A Nursing Case Analysis

on
FIBROMYALGIA

In Partial Fulfilment of the

Requirement for NCM 216 - RLE

NCM 216 RLE: PERCEPTION-COORDINATION ROTATION

Submitted to:
MR. RALPH HERMAN B. LEE, RN

Clinical Instructor

Submitted by:
Bai Shajade Mae G Abdula, St.N
Shanly Faye A. Aldueso, St.N
Ella G. Alvar, St.N
Nova Mae O. Balug, St.N
Raina Valerie B. Benignos, St.N
Harvey L. Beseril, St.N
Charisse Maryjoy A. Dy, St.N
Maaroupha B. Esmail, St.N
BSN 3C & 3D - GROUP 1- SUBGROUP 3

February 12, 2022

CRITERIA FOR GRADING

Introduction/Objectives 10%
Pathophysiology
a. Etiology 10%
b. Symptomatology 10%
c. Disease Process 5%
Management 15%
a. Diagnostic and Screening Test
b. Pharmacological Management
c. Surgical Management
d. Nursing Management
Prognosis 10%
Discharge Planning 10%
Nursing Theory 10%
Review of Related Studies 10%
References 5%
Promptness 5%

TOTAL 100%

1
 Table of Contents

INTRODUCTION/OBJECTIVES

PATHOPHYSIOLOGY
Etiology
Symptomatology
Disease Process

MANAGEMENT
Medical Management
Diagnostic and ScreeningTest
Pharmacological Management
Alternative Management
Surgical Management
Nursing Management

PROGNOSIS

DISCHARGE PLAN

NURSING THEORY

REVIEW OF RELATED STUDIES

REFERENCES

2
 I. INTRODUCTION

Perception and Coordination nursing rotation covers the concepts,

principles, and nursing care management theories for clients focused on any
population group with alterations or problems in perception and coordination. It
also deals with the physiological functioning in the different states of health and
diseases for patients including visual and hearing disabilities, neurological
damage, and musculoskeletal disorders to name a few. One disease that falls
under these types of problems is Fibromyalgia wherein current researches
suggests it involves of the nervous system, particularly the central nervous
system and is not from an autoimmune, inflammation, joint, or muscle disorder
(American College of Rheumatology Committee on Communications and
Marketing, 2021).

Fibromyalgia is a long-lasting condition that causes chronic pain all over

the body (widespread pain), sleep problems, fatigue, and often emotional and
mental distress (Fibromyalgia, 2022). The exact cause of fibromyalgia is
unknown, but researchers think that stressful or traumatic events, repetitive
injuries or viral infections might contribute to its cause (Fibromyalgia, 2021).
Another research suggests it is a problem of the brain and spinal cord
misinterpreting messages from the body so that normally nonpainful signals are
felt as painful. This causes people with fibromyalgia to become ultra-sensitive to
touch or movement. The condition can run in families, so genetics may also play
a role (MedlinePlus Magazine, 2018). There is no cure for it, but doctors and
other health care providers can help manage and treat the symptoms. Treatment
typically involves a combination of exercise or other movement therapies,
psychological and behavioral therapy, and medications (NIAMS, 2017).

Globally, Fibromyalgia affects 2.7% of the world's population

(Kovachevska, 2021). It is estimated that there is a 4.7% prevalence of
fibromyalgia in Europe while Brazil has an estimated 4.5% (Boomershine, 2020).
Fibromyalgia is prevalent in women with CHOICE: Pain and Rehabilitation

3
Center (2022) stating that women are reported to be twice as likely to suffer from
fibromyalgia as men because of factors such as hormonal changes and the
potential for higher stress, backed up by The Medical City (2017) expressing that
nine times out of ten Fibromyalgia patients are women, particularly of
childbearing age (20-65 years old peaking at 35 years old). There were no
references found indicating the incidence rate of fibromyalgia in the country of
Philippines and in Davao City.

The nursing implication of this case analysis, mainly for nursing education,
is to acquire knowledge about Fibromyalgia as this case analysis will be further
discussed specifically about the general overview of the condition, its causes,
symptoms, and treatments. It will also be of help in nursing practice, for this study
can function as a roadmap for clinical practitioners and student nurses, in terms
of delivering effective nursing interventions to achieve optimal health care
delivery. Lastly, for nursing research, this study can be used to perform further
research to generate new theories and conjectures regarding Fibromyalgia. The
treatment options currently available or mentioned would give us an idea on what
to possibly improve for future cases.

4
II. GOALS AND OBJECTIVES

General Objective
Within 4 weeks of Nursing Rotation, the student nurses of BSN 3C and 3D
Group 1 Subgroup 3 will be able to formulate a thorough case analysis regarding
Fibromyalgia. This will help contribute to the enhancement of knowledge, skills,
and attitudes of the student nurses and allow application of the principles and
theories learned specifically in the case study unto the clinical setting.

Specific Objectives
In order to achieve the general objective, the group specifically aims to:

a. present the concept and statistics of the disease, and the nursing
implications in the introduction;
b. formulate both general and specific objectives of the case study;
c. identify the predisposing and precipitating factors that contribute to the
onset of the disease;
d. state the symptomatology or cues which signify the presence of
Fibromyalgia;
e. trace the disease process of Fibromyalgia through a schematic diagram;
f. determine the diagnostic or laboratory confirmatory tests for Fibromyalgia;
g. categorize appropriate medical and nursing management;
h. devise appropriate nursing care plans for the client;
i. generate a discharge plan with the use of METHOD format;
j. summarize the prognosis of Fibromyalgia and chance of recovery whether
treated or untreated;
k. relate nursing theories that provides the best guide for nursing patients
with Fibromyalgia, and
l. cite books, references, and internet websites to be used as a source of
information.

5
III. PATHOPHYSIOLOGY

A. Etiology

Table 1.1 Predisposing Factors of Fibromyalgia

Factors Rationale

Sex Fibromyalgia is more common

in women than in men. According to
the National Institute of Arthritis and
Musculoskeletal and Skin
DiseasesTrusted Source (NIAMS),
women are eight to nine times more
likely than men to have fibromyalgia.
One of the reasons women may be at
greater risk is because of factors such
as hormonal changes and the
potential for higher stress due to
menstruation, menopause, or
pregnancy. As women's natural
response to stress can evoke a more
severe reaction than their male
counterparts as well as, chronic
stress can diminish the immune
system’s ability to respond to and fight
against diseases over time.

Age Fibromyalgia most often

develops during a woman's

6
 childbearing years and is most
commonly diagnosed between the
ages of 20 and 50. For this reason,
pregnancy can be accompanied with
high levels of stress both physical and
emotional which in return could trigger
fibromyalgia. As with pregnancy, there
are changes in the levels of estrogen,
progesterone, and other hormones.

Genetics Fibromyalgia tends to run in

families, there may be certain genetic
mutations that may make you more
susceptible to developing the disorder.
This may be due to multiple genetic
variants, rather than a single one.

Race African-American women have

a higher prevalence of fibromyalgia
than white women. This is due to the
increased body pain and tenderness
that are known to be associated with
decreased socioeconomic status.

7
 Table 1.2 Precipitating Factors of Fibromyalgia

Factors Rationale

Lupus Erythematosus Fibromyalgia is a disorder that

can occur alone or secondary to
connective tissue disorders such as
lupus. Studies suggest that about 25%
of people who have lupus also have
fibromyalgia. This is attributable to the
involvement of N-methyl-D-aspartate
(NMDA) and neurokinin receptor
systems. Thus, autoimmune activity
against these receptor systems in SLE
patients could result in pain, cognitive
defects, and chronic pain states
including fibromyalgia.

Obesity Being overweight or obese has

an associated increased risk of
fibromyalgia. As excess weight leads
to more pain and fatigue and lower
quality of life. Fibromyalgia hurts more
when you are overweight. Having too
much body fat and too little muscle
also increases fatigue and worsens
many other symptoms.

8
Osteoarthitis and Rheumatoid Arthritis Chronic pain from rheumatoid
arthritis and osteoarthritis can cause
changes in the way the nervous
system perceives and processes pain,
and that process can trigger
fibromyalgia.

Post Traumatic Stress Disorder Any type of trauma or stressful

(PTSD) event can trigger fibromyalgia. Thus,
PTSD is viewed as a marker of stress
vulnerability in which persons
susceptible to stress are more likely to
develop health problems including
fibromyalgia when a potential
traumatic event occurs.

Viral Infection The Epstein-Barr virus, and the

viruses that cause influenza, and
hepatitis B and C have all been
implicated in the development of
fibromyalgia. These viruses may have
long-term effects on the immune
system. To which, these viral particles
will attach to glial cells, which are cells
within the brain that affect
neurotransmission and influence the

9
 pain response.

B. Symptomatology

SYMPTOMS RATIONALE

Widespread pain and stiffness Repeated nerve stimulation

causes the brain and spinal cord of
people with fibromyalgia to change.
This change involves an abnormal
increase in levels of certain chemicals
in the brain that signal pain. The pain
associated with fibromyalgia often is
described as a constant dull ache that
has lasted for at least three months.
To be considered widespread, the pain
must occur on both sides of your body
and above and below your waist.
More so, the majority of
fibromyalgia patients are having a
state of central sensitization. In these,
there are changes in the muscles,
such as mitochondrial changes, a
change in the microcirculation and/or a
change in muscle metabolism, might
sensitize muscle nociceptors and
thereby cause pain and stiffness all
over the body.

Fatigue Fatigue is the result of your

10
 body trying to deal with the pain. This
constant reaction to pain signals in
your nerves can make you lethargic
and exhausted.

Cognitive difficulties A symptom commonly referred

to as "fibro fog" impairs the ability to
focus, pay attention and concentrate
on mental tasks. Fibro fog can be
related to the impact of fibromyalgia
pain. Managing chronic pain demands
attention and may some take mental
effort, which can reduce available
cognitive processing resources and
affect performance on a cognitive task.

Sleep problems Fibromyalgia patients lack the

restorative levels of deep, non-rapid
eye movement (REM) sleep. They are
constantly aroused by bursts of
"awake" brain activity, which limits the
amount of time they spend in these
critical deep stages of sleep. In EEG
studies, fibromyalgia patients in
deep-sleep stages have been found to
have alpha waves, which are signs of
arousal or wakening.

11
Depression and Anxiety The stress from fibromyalgia's
pain and fatigue can cause anxiety
and social isolation. The chronic deep
muscle and tender point pain can
result in less activity. Which in return
causes you to become more
withdrawn and can also lead to
depression.

Numbness and tingling sensation People with fibromyalgia may

experience numbness and/or tingling
in their arms, hands, legs, feet, and
sometimes face. This is a result of
generally heightened sensitivity of the
nerves as well as an amplified pain
response in the brain.

Digestive problems More than two-thirds of those

with fibromyalgia also have stomach
pain, bloating, gas, and nausea on a
regular basis. Constipation or diarrhea
can also occur regularly. These can be
resulted from a nervous system that is
overly sensitive or hyperactive, as well
as high levels of stress.

12
C. Disease Process

13
14
Narrative:

Fibromyalgia is a complicated condition with no specific cause, but it

appears to be linked to a problem with pain processing in the brain. Before
discussing the disease progression of this condition, let's state first the
predisposing and precipitating factors that increase risk of having fibromyalgia.
Age, sex, family history/genetics, and race are some of the predisposing factors.
On the other hand, precipitating factors include obesity, having lupus
erythematosus, osteoarthritis or rheumatoid arthritis, post-traumatic stress
disorder, and viral infection.

When stress levels rise, the hypothalamus releases corticotrophin

releasing factor (CRF), which activates or induces the release of
adrenocorticotrophic hormone (ACTH) from the anterior pituitary gland, which
activates or induces the activation of the HPA axis (Hypothalamic Pituitary
Adrenal Axis) which leads to the release of cortisol. Furthermore, when there is a
high level of cortisol for long period of time, it can lead to impaired T cell function
and natural killer cell activity. CRF can also cause microglial activation in the
brain and sympathetic nervous system activation, and it is usually a chronic
issue. Although other activities, such as exercise, can engage the sympathetic
nervous system, it can also trigger the activation of microglial cells, which is a
sort of activity that stimulates the sympathetic nervous system. Importantly,
activation of the sympathetic nervous system leads to the release of
norepinephrine and epinephrine, and activation of the microglia leads to the
activation of macrophages, and norepinephrine leads to the activation of
macrophages as well. TNF, or Tumor Necrosis Factor, and certain cytokines are
increased when macrophages are activated. Fibromyalgia cannot be diagnosed
by any medical test that is universally accepted. Instead, diagnostic tests are
carried out to discover if the symptoms are caused by something else. Typically,
blood tests are conducted to screen out illnesses that have similar symptoms.
Certain diagnostic test involve ar FM/a test, ANA test, Erythrocyte Sedimentation
Rate (ESR), C- Reactive Protein test (CRP) and Thyroid function test.

