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 2 Articles; 5,114 Posts Apr 9, 2012 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 Apr 10, 2012 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!
