Nursing Care Plan Hypertension | Acute Headache Pain

Nursing diagnosis: Acute headache pain 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; and reports of stiffness of neck, dizziness, blurred vision, nausea, and vomiting.

Desired Outcomes
Report pain/discomfort is relieved/controlled.
Verbalize methods that provide relief.
Follow prescribed pharmacologic regimen.

Nursing Intervention with Rationale:
1. Determine specifics of pain; e.g., location, characteristics, intensity (0–10 scale), onset/duration. Note nonverbal cues.
Rationale: Facilitates diagnosis of problem and initiation of appropriate therapy. Helpful in evaluating effectiveness of therapy.

2. Encourage/maintain bedrest during acute phase.
Rationale: Minimizes stimulation/promotes relaxation.

3. Provide/recommend nonpharmacologic 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.
Rationale: Measures that reduce cerebral vascular pressure and that slow/block sympathetic response are effective in relieving headache and associated complications.

4. Eliminate/minimize vasoconstricting activities that may aggravate headache; e.g., straining at stool, prolonged coughing, bending over.
Rationale: Activities that increase vasoconstriction accentuate the headache in the presence of increased cerebral vascular pressure.

5. Assist client with ambulation as needed.
Rationale: Dizziness and blurred vision frequently are associated with vascular headache. Client may also experience episodes of postural hypotension, causing weakness when ambulating.

6. Provide liquids, soft foods, frequent mouth care if nosebleeds occur or nasal packing has been done to stop bleeding.
Rationale: Promotes general comfort. Nasal packing may interfere with swallowing or require mouth breathing, leading to stagnation of oral secretions and drying of mucous membranes.

7. Administer medications as indicated: analgesics
Rationale: Reduce/control pain and decrease stimulation of the sympathetic nervous system.

8. Administer Antianxiety agents; e.g., lorazepam (Ativan), alprazolam (Xanax), diazepam (Valium)
Rationale: May aid in the reduction of tension and discomfort that is intensified by stress.