15
 Tryptophan normally is acted on by the enzyme Tryptophan hydroxylase
and there’s two isoforms of this enzyme Tryptophan 1 and 2. Both these
enzymes can add a hydroxyl group to tryptophan to form 5-Hydroxytryptophan
(5-HTP). Once we get 5-Hydroxytryptophan it gets acted on by the enzyme L-
aromatic amino acid decarboxylase to form 5-Hydroxytryptamine so it
decarboxylates 5 HTP, it removes CO2 molecule to form serotonin and there’s
some other steps in between but 5-Hydroxytryptamine can ultimately be
processed into melatonin which we refer to as a sleep hormone, it helps regulate
sleep cycles, so serotonin again is important in mood regulation, cognition and
melatonin which also derived from serotonin is important in regulating sleep wake
cycles. However, tryptophan may be degraded by enzymes such as indoleamine
2,3 Dioxygenase (IDO) or tryptophan dioxygenase (TDO) into the breakdown
product Kynurenine and then processed further into Kynurenine Metabolites
before it can be converted into 5-Hydroxytryptamine or melatonin. Another issue
is that cortisol can cause tryptophan dioxygenase (TDO) to become active,
causing tryptophan to be degraded into kynurenine and kynurenine Metabolites.
As a result, having a high level of TFN, IL-1, IL-6, and cortisol may basically
re-route tryptophan into the Kynurenine pathway and resulting in lower amounts
of tryptophan and dysfunctions in neurotransmitters like serotonin, and
melatonin, all of which may play a part in a variety of FM symptoms. This is more
common in animal models, and it is also known that serotonin regulates sections
of the spinal cord in humans, but it has been discovered that spinal cord 5HT 2C
and 5HT 3 receptors have anti-nociceptive or pain modulating properties in
animal models as well.

Antinociceptive means that they have abilities to reduce pain, so serotonin

activating these receptors in the spinal cord reduces pain. As we can see in
fibromyalgia, low serotonin levels can lead to decreased activation of 5HT 2C
and 5HT 3 receptors, as well as decreased activation of the serotonin receptor in
the spinal cord, which may lead to increased pain. This may be a possible
mechanism as to why serotonin plays a role in some of the symptoms of FM.

16
Another mechanism, descending inhibitory pain pathways, which control the
spinal cord's response to painful stimuli, are claimed to play a role in nociception.
They appear to be compromised in fibromyalgia patients, which adds to the
increased central sensitization. Central sensitization refers to the increased
sensitivity of the central nervous system's nociceptors to stimuli that are either
normal or sub-threshold afferent input, central sensitization includes certain signs
and symptoms like widespread pain and stiffness, fatigue, cognitive difficulties,
sleep problems, depression and anxiety, numbness and tingling sensation, and
digestive problems. The overall mortality of this condition is not increased and it
is not an organ-threatening disease. However, if left untreated, it may result in
long-term widespread pain and worsening of symptoms. On the contrary, patients
treated by primary care will have a much better prognosis. There is no cure for
fibromyalgia, but there are medical and therapeutic managements that can help
the patient to regain control and achieve significant improvement. Administration
of antidepressants, nonopioid analgesic, antipyretic, anticonvulsant, antianxiety
agents, skeletal muscle relaxants, anxiolytics, and elective norepinephrine are
used in managing fibromyalgia medically. Therapeutic management includes
radiofrequency ablation, physical therapy, occupational therapy, and
psychotherapy. More so, there is still no known surgical procedure that may
possibly treat this condition.

IV. MANAGEMENT
D. Medical Management
According to Weatherspoon (2020) and Healthwise (2021), there
are no specific tests that can confirm a diagnosis of fibromyalgia.
Physicians may rule out lab tests to check out other diseases and to check
if these tests can find out another disease along with fibromyalgia. There
is no definite result for the diagnosis of fibromyalgia except for the FM/a
test.

i. Diagnostic and Screening Test

17
 Diagnostic Test Definition
Complete blood count This test includes a count of
red blood cells, white blood
cells, and platelets. It also
tests the amount of
hemoglobin in the blood.
Erythrocyte This test examines how
sedimentation rate quickly red blood cells settle
in the bottom of a test tube.
It can help with finding
Nursing Responsibilities
1. Explain the procedure.
Explain that slight
discomfort may be felt
when the skin is
punctured.
2. Encourage to avoid stress
if possible because altered
physiologic status
influences and changes
normal hematologic
values.
3. Explain that fasting is not
necessary. However, fatty
meals may alter some test
results as a result of
lipidemia.
4. Apply manual pressure
and dressings over
puncture site on removal.
5. Monitor puncture site for
oozing or hematoma
formation.
6. Instruct to resume normal
activities and diet.
1. Inform the doctor if the
patient is taking any
medications. They may
ask to temporarily stop
18
diseases that cause taking it before the test
inflammation and diagnosing since certain medications
polymyalgia rheumatica. may affect ESR result (eg,
This is also a test that steroids, NSAIDs, and
indirectly measures stains may cause possible
inflammation. This test false lower ESR.)
measures how quickly 2. Inform that the procedure
erythrocytes or red blood might make them feel
cells (RBCs) settle at the uncomfortable at the sight
bottom of a test tube that of blood, or experience
contains a blood sample. discomfort seeing blood
When a sample of blood is drawn from the body. Talk
placed in a tube, the red "with the physician about
blood cells normally settle these concerns before
out relatively slowly, leaving getting their blood drawn.
a small amount of clear 3. Inform that they might feel
plasma. The red cells settle mild to moderate pain
at a faster rate when there is when the needle pricks
an increased level of into their skin and feel
proteins, such as C-reactive throbbing at the puncture
protein (CRP), that site after.
increases in the blood in 4. Inform that the doctor may
response to inflammation. order other tests like CRP
The ESR test is not test at the same time with
diagnostic; it is a nonspecific the ESR test because they
test indicating the presence can also predict the risk
or absence of an for Coronary artery
inflammatory condition disease and other
cardiovascular
diseases,,Monitor the

19
 patient for signs of
bleeding, fainting,
hematoma, bruising,
infection, inflammation of
the vein, tenderness, and
lightheadedness.

C-reactive protein test This test looks for a 1. Obtain a list of

substance the liver produces medications the patient is
that is a marker for taking, including herbs,
inflammation. CRP levels in nutritional supplements,
the blood increase when and nutraceuticals. Advise
there is a condition causing the laboratory and the
inflammation somewhere in physician about the
the body. CRP is a regular uses of the
nonspecific indicator of medications so that their
inflammation and one of the effects can be taken into
most sensitive acute phase consideration when
reactants, meaning it is reviewing results.
released into the blood 2. There are no food, fluid or
within a few hours after the medication restrictions
start of an infection or other unless by medical
cause of inflammation. directions.
3. Review the procedure with
the patient.
4. Inform the patient that
specimen collection takes
approximately 5 to 10
minutes.

20
 5. Observe the venipuncture
site for bleeding or
hematoma formation.
6. Evaluate test results in
relation to the patient’s
symptoms and other tests
performed.

Thyroid function tests This checks for low or high 1. If the patient is a female
thyroid gland activity. who is breastfeeding,
Thyroid problems can cause explain to the patient that
fatigue and muscle depending on the type of
soreness. radionuclide and dose
used, temporary or
complete cessation of
breastfeeding may be
recommended.
2. Explain that the procedure
takes about 30 to 60
minutes and is performed
in a nuclear medicine
treatment.
3. Instruct patient to remove
jewelry and other metallic
objects from the area to be
examined prior to the
procedure
4. Baseline vital signs and
neurological status are
recorded.
5. Positioning for this

21
 procedure is in a supine
position on a flat table to
obtain images of the neck
area.
6. Monitor the patient for
complications related to
the procedure.
7. Explain that the
radionuclide is eliminated
from the body within 6 to
24 hours.
8. Unless contraindicated,
instruct the patient to drink
increased amounts of
fluids for 24 to 48 hours to
eliminate the radionuclide
from the body.
9. Instruct the patient to
resume usual diet, fluids,
medications, and activity
as directed by the
healthcare provider.
10. Help them understand that
depending on the results,
additional testing may be
performed to monitor
disease progression and
determine the need for a
change in therapy.

Anti-nuclear antibody This test determines if the 1. Obtain a history of the

22
(ANA) test person has the types of
antibodies that proves the
diagnosis of RA.
2. Obtain a history of the
3. Obtain a list of the
4. There are no food, fluid, or
patient’s complaints,
including a list of known
allergens.
patient’s im- mune and
musculoskeletal systems,
as well as results of
previously per- formed
tests and procedures. For
re- lated tests, refer to the
immune and
musculoskeletal system
tables.
medications the patient is
taking, including herbs,
nu- tritional supplements,
and nutraceu- ticals. The
requesting health care
practitioner and laboratory
should be advised if the
patient regularly uses
these products so that
their effects can be taken
into consideration when
reviewing results.
medica- tion restrictions
unless by medical
direction.
23
5. Review the procedure with
the patient.
6. Inform the patient that
specimen collection takes
approximately 5 to 10
minutes.
7. Direct the patient to
breathe normally and to
avoid unnecessary
movement.
8. Label the specimen, and
promptly transport it to the
laboratory.
9. Evaluate test results in
relation to the patient’s
symptoms and other tests
performed. Related
laboratory tests include
alanine aminotrans-
ferase, aldolase,
antinuclear anti- body,
aspartate
aminotransferase, creatine
kinase, urine creatinine,
ery- throcyte
sedimentation rate, ex-
tractable nuclear
antibodies, lactate
dehydrogenase and
isoenzymes, muscle

24
 biopsy, myoglobin,
rheuma- toid factor,
scleroderma antibody,
Sjögren’s antibodies, and
skin biopsy.

FM/a test According to Weatherspoon

(2020), this test collects
plasma and peripheral blood
mononuclear cells (PBMC)
in a small sample of the
blood. It tests the
concentration of cytokines
within the blood sample.
Significantly lower levels of
cytokines may be an
indicator of fibromyalgia.
Abnormal levels of cytokines
have been linked to being a
trait in people with
fibromyalgia. Research has
been done to prove that
FM/a test may be able to
diagnose fibromyalgia.
However, it still needs more
clinical trials for it to be
recognized as an official
diagnostic tool for
fibromyalgia.

25
 ii. Pharmacological Management

Drug Rationale

Cymbalta (duloxetine) According to Mayo Clinic (2021), Duloxetine along with

milnacipran are both antidepressants that may help ease the
pain and fatigue associated with fibromyalgia.

Tylenol (acetaminophen) According to Dellwo (2021), Tylenol may provide ample relief
of acute symptoms with few side effects. These are much
preferable compared to NSAIDs like Advil (ibuprofen) and
Aleve (naproxen) since fibromyalgia is not an inflammatory
disease and regular use of most NSAIDs may increase the
risk of gastric bleeding, stomach ulcers, kidney impairment,
and cardiovascular disease.

Diazepam (Valium) According to NHS UK (2019), Diazepam is used as a muscle

relaxant that is indicated for muscle stiffness or spasms as a
result of fibromyalgia. This may only be prescribed as a short
course medication. This may also help improve sleep
because of their sedative (sleep-inducing) effect.

Milnacipran (Savella) Milnacipran, an antidepressant, is one of three medications

authorised by the FDA to treat fibromyalgia. While
fibromyalgia pain treatment may help patients feel less
exhausted, milnacipran seems to have a different impact on
fatigue. Milnacipran is a medicine that belongs to a family of
drugs known as selective serotonin and norepinephrine
reuptake inhibitors (SNRIs). While relieving fibromyalgia pain
may help patients feel less exhausted, milnacipran seems to
have an extra impact on fatigue that is distinct from the

26
 pain-relieving effect.

Cyclobenzaprine (Flexeril) Cyclobenzaprine is thought to treat fibromyalgia by

enhancing the effects of norepinephrine, a chemical found in
the brain and spinal cord that aids in the reduction of pain
signals. The medication tizanidine is marketed under the
trade name Zanaflex. If one suffers from muscular stiffness
or spasms (painful contractions of the muscles) as a
consequence of fibromyalgia, the physician may prescribe a
short course of a muscle relaxant such as diazepam. These
medications may also aid in sleep improvement due to their
sedative (sleep-inducing) impact.

Pregabalin (Lyrica) Lyrica (pregabalin) is a fibromyalgia medication that has

been licensed by the Food and Drug Administration.
Fibromyalgia can cause widespread muscular pain and
discomfort over an extended period of time, as well as
difficulty sleeping and extreme exhaustion. Lyrica is neither
an antidepressant nor a serotonin reuptake inhibitor. Rather
than that, it is a neuromodulatory medication. Historically, the
medication has been used to treat nerve pain in people
suffering from shingles and diabetic neuropathy. Additionally,
partial seizures are treated with this medication.

27
Generic Name duloxetine

Brand Name Cymbalta

Drug Antidepressants, SNRIs (serotonin-norepinephrine reuptake

Classification inhibitor); Fibromyalgia Agents

Suggested Dose According to Miller (2020), the recommended dose is 60 mg per day
to be taken by mouth once a day. However, the physician will likely
recommend taking 30 mg per day for the first week, before
increasing to the full dose. Taking more than 60 mg a day will not
further reduce the pain but could increase chances of side effects.

Mode of Action According to Miller (2020), this is a potent inhibitor of neuronal

serotonin and norepinephrine reuptake and a less potent inhibitor of
dopamine reuptake. Cymbalta helps calm down pain signals by
increasing the level of two naturally occurring substances called
serotonin and norepinephrine, which can affect mood and are
believed to help control and suppress feelings of pain. Symbalta and
other SNRIs block serotonin and norepinephrine from re-entering

28
 cells, and therefore increase the levels of these substances.

