Download Nursing Care Plan Migraine Headache-Acute Pain (1)...
Description
CUES
Nursing Diagnosis
Scientific Explanation
Planning
S=none
Acute Pain
The pt. is experiencing a migraine headache attack. Migraine causes unilateral pain that can debilitate a person significantly. Migraine causes are not accurate and the key to avoidance of attacks is avoidance of certain “triggers”. In the client’s case, a certain trigger precipitated a migraine attack causing Acute Pain.
SHORT TERM: After 2-4 hrs. of Ni, the pt. will display reduction of pain from a scale of 8/10 to 3-4.
>establish rapport
>to gain cooperation and trust from client
>monitor vital signs and perform preliminary assessment
>to obtain baseline and assess possible areas of immediate intervention
>identify pathology involved and possible migraine triggers
>to identify underlying cause and educate client for possible avoidance of personal migraine triggers
LONG TERM: After 2-3 days of NI, the pt. will identify personal triggers to avoid having migraine attacks and successfully be headache-free.
>determine if migraine has aura
>provides opportunities for medication prophylaxis
>assess for provocative factors for pain
>to determine possible contributing causes and plan to avoid them
>assess pain quality
>the quality of the pain indicates need for intervention. A sensation of and “ice pick puncture” may be a ruptured cerebral aneurysm.
>assess the pain’s radiation
>referred pain may ensure, providing clues for problems in other body sections
>assess for the pain’s severity
>determines the need for pharmacotherapy
O=>presence of: >photophobia >irritability >sensitivity to smells especially sweet scents >unilateral pain on the left side of the head with pain scale of 8/10 characterized as dull, aggravated by movement and relieved by rest and medication, onset is at 12noon today. >nausea
Intervention
Rationale
Expected Outcome SHORT TERM: After 2-4 hrs. of Ni, the pt. shall have displayed reduction of pain from a scale of 8/10 to 3-4.
LONG TERM: After 2-3 days of NI, the pt. shall have identified personal triggers to avoid having migraine attacks and successfully be headache-free.
>assess for the pain’s time of onset
>ask what the client has done to relieve pain
>accept the client’s description of pain
>note for non-verbal cues such as protection of painful part >allow to verbalize feelings of pain
>educate client about underlying pathology
>the onset of the pain is important. It determines the need for prompt intervention especially if the pain does not respond to treatment. >clients respond to pain management in a varying spectrum. Ask what has been effective for him >only the client feels the pain. Never assume. >correlates non-verbal to verbal responses
>to allay anxiety and provide psychological relief; relieves tension >to provide client with understanding of pathology and address queries; enhances participation
>involve significant others in care
>significant others may be barriers or support persons in care. Involve them
>provide a dimly-lit room
>to address underlying photophobia and prevent aggravation of pain
>provide a quiet and restful environment
>use diversion activities such as watching TV, listening to music, sharing stories
>to provide opportunities for sleep and rest and prevent fatigue; reduces oxygen demand as well >to divert attention away from pain
>instruct on relaxation activities such as deep breathing exercises
>to reduce tension and provide nonpharmacologic pain relief
>massage large muscles
>to promote closure of pain tracks towards the brain
>remove scents from client’s room >administer analgesics as ordered
>to prevent further nausea >to provide pharmacological pain relief
Thank you for interesting in our services. We are a non-profit group that run this website to share documents. We need your help to maintenance this website.