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    Migraine NCP

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    John Dexter Francisco
    The patient presented with a migraine headache with a pain level of 9/10. The nurse assessed the patient and found tenderness over the right temporal area. The patient's vital signs were taken. The nurse's short term goal was for the patient to report decreased pain within 4 hours of intervention. The long term goal was for the patient to verbalize relief of pain within 12 hours. The nurse's plan was to obtain consent, vital signs, medication history, and provide pain medication. The rationale was that patients are more cooperative when informed and vital signs can indicate underlying issues. The evaluation would be if the short and long term goals for pain relief were met.

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    Migraine NCP

    Uploaded by

    John Dexter Francisco
    469 views5 pages
    The patient presented with a migraine headache with a pain level of 9/10. The nurse assessed the patient and found tenderness over the right temporal area. The patient's vital signs were taken. The nurse's short term goal was for the patient to report decreased pain within 4 hours of intervention. The long term goal was for the patient to verbalize relief of pain within 12 hours. The nurse's plan was to obtain consent, vital signs, medication history, and provide pain medication. The rationale was that patients are more cooperative when informed and vital signs can indicate underlying issues. The evaluation would be if the short and long term goals for pain relief were met.

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    Original Title

    MIGRAINE-NCP

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    The patient presented with a migraine headache with a pain level of 9/10. The nurse assessed the patient and found tenderness over the right temporal area. The patient's vital signs were taken. The nurse's short term goal was for the patient to report decreased pain within 4 hours of intervention. The long term goal was for the patient to verbalize relief of pain within 12 hours. The nurse's plan was to obtain consent, vital signs, medication history, and provide pain medication. The rationale was that patients are more cooperative when informed and vital signs can indicate underlying issues. The evaluation would be if the short and long term goals for pain relief were met.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    469 views5 pages

    Migraine NCP

    Uploaded by

    John Dexter Francisco
    The patient presented with a migraine headache with a pain level of 9/10. The nurse assessed the patient and found tenderness over the right temporal area. The patient's vital signs were taken. The nurse's short term goal was for the patient to report decreased pain within 4 hours of intervention. The long term goal was for the patient to verbalize relief of pain within 12 hours. The nurse's plan was to obtain consent, vital signs, medication history, and provide pain medication. The rationale was that patients are more cooperative when informed and vital signs can indicate underlying issues. The evaluation would be if the short and long term goals for pain relief were met.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 5

    ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

    Subjective: Pain related to Short term goal: • Taken patient’s • Patients Short term goal:
    • Complains of headache as Within 4 hours of consent for become more Withing 4 hours of
    migraine evidence by nursing intervention, the medical cooperative nursing intervention,
    headache. episodes of patient will be able to intervention and with their the patient was able
    • She has had a migraine with report decrease of pain. care and explain treatment plans to report the
    long history of a pain scale of the reason for if they know decrease in pain.
    migraine 9 out of 10. Long term goal: each. about what’s
    headaches Within 12 hours of going on. Long term goal:
    and nursing intervention, the Within 12 hours of
    experienced patient will be able to • Obtain vital • These vital signs nursing intervention,
    her first verbalize relieve of pain. signs such as are the basic the patient was able
    episode at the blood pressure, indicators of to verbalize the
    age of 16. temperature, underlying relieve of pain.
    • Reports that heart rate, pathologic
    her father also respiratory rate, processes. Any
    had migraine oxygen derangement
    headaches saturation, will show up as
    until his mid- height and abnormal values
    50s. weight. and point to the
    • Relates that possible
    she has severe etiology of the
    throbbing pain condition.
    in the right
    temporal • Obtain list of • Some
    region. medication that medications
    • Has a pain the patient is may contribute
    scale of 9 out currently taking to the migraines
    of 10. including details that the patient
    • She feels such as dosage, is experiencing.
    nauseated but drug strength,
    denies frequency,
    vomiting. brand names
    • She and status of
    experiences compliance.
    visual
    disturbances
    about 2 hours
    ago and
    describes
    them
    beginning with
    the loss of her
    central field of
    vision
    followed by
    flashing lights
    and then
    “orange and
    blue triangles
    moving from
    left to right”
    across her
    visual field
    then an hour
    later, she
    experienced
    the pain.
    • A little
    lightheaded.
    • Took 600mg
    ibuprofen
    about 20
    minutes ago.
    • Sleeping for
    several hours
    is the remedy
    as verbalized
    by the patient.
    • I have not
    been getting
    enough
    adequate
    sleep and has
    been eating
    cheeseburgers
    on the run.

    Objective:
    • Skin is warm,
    pale, and dry
    to touch.
    • Voice
    trembles
    slightly when
    speaking.
    • Face round
    and symmetric
    with her head
    in a central
    position; no
    masses are
    noted.
    • Demonstrate
    normal ROM
    of the head
    and neck with
    no abnormal
    movements.
    • Trachea is in
    the midline.
    • Thyroid gland
    is
    nonpalpable.
    • Cervical and
    supraclavicular
    lymph nodes
    are
    nonpalpable
    and
    nontender.
    • Temporal area
    is tender to
    touch;
    temporal
    artery is
    palpated.
    • Test results of
    CN V, VII and
    XI are normal.
    • Posture is
    erect but
    holding her
    head with her
    hand.

    Vital signs taken as


    follows:
    T – 37.1
    PR – 78
    RR – 24
    BP – 128/74
    John Kyle Phillip Figueroa
    Student Nurse

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