Indications ● Major Depressive Disorder

● Generalized Anxiety Disorder
● Diabetic Peripheral neuropathy
● Fibromyalgia
● Chronic musculoskeletal pain
● Osteoarthritis of the knee in adults
● Chronic lower back pain (Adults)
● Stress Urinary Incontinence (adult women)

Contraindications ● taking medication called thioridazine

● Taking a medicine called MAOI or have used one in the lat 14
days
● Uncontrolled narrow-angle glaucoma
● Hepatic disease
● Hepatitis
● Jaundice
● Hypersensitivity

Side Effects ● difficulty having a bowel movement

● Dry mouth
● Frequent urination
● Ear congestion
● Headache
● Lack or loss of strength
● Loss of appetite
● Loss of voice
● Muscle aches
● Nausea
● Sleepiness or unusual drowsiness
● Sneezing

29
 ● Trouble sleeping
● Weight loss

Adverse Effects ● agitation

● Diarrhea
● Fever
● Loss of bladder control
● Muscle spasm or jerking of all extremities
● Overactive reflexes
● Poor coordination
● Restlessness
● Shivering
● Sleepiness or unusual drowsiness
● Sudden loss of consciousness
● Talking or acting with excitement you cannot control
● Trembling or shaking
● Twitching
● Vomiting

Drug Interactions Drug/Herb

● St. John’s wort; avoid using together - increases serotonin
syndrome
● Kava, valerian- increased CNS depression

Nursing 1. Assess BP lying and standing

Responsibilities 2. Check pulse every 4 hours.
3. If systolic pressure drops 20 mmHg, hold product, notify the
physician and take vital signs every 4 hours (especially for
patients with cardiovascular disease).
4. Assist patient with ambulation during the beginning of therapy
since drowsiness and dizziness may occur.
Patient/ family teaching

30
 5. Beers should be used with caution (older adults) since they
may exacerbate or cause SIADH.
6. Use sugarless gum, hard candy, frequent sips of water for dry
mouth.
7. Report urinary retention; signs and symptoms of bleeding (GI
bleeding, nosebleed, ecchymoses, bruising)
8. Use with caution when driving, performing other activities
requiring alertness because of drowsiness, dizziness, blurred
vision.
9. Notify physician for occurrence of nausea, vomiting,
dizziness, facial flushing, shivering, sweating, confusion,
hallucinations, incoordination (may indicate serotonin
syndrome)
10. Inform to not discontinue medication quickly after long-term
use as they may cause nausea, headache, malaise, and
taper.

Generic Name acetaminophen

Brand Name Tylenol

31
 Drug Non-opioid analgesic, antipyretic
Classification

Suggested Dose PO:

● 1000 mg tid to qid (not exeeding 4g/day)

Mode of Action May block pain impulses peripherally that occur in response to
inhibition of prostaglandin synthesis; does not possess
antiinflammatory properties; antipyretic action results from inhibition
of prostaglandins in the CNS (hypothalamic heat-regulating center).

Indications ● mild to moderate pain or fever

● Common cold, flu, other viral and bacterial infection with pain
and fever
● Arthralgia
● Dental pain
● Dysmenorrhea
● Headache
● Myalgia
● Osteoarthritis

Contraindications ● Hypersensitivity to the drug

● Phenacetin aspartame
● Saccharin
● Tartrazine

Side Effects ● rash

● Nausea
● Headache
● Tiredness (fatigue)
● Anorexia

Adverse Effects After 18 to 72 hours:

32
 ● cyanosis
● Right upper quadrant abdominal pain
● Anemia
● Neutropenia
● Jaundice
● Pancytopenia
● CNS stimulation
● Delirium followed by vascular collapse
● Seizures
● Serious skin reactions
● Kidney damage
● Thrombocytopenia
● Nausea
● Vomiting
● Constipation

Drug Interactions ● Warfarin

○ Acetaminophen may increase the anticoagulant effect
of warfarin

Nursing 1. Assess for fever and pain.

responsibilities 2. Check for rapid, weak pulse, dyspnea, cold, clammy
extremities, and report immediately to the physician as this
could indicate poisoning.
3. Check for any presence of rash and urticaria. If they occur,
discontinue right away as this could potentially be a sign of
fatal hypersensitivity allergic reaction.
4. Give drug with food if GI upset occurs.
5. Treatment of overdose: Monitor serum levels regularly,
N-acetylcysteine should be available as a specific antidote;
basic life support measures may be necessary.

33
 Patient/ family teaching
6. Instruct not to use with alcohol, herbals, OTC products
without the approval of the physician.
7. Recognize signs of chronic overdose ; bleeding, bruising,
malaise, fever, and sore throat
8. Notify the prescriber of pain or fever lasting for more than 3
days.
9. Not to be used in patients younger than 2 years old unless
prescribed by the physician.
10. Avoid use of other over the-counter preparations. They may
contain acetaminophen, which could lead to serious
overdosage. If in need of an over-the-counter preparation,
consult the physician first.

Generic Name diazepam

Brand Name Valium

Drug anticonvulsants, skeletal muscle relaxants, antianxiety agents,

Classification anxiolytics, benzodiazepines

34
Suggested Dose Adult: PO
● 2-10 mg every 6-8 hours as needed.

Mode of Action Potentiates the actions of GABA, especially in the limbic system,
reticular formation; enhances parasympathetic inhibition, inhibits
spinal polysynaptic afferent paths

Indications ● Anxiety
● Acute alcohol withdrawal
● Adjunct for seizure disorders
● relaxant for skeletal muscle relaxation
● Rectally for acute repetitive seizures

Contraindications
● pregnancy
● Hypersensitivity to benzodiazepines
● Closed-angle galucoma
● Coma
● Myasthenia gravis
● Ethanol intoxication
● Hepatic disease
● Sleep apnea
● Children under 6 months

Side Effects ● Drowsiness

● Dizziness
● Tiredness
● Muscle weakness
● Headache
● Dry mouth
● Nausea
● Constipation

Adverse Effects If any of these symptoms do not go away, the physician should be

35
 called right away:
● Bradycardia/tachycardia
● Hypotension cardiac arrest
● Amnesia
● Anxiety
● Depression
● Drowsiness
● Rash
● Constipation/diarrhea
● Nausea
● Vomiting

Drug Interactions ● Increase: toxicity- barbiturates, SSRIs, cimetidine, CNS

depressants, valproic acid, CYP3A4 inhibitors
● Increase: CNS depression- CNS depressants, alcohol;
monitor for increased sedation
● Decrease: diazepam metabolism- oral contraceptives,
valproic acid, disulfirams, isoniazid, propranolol
● Decrease: diazepam effect-CYP34A inducers (rifampin,
barbiturates, carbamazepine, ethotoin, phenytoin,
fosphenytoin), smoking
Drug/Herb
● Increase: CNS depression-kava, chamomile, valerian
Drug/Lab test
● AST/ALT

Nursing 1. Assess BP (lying, standing) and pulse. If systolic BP drops 20

responsibilities mmHg, hold the product and notify the physician.
2. Monitor for respiratory depression every 15 minutes.
Patient/ family teaching
3. Product should be taken with food

36
 4. Product should not be used for everyday stress or for more
than 4 months unless directed by prescriber.
5. Instruct to take no more than the prescribed amount.
6. Avoid OTC preparations unless approved by prescriber.
7. Avoid driving, activities that require alertness because
drowsiness may occur.
8. Avoid alcohol, other psychotropic medications unles directed
by prescriber.
9. Avoid smoking since it may decrease diazepam effect by
increasing the drug's metabolism.
10. To rise slowly because fainting may occur especially in
geriatric patients. Drowsiness may worsen at the beginning of
treatment.

Generic Name Milnacipran

Brand Name Savella

Drug Therapeutic: Antifibromyalgia agent

Classification Pharmacologic : Selective Norepinephrine

37
Suggested Dose Oral
- Adults
- Day 1: 12.5 mg
- Day 2-3: 12.5 twice daily
- After day 7: 50-100 mg twice daily

Mode of Action Milnacipran is an SNRI that inhibits the reuptake of

norepinephrine and serotonin, as well as N-methyl-D-aspartate, a
neurotransmitter with a weak affinity for inhibition. (NMDA).
Compared to venlafaxine (Effexor, Wyeth) and duloxetine,
milnacipran has a better selectivity for norepinephrine reuptake.
Milnacipran's specific mechanism and effectiveness in FM
are unclear, although it is suspected that its effects on modulating
malfunctioning noradrenergic and serotonergic pathways contribute
to its therapeutic qualities. Because both neurotransmitters have
impacts on pain regulation, norepinephrine selectivity over serotonin
has yet to establish an overall therapeutic benefit.

Indications Milnacipran is approved for the treatment of MDD in people 18 and

older owing to an increased risk of suicide thoughts, thinking, and
behavior in children, adolescents, and young adults using
antidepressants for MDD and other mental illnesses. Some regional
prescription advice states that the medicine is used to treat MDD
symptoms alone. However, it is crucial to remember that regulatory
approval and/or indications for milnacipran may differ substantially
across areas and countries.

Contraindications ● Hypersensitivity or allergy to milnacipran or levomilnacipran

● Kidney disease
● Liver disease
● Family history of glaucoma (angle-closure type)
● Cardiac problems

38
 ● Severe dehydration
● Mineral imbalance (low sodium)
● Painful or difficulty in voiding.

Side Effects ● Nausea

● Vomiting
● Constipation
● Stomach pain
● Weight loss
● Dry mouth
● Headache
● Blurred vision
● Decreased sexual desire
● Difficulty urinating
● Rash
● itching

Adverse Effects ● Hallucinations

● Confusion
● Difficulty breathing
● Severe muscle stiffness
● Uncontrollable shaking of a bodily part
● Seizures
● Extreme tiredness
● Jaundice
● Unusual bleeding or bruising
● Pain in the upper right part of the stomach

Drug Interactions - Concurrent use of:

● MAO inhibitors
○ may result in serious, potential fatal reactions.
Should not be used within 14 days following

39
 discontinuation
○ Isocarboxazid, Tranylcypromine, Phenelzine,
Selegiline
● Serotonergic drugs (triptans, lithium and tramadol).
○ May increase serotonin syndrome
○ Increase risk of coronary vasoconstriction and
hypertension
● NSAIDs, aspirin or other drugs affecting coagulation.
○ Increase risk of bleeding
● Digoxin
○ Adverse hemodynamics, including hypotension
and tachycardia
- Decrease effectiveness of antihypertensive effectiveness of
clonidine
- Increase risk of hypertension and arrhythmias with
epinephrine or norepinephrine

Nursing 1. Assess intensity, quality, and location of pain periodically

responsibilities during therapy.
R: To know the causal factors of the pain and be able to give
interventions to specific areas of pain in the patient’s body.
2. Monitor BP and heart rate before and periodically during
therapy.
R: Hypertension and Tachycardia are common side effects of
the medicine. People with hypertension and tachycardia
before and during the medication should be closely
monitored.
3. Treat pre-existing hypertension and cardiac disease prior to
therapy
R: Sustained hypertension may be dose related; decrease
dose or discontinue therapy if hypertension persists.

40
4. Monitor closely for changes in behavior that could indicate
the emergence or worsening of suicidal thoughts or behavior
or depression.
R: Most commonly in young patients tend to display suicidal
toughts and behavior when first time taking milnacipran.
5. Consider Lab tests such as increased alanin
aminotransferase (ALT), aspartate aminotransferase (AST)
and bilirubin.
R: imbalances on these tests may indicate ineffective or
complications in the therapy given.
6. Monitor for development of neuroleptic malignant syndrome
(fever, respiratory distress, tachycardia, convulsions,
diaphoresis, hypertension or hypotension, pallor, tiredness,
severe muscle stiffness, loss of bladder control). Report
symptoms immediately.
R: These are adverse effects of the medicine that should
immediately be intervened to prevent further complication
and permanent damage.
7. Encourage patient and family to be alert for emergence of
anxiety, agitation, panic attacks, insomnia, irritability, hostility,
impulsivity, akathisia, hypomania, mania, worsening of
depression and suicidal ideation, especially during early
antidepressant therapy. Assess symptoms on a day-to-day
basis as changes may be abrupt. If these symptoms occur,
notify health care professional
R: Psychotic side effects can be severe to some patients and
should be closely monitored.
8. Advise patients to avoid taking alcohol during milnacipran
therapy.
R: Milnacipran may cause liver damage, and taking it with

41
 alcohol may increase that risk. It should be avoided or limit
the use of alcohol while being treated with milnacipran.
9. Caution patient to avoid driving or other activities requiring
alertness until response to medication is known
R: Medication may cause dizziness.
10. Evaluate the therapeutic progress through the reduction in
pain and soreness associated with fibromyalgia.
R: This will help identify if the medical therapy is therapeutic
and safe for the patient.

Generic Name Cyclobenzaprine

Brand Name Amrix

Drug Therapeutic: Skeletal muscle relaxant

Classification

Suggested Dose Adult (oral)

- Fibromyalgia
- 5-40 mg at bedtime

Mode of Action The specific mechanism of action of cyclobenzaprine has not

42
 been completely defined in humans, and most of the information
known about it has come from early animal research. There is some
indication that cyclobenzaprine acts at the supraspinal level,
especially inside the brainstem's locus coeruleus, with little to no
activity at neuromuscular junctions or directly on skeletal muscle.
Action on the brainstem is hypothesised to cause decreased activity
of efferent alpha and gamma motor neurons, which is likely
mediated through suppression of coeruleus-spinal or reticulospinal
pathways, and eventually decreased spinal cord interneuron activity.
Recently, it has been proposed that cyclobenzaprine's reported
effects may be due to suppression of descending serotonergic
pathways in the spinal cord through action on 5-HT2 receptors.

Indications Cyclobenzaprine is suggested as a short-term (2-3 weeks) adjunct

treatment, together with rest and physical therapy, for the alleviation
of muscular spasms associated with acute, painful musculoskeletal
disorders. It has not been shown to be useful in the treatment of
spasticity caused by brain or spinal cord illness, or spasticity in
children with cerebral palsy. Cyclobenzaprine is frequently used
off-label to treat pain and sleep difficulties in fibromyalgia sufferers.

