Assessment S: O: Patient manifested: >Guarding behavior >Body pain >Pain scale of 8/10 Vital Signs as follows: T: 35.

8 PR: 63 bpm RR: 18 cpm BP: 110/80 Patient may manifest: >Sleep disturbance >Moaning behavior >Change to muscle tone >Diaphoresis

Nursing Diagnosis Acute Pain

Scientific Explanation In leptospirosis, toxins, specifically lectinese and enteroxins, are released in the body. Such toxins irritate the body causing breakdown of phospholipids which then leads to muscle tissue destruction. In muscle cell destruction, the body experiences myalgia which leads to the feeling of pain in the body.

Objectives Short Term: After 4-6 hours of nursing interventions, patient will be able to demonstrate cues that show relief from pain Long Term: After 4 weeks of nursing interventions, the patient will demonstrate use of relaxation techniques and diversional activities, as indicated, for individual situation to control and relieve from pain

Nursing Interventions 1. Establish rapport Monitor temperature and vital signs Assess pain, location, intensity, characteristic s Obtain clients assessment of pain Observe nonverbal cues of pain Provide comfort measures Provide adequate rest Instruct and encourage use of relaxation

Rationale

Expected Outcome

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technique 9. Administer medications as indicated

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To gain trust and cooperation Can be indications of altered pain Helps evaluate degree of discomfort and effectiveness of analgesia To rule out worsening or underlying condition or developing complications Observations may not be congruent with verbal reports To promote relaxation To decrease workload of heat To distract attention and reduce tension To relieve pain, enhance comfort and promote rest

Short Term: The patient shall have demonstrated cues pertaining to relief of pain Long Term: The patient shall have demonstrated use of relaxation techniques and diversional activities as indicated for individual situation to control and relieve from pain as evidenced by reduced irritability, restlessness, guarding behavior and facial grimaces.

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