I.

INTRODUCTION

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 groups 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 groups 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.

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. With the aforementioned reasons, the student nurses were able to come up with the decision of making Leptospirosis as their case study.

General Objectives That within the two weeks in the Medicine Ward exposure, 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. 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 Student nurse centered Short term: To be able to have a thorough history taking of the patient; To understand the disease process, etiology, signs and symptoms and Pathophysiology of the disease condition;

 To assist patient in overcoming the anxiety and depression brought about by the condition; To promote wellness to individuals by imparting knowledge so they could learn and understand more about the disease condition; To discuss and describe interventions for health promotion, prevention and treatment of patients with the disease condition;

Long term: To improve our skills in performing interventions to our future clients who suffers from such condition. To develop a teaching program that will educate patients by planning activities thatll focus the importance of healthy lifestyle. To improve our attitude in handling patients with the same condition in the future by learning the specifics of the disease condition.

Patient centered Short term: Patient will be able to understand the general description of the disease condition he is suffering from. Patient will be able to identify the history of his present illness by stating his lifestyle, familial predisposition, previous illnesses that could contribute to the occurrence of 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. 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. Long term:

 Patient will be able to demonstrate a healthier lifestyle brought about by the health teachings imparted by the student nurses. 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. Patient will be able to perform measures that will prevent further advancement and complications of the disease.

II.

NURSING ASSESSMENT A. Personal History

1. DEMOGRAPHIC DATA To secure outmost confidentiality with our patient, he will be referred to as Mr. Raticate throughout the study. Mr. Raticate is a 32 year old Filipino citizen, married and is currently residing in the city of San Fernando, Pampanga. He is of Kapampangan descent and was born in the said city on 10th of May 1980. He was admitted at a tertiary hospital in the city of San Fernando on the 20th of August 2012 at 10:00am.

2. SOCIO-ECONOMIC AND CULTURAL FACTORS Mr. Raticate is a wheeler driver and earns approximately 200php per day and that is approximately 6,000php a month. 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.

B. Family Health-Illness History In the family of the Mr. Raticate, the hereditary disease that is visible among them from the third generation up to his father is diabetes mellitus. The said disease scampers in the blood of his grandparents on his fathers side. In the process of data collection, the student nurses draw the line between the father and mother of Mr. Raticate. 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. 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.

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

C. HISTORY OF PAST ILLNESS Mr. 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. His past illness states that he was once afflicted with chicken pox when he was around 13 years old. D. HISTORY OF PRESENT ILLNESS Six days prior to admission, Mr. Raticate stated that he was exposed to flood water. Apparently, he had open wounds then. He also had abdominal tenderness and presence of calf pain. The occurrence of fever made him seek medical attention.

3. Physical Examination upon Admission (August 1, 2012; as lifted from the patients chart)

VITAL SIGNS RR: 21 cpm T: 36c/axilla

BP: 120/80 mmHg PR: 81 bpm

General Appearance: weak, lethargic Skin: Pale and dry Eyes: anicteric sclera, pale palpebral conjuctiva, (+) PERRLA

1st Patient-Nurse Interaction PHYSICAL EXAMINATION (September 20, 2012)

Mr. Raticate was seen lying on bed, conscious and appears weak, with an IVF of PNSS, 1 Liter regulated at 250 cc per hour, infusing well over the left metacarpal vein with an intact indwelling foley catheter connected to urine bag draining yellowish output @ 1800 cc level, with normal capillary refill of <3sec. Vital signs were taken and recorded as follows:

BP: 110/70 mmHg PR: 82 bpm

RR: 18 cpm T: 37C/axilla

A. HEAD-TO-TOE AND BODY SYSTEMS ASSESSMENT

Appearance and Mental Status He has proportionate built, has coordinated movements but appears weak. He is not properly groomed. His affect is appropriate to and is able to respond appropriately. Integument

Skin He is brown in complexion and has a dry skin. Skin is warm to touch;

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).

Nails He has smooth and convex curve nails, has dirty nails, and with a

capillary refill of less than 2 seconds. Skull and Face The head is round and there is no presence of scars. It is normocephalic and smooth, uniform consistency and there is absence of nodules or masses. He has symmetric facial movements and the palpebral fissures are equal in size. Eyes and eye Structure

Eyebrows The hair is evenly distributed, symmetrically aligned, and with equal

movement.

Eyelashes Equally distributed, and curled slightly outward.

Eyelids The lids close symmetrically, no discharge.

Bulbar Conjuctiva It is transparent, and the sclera appears white.

Palpebral Conjunctiva It is pinkish in color, appears shiny, and smooth.

Cornea It appears transparent, shiny and smooth.

Pupils Black in color, positive PERRLA (Pupils equally rounded, reactive to

light and accommodation), pupils converge when object is moved towards the nose, illuminated pupil constricts and non illuminated pupil constricts

Lacrimal gland, Lacrimal sac, Nasolacrimal duct No edema or tenderness over the lacrimal gland, no tearing.

