Headaches Nursing Care Plan Interventions

Sunday, March 4, 2012 ·
Headaches is one of the most important human physical complaints. Headache in fact is a symptom not a disease and may indicate organic disease (neurological or other disease), stress response, vasodilation (migraine), skeletal muscle tension (tension headache) or a combination of these responses (Brunner & Suddan).

Headaches classification of the most recently issued by the Headache Classification Comitte of the International Headache Society as follows:
  1. Migraine (with or without aura)
  2. Tension headaches
  3. Cluster headache and paroxysmal hemikranial
  4. A variety of headaches associated with structural lesions.
  5. Headache associated with head trauma.
  6. Headache associated with vascular disorders (eg, subarachnoid hemorrhage).
  7. Headache associated with non-vascular intracranial disorders (eg brain tumors)
  8. Headaches associated with the use of chemicals tau drug withdrawal.
  9. Headache associated with non-cephalic infection.
  10. Headache associated with metabolic disorders (hypoglycemia).
  11. Headache or facial pain associated with disorders of the head, neck or head around the structure (eg, acute glaucoma)
  12. Cranial neuralgia (persistent pain from cranial nerves)

Headaches Nursing Care Plan Interventions


Nursing Care Plans for Headaches

Acute pain r/t stess and tension, irritation / nerve pressure, vasospasm, increased intracranial pressures.

Nursing Interventions for Headaces
  1. Make sure the duration / episode problems, who have been consulted, and drug and / or what therapy has been used
  2. Thorough complaints of pain, record itensitasnya (on a scale 0-10), characteristics (eg, heavy, throbbing, constant) location, duration, factors that aggravate or relieve.
  3. Note the possible pathophysiological characteristic, such as brain / meningeal / sinus infection, cervical trauma, hypertension, or trauma.
  4. Observe for nonverbal signs of pain, are like: facial expression, posture, restlessness, crying / grimacing, withdrawal, diaphoresis, changes in heart rate / breathing, blood pressure.
  5. Assess the relationship of physical factors / emotional state of a person
  6. Evaluation of pain behavior
  7. Note the influence of pain such as: loss of interest in life, decreased activity, weight loss.
  8. Assess the degree of making a false step in person from the patient, such as isolating themselves.
  9. Determine the issue of a second party to the patient / significant others, such as insurance, spouse / family
  10. Discuss the physiological dynamics of tension / anxiety with the patient / person nearest
  11. Instruct patient to report pain immediately if the pain arises.
  12. Place on a rather dark room according to the indication.
  13. Suggest to rest in a quiet room.
  14. Give cold compress on the head.
  15. Massage the head / neck / arm if the patient can tolerate the touch.
  16. Use the techniques of therapeutic touch, visualization, biofeedback, hypnosis itself, and stress reduction and relaxation techniques to another.
  17. Instruct the patient to use a positive statement "I am cured, I'm relaxing, I love this life". Instruct the patient to be aware of the external-internal dialogue and say "stop" or "delay" if it comes up negative thoughts.
  18. Observe for nausea / vomiting. Give the ice, drinks containing carbonate as indicated.

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