🏥 Surgical Nursing Care Plan on Appendicitis with Appendectomy

Medical-Surgical Nursing | NANDA Nursing Care Plan Format

Surgical Nursing Care Plan | Practical File Ready

⚠️ Educational Purpose Only: This surgical nursing care plan is prepared for academic practical file work. Not for actual patient care or clinical decision-making.

📄 Page 1 — Student Information

Student Name	[Your Name]
Course	BSc Nursing / GNM / ANM
Subject	Medical-Surgical Nursing
Surgical Care Plan Topic	Appendicitis with Appendectomy
Format	NANDA-I Surgical Nursing Care Plan Format
Clinical Area	Surgical Ward / Operation Theatre / Post-operative Ward
Date of Submission	[Enter Date]
Clinical Instructor	[Instructor Name]

📄 Page 2 — Patient Identification Data

Name	Mr. Rohit Sharma
Age	24 Years
Sex	Male
Address	Jodhpur, Rajasthan
Occupation	College Student
Marital Status	Unmarried
Religion	Hindu
Diagnosis	Acute Appendicitis
Surgical Procedure	Appendectomy
Type of Surgery	Open Appendectomy
Type of Anesthesia	General Anesthesia
Type of Family	Nuclear Family
Family Size	5 Members
Ward Name	Male Surgical Ward
Bed Number	12
Date of Admission	10/05/2026
Date of Surgery	10/05/2026
Doctor Incharge	Dr. A. K. Meena, MS General Surgery
Hospital Name	Government Medical College Hospital, Jodhpur

📄 Page 3 — Chief Complaints & Present Illness History

Chief Complaints

Pain in abdomen, initially around umbilicus, later shifted to right lower abdomen — since 18 hours.
Nausea and 2 episodes of vomiting — since morning.
Loss of appetite — since 1 day.
Low-grade fever — since 8 hours.
Difficulty in walking due to abdominal pain.
Pain increased on coughing and movement.

History of Present Illness

Mr. Rohit Sharma, a 24-year-old male, was apparently well 1 day before admission. He developed sudden onset abdominal pain around the umbilical region in the evening. Initially, the pain was dull and intermittent, but after a few hours it shifted to the right lower quadrant of the abdomen. The pain became sharp, continuous and aggravated by movement, coughing and walking.

The patient also complained of nausea, vomiting, anorexia and low-grade fever. He took one tablet of painkiller at home, but pain was not relieved. Due to increasing abdominal pain and tenderness, he was brought to the emergency department by his father.

On examination, tenderness and guarding were present in the right iliac fossa. Rebound tenderness was positive. Blood investigation showed raised total leukocyte count. Ultrasonography abdomen showed inflamed, non-compressible appendix suggestive of acute appendicitis. The patient was admitted to the surgical ward and prepared for emergency appendectomy.

Past Medical History

No history of diabetes mellitus.
No history of hypertension.
No history of tuberculosis, asthma or epilepsy.
No history of chronic gastrointestinal disease.
No known drug allergy.

Past Surgical History

No previous history of surgery.
No history of previous hospitalization for any major illness.
No history of blood transfusion.

📄 Page 4 — Family History & Family Composition

Family History

The patient belongs to a nuclear family.
Total family members are 5.
No family history of appendicitis reported.
No family history of diabetes mellitus, hypertension, tuberculosis or hereditary disease.
Father is healthy and works as a shopkeeper.
Mother is healthy and is a homemaker.
One younger brother and one younger sister are healthy.

