Gracielle Marie E.

Dideles

Nursing Care Plan for Migraine Headache

Need
Diagnosis/Cue Desired outcomes Nursing Intervention Rationale Evaluation statement

Acute Pain r/t P After 4 hours of nursing INDEPENDENT

decreased cerebral H interventions, the patient
blood flow secondary will be able to; 1. assess contributingf 1. to determine underlying
to migraine as Y
actors to pain cause of pain and treat
manifested by S General: (ingestion of tyramine- accordingly.
guarding behavior , I • Become relieved containing foods,
facial grimace and O of signs and bright lights and
pallor L symptoms of pain strong fumes from
experienced as cleansing materials)
SUBJECTIVE CUES: O evidenced by:
G 2. review medication 2.certain drugs may cause
verbalized “I feel like I Specific: regimen fatigue and drowsiness.
my head is being C Goal met. Patient
• Verbalize pain is
crumpled from the verbalized “I feel better.
relieved (rate pain
inside and banged on 3. ask client to rate pain 3. to assist in evaluating My head isn’t throbbing
from 0-4 out of 10)
a hard surface on 0-10 scale (rated impact of pain on client’s life. anymore” rated pain as 0
repetitively.” as 9 out of 10) out of 10.

OBJECTIVE CUES:
4. provide comfort 4. to allow
Rated pain as 9 out measures such as nonpharmocological pain relief
of 10 repositioning the client and promote good circulation to
in a comfortable Goal met. Patient was
• Demonstrate use the brain and decrease
able to relax by utilizing
Facial grimace position and providing vasoconstriction
of diversional bed rest and deep
activities such as a hot or cold
Gurading behavior compress breathing.
relaxing and/or
(clutches head and sleeping
assumes fetal 5. provide calm and
position) quiet environment 5. to decrease
(adjust lights, environmental factors which
Palmar and facial temperature and contribute to migraine and
pallor. eliminate offensive promote rest. Goal met. Patient was
• Rest and feel odors which may
T: 37.2 contribute to able to sleep for 6 hours
rested after
P; 86 bpm adequate rest headache) straight and felt rested
R: 22 cpm interval afterwards.
BP: 130/90 mmHg 6. instructe in relaxation
techniques (deep
BACKGROUND breathing, imagery) 6. to distract attention from
KNOWLEDGE: • Utilize non- pain and decrease tension Goal met. Client was able
pharmacological 7. encrourage adequate to use deep breathing
Acute pain is an methods of pain rest periods and reported pain relief
unpleasant sensory relief ( deep 7. to conserve energy of the afterwards.
and emotional breathing, guided patient and prevent fatigue
experience arising imagery, etc)
from actual or 8. assist in self-care
potential tissue activities as tolerated
damage or described • Be able to perform 8. To promote client Goal met. Client was able
in terms of such ADLs as tolerated independence as much as to perform ADLs with
damage; sudden or possible and acquire sense of minimal assistance from
slow onset of any 9. provide peaceful \and function watchers (feeding, self-
intensity from mild to adequate resting care, etc)
severed with an environment (dim
anticipated or lights, adjust
predictable end and temperature, wrinkle- 9.to enhance quality sleep and
a duration of less free bed, quiet promote rest which harnesses
than 6 months. When surroundings) energy for future use.
migraine or any other
types of headaches
are diagnosed, the COLLABORATIVE:
goals of nursing
management is to 1. administer
enhance pain relief. It medications as
is reasonable to try ordered by physician 1. medications will
nonpharmacologic (analgesics, etc) provide synergistic effect
interventions first, but with nonphramacologic
the use of interventions for pain relief
pharmacologic and promote better
interventions must circulation by aiding in
not be delayed. The vasodilation for better blood
goal is to treat the flow to the brain and altering
acute event of the prostaglandin synthesis to
headache and to 2. encourage decrease pain
prevent recurrent watchers to assist
episodes. patient during 2. the significant others
diversional activities know the client more and
SOURCE: (minimize noise, allow will be able to aid in
client to verbalize diverting client’s attention
Nurse’s Pocket feelings and promote from pain.
Guide: Diagnoses, rest and sleep)
prioritized
interventions and
rationales 11th
Ediction by Marilynn
Doenges

Brunner and
Suddarth’s Textbook
of Medical-Surgical
Nursing 11th Edition
by Suzanne C.
Smeltzer