COLLEGE OF NURSING ALLIED HEALTH SCIENCES

In partial fulfillment of the requirements for

Related Learning Experience at
Nursing Care Management 106A
Communicable Diseases

NURSING CASE ANALYSIS

Diagnosis: Leptospirosis

Submitted by:

Balino, Iris Joy F.

Cabriga, Lady Diane M
Caparos, Clea O.
De Leon, Alexandra G.
Estuita, Al Rhensonn B.
Guevarra, Lemuel M.
Tangayan, Charles Xavier C.
Zoleta, Dayla Shaine May C

Submitted to:
Clinical Instructor
Dr. Dario Sumande PhD, RN, MAN, USRN
GENERAL OBJECTIVES
SPECIFIC OBJECTIVES
I. INTRODUCTION
a. Background
i. Incidence, race, gender, age, ration and proportion
ii. Rationale for choosing the case
iii. Significance of the study
iv. Scope of limitation of study
v. Conceptual Theoretical Theory
vi. Related Literature
II. CLINICAL SUMMARY
a. General Data Profile
b. Chief Complaint
c. Nursing theory
1. History of Present Illness
d. Family History {genogram}
e. Social History – Include theories of grown and development
f. Environment/Living Condition
g. Physical Assessment
h. Patterns of functioning
i. Health Management Pattern
ii. Nutritional/Metabolic
1. Numbers of meal/day
2. Appetite
3. Glass of water/day
4. Height & weight
iii. Elimination
1. Frequency of urination
2. Amount of urine/day
3. Frequency of BM
4. Consistency of the Feces
5. Amount defecated/day
iv. Activity and Exercise
 1. Exercise
2. Fatigability
3. ADL
v. Cognitive/Perceptual
1. Orientation
2. Responsiveness
vi. Roles/Relationship
1. As a son/daughter
2. As a brother/sister
3. As a boyfriend/husband/girlfriend/wife
4. As an employee and co-worker
vii. Self-Perception/Self-Concept
viii. Coping/Stress
ix. Values/Beliefs
i. Course in the ward
j. Laboratory/Diagnostic Exam
k. Impression/Diagnosis
III. CLINICAL DISCUSSION OF THE DISEASE
a. Anatomy and Physiology
b. Pathophysiology
i. Book Based
ii. Client Based
c. Drug Study
IV. NURSING PROCESS
a. Long Term Objective
b. Prioritized List Nursing Problem
c. Nursing Care Plan
d. Discharge Plan (METHOD)
General Objective:
That within the two weeks in the San Lazaro Hospital exposure, the student-nurses
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.
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, management and intervention will be given to meet basic needs, alleviate sufferings
and prevent complications.
The group has formulated the following specific objectives to guide them towards the
completion of this case study.

Specific Objectives:

 Understand condition of leptospirosis and associate it with the patient through the
introduction of the case.
 To illustrate the Anatomy and Physiology of the affected organ or the part of the
body.
 To discuss the pathophysiology of the disease.
 To be clinically aware of the clinical manifestation and its complication.
 To develop an effective skill on how to plan and manage proper care in patient with,
leptospirosis.
 To formulate a drug study with regards to the patient’s condition.
 To correlate the laboratory result to its normal value.
 To provide the client nursing care plan and discharge plan to assure client’s total
wellness during his hospitalization up to the time of his hospital discharge.
 To apply right attitude by respect through providing privacy and maintaining client’s
confidentiality.

I. INTRODUCTION

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 urine-
contaminated 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. The
Department of Health (DOH) has recorded 1,227 leptospirosis cases in Metro Manila from
January to August 2018. This is a 358% increase from the 268 recorded cases during the
same period in 2017, Health Secretary Francisco Duque III said on Wednesday, August 22.
the most common way humans contract leptospirosis is through cuts and abrasions on the
skin. It can also be acquired when infected animal urine gets in contact with the mucous
membranes in the eyes, nose, and mouth.
Individuals usually contract leptospirosis by wading in contaminated flood water. During
rainy season, the risk of contracting waterborne diseases is much greater.
Duque said the main factors that contributed to the rise in leptospirosis cases were inefficient
garbage collection and weak flood control interventions. He also said community awareness
of the disease and its effects was low "despite the DOH's nonstop reminders."
"People still take the risk, children playing in floodwaters still smiling not knowing the water
underneath is deadly,"
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, 2017, 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.

Rationale for choosing the case

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. It is also up to date and is continuing the increase number of deaths. 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.
Significance of the studies
The significance of this study is to enhance/gain knowledge, to develop skills and
apply the right attitudes of the student nurses in rendering and giving care to the patient with
leptospirosis, its importance and implication. This study will serve as guidelines in assessing
and providing proper nursing care to patient with the same problem or disease.
These are other significance of the study that would support the above statement:
1. Understand condition of leptospirosis and associate it with the patient through the
introduction of the case.
2. To know the Nursing history: the Personal data, Health history and Physical
assessment of the patient.
3. Illustrate the anatomy and physiology and pathophysiology of the affected organ
or part of the body.
4. Discuss and determine manifestation and complications.
5. Develop of an effective skill on how to manage a proper care in patient with
leptospirosis.
6. Formulate a drug study with regards to the patient’s condition.
7. Correlate the lab result to its normal value.
8. To provide the client nursing care plan and Discharge plan to assure for client’s
total wellness during his hospitalization up to the time of his hospital discharge

Scope of limitation of the study

The study would only focus on leptospirosis which is indicative to the
client’s health condition and its underlying nursing care relevant for the client
within the two- week duty at San Lazaro Hospital.

THEORETICAL FRAMEWORKS
Environmental Theory by Florence Nightingale
Define nursing as “What nursing has to do… is to put the patient in the best condition
for nature to act upon him. Nursing ought to signify the proper use of fresh air, light, warmth.
Cleanliness, quiet, and proper selection and administration of diet.

1. Human Beings- humans in relations to the environment and the impact of the
environment on them.
2. Environment- physical environment focusing on ventilation, warmth, noise, light and
cleanliness.
3. Health- pathology teaches the harm disease has done: Health is positive; pathology is
negative.
4. Disease is a reparative process or nature’s way to remedy a process of poisoning or
decay.
Her theory focused on the control of the environment of individuals needing nursing care
 Air
 Health of houses
 Ventilation and warming
 Light
 Minimal noise
 Cleanliness
 Appropriate nutrition
 Variety
 Beddings
 Chattering hopes
Nursing:
Is having the responsibility for someone’s health. On her writing “Note’s on Nursing”
provided guidelines on how to provide nursing care and how a nurse should think.

Person:
Is a patient needed to enhance the development of the recovery and this patient have the
preferences. However, Nightingale gave emphasis on nurses as was in control of the patient
environment.
Health:
Is being well and able to use the power to the fullest. Nightingale envisioned the
environmental control to maintain health and prevention of diseases through her
environmental theory.
Environment:
“Those elements external to and which affect the health of the sick and healthy person.
Everything from the patient food and flowers to the patient’s verbal and nonverbal
interactions with the patient.”

The theory is simple. In Nightingales theory, there are three major relationships. 1.
Environment to nurse, 2. Nurse to environment, and 3. Nurse to patient. Nightingale believes
that the environment is a big factor in creating disease while the disease is the reaction to the
person based on the environment. SoNightingale emphasized the importance of environment
in preventing disease. Preventing diseases through the manipulation of environment and to
enhance the recovery of a person. There is no proof that Nightingale intended to develop a
theory but it is clear that nightingale intended to give meaning in science and art of nursing
and to provide general rules for nursing care improvement for the patient.
                Nightingales theory remains relevant and the universality and timelessness also
remains pertinent. Nightingale concept about the relationship of nurse to patient and
importance of environment for the person recovery remain applicable today. These meet the
criterion of generality.

Since the diagnosis of our patient is leptospirosis we relate Nightingale’s theory

because, the environmental theory is a big factor in creating disease while the disease is the
reaction to the person based on the environment.
As a nurse our goal is to give comfort, care and maintain optimal health that can aid
the client in their fast recovery.

Related Literature
Leptospirosis
Leptospirosis is a zoonotic infection found worldwide, of which there are two forms:
Weil’s disease and Hardjo. Weil’s disease is a potentially serious bacterial infection. In
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.

While leptospirosis is rare in the United States, it is common through tropical and
semitropical regions. It can affect individuals of all ages. At least 75 percent of individuals
with leptospirosis are male, mainly because workers in jobs that are at risk of the infection
are more often held by males.
The infection is an occupational disorder affecting farmers, veterinarians, workers in
slaughter houses and sewer workers. However, many affected individuals are thought to be
exposed incidentally during recreational activities, such as swimming in water contaminated
by the urine of infected animals.
In recent years, several cases of leptospirosis have been reported in urban areas, especially
inner city neighborhoods. It is thought that these areas are infested with rats that carry the
infection

DEFINITION
A bacterial zoonotic disease caused by spirochaetes of the genus Leptospira that affects
humans and a wide range of animals, including mammals, birds, amphibians, and reptiles
First described by Adolf Weil in 1886 when he reported an “acute infectious disease with
enlargement of spleen, jaundice and nephritis”
CAUSATIVE AGENT
• Leptospira-genus bacteria was isolated in 1907 from post-mortem renal tissue slice
• commonly found: Leptospira pyrogenes, Leptospira manilae, & other species like
L. icterohemorrhagiae, L. canicola, L. batavia, L. Pomona, L. javinica
• in animals often is subclinical; an infected animal may appear healthy even as it
sheds leptospires in its urine; humans are dead-end hosts for the leptospire
(https://www.austincc.edu/microbio/2704x/li.htm)
Source of Infection
 Infection comes from contaminated food and water, and infected wild life and
domestic animals especially rodents.
1. Rats ( L. leterohemoragiae) are the source of Weil’s disease frequently
observed among miners, sewer, and abattoir workers.
2. Dogs (L. canicola) can also be the source of infection among veterinarians,
breeders, and owners of dogs.
3. Mice (L. grippotyphosa) may alos be a source of infection that attacks farmers
and flax workers.
4. Rats (L. bataviae) are the source of infection that attacks ricefield workers.
RESERVOIR
Wild animals including rodents, pigs, cows, as well as pets like dogs and horses.
RISK FACTORS
A Risk factor is something that increases your chance of getting a disease or a condition.
These risk factors increase your chance of getting a leptosprosis
• age: < 15 years of age
• sex: male
• season: rainy months
• geographic: prevalent in slum areas
MODE OF TRANSMISSION
Leptospirosis is spread by urine of wild animals infected with the bacterium, as well as the
waters and soil that those animals infect by urinating in them. It gets into the host via
mucous membranes and also through cuts and wounds on the skin.
INCUBATION PERIOD
• 6 – 15 days/ 2 – 8 weeks
Clinical Manifestations:
1ST STAGE: SEPTICEMIC/ LEPTOSPIREMIC PHASE (4 – 7 DAYS)

- onset of high remittent fever, chills, headache, anorexia, nausea & vomiting,
abdominal pain, joint pains, muscle pains, myalgia, severe prostration, cough,
respiratory distress, bloody sputum.
2ND STAGE: IMMUNE/ TOXIC PHASE (4 – 30 DAYS)

- if severe, death may occur between the 9th & 16th day
2 TYPES:
 - Anicteric (Without Jaundice) – return of fever of a lower degree with rash,
conjunctival injection, headache, meningeal manifestations like disorientation,
convulsions & signs of meningeal irritations (with CSF finding of aseptic meningitis)
- Icteric (With Jaundice) – Weil syndrome; hepatic & renal manifestations:
hemorrhage, hepatomegaly, hyperbilirubinemia, oliguria, anuria with progressive
renal failure; shock, coma & congestive heart failure in severe cases
3RD STAGE: CONVALESCENCE PHASE

- Relapses may occur during 4th or 5th week

TREATMENT

 specific measures: beneficial if done < 4 days of dse

 Aqueous penicillin G (50,000 units/kg/day in 4-6 divided doses intravenously for 7-10
days
 Tetracycline (20-40 mg/kg/day in 4 doses); may not be given to children < 8 years old
general measures

 symptomatic & supportive care

 administration of fluid, electrolytes & blood as indicated
 peritoneal dialysis (for renal failure)

Nursing Interventions:

 isolation of patient: urine must be properly disposed

 health teachings: keep a clean environment

References:
https://www.rappler.com/nation/210146-record-increase-leptospirosis-cases-metro-manila-
january-august-2018
http://www.hse.gov.uk/agriculture/zoonoses-data-sheets/leptospirosis.pdf

II. CLINICAL SUMMARY

a. General Data Profile

Name: Mr. MCM

Address: 1637 A. Mendoza St., Barangay 340, Santa Cruz, Manila, NCR
Birthday: September 20, 2001
Birthplace: Manila
Spouse Name: None
Nationality: Filipino
Religion: Catholic
Occupation(s): None
Date of Admission: August 21, 2019
Admitting Diagnosis: T/C Leptospirosis
Admitting Physician: Edna A. Miranda, MD

b. Chief Complaint

Abdominal Pain

c. Nursing history
History of Present Illness
Five days prior to consult, client had sudden onset of fever, undocumented. Client
also experienced body malaise, vomiting once, nausea, and crushing like pain
headache with pain scale of 7/10, squeezing like abdominal pain with pain scale of
6/10. Self-medicated with Biogesic and Alaxan for 4 days but client was not relieved.
One day prior to consult, symptoms still persist, hence client decided to seek consult.

a. Childhood Illness
- Common cold, cough, and fever
b. Immunizations
- Incomplete vaccine
c. Allergies
- No know allergies to food and drugs
d. Accidents
- No known accidents
e. Hospitalizations
- No previous hospitalizations
f. Medications used or currently taking
- Paracetamol, Penicillin G Sodium, and Ibuprofen + Paracetamol
 g. Domestic travel
- The usual route of travel is within Metro Manila.

d. Family History (genogram)

Male Female

e. Social History
 Stage Age Central Task Indicators of Indicators of Negative
Positive Resulting Resulting

Adolescence 17 Identity – Devotion, Fidelity, Lack of or giving up

Role confident sense of on goals, beliefs,
Confusion self, emotional values and productive
stability, roles. Feeling of
commitment to confusion, indecision,
career planning and alienation.
and realistic long- Vacillation between
term goals, sense dependence and
of having a place independence, and
in society, superficial, short-term
establishing relationship with
relationship with opposite sex.
opposite sex, Or.
fidelity to friends, Dramatic
development of overconfidence, acting
personal values, & out behaviors (includes
testing out adult alcohol and drug
roles. abuse, and flamboyant
display of sex role
behaviors)

Psychosocial Theory According to Erik Erikson

According to this theory, the adolescence refers to “identity-role confusion” to

integrate the tasks mastered in the previous stages into a secure sense of self. This is achieved
when allowed to experience independence in making decisions that influence their lives. This
is not attained when independence is discouraged; nurtured into dependency; discipline in
home is harsh, inconsistent or absent; and there is parenteral rejection or frequent shifting in
parental figures.

f. Environment/ living condition

Pt. MCM is living with his father and siblings. They are currently living in
Brgy. 340, Santa Cruz, Manila. The environment where he lives is a flooded prone area and is
very dirty, which is a usual habitat of rodents. His house is made with light materials such as
wood. His house is also close to a basketball court where he spends most of his time, playing
basketball with his peers.
g. Physical Assessment

Parameters Normal Findings Actual Findings Interpretation

General Appearance Clean in appearance and Body weakness noted; Body weakness and
well groomed body pain is a
General body pain common
Cooperative noted; manifestation of the
Negative for jaundice patient’s illness,
which is
Cooperative leptospirosis.

Skin With good skin turgor Poor skin turgor May be related to
dehydration

Hair Evenly distributed hair Evenly distributed hair Normal

Thick hair Thick hair

Nails With good capillary With poor capillary Poor capillary refill
refill of 1-2 seconds refill: 3 seconds. may be related to
With pinkish nail beds With pinkish nail beds dehydration.
With clean and short With clean and short
nails nails.

Skull and Face Mouth uniform Rounded smooth skull Sunken cheeks may
 consistency; absence of contour be related to
nodules & masses Symmetrical facial dehydration.
Rounded smooth skull movement
contour Slightly sunken cheeks
Symmetrical facial
movement

Eyes No eye discharges No eye discharges Reddish sclera is a

manifestation of
With anicteric sclera Reddish sclera leptospirosis.
Eyebrows hair evenly Eyebrows hair evenly
distributed/skin intact distributed/skin intact
(+) Blink reflex (+) Blink reflex
With pinkish With pinkish conjunctiva
conjunctiva
With sunken eyeballs.

Ears Auricle color same as Auricle color same as Normal.

facial skin facial skin
Auricle are mobile firm Auricle are mobile firm
and not tender and not tender
Able to hear on both Able to hear on both ears
ears No edema and discharge
No edema and discharge

Mouth Pinkish lips Pale and dry lips; Pale and dry lips may
be related to
Without missing teeth With dry oral mucus dehydration.
membrane
With pink gums
No foul odor
With symmetrical
contour

Musculoskeletal Symmetrical Abrasion on both Abrasions on

(Upper and Lower olecranon. patient’s extremities
Extremities) No atrophy are mainly caused by
Abrasion on right the patient’s active
With full range of knuckles lifestyle, which is
motion playing basketball.
Abrasion on right
 popliteal. Slow movements are
primary caused by
With full range of the manifestation of
motion, but with slow the patient’s illness,
movements. which is
leptospirosis.

Abdomen No abdominal distention Abdominal pain Abdominal pain can

also be manifested by
Soft and tender abdomen Soft and tender the patient’s illness,
abdomen. which is
Symmetrical contour
leptospirosis.
No surgical incision

h. Pattern of Functioning

Function Health Problem Before hospitalization During Interpretation

Hospitalization

Health management pattern First time to be He is just seeking medical

Self-medication hospitalized attention in severe cases that
needed immediate attention.
 Nutritional/ Metabolic The appetite of the patient
decreased and his built
A. Number of meals per 3-4 times a day 3 times a day became slightly smaller than
day before, the patient’s weight
w/ very good appetite w/ poor appetite also decreased. This is also a
B. Appetite manifestation of his illness,
which is leptospirosis.

C. Glass of water per day 8-10 glasses of water approximately 9

glasses of water

w/ normal body built Slightly smaller than

D. Body built before

E. Height and weight

5’8 and 66kg
5’8 and
approximately 58kg

Elimination The frequency of his

urination kept monitored
A. Frequency of urination 5-6 time per day through MIO, and the
Approximately 12
times per day amount of his urine
increased.
Moderate The frequency of his bowel
elimination decreased, and
B. Amount of urine per 3100ml per day the amount of his stool is
day Once a day scanty, this may be related
to his poor appetite.
C. Frequency of bowel Formed Every other day
movement
Moderate Formed
D. Consistency of the
feces
Scanty
E. Amount defecated per
day

Activity and Exercise

Inactive exercise

A. Exercise Easy to get tired He became inactive in daily

Active, plays
basketball every day. exercise because of his
 Dependent illness and he easily get
B. Fatigability Not easily to get tired, and dependent during
tired hospitalization, and he’s
always in bed.

C. ADL Independent

Cognitive
/Perceptual

Oriented to time, The cognitive and perceptual

A. Orientation Oriented to time, place and person. status of the patient is still
place and person. Responds intact and slightly normal.
B. Responsiveness Responds appropriately to
appropriately to verbal and physical
verbal and physical stimuli
stimuli

Roles/ Relationship

A. As a son Still has a good relationship

with his family.

· With good · With good

relationship to his relationship to
B. As a brother father. his parents and
he sometimes
provided
financial aid to
the family.
· With good
relationship to his · With good
brothers and relationship to
sisters. his brothers and
sisters.

Self-Perception/ Self Have a high self- Have a high self – He still has a high self-
Concept worth/ importance worth/ importance worth in spite of his illness
he still thinks that life is
important that should be
lived purposely.

Coping/ Stress He seeks for advice He seeks for care He definitely needed the care
from friends and from his family and of his family and moral
 relatives when he has moral support of his support of his friends
problems, is burdened friends during because of his condition.
and/or stressed. hospitalization
because of his
condition.

Values / Beliefs He has awareness that His awareness to Even he suffered from his
God really exist. God became illness, the patient never
stronger than before. blames God instead he
became more faithful than
before.

i. Course in The Ward

Date Medical Management Nursing intervention Rationale

08/21/19  Admit to San Lazaro  Admitted the patient  For further monitoring,
11:45pm Hospital under the as ordered management, and evaluation of
service of Dr.  Prepared and filled out patient’s condition
Villanueva necessary documents
 Obtained initial vital
signs and recorded
 Assisted the patient to
room of choice
 Assisted the patient to
room of choice.

 Signed consent  Assured that the  For documentation and legal

for admission patient understood the purposes
explanation done by
the doctor and secured
patient’s signature.
  DAT with SAP  Informed and  To maintain patient’s
explained to the nutritional status  
patient and significant  to avoid aspiration during
others about the feeding
ordered diet
 Informed the dietary
department regarding
the diet of the patient.

 Hematology  Explained the lab test  These entire lab test are
exam facilitated to the patient performed to screen for any
alteration and to serve as a
baseline data for future
comparison

 Paracetamol  Verified doctor’s order  Helps to reduce fever and/or

500mg 1tab Q4  Observed 10 R’s of mild to moderate pain
PRN to 37.8. drug administration

 Penicillin G  Verified doctor’s order  Antibiotic used to treat a

1.2million units  Observed 10 R’s of number of bacterial infections
Q6 ()ST drug administration  Drug of choice for
leptospirosis

08/22/19  Continue present  Inform the patient  For the patient to be aware to
9:45am management about the medicine the medication given
and its uses
 Observe the 10R’s
 Refer to ROD
 For safety of the patient

 Refer pedia
 Referred accordingly
Nephron referral
 For further assessment and
treatment if the child has
problems with kidney or
 urinary tract disease, kidney
stones, or high blood pressure,
a pediatric nephrologist has the
special skills and experience to
treat your child. Pediatric
nephrologists treat children
from infancy through late
adolescence and in some
centers up to young adulthood
08/23/19  Repeat Creatinine  Explained to the  To assess creatinine for the
10am after 2days patient about the patient to be aware to the
procedure. Told to medication given
patient that blood
sample will be taken.
 Explained to the client
that he might feel
slight discomfort
during needle
puncture.

 Continue present  Inform the patient  for the patient to be aware to

management about the medicine the medication given
and its uses
 Observe the 10R’s
 Refer to ROD
 for safety of the patient
  Follow up pedia
Nephron referral
 Referred accordingly
 For further assessment and
treatment if the child has
problems with kidney or
urinary tract disease, kidney
stones, or high blood pressure,
a pediatric nephrologist has the
special skills and experience to
treat your child. Pediatric
nephrologists treat children
from infancy through late
adolescence and in some
centers up to young adulthood.

j. LABORATORY AND DIAGNOSTIC EXAM (CLIENT BASED)

HEMATOLOGY

8/22/2019
Component Result Normal Range Interpretation Nursing
Responsibilities
WBC 11.78 x 4,000-10,000 Increased level caused WOF fever, chills and
10^9/L by bacterial infection other signs of
as manifested by fever, septicemic stage.
chills, headache, S/S Septicemic Stage:
anorexia, nausea & onset of high remittent
vomiting, abdominal fever, headache,
 pain, joint pains, and anorexia, nausea &
muscle pains. Increased vomiting, abdominal
level of WBC usually pain, joint pains,
happens at 1st stage: muscle pains, myalgia,
Septicemic/
Leptospiremic Phase (4 - Perform /
– 7 days) wherein encourage or
when the client was advise relative
admitted and taken to TSB when
with sample were at client Is with
day 6. fever
- Ensure client
take his due
medication

RBC 3.88 4.5 – 6.2 Decreased level of WOF septicemic stage

10^12/L RBC along with Severity of
neutrophilia are signs leptospirosis (S/S)
of severe
leptospirosis; but it - Provide
can also be coincide symptomatic
with anemia related to treatment and
nutritional deficiency care
as the client is - Nutritional
experiencing anorexia assessment.
during the 1st stage of Assessing the
the disease. nutritional
status and
habits is
important
because it may
indicate
deficiencies in
essential
nutrients such
as iron,
vitamin B12,
and folic acid.

Hematocrit 0.33 g/L 0.40 – 0.50 Decreased level of Hct WOF septicemic stage
is one of the sign of Severity of
leptospirosis; but it leptospirosis (S/S)
can also be coincide
with anemia related to - Provide
nutritional deficiency symptomatic
as the client is treatment and
experiencing anorexia care
during the 1st stage of
Nutritional assessment.
the disease.
Assessing the
nutritional status and
habits is important
because it may indicate
deficiencies in essential
nutrients such as iron,
vitamin B12, and folic
acid.
Hemoglobin 11.0 g/L 130 – 180 Decreased level of Hgb Nutritional assessment.
is one of the sign of Assessing the
leptospirosis; but it nutritional status and
can also be coincide habits is important
with anemia related to because it may indicate
nutritional deficiency deficiencies in essential
as the client is nutrients such as iron,
experiencing anorexia vitamin B12, and folic
during the 1st stage of acid.
the disease.
- Due
medication or
supplement
should be
given

Neutrophil 79.6% 55 – 65 Increased level or WOF septicemic stage

neutrophilia along with Severity of
decreased RBC are leptospirosis (S/S)
signs severe
leptospirosis. - Provide
symptomatic
treatment and
care

Lymphocyte 11.20 % 25 – 35 Decreased level caused WOF septicemic stage

by bacterial infection Severity of
as manifested by fever, leptospirosis (S/S)
chills, headache,
anorexia, nausea & - Provide
vomiting, abdominal symptomatic
pain, joint pains, and treatment and
muscle pains. Increased care
level of Lymphocytes
usually happens at 1st
stage: Septicemic/
Leptospiremic Phase (4
– 7 days) wherein
when the client was
admitted and taken
with sample were at
day 6.
Eos% 4.60 % 2.0 - 4.0 Inreased level caused WOF septicemic stage
by bacterial infection Severity of
as manifested by fever, leptospirosis (S/S)
chills, headache,
anorexia, nausea & - Provide
vomiting, abdominal symptomatic
pain, joint pains, and treatment and
muscle pains. Increased care
level of Eosinophil
usually happens at 1st
stage: Septicemic/
Leptospiremic Phase (4
– 7 days) wherein
when the client was
admitted and taken
 with sample were at
day 6.