Family Composition

Name	Age/Sex	Education	Occupation	Relationship	Health Status
Mr. Mahesh Sharma	52/M	10th Pass	Shopkeeper	Father	Healthy
Mrs. Sunita Sharma	48/F	8th Pass	Homemaker	Mother	Healthy
Mr. Rohit Sharma	24/M	B.A. Student	Student	Self / Patient	Acute Appendicitis with Appendectomy
Mr. Ravi Sharma	19/M	12th	Student	Brother	Healthy
Miss Pooja Sharma	16/F	Class 10	Student	Sister	Healthy

Family Tree

👨

Mr. Mahesh Sharma

Father

Healthy

♡

👩

Mrs. Sunita Sharma

Mother

Healthy

👨‍🦱

Mr. Rohit Sharma

Patient

Acute Appendicitis with Appendectomy

👦

Mr. Ravi Sharma

Younger Brother

Healthy

👧

Miss Pooja Sharma

Younger Sister

Healthy

Male Female Patient Highlighted

📄 Page 5 — Dietary, Personal, Socio-economic & Environmental History

Dietary History

The patient takes a mixed diet.
Usually takes 3 meals per day with tea and snacks.
Frequently eats spicy and oily foods such as samosa, kachori and fried snacks.
Low intake of fruits and green leafy vegetables.
Fluid intake is approximately 1.5–2 liters per day.
Loss of appetite was present since onset of abdominal pain.
Patient was kept NPO after admission for emergency surgery.

Personal History

Sleep: 7–8 hours per night before illness; disturbed sleep due to abdominal pain.
Appetite: Reduced since 1 day.
Bowel: No stool passed since morning of admission; no history of chronic constipation.
Bladder: Normal micturition, no burning or frequency.
Habits: No smoking, no alcohol, no tobacco chewing.
Activity: Active college student before illness; activity restricted after abdominal pain.
Allergy: No known drug or food allergy.

Socio-economic History

The patient belongs to a middle-class family.
Father is the main earning member of the family.
Family income is adequate for basic needs and treatment.
Patient has family support during hospitalization.
Family is cooperative and willing to follow medical advice.

Environmental History

The family lives in a pucca house with adequate ventilation and lighting.
Safe drinking water is available at home.
Sanitation facility is available.
No exposure to industrial pollutants or harmful chemicals.
Home environment is clean and suitable for post-operative recovery.

📄 Page 6 — Physical Examination

General Condition

Patient is conscious, oriented to time, place and person. He appears anxious and uncomfortable due to abdominal pain. Patient prefers lying still with knees flexed to reduce abdominal discomfort.

Vital Signs on Admission

Temperature: 100.4°F
Pulse: 104 beats/min
Respiration: 22 breaths/min
Blood Pressure: 118/76 mmHg
SpO₂: 98% on room air
Pain Score: 8/10

General Appearance

Built: Average
Nutrition: Moderate
Posture: Lying still with flexed knees
Facial expression: Anxious and painful
Skin: Warm, no cyanosis, no pallor, no edema
Hydration: Mild dehydration due to vomiting and reduced intake

Systemic Examination

Abdomen	Tenderness present in right iliac fossa, guarding present, rebound tenderness positive, bowel sounds slightly reduced, no visible distension.
Cardiovascular System	S1 and S2 heard normally, no murmur, pulse 104/min, regular rhythm.
Respiratory System	Chest clear bilaterally, normal vesicular breath sounds, no wheeze or crackles.
Central Nervous System	Conscious, oriented, GCS 15/15, no neurological deficit.
Skin	Skin warm, intact pre-operatively; post-operatively surgical incision present in right lower abdomen with sterile dressing.

📄 Page 7 — Vital Signs Monitoring Record

Date / Time	Temperature	Pulse	Respiration	BP	SpO₂	Pain Score
10/05/2026 — 8:00 AM Admission	100.4°F	104/min	22/min	118/76	98%	8/10
10/05/2026 — 2:00 PM Post-op	99.8°F	96/min	20/min	116/74	99%	6/10
11/05/2026 — 8:00 AM POD 1	99.2°F	88/min	18/min	118/78	99%	4/10
12/05/2026 — 8:00 AM POD 2	98.6°F	82/min	18/min	120/80	99%	2/10
13/05/2026 — Discharge	98.4°F	78/min	16/min	118/76	99%	1/10

Nursing Trend: Patient’s fever, pulse rate and pain score gradually reduced after appendectomy. Vital signs remained stable during post-operative period.

