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 impact
like my head is being C on 0-10 scale (rated of pain on clients life. Goal met. Patient
Verbalize pain is
banged on a wall. as 9 out of 10) verbalized I feel better.
relieved (rate pain
Its just a little sore from all
from 0-4 out of 10)
OBJECTIVE CUES: the swelling. But it is
4. provide comfort 4.to allow nonpharmocological tolerable pain. rated pain
Rated pain as 9 out measures such as pain relief and promote good as 4 out of 10.
of 10 repositioning the client circulation to the brain and
in a comfortable decrease vasoconstriction
Facial grimace position and providing
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 activities such as 5. provide calm and 5.to decrease environmental
position) quiet environment factors which contribute to bed rest and deep
relaxing and/or breathing.
sleeping (adjust lights, migraine and promote rest.
Palmar and facial temperature and
pallor. eliminate offensive
odors which may
T: 37.2 contribute to
P; 86 bpm headache)
R: 22 cpm Rest and feel
BP: 130/90 mmHg 6. instructe in relaxation 6.to distract attention from pain Goal met. Patient was
rested after able to sleep for 6 hours
 adequate rest techniques (deep and decrease tension straight and felt rested
BACKGROUND interval breathing, imagery) afterwards.
KNOWLEDGE:
7. encrourage adequate 7.to conserve energy of the
Acute pain is an rest periods patient and prevent fatigue
unpleasant sensory Utilize non- Goal met. Client was able
and emotional pharmacological to use deep breathing
experience arising methods of pain and reported pain relief
from actual or relief ( deep 8. assist in self-care 8. To promote client afterwards.
potential tissue breathing, guided activities as tolerated independence as much as
damage or described imagery, etc) possible and acquire sense of
in terms of such function
damage; sudden or
slow onset of any Be able to perform 9. provide peaceful \and Goal met. Client was able
intensity from mild to ADLs as tolerated adequate resting to perform ADLs with
severed with an environment (dim 9.to enhance quality sleep and minimal assistance from
anticipated or lights, adjust promote rest which harnesses watchers (feeding, self-
predictable end and temperature, wrinkle- energy for future use. care, etc)
a duration of less free bed, quiet
than 6 months. surroundings)

SOURCE:
COLLABORATIVE:
Nurses Pocket
Guide: Diagnoses, 1. administer 1. medications will provide
prioritized medications as synergistic effect with
interventions and ordered by physician nonphramacologic
rationales 11th (analgesics, etc) interventions for pain relief
Ediction by Marilynn and promote better
Doenges circulation by aiding in
vasodilation for better blood
Brunner and flow to the brain and altering
Suddarths Textbook prostaglandin synthesis to
of Medical-Surgical decrease pain
Nursing 11th Edition
by Suzanne C. 2. encourage watchers to 2. the significant others know
Smeltzer assist patient during the client more and will be
diversional activities able to aid in diverting
(minimize noise, allow clients attention from pain.
client to verbalize
feelings and promote
rest and sleep)