Nursing Care Plan Documentation (4 Column Layout) Template

1. NURSING DIAGNOSIS:  
Acute Pain associated with surgical incision as indicated by patient-reported pain level of 8/10 and protective behavior.
Supporting Data:  
- Objective data: Vital signs indicate an increased heart rate of 110 bpm, blood pressure at 150/90 mmHg. Physical examination shows tenderness and swelling around the incision area.  
- Subjective data: Patient describes sharp, throbbing pain at the incision site, exacerbated by movement.
2. GOALS & OUTCOMES:  
Anticipated patient outcomes include decreased pain level and enhanced mobility within 48 hours.
Short-Term Goals:  
- Achieve a pain level of 4/10 or less within 24 hours.  
- Patient will walk 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 carry out activities of daily living (ADLs) within two weeks.
3. INTERVENTIONS:
Assessment Interventions:  
- Monitor vital signs every 4 hours.  
- Evaluate pain level using a numeric scale every 2 hours.
Direct Care Interventions:  
- Administer prescribed pain medications as scheduled.  
- Assist with repositioning every 2 hours to reduce pressure on the incision site.
Patient Education:  
- Educate patient on the significance of pain management and medication adherence.  
- Instruct on deep breathing exercises to support relaxation and pain control.
Collaborative Interventions:  
- Consult with the pain management team for possible adjustment of pain medication regimen.  
- Coordinate with physical therapy for mobility exercises.
4. EVALUATION:
Achieved Goals:  
- Pain level decreased to 4/10 within 24 hours.
Partially Achieved Goals:  
- Patient walked 5 feet with assistance, showing progress but needing further intervention.
Unmet Goals:  
- Pain level remains above 2/10 after one week due to patient noncompliance with medication schedule.  
- Recommend increased patient education on medication adherence and consider alternative pain management strategies.