CLINICAL CHEMISTRY
Urinalysis (Microscopic / Chemical Examination)
Color: Light yellow
Transparency: Hazy
Hazy urine is a sign of buildup of white blood cells as the body tries to eliminate invading
bacteria.
Chemical Result Normal Interpretati Nursing
Analysis Range on Responsibilities
Leukocytes 125 / uL (+2) ≤ 14 /uL Increased WOF fever, chills
level is an and other signs of
evidence of septicemic stage.
that body is S/S Septicemic
fighting Stage:
back the onset of high
infection of remittent fever,
leptospirosis headache, anorexia,
. nausea & vomiting,
abdominal pain,
joint pains, muscle
pains, myalgia,

- Provide
symptomat
ic
treatment
and care

Urobilinogen 17mmol/L (+1) ≤ 4. mmol/L Increased WOF fever, chills

level, and other signs of
signifies septicemic stage.
leptospirosis S/S Septicemic
infection, at Stage:
septicemic onset of high
stage. remittent fever,
headache, anorexia,
nausea & vomiting,
abdominal pain,
joint pains, muscle
pains, myalgia,

- Provide
symptomat
ic
treatment
and care

MicroAlbumin 150 mg/dL(+3) ≤ 10 mg/L Increased WOF fever, chills

Level, and other signs of
proteinuria septicemic stage.
is an early S/S Septicemic
sign of Stage:
leptospirosis onset of high
infection. remittent fever,
headache, anorexia,
nausea & vomiting,
abdominal pain,
joint pains, muscle
pains, myalgia,

- Provide
symptomat
ic
treatment
and care

Calcium 2.5 mmol/L ≤ 2.4 mmol/L With trace

(Trace)
Blood Urea 28.90 mmol/L 3.2 – 7.1 Increased - Monitor urinary
Nitrogen Level, output. Measure /
consequence estimate fluid losses
of the from all sources
glomerular
filtration rate • Palpate peripheral
reduction pulses; note
caused by capillary refill, skin
the severe color/temperature.
SERIOLOGICAL TEST RESULT – IMMUNOCHROMATOGRAPHY METHOD
IgM: Positive for Leptospira
IgG: Negative for Leptospira
Presence of IgM for Leptospira suggestive for current recent infection white negative at IgG
does not preclude of the infection.

III. CLINICAL DISCUSSION OF THE DISEASE

I. CLINICAL DISCUSION OF THE DISEASE

1. ANATOMY AND PHYSIOLOGY

Kidneys
The kidneys lie on either side of the spine in the retroperitoneal space between the parietal
peritoneum and the posterior abdominal wall, well protected by muscle, fat, and ribs. They
are roughly the size of your fist, and the male kidney is typically a bit larger than the female
kidney. The kidneys are well vascularized, receiving about 25 percent of the cardiac output at
rest.
There have never been sufficient kidney donations to provide a kidney to each person
needing one. Watch this video to learn about the TED (Technology, Entertainment, Design)
Conference held in March 2011. In this video, Dr. Anthony Atala discusses a cutting-edge
technique in which a new kidney is “printed.” The successful utilization of this technology is
still several years in the future, but imagine a time when you can print a replacement organ or
tissue on demand.
On the superior aspect of each kidney is the adrenal gland. The adrenal cortex directly
influences renal function through the production of the hormone aldosterone to stimulate
sodium reabsorption.
Internal Anatomy
A frontal section through the kidney reveals an outer region called the renal cortex and an
inner region called the medulla (Figure 2). The renal columns are connective tissue
extensions that radiate downward from the cortex through the medulla to separate the most
characteristic features of the medulla, the renal pyramids and renal papillae. The papillae are
bundles of collecting ducts that transport urine made by nephrons to the calyces of the kidney
for excretion. The renal columns also serve to divide the kidney into 6–8 lobes and provide a
supportive framework for vessels that enter and exit the cortex. The pyramids and renal
columns taken together constitute the kidney lobes.
Figure 2. Left Kidney.
Nephrons are the “functional units” of the kidney; they cleanse the blood and balance the
constituents of the circulation. The afferent arterioles form a tuft of high-pressure capillaries
about 200 µm in diameter, the glomerulus. The rest of the nephron consists of a continuous
sophisticated tubule whose proximal end surrounds the glomerulus in an intimate embrace—
this is Bowman’s capsule. The glomerulus and Bowman’s capsule together form the renal
corpuscle. As mentioned earlier, these glomerular capillaries filter the blood based on particle
size. After passing through the renal corpuscle, the capillaries form a second arteriole, the
efferent arteriole (Figure 4). These will next form a capillary network around the more distal
portions of the nephron tubule, the peritubular capillaries and vasa recta, before returning
to the venous system. As the glomerular filtrate progresses through the nephron, these
capillary networks recover most of the solutes and water, and return them to the circulation.
Since a capillary bed (the glomerulus) drains into a vessel that in turn forms a second
capillary bed, the definition of a portal system is met. This is the only portal system in which
an arteriole is found between the first and second capillary beds. (Portal systems also link the
hypothalamus to the anterior pituitary, and the blood vessels of the digestive viscera to the
liver.)

Figure 4. Blood Flow in the Nephron. The two capillary beds are clearly shown in this figure.
The efferent arteriole is the connecting vessel between the glomerulus and the peritubular
capillaries and vasa recta.
(https://opentextbc.ca/anatomyandphysiology/chapter/25-3-gross-anatomy-of-the-kidney/)

Cardiovascular System

The cardiovascular system is an organ system that permits blood to circulate and
transport nutrients, oxygen, carbon dioxide, hormones, and blood cells to and from the cells
in the body to provide nourishment and help in fighting diseases, stabilize temperature and
pH, and maintain homoeostasis.

