| A | B |
|---|
| assessment | Ask the client to describe previous experiences with headaches and methods used to manage them effectively |
| assessment | Check patient for signs of exertional dyspnea, chest pain, diaphoresis, or dizziness. |
| assessment | Nurse notices failure to adhere to treatment plan while in hospital. |
| assessment | Take vital signs every hour |
| assessment | Listen to lung sounds by ausculating chest |
| assessment | Check peripheral pulses in lower extremities |
| assessment | Nurse notices patient has tears during inteview. |
| assessment | Ask patient when pain usually occurs in relation to meals. |
| diagnosis | Pain: headache related to distention of the cerebral blood vessels associated with increased vascular pressure. |
| diagnosis | Activity intolerance related to difficulty resting and sleeping associated with fear, anxiety, frequent assessments, and headache. |
| diagnosis | Ineffective management of therapeutic regimen related to lack of understanding of the implications of not following the prescribed treatment plan. |
| diagnosis | Sleep pattern disturbance related to pain, frequent assessments and treatments, fear, and anxiety. |
| diagnosis | Ineffective airway clearance related to copious secretions. |
| diagnosis | Risk for injury related to generalized weakness. |
| diagnosis | Impaired skin integrity (right heel) related to unrelieved pressure point. |
| diagnosis | Altered nutrition: Less than Body requirements related to poor appetite. |
| planning | Client will obtain relief of headache as evidenced by relaxed facial expression and body positioning. |
| planning | Client will demonstrate an increased tolerance for activity as evidenced by verbalization of feeling less fatigued and weak. |
| planning | Client will demonstrate the probability of effective management of the therapeutic regimen as evidenced by willingness to learn about and participate in treatments and care. |
| planning | Client will obtain optimal amounts of sleep as evidenced by statements of feeling well rested. |
| planning | Client will walk with a cane at least to the end of the hall and back by Friday. |
| planning | Client will demonstrate how to use her walker unassisted by Saturday. |
| planning | Client will list the equipment needed to change sterile dressing by tomorrow. |
| planning | Client will ambulate to the bathroom using her cane by Thursday. |
| intervention | Administer analgesics before activities and procedures that can cause headaches. |
| intervention | Organize nursing care to allow for periods of uninterrupted rest. |
| intervention | Encourage nursing care to allow for periods of uninterrupted rest. |
| intervention | Encourage questions and clarify misconceptions client has about hypertension and its effects and side effects of medication. |
| intervention | Discourage long periods of sleep during the day. |
| intervention | Reposition side, back, side every 2 hours. |
| intervention | Monitor back and hips for signs of decreased circulation. |
| intervention | Place air mattress and sheepskin on bed. |
| evaluation | Client describes relief from headaches with administration of analgesics before activity |
| evaluation | Client states no chest pain, dizziness. |
| evaluation | Describes understanding of hypertension, why medications are important and common side effects of medications they are taking. |
| evaluation | Describes feeling rested and refreshed with no sleep interruptions. |
| evaluation | Can walk unassisted the length of the hall, but becomes unsteady toward the end of the hall. |
