NCP Notes (3 Column Format)

1. NURSING DIAGNOSIS: Acute Pain related to surgical incision as evidenced by patient-reported pain level of 8/10 and guarding behavior. Supporting Data: - Objective data: Vital signs show elevated heart rate of 110 bpm, blood pressure 150/90 mmHg. Physical assessment reveals tenderness and swelling around the incision site. - Subjective data: Patient reports sharp, throbbing pain at the incision site, rated 8/10 on the pain scale, and states, "It hurts more when I move." 2. OUTCOMES & EVALUATION: The patient will report a pain level of 3/10 or less within 48 hours post-intervention. Expected Outcomes: - Pain relief to a manageable level, allowing for increased mobility and comfort. - Measurable indicators: Patient reports pain level reduction to 3/10 or less, increased ability to perform activities of daily living. Evaluation: - Observed patient response: Pain level reduced to 4/10 after administration of analgesics and repositioning. - Remaining challenges: Patient still experiences discomfort during movement, requiring ongoing pain management. 3. INTERVENTIONS: Assessment Interventions: - Monitor vital signs every 4 hours to assess for changes in pain-related physiological responses. - Observe for signs of pain relief or exacerbation, such as changes in facial expression or movement. Direct Care Interventions: - Administer prescribed analgesics as per physician's orders, ensuring timely pain relief. - Assist with repositioning every 2 hours to alleviate pressure and enhance comfort. Patient Education: - Educate the patient on the importance of reporting pain levels accurately for effective management. - Use simple language and visual aids to explain pain management techniques. Collaborative Interventions: - Consult with the pain management team for potential adjustment of analgesic regimen. - Coordinate with physical therapy to develop a mobility plan that minimizes pain while promoting recovery.