It is divided into two main parts:

Heart: The heart is a muscular organ which pumps blood through the blood vessels of the
circulatory system.

Blood vessels: Blood vessels transport blood throughout the human body. There are three
major types of blood vessels: arteries (carry blood away from the heart), capillaries (enable
exchange of water and chemicals between the blood and the tissues) and veins (carry blood
from the capillaries back toward the
heart).

The lymphatic system is connected

with the cardiovascular
system both structurally and
functionally.

The cardiovascular system has two

distinct circulatory paths:
 Pulmonary circulation
 Systemic circulation
The right side of the heart pumps blood to the lungs (pulmonary circulation). In the lungs
blood gets oxygenated from the air sacs. At the same time, carbon dioxide diffuses into the
air sacs and is exhaled into the atmosphere.

Skeletal muscle

Skeletal muscle, also called voluntary muscle, in vertebrates, most common of the three
types of muscle in the body. Skeletal muscles are attached to bones by tendons, and they
produce all the movements of body parts in relation to each other. Unlike smooth
muscle and cardiac muscle, skeletal muscle is under voluntary control. Similar to cardiac
muscle, however, skeletal muscle is striated; its long, thin, multinucleated fibres are crossed
with a regular pattern of fine red and white lines, giving the muscle a distinctive appearance.
Skeletal muscle fibres are bound together by connective tissue and communicate with nerves
and blood vessels. For more information on the structure and function of skeletal
muscle, see muscle and muscle system, human.
IV. NURSING PROCESS
A. LONG TERM OBJECTIVES
The study aims to know more about the case and reduce complications of the client
through the collaborative management with physician, nurses, physical therapist together
with the nutritionist.
B. PRIORITIZED LIST NURSING PROBLEM
PROBLEM
Fluid volume deficit related
to active fluid loss as
evidenced by increase
urination and frequency
Risk for fluid and electrolyte
imbalanced related to
inadequate dietary intake
as manifested by poor skin
turgor
Risk for falls related to body
weakness and loss of weight
Readiness for enhance
knowledge related to
unsanitized environment as
evidenced by lack of
knowledge about cleanliness
of his environment
RANKING JUSTIFICATION
1 It was prioritized because one
of the prognosis or the cause
of death is renal failure.s
2 Fluid and electrolytes are
importance in our body, we
rank this as the to be priority
because if it’s not treated the
patients will become
dehydrated
3 Although this is under
physiologic needs of a human
we ranked this as the second
priority, it should be the first
thing to be managed because it
can be fatal if left untreated
4 This is the 4th prioritized
nursing diagnosis because a
pattern of cognitive and
behavioural efforts to manage
demands that is sufficient for
well-being and can be
strengthen.
 c. Nursing Care Plan
ASSESSMEN DIAGNOSI PLANNIN INTERVENTIO RATIONALE EVALUATIO
T S G N N
Subjective: Fluid volume Independent: Goals Met:
“Ihi po ako ng deficit • Monitor • CVP measurements
ihi minsan wala related to After 3 vital signs and are useful in After 3 hours of
pa pong isang active fluid hours of CVP. Note determining degree of nursing
oras naihi na loss as nursing presence degree fluid deficit and intervention,
po uli ako” as evidenced by intervention, of postural BP response to goal was
verbalized by increase the patient changes. Observe replacement therapy. partially met as
the client urination and will be able for fever. Fever increases evidenced by
Objective: frequenc metabolism and patient being
to maintain
• Vital Signs: exacerbates fluid loss able to
fluid
T- 37.8 °C • Monitor urinary normalize
P- 66 bpm volume at output. Measure / • Fluid replacement output and
R- 26 bpm functional estimate fluid needs are based on moist mucous
BP: 100/70 level as losses from all correction of current membranes.
mmHg evidenced sources deficits and ongoing Patient still
Urinary output: by adequate losses experiences
2,510L / day urinary • Palpate episodes of
• Generalized output. peripheral pulses; Conditions that bradycardia and
body weakness note capillary contribute to shortness of
• Episodes of refill, skin extracellular fluid breath.
shortness of color/temperature deficit can result in
breath . Assess inadequate organ
• Weakened mentation. perfusion to all areas
pulse and may cause
• Dry oral circulatory
mucosa collapse/shock.
• Decreased Dependent:
skin turgor • Administer IV
solutions as Crystalloids provide
indicated: prompt circulatory
Isotonic solutions improvement, although
such as 0.9% the benefit may be
NaCl (normal transient (increased
saline), 5% renal clearance).
dextrose/water

Collaborative:
• Monitor May be given to
laboratory studies correct severe acidosis
as indicated while correcting fluid
(electrolytes, balance
 glucose, pH/Pco2, To assist with
coagulation identification/treatmen
studies t of underlying cause.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Risk for falls Within 3 to 4  Identify factors  To know the After 3 to 4 hours
“Wala akong related to body hours of nursing that affect intervention that of rendering
ganang kumain weakness and intervention, the safety needs will be proper nursing
minsan, kung loss of weight. patient will be established intervention, the
kumain man ay free from fall. patient will be
sobrang kaunti  Weight patient  Changes in free from fall as
lang kaya ang laki daily weight can evidenced by
ng ipinayat ko’’as provide ability to explain
verbalized by the information in the safety
patient fluid balance precautions.
and the
OBJECTIVES: adequacy of
 Weak in fluid volume
appearance  Ask the replacement
 Absence of significant
side rails others to
 Weight loss always stay  To ensure clients
from 66kg to with the client safety
approximatel
y 58kg
 Instruct the
patient to call  To prevent the
for assistance patient from
when moving falling on bed

