Nursing Care Plan

Date: October 11, 2009 Name: D.D. Age: 32 years old Medical Diagnosis: Leptospirosis Nursing Diagnosis: Hyperthermia related to infection as manifested by temperature 38 oC Short Term Goal: After rendering nursing interventions, patient’s temperature will return to normal range.

Long Term Goal: At the end of hospitalization the patient will maintain core temperature within normal range.

chills.  To promote surface cooling of the body EVALUATION Goal met.  To reduce or to return to normal body temperature.)  Once permitted. D. myalgias. Objective: PROBLEM Hyperthermia SCIENTIFIC REASON Leptospirosis is a biphasic disease that begins with flu-like symptoms (fever. as verbalized by the client.: 38oC  Skin warm to touch  Dry skin  Poor skin turgor  Remove excess clothing or change clothes to comfortable ones.Nursing Care Plan CUES Subjective: “Mainit ang pakiramdam ko ngayon”.  To replace fluid loss and to support circulating volume and tissue perfusion. encourage to increase intake of fluid at least 2L/day.  Maintain bedrest.  To reduce metabolic demands. intense headache). . Source: Handbook of Common Communicable and Infectious Diseases (Navales. Temp. RATIONALE  To evaluate the effects or degrees of hyperthermia.  To lower down body temperature by cooling the body surface of the patient.  Administer prescribed meds. Patient’s temperature return to normal range from 38 to 37 oCelsius.  Febrile.  Provide tepid sponge bath. Paracetamol. NURSING INTERVENTION  Monitor vital signs especially temperature.

2009 Name: D. stable vital signs. . Short Term Goal: After rendering nursing interventions. and normal specific gravity. Age: 32 years old Medical Diagnosis: Leptospirosis Nursing Diagnosis: Fluid volume deficit related to active fluid volume loss as manifested by decreased urine output.Nursing Care Plan Date: October 10. patient will achieve fluid volume at a functional level as evidence by good skin turgor. poor skin turgor. and high specific gravity. and dry skin.D. Long Term Goal: At the end of hospitalization the patient will maintain fluid volume at a functional level.

 Note possible conditions that may lead to deficits e.g. NURSING INTERVENTION RATIONALE  To assess causative/ precipitating factors.  To return the body’s fluid and electrolytes level to normal. Objective:  Poor skin turgor  Dry skin  Specific Gravity: 1. EVALUATION Goal partially met. vomiting.  Administer fluid and electrolytes as indicated.  Monitor vital signs especially BP and note physical signs e.  To correct/ replace fluid loss. increase fluid intake at least 2L/day. diarrhea. poor skin turgor. After rendering nursing interventions.g.  Because this beverages .  To be accurate in replacement needs. dry skin.  Monitor urine output and measure amount. patient urinated 20cc/hr but still with poor skin turgor and dry skin.022 PROBLEM Fluid volume deficit SCIENTIFIC REASON Symptoms of leptospirosis include vomiting and diarrhea which often causes dehydration.  To evaluate degree of fluid loss.Nursing Care Plan CUES Subjective: “Tatlong beses na akong nagsusuka at limang beses ng nagtatae” as verbalized by the client. Source: Handbook of Common Communicable and Infectious  Once permitted.

 To prevent injury from dryness Date: October 11. Age: 32 years old Medical Diagnosis: Leptospirosis Nursing Diagnosis: Impaired urinary elimination r/t disease process. tend to be diuretics that will help more for fluid loss.D. patient will be able to urinate at least 30cc per hour.  Provide frequent oral and eye care. 2009 Name: D. . Short Term Goal: After rendering nursing interventions.Nursing Care Plan Diseases (Navales.)  Limit intake of alcoholic or caffeinated beverages. D.

CUES NURSING PROBLEM SCIENTIFIC REASON NURSING INTERVENTION RATIONALE EVALUATION .Nursing Care Plan Long Term Goal: At the end of hospitalization the patient will be able to achieve normal elimination pattern.

 For fluid replacement. and tubular lumen and cause interstitial nephritis. tubular necrosis and damage and altered capillary permeability.  Determine client’s usual daily fluid intake.  Due medication given Furosemide 40mg TIV. it migrates to interstitium.  Monitor urine output. Objective: Impaired urinary elimination After the organism gains access to the kidney.Nursing Care Plan Subjective: ”Kaunti lang iniihi ko.  Assist with physical examination.  To help determine level of hydration.  To help determine level of hydration  To determine effectiveness of management or progression of disease.  Note condition of skin mucous membrane and colour of urine.  To assess causative contributing factors. renal tubules.  To increase urine output Goal partially met.  UO: 15cc/hr  Administered IVF 1L D5NNM x 12hrs.  Monitor vital signs.” as verbalized by the client. Source: Nurse’s Pocket Guide Edition 11 (Doenges et al) .  For baseline data of the patient. Patient produced urine output in the amount of 20cc/hr.

2009 Name: D. Short Term Goal: After rendering nursing interventions the patient will appear relaxed and report anxiety is reduced to a manageable level.Nursing Care Plan Date: October 11. Long Term Goal: At the end of hospitalization the patient will be free from anxiety. .D. Age: 32 years old Medical Diagnosis: Leptospirosis Nursing Diagnosis: Mild Anxiety related to change in health status as evidenced apprehension and restlessness.

Nursing Care Plan .

sharing questions and concerns. Nursing Care Plan RATIONALE EVALUATION  To elicit the trust and comfort of the patient  Patient and SO can be affected by the anxiety/uneasin ess displayed by health team members. conveying empathy and unconditional positive regard. Source: Nurse’s Pocket Guide Edition 11 (Doenges et al)  Encourage patient and SO to communicate with one another. . The patient appears relaxed and reported anxiety is reduced.” verbalized the patient.  Maintain confident manner (without false reassurance). quiet surroundings. Goal met.CUES Subjective: “Kinakabahan ako sa lagay ko ngayon. Provide consistent information. Objective:  restless  poor eye contact NURSING PROBLEM Mild anxiety SCIENTIFIC REASON Due to acquisition of a disease.  Answer all questions factually. the patient became uneasy and began to dread for the unknown. Honest explanations can alleviate anxiety. NURSING INTERVENTION Independent:  Establish therapeutic relationship.  Accurate information about the situation reduces fear and assists patient and SO to deal realistically with situation.  Provide rest periods/uninterrup ted sleep time.  Sharing information elicits support and comfort and can relieve tension of unexpressed worries.  Conserves energy and enhances coping abilities.

D.Nursing Care Plan Date: October 10. 2009 Name: D. Age: 32 years old .

patient will verbalize understanding of body changes.Nursing Care Plan Medical Diagnosis: Leptospirosis Nursing Diagnosis: Disturbed body image related to presence of jaundice as evidence by elevated bilirubin levels. Long Term Goal: At the end of hospitalization the patient will verbalize acceptance of self in the present situation. . Short Term Goal: After rendering nursing interventions.

 Observe emotional changes.Nursing Care Plan CUES Subjective: “Sabi nila naninilaw ako” as verbalized by the patient. Source: Handbook of Common Communicable and Infectious Diseases (Navales.  Assist patient/SO to cope with change in appearance. or black clothing.)  Assist with grooming needs as necessary..  Enhances feelings of competency /selfworth.  This may indicate acceptance or nonacceptance of situation. blue. Explain relationship between nature of disease and symptoms. Providing support can enhance self-esteem and promote patient sense of control.0 mmol/L NURSING PROBLEM Disturbed body image SCIENTIFIC REASON The severe form of leptospirosis results to hepatic impairment which causes elevated bilirubin levels. future expectations.  Provides opportunity to identify fears and misconceptions and deal with them directly. use of red. suggest clothing that does not emphasize altered appearance. e. encourages independence and participation in therapy . Bilirubin gives a yellow color to the skin and sclera which is known as jaundice. INTERVENTIONS RATIONALE EVALUATION After rendering nursing interventions.g.  Patient may present unattractive appearance as a result of jaundice.  Involve patient in planning care and scheduling activities  Maintaining appearance enhances self-image. D. Objective:  icteric sclera  yellow skin color (jaundice)  Total Bilirubin: 513.  Encourage verbalization about concerns of disease process.  To help the patient understand the cause of his change in appearance. patient verbalized understanding of body changes.  Discuss situation.

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