Back pain is a common health concern that can significantly impact a patient’s quality of life and daily activities. This nursing diagnosis focuses on identifying and managing back pain symptoms, preventing complications, and promoting optimal recovery.
Causes (Related to)
Back pain can affect patients in various ways, with several factors contributing to its severity and progression:
- Musculoskeletal conditions
- Nerve compression or damage
- Degenerative disc disease
- Trauma or injury
- Poor posture or body mechanics
- Medical conditions such as:
- Herniated disc
- Spinal stenosis
- Osteoarthritis
- Fibromyalgia
- Pregnancy
- Lifestyle factors including:
- Sedentary behavior
- Obesity
- Occupational strain
- Improper lifting techniques
Signs and Symptoms (As evidenced by)
Back pain presents with distinctive signs and symptoms that nurses must recognize for proper diagnosis and treatment.
Subjective: (Patient reports)
- Localized or radiating pain
- Muscle stiffness
- Limited range of motion
- Numbness or tingling
- Sleep disturbance
- Anxiety about movement
- Impact on daily activities
Objective: (Nurse assesses)
- Altered gait pattern
- Muscle guarding
- Postural changes
- Decreased range of motion
- Signs of nerve compression
- Positive straight leg raise test
- Pain with movement
Expected Outcomes
The following outcomes indicate successful management of back pain:
- The patient will report decreased pain levels
- The patient will demonstrate proper body mechanics
- The patient will maintain optimal mobility
- The patient will perform ADLs independently
- The patient will verbalize understanding of pain management strategies
- The patient will avoid complications
- The patient will return to normal activities as tolerated
Nursing Assessment
Pain Assessment
- Evaluate pain characteristics
- Document pain intensity
- Note aggravating and relieving factors
- Assess the impact on daily activities
- Monitor response to interventions
Physical Assessment
- Observe posture and gait
- Assess range of motion
- Evaluate muscle strength
- Check for neurological symptoms
- Document skin integrity
Functional Assessment
- Evaluate mobility status
- Assess ability to perform ADLs
- Document activity tolerance
- Note the use of assistive devices
- Monitor safety awareness
Psychosocial Assessment
- Assess anxiety levels
- Evaluate coping mechanisms
- Document social support
- Note the impact on quality of life
- Monitor sleep patterns
Risk Assessment
- Review medical history
- Document occupational factors
- Assess lifestyle habits
- Note previous injuries
- Evaluate environmental hazards
Nursing Care Plans
Nursing Care Plan 1: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to musculoskeletal condition as evidenced by verbal reports of pain intensity 7/10 and altered mobility.
Related Factors:
- Tissue inflammation
- Muscle tension
- Nerve compression
- Physical deconditioning
Nursing Interventions and Rationales:
- Assess pain characteristics regularly
Rationale: Enables appropriate pain management strategies - Administer prescribed medications
Rationale: Provides pain relief and reduces inflammation - Teach non-pharmacological pain management
Rationale: Promotes self-management and reduces medication dependence
Desired Outcomes:
- The patient will report decreased pain intensity
- The patient will demonstrate effective pain management techniques
- The patient will maintain the optimal comfort level
Nursing Care Plan 2: Impaired Physical Mobility
Nursing Diagnosis Statement:
Impaired Physical Mobility related to pain and muscle weakness as evidenced by difficulty with position changes and decreased range of motion.
Related Factors:
- Musculoskeletal impairment
- Pain with movement
- Decreased muscle strength
- Fear of movement
Nursing Interventions and Rationales:
- Assist with gradual mobilization
Rationale: Prevents deconditioning and promotes independence - Teach proper body mechanics
Rationale: Reduces strain and prevents injury - Implement exercise program as ordered
Rationale: Improves strength and flexibility
Desired Outcomes:
- The patient will demonstrate improved mobility
- The patient will perform ADLs independently
- The patient will use proper body mechanics
Nursing Care Plan 3: Risk for Falls
Nursing Diagnosis Statement:
Risk for Falls related to impaired mobility and altered gait pattern as evidenced by unsteady movement and use of assistive devices.
Related Factors:
- Altered balance
- Muscle weakness
- Pain with movement
- Environmental hazards
Nursing Interventions and Rationales:
- Implement fall precautions
Rationale: Prevents injury and maintains safety - Assess the environment for hazards
Rationale: Reduces risk of accidents - Teach safe transfer techniques
Rationale: Promotes independence while maintaining safety
Desired Outcomes:
- The patient will remain free from falls
- The patient will demonstrate safe mobility
- The patient will identify and minimize fall risks
Nursing Care Plan 4: Activity Intolerance
Nursing Diagnosis Statement:
Activity Intolerance related to pain and decreased mobility as evidenced by fatigue with activity and limited participation in ADLs.
Related Factors:
- Physical deconditioning
- Pain with movement
- Muscle weakness
- Reduced endurance
Nursing Interventions and Rationales:
- Plan activities with rest periods
Rationale: Prevents fatigue and promotes participation - Gradually increase activity tolerance
Rationale: Builds endurance safely - Monitor response to activity
Rationale: Ensures appropriate activity progression
Desired Outcomes:
- The patient will demonstrate improved activity tolerance.
- The patient will participate in daily activities
- The patient will maintain energy conservation
Nursing Care Plan 5: Disturbed Sleep Pattern
Nursing Diagnosis Statement:
Disturbed Sleep Pattern related to chronic pain and discomfort as evidenced by difficulty maintaining sleep and daytime fatigue.
Related Factors:
- Physical discomfort
- Anxiety
- Poor positioning
- Pain with movement
Nursing Interventions and Rationales:
- Promote comfort measures
Rationale: Enhances sleep quality - Establish bedtime routine
Rationale: Promotes regular sleep patterns - Teach relaxation techniques
Rationale: Reduces anxiety and promotes rest
Desired Outcomes:
- The patient will report improved sleep quality
- The patient will demonstrate adequate rest periods
- The patient will identify effective comfort measures
References
- Alfalogy E, Mahfouz S, Elmedany S, Hariri N, Fallatah S. Chronic Low Back Pain: Prevalence, Impact on Quality of Life, and Predictors of Future Disability. Cureus. 2023 Sep 22;15(9):e45760. doi: 10.7759/cureus.45760. PMID: 37872924; PMCID: PMC10590648.
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- George SZ, Fritz JM, Silfies SP, Schneider MJ, Beneciuk JM, Lentz TA, Gilliam JR, Hendren S, Norman KS. Interventions for the Management of Acute and Chronic Low Back Pain: Revision 2021. J Orthop Sports Phys Ther. 2021 Nov;51(11):CPG1-CPG60. doi: 10.2519/jospt.2021.0304. PMID: 34719942; PMCID: PMC10508241.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Mauck MC, Aylward AF, Barton CE, Birckhead B, Carey T, Dalton DM, Fields AJ, Fritz J, Hassett AL, Hoffmeyer A, Jones SB, McLean SA, Mehling WE, O’Neill CW, Schneider MJ, Williams DA, Zheng P, Wasan AD. Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach. Pain Rep. 2022 Sep 30;7(5):e1019. doi: 10.1097/PR9.0000000000001019. PMID: 36203645; PMCID: PMC9529058.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
