This action might not be possible to undo. Are you sure you want to continue?
“Anytime you have rain, followed by standing water and movement in rodents you see an increase in leptospirosis — a liver disease often confused with yellow fever.‖ ~ Leon Russell For thousands of years rodents have been viewed and treated as pests, disease carriers, vandals and the harbingers of catastrophic epidemics. Poisons and traps have been used for centuries to rid homes and neighborhoods of these destructive creatures, the population perpetually frightened by the consequences of allowing the rats to live. For centuries, however, there has existed a completely separate world; very different people who see beyond the stigma and usual image of rats – these people keep and adore them as pets. Rats are intelligent, friendly, affectionate and full of personality – and though many people believe them to be pests no matter what form they come in many, many people still keep them as friends and companions. According to the World Health Organization (WHO), Leptospirosis is a bacterial disease that affects both humans and animals. Humans become infected through direct contact with the urine of infected animals or with a urinecontaminated environment. The bacteria enter the body through cuts or abrasions on the skin, or through the mucous membranes of the mouth, nose and eyes. Person-to-person transmission is rare. In the early stages of the disease, symptoms include high fever, severe headache, muscle pain, chills, redness of the eyes, abdominal pain, jaundice, hemorrhages in the skin and mucous membranes, vomiting, diarrhea, and rash. Caused by Leptospira bacteria, leptospirosis is an illness that can be acquired by wading in flood water or getting in contact with soil contaminated with the urine of infected animals, particularly rats. It usually takes three to 10 days before symptoms manifest. DOH records show that from Jan. 1 to Aug. 11, a
total of 2,374 leptospirosis cases were reported to the health department. This is 70.18 percent higher than the 1,395 cases during the same period in 2011. The DOH said the number of cases was high due to the flashflood that hit Cagayan de Oro late last year. Death toll this year is 121. After typhoon Ondoy struck Luzon in 2009, more than 2,089 people were treated for leptospirosis in Metro Manila and surrounding provinces and 162 people died from the disease. This was more than five times the number of Leptospirosis deaths in the entire country in 2008. Cases of leptospirosis continue to increase in parts of Metro Manila, according to latest statistics of the Department of Health. Latest statistics from the Regional Epidemiology Surveillance Unit (RESU) showed a total of 456 cases and 45 deaths from January 1 to October 15, 2011, which is 221% higher compared to the 142 cases and 7 deaths recorded during the same period last year. San Lazaro Hospital is among the top surveillance disease reporting units with 226 cases and 8 deaths, followed by Jose Reyes Memorial Medical Center with 39 cases and 4 deaths, Quezon City General Hospital with 32 cases and 3 deaths, East Avenue Medical Center with 25 cases and 13 deaths, Ospital Ng Makati with 18 cases and 1 death and Quirino Memorial Medical Center with 12 cases and 2 deaths. Majority of the cases were male and belonged to the age group from 15-30 years old, with 181 cases and 12 deaths. In an January 14 issue from the Journal of Medical Case Reports, they have published an article entitled ―Fulminant Leptospirosis (Weil's disease) in an urban setting as an overlooked cause of multiorgan failure: a case report”. According to this article, Leptospirosis has recently come to international attention as a globally important re-emerging infectious disease. Case presentation included a 49-year-old healthy Chinese man presented to the hospital with sepsis and multiorgan failure. The patient did not respond to antibiotics and his multiorgan failure worsened. His workup did not show any significant findings except for a positive nasopharyngeal swab result for influenza A. Later the patient developed hemoptysis with evidence of bilateral infiltrates on radiography. His status mildly improved after he was started on steroids. Eventually, a microagglutination test confirmed the presence of antibodies
against Leptospira icterohaemorrhagiae. The patient subsequently recovered after a course of intravenous antibiotics. The article concluded that the case of fulminant leptospirosis presented should serve to alert health care providers and the general public to the clinical importance of this severe, sometimes fatal, disease. Leptospirosis should be considered early in the diagnosis of any patient with acute, non-specific febrile illness with multiorgan system involvement or high fever in a returning traveler. In addition, not only should it be considered in tropical and rural areas between late summer to early fall, but also in any location or time if the risk factors are present. Reasons for choosing such case for presentation The student-nurses have chosen this patient for their case study due to the following reasons: First of all, it is the group‘s first time to handle a patient diagnosed with Leptospirosis. They want to explore disease conditions that they were not able to handle previously which would allow them to expound their knowledge regarding the progression of the disease as well as its management. Second reason would be the benefit of the case for nursing students. The case will provide and present different instances wherein nursing responsibilities must be observed and as nursing students from these instances they can enhance their knowledge about the different interventions that they can provide in the future whenever they handle patients that suffers from the said disease condition. The case would be helpful and useful at the same time for the researchers as student nurses. Another reason is the significance of the case itself. The group‘s chosen case is significant in a sense that it will help them gain and understand more the major concepts associated with the major diseases and as student nurses it is very important for them to know and be familiar with these concepts because they will apply this in their field of work so the case they chose is really significant.
alleviate sufferings and prevent complications. Specific Objectives Student nurse centered Short term: To be able to have a thorough history taking of the patient. The main objective of the group in conducting this case study is to be able to evaluate and have a firm background on the health condition of the patient and his needs so that proper planning. etiology. the student nurses were able to come up with the decision of making Leptospirosis as their case study. signs and symptoms and Pathophysiology of the disease condition. The group has formulated the following specific objectives to guide them towards the completion of this case study. With the aforementioned reasons. .Next reason is to have an experience in handling and providing humanitarian health services to a patient who has it and provide any intervention or treatment indicated based on the specific etiology and the course it follows in that specific patient. General Objectives That within the two weeks in the Medicine Ward exposure. To understand the disease process. management and intervention will be given to meet basic needs. the studentnurses may be able to choose a case study that will contribute and expand their knowledge and improve their skills on specific procedures that had already been initiated to them during their preceding clinical exposures.
Patient centered Short term: Patient will be able to understand the general description of the disease condition he is suffering from. Long term: To improve our skills in performing interventions to our future clients who suffers from such condition. previous illnesses that could contribute to the occurrence of the disease condition. To discuss and describe interventions for health promotion. To promote wellness to individuals by imparting knowledge so they could learn and understand more about the disease condition. Patient will be able to overcome anxiety brought about by his condition through the help of the student nurses explanation of his current disease. To develop a teaching program that will educate patients by planning activities that‘ll focus the importance of healthy lifestyle. To assist patient in overcoming the anxiety and depression brought about by the condition. Long term: . Patient will be able to identify the history of his present illness by stating his lifestyle. familial predisposition. Patient will be able to identify techniques to alleviate the other problems that arise from his disease condition with the health teachings imparted by the student nurses. To improve our attitude in handling patients with the same condition in the future by learning the specifics of the disease condition. prevention and treatment of patients with the disease condition.
Patient will be able to demonstrate a healthier lifestyle brought about by the health teachings imparted by the student nurses. Patient will be able to perform measures that will prevent further advancement and complications of the disease. Patient will show improvement when it comes to his attitude in perceiving the disease condition because of his full understanding of the disease. Patient will be able to effectively perform interventions taught by the student nurses concerning the problems being experienced or possible problems that the patient will experience due to her disease condition. .
the student nurses draw the line between the father and mother of Mr. In the process of data collection. Mr. He is of Kapampangan descent and was born in the said city on 10th of May 1980. Pampanga. NURSING ASSESSMENT A. He is a high school graduate and is affiliated in the Roman Catholic sect which is also the religion of the rest of his family. The said disease scampers in the blood of his grandparents on his father‘s side. . the hereditary disease that is visible among them from the third generation up to his father is diabetes mellitus. His mother does not have any debilitating disease as of the moment and as to what he utters they do not have any familial history of other hereditary disease except for diabetes mellitus. married and is currently residing in the city of San Fernando. Raticate. Raticate is a wheeler driver and earns approximately 200php per day and that is approximately 6. Personal History 1. He was admitted at a tertiary hospital in the city of San Fernando on the 20th of August 2012 at 10:00am. he will be referred to as ―Mr. Raticate is a 32 year old Filipino citizen.000php a month. DEMOGRAPHIC DATA To secure outmost confidentiality with our patient. Family Health-Illness History In the family of the Mr. B. Mr. Raticate.II. SOCIO-ECONOMIC AND CULTURAL FACTORS Mr. Raticate is the 3rd among the siblings and among the five and fortunately he did not acquire the said hereditary disease that runs in their blood. Raticate‖ throughout the study. 2.
GRANDPA (+) Diabetes Mellitus GRANDMA (+) GRANDPA (+) GRANDMA (+) FATHER Diabetes Mellitus MOTHER BRO 1 Diabetes Mellitus SISTER 1 Patient Leptospirosis BRO 2 Diabetes Mellitus BRO 3 (+) = deceased .
he had open wounds then.C. The occurrence of fever made him seek medical attention. Raticate states that he had no other illnesses other than having cough and colds for thrice a year or fever at least twice a year. HISTORY OF PRESENT ILLNESS Six days prior to admission. HISTORY OF PAST ILLNESS Mr. D. Mr. His past illness states that he was once afflicted with chicken pox when he was around 13 years old. Raticate stated that he was exposed to flood water. He also had abdominal tenderness and presence of calf pain. . Apparently.
with an IVF of PNSS. with normal capillary refill of <3sec. pale palpebral conjuctiva.3. lethargic Skin: Pale and dry Eyes: anicteric sclera. infusing well over the left metacarpal vein with an intact indwelling foley catheter connected to urine bag draining yellowish output @ 1800 cc level. (+) PERRLA 1st Patient-Nurse Interaction PHYSICAL EXAMINATION (September 20. as lifted from the patient’s chart) VITAL SIGNS RR: 21 cpm T: 36°c/axilla BP: 120/80 mmHg PR: 81 bpm General Appearance: weak. 1 Liter regulated at 250 cc per hour. conscious and appears weak. 2012) Mr. 2012. Vital signs were taken and recorded as follows: BP: 110/70 mmHg PR: 82 bpm RR: 18 cpm T: 37°C/axilla . Raticate was seen lying on bed. Physical Examination upon Admission (August 1.
with good skin turgor as evidenced by when the skin in the abdomen is pinched it goes back immediately to its previous state (less than 2 seconds). Eyes and eye Structure Eyebrows The hair is evenly distributed. It is normocephalic and smooth. His affect is appropriate to and is able to respond appropriately.A. symmetrically aligned. He has symmetric facial movements and the palpebral fissures are equal in size. uniform consistency and there is absence of nodules or masses. Integument Skin He is brown in complexion and has a dry skin. and with equal movement. Skull and Face The head is round and there is no presence of scars. Skin is warm to touch. Nails He has smooth and convex curve nails. has coordinated movements but appears weak. has dirty nails. and with a capillary refill of less than 2 seconds. . HEAD-TO-TOE AND BODY SYSTEMS ASSESSMENT Appearance and Mental Status He has proportionate built. He is not properly groomed.
Nasolacrimal duct No edema or tenderness over the lacrimal gland. no discharge. and curled slightly outward. reactive to light and accommodation). and the sclera appears white. Lacrimal sac. no tearing. Eyelashes Equally distributed. Pupils Black in color. Cornea It appears transparent. pupils converge when object is moved towards the nose. appears shiny. illuminated pupil constricts and non illuminated pupil constricts Lacrimal gland. shiny and smooth. . and smooth. Palpebral Conjunctiva It is pinkish in color. positive PERRLA (Pupils equally rounded. Bulbar Conjuctiva It is transparent. Eyelids The lids close symmetrically.
symmetric and straight. no presence of discharges. mobile. Nose and Sinuses External Nose Air moves freely as he breathes through the nares.Ear Auricles The color of the auricles is same as facial skin. nasal septum intact and in midline. with pinkish nasal mucosa. The auricles are firm and not tender. firm. symmetrical. . Facial Sinuses All of the sinuses have no tenderness upon palpation. Inspection of Nasal Cavity Mucosa is pink. auricles are aligned with the outer canthus of the eye. nontender. no lesions and nasal septum intact and in midline. the pinna recoils after it is being folded. not tender. aligned with the outer canthus of the eye. External Ear Canal Minimal wet cerumen is seen on distal thirds of both ears.
Lymph Nodes Not palpable and not enlarged cervical lymph node. Tongue and floor of the mouth It is light pink in color.Mouth and Oropharynx It is symmetrical. head is centered. and without discomfort. with coordinated smooth movement. uniform pink. uvula positioned midline of soft palate. and has smooth lips. Gag reflex It is present when elicited through the use of a tongue depressor. Palates and Uvula The hard palate and soft palate appears pink in color. and is able to protrude the tongue upon inspection. Lips and Buccal Cavity Pale pinkish in color. moves freely. able to purse lips. moist. Neck Muscles are equal in size. . in central position. appears moist and smooth.
Auscultation of the chest No adventitious breath sounds are heard upon auscultation on inspiration on both lung fields. equal spaces on both sides There is absence of bruit upon auscultation. Trachea Central placement in midline of neck. without tenderness and masses upon palpation. with normal rise and fall of chest when breathing. Anterior Thorax: With effortless respiration. glands ascends but not visible during swallowing. . and the spine is vertically aligned. Thorax and lungs Chest With symmetric movement. Thyroid Gland It is not visible on inspection. with resonant sound upon percussion over the lungs. Posterior Thorax With full and symmetric chest expansion. with resonant sound upon percussion over the lungs.
not distended. Abdomen Appears rounded. no edema. Upon auscultation. Peripheral perfusion The skin color is pink. Respiratory excursions Full symmetric excursions. and the limbs are not tender. thumb separate in two inches. Peripheral Pulses There are full pulsations on radial pulse. Heart Heart rhythm is regular. without evidence of enlargement of liver and spleen. no sound on auscultation on carotid artery. Respiratory rate of 18 breaths per minute. with tenderness. Abdominal movements Symmetrical movements caused by respirations. . with audible bowel sounds upon auscultation. heart beat is heard at space sites usually louder at apical area Carotid arteries It has full pulsations. temperature not excessively hot or cold.
Auscultation of bowel sounds With audible bowel sounds of 10 bowel sounds per minute. . without bone deformities. without paralysis or weakness observed. muscles are equal in size. with pain on calf. Upper and Lower Extremities Upper and lower Extremities: hair is evenly distributed.
