Help with a care plan

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Specializes in telemetry.

I am working on a care plan for a patient, and have to come up with anywhere from 6 to 8 diagnoses, and work up the top 2 plus whatever other one that I want. I believe that the priority for the patient is the chronic pain that he experiences, but I am not sure how to word it. I have the actual diagnosis and the AMB, but am trying to figure out the best reason. He has osteoarthritis in his shoulders, but also has leukemia which could be referenced. The problem is, wouldn't both of those be considered a medical diagnosis? How should it be worded to not be "medical"? Any advice would be appreciated - Thanks!

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Chronic pain

related to tissue damage,joint damage, whatever is damaged, or tumor progression and related pathology

secondary to osteoarthritis, leukemia, whatever his medical diagnosis is

as evidenced by patient reporting pain of ___ out of 10 on the pain scale.

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you can use medical diagnoses. i had a careplan a few weeks ago that was something like "chronic pain r/t metastatic carcinoma AEB pt's verbal report of pain"

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Specializes in telemetry.

Thank you so much for your help guys. I appreciate it greatly. Unfortunantely, my instructors are sticklers on the no medical diagnoses rule and will mark you off if you use them so I am trying to get around that as much as possible. Thanks again everyone, I appreciate it!

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You can (and should when possible) use the medical diagnosis in the secondary to part, making it a true 4 part statement.

Thank you so much for your help guys. I appreciate it greatly. Unfortunantely, my instructors are sticklers on the no medical diagnoses rule and will mark you off if you use them so I am trying to get around that as much as possible. Thanks again everyone, I appreciate it!
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Specializes in Pediatric Hem/Onc.

Why can't you use the medical diagnosis in a 4 part statement? As far as I know, that's acceptable.

Chronic pain r/t joint damage secondary to osteoarthritis AMB... or Chronic pain r/t localized masses secondary to leukemia AMB...

That second one was flimsy :) but you get the idea

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