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Dideles Nursing Care Plan for Head Injury Diagnosis/Cue Acute Pain r/t decreased cerebral blood flow secondary to physical trauma as manifested by guarding behavior , facial grimace and pallor
Desired outcomes After 4 hours of nursing interventions, the patient will be able to; General: • Become relieved of signs and symptoms of pain experienced as evidenced by: Specific: • Verbalize pain is relieved (rate pain from 0-4 out of 10)
Nursing Intervention INDEPENDENT
P H Y S I O L SUBJECTIVE CUES: O G I verbalized “I still feel like my head is being C
banged on a wall.” OBJECTIVE CUES: Rated pain as 9 out of 10 Facial grimace Gurading behavior (clutches head and assumes fetal position) Palmar and facial pallor. T: 37.2 P; 86 bpm R: 22 cpm BP: 130/90 mmHg
contributing factors to pain (noise, wrong positioning, environment) medication
to determine underlying cause of pain and treat accordingly. 2.certain drugs may cause fatigue and drowsiness.
2. review regimen
3. ask client to rate pain
on 0-10 scale (rated as 9 out of 10) 4. provide comfort measures such as repositioning the client in a comfortable position and providing a hot or cold compress 5. provide calm and quiet environment (adjust lights, temperature and eliminate offensive odors which may contribute to headache) 6. instructe in relaxation
to assist in evaluating impact of pain on client’s life.
to allow nonpharmocological pain relief and promote good circulation to the brain and decrease vasoconstriction
Goal met. Patient verbalized “I feel better. It’s just a little sore from all the swelling. But it is tolerable pain.” rated pain as 4 out of 10.
Demonstrate use of diversional activities such as relaxing and/or sleeping
to environmental contribute to promote rest.
decrease factors which migraine and
Goal met. Patient was able to relax by utilizing bed rest and deep breathing.
Rest and feel rested after
Goal met. Patient was
etc) • Be able to perform ADLs as tolerated To promote client independence as much as possible and acquire sense of function 9. to distract attention from pain and decrease tension able to sleep for 6 hours straight and felt rested afterwards. Smeltzer • adequate rest interval techniques (deep breathing. allow 1. Client was able to use deep breathing and reported pain relief afterwards. imagery) 7. etc) 2.to enhance quality sleep and promote rest which harnesses energy for future use. wrinklefree bed. the significant others know the client more and will be able to aid in . assist in self-care activities as tolerated to conserve energy of the patient and prevent fatigue Goal met. quiet surroundings) COLLABORATIVE: 1. 8. adjust temperature. 8. Utilize nonpharmacological methods of pain relief ( deep breathing. Goal met. 9. guided imagery. prioritized interventions and rationales 11th Ediction by Marilynn Doenges Brunner and Suddarth’s Textbook of Medical-Surgical Nursing 11th Edition by Suzanne C. medications will provide synergistic effect with nonphramacologic interventions for pain relief and promote better circulation by aiding in vasodilation for better blood flow to the brain and altering prostaglandin synthesis to decrease pain 2. SOURCE: Nurse’s Pocket Guide: Diagnoses. encrourage adequate rest periods 6. sudden or slow onset of any intensity from mild to severed with an anticipated or predictable end and a duration of less than 6 months.BACKGROUND KNOWLEDGE: Acute pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. administer medications as ordered by physician (analgesics. provide peaceful \and adequate resting environment (dim lights. selfcare. etc) 7. Client was able to perform ADLs with minimal assistance from watchers (feeding. encourage watchers to assist patient during diversional activities (minimize noise.
client to verbalize feelings and promote rest and sleep) diverting client’s from pain. attention .