Assessment Subjective: Sobrang sakit ng ulo ko.

Siguro 9/10 yung pain scale, as verbalized by the client

Nursing Diagnosis Acute pain related to inflammatory process secondary to Dengue Hemorrhagic Fever

Rationale When the Dengue Virus is already recognized by the infected monocytes, there will be a release of cytokines, which consist of vasoactive agents such as interleukins, tumor necrosis factor, urokinase and platelet activating factors which stimulates WBCs and pyrogen release Such cytokines are involved in not only the initiation but also the persistence of pathologic pain by directly activating nociceptive sensory neurons. Source: Brunner & Suddarths Medical & Surgical Nursing

Goals and Objectives After 30 mins of nursing interventions the patient will be able feel lessening of pain as manifested by: -Verbalization of lessening of pain scale of 9/10 to 5/10.

Interventions Independent: -Note or investigate changes from previous report of pain.

Rationale

Evaluation After 30 mins of nursing interventions the goal was met. The patient was able to feel lessening of pain as manifested by: -Lessening of pain scale from 9/10 to 5/10 -Absence of facial grimace & guarding behavior -Less irritability -Demonstrated deep-breathing technique -Utilized music therapy to refocus attention

-To rule out worsening of underlying condition/development of complications. -Body language or nonverbal cues may be both physiological and psychological and may be used in conjunction with verbal cues to determine extent and severity of the problem. -These may point precipitating or aggravating factors or identify developing complications. -To provide an environment that is conducive for resting & relaxation. -Patients may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing them. -This has thought to reduce the perception of pain by stimulating the descending control system,

Objective: -P-Peak of Fever -Q- dull pain -R- non-radiating -S- severe pain, 9 out of 10 pain scale -T- constant -Temp: -Facial grimace -Guarding behavior (curled up on a fetal position while supporting head) -Restless & Irritable -CBC result of: Hgb: 123 gms/L RBC: 4.06 x 1012/L

-Note nonverbal cues, such as restlessness, reluctance to move, abdominal guarding, withdrawal and depression.

-Absence of facial -Review factors that aggravate or grimace & guarding alleviate pain. behavior. -Absence of restlessness & irritability. -Demonstrate ways on how to lessen pain through a nonpharmacological way. -Maintain a quiet & nonstimulating environment.

-Eliminate additional stressors, such as noise or sources of discomfort whenever possible.

-Teach patient diversional activities such as Music Therapy, Imagery and Distraction

by Bare (12th edition), pages 232 to 234.

techniques.

resulting in fewer painful stimuli being transmitted to the brain. -To promote a nonpharmacological way of pain management. The gate control theory of pain proposes that stimulation of fibers transmit non-painful sensations can block or decrease the transmission of pain impulses. -Only the client can judge the level and distress of pain; pain management should be a team approach that includes the client.

-Provide comfort measures such as back rub & deepbreathing

-Instruct the patient to report immediately any improvement / exacerbations in pain experience.

Dependent: -Administer Paracetamol 500 mg PO q8h as ordered by the doctor.

- Paracetamol are thought to decrease pain by inhibiting cyclooxygenase, the enzyme involved in the production of prostaglandin. Source: Nurses Pocket Guide 11th Edition, pp 498-503. Brunner & Suddarths Medical & Surgical Nursing. Pages 247257.