The vertigo is: taste sensation of movement or movement of the body or the environment, can be accompanied by other symptoms, particularly from the network due to interference otonomik tool Vertigo balance the body may not be the only symptoms of a headache only, but the collection of symptoms or the syndrome consisting of symptoms somatik (nistagmus, unstable), otonomik (pale, cold sweat, nausea, vomiting) and dizziness.
Assessment
- Summary / Rest
- Tired, weakness, malaise
- Limitation of movement
- Stress the eyes, difficulty in reading
- Insomnia, awake in the morning with sore heads.
- Pain Management at the great changes in body postures, activities (work) or because the weather changes.
- Circulation
- Historical hypertension
- Flutter vaskuler, eg the Temporal.
- Pale, reddish face appears.
- Ego Integrity
- Factors emotional stress / environment
- Concerns, ansietas, sensitive stimulus for headache
- Mechanism refresif / dekensif (headache chronicles).
- Food and liquids
- Food vasorektiknya such as the high caffeine, chocolate, onion, cheese, alcohol, wine, meat, tomatoes, fatty food, citrus, sauce, hotdog, MSG (in migraine).
- Nausea / vomiting, anoreksia (for pain)
- A decrease in body weight
- Neurosensoris
- Dizziness, disorientation (during headache)
- Historical convulsions, head of the new injury occurred, trauma, stroke.
- Aura; fasialis, olfaktorius, tinitus.
- Changes in the visual, sensitive to light / sound that hard, epitaksis.
- Parastesia, progressive weakness / paralysis one side tempore
- Changes in the pattern of speech / thought patterns
- Easy to inflame, is sensitive to stimulus.
- The decline in the tendon reflex
- Papiledema.
- Pain / comfort
- Characteristics of pain depends on the type of headache, ie migraine, muscle tension, cluster, brain tumor, pascatrauma, sinusitis.
- Pain, redness, pale face in the region.
- Focus on narrow
- Focus on self
- Response emotional / behavior is not effective, such as crying, anxiety.
- Musculature also strain the neck, vocal frigiditas.
- Security
- Historical allergic reaction or allergy
- Fever (headache)
- Disturbance walk, parastesia, paralisis
- Residents purulent nasal (headache sinus on interference).
- Social interaction
- Changes in the responsibility / role of social interaction associated with the disease.
- Counseling / learning
- Historical hypertensi, migraine, stroke, disease in the family
- Use of alcohol / other drugs, including caffeine. Oral contraceptives / hormone, menopause.
Nursing Diagnosis
Pain (acute / chronic) associated with stress and tension, irritation / nerve pressure, vasospressor, with a marked increase in intrakranial states that pain is influenced by factors eg changes in position, changes in sleep patterns, anxiety.
Intervension
Results Criteria:
- Client revealed reduced pain
- Vital signs normal
- The patient appears quiet and rileks.
Intervention:
- Monitor vital signs, the intensity / pain scale.
- Suggest the client resting place to sleep.
- Set the position of the patient may senyaman.
- Teach relaxation techniques and breath in.
- Collaboration for the analgetik.
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