January 15, 2050

Patient recovering from abdominal surgery, experiencing mild pain (3/10).

Acute pain related to surgery.

Administer prescribed analgesics as per doctor’s order.

Pain reduced to 0-2/10 within 2 hours.

January 16, 2050

Surgical site clean, no signs of infection. Swelling present but manageable.

Risk for infection related to surgical incision.

Monitor the incision site for signs of infection, ensure sterile dressing changes.

No signs of infection within 48 hours.

January 17, 2050

Patient reports increased mobility, able to sit up for 15 minutes.

Impaired physical mobility related to pain and surgery.

Encourage gradual ambulation, provide physical therapy sessions.

Able to walk 10-15 feet independently by January 20, 2050.

January 18, 2050

Patient reports no new pain, sleeping through the night.

Anxiety related to surgery recovery.

Provide emotional support, reassure the patient, encourage deep breathing exercises.

Decrease in anxiety, patient reports feeling more relaxed by January 19, 2050.

January 20, 2050

Patient feels confident with mobility, walking short distances without pain.

Knowledge deficit regarding post-operative care.

Educate patient on signs of infection, pain management, and activity restrictions.

Patient verbalizes understanding and adherence to care instructions.