Group Members: Vhince Pisco, Hyde Bacalucos,Rosa Mae Gumilo, Krystal Jane Salinas
Year and Section: III - A
ASSESSMENT
Subjective Cues:
The client verbalized "Ni-sakit akung
ulu kaganiha katung pagmata naku."
"I had headache when I woke up"
The patient verbalized "Sakit, pero
inig makainum na ku ug kape mawala
na intawun"
"It hurts, but if I already took my
coffee, the pain subsides"
Objective Cues:
BP: 130/80 mmHg
Client reports radiating pain in the
left temporal part of the head
Client is rubbing her head
Client is holding her efficascent.
NURSING CARE PLAN
NURSING PLANNING WITH RATIONALE IMPLEMENTATION EVALUATION
DIAGNOSIS
Acute Pain related After four hours of nursing intervention the client • Goal Met
will be expected to manifest improvements as
to Increased evidenced by: After four hours of
nursing intervention the
cerebral vascular •Client will report relief of pain/discomfort. patient was able to
pressure display improvement as
•Rationale: The verbal cue of the client about the evidenced by:
dissipation of the headache will confirm that the
headache has already subsided. • Let the client take her •The client took her
maintenance medicine. medication.
•Encourage and maintain • The client verbalized
•Client will verbalize methods that provide relief. bed rest during acute that the pain already
phase especially if the subsided and she no
•Rationale: The methods that the client was able episode occurs in the longer feels radiating
to mention will be used to manage the headache morning before the client pain.
the next time it will appear again. goes to work.
BP: 130/80 mmHg
•Recommend methods of
relief, such as neck and • The client successfully
•Client will appear comfortable and pain-free. back rubs, applying cool identified and recalled
cloths to the forehead, and four methods to
•Rationale: The general appearance of the client avoiding bright lights and minimize the episode
is one of the determinants that the client has diversional tactics such as and severity of
already managed the pain. guided imagery. headache.
•Limit how much the
patient moves around
Reference: during morning and • The general
emphasize the importance appearance of the client
www.PrepScholar.com of taking maintenance has improved.
medicine.
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