📄 Page 8 — Diagnostic Investigations

Sr. No.	Investigation	Normal Value	Patient Value	Interpretation
1	Hemoglobin	13–17 g/dL	13.8 g/dL	Normal
2	Total WBC Count	4,000–11,000/mm³	14,800/mm³	Elevated due to acute infection/inflammation
3	Neutrophils	40–70%	82%	Neutrophilia
4	Platelet Count	1.5–4 lakh/mm³	2.6 lakh/mm³	Normal
5	Random Blood Sugar	80–140 mg/dL	112 mg/dL	Normal
6	Blood Urea	15–40 mg/dL	28 mg/dL	Normal
7	Serum Creatinine	0.7–1.3 mg/dL	0.9 mg/dL	Normal
8	Serum Sodium	135–145 mEq/L	138 mEq/L	Normal
9	Serum Potassium	3.5–5.0 mEq/L	4.1 mEq/L	Normal
10	Urine Routine	No sugar/protein	Normal	No abnormality
11	Ultrasonography Abdomen	Normal appendix not visualized	Inflamed non-compressible appendix, diameter 8 mm, periappendiceal fat stranding	Suggestive of acute appendicitis
12	Blood Group	-	B Positive	Recorded for surgical safety

📄 Page 9 — Medical & Surgical Management / Drug Chart

Medical Management

Patient was kept NPO after admission to prevent aspiration during emergency surgery.
IV line was secured and intravenous fluids were started to maintain hydration.
Broad-spectrum antibiotics were administered as prescribed to control infection.
Analgesics were given to relieve abdominal and post-operative pain.
Antiemetic medication was given to control nausea and vomiting.
Antipyretic was given for fever management.
Vital signs, abdominal pain, vomiting and hydration status were monitored regularly.
Pre-operative investigations were completed before surgery.

Surgical Management

Name of Surgery: Open Appendectomy
Indication: Acute Appendicitis
Date of Surgery: 10/05/2026
Type of Anesthesia: General Anesthesia
Incision Site: Right lower abdomen / McBurney’s incision
Operative Finding: Inflamed appendix without perforation
Procedure Done: Appendix removed, stump ligated, abdominal cavity inspected, wound closed in layers and sterile dressing applied.
Drain: Not placed
Post-operative Status: Patient shifted to post-operative ward in stable condition.

Pre-operative Nursing Care

Verified patient identity, diagnosis and planned surgical procedure.
Checked informed written consent for surgery and anesthesia.
Maintained NPO status as ordered.
Recorded baseline vital signs and pain score.
Secured IV cannula and administered IV fluids as prescribed.
Administered prescribed antibiotics before surgery.
Removed ornaments, dentures and valuables if present.
Prepared operative site as per hospital protocol.
Encouraged patient to pass urine before shifting to operation theatre.
Provided psychological support and explained procedure in simple language.
Completed pre-operative checklist and shifted patient safely to OT.

Post-operative Nursing Care

Maintained airway, breathing and circulation after surgery.
Monitored vital signs frequently during immediate post-operative period.
Observed surgical dressing for bleeding, soakage and discharge.
Assessed pain score and administered analgesics as prescribed.
Maintained IV fluids until oral intake was allowed.
Observed for nausea, vomiting, abdominal distension and bowel sounds.
Encouraged deep breathing and coughing exercises.
Encouraged early ambulation as tolerated.
Maintained aseptic technique during wound care.
Educated patient regarding wound care, diet, activity and follow-up.

Drug Chart

Drug Name	Dose	Route	Frequency	Purpose	Nursing Responsibility
Inj. Ceftriaxone	1 g	IV	BD	Broad-spectrum antibiotic	Check allergy, administer slowly, monitor rash or diarrhea.
Inj. Metronidazole	500 mg	IV	TDS	Anaerobic infection control	Give slowly, monitor nausea, metallic taste and IV site.
Inj. Pantoprazole	40 mg	IV	OD	Prevents gastric irritation	Administer before meals/early morning, monitor abdominal discomfort.
Inj. Ondansetron	4 mg	IV	SOS/BD	Controls nausea and vomiting	Assess nausea, monitor headache and constipation.
Inj. Paracetamol	1 g	IV	TDS/SOS	Pain and fever relief	Monitor temperature, pain score and total daily dose.
Inj. Tramadol	50 mg	IV/IM	SOS	Moderate to severe post-operative pain	Monitor sedation, dizziness, nausea and respiratory depression.
IV Ringer Lactate	500 ml	IV	As ordered	Maintains hydration and electrolyte balance	Monitor flow rate, IV site, intake-output and signs of overload.
IV Normal Saline	500 ml	IV	As ordered	Fluid replacement	Check patency, monitor input-output and edema.