Contraindications ● Hypersensitivity
● Should not be used within 14 days of MAO inhibitor therapy
● Severe ir symptomatic cardiovascular disease
● Cardiac conduction disturbances
● Hyperthyroidism

Side Effects ● Dizziness

● Drowsiness
● Confusion
● Headache
● Constipation

43
 ● Dyspepsia
● Nausea
● Unpleasant taste
● Urinary retention

Adverse Effects ● Skin rash

● Hives
● Swelling of the face or tongue
● Difficulty breathing or swallowing
● Irregular or fast heart rate
● Chest pain

Drug Interactions Cyclobenzaprine should not be taken during or within 14 days of

taking MAO inhibitors which includes:
- Isocarboxazid
- Tranylcypromine
- Phenelzine
- selegiline

Nursing 1. Assess patient for pain, muscle stiffness, and range of motion
responsibilities before and periodically throughout therapy
R: This will serve as a baseline data and to have an in depth
understanding of the severity of the case.
2. Assess for serotonin syndrome, mental changes,
neuromuscular aberrations [hyperreflexia, incoordination],
and/or GI symptoms, nausea, vomiting, diarrhea, especially
in patients taking other serotonergic drugs (SSRIs, SNRIs,
triptans)
R: These are adverse effects of cyclobenzaprine that must be
monitored to avoid further complications and permanent
damage.
3. Oral medication may be administered with meals

44
 R: to minimise gastric irritation
4. Instruct patient to take medication as directed; do not take
more than the prescribed amount. Take missed doses within
1 hr of time ordered; otherwise, return to normal dose
schedule. Do not double dose.
R: Double dosing or under dosing will affect the effectiveness
of the medical therapy.
5. Advise patient to avoid concurrent use of alcohol or other
CNS depressants with this medication.
R: Cyclobenzaprine is a skeletal muscle relaxant structurally
related to tricyclic antidepressants. This can increase the
effect of the nervous system side effects such as dizziness,
drowsiness and difficulty in concentrating.
6. Advise patient to notify health care professionals if symptoms
of urinary retention (distended abdomen, feeling of fullness,
overflow incontinence, voiding small amounts) occur.
R: Doctors can judge that the benefit of the drug is greater
than the risk of the side effects.
7. Instruct patient to notify health care professional immediately
if signs and symptoms of serotonin syndrome occur
R: Cyclobenzaprine is a potent blocker of the transporters of
the monoamines serotonin and norepinephrine. Serotonin
syndrome is one of the side effects to be monitored.
8. Evaluate the relief of muscular spasm in acute skeletal
muscle conditions. Maximum effects may not be evident for
1–2 wk. Use is usually limited to 2–3 week; however, it is
effective for at least 12 week in the management of
fibromyalgia.
R: Effectiveness of the treatment can be evaluated through
the relief of muscular spasm. This will help if the treatment

45
 should be continued.

Generic Name Pregabalin

Brand Name Lyrica

Drug Therapeutic: Anti-convulsant, Anti-seizure

Classification

Suggested Dose Fibromyalgia

- Initial
- 75 mg PO every 12 hours (150mg /day)
- Maintenance
- May increase to 150 mg every 12 hours after 1 week
as needed (300-400 mg/day)

Mode of Action Pregabalin's anti seizure and antinociceptive actions in animal

models are thought to be due to its presynaptic binding to
voltage-gated calcium channels. Pregabalin controls excitatory
neurotransmitters such as glutamate, substance-P, norepinephrine,
and calcitonin gene related peptide by binding presynaptically to the
alpha2-delta subunit of voltage-gated calcium channels in the
central nervous system. It also blocks alpha2-delta subunit
trafficking from DRG to SDH, which might be part of its mechanism.

46
 As a structural derivative of GABA, pregabalin does not directly bind
to GABA or benzodiazepine receptors.

Indications Pregabalin is used to treat neuropathic pain associated with diabetic

peripheral neuropathy, postherpetic neuralgia, fibromyalgia,
neuropathic pain associated with spinal cord injury, and as
supplementary therapy for the treatment of partial-onset seizures in
patients 1 month and older.

Contraindications ● Hypersensitivity to the drug

● Severe heart problems
● Substance use disorder
● Severe kidney disease

Side Effects ● Dizziness

● Lethargy
● Ataxia
● Peripheral edema
● Fatigue
● Weight gain
● Diplopia
● Tremor
● Xerostomia

Adverse Effects ● Angioedema

● Suicidal behavior or ideation
● Creatinine kinase
● Decreased platelet count
● Pneumonia
● Viral infection
● Bullous pemphigoid
● Respiratory Depression

47
Drug Interactions ● Gabapentin
○ It can cause a decrease in pregabalin rate of
absorption
● CNS depressants
○ Additive CNS effects may occur such as somnolence
or drowsiness
● Lorazepam, oxycodone
○ It can exacerbate effects on cognitive and gross motor
functioning
● Thiazolidinedione antidiabetics
○ Can possibly increase the risk of peripheral edema
and weight gain
● ACE inhibitors
○ Increases the risk of pregabalin-induced angioedema

48
 Nursing 1. Monitor the patient closely for hypersensitivity reaction and
responsibilities angioedema; if these effects occur, discontinue the drug and
begin emergency measures immediately.
R: To provide prompt intervention and to avoid potentially
life-threatening allergic reactions.
2. Monitor patient closely for evidence of suicidal thinking or
behavior, especially when therapy starts or dosage changes.
R: Pregabalin increases the risk of suicidal thoughts and
behavior that poses danger to the patient.
3. Warn the patient to avoid stopping pregabalin abruptly
R: Abruptly stopping the drug can increase seizure frequency
4. Inform a male patient who plans to father a child that drugs
could impair his fertility.
R: For the patient to be aware of the possible effect of the
drug.
5. Inform patients that drugs may cause weight gain and
edema.
R: Being aware of the changes helps the patient make small
changes in their lifestyle and seek treatment plans from the
healthcare professionals
6. Instruct patients to avoid drinking alcohol while taking drugs.
R: Mixing pregabalin with alcohol may potentiate the
impairment of motor skills, sedation, dizziness, and
respiratory depression.
7. Advise patients to avoid driving and other hazardous
activities until the drug's effects on vision and alertness are
known.
R: Taking pregabalin can cause changes in vision and
drowsiness which increases the risk of accidents or injury.
8. Teach patients to recognize signs and symptoms of

49
 angioedema
R: To discontinue drugs and for patients to seek immediate
medical care if these arise.
9. Inform patients that the drug may cause hypersensitivity
reactions, such as wheezing, dyspnea, rash, hives, and
blisters. Advise patients to discontinue drugs and seek
medical care if these reactions occur.
R: To report significant changes to healthcare professionals.

iii. Alternative Management

THERAPY RATIONALE

Radiofrequency Ablation In managing Fibromyalgia, reducing pain

is critical. Radiofrequency Ablation is a
minimally invasive Non-surg
Radiofrequency ablation is a procedure
that employs radio waves to burn nerves
that transmit pain signals to the brain. This
will cause the nerve impulses to be
disrupted, resulting in instant pain
alleviation. This procedure blocks or
lowers pain impulses for up to 6 - 9
months.

Physical therapy Physical therapists, according to the

American Physical Therapy Association,
teach self-management methods to those
suffering from a variety of diseases,
including fibromyalgia. Physical therapists
can teach the patient with fibromyalgia
how to manage pain and stiffness on a

50
 daily basis. These health care specialists
instruct individuals with fibromyalgia on
how to increase their strength and range
of motion. They demonstrate techniques
for relieving deep muscular discomfort.
Additionally, they can teach patients with
fibromyalgia how to make rational daily
activity choices that can help avoid painful
flare-ups.

Occupational Therapy Occupational therapy is in a unique

position to teach patients with fibromyalgia
self-management skills that they may use
for the rest of their lives. Occupational
therapy focuses on the full person and
their everyday activities (ADL).

Psychotherapy Fibromyalgia is a chronic pain syndrome

that affects the whole body and generates
sore areas that are sensitive to touch.
Although fibromyalgia is not considered a
mental condition, many persons who have
it also suffer from sadness and/or anxiety.
Therapy is an important part of
fibromyalgia therapy. With fibromyalgia,
people who suffer from fibromyalgia can
have three times as likely to develop
serious depression than those who don't
have it. Negative emotions may
exacerbate fibromyalgia symptoms.

51
 Psychotherapy may assist afflicted
persons in comprehending and resolving
their conflicting emotions. Individuals
receiving cognitive behavioural therapy or
operant behavioural therapy, for example,
report a significant reduction in
fibromyalgia pain following treatment.

iv. Surgical Management

There are currently no known definite surgeries specifically for
Fibromyalgia.

52
 E. Nursing Management

CLUSTERED DATA NURSING DIAGNOSIS PRIORITY

Sleep-Rest Pattern

● Presence of eyebags Disturbed sleep pattern Medium Priority 3

● yawning

Activity-Exercise Pattern

● Lethargic
● Extreme Tiredness Fatigue Medium priority - 1
● Severe Exhaustion

● Limited range of motion Impaired physical mobility High priority - 2

● Decreased muscle strength

● Shortness of breath upon mild

Activity intolerance High priority - 3
exertion or during activity

● Inability to perform ADLs

Self-Care Deficit Low priority - 1

Self-Perception And Self Concept Pattern

● Restlessness
● Irritability

53
 ● Feeling of helplessness Anxiety Medium priority - 2
● Poor eye contact
● RR: 26 cpm
● PR: 115 bpm
● BP: 150/100

Cognitive-Perceptual Pattern

● Pain all over the body

● Grimace face

Pain scale of 3 out of 3 as: Chronic pain High priority - 3

● 0 – No pain
● 1 – Mild pain
● 2 – Moderate pain
● 3 – Severe pain
VS:
● T: 37.8 C
● RR: 26 cpm
● PR: 115 bpm
● BP: 150/100 mmHg

● Patient verbalized “Wala ko

kasabot…Ha?” when asked
about normal day to day Acute confusion Low priority - 2
questions.

54
DATE CUES NEED NURSING PATIENT INTERVENTIONS IMPLEMENTATION EVALUATION
DIAGNOSIS OUTCOME

55
F Subjective: C Chronic pain Within 4 hours Assess and record February 10,
1
related to span of nursing the patient’s pain 2022 at 11 am,
E “Sakit jud O
painful care, the using the PQRST “GOAL
B kaayo akong G sensations patient will be tool. PARTIALLY
tibuok lawas
R N associated with able to MET.”
P – provoke: what
ug ma feel fibromyalgia as manifest
U I makes the pain
nako nga evidenced by a improved
worse? What
A luya ko T pain score of 3 conditions Within 4 hours
makes it better?
pirme. Kapoy out of 3, such as: span of nursing
R I
generalized Q – quality: what care, the
ako lawas na
a. verbalize
Y I muscle does the pain feel patient was
d nako relief of pain;
weakness and like? able to manifest
masabtan. V
changes in vital improve
Dugay na R – radiation:
1 E
signs. b. modify vital conditions such
nako ning where is the pain
0 - signs within as:
R: Fibromyalgia located?
ginabati” as
normal range
P is a condition a. verbalized
verbalized by
(T: 36.5 to
that causes pain S: severity: rate the “Karon kay
2 the patient. E 37.5C; RR:
all over the body pain on a scale of medyo arang2
0 R 16-20 cpm; HR
(also referred to 3.
Objectives: na ako gibati.
60-100 bpm;
2 C as widespread T – timing: when Dili na kaayo
• Pain scale of BP: a.
pain), sleep does the pain start labad ug sakit
2 3 out of 3 as: E 110/70-130/90
problems, and how long does akoang

56
@ 0 – No pain P fatigue, and mmHg), and it last? lawas.”
often emotional
7AM 1 – Mild pain T
and mental b. modified
c. demonstrate
2 – Moderate U distress. It is a R: A record of the
vital signs
use of
pain chronic, patient’s pain
A within normal
pharmacologic
long-term illness assessment can
3 – Severe range (T: 37.5
L al and
that lasts for help direct patient
pain C RR: 20 cpm;
nonpharmacol
more than 12 care and help in the
HR 88 bpm;
VS ogical pain
weeks, which evaluation of the
P BP: 130/80
relief
-T: 37.8 C causes all-over success of pain
mmHG), and
strategies.
A management and
muscle pain,
-RR: 26 cpm
joint pain and other treatments.
T c.
.
-PR: 115 bpm
fatigue. It can demonstrated
T
-BP: 150/100 be mild or Instruct in regular use of
E 2
mmHg excruciating, use of pain rating pharmacologica

R episodic or scale, such as 0 to l and

• Pain all over
continuous, 3. nonpharmacolo
the body noted N
merely gical pain relief
• Grimace face inconvenient or strategies.
R: Standardized
noted totally
tool for rating pain
• Generalized incapacitating.
helps in
muscle Thus, people
assessment and
weakness with Maaroupha B.
management of
fibromyalgia

57
noted experience pain. Esmail, St.N.
chronic, all-over
• Diaphoresis
muscle and joint
noted
pain. They are Explain the
• Pallor noted diagnosis to the 3
known to be
more sensitive patient. Encourage

to pain than the patient to speak

people without up and ask

fibromyalgia. questions.

