I'm a first semester nursing student and I'm writing a nursing diagnosis for my patient. She has chronic back pain caused by a Fx to her dorsal and lumbar vertabra. I wrote my diagnosis like this,
Chronic pain related to compression of the spine as evidence by client rating pain an 8 on a scale of 1-10, client grimacing and showing great difficulty while standing and sitting, an exaggerated rounding of her back, and the medical chart stating a prior fracture to the dorsal and lumbar vertebra.
Does that sound alright? I'm still very new at writing these and I'm not sure what I can and cannot use for related to and as evidence by factors. Thanks in advance!
Apr 9, '12
sounds perfect. my compliments to your faculty.
there are those who say you cannot mention a medical diagnosis when you write your nursing diagnoses. however, since nanda-i is not among them (many, many nursing diagnoses have a medical diagnosis as one of many defining factors), i would ignore that when you hear it.
Apr 9, '12
This may be the way I was taught but we have always had to use a pain scale of 0-10. Although your patient's diagnosis is chronic pain, it is possible for another client to experience a "zero" or no pain. Good job though!