📄 Page 10 — NANDA Nursing Diagnoses

Sr. No.	NANDA Nursing Diagnosis	Related To	Evidenced By / Risk Factors
1	Acute Pain	Inflammation of appendix and surgical incision	Pain score 8/10 pre-op, guarding, facial grimacing, post-operative wound pain
2	Risk for Infection	Surgical incision and inflammatory abdominal condition	Open appendectomy wound, raised WBC count, invasive procedure
3	Impaired Skin Integrity	Surgical incision and tissue trauma	Incision wound in right lower abdomen with sterile dressing
4	Deficient Knowledge	Lack of information regarding post-operative care, wound care, diet and activity	Patient asks about wound care, diet, bathing and return to college
5	Risk for Constipation	Reduced mobility, anesthesia effect, opioid analgesic and decreased oral intake	Post-operative state, decreased bowel sounds, limited ambulation

Note: Main detailed nursing care plans are prepared for the first three priority diagnoses: Acute Pain, Risk for Infection and Impaired Skin Integrity.

📄 Page 11 — Nursing Care Plan 1: Acute Pain

Assessment	Nursing Diagnosis	Goal / Expected Outcome	Planning	Implementation	Evaluation
Subjective Data: Patient complains, “Mere pet ke right side me bahut dard ho raha hai.” Pain increases during movement and coughing. Objective Data: Pain score 8/10 before surgery and 6/10 after surgery. Facial grimacing, guarding of abdomen, restlessness and surgical incision present in right lower abdomen.	Acute Pain related to inflammation of appendix and surgical tissue trauma as evidenced by verbal complaint of pain, guarding, facial grimacing and pain score 8/10.	Short-Term Goal: Patient will report reduction in pain from 8/10 to 4/10 within 24 hours. Long-Term Goal: Patient will remain comfortable and perform deep breathing, coughing and ambulation with minimal pain before discharge.	Assess pain location, intensity, duration and aggravating factors. Monitor vital signs regularly. Provide comfortable position. Administer analgesics as prescribed. Teach splinting technique during coughing and movement. Promote relaxation and rest.	Assessed pain score using 0–10 pain scale every 4 hours. Observed facial expression, guarding and restlessness. Positioned patient in semi-Fowler’s position with knees slightly flexed. Administered Inj. Paracetamol and Inj. Tramadol as prescribed. Supported incision site with pillow during coughing and movement. Encouraged deep breathing and relaxation exercises. Reduced unnecessary movement during acute pain phase. Reassessed pain after analgesic administration.	Patient reported pain reduction from 8/10 to 3/10 within 24–48 hours. Patient was able to cough, deep breathe and ambulate with minimal discomfort before discharge.

Outcome: Goal achieved. Patient’s pain reduced and comfort improved.

📄 Page 12 — Nursing Care Plan 2: Risk for Infection

Assessment	Nursing Diagnosis	Goal / Expected Outcome	Planning	Implementation	Evaluation
Subjective Data: Patient asks, “Operation ke baad infection to nahi hoga?” Objective Data: Open appendectomy done. Surgical incision present in right lower abdomen with sterile dressing. WBC count 14,800/mm³ before surgery. Low-grade fever present on admission.	Risk for Infection related to surgical incision, tissue trauma, invasive procedure and inflammatory abdominal condition.	Short-Term Goal: Patient will remain free from signs of wound infection during hospitalization. Long-Term Goal: Surgical wound will heal without redness, swelling, pus discharge or fever before follow-up.	Monitor temperature and signs of infection. Observe wound dressing for soakage and discharge. Maintain aseptic technique during wound care. Administer antibiotics as prescribed. Promote hand hygiene. Educate patient about wound infection warning signs.	Monitored temperature, pulse and wound condition regularly. Observed surgical dressing for bleeding, pus, foul smell and excessive soakage. Performed hand hygiene before and after patient care. Maintained aseptic technique during dressing and wound inspection. Administered Inj. Ceftriaxone and Inj. Metronidazole as prescribed. Encouraged adequate fluid intake after oral intake was allowed. Encouraged protein-rich diet to support wound healing. Educated patient to report fever, increased pain, redness, swelling or discharge from wound.	Patient remained afebrile after post-operative day 2. Surgical dressing was dry and clean. No redness, swelling, pus discharge or foul smell was observed. Patient understood infection prevention measures.

Outcome: Goal achieved. No signs of surgical wound infection were observed.

📄 Page 13 — Nursing Care Plan 3: Impaired Skin Integrity / Surgical Wound

Assessment	Nursing Diagnosis	Goal / Expected Outcome	Planning	Implementation	Evaluation
Subjective Data: Patient asks, “Mere operation ke tanke kab theek honge?” Patient reports mild discomfort at incision site. Objective Data: Open appendectomy performed. Surgical incision present in right lower abdomen with sterile dressing. Mild tenderness present around incision site. Dressing dry and intact.	Impaired Skin Integrity related to surgical incision and tissue trauma secondary to appendectomy as evidenced by incision wound in right lower abdomen with sterile dressing.	Short-Term Goal: Patient’s surgical wound will remain clean, dry and intact during hospitalization. Long-Term Goal: Patient will demonstrate proper wound care and incision will show progressive healing without complications.	Assess wound site regularly. Maintain sterile dressing as ordered. Prevent pressure and strain on incision site. Promote adequate nutrition for wound healing. Teach wound care and hygiene. Observe for wound dehiscence and discharge.	Inspected surgical dressing for dryness, soakage and discharge. Maintained aseptic technique during dressing care. Kept wound area clean and dry. Supported incision during coughing, turning and ambulation. Encouraged protein-rich diet including dal, milk, curd, paneer and pulses as tolerated. Advised patient to avoid scratching or touching wound with unclean hands. Educated patient not to lift heavy objects until advised by doctor. Taught signs of wound complications such as redness, swelling, pus discharge, fever and wound opening.	Wound dressing remained clean and dry. No wound dehiscence, pus discharge or excessive redness was observed. Patient verbalized proper wound care instructions before discharge.

Outcome: Goal achieved. Surgical wound remained clean, dry and healing was satisfactory.

📄 Page 14 — Discharge Summary

Patient Name: Mr. Rohit Sharma
Age/Sex: 24 Years / Male
Hospital Name: Government Medical College Hospital, Jodhpur
Ward: Male Surgical Ward
Date of Admission: 10/05/2026
Date of Surgery: 10/05/2026
Date of Discharge: 13/05/2026
Final Diagnosis: Acute Appendicitis
Surgery Performed: Open Appendectomy under General Anesthesia

Summary of Hospital Stay

Mr. Rohit Sharma, a 24-year-old male, was admitted to the surgical ward with complaints of abdominal pain, nausea, vomiting, anorexia and low-grade fever. The abdominal pain initially started around the umbilical region and later shifted to the right lower quadrant. On examination, tenderness and guarding were present in the right iliac fossa with positive rebound tenderness.

Blood investigation showed raised total leukocyte count and neutrophilia. Ultrasonography abdomen showed inflamed non-compressible appendix suggestive of acute appendicitis. The patient was kept NPO, IV fluids and antibiotics were started, and emergency appendectomy was planned after pre-operative preparation and informed consent.

Open appendectomy was performed on 10/05/2026 under general anesthesia. The inflamed appendix was removed, wound was closed in layers and sterile dressing was applied. Post-operatively, the patient was monitored for pain, bleeding, infection, bowel activity and vital signs. The patient’s condition improved gradually. Pain reduced, fever subsided and wound remained clean and dry.