Potassium is also important in how nerves and muscles work. . Raticate‘s sodium level is within the normal range. Sodium is both an electrolyte and mineral.50 mmol/L Sodium DO: 9-20-12 DI: 9-20-12 137 135-150 mmol/L Mr. Raticate‘s potassium level is within normal range. DIAGNOSTIC AND LABORATORY PROCEDURES A. It helps keep the water (the amount of fluid inside and outside the body's cells) and electrolyte balance of the body. Sodium is also important in how nerves and muscles work. Potassium is both an electrolyte and a mineral. A sodium test checks how much sodium (an electrolyte and a mineral) is in the blood. It helps keep the water (the amount of fluid inside and outside the body's cells) and electrolyte balance of the body.50-5.4.68 3. A potassium test checks how much potassium is in the blood. CLINICAL CHEMISTRY (FLUID AND ELECROLYTES) DIAGNOSTIC/ LABORATORY PROCEDURES Potassium DATE ORDERED DATE RESULTS IN DO: 9-20-12 DI: 9-20-12 INDICATIONS RESULTS NORMAL VALUES ANALYSIS AND INTERPRETATION (Patient-Based) Mr. 3.
Explain that there is no special preparation. Document. During: Use the sterile technique. .Nursing Responsibilities: Prior: Define and explain the test. State the specific purpose of the test. After: Keep the past records especially the latest ones.
45 Mr. . whether the blood is too thick or too thin. It is used as a rapid direct measurement of the hemoglobin within normal range. is Raticate‘s within the range indicates normal hematocrit level normal which a DATE ORDERED DATE RESULT(S) IN INDICATION(S) RESULTS NORMAL VALUES1 ANALYSIS AND INTERPRETATION concentration of red blood cells within the blood volume. COMPLETE BLOOD COUNT DIAGNOSTTIC/ LABORATORY PROCEDURES Hematocrit (Hct) DO: 9-20-12 DI: 9-20-12 The hematocrit shows the This oxygen-carrying value also tells capacity of the blood.41 0. Hemoglobin (Hgb) This is a test of of 135 125-175 g/L Mr. 0.B. Useful as a measurement of red blood cells only if the hydration of the client is normal. Raticate‘s is the measure of the total amount hemoglobin in the blood.36-0.
9 5-10x103/L Mr. Leukocytes WBC or leukocytes are cells of the immune system which defend the body against both infectious 5. It is an of integral part of the evaluation anemic patients. Hemoglobin acts as an important acidbase buffer system. It is repeated patients ongoing or as a bleeding routine part of the complete cell blood count.red serially with blood in cell count. Raticate‘s leukocyte count is within the range. normal .
neutrophil count is within the range. Raticate‘s helps us detect the levels of neutrophils in our body. evaluates the body‘ capacity to resist and overcome infection to detect leukemia to determine severity of infection. These neutrophils are an integral part of our immune system and through a process called chemotaxis. Neutrophils A neutrophils test 0. normal .disease and foreign materials.68 0.18-0.70 Mr.
In fact.20-0. This test measures . It is also important to go in for a high neutrophils test as indicative of Lymphocytes stress in blood are of an 0. cells take about an hour to reach the site of infection.27 0. Raticate‘s they extremely high levels individual.35 Mr. they are one of the main components of pus and are to blame for its whitish color.they place reach where any an has These infection occurred.
normal Mr.the number of lymphocytes (a type of white blood cell) in blood. It may be used as part of the 77 150-400x10 9L lymphocyte count is within the range. Platelet Count A platelet count may be used to screen for or diagnose various diseases and conditions that affect the number of platelets in the blood. . It is used to evaluate and manage disorders of the blood or the immune system. It is also used to evaluate and manage certain types of cancer and tumors. is Raticate‘s count the range of for below platelet normal which might be indicative risk bleeding.
bone marrow disease. to name just a few. .workup of a bleeding disorder. or excessive clotting disorder. It may also be used to monitor those being treated for a platelet disorder to determine if therapy is effective. The test may used as a monitoring tool for people with underlying conditions or undergoing treatment with drugs known to affect platelets.
The tourniquet should be less on a minute. No food or fluid restrictions. Explain the purpose and what to expect. During: Do not take the blood sample from hand or arm with receiving IVF.Nursing Responsibilities: Prior: Explain the procedure. After: Label the specimen. Check the doctor's order. Wipe away the first drop of blood. . Secure the results. Document. Note for inflammation of punctured site. Do not squeeze the punctured site rightly.
C. Raticate‘s Creatinine is within normal range. A serum creatinine test measures the level of creatinine 114. an increased level of creatinine may accumulate in your blood. If your kidneys aren't functioning properly. . RENAL FUNCTION TEST DIAGNOSTIC / LABORATORY PROCEDURES Creatinine DO: 9-20-12 DI: 9-20-12 A creatinine test reveals important information about your kidneys. Healthy kidneys filter creatinine and other waste products from your blood. The filtered waste products leave your body in your urine. Creatinine is a chemical waste product that's produced by your muscle metabolism and to a smaller extent by eating meat.7 DATE ORDERED / DATE RESULT(S) IN INIDICATION (S) / PURPOSE(S) RESULT(S) NORMAL VALUES (UNITS USED IN THE HOSPITAL) 60-120 ANALYSIS AND INTERPRETATION OF RESULTS Mr.
most urea nitrogen is filtered out by the kidneys and leaves the body in the urine. the BUN level will rise. A creatinine urine test can measure creatinine in your urine. .8 1. Urea then circulates in the blood in the form of urea nitrogen. If the patient's kidneys are not functioning properly or if the body is using large amounts of protein.Blood Urea Nitrogen (BUN) DO: 9-20-12 DI: 9-20-12 and gives you an estimate of how well your kidneys filter waste (glomerular filtration rate). Urea is a substance that is formed in the liver when the body breaks down protein. The blood urea nitrogen (BUN) test measures the level of urea nitrogen in a sample of the patient's blood.3 Mr. In healthy people. Raticate‘s BUN level is within normal range.7-8. If the patient has severe liver disease. the 5.
BUN will drop. blockage of urine flow. Patients with kidney failure are sometimes disoriented and confused. mental confusion. . abnormal loss of water from the body (dehydration). The BUN level may be checked in order to assess or monitor: the presence or progression of kidney or liver disease. The body uses larger than normal amounts of protein following serious burns. recovery from severe burns.
They lie behind a protective sheet of tissue within the abdomen. Humans produce about 1. ANATOMY AND PHYSIOLOGY Renal System The kidneys are bean-shaped organs which help the body produce urine to get rid of unwanted waste substances. tubes called ureters transport it to the urinary bladder. . if we drink more water. This is why it's very important to drink lots of water on hot summer days. where it is stored and excreted via the urethra. On hot days. When urine is formed. if we get dehydrated and sweat more.III. However. we may produce less urine. The kidneys regulate the amount of water in the body. For example. A special system of tubes within the kidneys allow substances such as sodium (salt) and chloride to be filtered. The kidneys are also important in controlling our blood pressure and producing red blood cells. Components of the urinary system Kidneys and ureters The kidneys are large. The kidneys perform many vital functions which are important in everyday life. they help us get rid of waste products by making urine and excreting it from the body. bean-shaped organs towards the back of the abdomen (belly). we may produce more urine.5 litres of urine a day.
There is an outer red-brown part (cortex) and inner lighter coloured part (medulla). A small blood vessel network called the vasa recta supplies the medulla. where blood vessels. where urine collects. Each nephron is supplied by a ball of small blood vessels.The kidneys also produce renin (a hormone important in regulating blood pressure) and erythropoietin (helps produce red blood cells). and the ureters enter the kidney. A diagram of a single glomerulus is seen below. The inner part of the kidney (the medulla) is a continuation of the specialized nephrons in the kidney. On one end of the ureters is a funnel-shaped expansion. Blood is filtered through the small blood vessels to produce a mixture that is the precursor of urine. This mixture then passes through more tubules. there are many nephrons which act as filtering units. and a system of straight and curvy collecting tubules supplied by many blood vessels. the right kidney is slightly lower in position than the left. The ureters enter the bladder at an angle. Each kidney is supplied by the renal arteries. so urine doesn't flow up the wrong way. salt and nutrients are reabsorbed. In the outer part of the kidney. 5 cm width and 2. they are 25–30 cm long tubes lined withsmooth muscle. nerves. allowing room for the liver. Located in the lower part of our bellies. nephrons. On the side of the kidney with the smaller curve is an opening called the hilum.5 cm thick. The muscular tissue helps force urine downwards. The kidneys are reddish brown in colour and measure about 10 cm in length. The cortex is made up of special units called corpuscles. called the renal pelvis. where water. The ureters carry urine to the bladder. which . called glomeruli. The kidney can be divided into two distinct regions.
The veins follow these blood vessels. under the appropriate signals. stretch receptors in the bladder are activated. allowing urine to flow. a venous network drains blood from the bladder arteries into the internal iliac vein. the obturator. In females. The female urethra is supplied by the internal pudendal and vaginal arteries. The main function of the bladder is to store urine and. running from the bladder to the tip of the penis. Normally. The bladder has three openings: two for the ureters and one for the urethra (tube carrying urine out of the body). which send signals to our brain and tell us that the bladder is full. Bladder The bladder is a pyramid-shaped organ which sits in the pelvis (the bony structure which helps form the hips). Renal veins drain the kidney. The blood supply of the bladder is from many blood vessels. Urethra The male urethra is 18–20 cm long. When we want to urinate. The bladder consists of smooth muscles. Nervous control of the bladder involves centres located in the brain andspinal cord. . uterine. The main muscle of the bladder is called the detrusor muscle.give off many smaller branches to the surrounding parts of the kidneys. it is more likely to get infections from bacteria in the vagina. The ring-like muscle relaxes and the detrusor muscle contracts. gluteal and vaginal arteries. As the female urethra is shorter than the male urethra. The nerve supply is via the pudendal nerve. release it into a tube which carries the urine out of the body. The female urethra is 4–6 cm long and 6 mm wide. The male urethra is supplied by the inferior vesical and middle rectal arteries. Muscle fibres around the opening of the urethra forms a ring-like muscle that controls the passage of urine. the bladder can hold up to 500 mL of urine. Some of these blood vessels are named: the vesical arteries. It is a tube running from the bladder neck and opening into an external hole located at the top of the vaginal opening.
Each lobule is made up of millions of hepatic cells which are the basic metabolic cells. Cell types Two major types of cells populate the liver lobes: parenchymal and nonparenchymal cells. Lobules are the functional units of the liver. It is located in the right upper quadrantof the abdominal cavity. It is connected to two large blood vessels. which then lead to a lobule.2–3. . The liver lies to the right of the stomach and overlies the gallbladder. and is a soft. It is both the largest internal organ (the skin being the largest organ overall) and the largest gland in the human body.66 kg (3. Kupffer cells and hepatic stellate cells are some of the non-parenchymal cells that line the hepatic sinusoid. resting just below the diaphragm. one called the hepatic artery and one called the portal vein. whereas the portal vein carries blood containing digested nutrients from the entire gastrointestinal tract and also from the spleen and pancreas. Non-parenchymal cells constitute 40% of the total number of liver cells but only 6.44–1. The hepatic artery carries blood from the aorta.Liver The liver is a reddish brown organ with four lobes of unequal size and shape. These blood vessels subdivide into capillaries. 80% of the liver volume is occupied by parenchymal cells commonly referred to as hepatocytes. triangular organ.5% of its volume. A human liver normally weighs 1. pinkish-brown. Sinusoidal endothelial cells.7 lb).
Surface anatomy Peritoneal ligaments Apart from a patch where it connects to the diaphragm (the so-called "bare area"). Bile can either drain directly into the duodenum via the common bile duct. The common bile duct and the pancreatic duct enter the second part of the duodenum together at the ampulla of Vater. a thin. liver gets a dual blood vein supply from the hepatic blood drained portal from vein and hepatic arteries. . doublelayered membrane that reduces friction against other organs. which merge to form the common hepatic duct. The intrahepatic ducts eventually drain into the right and left hepatic ducts.Blood flow The supply. Blood flows through the liver sinusoids and empties into the central vein of each lobule. gastrointestinal tract. or be temporarily stored in the gallbladder via the cystic duct. and its associated organs. which leave the liver. accounting for the remainder of its blood flow. The bile produced in the liver is collected in bile canaliculi. Within the liver. Biliary flow The term biliary tree is derived from the arboreal branches of the bile ducts. and once they exit the liver they are consideredextrahepatic (outside the liver). The central veins coalesce into hepatic veins. The hepatic arteries supply arterial blood to the liver. Supplying approximately 75% of the liver's blood the hepatic portal carries venous the spleen. Oxygen is provided from both sources. The cystic duct from the gallbladder joins with the common hepatic duct to form the common bile duct. the liver is covered entirely by visceral peritoneum. and half is met by the hepatic arteries. which merge to form bile ducts. these ducts are called intrahepatic (within the liver) bile ducts. approximately half of the liver's oxygen demand is met by the hepatic portal vein.
which attaches the liver to the posterior portion of the anterior body wall. The falciform ligament is visible on the front (anterior side) of the liver. Lobes Traditional gross anatomy divided the liver into four lobes based on surface features. Functional anatomy The central area where the common bile duct. veins and arteries that carry fluids to and from them. there are ducts. On the surface of the lobules. and the right sagittal fossa. and artery divide into left and right branches. From behind. . to look at it from behind (the visceral surface). Each of the lobes is made up of lobules. there are two additional lobes between the right and left. and have essentially no known functional importance. The transverse fissure(or porta hepatis) divides the caudate from the quadrate lobe. These are the caudate lobe (the more superior) and the quadrate lobe (the more inferior). and hepatic artery proper enter is the hilum or "porta hepatis". a vein goes from the centre. which the inferior vena cava runs over. the lobes are divided up by the ligamentum venosum and ligamentum teres (anything left of these is the left lobe). If the liver is flipped over. An exception to this is the falciform ligament. vein. hepatic portal vein. This divides the liver into a left anatomical lobe. The duct. which then joins to the hepatic vein to carry blood out from the liver. but they are easily recognizable surface landmarks. These "lits" are in no way related to the true anatomic ligaments in joints. separates these two lobes from the right lobe. and the portions of the liver supplied by these branches constitute the functional left and right lobes. and a right anatomical lobe.The peritoneum folds back on itself to form the falciform ligament and the right and left triangular ligaments.
