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Nursing Care Plan: Kathleen Parks
Patient Information
• Name: Kathleen Parks
• Age: 26 years old
• Occupation: Graphic Designer
• Medical Diagnosis: Migraine without aura (G43.009), with
occasional migraine with aura
• Chief Complaint: "More frequent severe headaches" occurring 4-
5 times per week, rated 8/10 in severity
Nursing Assessment (Subjective & Objective Data)
Subjective Data (Patient Reports)
• "My headaches are throbbing and usually on one side of my head."
• "I see flashing lights and zig-zag lines before some headaches."
• "Light and noise make the pain so much worse. I just have to lie
down in a dark, quiet room."
• "I feel nauseous, and sometimes I vomit when it's really bad."
• "My job as a graphic designer means I'm at the computer 8-10
hours a day. I think that's a trigger."
• "I'm not sleeping well—only about 5-6 hours a night."
• "I skip meals often because I'm so busy at work."
• "Over-the-counter ibuprofen barely helps anymore."
• "My mom has migraines too."
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Objective Data (Physical Exam & Diagnostics)
• Vital Signs: BP 122/78 mmHg, HR 80 bpm, RR 16, Temp 98.4°F
(36.9°C), SpO2 99%
• General Appearance: Alert, oriented, well-nourished, in no acute
distress (between headache episodes)
• Head and Neck: Normocephalic, atraumatic. Non-tender temporal
arteries. Non-tender sinuses. No nuchal rigidity.
• Neurological Exam:
oCranial nerves II-XII: Intact
o PERRL: 3mm → 2mm, brisk reaction
o Fundoscopic exam: Optic discs sharp with distinct margins
(no papilledema)
o Motor strength: 5/5 all extremities
o Sensation: Intact to light touch
o Coordination: Finger-to-nose intact, gait steady
o Romberg: Negative
• Diagnostic Results:
o Urine pregnancy: Negative
o CBC: Normal
o ESR/CRP: Normal
o TSH: Normal
Nursing Diagnoses (Prioritized)
1. Acute Pain related to neurovascular changes (cranial vasodilation
and trigeminal nerve activation) as evidenced by patient reports of
throbbing unilateral pain rated 8/10, photophobia, phonophobia,
and nausea.
Nursing Care Plan: Kathleen Parks
Patient Information
• Name: Kathleen Parks
• Age: 26 years old
• Occupation: Graphic Designer
• Medical Diagnosis: Migraine without aura (G43.009), with
occasional migraine with aura
• Chief Complaint: "More frequent severe headaches" occurring 4-
5 times per week, rated 8/10 in severity
Nursing Assessment (Subjective & Objective Data)
Subjective Data (Patient Reports)
• "My headaches are throbbing and usually on one side of my head."
• "I see flashing lights and zig-zag lines before some headaches."
• "Light and noise make the pain so much worse. I just have to lie
down in a dark, quiet room."
• "I feel nauseous, and sometimes I vomit when it's really bad."
• "My job as a graphic designer means I'm at the computer 8-10
hours a day. I think that's a trigger."
• "I'm not sleeping well—only about 5-6 hours a night."
• "I skip meals often because I'm so busy at work."
• "Over-the-counter ibuprofen barely helps anymore."
• "My mom has migraines too."
, 2|Page
Objective Data (Physical Exam & Diagnostics)
• Vital Signs: BP 122/78 mmHg, HR 80 bpm, RR 16, Temp 98.4°F
(36.9°C), SpO2 99%
• General Appearance: Alert, oriented, well-nourished, in no acute
distress (between headache episodes)
• Head and Neck: Normocephalic, atraumatic. Non-tender temporal
arteries. Non-tender sinuses. No nuchal rigidity.
• Neurological Exam:
oCranial nerves II-XII: Intact
o PERRL: 3mm → 2mm, brisk reaction
o Fundoscopic exam: Optic discs sharp with distinct margins
(no papilledema)
o Motor strength: 5/5 all extremities
o Sensation: Intact to light touch
o Coordination: Finger-to-nose intact, gait steady
o Romberg: Negative
• Diagnostic Results:
o Urine pregnancy: Negative
o CBC: Normal
o ESR/CRP: Normal
o TSH: Normal
Nursing Diagnoses (Prioritized)
1. Acute Pain related to neurovascular changes (cranial vasodilation
and trigeminal nerve activation) as evidenced by patient reports of
throbbing unilateral pain rated 8/10, photophobia, phonophobia,
and nausea.
