35410328 Ncp Headache

Gracielle Marie E. Dideles Nursing Care Plan for Migraine Headache Diagnosis/Cue

Need

Desired outcomes

Nursing Intervention

Acute Pain r/t decreased cerebral blood flow secondary to migraine as manifested by guarding behavior , facial grimace and pallor 

P H Y S I O L O G I C

After 4 hours of nursing interventions, the patient will be able to;

INDEPENDENT

SUBJECTIVE CUES: verbalized “I feel like my head is being crumpled from the inside and banged on a hard surface repetitively.”

assess 1. assess

General: Become relieved of signs and symptoms of pain experienced as evidenced by: •

2. Specific: Verbalize pain is • relieved (rate pain from 0-4 out of 10)

Rationale

Evaluation statement

1.

contr contribu ibutin tingf  gf  actors to pain (ingestion of tyraminecont contai aini ning ng food foods, s, bright lights and stro strong ng fume fumes s from from cleansing materials)

to determine determine underlying underlying cause of pain and treat accordingly.

review regimen

2.cer 2.certa tain in drug drugs s may may fatigue and drowsiness.

medication

3. ask client to rate pain

on 0-10 0-10 scale scale (rated (rated as 9 out of 10)

caus cause e

to assist assist in evalua evaluatin ting g 3. impact of pain on client’s life.

Goal met. Patient verbalized verbalized “I feel better. My head head isn’t isn’t throbb throbbing ing anymore” rated pain as 0 out of 10.

OBJECTIVE CUES: Rated pain as 9 out of 10 Facial grimace

•

Gurading behavior  (clutches head and assumes fetal position)

Demonstrate use of diversional activities such as relaxing and/or  sleeping

Palmar and facial pallor. T: 37.2

•

Rest and feel rested after 

4.

provide comfort meas measur ures es such such as repositioning the client in a comfortable position and providing a hot or cold compress

to allow 4. nonpharmocological nonpharmocological pain relief  and promote good circulation to Goal Goal met. met. Pati Patien entt was was the brain and decrease able to relax relax by utilizing utilizing vasoconstriction bed rest and deep breathing.

5.

provide calm and quie quiett envi enviro ronm nmen entt (adjust lights, temperature and elim elimin inat ate e offe offens nsiv ive e odors which may contribute to

to 5. enviro environme nmenta ntall contr contribu ibute te to to promote rest.

decrease factor factors s which which migrai migraine ne and and Goal Goal met. met. Pati Patien entt was was able to sleep for 6 hours

P; 86 bpm R: 22 cpm BP: 130/90 mmHg BACKGROUND KNOWLEDGE: Acute pain is an unpleasant sensory and emotional experience arising from actual or  potential tissue damage or described in terms of such damage; sudden or  slow onset of any intensity from mild to severed with an anticipated or  predictable end and a duration of less than 6 months. When migraine or any other  types of headaches are diagnosed, the goals of nursing management is to enhance pain relief. It is reasonable to try nonpharmacologic interventions first, but the use of  pharmacologic interventions must not be delayed. The goal is to treat the acute event of the headache and to prevent recurrent

adequate rest interval

headache) 6. instructe in relaxation techniques (deep breathing, imagery)

•

Utilize nonpharmacological methods of pain relief ( deep breathing, guided imagery, etc)

6.

to distract attention from pain and decrease tension

7. encrourage adequate rest periods 7.

to conserve energy of the patient and prevent fatigue 8.

•

straight and felt rested afterwards.

Goal met. Client was able to use deep breathing and reported pain relief  afterwards.

assist in self-care activities as tolerated 8.

Be able to perform ADLs as tolerated 9. provide peaceful \and

adequate resting environment (dim lights, adjust temperature, wrinklefree bed, quiet surroundings)

To promote client independence as much as possible and acquire sense of  function

9.to enhance quality sleep and promote rest which harnesses energy for future use.

COLLABORATIVE: 1. administer   medications as ordered by physician (analgesics, etc)

2.

watchers

encourage to assist

1. medications will provide synergistic effect with nonphramacologic interventions for pain relief  and promote better   circulation by aiding in vasodilation for better blood flow to the brain and altering prostaglandin synthesis to decrease pain

Goal met. Client was to perform ADLs minimal assistance watchers (feeding, care, etc)

able with from self-

episodes. SOURCE: Nurse’s Pocket Guide: Diagnoses, prioritized interventions and rationales 11th Ediction by Marilynn Doenges Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 11th Edition by Suzanne C. Smeltzer 

patient during diversional activities (minimize noise, allow client to verbalize feelings and promote rest and sleep)

2. the significant others know the client more and will be able to aid in diverting client’s attention from pain.