Condition at Discharge

Patient is conscious, oriented and hemodynamically stable.
No fever at the time of discharge.
Pulse: 78/min, BP: 118/76 mmHg, Respiratory rate: 16/min.
SpO₂: 99% on room air.
Pain score: 1/10.
Surgical dressing is clean and dry.
No redness, swelling, pus discharge or wound gaping present.
Patient is able to walk independently.
Patient tolerates soft oral diet.
Patient and family understand discharge instructions.

Discharge Medications

Medication	Dose	Frequency	Purpose
Tab. Cefixime	200 mg	Twice daily for 5 days	Antibiotic
Tab. Metronidazole	400 mg	Three times daily for 5 days	Anaerobic infection control
Tab. Paracetamol	500 mg	SOS after food	Pain and fever relief
Tab. Pantoprazole	40 mg	Once daily before breakfast for 5 days	Gastric protection
Multivitamin	1 tablet	Once daily	General recovery support

Follow-Up Advice

Follow-up in surgical OPD after 7 days for wound inspection and suture removal as advised.
Continue prescribed medicines as directed.
Keep wound clean and dry.
Avoid heavy lifting, running and strenuous activity until doctor permits.
Take soft, easily digestible and protein-rich diet.
Report immediately if fever, severe abdominal pain, vomiting, wound discharge or wound opening occurs.

📄 Page 15 — Health Education

1. Wound Care

Keep the surgical wound clean and dry.
Do not touch the wound with unwashed hands.
Do not remove dressing unless advised by doctor or nurse.
Observe the wound daily for redness, swelling, discharge, foul smell or wound opening.
Visit hospital for dressing and suture removal as advised.

2. Medication Advice

Take antibiotics for the full prescribed course.
Do not skip or stop medicines without doctor’s advice.
Take pain medicine only as prescribed.
Take gastric protection medicine before breakfast if prescribed.
Report allergy symptoms such as rash, itching, swelling or breathing difficulty immediately.

3. Diet Advice

Start with soft and easily digestible food after surgery.
Take small frequent meals instead of heavy meals.
Include protein-rich foods such as dal, milk, curd, paneer, egg or pulses to promote wound healing.
Drink adequate water unless restricted.
Avoid oily, spicy, fried and junk foods during recovery.
Include fruits and vegetables to prevent constipation.

4. Activity and Rest

Take adequate rest during the recovery period.
Walk slowly at home to improve circulation and prevent complications.
Avoid heavy lifting, running, cycling and strenuous exercise until advised by doctor.
Support the incision site while coughing, sneezing or getting up from bed.
Return to college/work only after medical advice.

5. Prevention of Constipation

Drink adequate fluids.
Take fiber-rich foods such as fruits, vegetables and whole grains.
Walk regularly as tolerated.
Do not strain during defecation.
Inform doctor if constipation persists.

6. Warning Signs Requiring Immediate Medical Help

Fever above 100.4°F.
Severe abdominal pain or increasing pain.
Persistent vomiting.
Redness, swelling, pus discharge or foul smell from wound.
Bleeding from wound site.
Wound opening or suture breakage.
Abdominal distension or inability to pass stool/gas.

Patient Teaching Outcome: Patient and family verbalized understanding of wound care, medication, diet, activity restriction, follow-up and warning signs.

📄 Page 16 — Bibliography

Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, Latest Edition, Wolters Kluwer.
NANDA International Nursing Diagnoses: Definitions and Classification 2024–2026.
Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Latest Edition.
Bailey & Love’s Short Practice of Surgery, Latest Edition.
Indian Nursing Council recommended Medical-Surgical Nursing syllabus and clinical practical guidelines.
Hospital surgical nursing care protocols for pre-operative and post-operative care.

⚕️ Medical Disclaimer: This surgical nursing care plan is prepared for educational and academic purposes only for ANM, GNM and BSc Nursing students. It is not intended for actual patient care or clinical decision-making. Always follow hospital protocol, physician orders and standard nursing textbooks.