Case Study Headache
Headache related to increased in cerebral vascular pressure Planning/lamentation/Rationale 1 . Assess blood pressure in both arms, using a cuff and proper techniques In measuring BP, Blood pressure measurement is more accurate when using the bell rather than the diaphragm of the stethoscope (Lockwood et al,2004. ) 2.
Minimize disruption and provide a quite environment by minimizing environment stimuli. Promotes relaxation 3. Eliminate vasoconstriction satellites that may aggravate headache, e. G. , straining at stool, prolonged coughing, bending over.
This activities increases vasoconstriction accentuates the headache in the presence of increased cerebral vascular pressure.
4. Medical collaboration in providing analgesics. Reduces pain and decrease stimulation of the sympathetic nervous system. Evaluation: The patient reports relieved of headache, Verbalize methods that provide relief and maintains blood pressure within an acceptable range. Nursing Diagnosis #2 Ineffective tissue perfusion related to impaired circulation Planning/elimination/ Rationale 1 . Observation of the skin color and temperature Skin pallor or mottling, cool or old skin temperature.
R an absent pulse can signal arterial obstruction. Which Is an emergency that requires immediate intervention. Rubber (reddish-blue color accompanied by dependency) indicates dilated or damaged vessels. Brownish disconsolation of skin indicates chronic venous insufficiency (Bright, George, 1992; Feldman, 1998). 2.
Check dorsal piped and posterior tibiae pulses bilaterally. When the pulse is palpated, characteristics other than the rate also need to be assessed (Elliot,M. & Convector, A. 2012) 3. Check capillary refill. Nail beds usually return o a pinkish color within 3 seconds after nail bed compression (Dyke’s, 1993).
. Do not elevate legs above the level of the heart. Leg elevation decreases arterial blood supply to the legs 5. Keep client warm to maintain vacillation and blood supply I nee patient demonstrated adequate tissue perfusion as vengeance Day palpable peripheral pulses, warm and dry skin and absence of respiratory distress. Nursing Diagnosis #3 Ineffective breathing pattern related to disease condition Planning/elimination/Rationale 1 .
Position patient to semi fowlers’ position to obtain optimal breathing pattern. Sitting position allows good lung expansion. 2. Ensure that 02 delivery system is given to the patient.
An 02 saturation of 90% should be maintained for adequate oxygenation 3. Encourage sustained deep breathing exercises by demonstrating or by asking patient to yawn to promote deep inspiration 4.
Use pain management to allow for pain relief and the ability to deep breathe. Researches has also found that appropriate pain management results in decreased length of hospital stay and improved functional outcomes (Classes et al, 2009) Evaluation: Patients breathing pattern is maintained as evidenced by panel, normal skin color and regular respiratory rate and pattern.
Summary of Key Concepts * Taking vital signs is one of the most important parts of nursing care in any settings. Health status is reflected to this indicators and any irregularity or change might indicate a problem in the patients’ health equilibrium. For over 100 years, nurses have performed this surveillance using the same vital signs: temperature, pulse, blood pressure, respiratory rate and in recent years, oxygen saturation (Earns, 2008). Taking temperature the nurse must also be aware of the difference in the core temperature between anatomical sites.
Approach I Temperature I Rectal | 37. 6 CLC Auxiliary 1 37. C I Ear 136. C I oral 1 37. C I * Pulse rate is the pattern of a person’s heartbeat, recorded as beats per minute, it varies as a person ages, infants may have a higher pulse than children and adult, Normal pulse rate ranges from 60-100 beats/minute.
* Respiratory rate in which is maintained within the range of 10 to 20 times in each minute, but children and infants tend to breathe more rapidly than adults. Patients’ blood pressure that refers to the force of the blood against arterial walls has normal rate of 120/80 * Pain is known as the fifth vital sign assessing pain is the key to effective mug. Main control. The severity of pain may be measured with the use of pain scale, the scale of 1 to 10 referring 1 as the lowest and 10 as the highest intensity of pain. * Research suggests that pulse geometry is useful for detecting a change in condition that may otherwise have been missed, resulting in changed patient management and a reduction in the number of investigations undertaken (Lockwood et al, 2004).
Hypertension is a blood pressure that is above the normal rate, with a systolic pressure of ; 120 and a diastolic pressure of ; 80 mug.