In the widely used Couinaud (or "French") system. The fissure for the ligamentum teres also separates the medial and lateral segments. The liver has a multitude of important and complex functions. The left lobe is divided into the medial and lateral segments by the left hepatic vein.The functional lobes are separated by an imaginary plane (historically called Cantle's line) joining the gallbladder fossa to the inferior vena cava. E. D. Eliminate. The caudate lobe is a separate structure which receives blood flow from both the right. drugs. . which are used as the source for the sugar (glucose) in blood that red blood cells and the brain use Form and secrete bile that contains bile acids to aid in the intestinal absorption (taking in) of fats and the fat-solublevitamins A. Some of these functions are to: Manufacture (synthesize) proteins. The right lobe is further divided into an anterior and posterior segment by the right hepatic vein. the functional lobes are further divided into a total of eight subsegments based on a transverse plane through the bifurcation of the main portal vein. including fatty acids (used for energy) and cholesterol Metabolize and store carbohydrates. The plane separates the liver into the true right and left lobes. including albumin (to help maintain the volume of blood) and blood clotting factors Synthesize. and ammonia from the breakdown of proteins Detoxify. The middle hepatic vein also demarcates the true right and left lobes. The medial segment is also called the quadrate lobe. and process (metabolize) fats. by metabolizing and/or secreting. such as bilirubin from the breakdown of old red blood cells. and K.and left-sided vascular branches. alcohol. the potentially harmful biochemical products produced by the body. by metabolizing and/or secreting. and environmental toxins. store.
IV. THE PATIENT AND HIS ILLNESS A. PATHOPHYSIOLOGY (BOOK- CENTERED)
Predisposing Factor: Dirty environment, age, seasons, males, geographic areas Cattle, swire and other livestock History taking (history of exposure)
Rodents, wild animals
Infected urine or carcasses
Ingestion of contaminated food and water
Entry through eyes, nose and broken skin
Incubates for 6 to 15 days
Profileration and widespread dissemination
Kidney and Liver Functions Test
Organ systems are affected
Septic stage: Febrile lasting for 4 to 7days, chills, head ache, anorexia, abdominal pain Immune or Toxic stage: Can be with or without jaundice last for 4 to 30 days, iritis, headache, meningeal manifestations, oliguria and anuria with progressive renal failure, shock, coma, CHF in severe cases. Convalescence: Relapse may occur during 4th o 5th week
CSF and urine culture, Agglutination test Death
Complications: Pneumonia Optic Neuritis Peripheral neuritis
SYNTHESIS OF THE DISEASE (BOOK-CENTERED) b. severe prostration. muscle pains.onset of high remittent fever. It was first described by Adolf Weil in 1886 when he reported an ―acute infectious disease with enlargement of spleen.1. It is considered the most common zoonosis in the world. cough. Leptospirosis has recently been recognized as a re-emerging infectious disease among animals and humans and has the potential to become even more prevalent with anticipated global warming. headache. respiratory distress. joint pains. jaundice and nephritis.‖ b. Mud fever. also known as Weil‘s disease. chills. bloody sputum. anorexia. nausea & vomiting. myalgia.B. abdominal pain. Canicola fever.3. Predisposing or Precipitating Factors Factors that may put an individual at risk for acquiring Leptospirosis includes the following: Age: less than 15 years of age Sex: Male Season: Rainy months Geographic: Prevalent in slum areas b. Signs and Symptoms 1st stage: Septicemic/ Leptospiremic Phase (4 – 7 days) . Leptospirosis is distributed worldwide (sparing the Polar Regions) but is most common in the tropics. Definition of the disease Leptospirosis. . Swineherd‘s Disease. and Japanese Seven Days fever is a disease that is caused by pathogenic spirochetes of the genus Leptospira. Flood fever.2.
anuria with progressive renal failure. hepatic & renal manifestations: hemorrhage. coma & congestive heart failure in severe cases. injection.if severe. death may occur between the 9th & 16th day2 types: •Anicteric (without jaundice) – return of fever of a lower degree with rash. shock.Relapses may occur during 4th or 5th week. hepatomegaly. oliguria. headache. meningeal manifestations like disorientation. hyperbilirubinemia. 3rd stage: Convalescence Phase .convulsions & signs of meningeal irritations (with CSF finding of .2nd stage: Immune/ Toxic Phase (4 – 30 days) .conjunctival asepticmeningitis) •Icteric (with jaundice) – Weil syndrome.
Rodents.PATHOPHYSIOLOGY (CLIENT-CENTERED) Predisposing Factor: Dirty environment. nose and broken skin Incubates for 6 days A . seasons. wild animals Infected urine or carcasses Man Entry through eyes. males.
calf pain Leptospirosis . abdominal tenderness. chills.A Profileration and widespread dissemination Septic stage: Febrile.
Canicola fever. Leptospirosis is distributed worldwide (sparing the Polar Regions) but is most common in the tropics. Swineherd‘s Disease.B. abdominal tenderness and calf pain.3. Signs and Symptoms 1st stage: Septicemic/ Leptospiremic Phase (4 – 7 days) .2. Flood fever. Predisposing or Precipitating Factors Factors that may put an individual at risk for acquiring Leptospirosis includes the following: Sex: Male Season: Rainy months b. . chills.1. It is considered the most common zoonosis in the world. and Japanese Seven Days fever is a disease that is caused by pathogenic spirochetes of the genus Leptospira.SYNTHESIS OF THE DISEASE (CLIENT-CENTERED) b.‖ b. Mud fever. jaundice and nephritis. also known as Weil‘s disease. Leptospirosis has recently been recognized as a re-emerging infectious disease among animals and humans and has the potential to become even more prevalent with anticipated global warming. Definition of the disease Leptospirosis.onset of high remittent fever. It was first described by Adolf Weil in 1886 when he reported an ―acute infectious disease with enlargement of spleen.
MEDICAL MANAGEMENT a. 2012 Is an Isotonic solution. this solution maintains plasma concentration in blood to restore osmotic equilibrium. PNSS contains 154 meq/L Na 154 meq/L Cl PNSS is used because it has little to no effect on the tissues and also makes the patient feel hydrated preventing hypovolemic shock or hypotension. The patient was able to tolerate the infusion.V. The patient had no untoward reaction to the treatment. Intravenous Fluids MEDICAL MANAGEMENT OR TREATMENT DATE ORDERED DATE PERFORMED DATE or D/C CHANGED GENERAL DESCRIPTION INDICATIONS OR PURPOSES CLIENT’S RESPONSE TO THE TREATMENT PNSS 1L Date Ordered: September 20. . 2012 Date Consumed: September 20-21. PATIENT AND HIS CARE A.
