Name:

Date :

Care Plan

Pt. Initials: ZXC Age: 34 D.O.B.

Gender: M Weight:52.7 Height:
BMI: 18.20 BP Range:115/74 Allergies: NKFDA
Admit Date: Surgery Date: Unit/Room:

Diagnosis/Diagnoses: Acute abdominal pain

Pathophysiology for medical dx:

Acute abdominal pain can have a variety of underlying causes. Inflammation, infection, ischemia, or blockage
of the abdominal organs are common reasons. Appendicitis and pancreatitis are examples of inflammatory
disorders that cause pain by activating nociceptive receptors and starting the production of inflammatory
mediators. The most prevalent medical illness associated with right-sided or periumbilical abdominal pain is
appendicitis. Periumbilical pain, which begins around the navel and moves to the right lower quadrant of the
belly, is the usual beginning of appendicitis. As the appendix's inflammation develops and irritates the adjacent
tissues, this migration takes place. When an appendicitis is present, the right lower abdominal pain is frequently
accompanied by symptoms including nausea, fever, vomiting, and localized discomfort (Moris et al., 2021).
However, other medical disorders including right-sided diverticulitis, ovarian cysts, or kidney stones might also
be the cause of this kind of pain pattern. To correctly identify the particular cause of periumbilical to right-sided
stomach pain and choose the best course of action, a thorough medical evaluation is necessary.

Rationale for treatments (Resp Tx, Neuro check 2hr, CXR, MRI, feeding tubes):
The patient was given Zofran to treat vomiting and nausea, Morphine to treat pain, Normal Saline to maintain
fluid and electrolyte balance, and Ofirmev, perhaps for intravenous pain control as an alternative to Morphine or
in combination for more potent pain relief. These drugs work to treat both the patient's symptoms and general
health.
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Labs and Diagnostic Test: (explain at least 3 abnormal results r/t diagnosis):
Elevated WBC count (18.4): This indicates presence of an infection or inflammation.
Elevated C-reactive proteins (10.7 mg/dl): This indicates inflammation in the abdomen which may be
appendicitis (Moris et al., 2021).
Elevated neutrophils (83%): In appendicitis, an elevated neutrophil percentage—often above 75%—is
frequently observed. The "left shift" on a differential white blood cell count illustrates this.
History of present illness:
This is a patient who presents to the Emergency department with complaints of periumbilical to right-sided
abdominal pain which has been ongoing for approximately 1-2 day. The patient began having nausea vomiting
and diarrhea was seen earlier on in clinic and given oral Zofran and discharged home and was instructed if
worsening pain to return to the emergency department or urgent care family elected to go to urgent care he was
evaluated referred to the ER for appendicitis workup. No URI symptoms.
Past medical history:
No prior medical history.
No prior surgeries.

Social/family history:
Patient lives with parents.
No history of drug and substance abuse.

Change of Shift / Report Notes:

This is a patient who presented to the Emergency department with complaints of periumbilical to right-sided
abdominal pain which has been ongoing for approximately 1-2 day. The patient began having nausea vomiting
and diarrhea was seen earlier on in clinic and given oral Zofran and discharged home and was instructed if
worsening pain to return to the emergency department or urgent care family elected to go to urgent care he was
evaluated referred to the ER for appendicitis workup. No URI symptoms. Plan is to administer treatment as per
treatment sheet.

VS 0800 1200 1600

Temp 37.7 37.5 37.8
Pulse 106 107 106
Resp 18 19 18
BP 115/74 117/73 115/79
2
SaO2 99 99 100
Pain 7 6 4

Physical Assessment:

General: Alert, well, hydrated

Skin: Well hydrated.

HEENT/Neuro: Normal oropharynx, nares, tympanic membranes.

Respiratory: Clear breath sounds, no use of accessory muscles in breathing

CV/Fluids: No murmur

GI: Right lower quadrant pain to palpation + guarding, no masses.

GU: Normal urinary output

M/S: Normal muscle tone

Pulses: Capillary refill <2 seconds

Activity Level: Moderate.

