Assessment

Diagnosis

Inference

Planning

Interventions

Rationale

Evaluation

Subjective:

Impaired comfort
related headache

traction to or
irritation of the
meninges and
blood vessels

After 4 hours
of nursing
interventions
, patients
subjective
perception
of altered
comfort/pain
will be
decreased;
patient will
be able to
verbalize
relief of pain;
there will be
diminished
or absent
nonverbal
indicators.

Note for the

location, scale,
intensity and onset
of pain

To determine the
nursing care to be
given to the
patient.

Maintain a calm and

quite environment.

To minimize
stimulus that
could aggravate
the condition of
the patient

After 4 hours of
nursing
interventions,
goal met. Patient
verbalized being
relieved of pain
and there is no
nonverbal
indicators of
pain/discomfort
present.

My head hurts,
as verbalized by
the patient.
Pain scale of 6 out
of 10.

stimulation of
nociceptors

Objectives:
Facial mask
of pain
Facial
grimace
Restlessness

nociceptor sends
a message up the
length of the
nerve fiber to the
nerve cells in the
brain

Headache/pain
Vital signs
T- 36.2
P- 86
R- 22
BP
140/60mmh
g

unpleasant feeling
that is conveyed
to the brain by
sensory neurons

alters comfort/
impairs ability of
person to function

Use relaxation
technique such as:
heat and cold
application an deep
breathing exercise

To promote
comfort and
relaxation.

Provide a dim and

light but providing
good ventilation.

To add comfort to
the patient

Offer back rubs,

massages, slow
rhythmic breathing,
repositioning and
other diversional
activities such as

They serve as
nonpharmacological
methods for
reducing

music, TV, etc.

pain/promoting
comfort

Dependent:
Administer pain
medications as
ordered

To help relieve
of pain.