NURSING DIAGNOSIS: Pain, acute, headache
Acute Pain — Hypertension Nursing Care Plans
May be related to
- Increased cerebral vascular pressure
Possibly evidenced by
- Reports of throbbing pain located in suboccipital region, present on awakening and disappearing spontaneously after being up and about
- Reluctance to move head, rubbing head, avoidance of bright lights and noise, wrinkled brow, clenched fists
- Reports of stiffness of neck, dizziness, blurred vision, nausea, and vomiting
Desired Outcomes
Pain Control Behavior (NOC)
- Report pain/discomfort is relieved/controlled.
- Verbalize methods that provide relief.
- Follow prescribed pharmacological regimen.
6 Hypertension Nursing Care Plan (NCP)
- Decreased Cardiac Output — Hypertension Nursing Care Plan (NCP)
- Activity Intolerance — Hypertension Nursing Care Plan (NCP)
- Acute Pain — Hypertension Nursing Care Plan (NCP)
- Ineffective Coping — Hypertension Nursing Care Plan (NCP)
- Imbalanced Nutrition — Hypertension Nursing Care Plan (NCP)
- Knowledge Deficit — Hypertension Nursing Care Plan (NCP)
Acute Pain — Hypertension Nursing Care Plan (NCP)
| Nursing Interventions | Rationale |
| Determine specifics of pain, e.g., location, characteristics, intensity (0–10 scale), onset/duration. Note nonverbal cues. | Facilitates diagnosis of problem and initiation of appropriate therapy. Helpful in evaluating effectiveness of therapy. |
| Encourage/maintain bedrest during acute phase. | Minimizes stimulation/promotes relaxation. |
| Provide/recommend nonpharmacological measures for relief of headache, e.g., cool cloth to forehead; back and neck rubs; quiet, dimly lit room; relaxation techniques (guided imagery, distraction); and diversional activities. | Measures that reduce cerebral vascular pressure and that slow/block sympathetic response are effective in relieving headache and associated complications. |
| Eliminate/minimize vasoconstricting activities that may aggravate headache, e.g., straining at stool, prolonged coughing, bending over. | Activities that increase vasoconstriction accentuate the headache in the presence of increased cerebral vascular pressure. |
| Assist patient with ambulation as needed. | Dizziness and blurred vision frequently are associated with vascular headache. Patient may also experience episodes of postural hypotension, causing weakness when ambulating. |
| Provide liquids, soft foods, frequent mouth care if nosebleeds occur or nasal packing has been done to stop bleeding. | Promotes general comfort. Nasal packing may interfere with swallowing or require mouth breathing, leading to stagnation of oral secretions and drying of mucous membranes. |
| Administer medications as indicated:Analgesics;
Antianxiety agents, e.g., lorazepam (Ativan), alprazolam (Xanax), diazepam (Valium). | Reduce/control pain and decrease stimulation of the sympathetic nervous system.May aid in the reduction of tension and discomfort that is intensified by stress. |