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 will be able to; 1. assess contributingf 1.to determine underlying
secondary to Y actors to pain cause of pain and treat
migraine as S General: (ingestion of accordingly.
manifested by I  Become relieved tyramine-containing
guarding behavior , O of signs and foods, bright lights
facial grimace and L symptoms of pain and strong fumes
pallor experienced as from cleansing
O evidenced by: materials)
SUBJECTIVE G 2.certain drugs may cause
CUES: I Specific: 2. review medication fatigue and drowsiness.
regimen Goal met. Patient
C  Verbalize pain is
verbalized “I feel better.
verbalized “I feel like relieved (rate
my head is being 3.to assist in evaluating impact My head isn’t throbbing
pain from 0-4 out
crumpled from the 3. ask client to rate pain of pain on client’s life. anymore” rated pain as 0
of 10)
inside and banged on 0-10 scale (rated out of 10.
on a hard surface as 9 out of 10)
repetitively.”
4.to allow nonpharmocological
OBJECTIVE CUES: 4. provide comfort pain relief and promote good
measures such as circulation to the brain and
Rated pain as 9 out repositioning the decrease vasoconstriction Goal met. Patient was
of 10 client in a comfortable able to relax by utilizing
 Demonstrate use bed rest and deep
of diversional position and providing
Facial grimace a hot or cold breathing.
activities such as
relaxing and/or compress
Gurading behavior sleeping 5.to decrease environmental
(clutches head and 5. provide calm and factors which contribute to
assumes fetal quiet environment migraine and promote rest.
position) (adjust lights,
temperature and
Palmar and facial eliminate offensive Goal met. Patient was
pallor. odors which may able to sleep for 6 hours
 Rest and feel straight and felt rested
 rested after contribute to afterwards.
T: 37.2 adequate rest headache)
P; 86 bpm interval 6.to distract attention from
R: 22 cpm 6. instructe in relaxation pain and decrease tension
BP: 130/90 mmHg techniques (deep Goal met. Client was able
breathing, imagery) to use deep breathing
BACKGROUND  Utilize non- 7.to conserve energy of the and reported pain relief
KNOWLEDGE: pharmacological 7. encrourage adequate patient and prevent fatigue afterwards.
methods of pain rest periods
Acute pain is an relief ( deep
unpleasant sensory breathing, guided
and emotional imagery, etc) 8. To promote client
experience arising 8. assist in self-care independence as much as Goal met. Client was able
from actual or activities as tolerated possible and acquire sense of to perform ADLs with
potential tissue  Be able to function minimal assistance from
damage or perform ADLs as watchers (feeding, self-
described in terms of tolerated care, etc)
such damage; 9. provide peaceful \and
sudden or slow adequate resting 9.to enhance quality sleep and
onset of any environment (dim promote rest which harnesses
intensity from mild to lights, adjust energy for future use.
severed with an temperature, wrinkle-
anticipated or free bed, quiet
predictable end and surroundings)
a duration of less
than 6 months.
When migraine or COLLABORATIVE:
any other types of 1. medications will provide
headaches are 1. administer synergistic effect with
diagnosed, the goals medications as nonphramacologic
of nursing ordered by physician interventions for pain relief
management is to (analgesics, etc) and promote better
enhance pain relief. circulation by aiding in
It is reasonable to try vasodilation for better blood
nonpharmacologic flow to the brain and
interventions first, altering prostaglandin
but the use of synthesis to decrease pain
pharmacologic
interventions must 2. the significant others know
not be delayed. The 2. encourage watchers the client more and will be
goal is to treat the to assist patient able to aid in diverting
acute event of the during diversional client’s attention from pain.
headache and to activities (minimize
prevent recurrent noise, allow client to
episodes. verbalize feelings and
promote rest and
SOURCE: sleep)

Nurse’s Pocket
Guide: Diagnoses,
prioritized
interventions and
rationales 11th
Ediction by Marilynn
Doenges

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