NCP-Headache - NCP PDF

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HEADACHE ASSESSMENT

NURSING DIAGNOSIS

PLANNING AND IMPLEMENTATION GOALS AND OBJECTIVES

SUBJECTIV E DATA: “Nung 3rd trimester ko, dumalas ang pagsakit ng ulo ko parang may tumitibok sa Sa right side ng muka, tuwing hapon at gabi” As verbalized by the patient. -Stress - Poor lifestyle Activity OBJECTIVE DATA: -Vital signs BP: 110/80 mmhg RR: 22 PR: 103 -Pain scale of 6/10 -Facial

Acute pain related to headache evidence by stress, pulsating sensation and pain scale of 6/10

INTERVENTION

EVALUATION RATIONALE

After 5 days of 3 hours of nursing intervention, goals are fully met. The client was able to report decrease sensation and non- recurrence of pain as evidenced by:

Goals: Within 30-1 hours of nursing intervention, the client will be able to report decrease of pain.

> Pain scale of 3 out of 10 (short term) > Pain scale of 0 out of 10 (long term) > Verbalized adequate rest period and provide calm environment. (Independent) Objectives: > Verbalized use of relaxation technique and 1. The mother will - Perform pain assessment to -To determine and rule out diversional activity. verbalize attributes evaluate characteristic of pain. worsening of underlying condition or > Absence of facial of pain. Note and investigate changes development of complications grimace from previous reports > Recorded pre-natal - Monitor vital signs Ref: Doenges, M., Moorhouse, M.F., Visit. Murr, A. (2008). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales. (10th Edition), p.389 Within 1-2 days of nursing intervention, the client will be able to verbalize relieve of pain.

2. The mother and the significant others will demonstrate use of relaxation skills and diversional

- Perform comfort steps such as repositioning the client in a relaxed position. - Advice breathing technique, massage, imagery. - Applying cold compress on

- To promote non-pharmacological pain management and reduce tension Ref: Doenges, M., Moorhouse, M.F., Murr, A. (2008). Nurse’s Pocket Guide: Diagnoses, Prioritized

grimace -

activities.

Interventions, and Rationales. (10th head and neck. Edition), p.390 - Manage stress by finding ways to cope with stressor. (e.g through pet socialize with family.

2. The mother will - Promote wellness (Teaching be able to display Considerations): - Encourage adequate rest improvement in periods. Follow a regular mood and action sleep schedule - Provide calm and quite environment - Avoid exposure to radiation. (e.g avoid too much usage of cellphone and television) - Include physical activity in daily routine. Try a daily walk or other moderate aerobic exercise. - Increased intake of food and drink plenty of water. 4. The mother will - Advice the mother to recognize if promptly to see doctor if there immediate action is are severe headaches. needed by a professional.

- To prevent fatigue that can lead to headache Ref: Doenges, M., Moorhouse, M.F., Murr, A. (2008). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales. (10th Edition), p.390

- For further assessment and possible medication applicable for pregnant woman. Ref: National Center for Biotechnology Information, U.S. National Library of Medicine 8600 Rockville Pike, Bethesda MD, 20894 USA Retrieved from https://www.ncbi.nlm.nih.gov/books/ NBK83253

(Collaborative) 5. The mother will - Refer to health care centers for - To capture potential problems early be able to appreciate pre-natal care throughout and reducing the risk of pregnancy the significance of pregnancy. and birth complications. regular pre-natal Kim Tustison,MD “UCR Women’s visit. Health OB/Gyn” Retrieved from: https://www.ucrhealth.org/2018/07/he althy-pregnancy-the-importance-ofprenatal-care/

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