The chronic
pain which they
R: A deeper
experience can
understanding of
lead to
the disease
generalized
process can help
muscle
patients .
weakness, as
comprehend the
well as changes
symptoms they are
in vital signs.
experiencing.
Reference:
Fibromyalgia.
(2022). Educate patient on
4
https://www.may non-pharmacologic
oclinic.org al pain

58
management
techniques such as
the following:

· Reading
· Chatting
with
someone
else

· Listening
to music
· Watching
a
television
show
· Meditating
· Yoga

R:
Non-pharmacologic
al pain
management
involves pain

59
treatment without
the use of
medications. They
can be used as
standalone
therapies, or they
can be done in
combination with
drug therapies.

Advise the patient

on where to ask or 5
where to get more
information
regarding pain
management
including both
pharmacological
and
non-pharmacologic
al pain treatments.

60
R: Pain
management is a
broad discipline.
Information
overload can occur
if advice is given to
the patient at once.
Allowing them to

have the option to

get the information
when needed gives
the patients more
control of their care.

Plan care activities

6
around periods of
greatest comfort
whenever possible.

R: Pain diminishes
activity.

61
 7
Encourage client to
assume a position
of comfort.

R: Positioning in
the supine position
is often used to
create comfort for
the client, to relieve
pressure and
prevent pain.
Readjustment of
this aids in relieving
muscle fatigue as
well as discomfort.

8
Provide a diet that
is high in lean
protein and fiber,
lower in
carbohydrates,

62
fruits with a low
glycemic index,
vegetables and
whole grains.

R: A well-balanced
diet can improve
energy level, and
help fibromyalgia
patients stay
physically active.

9
Encourage the
patient to increase
oral fluid intake.

R: To replenish the
lost fluid from
sweating.

Encourage 10

63
adequate rest
periods and
uninterrupted
night-time sleep.

R: Systemic rest is
helpful in the
management of
fibromyalgia.

Administer pain
11
medications
regularly.

R: Regular
administration of
analgesics can help
manage the pain to
tolerable levels.
Regular
assessment of pain

64
will help evaluate
the effectiveness of
drug therapy.

Refer the patient to 12

a pain specialist.

R: A pain specialist
is a doctor that
specializes in
assessing the
chronic pain of the
patient, prescribing
a suitable pain
relief drug regimen
and adjusting
doses or changing
drugs accordingly,
and recommending
non-pharmacologic
al methods to ease
the chronic pain

65
and help improve
the patient’s quality
of life.

Reference: Wayne,
G. (2020). Chronic
Pain Nursing Care
Plan.
https://nurseslabs.c
om

66
 NEED IMPLEMENTATION
DATE CUES NURSING PATIENT INTERVENTIONS EVALUATION
DIAGNOSIS OUTCOME

February 10, Subjective: A Impaired Physical At the end 36 •Assess the patient's 1 Goal met, at
2022 - “Ang sakit ng C Mobility related to hours of vital signs. the end of 36
@ mga parte ng T decreased range of Nursing R: to serve as a hours of
8 AM katawan ko I motion and Intervention baseline data and to nursing
lalo na pag V expression of the patient will know the effectiveness intervention the
ginagalaw ko” I discomfort as be able to of the therapy done patient was
T evidenced by 3/3 avoid hazards able to avoid
-“di ko kayang Y pain scale, of immobility •Continuously monitor hazards of
igalaw dahil - decreased muscle and improve the degree of immobility and
sa sakit” E strength and functional inflammation or pain. 2 improve
X reluctance in independence R: The amount of functional
Objective: C attempting as evidenced movement or exercise independence
● Limited E movement by: done is determined by as evidenced
range R how far the by:
of C Rationale: • Present no inflammation or pain
motion I Fibromyalgia is a injuries and has progressed and •Displayed no
● Relucta S condition marked by complications how quickly it has injuries and
nce to E exhaustion, due to resolved. complications
attempt musculoskeletal pain immobility that were due
movem P and stiffness, sleep hazards •Raise side rails and to immobility
ent A disruption, and remove possible 3 hazards
● Decrea T painful areas on •Not worsen hazards that can injure
sed T physical range of or cause accidents to •Presented
Muscle E examination. motion patients. improved
strengt R Disability and R: To prevent further range of
h( N inability to sustain •decrease injuries and accidents motion
● Inability functioning duties pain scale that is possible due to
to are two of the the immobility of the •Reported
perform disease's •absence of patient decrease in
67
 actions complications. face grimace pain scale. (1
as and discomfort out of 3)
instruct •Maintain bed rest or
ed •absence of chair rest as ordered. 4 •Exhibit
indepe lethargy R: To relieve tiredness absence of
ndently Reference: and enhance strength, lethargy and is
● Grimac NANDA nursing systemic rest is well rested
e face diagnosis: required and useful at
● 3 out of Definitions and all stages of illness.
3 pain classification,
scale 2018-2020. (2018). •Assist with active or
Philadelphia, PA: passive range of 5
North American motion exercises
Nursing Diagnosis R: Supports or Harvey L.
Association. promotes muscular Beseril St. N
strength and joint Feb 14 , 2022
function. 8:00 am

•Encourage minimal
physical activities for
the patient. 6
R: Physical inactivity
itself produces
increased oxidative
stress and chronic
inflammation, factors
present in fibromyalgia.
Therefore, increasing
physical activity should
benefit patients with
fibromyalgia.

68
•Encourage patient to
maintain upright and
erect posture when 7
sitting, standing and
walking
R: To maximize joint
function and maintain
mobility.

•Discuss and provide

safety needs
R: Helps the patient 8
and the patient’s family
prevent accidental
injuries and fall that are
possible. Also
encourages patient to
participate and have
less anxiety.

•Reposition patient
frequently
R: Relieves pressure 9
on tissues and
promotes circulation.

•Refer with a physical

or occupational
therapist as ordered.

69
R: While there is no
cure for fibromyalgia, 10
physical therapy may
aid with the pain
symptoms. It may also
aid in the reduction of
stiffness and
discomfort. Physical
therapists employ a
variety of tools in
addition to exercise.

•Administer analgesics 11
as ordered
R: to reduce the pain
threshold of the patient
and improve sleep.

•Administer muscle
relaxant drugs as 12
ordered.
R: These medicines, at
very low dosages, may
help patient sleep
better. It may also help
with pain and
exhaustion.

70
Date and Cues Need Nursing Patient Nursing Impleme Evaluatio
Time Diagnosis Outcome Interventions ntation n

71
February Subjective: A Activity Intolerance After 3 days of Assess the physical 1 February
10, 2022 "Paspas C related to nursing activity level and 13, 2022
@ 8:00 kayko T generalized interventions mobility of the patient. @ 8:00 am
am kapoyon if I muscle weakness the patient will Goal Met
naa koy V secondary to be able to R: Provides baseline After 3
buhaton nya I fibromyalgia as increase information for days of
mura sd kog T evidence by tolerance for formulating nursing nursing
mahutdan Y extreme tiredness, and endurance goals and care. interventio
ginhawa" & discomfort and of activity as ns the
Establish guidelines
the patient E dyspnea with mild evidenced by: patient
and goals of activity
stated. X exertion, and 2 was able
with the patient and/or
"Maong mas E above normal vital A. Patient to increase
SO.
gusto na R signs verbalizes and tolerance
lang nko C uses for and
R: Motivation and
walay I Rationale: Reduce energy-conser endurance
cooperation are
buhaton kay S tolerance of vation of activity
enhanced if the
mangluya E activity has been a techniques; as
patient participates in
kog tapat ug P long feature of B. Absence of evidenced
goal setting.
wa jd ko A fibromyalgia. the following by:
kasabot T Activity Intolerance upon mild A.
Assess vital signs
sakong T is defined as an exertion or Verbalized
before initiating
gibati mag E insufficient during activity: 3 "Wa na
activity/exercise.
lihok mn ko R physiological or l Dyspnea; kayko
R: This will serve as
o dili" the N psychological ginahapo if
a baseline and guide

72
patient energy to support l Extreme in case overexertion naa koy
added. or supplement the tiredne occurs. buhaton.
Objective: required or desired ss; and Dako jd na
Shortness of daily activities. l Monitor VS including tabang
breath upon This could be due Disco O2 sat during ang
mild exertion to pain, mfort activity/exercise. pagtipid
or during depression, sleep C. Vital signs R: There will be an skong
activity disturbance, within normal increase in VS during 4 energy ug
Generalized muscle weakness, range: activity. If O2 sat ang pag
muscle and so on. In the RR: 16-20 cpm declines, stop activity amat-amat
weakness case of PR: 80-100 and apply skong
noted fibromyalgia, the bpm supplemental oxygen. aktibidade
VS taken as generalized BP: s";
follows: muscle weakness 90/60-120/90 Assist patient to plan B.
RR: 26 cpm is related to the activities for times Absence
PR: 115 condition itself. As when they have the of
bpm a result of it, the most energy. If the dyspnea,
BP: 150/100 body will not be goal is too low, extreme
mmHg able to handle the negotiate. 5 tiredness
strain of everyday R: Activities should be and
activities like they planned ahead to discomfort
should be and it coincide with the upon mild
may lead to patient’s peak energy exertion or
extreme tiredness, level. during

73
discomfort, and activity;
dyspnea even Have the patient and
during mild perform the activity C. Vital
exertion. Changes more slowly, in a signs
in VS are also be longer time with more within
noted in this rest or pauses, or with normal
condition. assistance if range:
Reference: Terry, necessary. ( HR: 88
S. (2021). R: this will help in 6 bpm; RR:
Fibromyalgia increasing the 20 cpm;
symptoms: Muscle patient's tolerance for BP: 130/80
Weakness. the activity.
Retrieved
February 9, 2022 Gradually progress
from patient activity with
http://fibromyalgia.t the following:
echie.org/muscular ·Range-of-motion
BAI
-weakness/#:~:text (ROM) exercises
SHAJADE
=Objective%20mu in bed, gradually
MAE G.
scle%20weakness increasing 7
ABDULA,
%20means%20tha duration and
St. N
t%20there%20is% frequency (then
20an,under-use%2 intensity) to
0due%20to%20de

74
creased%20mobilit sitting and then
y%20and%20phys standing.
ical%20activity. · Deep-breathing

exercises three
or more times
daily.
· Sitting up in a
chair 30 minutes
TID.
· Walking in room
1 to 2 minutes
TID.
· Walking down
the hall 20 feet,
then slowly
progressing
walking outside.

Encourage
verbalization of
feelings regarding
limitations.
R: helps the patient to
cope.

75
Teach the patient 8
and/or SO to
recognize signs of
physical overactivity
or overexertion.
R: Knowledge
promotes awareness
to prevent the 9
complication of
overexertion.

Encourage OFI.
R: to replenish fluid
loss during activity
and avoid
dehydration.

Teach energy 10
conservation
techniques, such as:
· Sitting to do
tasks

76
 · Frequent

position changes 11
· Pushing rather
than pulling
· Sliding rather
than lifting
· Working at an
even pace
· Placing

frequently used
items within easy
reach
R: These techniques
reduce oxygen
consumption,
allowing a more
prolonged activity.

77
Date and Cues Need Nursing Patient Nursing Intervention Impleme Evaluation
time Diagnosis Outcome ntation

78
February Subjective Cues: Fatigue related Within 24 hours ● Assess and note 1 February 11,
10, 2022 “Wala koy kusog A to sleep of nursing the severity of 2022 at 7:00
at 7:00 maam ug kapoy C deprivation and intervention the fatigue by letting am
am permi akong T physical patient will be the patient rate her
kalawasan tibuok I deconditioning able to improve fatigue level from GOAL
adlaw, wala koy V as evidenced by sense of energy mild to severe. PARTIALLY
gana mulihok kay I pain, lethargy, as she will: R: To obtain baseline MET.
dili nako makaya. T and difficulty a. Verbalize data for her activity levels
Tungod guro ni Y attending relief because fatigue is one of After 24 hours
sa wala koy self-needs. from the persistent symptoms of providing a
tarung nga tulog A exhausti of the disease wherein it nursing
dala sa kasakit N Rationale: on and is more severe than the intervention, the
sa akong D In Fibromyalgia, tiredness usual fatigue. patient was only
ginabati” as the body is . able to improve
verbalized by the E constantly b. Exhibits ● Educate patient sense of energy
patient. X dealing with enhance about the nature of 2 as she:
E pain due to mood. fibromyalgia.
Objective Cues: R abnormally low c. Manifest R: To allow the patient to a. Verbalize
● Extreme C levels of improved understand how it affects “kapoy
tiredness I hormones that tolerance her body and for her to gihapon
● Lethargic S transmit signals to adapt to these changes akong
● Severe E all over the physical especially with her lawas
exhaustion body. As the activities lifestyle. maam
P body constantly such as pero

79
 ● Difficulty A deals with pain, lifting up ● Evaluate arang
attending T and reacting to from bed adequacy of arang na
self needs T the pain signal or in nutrition and sleep 3 karun.”
and E in the nerve, it sitting patterns of the b. Exhibited
maintainin R gets exhausted, position patient. enhance
g usual N thus causing d. Demonst R: Proper nutrition is ment of
physical lethargy. rate use important to prevent flare patient
activities In relation to the of up of the symptoms and mood
● Irritable roles of pain in relaxatio good sleeping patterns where
Vital Signs: FM, it will lead n skills help the body regenerate. she
● RR: 26 to disruption in such as appeare
cpm slow-wave deep ● Administer d relaxed
● BP: sleep, causing breathin medications as c. Manifest
150/100m patients to feel g prescribed. 4 ed
mHg unrefreshed exercise R: Medications that will partially
● PR: upon help control the improved
115bpm awakening. All symptoms of fibromyalgia tolerance
● Temp: associated to lessen or manage the to
37.8 symptoms of fatigue of the patient physical
degree FM, have all the brought by the disease. activities
celsius potential such as
contribution to ● Assist the patient lifting up
fatigue. in doing necessary from bed
ADLs that will 5 but still

80
 require her to exert requires
Reference: enormous assistanc
Perry M amounts of energy e.
Nicassio; Ellen while promoting d. Demonst
G Moxham; independence. rated
Catherine E R: This will help the breathing
Schuman; patient to reduce feelings exercise
Richard N of exhaustion and correctly
Gevirtz (2019). tiredness.
The contribution
of pain, ● Secure that the
reported sleep patient's valuables
quality, and or personal
depressive belongings are 6 SHANLY FAYE
symptoms to within reach. ALDUESO,
fatigue in St.N
R: This will conserve
fibromyalgia. ,
patient’s energy and
100(3),
overexertion
0–279.doi:10.10
16/s0304-3959(
● Instruct client on
02)00300-7
how to do the
deep breathing
exercise.

