PROBLEM PRIORITIZATION Nursing Problem Acute headache pain related to increased cerebral vascular pressure.

Rank 1 Justification It is an actual problem. The problem is life-threatening. Pain is our highest priority for the reason that: Pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. Facial grimace, malaise, restlessness, irritability are signs of discomforts brought by pain and may indicate other signs and symptoms. Sleep disturbances may reduce resting periods which may affect fast recovery. Underlying conditions related to hypertension can be prevented. Activity intolerance related to generalize weakness is a health threatening because limited capabilities will lead to poor body movement. There is discomfort which is associated with difficulty in moving. And because that there is activity intolerance, the patient will be having difficulty supporting and maintain stability. 3 Self-esteem promotes cooperation of the patient during treatment. Self-esteem is also a part of Maslows Hierarchy of Needs. Conditions may arise if this is not treated.

Activity intolerance related to generalized weakness as manifested by inability to perform activity.

Risk for prone behavior related to lack of knowledge about the disease

Assessment Subjective nagpa-admit na ako dahil sa sakit ng ulo ko, nahihilo minsan at utos din ng doktor ko Objective Blurred vision Nausea and Vomiting V/S taken as follows: T 36 PR 54 RR 14 BP 150/100

Nursing Diagnosis Acute headache pain related to increased cerebral vascular pressure.

Analysis Because of poor tissue perfusion, the heart tries to compensate thus pumping double to meet the demands of the body. Since there is compensatory mechanism, there is increase in blood pressure which leads to acute headache.

Goal and Objectives After 8 hours of nursing interventions, the patient will be able to report pain is relieved or controlled. Specifically, the patient will be able to Verbalize methods that provide relief.

Interventions Determine specifics like location, characteristics, intensity duration of pain.

Rationale Facilitates diagnosis of problem and initiation of appropriate therapy. Helpful in evaluating effectiveness of therapy.

Evaluation Effectiveness: Does the client able to gain knowledge about methods that provide relief? Yes_ No_ Why? Efficiency: Were the time, materials and human resources used efficiently? Yes_ No_ Why? Adequacy: Were the numbers of interventions adequate? Yes_ No_ Why? Acceptability: Were the interventions appropriate for the client? Yes_ No_ Why? Appropriateness: Were the interventions and setting sensible to the client? Yes_ No_ Why?

Provide non pharmacologic al measures for relief of headache like applying cool cloth to forehead, back and neck rubs and relaxation techniques and diversional activities. Maintain bed rest during acute phase.

Reduce cerebral vascular pressure and those slow sympathetic responses are effective in relieving headache and associated complications. Control pain and decrease stimulation of the sympathetic nervous system. Dizziness and blurred vision frequently are Associated with vascular headache. Decrease stimulation of the sympathetic nervous system.

Demonstr ate use of relaxati on skills and divertiona l activities.

Assist patient with ambulation as needed.

Administer medications as indicated.