Gracielle Marie E.

Dideles
Nursing Care Plan for Head Injury
Diagnosis/Cue
Need
Desired outcomes Nursing Intervention Rationale Evaluation statement
Acute Pain r/t
decreased cerebral
blood flow secondary
to physical trauma as
manifested by
guarding behavior ,
facial grimace and
pallor
SUBJE!"#E UES$
verbali%ed &" still feel
li'e my head is being
banged on a wall()
*BJE!"#E UES$
+ated pain as , out
of -.
/acial grimace
0urading behavior
1clutches head and
assumes fetal
position2
Palmar and facial
pallor(
!$ 34(5
P6 78 bpm
+$ 55 cpm
BP$ -3./,. mm9g
P
9
:
S
"
*
;
*
0
"

After < hours of nursing

interventions, the patient
will be able to6
0eneral$
Become relieved
of signs and
symptoms of pain
e=perienced as
evidenced by$
Specific$
#erbali%e pain is
relieved 1rate pain
from .>< out of -.2
?emonstrate use
of diversional
activities such as
rela=ing and/or
sleeping
+est and feel
rested after
"@?EPE@?E@!
-( assess contributing
factors to pain 1noise,
wrong positioning,
environment2
5( review medication
regimen
3( as' client to rate pain
on .>-. scale 1rated
as , out of -.2
<( provide comfort
measures such as
repositioning the client
in a comfortable
position and providing
a hot or cold
compress
A( provide calm and
Buiet environment
1adCust lights,
temperature and
eliminate offensive
odors which may
contribute to
headache2
8( instructe in rela=ation
-(to determine underlying
cause of pain and treat
accordingly(
5(certain drugs may cause
fatigue and drowsiness(
3(to assist in evaluating impact
of pain on clientDs life(
<(to allow nonpharmocological
pain relief and promote good
circulation to the brain and
decrease vasoconstriction
A(to decrease environmental
factors which contribute to
migraine and promote rest(
8(to distract attention from pain
0oal met( Patient
verbali%ed &" feel better(
"tDs Cust a little sore from all
the swelling( But it is
tolerable pain() rated pain
as < out of -.(
0oal met( Patient was
able to rela= by utili%ing
bed rest and deep
breathing(
0oal met( Patient was
BAE0+*U@?
E@*F;E?0E$
Acute pain is an
unpleasant sensory
and emotional
e=perience arising
from actual or
potential tissue
damage or described
in terms of such
damage6 sudden or
slow onset of any
intensity from mild to
severed with an
anticipated or
predictable end and
a duration of less
than 8 months(
S*U+E$
@urseDs Poc'et
0uide$ ?iagnoses,
prioriti%ed
interventions and
rationales --
th

Ediction by Garilynn
?oenges
Brunner and
SuddarthDs !e=tboo'
of Gedical>Surgical
@ursing --
th
Edition
by Su%anne (
Smelt%er
adeBuate rest
interval
Utili%e non>
pharmacological
methods of pain
relief 1 deep
breathing, guided
imagery, etc2
Be able to perform
A?;s as tolerated
techniBues 1deep
breathing, imagery2
4( encrourage adeBuate
rest periods
7( assist in self>care
activities as tolerated
,( provide peaceful Hand
adeBuate resting
environment 1dim
lights, adCust
temperature, wrin'le>
free bed, Buiet
surroundings2
*;;AB*+A!"#E$
-( administer
medications as
ordered by physician
1analgesics, etc2
5( encourage watchers to
assist patient during
diversional activities
1minimi%e noise, allow
client to verbali%e
and decrease tension
4(to conserve energy of the
patient and prevent fatigue
7( !o promote client
independence as much as
possible and acBuire sense of
function
,(to enhance Buality sleep and
promote rest which harnesses
energy for future use(
-( 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
5( the significant others 'now
the client more and will be
able to aid in diverting
clientDs attention from pain(
able to sleep for 8 hours
straight and felt rested
afterwards(
0oal met( lient was able
to use deep breathing
and reported pain relief
afterwards(
0oal met( lient was able
to perform A?;s with
minimal assistance from
watchers 1feeding, self>
care, etc2
feelings and promote
rest and sleep2