81
R: To let the patient relax 7
while at rest.

● Encourage the
patient to establish
a regular pattern to
relax each day. 8
R: This will help reduce
the stress that can bring
symptoms.

● Encourage the
patient to increase
fluid intake 9
R. Hydration helps
decrease fatigue brought
about by fibromyalgia.

● Advise patient to
limit physical
activities that
require
overexertion of
energy. 10

82
R: Limiting workload and
controlling pace rather
than rushing through
activities helps patient to
conserve energy.

● Refer the patient

to a physical 11
therapist as
needed.
R: To let the patient have
a more specialized care
that focuses on helping
balancing daily physical
activities and rest
periods.

83
Date and Cues Need Nursing Diagnosis Patient Nursing Intervention Implemen Evaulation
time Outcome tation

84
F Subjective Cues: Anxiety related toWithin 8 hours ● Assess patient’s level 1 February 10,
E “Kulbaan ko ug lack of knowledge of nursing of anxiety. 2022 at 3:00 pm
S
B gakahadlok sa regarding intervention the R: Different levels of
E
R akong ginabati. symptoms, patient will be anxiety will affect the
L GOAL
U Wala ko kabalo progression of able to lessen coping mechanism of
F PARTIALLY
A unsa ako condition, and feelings of the client.
MET.
R himuon.” as anxiety by:
P treatment regimen
Y verbalized by the ● Monitor vital signs.
E aeb restlessness, After 8 hours of
patient. a. verbalize R: To identify physical
R feeling of providing a
1 their responses associated 2
C helplessness nursing
0 Objective Cues: feelings of with both medical and
E intervention, the
● Restlessness anxiety; emotional conditions.
P patient was able
2 ● Irritability
T Rationale: to lessen
0 ● Feeling of b. demonstrat ● Teach signs and
I Anxiety is a feelings of
2 helplessness e relaxation symptoms of
O common problem anxiety by:
2 ● Poor eye techniques escalating anxiety, and
N for people with
contact to be taught ways to interrupt its
fibromyalgiaand is a. verbalizing
@ ● VS (e.g. deep- progression (e.g.,
/ associated with feelings of
RR: 26 cpm breathing relaxation techniques, 3
more severe anxiety;
7 PR: 115bpm exercises, deep- breathing
S symptoms and
A BP: physical exercises, physical
E lower quality of life. b. demonstratin
M 150/100mmH exercises, exercises, brisk walks,
L In someone with g relaxation
g brisk walks, jogging, meditation).
F fibromyalgia, techniques
jogging, R: So the client can start
anxiety is often to be taught
meditation), using relaxation
C listed as a (e.g. deep-
and; techniques; gives the
O symptom, but just breathing
client confidence in
N as frequently exercises,
c. exhibit having control over his
C considered a physical
absence of anxiety.
E common exercises,
restlessnes
P overlapping brisk walks,
s. ● Educate patient
T condition. Learning jogging,
about the nature of
what triggers 4 meditation),
fibromyalgia.
P anxiety, how to and;
R: To allow the patient
A recognize it, its to understand how it
T potential causes, affects her body and
85
T and how to deal for her to adapt to c. exhibiting
E with it are important these changes absence of
R parts of living well especially with her restlessness
N with fibromyalgia. lifestyle. .

● Assist the patient in

Reference: developing
anxiety-reducing skills.
Dellwo, A. (2020). R: Using Raina Valerie B.
Anxiety in anxiety-reduction Benignos, St.N
Fibromyalgia: strategies enhances
5
Symptoms, patient’s sense of
Causes, and personal mastery and
Treatments. confidence.
VeryWellHealth.
Retrieved from: ● Encourage the client’s
https://www.verywel participation in
lhealth.com/anxiety relaxation exercises
-in-fibromyalgia-508 such as deep
4611 breathing, progressive
muscle relaxation,
guided imagery,
meditation and so
6
forth.
R: Relaxation exercises
are effective
nonchemical ways to
reduce anxiety.

● Provide reassurance
and comfort
measures.
7
R: Helps relieve anxiety.

● Remain with the client

at all times when
86
 levels of anxiety are
high (severe or panic);
reassure client of their
safety and security.
R: The client’s safety is
8
utmost priority. A
highly anxious client
should not be left
alone as their anxiety
will escalate.

● When level of anxiety

has been reduced,
explore with the client
the possible reasons
for occurrence.
R: Recognition of
9
precipitating factors is
the first step in
teaching client to
interrupt escalation of
anxiety.

● Use simple language

and brief statements
when instructing
patients about
self-care measures or
about diagnostic and
surgical procedures.
R: When experiencing
moderate to severe
anxiety, patients may
be unable to
comprehend anything
10
more than simple
87
 clear, and brief
instructions.

Date & Cues Ne Nursing Patient Nursing Impleme Evaluation

Time ed Diagnosis Outcome Interventions ntation

February Subjective Disturbed Sleeping After 8 hours of Independent: February

10, 2022 Cues: Pattern related to nursing 10, 2022
@ neurological interventions, -Assess the @
1:00PM “Dili jud ko dysfunction as the patient will patient’s sleep 9:00 PM
makatulog inig evidenced by be able to show pattern and take 1
gabie na nurse, “Dili jud ko improvement in note of the Goal Partially Met
naa sad oras makatulog inig sleeping pattern following:
nga maka mata gabie na nurse, naa as evidenced ● Amount of After 8 hours of nursing
mata ko tunga sad oras nga maka by: sleep interventions, the
sa gabie, mata mata ko tunga ● Position patient were be able to
hangtod na na sa gabie, hangtod a. Verbalization ● Sleep routine show improvement in
mu kaadlawon na na mu of feeling rested; ● Depth sleeping pattern as
usahay kaadlawon usahay ● Extent evidenced by:
maabtan kog maabtan kog b. Showing ● Interferences
buntag way buntag way tulog decrease Rationale: a. Verbalization of
feeling rested;
88
 tulog imbes S imbes gusto unta
gusto unta nako nako magpahulay” eyebags; and
magpahulay” as L as verbalized by the
verbalized by E patient.
the patient. absence of
E restlessness.
P Rationale:
- A Chronic
Objective R musculoskeletal
Cues: pain is also known
E as Fibromyalgia
-Restlessness S (FM), despite the
fact that pain is the
-Weakness T most common
chronic symptom of
-Irritable FM, patients with
P FM also have
-Yawning A disturbed sleeping.
The patients tend to
-Presence of T report that they
eyebags T have trouble getting
asleep, have a lot
-Vital signs: E more midnight
RR: 26cpm R awakenings, and
PR:115bpm their sleep was not
BP: 150/100 N very refreshing.
The regular
arrangement of
brain waves gets
messed up with
fibromyalgia, which
could explain why
patients have
difficulty sleeping.
Brain waves that
presence of Sleep patterns may “Nurse medjo nakatulog
vary for each nako karon ug
individual. nakapahulay kaysa
c. present Evaluating these atong niagi”
patterns will provide
general information b. Showed decrease
and details on presence of eyebags;
​ certain areas of and
sleep that need to
be addressed or c. presented absence of
improved. restlessness.
-Observe for any
signs of sleep-wake 2
problems. Note the
patient’s hours of
sleep.
Rationale:
To attain baseline
information for the
investigation of
insomia.
-Take note of the 3
physical (ex:
background noise,
discomfort, frequent
urination during
bedtime, pain) or
physiologic factors
(ex: fear, anxiety
that hinders sleep)
Rationale:
To aid with insomia
evaluation and help
its management.
89
 indicate
wakefulness disturb
deep sleep -Explain necessity
patterns. of disturbances for 4
monitoring VS and
care when
References: hospitalized.
Rationale:
Zelman, D.(2020). To make the patient
Get Better understand the
Sleep When importance of care
being done to
You Have
him/her and to
Fibromyalgia minimize
. Healthline. complaints.
Retrieved
from -Perform nursing
https://www. care without waking 5
webmd.com/f the client, and did
as much care as
ibromyalgia/g
possible while the
uide/fibromy patient is still
algia-and-sle awake.
ep Rationale:
To avoid
disturbances during
sleep, and to
maximize sleeping
process.

-Educate the patient

on several measure 6
for sleeping
promotion, such as
avoiding heavy
meals, smoking
90
 before bedtime,
caffeine containing
beverages and
alcohol. Also,
mention proper fluid
and food intake.
Rationale:
It is important to
mention the needed
precautions and
reminders to better
promote sleep.
Beverages such as
tea, chocolate,
colas, and coffee
contain caffeine that
activates and
energizes the
nervous system.
Whereas taking full
meals before
bedtime may induce
indigestion or an
upset stomach,
hindering sleep
onset. Alcohol
should also be
avoided, albeit its
ability to induced
sleep, since it
hampers REM
sleep.

-Encourage the
patient to adhere to 7
a dedicated and
91
 consistent sleep,
rest schedule and
drinking a glass of
milk.
Rationale:
Adhering to a
consistent sleep
and rest schedule
helps regulate and
manage the
circadian rhythm. It
also like to reduce
energy fluctuations
or consumption
required for
adaptation to
alterations.
Meanwhile, drinking
a glass of milk has
been correlated
with sleep
promotion, mainly
because of its
L-tryptophan
component.

Dependent: Nova Mae O. Balug,

St.N
-Administer
Hyptonics or 8
sedatives as
prescribed;
evaluate
effectiveness.
Rationale:
Use of hypnotic
92
 medications should
be thoughtfully
considered and
avoided if less
aggressive means
are effective
because of their
potential for
cumulative effects
and generally
limited period of
benefit.

DATE/TIM CUES NEED NURSING PATIENT NURSING IMPLEME EVALUATION

E DIAGNOSIS OUTCOME INTERVENTIONS NTATION

1
F Subjective Cues: A Self Care Deficit After 8 hours span of Established a After 8hours span of
related to nursing interventions therapeutic relationship nursing interventions
E “Wala man koy C
musculoskeletal the patient will be with patients. the patient was able
gana magligo og
B T impairment, able to: to:
maglihok lihok R:To receive patients'
decreased strength/
93
R kay kapoy kaayo I endurance, pain on a) Demonstrate cooperation during a) The patient will be
akong lawas”as movement as self-care activities/ interventions. able to demonstrate
U V
verbalized by the evidenced by ADLs within level of optimal performance
A patient. I inability to manage own ability (bathing, of ADLs or activities
activities of daily feeding); Assess the patient’s of daily living;
R T living (feeding, 2
limitations to self-care
b) Acquire b) Acquire
Y Objective Cues: Y bathing, dressing, by asking open-ended
therapeutic therapeutic
and/or toileting). questions
-Dry tangled hair; interventions, such interventions, such as
as modifications or R:To explore the modifications or
1 -lethargic; - adaptations to adaptations to
patient’s self-care
Rationale:
0 -weakness noted; personal care tasks limitations and needs personal care tasks
Fibromyalgia is a or routines to while allowing him/her to or routines to
-Inability to E condition that maximize express his/her thoughts maximize
perform ADLs; causes pain all over independence and and feelings related to independence and
2 X
- Vital Signs: the body (also safety; ADLs. safety;
0 E referred as
RR: 26cpm c) Obtain active Offer appropriate pain c) Obtain active
2 R widespread pain) 3
participation and medication, as participation and
PR:115bpm sleep problems,
independence in prescribed at least 30 independence in daily
2 BP: 150/100 C fatigue, and often
daily activity; provide activity; provide level
minutes before the
emotional and
I level of assistance patient, performs of assistance
mental distress.
required for safety. self-care activities. required for safety.
@ S Chronic pain can be
mild or excruciating, R:Pain might discourage
7AM E episodic or the patient to mobilize
continuous, merely and carry out self-care
inconvenient or activities.
P totally
incapacitating. Determine exact cause
A of each deficit. For 4
Eventually, it
T becomes more Instance,weakness,
difficult for the visual problems, and
T cognitive impairment.
patient to
E differentiate the R:Varied etiological
exact location of the factors may require
R ELLA ALVAR, St.N
pain and clearly more specific
identify the intensity interventions to enable
N
of the pain. Some self-care.
may suffer chronic
Evaluated capability and
94
pain in the absence level of deficit (04 5
of any past injury or scale)to perform ADLs
evidence of body such feeding,
damage. It may limit bathing,dressing, and/or
the person’s toileting.
movements, which
R: The patient may only
reduce flexibility,
need support with some
strength, and
self-care measures.
stamina. This
Also help In anticipating
difficulty in carrying
and developing for
out important and
managing patient needs.
enjoyable activities
can lead to disability Educate the patient’s
and despair. significant other on
providing appropriate 6
Reference:
assistance to the patient
Mayo Clinic(2021). while he/she performs
Fibromyalgia. self-care tasks.
Retrieved from:
R: To provide learning to
https://www.mayocli
the significant other and
nic.org/diseases-co
to ensure that the
nditions/fibromyalgi
patient has a good
a/symptoms-causes
amount of support while
/syc-20354780
doing ADLs at home.
Skilled home services
might be needed if there
is no available
significant other to care
for the patient.
Refer the patient to an
occupational therapist.
7
R: Occupational
therapists are skilled
professionals in helping
clients achieve optimal
performance in their
daily activities like

95
bathing, dressing and
personal hygiene.
Coordinate with the
physical therapy team
8
on how to create and
initiate an exercise
program for the patient.
R: A customized
exercise plan can help
the patient in terms of
increasing his/her
endurance and strength
which he/she will need
when doing self-care
activities.
Encourage the patient to
use assistive devices
and grooming aids as 9
needed.
R: To promote autonomy
when performing
self-care activities.
Assess barriers to
participation.
R:To be able to provide 10
deeper intervention
depending on the
assessed reasons of
non-participation.
Encourage
independence, but
intervene when a patient 11
cannot perform.

