NCP Notes (4 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, worsened by movement. 2. GOALS & OUTCOMES: Expected patient outcomes include reduction in pain level and improved mobility within 48 hours. Short-Term Goals: - Achieve a pain level of 4/10 or less within 24 hours. - Patient will ambulate 10 feet with assistance by the end of the day. Long-Term Goals: - Patient will report a pain level of 2/10 or less within one week. - Patient will independently perform activities of daily living (ADLs) within two weeks. 3. INTERVENTIONS: Assessment Interventions: - Monitor vital signs every 4 hours. - Assess pain level using a numeric scale every 2 hours. Direct Care Interventions: - Administer prescribed analgesics as per schedule. - Assist with repositioning every 2 hours to alleviate pressure on the incision site. Patient Education: - Educate patient on the importance of pain management and medication adherence. - Instruct on deep breathing exercises to aid in relaxation and pain control. Collaborative Interventions: - Consult with the pain management team for potential adjustment of analgesic regimen. - Coordinate with physical therapy for mobility exercises. 4. EVALUATION: Achieved Goals: - Pain level reduced to 4/10 within 24 hours. Partially Achieved Goals: - Patient ambulated 5 feet with assistance, indicating progress but requiring further intervention. Unmet Goals: - Pain level remains above 2/10 after one week due to patient noncompliance with medication schedule. - Suggest increased patient education on medication adherence and consider alternative pain management strategies.