ASSESSMENT

SUBJECTIVE:
Well, my head is
throbbing, and Im sort
of dizzy. I think Im just
overdoing it and not
getting enough rest. You
know,
raising
eight
children is a lot of work
and expense. I just
started working part
time so we wouldnt get
behind in our bills. I
thought
the
extra
money might relieve
some of my stress, but
Im not sure thats
really happening. Im
not getting any better
and Im worried that Ill
lose my job or become
disabled and that my
husband wont be able
to manage the children
by himself. I really need
to go home, but first, I
want to get rid of this
awful headache. Would
you please get me a
couple of aspirin or
something?

As verbalized by the
patient.
OBJECTIVE:
RESTLESS
UPSET
NO FAMILY HISTORY
OF HYPERTENSION.
T : 37.2C

NURSING
DIAGNOSIS
Headache related to
Stress and situational
crisis.

PLANNING
SHORT TERM:
After 6 hours of
nursing interventions,
the patient report will
not have headache.

INTERVENTION

RATIONALE

EVALUATION

-assess current
functional capacity.

-pain of headache can

interfere with coping
ability.

-Ascertain duration of
problem/episodes,
who has been
consulted; and what
drugs and/or
therapies have been
used.

-expedites choice of
appropriate
interventions. Helps
identify actions that
may have been
overlooked or not
tried.

After 6 hours of
nursing interventions,
the patient was able
to relieved from the
pain that caused by
her headache.

-treat the patient with

courtesy and respect.
Take advantage of
teachable moments.

-meets psychological
needs, enhancing
self-esteem and
promoting
opportunities for
learning a new ways
to cope with
situation.

-assess/correlate
emotional
components of
individual situation.
-message head/neck/
shoulder area if
patient can tolerate
touch
-

-factors that affect

presence/perception
of pain.
-relieves tension and
promotes relaxation
of the patient.

P : 100
R : 16
BP :
LYING: 180/115
mmHg
SITTING: 170/110
mmHg
STANDING:
165/105mmHg
HEIGHT: 160 cm
WEIGHT: 225 lbs

ASSESSMENT

NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE:
The patient is
complaining of
abdominal pain.
OBJECTIVE:
skin is pale and
moist
pupils dilated
restless

T : 37C
P : 90
R: 24
BP : 158/82 mmHg

Chronic pain

SHORT TERM:
After 4 hours of
nursing interventions,
the patient will
relived and control
the pain and
discomfort. Recognize
the interpersonal
dynamics and
reaction that affects
pain problem.

-note gender and age

of client.

-determine issues of
secondary gain for
the client

-evaluate pain
behavior.

-include client and

SO(s) in establishing
pattern of discussing
pain for specified
length of time.

-current literature
suggest there may be
differences between
women and men as
to how they perceive
and/or respond to
pain

-may interfere with

progress in pain
management/resoluti
on of situation
-may be exaggerated
because clients
perception of pain is
not believed or
because client
believes caregivers
are discounting
reports of pain.

-to limit focusing on

pain.

-review client
expectation versus
reality.
-pain may not
resolved but can be
significantly lessened
or managed.

After 4 hours of
nursing interventions,
the patient was able
to relieved and
controls the pain and
discomfort, and able
to recognized the
interpersonal
dynamics and
reactions that effects
pain problem.