Published Apr 9, 2012
Cass182
1 Post
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!
nurseprnRN, BSN, RN
1 Article; 5,116 Posts
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.
Rebecca929
22 Posts
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!