step #1. . .start by making a list of all the non-normal items you obtained in your assessment of the patient. these now become the defining characteristics, or symptoms, of the nursing diagnoses, you are going to develop in the next step.
step #2. . .go shopping for nursing diagnoses. this requires that you have some knowledge, or at the least, a reference of some sort that tells you something about the various nursing diagnoses. each nursing diagnosis has a definition, defining characteristics and related factors. if any of your patient's defining characteristics fit with one or more nursing diagnoses, then you need to look a little more closely at that diagnosis and the symptoms your patient has to see if it will be appropriate to use. once you decide on one or more nursing diagnoses, you need to then actually write out the nursing diagnostic statement. that's usually a three-part statement that follows the pes guideline:
p (problem)--e (etiology, cause or related factors)--s (symptoms, or defining characteristics)
your nursing instructors may have given you specific instructions as to how these nursing diagnostic statements are to be written, so follow their directions.
step #3. . .is where you start to actually write your nursing interventions and develop outcomes (and goals). your nursing interventions actually address the symptoms, or defining characteristics, you determined way back in step #1. your outcomes should be measurable, patient centered and specific. they should also have a specific time limit put upon them. outcomes are the predicted results of the things that a nurse can prescribe, or order, for a patient that do not require a physician order.
step #4. . .implement the plan.
step #5. . .evaluate the successful or failure of the care plan and make adjustments as necessary.
now, for a surgical patient, there are some very general things you should be looking for when performing your assessment. you should be checking out the chapter(s) in your nursing textbook on the surgical patient to find this information. but, in general, patients undergoing general anesthesia, as is likely the case in an appendectomy, are going to experience these possible problems:
- breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
- hypotension (shock, hemorrhage)
- thrombophlebitis in the lower extremity
- elevated or depressed temperature
- any number of problems with the incision/wound (dehiscence, evisceration, infection)
- fluid and electrolyte imbalances
- urinary retention
- surgical pain
- nausea/vomiting (paralytic ileus)
however, there are a few problems that are specific to appendectomies. first of all, i'm assuming this was an emergency situation. did the appendix rupture before the surgeon got in and got it out? that is important to know. if there was no rupture, the patient will be stitched up and sent on his/her way. the patient may have only had a laparoscopic procedure done as opposed to an open incision. however, a ruptured appendix complicates things. there will usually need to be extensive antibiotic therapy and there may be wound healing issues and delayed healing depending on the extent of the peritonitis that was present before the patient went into surgery as well as the patient's response to antibiotic therapy.
here is information about appendectomies:
- information on appendicitis with links to information on webmd and medicinenet
if you give me a list of your patient's non-normal symptoms, or defining characteristics, i will help you develop your list of nursing diagnoses and give you some online resources for help in putting together some nursing outcomes and interventions for them, if you would like this assistance.