Manguiat, Ciara Loreal M.

BSN 1-Y2-5

NCMA 111
NURSING CARE PLAN
Dorothy Grant

Subjective Data: Objective Data:

- Patient reports that she experienced migraine headache and rates her o Skin is warm, pale, and dry to touch. Height: 162.5cm
pain as a 9. o Voice trembles slightly when speaking Weight: 63.5kg
- Intense throbbing pain in right temporal area and she has a significant o Head and face are round and symmetric, with her head in a Pulse: 78 bpm
history of migraine headaches. central position; no masses are noted. Respirations: 24 bpm
- Reports feeling a little lightheaded o Normal range of motion of the head and neck, with no abnormal
- Nauseated but denies vomiting. BP: 128/74 mmHg
movements.
- Orange and blue triangles traveling from left to right across her visual o Trachea is in the midline and the thyroid gland is nonpalpable. Temp.: 37.1°C / 98.8°F
field, starting with the loss of her core field of vision and progressing to o Cervical and supraclavicular lymph nodes are nonpalpable and
flashing lights. nontender.
- Patient has not been getting adequate sleep and has been eating o Temporal area is tender to touch; the temporal artery is palpated.
cheeseburgers on the run. o Cranial nerves V, VII and XI are normal.
- Patient has not attended any Zumba classes for the past 2 weeks o Posture is erect, but she is holding her head with her hand.

- Patient reports that she experienced migraine headache and - Not getting adequate sleep and has - Been nibbling on crackers, lunch meat,
rates her pain as a 9. been eating cheeseburgers on the and sodas daily
- Intense throbbing pain in right temporal area run.
- Significant history of migraine headaches. - Voice trembles slightly when
- Reports feeling a little lightheaded speaking
- Temporal area is tender to touch; the temporal artery is - Patient has not attended any Zumba
palpated. classes for the past 2 weeks
- Nausea - Nausea

-
The patient is experiencing lack of sleep and positively Vestibular The client was not eating a proper meal, is The patient is experiencing lack of sleep,
Migraine, sensitivity to light. experiencing inactiveness and, lack of light and sound sensitive, and nausea.
energy.

Vestibular Migraine (Vertigo) and/or Severe migraine secondary Fatigue Stress and/or Electrolyte Imbalance
to Aneurysm

Major: Dry-skin, tender temporal area, extreme sensitivity to light Major: Expresses lack of energy, nausea, and Major: Lightheadedness and migraine
and sound, and pain scale as 9. extreme sensitivity to light and sound. headaches

Confirm the diagnosis because it meets the defining Confirm the diagnosis because it meets the Confirm the diagnosis because it meets the
characteristics and is confirmed by the patient. defining characteristics and is confirmed by defining characteristics and is confirmed by
the patient. the patient.
 ASSESSMENT
Subjective:
Patient reports that she
experienced migraine
headache and rates her pain
as a 9. She has an intense
throbbing pain in right
temporal area and she has a
significant history of
migraine headaches, with her
first episode occurring when
she was 16 years old. Also
reports feeling a little
lightheaded. She says she is
nauseated but denies
vomiting. She described
them as orange and blue
triangles traveling from left
to right across her visual
field, starting with the loss of
her core field of vision and
progressing to flashing lights.
Objective:
Height: 162.5cm
Weight: 63.5kg
Physical Assessment:
o Skin is warm, pale,
and dry to touch.
o Voice trembles
slightly when
speaking
Pulse: 78 bpm
Respirations: 24 bpm
BP: 128/74 mmHg
Temp.: 37.1°C / 98.8°F
Head and face are round and
symmetric, with her head in a
DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Severe migraine Short term: Get the patient’s consent Patients become more Short term:
secondary to After 24 hours of nursing for medical intervention cooperative with their After a week of nursing
Aneurysm. The patient intervention, the patient and care and explain the treatment plans if they knowintervention, the patient
is experiencing a will be able to verbalize reason for each. what is going on. verbalized a reduce of
Migraine headache. reduce of pain scale from pain scale from 9/10 to
Migraine creates lateral 9/10 to 4/10 or 3/10. Assess conditions that Proper assessment helps 4/10 or 3/10.
discomfort which can can increase the patient’s determine needed fall
severely impair a Long term: level of fall risk, such as precautions. Long term:
person’s ability to After 3-4 days of nursing a history of falls, After 3-4 days of nursing
function. Migraine intervention, the patient changes in mental status, intervention, the patient
causes are unknown, will identify personal sensory deficits, balance, identified the personal
and avoiding specific triggers to avoid having medications, and triggers to avoid having
“triggers” is the key to migraine attacks and symptoms related to migraine attacks and
avoiding attacks. In the successfully be migraine diseases. successfully be migraine
client’s case, a certain free. free.
trigger precipitated a Bring the patient to Like the laboratory tests,
migraine attack causing imaging studies such as imaging aids in the The goal was met.
the severe pain. MRI and CT scan. diagnosis of the patient's
underlying conditions.
Vestibular Migraine
(Vertigo) related to Obtain a list of Some medications may
significant history of medications that the contribute to the migraines
migraine headaches as patient is currently that the patient is
evidenced by a taking experiencing.
throbbing pain in right
temporal area, blurred Independence promotion is
vision, nausea, and Evaluate the patient’s essential in patientcare.
sensitivity to light and knowledge on comfort
sound. measures during
headache attacks.
Sudden movements can
Teach the patient to trigger dizziness.
move slowly, like sitting
up slowly and taking a
few minutes before
standing up.
During migraine attacks, Bright light and sounds
provide non-stimulating exacerbate the patient’s
environment. migraine.
central position; no masses Encourage the patient to This maintains the patient’s
are noted. seek assistance as sense of control and reduces
necessary. the fear of feeling isolated.
Normal range of motion of
the head and neck, with no
abnormal movements. Prescribed medications can
Give medications as help reduce dizziness as
Trachea is in the midline and ordered. well as the associated
the thyroid gland is nausea.
nonpalpable.

Cervical and supraclavicular

lymph nodes are nonpalpable
and nontender.

Temporal area is tender to

touch; the temporal artery is
palpated.

Cranial nerves V, VII and XI

are normal.

Posture is erect, but she is

holding her head with her
hand.