Gracielle Marie E.

Dideles

Nursing Care Plan for Head Injury

Need
Diagnosis/Cue Desired outcomes Nursing Intervention Rationale Evaluation statement

Acute Pain r/t P After 4 hours of nursing INDEPENDENT

decreased cerebral H interventions, the patient
blood flow secondary will be able to; 1. assess contributing 1. to determine underlying
to physical trauma as Y
factors to pain (noise, cause of pain and treat
manifested by S General: wrong positioning, accordingly.
guarding behavior , I • Become relieved environment)
facial grimace and O of signs and
pallor L symptoms of pain 2. review medication 2.certain drugs may cause
experienced as regimen fatigue and drowsiness.
SUBJECTIVE CUES: O evidenced by:
G
verbalized “I still feel I Specific: 3. ask client to rate pain 3. to assist in evaluating
like my head is being C Goal met. Patient
• Verbalize pain is on 0-10 scale (rated impact of pain on client’s life.
banged on a wall.” as 9 out of 10) verbalized “I feel better.
relieved (rate pain
It’s just a little sore from all
from 0-4 out of 10)
OBJECTIVE CUES: the swelling. But it is
tolerable pain.” rated pain
4. provide comfort 4. to allow
Rated pain as 9 out measures such as as 4 out of 10.
nonpharmocological pain relief
of 10 repositioning the client and promote good circulation to
in a comfortable the brain and decrease
Facial grimace position and providing vasoconstriction
a hot or cold
Gurading behavior • Demonstrate use compress
(clutches head and Goal met. Patient was
of diversional able to relax by utilizing
assumes fetal 5. provide calm and
activities such as bed rest and deep
position) quiet environment 5. to decrease
relaxing and/or breathing.
sleeping (adjust lights, environmental factors which
Palmar and facial temperature and contribute to migraine and
pallor. eliminate offensive promote rest.
odors which may
T: 37.2 contribute to
P; 86 bpm headache)
R: 22 cpm
• Rest and feel Goal met. Patient was
BP: 130/90 mmHg 6. instructe in relaxation
rested after
 adequate rest techniques (deep able to sleep for 6 hours
BACKGROUND interval breathing, imagery) 6. to distract attention from straight and felt rested
KNOWLEDGE: pain and decrease tension afterwards.
7. encrourage adequate
Acute pain is an rest periods
unpleasant sensory • Utilize non- 7. to conserve energy of the
and emotional pharmacological patient and prevent fatigue Goal met. Client was able
experience arising methods of pain to use deep breathing
from actual or relief ( deep 8. assist in self-care and reported pain relief
potential tissue breathing, guided activities as tolerated afterwards.
damage or described imagery, etc) 8. To promote client
in terms of such independence as much as
damage; sudden or possible and acquire sense of
slow onset of any • Be able to perform 9. provide peaceful \and function
intensity from mild to ADLs as tolerated adequate resting Goal met. Client was able
severed with an environment (dim to perform ADLs with
anticipated or lights, adjust minimal assistance from
predictable end and temperature, wrinkle- 9.to enhance quality sleep and watchers (feeding, self-
a duration of less free bed, quiet promote rest which harnesses care, etc)
than 6 months. surroundings) energy for future use.
SOURCE:
COLLABORATIVE:
Nurse’s Pocket
Guide: Diagnoses, 1. administer
prioritized medications as
interventions and ordered by physician 1. medications will
rationales 11th (analgesics, etc) provide synergistic effect
Ediction by Marilynn with nonphramacologic
Doenges interventions for pain relief
and promote better
Brunner and circulation by aiding in
Suddarth’s Textbook vasodilation for better blood
of Medical-Surgical flow to the brain and altering
Nursing 11th Edition prostaglandin synthesis to
by Suzanne C. 2. encourage decrease pain
Smeltzer watchers to assist
patient during 2. the significant
diversional activities others know the client more
(minimize noise, allow and will be able to aid in
client to verbalize diverting client’s attention
feelings and promote from pain.
rest and sleep)