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.
1. NURSING DIAGNOSIS:
[describe the identified nursing diagnosis]
(Clearly state the nursing diagnosis based on patient assessment. Use standardized NANDA-I nursing diagnoses when applicable. Describe the underlying causes, contributing factors, and defining characteristics that justify the diagnosis. Ensure clarity and specificity.)
Supporting Data:
- [Objective data] (List observable and measurable findings such as vital signs, lab results, physical assessment observations, or diagnostic reports.)
- [Subjective data] (Include the patientβs reported symptoms, concerns, or statements relevant to the diagnosis.)
2. OUTCOMES & EVALUATION:
[describe the expected outcomes and how the patientβs progress will be evaluated]
(Define expected improvements in the patientβs condition based on the nursing interventions. Use **specific, measurable, attainable, relevant, and time-bound (SMART)** criteria.)
Expected Outcomes:
- [List expected patient improvements] (Include symptom relief, stabilization of vital signs, improved comfort, or enhanced functional status.)
- [Describe measurable indicators] (State how the patientβs progress will be assessed, such as reduced symptom severity, increased activity tolerance, or patient-reported improvement.)
Evaluation:
- [Describe observed patient response to interventions] (Indicate whether expected outcomes were met, partially met, or unmet.)
- [List remaining challenges] (Identify ongoing symptoms, functional limitations, or areas requiring continued intervention.)
3. INTERVENTIONS:
[list nursing interventions to address the nursing diagnosis and achieve the expected outcomes]
(Provide detailed, structured interventions in bullet points. Include assessment actions, direct care measures, patient education, and collaborative efforts.)
Assessment Interventions:
- [Describe ongoing monitoring activities] (Include frequency and method of tracking patient condition, such as checking vital signs, assessing respiratory function, or monitoring mobility levels.)
- [Describe indicators of progress or deterioration] (List signs that suggest improvement or worsening of the patientβs condition.)
Direct Care Interventions:
- [List nursing actions that directly address the patientβs condition] (Include strategies such as positioning, mobility support, airway management, pain control, or wound care.)
- [Describe any emergency measures if necessary] (Include steps for managing acute deterioration.)
Patient Education:
- [List key teaching topics] (Include information on symptom management, lifestyle modifications, medication adherence, and self-care instructions.)
- [Describe effective communication strategies] (Ensure instructions are tailored to the patientβs literacy level, language, and cultural background.)
Collaborative Interventions:
- [List interdisciplinary care strategies] (Include consultations or referrals to physicians, physical therapists, dietitians, social workers, or other healthcare professionals.)
- [Describe prescribed treatments, therapies, or medications] (Include dosage, administration guidelines, and necessary monitoring.)
(Use as many lines, paragraphs, or bullet points as needed to comprehensively document the nursing care plan. Never come up with your own patient details, assessment, plan, interventions, or evaluationβuse only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, do not state that the information has not been explicitly mentioned in your outputβjust leave the relevant placeholder blank or omit it completely.)
