Back Pain Nursing Diagnosis & Care Plan

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:

1. Assess pain characteristics regularly
   Rationale: Enables appropriate pain management strategies
2. Administer prescribed medications
   Rationale: Provides pain relief and reduces inflammation
3. 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:

1. Assist with gradual mobilization
   Rationale: Prevents deconditioning and promotes independence
2. Teach proper body mechanics
   Rationale: Reduces strain and prevents injury
3. 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:

1. Implement fall precautions
   Rationale: Prevents injury and maintains safety
2. Assess the environment for hazards
   Rationale: Reduces risk of accidents
3. 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:

1. Plan activities with rest periods
   Rationale: Prevents fatigue and promotes participation
2. Gradually increase activity tolerance
   Rationale: Builds endurance safely
3. 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:

1. Promote comfort measures
   Rationale: Enhances sleep quality
2. Establish bedtime routine
   Rationale: Promotes regular sleep patterns
3. 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

1. 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.
2. 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. 
3. 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.
4. Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
5. Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
6. Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
7. 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.
8. Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.