During: Be sure to clean the site of entry with cotton and alcohol in a circular motion. Check regularly. then regulate flow rate as per doctor‘s order. edema. Document relevant data. Wash hands and observe other appropriate infection control procedures. Always observe and check for the correct type of IVF as well as the clarity of the fluid. Adhere to standard precautions.NURSING RESPONSIBILITIES: Before: Check for the doctor‘s order. Provide client privacy. Make sure that the IVF is patent and properly regulated. Explain the procedure to the patient/SO with its purpose and importance. After: Check and observe the puncture site for bleeding. Ensure appropriate infusion flow. or thrombophlebitis. .
sterile tube inserted into the bladder to drain urine. it is indicated for Acute urinary retention. As a diagnostic procedure. For therapeutic purposes. Chronic obstruction causing hydronephrosis. which is filled with sterile water to prevent the catheter from being removed from the bladder. 2012 A Foley catheter is a thin. The patient tolerated the procedure and had drainage of yellowish colored urine. 2012 Date Performed: September 20. Indwelling Foley Catheter MEDICAL MANAGEMENT OR TREATMENT DATE ORDERED DATE PERFORMED DATE or D/C CHANGED GENERAL DESCRIPTION INDICATIONS OR PURPOSES CLIENT’S RESPONSE TO THE TREATMENT Indwelling Foley Catheter Date Ordered: September 20. intermittent bladder decompression for neurogenic bladder and for Chronically bed-ridden patients for hygiene.b. It is held in place with a balloon at the end. . An indwelling Foley Catheter is performed as a diagnostic procedure and for therapeutic purposes. it is used to collect uncontaminated urine specimen and for urine output monitoring.
apply sterile gloves Check balloon for patency. lift the penis to a position perpendicular to patient's body and apply light upward traction (with non-dominant hand) Identify the urinary meatus and gently insert until 1 to 2 inches beyond where urine is noted Inflate balloon. using correct amount of sterile liquid (usually 10 cc but check actual balloon size) Gently pull catheter until inflation balloon is snug against bladder neck Connect catheter to drainage system Secure catheter to abdomen or thigh.NURSING RESPONSIBILITIES: Before: Gather equipment. Cleanse anterior to posterior. Maintain hand position until preparing to inflate balloon. inner to outer. without tension on tubing Place drainage bag below level of bladder . separate labia using non-dominant hand. discard swab away from sterile field. In the male. If male. cleanse peri-urethral mucosa with cleansing solution. one swipe per swab. Generously coat the distal portion (2-5 cm) of the catheter with lubricant Apply sterile drape During: If female. Using dominant hand to handle forceps. Hold end of catheter loosely coiled in palm of dominant hand. Explain procedure to the patient Assist patient into supine position with legs spread and feet together Open catheterization kit and catheter Prepare sterile field. Pick up catheter with gloved (and still sterile) dominant hand. hold the penis with the non-dominant hand.
wash hands After: Document size of catheter inserted. and quality of urine Remove gloves. patient's response to procedure. and assessment of urine. Evaluate catheter function and amount. amount of water in balloon. . odor. dispose of equipment appropriately. color.
Drug Classes: Antibiotic For use in the treatment of severe infections caused by penicillin Gsusceptible microorganisms when rapid and high penicillin levels are required. Penicillin G may also be used in some cases as prophylaxis against susceptible organisms.000 IU Q4 IV + 30cc D5W x 30 minutes Brand Names: Penicillin Potassium G Penicillin G is narrow spectrum antibiotic used to treat infections caused by susceptible bacteria. The patient was able to comply with the drug therapy and did not manifest any side-effects of the drug. to the Medication Actual Administration Generic Name: Penicillin G Date Ordered: September 20. Date D/C Route Dosage. It is a natural penicillin antibiotic that is administered intravenously or intramuscularly due to poor oral absorption. 2012 2. Drugs Date Ordered. Name Drugs of Date Given.B. 2012 Date Given: September 20. . Frequency of and of General Action/ Mechanism of Indication / Action Purpose(s) Client’s with Effects Response Side Administration.000.
. secure the needle and medication used. AFTER: Monitor for any side effects or abnormal findings regarding the administered drug. If the medication is to be infuse through IV push. Read the drug label three times before administering.NURSING RESPONSIBILITIES: BEFORE: Verify the doctor‘s order. Reduce the amount of drug with patient having renal or hepatic impairment. Emphasize proper IV administration. Document for any abnormal findings and for the procedure done. After administering the medication. Monitor VS. Be cautious enough in preparing drug‘s amount because exceeding in the prescribed amount may cause toxicity. Explain the need for the patient to intake all the medicine prescribed DURING: Maintain aseptic technique throughout the procedure. Assess for previous history of reactions to other cephalosporin or penicillin. then inject the drug slowly and be sure that the medication goes directly in vein.
fluid intake of 2-3 L monitoring Increased oral fluid intake is for hydration purposes. based basic on 6 when client can He complied well with the diet the now tolerate any food he and ate the foods that he can food desires that is nutritious. if tolerate as well increased his Increased oral 2012 Date Started: September 2012 groups that have this will not lead to any oral fluid intake.Type of Diet Date Ordered Date Started Date Changed General Description Indication or Purposes Client’s Response and/or reaction to diet Diet tolerated fluid intake as Date Ordered: with September Nearly normal diet Given 20. needs for further lab test. with increased oral client of water a day. no food restriction complications and if the 20. .
The ordered diet should be monitored. . Continuous monitoring of the client‘s diet should be observed. The benefits as well as the disadvantages should be explained well to the client. The nurse should make sure that the patient adheres to the ordered diet. The nurse must reinforce the low salt low fat diet. Check vital signs to obtain baseline data.NURSING RESPONSIBILITIES: Explain to the patient the importance and significance of the diet to his current situation Place ‗Diet as tolerated with increased oral fluid intake‘ signs on the door and on the bed.
oxygenation work of prevent promote The patient was able and to demonstrate deep and respiratory breathing and increase the the complication such as coughing effectively. However. May sit on side of bed. To prevent respiratory Patient sat on bed Ambulation dangle feet. proper circulation. around the room and/or as thromboembolism for 2 hours. . and of the ventilation. nearby areas. 2012 efficiency decrease breathing. 2012 Date Started: September 20. gas atelectasis post-op. and excursion of the diaphragm pneumonia improve exchange oxygenation.Type Activity Exercise of Date Ordered / Date Started Date Changed General Description Indication(s) Purpose(s) or Client’s Response to the Activity / Exercise Designed to improve the To Deep breathing and coughing exercise Date ordered: September 20. and walk complications as well and has tolerated it thus promoting the patient chose to walk around.
Instruct SO to assist the client perform his normal ADL‘s. Nursing Responsibilities for Ambulation: Explain the procedure and the purpose of the exercise or activity. Encourage patient to ambulate in order to hasten wound healing and prevent postoperative complications Do close monitoring of the patient to ensure that the patient does not experience any injuries or falls while ambulating . Watch closely for signs of orthostatic hypotension like dizziness or lightheadedness upon standing. Demonstrate deep breathing exercise to the client. Instruct the client to inhale through the nose and exhale through pursed lips.Nursing Responsibilities for Deep Breathing and Coughing Exercise: Explain the procedure and the purpose of the activity or exercise. Instruct the client to support the incision site using a pillow or his hands. Instruct the client to perform the procedure slowly by dangling the legs first before ambulating. Instruct the client to breathe three times before attempting to expectorate secretions. to give the client an illustration of the exercise.