R: An appropriate level

96
 of assistive care can
prevent pain with
activities without
causing frustrations.

DATE CUES NEED NURSING PATIENT INTERVENTIONS IMPLEME EVALUATION

DIAGNOSIS OUTCOME NTATION

February Subjective: C After 8 hours of INDEPENDENT

10, 2022 • Patient O Acute confusion nursing February 10, 2022
@ verbalized “Wala G related to interventions, 1. Maintain a calm @
8 AM ko kasabot N alteration in the patient will 4 PM
environment and
…Ha?” when I sleep-wake cycle have an 1
asked about T as evidenced by improved eliminate extraneous “Goal Partially Met”
normal day to day I alteration in condition and
noise or other stimuli
questions. V cognitive function level of After 8 hours of
E or decreased consciousness R: To prevent nursing
• Watcher - level of as evidenced interventions, the
overstimulation.
verbalized “naa P consciousness by: patient showed an
jud kas-a na sige E with a GCS of 13 a. Verbalize improved condition
ra syag kalimot R and restlessness understanding and level of
2. Evaluate vital signs.
murag wala sya C at night of the effect of consciousness as
saiyang sarili E associated with fibromyalgia to R:For indicators of poor evidenced by:
unya di nimo sya P fibromyalgia the cognition of a. Verbalized
tissue perfusion or
masturya kay T the patient understanding of the
mawala sya sa U Rationale: (atleast 1): stress response effect of
gina istoryaan. A According to fibromyalgia to the
2. Talk with significant
Sige ra syag L Dumain (2020), >Decreased 2 cognition of the
tanga sa gawas.” Fibromyalgia alertness others to know patient (atleast 1)
P causes aches >Difficulty “Mao diay usahay di
observed changes, as
• Watcher A and pains all over holding a gyud ko kasabot
97
verbalized T the body, as well conversation well as the onset of saakong gibati mura
“Manglisod sad T as fatigue, sleep, >Impaired ability kog wala saakong
recurrence of changes.
syag tulog sa E and mood issues. to concentrate sarili. Kay tungod
gabii gyud kay R It can also lead to or stay focused R: To understand and diay ni sa akong ma
mutukar ang sakit N problems with >Memory issues bati na sakit ug sa
clarify the current
mao luya na sya memory or or forgetfulness; tambal ”;
pirmi.” thinking clearly. b. Demonstrate situation. b.
Fibromyalgia can atleast 1 lifestyle Demonstrated
3. Determine the
Objective: cause part of their or behavior atleast 1 lifestyle or
• Blood brain to not changes to current medications or behavior changes to
pressure: 150/100 receive enough prevent or prevent or reduce
drug use especially
mmHg (normal: oxygen because reduce risk of risk of fibro fog
120/80 mmHg) of the pain, which fibro fog (e.g. anti-anxiety drugs, (sleeping/resting);
• Decreased results to sleep; avoiding and
barbiturates,
alertness upon confusion or caffeine;
calling the disorientation. Breathe deeply; antipsychotic agents, or 3 c. GCS of 14
patient’s attention. These cognitive Meditation;
opiates.
• GCS: 13 difficulties called Eating healthy;
(Confused)- “fibro fog” are mental R: These drugs are
normal: 15 common. exercises, or
associated with a high
Research low impact Charisse Maryjoy A.
suggests more exercise) and; risk of confusion and Dy, St.N
than half of
delirium. Any
people with C. GCS of
fibromyalgia show atleast 14 combination with drugs
a decline in
such as cimetidine,
memory and clear
thinking. When antacid or digoxin, and
one has fibro fog,
diuretics can increase
it can cause one
to be in a state of the risk of adverse
confusion that
actions and
they don’t even
know they are in. interactions. One of the
They can’t find
medications for
the words they
want to say or fibromyalgia is
misspeak without
pregabalin which can
realizing it. One

98
may also cause confusion and
experience:
dizziness.
memory issues or
forgetfulness;
Impaired ability to
4. Give simple
concentrate or
stay focused; directions.
Decreased
R: This allows sufficient
alertness; 4
Problems thinking time for the client to
clearly or mental
respond, communicate,
slowness; and
difficulty holding a and make decisions.
conversation.

Reference:
Dumain, T.
5. Orient the client to
(2020). Fibro Fog,
Explained: Why surroundings, staff,
You Get It and
necessary activities, as
What to Do About 5
It. Retrieved from needed. Present reality
https://creakyjoint
concisely and briefly,
s.org/about-arthrit
is/fibromyalgia/fib making sure to avoid
romyalgia-sympto
challenging illogical
ms/fibro-fog/
thinking at the same
time.
R: the client may have
defensive reactions as
a result.

6.Explain the cause of

confusion to the client
6

99
and the family.
R: Fibromyalgia can
cause part of their brain
to not receive enough
oxygen because of the
pain, which results to
confusion or
disorientation.

7. Teach patient or
family/SO(s) the steps
to help alleviate
fibromyalgia related
symptoms, including
feeling brain fog.
• Avoid caffeine
7
• Breathe deeply
• Get better sleep
• Meditation
• Eat healthy
• Low impact
exercise

R: cognitive difficulties
is a common
fibromyalgia symptom.

100
Caffeine can worsen
the condition of people
with fibromyalgia. A
small amount of
caffeine can contribute
to sleep disturbances
since it is a stimulant.
Stress may cause fibro
fog to worsen and
according to
everydayhealth (2022),
meditation or yoga
helps in overcoming
fibro fog. Taking deep
breaths relaxes the
body. One of the most
important fibromyalgia
treatments is getting
quality sleep. To
improve sleep, they
have to go to bed and
wake uup the same
time every day, even on
the weekends. Keep
the bedroom dark,
quiet, and cool.

101
Low-impact exercises
help improve blood
flow, as well as
improving sleep, which
can help alleviate some
of the cognitive
difficulties associated
with fibromyalgia pain.
Eating healthy means
drinking healthy too.
Proceed foods, sugars,
and fast foods should
be avoided.

8. Encourage practicing 8
mental exercises.
R: Brainteasers,
crossword puzzles, and
other mentally
stimulating activities
may also help ward off
fibro fog. Games that
require strategic thining
help keep the brain
active and blood
9
flowing.

102
9. Encourage family or
SO(s) to participate in
reorientation as well as
providing ongoing input
(e.g., current news or
family happenings)
R: The client may
respond positivelt to a
well-known person and
familiar items.

DEPENDENT

10
10. Administer
medications as
prescribed by the
physician.
R: Accoding to
Carteron (2017), to
relieve fibro fog, the
physician may
prescribe one or more
medications such as
pregabalin, gabapentin,
duloxetine, and

103
milnacipran. They may
also prescribe
cyclobenzaprine or
amitriptyline to help
improve the client’s
quality of sleep which
11
will help them feel more
alert and focused.

INTERDEPENDENT
11. Collaborate with
medical and psychiatric
providers to review
patient’s diagnostic
studies such as Mini-
Mental State
Examination (MMSE)
or Confusion
Assessment Method
(CAM), as well as their
Glasgow Coma Scale
(GCS).
R: To evaluate the
extent of impairment in
orientation, attention
span, ability to follow

104
directions, send and
receive communicatino,
and appropriateness of
response.

105
V. PROGNOSIS

Fibromyalgia is a condition characterized by chronic widespread

musculoskeletal pain. The overall mortality is not increased in patients with
fibromyalgia, and it is not an organ-threatening disease. Yet, many patients with
fibromyalgia continue to suffer from long-term widespread pain. Once the
diagnosis is confirmed, many fibromyalgia patients find their overall sense of
well-being and their pain improves to pain levels that are more moderate with the
treatments. There are some patients who experience a dramatic reduction in pain
with changes in their life to reduce stress. However, these patients are always at
risk for worsening their symptoms in the future and should maintain efforts for a
healthy lifestyle, including sleep hygiene, ongoing exercise, and stress
management. Fibromyalgia patients have a higher rate of disability than the
general population, but seeking permanent disability status is generally
discouraged because it frequently leads to worsening of symptoms.

In contrast, patients treated by primary care have a much better

prognosis. Many demographic and psychosocial factors significantly impact the
prognosis and outcome in patients with fibromyalgia. Female gender, low
socioeconomic status, unemployment, obesity, depression, and history of abuse
had adverse effects on the outcome. Overall the prognosis is poor for many
patients. Factors associated with poor prognosis include a long duration of
disease, high-stress levels, presence of depression or anxiety that has not been
adequately treated, long-standing avoidance of work, alcohol or drug
dependence, and moderate to severe functional impairment.

106
VI. DISCHARGE PLAN

METHOD HEALTH TEACHINGS RATIONALE

Medication 1. Advise the patient to take R. Failing to use medication

medicine religiously exactly as prescribed can result in
as prescribed, even if the worsened health, longer
pain subsides. recovery, unwanted side
effects, substance use
disorders, death, and other
serious health conditions
that require intensive
treatment.

2. Educate the patient or the R. Improper storage of drugs

guardian on the proper will likely decrease the
storage of the medicine. potency of the drug long
before the stated expiration
date.

3. Instruct the patient to check R. Outdated drugs may be

first the expiration date ineffective and may lead to
before taking the prescribed harmful effects on the body
medication. if used.

4. Advise the patient to keep a R. To prevent errors, such

list of all medications as missing medication or
prescribed by the doctor. doubling medication on the
same or similar medicine.

107
Exercise 1. Advise the patient to R. Keeping the body active
exercise regularly and to helps reduce the pain,
slowly increase the activity fatigue, for the patient to
level by doing light sleep better, and makes the
exercises as instructed by patient feel relaxed.
the doctor. Begin with
physical activity like taking
the stairs instead of the
elevator. Then, add in some
walking, and stretching
exercises.

2. Encourage to follow activity R. To avoid accidents and to

restrictions, such as not promote patient safety.
driving or operating
machinery, as
recommended by the doctor
when taking pain medicine.

3. Advise the patient to do R. People with fibromyalgia

some stress-relief methods. are at risk for depression,
This includes yoga, t’ai chi, thus doing some stress-relief
light massage, breathing methods aids in rewiring the
exercise, and acupuncture. mind and keeping away
negative feelings.

108
Treatment 1. Advise the patient to comply R. Proper adherence of
with medication medications helps control
the symptoms of
fibromyalgia

2. Advise patients to keep a R. To help patients track

pain diary, including the pain cycles and show a
symptoms felt and what pattern to the symptoms.
activity caused them.

3. Instruct patients to schedule R. To help reduce the stress

time to relax each day. that can bring symptoms.

4. Instruct patients to get R. Getting enough sleep

enough sleep and establish allows the body to repair
a regular pattern for going to itself, physically and
bed and waking up. psychologically.

5. Advise the patient to avoid R. Daytime napping may

daytime napping and limit interfere with the sleep
caffeine that can disrupt schedule of the patient at
sleep. night.

Hygiene 1. Encourage the patient’s R. Some patients may have

family to assist in the difficulty attending to their
patient’s hygiene, such needs due to pain and
as combing, bathing, fatigue.
getting dressed, and or
toothbrushing.

109
Outpatient 1. Encourage the patient to R. Follow-up care is a key
adhere to follow-up care part of the treatment of
and treatment plan advice fibromyalgia and for patients'
by the physician. safety.

2. Educate the family R. Monitoring patients helps

regarding the importance of promote safety and helps
monitoring the patient monitor mental health and
activities and behaviors. worsening of patient signs
and symptoms.

3. Instruct clients to seek R. Fibromyalgia patients

immediate medical attention have an increased risk of
if symptoms worsen. developing stroke and
Symptoms such as epileptic seizure which
· Chest pain requires immediate
· Epileptic seizures attention.

110
Diet 1. Encourage the patient or R. A well-balanced diet can
family to provide a balanced improve energy level and
diet with a variety of foods. plays a role in providing
● Offer foods that are relief to the client. Foods
high in lean protein high in carbohydrates or
and fiber and lower in refined sugar and those
carbohydrates, low containing aspartame or
glycemic index, MSG have been shown to
vegetables, and cause flare-ups.
whole grains.
● Limit foods that are
high in saturated fat
and cholesterol
● Cut down on refined
sugars.
● Limit foods that are
high in sodium and
use less salt.

2. Encourage the client to R. Fibromyalgia patients

increase fluid intake. become dehydrated easily.
Drinking more water can
help flush all the toxins and
aids in fatigue and
headache.

3. Advise the patient to avoid R. Smoking and alcohol

smoking, drinking alcohol, and consumption can make
caffeine. symptoms flare-up.
Caffeinated drinks can

111
 cause trouble sleeping,
increase pain, and fatigue.

