nanda allows for two-part and three-part nursing diagnosis statements. most nursing schools want their students to use three-part nursing diagnostic statements so that students become familiar with the construction of the statement as well as develop an understanding of how all the elements are related and fit together. nanda currently has 172 approved nursing diagnoses of which acute pain is one. they have given it a definition and assigned related factors (causes of the pain) and developed a list of defining charactersitics (symptoms of the acute pain). when you are first learning to work with a nursing diagnosis you should try to use these are guidelines for writing you nursing diagnoses.
remember that your care plan is merely the written expression of the nursing process. step #1 is the assessment of the patient and collection of data. step #2 is to look at the abnormal data and use it to formulate nursing diagnoses. your abnormal assessment data on this patient is "patient's statement of 10/10 pain
". in the nanda world this is called a defining characterisitc
. in the nursing diagnostic statement this kind of information always follows the words "as evidenced by", "as manifested by", or something similar. your instructors want you to use e/b. that's what you should use.
the related factor
is the part of your nursing diagnostic statement that is giving you trouble. related factors are what is causing
the nursing diagnosis, in this case, acute pain. so, you must ask "is altered comfort (secondary to vascular surgery) causing acute pain"? does that question make sense to you? what is
causing the patient to have pain? well, he had surgery where his skin and tissues were cut into. this would have set off an inflammatory response in his body resulting, among other things, some swelling of the involved tissues that pushed on some nerves setting them off and telling the brain, "ouch!" so, the cause
of the patient's acute pain is surgical disruption of tissues. now, if you ask "is surgical disruption of tissues causing acute pain?" the answer is yes. usually, when you qualify the related factor, you do it with a medical diagnosis, rather than a procedure. so, the complete part of this section of the nursing diagnostic statement should read "surgical disruption of tissues secondary to ? medical diagnosis
(you need to fill in the correct medical diagnosis)".
now, you have a good nanda three part nursing diagnostic statement that looks like this:
- acute pain r/t surgical disruption of tissues s/t ? m/b patient's statement of 10/10 pain
the guideline for constructing a three part nursing diagnostic statement is pes. problem-etiology(cause)-symptom. in this case:
- problem: pain
- etiology: surgical disruption of tissues
- symptom: pain level of 10/10
your school uses e/b rather than m/b because that is what some of the instructors at one time decided to use. this is not a big deal. just follow the rules you are being given. your grade may depend on it. it is more important that you understand what the related factors and defining characteristics are and get them correct.
now, go to these links and read about this nursing diagnosis, it's definition, related factors, defining characteristics, outcomes and nursing interventions: