NURSING DIAGNOSIS: Pain: headache

related to:
  1. trauma to the cerebral tissue associated with the surgical procedure;
  2. stretching or compression of cerebral vessels and tissue associated with increased intracranial pressure if it occurs;
  3. irritation of the meninges associated with bleeding from meningeal vessels, leakage of blood into the cerebrospinal fluid (CSF), and/or inflammation of the meninges.
Desired Outcome
The client will obtain relief from headache as evidenced by:
  1. verbalization of same
  2. relaxed facial expression and body positioning.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for signs and symptoms of headache (e.g. statements of same, restlessness, irritability, grimacing, rubbing head, avoidance of bright lights and noises, reluctance to move).
  2. Assess client's perception of the severity of the headache using a pain intensity rating scale.
  3. Assess the client's pain pattern (e.g. location, quality, onset, duration, precipitating factors, aggravating factors, alleviating factors).
  4. Implement measures to relieve headache:
    1. perform actions to reduce fear and anxiety about the pain experience (e.g. assure client that his/her need for headache relief is understood, plan methods for relieving headache with client)
    2. perform actions to reduce fear and anxiety (e.g. assure client that staff members are nearby, respond to call signal as soon as possible) in order to promote relaxation and subsequently increase the client's threshold and tolerance for pain
    3. administer analgesics before activities and procedures that can cause headache and before headache becomes severe
    4. perform actions to minimize environmental stimuli (e.g. provide a quiet environment, limit number of visitors and their length of stay, dim lights)
    5. avoid jarring bed or startling client to minimize risk of sudden movements
    6. perform actions to prevent and treat increased intracranial pressure and meningitis (see Postoperative Diagnosis 3, actions B and C in IICP complication and actions C and D in meningitis complication)
    7. provide or assist with nonpharmacologic measures for headache relief (e.g. cool cloth to forehead, progressive relaxation exercises)
    8. administer nonnarcotic analgesics or codeine if ordered (other narcotic [opioid] analgesics are usually contraindicated because they have a greater depressant effect on the central nervous system).
  5. Consult physician if above actions fail to relieve headache.