4. Advise patients to reach or R. Obesity can make

maintain a healthy weight. fibromyalgia symptoms
worse.

VII. NURSING THEORY

“Comfort Theory”

Katharine Kolcaba

Kolcaba developed her nursing theory in the 1990s. It is a middle range

nursing theory designed for nursing practice, research, and education. According
to her theory, patient comfort exists in three forms: relief, ease, and
transcendence. These comforts can occur in four contexts: physical,
psychospiritual, environmental, and sociocultural. Relief comfort usually comes in
the form of pain management through medications. When medications are
administered, the patient has a sense of relief from the pain. Ease comfort is
focused more on the environment and psychological state of the patient.

112
 The Theory of Comfort considers patients to be individuals, families,
institutions, or communities in need of health care. The environment is any
aspect of the patient, family, or institutional surroundings that can be manipulated
by a nurse or loved one in order to enhance comfort. Health is considered to be
optimal functioning in the patient, as defined by the patient, group, family, or
community. In the model, nursing is described as the process of assessing the
patient’s comfort needs, developing and implementing appropriate nursing care
plans, and evaluating the patient’s comfort after the care plans have been carried
out. Nursing includes the intentional assessment of comfort needs, the design of
comfort measures to address those needs, and the reassessment of comfort
levels after implementation.

In this theory, the role of a nurse specifically towards patients with

Fibromyalgia is to assess a patient’s comfort needs and create a nursing care
plan to meet those needs. As a patient’s comfort needs change, the nurse’s
interventions change, as well. Through this method, nurses are able to ensure
their patients are properly cared for, and that they are comfortable, especially
fibromyalgia patients who are experiencing stressors like anxiety, poor sleep, and
other medical conditions that triggers them and may predispose them towards
the disease. Thus if a patient is comfortable, he or she will feel emotionally and
mentally better, which will aid in recovery.

“Self-care Deficit”

Dorothea Orem

113
 When an individual can no longer care for themselves, they will seek out
professional care from a provider, such as a nurse. In Self Care Deficit Nursing
Theory of Dorothea Orem, it was stated that the role of a nurse is to fill-in the
gaps of care that an individual cannot provide for themselves. Orem theorizes
that individuals will initiate and perform their own self-care activities on a regular
basis to maximize their overall health and well-being. When an individual cannot
care continuously for themselves, the nurse's role will be to provide assistance.

Self-care deficit is defined as a client's inability to perform self-care on his/her

own. Self-care involves activities of daily living (ADL) such as feeding, bathing,
toileting, grooming, and dressing. In cases of fibromyalgia, patients will
experience widespread musculoskeletal pain accompanied by fatigue, sleep
disturbance, memory and mood issues that can interfere with their ability to
function and perform self-care activities. Thus, a nurse must provide and/or
assist in ADLs of the patients until they are able to restore their own self-care. In
this theory, Orem developed a 3-step process that helps to determine when there
is a self-care deficit that would need to be addressed. These steps are applicable
in patients with fibromyalgia. The first step is data collection, this is to determine
why nursing is required and what nursing care to provide to improve the patient's
condition. Next is the organization which has the nurse designing a system that
will be at least partially compensatory or supportive in the education of the
patient. This is done through an organization of the components an individual
would need to perform effective future self-care and then selecting the correct
combination of methods to create a treatment plan. Last would be assistance.
Once the methods for overcoming a self-care deficit are identified, the nurse will
then assist the individual or the family/caregivers of the individual in self-care
matters. These steps will be implemented with current technologies, policies, and
skills that are available to the nurse.

“Nursing Need Theory”

Virginia Henderson

114
 Virginia Henderson developed the Nursing Need Theory to define the
unique focus of nursing practice. This theory focuses on the importance of
increasing the patient’s independence to hasten their progress in the hospital.
Henderson’s theory emphasizes the basic human needs and how nurses can
assist in meeting those needs. She was more of a result of an individual because
the nurses expected task is to nurse the individual get back to his/her healthy
state. This means that the individual can perform task independently in the 14
basic human needs components.

In cases of fibromyalgia, the pain experienced all over the body together
with fatigue and problems in sleep and memory will greatly affect an individuals
ability to satisfy one or more of the 14 human basic needs. These needs includes
physiological, psychological, spiritual, and social needs that are necessary in
maintaining the well-being of an individual. This theory is applicable in caring for
patients with fibromyalgia as it will assist in planning nursing care. Our goal is
based on the 14 components, this basis will be of good help to us because it will
open our eyes and see what is the target for our client's performance to be better.
According to her, the nurse role in this is to temporarily assist an individual who
lacks the necessary strength, will, and knowledge to satisfy one or more of these
needs. She states: “The nurse is temporarily the consciousness of the
unconscious, the love life for the suicidal, the leg of the amputee, the eyes of the
newly blind, a means of locomotion for the infant, knowledge, and confidence of
the young mother, the mouthpiece for those too weak or withdrawn to speak.” To

115
be brief, nurses will take care of the patient until they are able to take care of
themselves.

VIII. REVIEW OF RELATED STUDIES

‌ itle: The Role of Vitamin D in the Management of Chronic Pain in Fibromyalgia:

T
A Narrative Review.

Fibromyalgia is defined as a complex disorder mainly characterized by

chronic and widespread musculoskeletal pain. While there is already established
pain treatment management for Fibromyalgia’s pain symptoms, the
pharmaceutical intervention has lacked consistent pain relief effect among all its
patients. The drugs mentioned to treat fibromyalgia are: pregabalin, duloxetine,
and milnacipran. This incites the increased investigation onto alternative
treatment options which this study aimed to evaluate the present evidence
regarding Vitamin D as a treatment option for fibromyalgia.

It is usually managed with a multidisciplinary treatment plan which

includes pharmaceutical interventions, supportive cognitive therapies (for
symptoms of cognitive disturbances), and lifestyle modifications (increasing
exercise, teaching proper sleep hygiene because of one of its primary symptoms
of sleep problems, and improving diet quality). These non-pharmacological
treatments are designed to address the physical, emotional, and psychological
effects of the disease on patients. One mentioned novel approach included that
additional nutritional supplementation support in the form of vitamins has gained
popularity for the treatments of pain management, especially Vitamin D. It is
important to note that there is not much evidence regarding its exact efficacy as a
means of therapeutic adjunct therapy, so it remains inconclusive and requires
further investigation.

Some studies reported vitamin D supplementation in fibromyalgia patients

are notable for finding improvement in pain symptoms with vitamin D

116
administration. It plays a vital role in maintaining homeostatic processes,
regulation of hormones, and nocireceptor innervation in the skeletal muscle.
Some studies show that it decreases the risk for developing osteomalacia (from
relieving the chronic pain while doing physical activities) and keeps muscle
strength from decreasing. Yet some studies also refute the idea providing that
low vitamin D levels facilitate increased sensitivity to pain in the CNS for patients
with fibromyalgia. But it is significant to notice that vitamin D supplementation is
inexpensive, has minimal adverse effects and can provide benefits towards
patients with fibromyalgia regardless of efficacy in pain control like improving
long-term bone health.

Title: “Everyone thinks I am just lazy”: Legitimacy narratives of Americans

suffering from fibromyalgia.

Fibromyalgia (FM or FMS) is a disorder that results in chronic body pain

for approximately 200 million people worldwide. Within the United States, FM
affects an estimated 5 million people, 80% to 90% of whom are women (National
Institute of Arthritis, Musculoskeletal, and Skin Diseases (NIAMS), 2019). FM is
often associated with fatigue, headaches, trouble sleeping, morning stiffness,
difficulty swallowing, tingling in hands and feet, painful menstrual periods, bowel
and bladder problems, and problems with thinking and memory (often called
“fibro fog”). Many FM sufferers detail their symptoms, which are constantly
painful and unyielding.

To be diagnosed with FM, an individual must have had at least 3 months

of widespread pain, and pain and tenderness in at least 11 of 18 areas, including
the arms, buttocks, chest, knees, lower back, neck, rib cage, shoulders, and
thighs. One participant in the study conducted by Paxman (2019) said that the
pain resulting from FM is getting too much. If she stands, it hurts. If she sits, it
hurts. If she lays down a certain way, it hurts. She’s uncomfortable all the time.
She felt alone in her situation. Also, Tammy, who also suffers from FM, explains

117
that FM is painful and presents cognitive challenges such as anxiety and
depression.

On the other hand, people with FM struggle to complete various everyday

tasks, including those inside the home (e.g., housework) and outside the home
(e.g., running errands). One participant shares that even the most seemingly
“light” tasks can be complex, aside from having difficulty performing tasks. FM
patients testify that working outside the home is challenging and exhausting to
the point that they have had to use sick days and vacation days to stay home, or
they have to scale down their work to part-time and quit their job altogether. It
also compromises their ability to perform their gender roles as wives, husbands,
mothers, and fathers. Hence, Fibromyalgia as a chronic disease can threaten
personal relationships. It can be problematic because it might result in reduced
social support for the individual battling chronic disease.

Title: Dysfunctional Neurotransmitter Systems in Fibromyalgia, Their Role in

Central Stress Circuitry and Pharmacological Actions on These Systems

Fibromyalgia is frequently regarded as a stress-related illness, and altered

stress systems have been linked to pain and other symptoms in this condition. In
fibromyalgia, the two stress systems in the body, the
hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system,
are compromised. However, the effects of these changes are not always
consistent. According to the cumulative evidence, defective transmitter systems
are being identified as a possible cause of the condition's significant symptoms.

The altered neurotransmitters include serotonin, noradrenaline, and

dopamine. These neurotransmitters, the central serotonin, and noradrenaline are
essential in endogenous pain pathways, and serotonin plays a significant role in
descending pain facilitation via the 5HT3 receptor. It has been found that CNS
levels of serotonin and noradrenaline appear to be lowered, indicated by
decreased levels of metabolites in the CS. And serotonin and noradrenaline in

118
blood, possibly contributing to dysfunctional descending pathways and
attenuated descending inhibition.

Aside from these neurotransmitters, CSF concentrations of substance P

and glutamate have been repeatedly found to be increased in fibromyalgia
patients. Concerning glutamate, proton magnetic resonance spectroscopy
studies could show that this neurotransmitter is elevated in pain-processing
regions, which are the insula, amygdala, and cingulate cortex. Increased
glutamate levels in the insular cortex have been linked to low-pressure pain
thresholds, suggesting that an overactive glutamate system contributes to
increased pain sensitivity and other fibromyalgia symptoms. In fibromyalgia
patients, changes in serotonin, noradrenalin, and substance P may contribute to
sleep and mood disorders in addition to increased pain sensitivity. Circadian
rhythms are strongly linked to serotonin which plays a role in deep sleep, and
noradrenaline. In addition, in fibromyalgia, a weak serotonin pathway is
significantly related to substantial depression.

As previously mentioned, persistent stress causes changes in

neurotransmitters that are important. Changing transmitter systems as a result of
stress would cause pain and other symptoms in fibromyalgia and contribute to
the changes in the sympathetic and HPA stress systems that have been seen in
fibromyalgia. Furthermore, chronic stress directly affects the HPA axis and the
autonomic nervous system, and the stress systems are likely to impact the
transmitter systems. It is conceivable that both systems may change
simultaneously, interact, and contribute to the fibromyalgia phenotype.

119
IX. REFERENCES

American College of Rheumatology Committee on Communications and Marketing.

(2021). Fibromyalgia. Rheumatology.org.
https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibr
omyalgia

Choicepain.com. (2022). Why Women Are More Prone to Fibromyalgia : CHOICE Pain &
Rehabilitation Center: Physical Medicine, Rehabilitation, and Pain Management.
https://www.choicepain.com/blog/why-women-are-more-prone-to-fibromyalgia

Cleveland Clinic (2020). Fibromyalgia: Symptoms, Causes, Treatment.

https://my.clevelandclinic.org/health/diseases/4832-fibromyalgia

Diazepam. (2021, August 17). RxList; RxList. Retrieved from

https://www.rxlist.com/consumer_diazepam_valium_diastat_diastat_acudial/drug
s-condition.htm

Dellwo, A. (2021). How Fibromyalgia is Treated: Tradition and Complementary

Approaches to Treatment.
https://www.verywellhealth.com/fibromyalgia-treatment-716035

DrugBank Online. (2016). Duloxetine: Uses, Interactions, Mechanism of Action |

Drugbank.com; DrugBank. https://go.drugbank.com/drugs/DB00476

Duloxetine. (2021, August 19). RxList; RxList.

https://www.rxlist.com/consumer_duloxetine/drugs-condition.htm

Fibromyalgia. (2022).
https://www.cdc.gov/arthritis/basics/fibromyalgia.htm#:~:text=Fibromyalgia%20(fi
%C2%B7bro%C2%B7my,pain%20than%20people%20without%20fibromyalgia.

Fibromyalgia - Symptoms and causes. (2021, October 26). Mayo Clinic.

https://www.mayoclinic.org/diseases-conditions/fibromyalgia/symptoms-causes/s

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,process%20painful%20and%20nonpainful%20signals.

‌Fibromyalgia. (2021). Medlineplus.gov; National Library of Medicine.

https://medlineplus.gov/fibromyalgia.html

Fibromyalgia: Can acupuncture relieve symptoms?. (2021, May 28).

https://www.mayoclinic.org/diseases-conditions/fibromyalgia/expert-answers/fibro
myalgia/faq-20057978#:%7E:text=Acupuncture%20appears%20to%20modestly
%20reduce,may%20have%20a%20beneficial%20role.

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