which is accentuated by supine position.

4. Encourage early ambulation.
Rationale: Promotes normalization of organ function; stimulates peristalsis and passing of flatus, reducing abdominal discomfort.

5. Provide diversional activities.
Rationale: Refocuses attention, promotes relaxation, and may enhance coping abilities.

6. Keep NPO and maintain NG suction initially.
Rationale: Decreases discomfort of early intestinal peristalsis and gastric irritation or vomiting.

7. Administer analgesics, as indicated.
Rationale: Relief of pain facilitates cooperation with other therapeutic interventions, such as ambulation and pulmonary toilet.

8. Place ice bag on abdomen periodically during initial 24 to 48 hours, as appropriate.
Rationale: Soothes and relieves pain through desensitization of nerve endings. Note: Do not use heat because it may cause tissue congestion and increase edema formation.