OBJECTIVES Short-term: > After 4 hours of nursing interventions. Nursing Management 1. RATIONALE EXPECTED OUTCOME Short-term: >The patient shall have maintained core temperature within normal range (36.5°C). 1) To gain trust and cooperation of patient. Long-term: > The patient shall have demonstrated behaviors to monitor and promote normothermia. 2) Monitor and record vital signs. the patient will be able to maintain core temperature within normal range (36. the patient will be able to demonstrate behaviors to monitor and promote normothermia. Nursing Care Plan Problem #1: Hyperthermia ASSESSMENT S>Ø Hyperthermia O> the patient may manifest: Seizures Convulsions Increase in respiratory rate (26cpm) Flushed skin. 3) To make the patient aware of his condition.5°C). 2) To obtain baseline data.B.5°C37. warm to touch Restlessness NURSING DIAGNOSIS SCIENTIFIC EXPLANATION Hyperthermia is an elevation of the body temperature due to failed thermoregulation. When the elevated body temperature is sufficiently high. 5) To promote 5) Provide . It occurs when the body produces or absorbs more heat than it can dissipate. Long-term: > After 2-3 days of nursing interventions. INTERVENTIONS Independent: 1) Establish rapport. 3) Discuss with the patient why the disease causes the body to increase in temperature. hyperthermia is a medical emergency and requires immediate treatment to prevent disability or death. 4) Perform tepid sponge bath.5°C37. 4) To decrease temperature through evaporation and conduction.
heat loss. 8) Provide high calorie diet.ventilation. 6) Promote bed rest. 7) Instruct patient to increase fluid intake. 9) To improve immune system of the patient. 6) To reduce metabolic demands/oxygen consumption. . 1) To facilitate fast recovery. Dependent: 1) Administer antipyretics orally or rectally as prescribed by the physician. 8) To meet increase metabolic demands. 7) To prevent dehydration. 9) Instruct patient to increase intake of protein-rich food and food rich in vitamin C.
) Instruct to do deep breathing exercise 2. In comfortable position. may manifest: joint pain body malaise facial grimacing irritability guarding the affected areas 3.) Establish rapport 1.) Help in relieving the pain. 3.) Encourage to Long-term goal: have diversional activities like > After 3 days of nursing interventions. pain.) To provide comfort. the 5. 4.) Place the pt.) To divert attention from pain and reduce pain felt. the patient will be able to verbalize relief of pain. Short-term goal: > After 4 hours of nursing interventions. Long-term goal: > After 3 days of nursing interventions. the patient shall have verbalized relief of O> pt.Problem #2: Acute Pain Nursing Assessment Diagnosis Scientific Explanation Objectives Nursing Interventions Rationale Expected Outcome S> Patient may verbalize headaches and body pain.) Monitor and record VS > After 4 hours of nursing 2. patient demonstrated relaxed body posture and .V.) To gain the trust and cooperation of the patient. watching T.) To obtain baseline data. Acute Pain related to bacterial infections in the body This is due to entry of pathogens in circulation leading to release of antiinflammatory mediators and as a vascular response it cause increase in capillary permeability leading to hyperemia and cellular exudation swelling and pain Short-term goal: 1. the patient will demonstrate relax body posture and 5. 4. interventions.
) To prevent formation of ulcer. adequate sleep and rest appropriately. 8. 8.) Helps in relieving the pain.) Administer Ranitidine as ordered. 6.) To regain energy. . 6.) Encourage to have adequate rest. 7.) Provide therapeutic touch. 7.be able to sleep and rest appropriately.
weight gain .cyanosis . Short-term: 1.) trust To gain of the and elicit Short-term: O> The patient may related altered After 4 hours of nursing interventions.presence of crackles on both lungs rate/rhythm.bradycardia .) the To gain workload the heart. workload of the heart.dry skin .cough .altered heart rhythm .) Establish rapport 1.) To been able to display hemodynamic stability. future obtain baseline data for After 4-5 days of nursing intervention.murmurs .difficulty breathing . the patient display will .visible use of accessory muscle . this situation results to the altered heart rate of the client. quality exchange information. knowledge of the patient’s Long-term: Long-term: general condition The patient shall have 3.) Assess patient’s general condition patient SO to The shall patient have manifest: .Problem #3: Decreased Cardiac Output NURSING ASSESSMENT DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTIONS RATIONALE EXPECTED OUTCOME S> ø Decrease cardiac output to heart Inability of the heart to keep up with the demands on it. the patient will participate activities reduce in that the 2. of been able to participate activities reduce in that the of 2. due to increase in the fluid.) Monitor record signs and vital 3.
) Note for the of 6.) This presence pulsus paradoxus 7.) determine cognitive status of the client 5.) Monitor cardiac rhythms 8.) To for assess signs of poor ventricular function 5.hemodynamic stability. 4.) To oxygen therapy increase oxygen 8.) For comparison to follow trends and evaluate response to interventions 6.) To monitor .) Evaluate client report/evidence of fatigue extreme reference 4.) Administer suggest cardiac tamponade 7.
effectiveness of medications 9.) To maximize sleep periods .) Schedule activities assessment and 9.
) Maintaining clean.) Improved Short-term: > After 4 hours of nursing interventions. wash thoroughly and pat dry carefully. it may further cause inflammation in the affected part.) Establishes comparative baseline providing opportunity for timely intervention. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin.) Demonstrated good skin hygiene. infection may occur. and sensation. Infection of humans usually Long-term: > After 3 days of nursing intervention. In not treated promptly. Described and measured wounds and observed changes.) Assessed skin.. turgor. 1. Noted color.g. Long-term: > Proper skin hygiene and maintenance of skin integrity shall have been demonstrated. Objectives Interventions Rationale Expected Outcome Short-term: > The patient and SO shall have verbalized understanding of individual factors that contribute to possibility of infection.Problem #4: Impaired Skin Integrity Assessment Nursing Diagnosis S>Ø Impaired skin integrity related to O> The patient may manifest: Localized erythema Purulent drainage Pruritus on the site of the wound Pain Infection break in the skin and inflammatory response Scientific Explanation Impaired skin integrity is a break in the skin which may be caused by mechanical or chemical factors. the bacteria called Leptospira may enter open wounds. 2. proper skin hygiene and maintenance 3. 2. In Leptospirosis. the patient and SO will be able to verbalize understanding of individual factors that contribute to possibility of infection. . e. dry skin provides a barrier to infection. . Upon entering.
of skin integrity is demonstrated. 4. lakes and rivers.) Wound dressings protect the wound and the surrounding tissues. 4. It can be contracted from contact with any fresh or untreated water including ponds. nutrition and hydration will improve skin condition. canals. 6. 5. 6.) Providing the family with alternative solution assists them in optimal healing with less expensive resources.) Instructed family to clip and file nails regularly. 5.) Demonstrated to the family members on how to make a guava decoction to apply to the wound as alternative disinfectant.) Long and rough nails increase risk of skin damage. as well as flood waters that are contaminated. 3. .) Provided and applied wound dressings carefully.occurs where open wounds are immersed in relatively stagnant water contaminated with rat or cattle urine.) Emphasized importance of adequate nutrition and fluid intake.
