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    Nursing Care Plan Migraine Headache-Acute Pain

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    William Oz Cifer
    The patient is experiencing an acute migraine headache with unilateral left-sided pain rated 8/10, photophobia, irritability, and nausea. The nursing diagnosis is acute pain. The migraine was likely triggered by an unknown factor and causes significant debilitating pain. The short-term goal is to reduce the patient's pain level to 3-4/10 within 2-4 hours through nursing interventions including medication, rest, and establishing rapport. The long-term goal is for the patient to identify personal triggers to avoid future migraines and be headache-free after 2-3 days of nursing care.

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    Nursing Care Plan Migraine Headache-Acute Pain

    Uploaded by

    William Oz Cifer
    64K views3 pages
    The patient is experiencing an acute migraine headache with unilateral left-sided pain rated 8/10, photophobia, irritability, and nausea. The nursing diagnosis is acute pain. The migraine was likely triggered by an unknown factor and causes significant debilitating pain. The short-term goal is to reduce the patient's pain level to 3-4/10 within 2-4 hours through nursing interventions including medication, rest, and establishing rapport. The long-term goal is for the patient to identify personal triggers to avoid future migraines and be headache-free after 2-3 days of nursing care.

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    ncp for headaches

    Original Title

    Nursing Care Plan Migraine Headache-Acute Pain (1)

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    The patient is experiencing an acute migraine headache with unilateral left-sided pain rated 8/10, photophobia, irritability, and nausea. The nursing diagnosis is acute pain. The migraine was likely triggered by an unknown factor and causes significant debilitating pain. The short-term goal is to reduce the patient's pain level to 3-4/10 within 2-4 hours through nursing interventions including medication, rest, and establishing rapport. The long-term goal is for the patient to identify personal triggers to avoid future migraines and be headache-free after 2-3 days of nursing care.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    64K views3 pages

    Nursing Care Plan Migraine Headache-Acute Pain

    Uploaded by

    William Oz Cifer
    The patient is experiencing an acute migraine headache with unilateral left-sided pain rated 8/10, photophobia, irritability, and nausea. The nursing diagnosis is acute pain. The migraine was likely triggered by an unknown factor and causes significant debilitating pain. The short-term goal is to reduce the patient's pain level to 3-4/10 within 2-4 hours through nursing interventions including medication, rest, and establishing rapport. The long-term goal is for the patient to identify personal triggers to avoid future migraines and be headache-free after 2-3 days of nursing care.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    The passage discusses nursing diagnoses, planning, interventions and expected outcomes for a patient experiencing an acute migraine headache.

    Nursing interventions discussed include establishing rapport, monitoring vital signs, identifying migraine triggers, providing pharmacological pain relief with analgesics, and educating the patient about their condition.

    Assessments that should be performed include assessing the quality, location, severity and onset of the pain, what relieves the pain, and looking for non-verbal pain cues.

    CUES S=none 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

    Nursing Diagnosis Acute Pain

    Scientific Explanation 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 clients case, a certain trigger precipitated a migraine attack causing Acute Pain.

    Planning SHORT TERM: After 2-4 hrs. of Ni, the pt. will display reduction of pain from a scale of 8/10 to 3-4.

    Intervention >establish rapport

    Rationale >to gain cooperation and trust from client >to obtain baseline and assess possible areas of immediate intervention >to identify underlying cause and educate client for possible avoidance of personal migraine triggers >provides opportunities for medication prophylaxis >to determine possible contributing causes and plan to avoid them >the quality of the pain indicates need for intervention. A sensation of and ice pick puncture may be a ruptured cerebral aneurysm.

    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.

    >monitor vital signs and perform preliminary assessment >identify pathology involved and possible 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

    >assess for provocative factors for pain

    >assess pain quality

    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 the pains radiation

    >referred pain may ensure, providing clues for problems in other body sections >determines the need for pharmacotherapy

    >assess for the pains severity

    >assess for the pains time of onset

    >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

    >ask what the client has done to relieve pain

    >accept the clients description of pain

    >note for non-verbal cues such as protection of painful part >allow to verbalize feelings of pain

    >to allay anxiety and provide psychological relief; relieves tension >to provide client with understanding of pathology and address queries; enhances participation >significant others may be barriers or support persons in care. Involve them >to address underlying photophobia and prevent aggravation of pain

    >educate client about underlying pathology

    >involve significant others in care

    >provide a dimly-lit room

    >provide a quiet and restful environment

    >to provide opportunities for sleep and rest and prevent fatigue; reduces oxygen demand as well >to divert attention away from pain

    >use diversion activities such as watching TV, listening to music, sharing stories >instruct on relaxation activities such as deep breathing exercises

    >to reduce tension and provide nonpharmacologic pain relief >to promote closure of pain tracks towards the brain >to prevent further nausea >to provide pharmacological pain relief

    >massage large muscles

    >remove scents from clients room >administer analgesics as ordered

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