August 13, 2013, Day 1 ASSESSMENT SUBJECTIVE: Masakit ang buong katawan ko.

Lalo na itong mga paa ko (pertaining to his calf). as verbalized by the patient. P: movements Q: aching R: localized S: 5/10 T: starts when he moves or attempts to move and ends when he rests or stops from moving NURSING DIAGNOSIS Acute Pain related to infection secondary to Leptospirosis SCIENTIFIC EXPLANATION Circulation and multiplication of bacteria Through bld. Vessels and lymphatics PLANNING SHORT TERM GOAL: After 3-4 hours of quality nursing interventions, the patient will be able to manifest alleviated pain as evidenced by: Patient will rate pain as 3-4 out of 10 Able to move with minimal pain Vitals signs within normal range as follows: BP: 120-139/80-99 mmHg Temp: 36.5-37.5C PR: 60-100 bpm RR: 12-20 cpm Minimal grimace Absence of difficulty of breathing IMPLEMENTATION INDEPENDENT: Establish rapport. Obtain patients assessment of pain to include location, characteristics, onset and duration, frequency, quality, intensity, and precipitating or aggravating factors. Observe nonverbal cues and pain behaviors. RATIONALE To gain the patients trust. To rule out worsening or underlying condition or development of complications. EVALUATION SHORT TERM GOAL: After 4 hours of quality nursing interventions, the goal was met, as evidenced by: Patient rated pain as 4 out of 10 Able to move with minimal pain Vital signs were as follows: BP:100/70 Temp: 36.8C PR: 94 bpm RR:20 cpm Minimal grimace Absence of difficulty of breathing

Invasion in Skeletal muscles

Decreased blood flow in muscle components related to damage to vessels

Vaculization of myofibril related to inflammation

Necrosis in some Myofibrils

Compression of nerve endings in muscles

OBJECTIVE: Vital signs: BP: 90/60 mmHg Temp: 36.8C PR:125 bpm RR: 25 cpm Muscle strength: RA 3/5 RF 3/5 LA 3/5 LF 3/5

Lactic acid formation through anaerobic process

Pain

Appears weak Facial grimace Difficulty of breathing

LONG TERM GOAL: After 1-2days, the patient will be able to manifest absence of pain, as evidenced by: Patient will rate pain as 0 out of 10 Able to move without experiencing pain Vitals signs within normal range as follows: BP: 120-139/80-99 mmHg Temp: 36.5-37.5C

Observations may not be congruent with verbal reports or may be only indicator present when client is unable to verbalize. To promote nonpharmacological pain management. To divert the patients attention. To prevent fatigue. To promote

Provide comfort measures Encourage diversional activities. Encourage adequate rest periods. Encourage patient

LONG TERM GOAL: After 2 days, the goal was met, as evidenced by: Patient rated pain as 0 out of 10 Able to move without experiencing pain Vitals signs within normal range as follows: BP: 120/80 Temp: 36.5C PR: 95 bpm RR: 20 cpm Absence of grimace Muscle strength of:

PR: 60-100 bpm RR: 12-20 cpm Absence of grimace Muscle strength of: RA LA 5/5 5/5 RF LF 5/5 5/5

to assume position where he feels comfortable COLLABORATIVE: Administer Paracetamol 500 mg 1 tab, as ordered Administer oxygen 2 Lpm via nasal cannula

comfort for the patient

RA 5/5 RF 5/5

LA 5/5 LF 5/5