NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Independent:
SUBJECTIVE: ♦ Acute pain ♦ Leptospirosis is ♦ After 8 hours ♦ Assess reports of ♦ To provide base ♦ After 8 hours of
related to a bacterial of nursing pain, including line information. nursing
“Napakasakit ng bacterial disease that interventions, location and interventions,
ulo at buong infections in affects humans the patient intensity (scale of the patient was
katawan” (I had the body. and animals. It will 0-10). able to
a horrible is caused by demonstrate demonstrate
headache and bacteria of the use of ♦ Observe non- ♦ Pain is unique to use of
body aches) as genus relaxation verbal cues. each patient. relaxation skills,
verbalized by the Leptospira. In skills, other One may other methods
patient. humans it methods to encounter to promote
causes a wide promote varying comfort and to
OBJECTIVE: range of comfort and descriptions relieve pain.
symptoms, and to relieve because of
♦ Facial some infected pain. individualized
grimacing persons may perceptions. Non
have no verbal cues may
♦ Irritability symptoms at aid in evaluation
all. Symptoms of pain and
♦ Guarding of of leptospirosis effectiveness of
the affected include high therapy.
areas. fever, severe
headache, ♦ Explore alternative ♦ Cognitive
chills, muscle pain relief behavioral
♦ V/S taken as aches, and measure like interventions
follows: vomiting, and relaxation may reduce
may include technique, reliance on
T: 37.3 jaundice (yellow breathing pharmacological
P: 89 skin and eyes), techniques and therapy and
R: 23 red eyes, guided imagery. enhance
BP: 110/70 abdominal pain, patient’s sense of
diarrhea, or a control.
rash. If the
disease is not
treated, the ♦ Reduces
patient could ♦ Carefully position discomfort, and
develop kidney affected part. risk for injury.
damage,
meningitis ♦ Apply local ♦ Help reduce
(inflammation massage gently to muscle tension.
of the affected areas.
membrane
around the ♦ Encourage range ♦ Prevents joint
brain and spinal of motion stiffness and
cord), liver exercises. possible
failure, and contracture
respiratory formation.
distress. In rare
cases death ♦ Maintain adequate ♦ Dehydration
occurs fluid intake. increases sickling
and
corresponding
pain.

Collaborative:

♦ Administer ♦ Analgesics
medication as reduces pain and
indicated like promotes rest
analgesics and and comfort,
antibiotics. while antibiotics
inhibits further
bacterial
infection.