- Acute Pain Related to pressure, throbbing, or aching to the temples, eyes, sinuses, or base of the skull and Migraine episode as evidenced by Facial grimace and Reports of pain
- Deficient Knowledge related to lack of information and misinformation as evidenced by Inaccurate follow-through of instructions and Poor control of symptoms
- Impaired Comfort Related to Headache and migraine pain and associated symptoms such as nausea/vomiting, dizziness, etc. as evidenced by expressed pain, anxiety, or worry and Difficulty relaxing
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbal reports from the patient Expressions of pain, such as crying Unpleasant feeling Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns -Guarding or protective behave | Acute Pain Related to pressure, throbbing, or aching to the temples, eyes, sinuses, or base of the skull and Migraine episode as evidenced by Facial grimace and Reports of pain | Patient will report a reduction in pain using the numeric pain scale. Patient will be able to complete daily tasks without disruption due to pain. | 1. Administer pain medications as indicated. OTC medications specific to migraines are available. Prescription-strength medication such as Fioricet may be required. Pain medications should be administered before the onset of the pain or during the prodrome phase when symptoms such as irritability or difficulty concentrating begin. 2. Teach patients non-pharmacologic pain management. Nonpharmacologic pain management techniques like relaxation, cool compresses, darkness, and massage can help with pain relief. Moreover, these do not have any side effects or risk of dependence. 3. Schedule activities during the peak effects of pain relievers. Headache pain can be debilitating and prevent the patient from working, caring for family, and ADLs. Schedule nursing tasks and patient care when pain is most controlled. 4. Identify precipitating factors. Migraine headaches can have triggers such as stress, missed meals, too much caffeine or caffeine withdrawal, weather changes, exhaustion, exposure to smoke or strong odors, and more. Helping the patient identify specific instances of migraine occurrences can decrease episodes. | Patient reported a reduction in pain using the numeric pain scale. Patient completed daily tasks without disruption due to pain. |
| Subjective data: -Verbalizes poor understanding -Seeks additional information Objective data: -Inaccurate demonstration or teach-back of instructions Inability to recall instructions -Poor adherence to recommended treatment or worsening medical condition | Deficient Knowledge related to lack of information and misinformation as evidenced by Inaccurate follow-through of instructions and Poor control of symptoms | Patient will verbalize understanding their disease process by exhibiting adherence to the treatment regimen. Patient will seek information on adjunctive treatment and lifestyle changes to improve health. | 1. Educate on different treatment options. Migraine treatments continue to improve. Other than analgesics, antidepressants, anti-seizure drugs, blood pressure medications, vitamins, and even Botox injections are used to treat migraines. 2. Provide accurate information and dispel myths. There is still much to learn about headaches and migraines. Provide accurate information from reputable sources that the patient is able to understand. 3. Encourage a headache diary. Have the patient keep a diary surrounding headaches and migraine episodes. This information can help with understanding possible triggers and changes to make in diet or lifestyle. 4. Consider resources. Headaches and migraines can feel isolating. If the patient does not already see a neurologist, this specialist can offer expert treatment. Support groups may also help with feeling understood by others by sharing similar experiences. | Patient verbalized understanding their disease process by exhibiting adherence to the treatment regimen. Patient seeked information on adjunctive treatment and lifestyle changes to improve health. |
| Subjective data: -Verbalizes pain, exhaustion, or general unwellness -Expresses feeling stressed or worried -Expresses concern about their health or a procedure Verbalizes a sense of unease Objective data: -Signs of pain: grimacing, guarding, moaning, diaphoresis -Rapid breathing Increased heart rate | Impaired Comfort Related to Headache and migraine pain and associated symptoms such as nausea/vomiting, dizziness, etc. as evidenced by expressed pain, anxiety, or worry and Difficulty relaxing | Patient will verbalize an improved sense of emotional relief and comfort. Patient will participate in strategies and interventions to improve spiritual and psychological comfort. | 1. Administer medications as indicated. Pain medications can initially assist with pain that is causing impaired comfort. Additional medications such as antiemetics to help with nausea or antihistamines for dizziness and sleep aids can all improve comfort. 2. Establish a reliable and trusting relationship with the patient. A trusting relationship encourages open and honest communication. Building a rapport can increase adherence to the treatment plan. 3. Minimize noise and stimuli. Dim lighting in a cool and quiet room can induce comfort. Speak calmly and quietly to the patient when required. 4. Consider therapy consults. Outward stress and personal issues can trigger headaches and prevent feelings of comfort. Encourage or provide opportunities to work with a counsellor that may be able to develop coping strategies to control emotional stress. | Patient verbalized an improved sense of emotional relief and comfort. Patient participated in strategies and interventions to improve spiritual and psychological comfort. |