Nursing Care Plan Migraine Headache-Acute Pain (1)

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