University:
West Coast University
Course:
NURS 122 | Introduction to Medical Surgical Nursing
Academic year:

2020
Views:

471

Pages:

3
Author:

Marin Mason

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 Goals: 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: Within 30-1 hours of nursing intervention, the client will be able to report decrease of pain. Within 1-2 days of nursing intervention, the client will be able to verbalize relieve 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 - Perform pain assessment to -To determine and rule out 1. The mother will diversional activity. verbalize attributes evaluate characteristic of pain. worsening of underlying condition or > Absence of facial of pain. grimace Note and investigate changes development of complications 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 - Perform comfort steps such 2. The mother and as repositioning the client in a the significant relaxed position. others will demonstrate use of - Advice breathing technique, relaxation skills and massage, imagery. - Applying cold compress on diversional - 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. head and neck. Interventions, and Rationales. (10th - Manage stress by finding Edition), p.390 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. - 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 4. The mother will - Advice the mother to - For further assessment and possible recognize if promptly to see doctor if there medication applicable for pregnant immediate action is are severe headaches. woman. needed by a professional. (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 visit. -