ADPIE Nursing process

Nursing Process

Nursing Process: is a scientific approach used by nurses to provide quality care to a patient using a dynamic and organized step to achieve the outcome (“alleviate pain, restore health and save life”).

1. Assessment

· Verify patient with two-way verification

Access health history

What brought you here today?

When did your headache started?

Where do you feel the pain during your headache? Right side, left side, or on both sides?

On average how often do you have headaches? Once a week, a month or seasonal?

On the scale of 0 to 10, how painful do you rate your headaches? 0 being no pain and 10 being the worst pain.

What kind of pain do you feel with your headache? Throbbing, stabbing, dull ache or burning?

Do you experience any of these warning symptoms before your headache begins? Flashes of light in your vision, zigzag lines, dizziness or vertigo, numbness/tingling, blurry vision and nausea.

Do you experience any of these symptoms during your headaches? Difficulty concentrating, vomiting, sensitivity to light, bothered by loud sound, irritability.

What makes you feel better?

Are you taking any medication? Any allergies to medication?

How many hours of sleep do you get each night?

Do you have stress? How do you manage your stress?

Does anybody in your family have a history of heart disease (heart attack, stroke, high blood pressure…), neurologic disease (seizure, brain tumor…) and migraines or other headaches?

When was your last visit to the doctor’s office for headaches?

Any of the following testing done previously? Such as Sinus X-rays, CT scan and MRIs.

Physical examination and vital signs

1. Body temperature

2. Pulse rate

3. Blood pressure

4. Respiration rate

5. Oxygen saturation

6. Pain

2. Diagnosis

Compare clinical findings with normal and abnormal events. Interpret the data collected make hypotheses, test hypotheses and drive diagnoses, then document validated diagnoses.

Nursing diagnosis

Activity intolerance related to acute pain and headache as evidenced by throbbing or pulsing pain on the left side of the head, sensitivity to light, sounds, and sometimes smells and touch.