Name:

Age: 28
Civil Status: single
Sex: Female
ASSESSMENT NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Independent :
Subjective:
 Acute pain  It s a sudden or  After 4 hours of  Evaluate the pain  Provide information about  After 4 hours of
“Masaki tang ulo slow onset of nursing regularly noting the need for or effectiveness of nursing
ko” as verbalized any intensity intervention the characteristics, location interventions. intervention the
by the patient from mild to client’s should a, intensity (0 – 10 goal is met as
severe pain manifest a scale). evidence of
with an decrease of pain clients decrease
Objective: anticipated scale from 5/10  Encourage / maintain  Minimized stimulation/ in pain scale
end. to 3/10 or lower. bed rest during acute promotes relaxation. from 5/10 –
 Pain scale of phase 3/10, (-) facial
5/10, 0 being grimace
the lowest and  Eliminate / minimize
ten being the Nursing vasoconstriction  Activities that increase
highest Diagnosis activities that may vasoconstriction accentuate
pocketbook by: aggravate headache eg. the headache in the presence
 (+) facial Mary Ellen Bending over. of increase cerebral vascular
grimace Murray RN PhD pressure.
and Leslie  Assist patient with
Atkinson RN ambulation as needed.  Dizziness and blurred vision
MSN frequently are associated with
vascular headache. Patient
page 41 may also experience episodes
of postural hypotension,
causing weakness when
ambulating.

Collaborative:

 Administer medication  Reduce/control pain and

as needed: analgesic decrease stimulation of the
sympathetic nervous
system