the patient and SO will be able to verbalize understanding of individual factors that contribute to possibility of bleeding. there will be increased possibility for various bleeding sites (internal and external) in the body in which due to the spontaneous bleeding. Independent 1) Assess client’s muscle strength. Objectives Interventions Rationale Expected Outcome Short-term: > The patient and SO shall have verbalized understanding of individual factors that contribute to possibility of bleeding. lifestyle changes to reduce risk factors and protect self from bleeding. Short-term: > After 4 hours of nursing interventions. In the presence of thrombocytopenia. gross and fine motor coordination. Long-term: > The patient and SO shall have demonstrated behaviors.Problem #5: Risk for bleeding r/t decreased platelet count Assessment Nursing Diagnosis S>Ø Risk for bleeding r/t decreased O> The patient may manifest: Increased heart rate or blood pressure response to activity Cyanosis Orthostatic hypotension Irritability Muscle weakness Ecchymosis/bruising Epistaxis platelet count Scientific Explanation There is a risk for bleeding in the patient’s condition because there is a decrease in platelet levels in the blood that would help in clotting. 1) To identify risk for falls. 3) Monitor environment for potentially unsafe conditions and modify as needed. . 3) To assist client/caregiver to reduce or correct individual risk factors. the patient and SO will be able to demonstrate behaviors. community. and work setting. the body Long-term: > After 2 days of nursing interventions. 2) Ascertain knowledge of safety needs/injury prevention and motivation. 2) To prevent injury at home.
there will be extravasation of fluids in which plasma moves from intravascular spaces and with markedly elevated Hct is present causing shock to the patient because of inadequate tissue perfusion due to decrease in blood lifestyle changes to reduce risk factors and protect self from bleeding. 4) Provide healthcare within a culture of safety. 5) Failure to 5) Perform thorough assessments regarding safety issues when planning for client care and/or preparing for discharge from care. promote client safety.will be receiving inadequate blood to be perfuse in the periphery causing ineffective tissue perfusion and also with the increased in vascular permeability. 6) Promotes healing and boost the resistance of 6) Encourage intake of foods the body against infection. 4) To prevent errors resulting in client injury. and model safety behaviors for client/SO. . accurately assess and intervene or refer these issues can place the client at needless risk and creates negligence issues for the healthcare practitioner.
7) To boost the immune system. .supply. acquiring diseases that can worsen the condition. 8) To prevent the patient in 8) Provide information regarding disease or conditions that increase risk of injury. with high content of Vitamin C. 9) Instruct patient to increase fluid intake as tolerated. 9) To prevent dehydration. 7) Instruct client to increase intake of Vitamin C like orange juice or citrus fruits.
> Goal met as evidenced by the patient understood and verbalized health teachings given .ACTUAL SOAPIERs Activity Intolerance D> Received sitting on bed with ongoing intravenous fluid of PNSS 1L regulated at 250cc/hr. with an intact indwelling Foley catheter connected to a urine bag draining yellowish urine at 1800ml Good skin turgor Capillary refill less than 3 seconds After 3-4 hours of nursing interventions the patient will be able to understand and verbalize health teachings given A> Established therapeutic relationship Monitor general condition Instructed to increase oral fluid intake Monitored intake and output Kept bed rest Drained Foley catheter R.
Acute pain 3. 2012 5. Risk for bleeding related to decreased platelet count Vital Signs Temperature 10:00am 38 1:50pm 37. 2012 Nursing Problems 1.6°C 8am 36. CLIENT’S DAILY PROGRESS IN THE HOSPITAL 1. Hyperthermia 2. Impaired Skin Integrity 1st Nurse – Patient Interaction September 21.VI.4°C 12nn . Client’s Daily Progress Chart Admission Days September 20. Decreased Cardiac Output 4.
6°C Pulse Rate 10:00am 82bpm 1:50pm 90bpm 4am 36°c 8am 96bpm 12nn 97bpm 4pm 85bpm 8pm 87bpm 12mn 90bpm 4am 92bpm Respiratory Rate 10:00am 8am 12mn 36.5°C 5:35pm 36.4°C 8pm 36.2°C 4pm 36°C .36.3°C 8pm 36.5°C 12mn 37°C 4am 36.
68 .18cpm 1:50pm 20cpm 26cpm 12nn 20cpm 4pm 22cpm 8pm 21cpm 12mn 19cpm 4am 13cpm Diagnostic and Lab Procedures CBC Hgb: Hct: WBC: Platelet ct: Lymph: Neutrophils: 135 0.9 77 0.27 0.41 5.
40 5.Blood Chemistry Creatinine: RBS: BUN: Na: 3.8 137 .000.7 5.68 K: Medical Management IVF D5 LRS 1L × 250cc/hr Drugs Penicillin G 2.000 IU q4 + 30cc D5Wx 30mins Diet DAT with OFI Activity and Exercise Passive ROM 114.
DISCHARGE PLANNING A.VII. and Vitamin C rich foods such as citrus fruits. General Condition of the Client upon Discharge * Did not observed B. Method M. O-Instructed to return for follow-up check-up on the specified date.Encouraged to do ambulation T. time and room number D.000IU E.Advised to eat foods rich in protein such as fish.Explained appropriate diet .Encouraged to continue home medication/treatment regimen H.000. soft meat.Instructed to take the following medications: Penicillin G 2.
and shared is one of the greatest treasures that they will surely keep. Seeing a child experience difficulty because of a disease condition is an eye opener. we should appreciate their kindness of sharing themselves especially their time to us. making a mistake or assumption must never be an option. they have been supplied with sufficient knowledge on the basic care that shall be rendered. felt. it must never be a reason for us to stop from carrying out our duties as a nurse. When we were asked to conduct a research about a specific condition. However. CONCLUSION Case study is not just a requirement but a fulfilling task. it is still a fact that this study provides partial information concerning the specific disease condition the group had chosen. if not more of the disease. Not all patients and SO are cooperative enough to accommodate us with this case study. Therefore. ―When you‘re a nurse you know that every day you will touch a life or a life will touch yours. But what makes this piece of work essential to them is that through this. not just on a specific condition but how student nurses intervene. heard.VIII. With all these. It is a mind opener for us. study helped them to see the reality that surround their profession may it be life or that such appreciation and experienced can never be stolen from them. What they have seen. the first thing that came into our minds was how we can accomplish such work. In line with this struggle. Learning is a continuous process which we gain not only through books but also with the situations we encounter around us in our day to day life. As future nurses. Life is at stake in this profession. Thus. perseverance is always a key to our profession. Furthermore this.‖ . We learned that we can always find a good case if we persevere. we also learned the value of building a trusting relationship with our patient. It is true that every information they share is a part of them they entrust to us.
. et.com/nation/metro-manila/10/19/11/doh-leptospirosiscases-increase-221 http://www.healthline.com/galecontent/blood-urea-nitrogen-test http://www. J.com/doc/17091849/Case-Study-of-Leptospirosis http://www.com/content/5/1/7http://www.medscape.com/anatomy/urinary-system-renal-system/14 http://www. BIBLIOGRAPHY Published Sources Book Black.M.in-leptospirosiscases http://labtestsonline.com/digestive-disorders/picture-of-the-liver .webmd. Medical Surgical Nursing: Clinical Management for Positive Outcomes.org/wiki/Liver http://www.org/understanding/analytes/bun/tab/test http://www.com/na tion/11003-health-department-warns-of-possible-rise.rappler.IX.jmedicalcasereports.al. Online Sources http://emedicine.scribd.virtualmedicalcentre.com/article/220563-clinical http://en.abs-cbnnews.7th ed.wikipedia.
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.