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Nursing Diagnosis #1: Nursing Diagnosis #2:

Acute Pain related to abdominal inflammation as Risk for Deficient Fluid Volume related to nausea,
evidenced by the patient's report of periumbilical to vomiting, and diarrhea, as evidenced by the patient's
right-sided abdominal pain persisting for 1-2 days history of these symptoms and potential fluid loss, as
and increased pain intensity rating 7/10. well as the need for an appendicitis workup, which
may require fasting and intravenous fluids.
Goal Goal
To alleviate the patient's pain and provide a sense of To ensure that the patient maintains an appropriate
comfort. fluid balance and remains adequately hydrated

Interventions Interventions

1. Follow the doctor's instructions for giving the 1. Monitor the patient's fluid intake and urinary
pain medicine. output.
2. Assist the patient in feeling more at ease by 2. Administer anti-emetics as prescribed.
placing them in a comfortable position. 3. In order to stay hydrated, the patient should
3. Provide methods to divert their attention, be given clear fluids to drink and ice chips to
such as listening to music or having a suck on.
discussion. 4. Prevent dehydration by giving intravenous
4. Instruct the patient on the significance of fluids as directed by a medical professional.
reporting discomfort and taking medications 5. Monitor the patient's heart rate, respiration
as prescribed. rate, skin turgor, and mucous membrane
moisture levels continuously for early
detection of dehydration.
Medication Dosage/ Metho Why is the Side effects Nursing
Frequency d of patient on the responsibilities
Admi medication
n.
Normal Saline 500 ml IV To maintain Minimal side Monitor vital signs,
Bolus hydration, effects when fluid intake, and urine

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 correct fluid administered output.
imbalance correctly Assess for signs of
fluid overload or
dehydration.
Zofran 40 mg IV Antiemetic to May cause Administer as ordered.
(Ondansetron) relieve nausea headache, Monitor for allergic
and vomiting constipation, or reactions.
dizziness Assess for nausea and
vomiting relief.
Morphine 5 mg IV Analgesic for Common side Administer with
pain effects include caution, monitor
management respiratory respiratory rate, and
depression, assess pain relief.
sedation, and Be prepared to
constipation administer naloxone in
case of respiratory
depression.
Ofirmev 1000 mg IV Analgesic and Minimal side Administer as ordered.
fever reducer effects when Monitor for pain relief
administered and any adverse
correctly reactions.
D5 NS + 20 1000 ml IV To provide May cause Administer as
KCL dextrose, hyperkalemia prescribed and monitor
sodium, and or fluid for signs of electrolyte
potassium for overload imbalance or fluid
fluid and overload.
electrolyte
balance

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 PLAN OF CARE
DATE: PATIENT’S INITIALS: ZXC
STUDENT NAME: AGE/SEX: 34/M
PATTERN NURSING MUTUAL NURSING SCIENTIFIC RATIONALES EVALUATION AND
MANIFESTATI DIAGNOSIS GOALS INTERVENTIONS AND REFERENCES MODIFICATION
ON

Subjective and Acute Pain To alleviate the Follow the doctor's It is crucial to give pain medicin Check in on the patient's pain
Objective related to patient's pain and instructions for e at the appropriate time in orde levels on a regular basis after
Information abdominal provide a sense giving the pain r to reduce suffering and impro the intervention. If pain
inflammation as of comfort. medicine. ve patient comfort. medicine isn't reducing the
evidenced by Interventions Controlling pain as soon as it be pain, improve pain
Subjective: the patient's gins helps lessen the likelihood management by continually
Patient's report of report of that it will worsen, which in tur assessing and modifying
periumbilical to periumbilical to n benefits the patient and speed comfort measures.
right-sided right-sided s up their recovery (Moris et al.,
abdominal pain abdominal pain 2021).
persisting for 1-2 persisting for 1- Assist the patient in A change in position can help
days 2 days and feeling more at ease lessen pressure on the painful
Objective: increased pain by placing them in a location and associated
Increased pain intensity rating discomfort. It improves the

