You are on page 1of 4

ASSESSMENT

SUBJECTIVE:
Sobrang sakit
ng ulo ko as
verbalized by
patient
OBJECTIVE:
-Irritability
-Restlessness
-Facial grimacing
Pain Scale of
10/10
V/s are taken as
follows:
BP- 200/120
TEMP-37
RR-20
PR-80

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

Acute Pain
related to
intracranial
pressure as
manifested by
severe headache.

Within 2-3 hours


of nursing
intervention, the
patient pain
lessen from
10/10 1/10.

Monitor closely
for and document
neurologic
deterioration,
and maintain a
neurologic flow
record.

To assess for
level of
consciousness,
increased
intracranial
pressure, the
location and
extent.

Patient
demonstrate
improved vital
signs from
200/120 to
150/90.

Check blood
pressure, pulse,
level of
consciousness,
pupilliary
response and
motor function
hourly, monitor
respiratory status
and report
changes
immediately.
Encourage
patient to have
immediate and
absolute bed rest
in a quiet, non
stressful
environment.

To obtain
baseline data.

To prevent
activity, pain ,
and anxiety thay
may trigger to
elevate the blood
pressure.

EVALUATION

After 8 hours of
nursing
intervention,
goals met,
Patient
demonstrate Pain
scale of 10/ 100/10.
Improved vital
signs from 200/
120- 140/80.

Avoid any activity


that will suddenly
increases blood
pressure or
obstruct venous
return. (Valsalva
Maneuver/straini
ng, forceful
sneezing, etc.)
Monitor for input
and output
hourly,
temperature.
Keep the bed
elevated 15 30
degrees.

Administer
Calcuim channel
blockers such as
(Nicardipine) as
prescribed.
Administer pain
reliever, mild
sedation as

To prevent
obstruction of
venous return.

To prevent
infection.

To promote
venous return
and it may help
to decrease
intracranial
pressure.

To decrease
blood pressure.

To relieve pain
and prevent
agitation such as
rebleed,

prescribed.

vasospasm,and
seizure.

Administer
prescribed
medications such
as anti
hypertensive
drugs, anti
seizure, stool
softeners, anti
emetic.

To prevent
possible
complications.

Instruct patient
adequate
hydration.

To decrease
blood volume
and maintain
normal
circulating
volume.