 Put side rails

 To reduce the
risk of falling

 Provide
assistive
devices for  For the clients
walking such support
as cane,
crutches and
wheelchairs.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Risk for fluid After 4 hours of Assess for the This will provide Goals met.
“Sige man siya ng and electrolyte nursing signs of a data that could After 4 hours of
suka bago kami imbalanced intervention the dehydration be used to nursing
pumunta ng related to client: including skin evaluate the intervention the
hospital” as inadequate Improve skin turgor, oral proper client was able
verbalized by the dietary intake turgor of the mucosa, etc intervention that to improve skin
mother as manifested patient from the client needs. turgor of the
by poor skin poor to fair patient from
OBJECTIVES: turgor Ensure that the To reduce the poor to fair,
 Poor skin client is dryness of the ensure that the
turgor receiving right Monitor oral mucosa client is
 Dry mucous amount of accurate Intake To determine if receiving right
membrane maintenance and Output, IV fluid and amount of
fluids calculate 24 electrolyte maintenance
 Sunken eyeball
Completely hours fluid replacement are fluids and
 Capillary refill
eliminate the balance and needed completely
at 3 seconds
occurrence of weight daily eliminate the
 Weight loss
from 66kg to vomiting To prevent injury occurrence of
approximately from dryness vomiting
Provide
58kg frequent oral
and skin care To reduce stress
and anxiety

Keep a quiet
To promote
environment
and calm awareness on
activities related factors

Provide health
teachings on
avoidance of
dehydration

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Readiness for After 4hours of  Cognitive After 4hours of
“Ano ba ang pwede enhance nursing impairments nursing
kong gawin?” as knowledge intervention  Assess ability to must be intervention the
related to recognized so
verbalized by the client unsanitized the patient will an appropriate patient was able
environment as be able to: learn or perform teaching plan to demonstrate
Objective: evidenced by Patient desired health- can be how to
lack of demonstrates related care. outlined. incorporate new
 Keep asking knowledge how to health regimen
questions on about incorporate  Learning into lifestyle.
cleanliness of new health requires
the members of  Assess
his environment energy.
the health team regimen into motivation and Patients must
lifestyle. willingness of see a need or
 Willingness to patient to learn. purpose for
go back at home learning. They
and manage the also have the
disease right to refuse
educational
 Confused services.

 Lack of  Older patients

knowledge  Allow the often share life
about the patient to open experiences to
up about each learning
cleanliness of
previous session. They
his environment
experience and learn best when
health teaching. teaching builds
on previous
knowledge and
experience

 Grant a calm  A calm

and peaceful environment
environment allows the
without patient to
interruption concentrate and
focus more
completely.
 Help patient in  This technique
integrating aids the learner
information into make
daily life. adjustments in
daily life that
will result in
the desired
change in
behavior.
D. Discharge Plan (M.E.T.H.O.D)
 Medication
 Advised patient to take the prescribed medication continuously at home.
 Always check the expiration date of the medicine before taking.

Name of Drug Dosage & Route Curative Effects Side Effects

Frequency
Paracetamol 500mg ORAL Pain reliever ; Low fever,
Q4 for fever PO fever reducer nausea, stomach
pain, loss
appetite , dark-
urine, jaundice,
clay colored stools
Penicillin 2.4 m u TIV Q6 IV Antibiotic Diarrhea, fever,
(-) ANST chills, urinating
less than usual,
seizure, easily
bruising or
bleeding, unusual
weakness, body
aches
Paracetamol 300mg IV Central nervous Negligible with
TIV system agent; recommended
nonnarcotic dosage; rash.
analgesic, Acute poisoning:
antipyretic Anorexia, nausea,
vomiting,
dizziness,
lethargy,
diaphoresis, chills,
epigastric or
abdominal pain,
diarrhea;

 Environment/Exercise:
 Maintain quiet, pleasant, environment to promote relaxation.
 Provide clean and calm environment
 Deep Breathing Exercises
 Provide proper ventilation

 Therapy/Treatment:
 Continue home medication for the follow up repeat.
 Antibiotic therapy should be administered to shorten the duration of illness and
reduce shedding of organism in the urine.
  Increase Fluid Intake

 Health Teaching :

 Provide written and oral instructions about the activity, diet recommendation,
medication and follow up visits.
 Encouraged parents to do proper hygiene for the patient
 Instruct to avoid contaminated water
 Encouraged parents to maintain clean environment
 Instructed to keep away from infected animals
 Instructed to be aware of your surrounding
 Instructed to use disinfectant
 Instructed the patients family to position the patient in fowlers position while eating
to avoid aspiration

 Out-Patient

 Advise the patient’s family to follow-up checkup as physician’s ordered

 Advise patient and family to consult with physician if signs and symptoms of disease
occur
 A medical history and physical examination are recommended every 3 to 6 months
for 2 years, then every 6 months for 5 years.

 Diet
 Diet as tolerated
 Eat healthy foods such as fruits and vegetables and meat
 Drink a lot of water, at least 10-12 glasses of water a day