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intensity rating 7/10. comfortable position. patient's state of mind and
7/10. alleviates some of the
. discomfort (Azili et al., 2021).
Provide methods to The idea is that if the patient's
divert their attention, attention is taken off of their
such as listening to pain, they'll feel better and pay
music or having a less attention to it. Positive
discussion. emotional states and decreased
pain perception can result from
engaging in pleasurable
activities or conversation with
the patient (Azili et al., 2021).
Instruct the patient on Patients need to be taught the
the significance of importance of reporting
reporting discomfort discomfort immediately and
and taking taking their medications as
medications as directed (Azili et al., 2021). As
prescribed a result, the patient is better able
to control their discomfort and
make a full recovery.

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 PLAN OF CARE
DATE: PATIENT’S INITIALS: ZXC
STUDENT NAME: AGE/SEX: 34/M

8
 PATTERN NURSING MUTUAL NURSING SCIENTIFIC EVALUATION AND
MANIFESTATION DIAGNOSIS GOALS INTERVENTIONS RATIONALES AND MODIFICATION
REFERENCES

Subjective and Risk for To ensure that Monitor the The patient's risk of Assess if the patient
Objective Deficient the patient patient's fluid developing a fluid shows no symptoms of
Information Fluid Volume maintains an intake and urinary volume deficit can be dehydration.
related to appropriate output. evaluated and treated If the patient develops
nausea, fluid balance promptly by keeping a dehydration symptoms
Subjective: vomiting, and and remains close eye on their fluid or their intake does not
diarrhea, as adequately intake and output improve, consider
Patient history of evidenced by hydrated (Salahuddin et al., 2022). increasing the frequency
nausea and the patient's Interventions Administer anti- Anti-emetics would of oral fluids and talk to
vomiting history of emetics as reduce incidences of their doctor about
Objective: these prescribed. nausea and vomiting making changes to their
symptoms and minimizing fluid loss. intravenous fluids.
Potential fluid loss, potential fluid In order to stay Motivating patients to
as well as the need loss, as well hydrated, the drink more water keeps
for an appendicitis as the need patient should be their fluid levels stable
workup, which may for an given clear fluids to and reduces the risk of
require fasting and appendicitis drink and ice chips dehydration. When

9
intravenous fluids. workup, to suck on. feeling sick, it's best to
which may stick with clear liquids
require fasting and ice chips (Salahuddin
and et al., 2022).
intravenous Prevent dehydration When a patient cannot
fluids. by giving drink enough fluids
intravenous fluids orally, intravenous fluids
as directed by a are necessary. They aid
medical in the fight against
professional. dehydration and the
upkeep of the body's
electrolyte and fluid
balance (Lounis et al.,
2020).
Monitor the By doing regular checks,
patient's heart rate, symptoms of dehydration
respiration rate, such dry mucous
skin turgor, and membranes, diminished
mucous membrane skin turgor, and
moisture levels abnormalities in vital
continuously for signs can be caught early

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 early detection of on. Fluid volume
dehydration. deficiency can lead to
problems, although they
can be avoided with
prompt treatment (Lounis
et al., 2020).

References
Azılı, M. N., Güney, D., Oztorun, C. I., Ertürk, A., Erten, E. E., Demir, S., ... & Senel, E. (2021). Determination of factors to
distinguish MIS-C from acute appendicitis in children with acute abdominal pain. European Journal of Pediatric
Surgery, 32(03), 240-250.
Lounis, Y., Hugo, J., Demarche, M., & Seghaye, M. C. (2020). Influence of age on clinical presentation, diagnosis delay and outcome
in pre-school children with acute appendicitis. BMC pediatrics, 20, 1-9.

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Moris, D., Paulson, E. K., & Pappas, T. N. (2021). Diagnosis and management of acute appendicitis in adults: a
review. Jama, 326(22), 2299-2311.
Salahuddin, S. M., Ayaz, O., Jaffer, M., Naeem, R., Tikmani, S. S., & Mian, A. I. (2022). Pediatric appendicitis score for identifying
acute appendicitis in children presenting with acute abdominal pain to the emergency department. Indian pediatrics, 59(10),
774-777.

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