C10 · Headache
Actual Comfort and rest
Definition
Pain in the head that may limit rest and activity.- Tension
- migraine
- high blood pressure
- dehydration
- head injury
- Head pain
- sensitivity to light
- nausea
- squinting
- wants to lie in the dark
📋 Scenario
A woman says her head is pounding and bright light makes her feel sick.
Subjective (S): "My head is pounding and the light makes me feel sick."
Objective (O): Pain 8/10; squints in light; nausea; blood pressure 138/84; no neurological deficit.
Assessment tools for this scenario: CP-PAIN Pain & Comfort Score CP-SKIN Skin & Wound Score CP-BREATH Breathing & Circulation Check
Validated scales to consider: NRS 0–10, FLACC, PAINAD, Braden Scale, TIME wound chart, NEWS2, SpO₂, ECG
**CarePath diagnosis:** Headache related to tension, as evidenced by head pain and sensitivity to light.
**Interventions and rationale**
| Intervention | Rationale |
|---|---|
| Assess pain and warning signs. | Assessing pain and warning signs rates severity and detects danger signs that suggest a more serious cause than tension. |
| Rest in a quiet dark room. | A quiet, dark room reduces light and noise, which worsen pain and nausea, so the patient can rest. |
| Give pain relief as ordered. | Pain medicine acts on pain pathways or inflammation, lowering the pain so the patient can rest and recover. |
| Report sudden severe headache or neurological signs. | Sudden severe headache or neurological signs can mean a serious problem such as bleeding or stroke, which needs urgent medical assessment. |
**Expected outcomes**
- Within 1-2 hours: pain 3/10 or lower and resting comfortably.
- No neurological changes.
- Patient names triggers to avoid.
**Linking the data to the diagnosis**
The woman says her head is pounding and the light makes her feel sick. The nurse found pain of 8/10, squinting in light, nausea, blood pressure 138/84 and no neurological deficit. Head pain with light sensitivity and nausea fits this diagnosis, and the lack of neurological signs fits a cause such as tension, though warning signs must still be watched. The headache is present now, so it is an actual diagnosis. The plan aims within 1 to 2 hours for pain of 3/10 or lower and comfortable rest, with no neurological changes and the patient naming triggers to avoid.
CarePath diagnosis
Headache related to tension, as evidenced by head pain and sensitivity to light.
Interventions and rationale
Listed in priority order.
| Intervention | Rationale |
|---|---|
| 1. Assess pain and warning signs. | Assessing pain and warning signs rates severity and detects danger signs that suggest a more serious cause than tension. |
| 2. Rest in a quiet dark room. | A quiet, dark room reduces light and noise, which worsen pain and nausea, so the patient can rest. |
| 3. Give pain relief as ordered. | Pain medicine acts on pain pathways or inflammation, lowering the pain so the patient can rest and recover. |
| 4. Report sudden severe headache or neurological signs. | Sudden severe headache or neurological signs can mean a serious problem such as bleeding or stroke, which needs urgent medical assessment. |
Expected outcomes
- Within 1-2 hours: pain 3/10 or lower and resting comfortably.
- No neurological changes.
- Patient names triggers to avoid.
Linking the data to the diagnosis
The woman says her head is pounding and the light makes her feel sick. The nurse found pain of 8/10, squinting in light, nausea, blood pressure 138/84 and no neurological deficit. Head pain with light sensitivity and nausea fits this diagnosis, and the lack of neurological signs fits a cause such as tension, though warning signs must still be watched. The headache is present now, so it is an actual diagnosis. The plan aims within 1 to 2 hours for pain of 3/10 or lower and comfortable rest, with no neurological changes and the patient naming triggers to avoid.