Patient is a 34-year-old female presenting with a 3-day history of progressive frontal headache rated 7/10 in severity. Patient reports the headache is throbbing, worse in the morning, and partially relieved by over-the-counter ibuprofen. Associated symptoms include mild nausea and photophobia. Patient appears mildly uncomfortable but alert and oriented. Vital signs notable for elevated blood pressure at 152/94 mmHg.
- Past Medical History: Type 2 Diabetes Mellitus (diagnosed Jan 2024), Essential Hypertension (diagnosed Jun 2022)
- Allergies: Penicillin (severe reaction — anaphylaxis)
- Current Medications: Losartan 100mg daily, Metformin 500mg BID, Amlodipine 5mg daily, Sumatriptan 50mg PRN
- Social History: Non-smoker, occasional alcohol use, works as an accountant, reports increased work-related stress
- Functional Status: Independent in all ADLs, ambulatory without assistance
- Sleep: Reports poor sleep quality over past 2 weeks (4-5 hours/night)
- Neurological: Alert and oriented x4 (person, place, time, event). GCS 15/15. Pupils equal, round, reactive to light (PERRLA). No focal neurological deficits.
- Cardiovascular: Regular rate and rhythm, no murmurs. Peripheral pulses 2+ bilaterally. No pedal edema. Capillary refill <2 seconds.
- Respiratory: Breath sounds clear and equal bilaterally. RR 16/min, SpO2 98% on room air. No cough or dyspnea.
- Gastrointestinal: Abdomen soft, non-tender, non-distended. Bowel sounds present in all four quadrants. Patient reports mild nausea, no vomiting.
- Integumentary: Skin warm, dry, intact. No rashes, lesions, or pressure injuries. Braden Scale score: 23 (no risk).
- Musculoskeletal: Full range of motion in all extremities. No tenderness. Steady gait.
- Acute Pain related to headache as evidenced by patient report of 7/10 pain and facial grimacing
- Disturbed Sleep Pattern related to work-related stress and pain as evidenced by patient report of 4-5 hours sleep/night
- Risk for Ineffective Health Maintenance related to elevated blood pressure (152/94) and suboptimal glycemic control (HbA1c 7.2%)
- Administer prescribed medications as ordered (Losartan 100mg, Sumatriptan 50mg PRN)
- Monitor vital signs Q4H with focus on blood pressure trends
- Maintain dim, quiet environment to reduce headache triggers
- Assess pain level using numeric rating scale every 2 hours
- Educate patient on medication compliance and importance of home BP monitoring
- Provide sleep hygiene education and stress management resources
- Document intake and output; encourage adequate oral hydration
- Implement fall precautions due to headache and potential medication side effects