Ear

Auricles The color of the auricles is same as facial skin, symmetrical, auricles

are aligned with the outer canthus of the eye, mobile, firm, nontender, the pinna recoils after it is being folded. The auricles are firm and not tender, aligned with the outer canthus of the eye.

External Ear Canal Minimal wet cerumen is seen on distal thirds of both ears.

Nose and Sinuses

External Nose Air moves freely as he breathes through the nares, symmetric and

straight; with pinkish nasal mucosa, no presence of discharges, nasal septum intact and in midline.

Facial Sinuses All of the sinuses have no tenderness upon palpation.

Inspection of Nasal Cavity Mucosa is pink, no lesions and nasal septum intact and in midline,

not tender.

Mouth and Oropharynx It is symmetrical, uniform pink, moist, and has smooth lips.

Lips and Buccal Cavity Pale pinkish in color, appears moist and smooth, able to purse lips.

Tongue and floor of the mouth It is light pink in color, in central position, moves freely, and is able to

protrude the tongue upon inspection.

Palates and Uvula The hard palate and soft palate appears pink in color, uvula

positioned midline of soft palate.

Gag reflex It is present when elicited through the use of a tongue depressor.

Neck Muscles are equal in size; head is centered, with coordinated smooth movement, and without discomfort.

Lymph Nodes Not palpable and not enlarged cervical lymph node.

Trachea Central placement in midline of neck, equal spaces on both sides

There is absence of bruit upon auscultation. Thyroid Gland It is not visible on inspection, glands ascends but not visible during swallowing.

Thorax and lungs

Chest With symmetric movement, without tenderness and masses upon

palpation, with normal rise and fall of chest when breathing, and the spine is vertically aligned.

Posterior Thorax With full and symmetric chest expansion; with resonant sound upon

percussion over the lungs.

Auscultation of the chest No adventitious breath sounds are heard upon auscultation on

inspiration on both lung fields.

Anterior Thorax: With effortless respiration, with resonant sound upon percussion

over the lungs.

Respiratory excursions Full symmetric excursions, thumb separate in two inches.

Respiratory rate of 18 breaths per minute.

Heart Heart rhythm is regular. Upon auscultation, heart beat is heard at space sites usually louder at apical area

Carotid arteries It has full pulsations, no sound on auscultation on carotid artery.

Peripheral Pulses There are full pulsations on radial pulse, and the limbs are not

tender.

Peripheral perfusion The skin color is pink, temperature not excessively hot or cold, no

edema.

Abdomen Appears rounded, not distended, without evidence of enlargement of liver and spleen, with audible bowel sounds upon auscultation, with tenderness.

Abdominal movements Symmetrical movements caused by respirations.

Auscultation of bowel sounds With audible bowel sounds of 10 bowel sounds per minute.

Upper and Lower Extremities Upper and lower Extremities: hair is evenly distributed; muscles are equal in size, without paralysis or weakness observed, without bone deformities, with pain on calf.

4. DIAGNOSTIC AND LABORATORY PROCEDURES

A. 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. Raticates potassium level is within normal range.

A potassium test checks how much potassium is in the blood. Potassium is both an electrolyte and a mineral. It helps keep the water (the amount of fluid inside and outside the body's cells) and electrolyte balance of the body. Potassium is also important in how nerves and muscles work.
A sodium test checks how much sodium (an electrolyte and a mineral) is in the blood. Sodium is both an electrolyte and mineral. 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.

3.68

3.50-5.50 mmol/L

Sodium

DO: 9-20-12 DI: 9-20-12

137

135-150 mmol/L

Mr. Raticates sodium level is within the normal range.

Nursing Responsibilities: Prior: Define and explain the test. State the specific purpose of the test. Explain that there is no special preparation.

During: Use the sterile technique. After: Keep the past records especially the latest ones. Document.

B. 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. whether the blood is too thick or too thin. Useful as a measurement of red blood cells only if the hydration of the client is normal. 0.41 0.36-0.45 Mr. is Raticates 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.

Hemoglobin (Hgb)

This

is

test

of of

135

125-175 g/L

Mr.

Raticates is the

measure of the total amount hemoglobin in the blood. It is used as a rapid direct measurement of the

hemoglobin within normal range.

red serially with

blood in

cell

count. It is repeated patients ongoing or as a

bleeding

routine part of the complete cell blood count. It is an of integral part of the evaluation anemic patients. Hemoglobin acts as an important acidbase buffer system. Leukocytes WBC or leukocytes are cells of the immune system which defend the body against both infectious 5.9 5-10x103/L Mr. Raticates leukocyte count is within the range. normal

disease and foreign materials. evaluates the body capacity to resist and overcome infection to detect leukemia to determine severity of infection. Neutrophils A neutrophils test 0.68 0.18-0.70 Mr. Raticates helps us detect the levels of neutrophils in our body. These neutrophils are an integral part of our immune system and through a process called chemotaxis, neutrophil count is within the range. normal

they place

reach where

any an has These

infection occurred.

cells take about an hour to reach the site of infection. In fact, they are one of the main components of pus and are to blame for its whitish color. It is also important to go in for a high neutrophils test as indicative of Lymphocytes stress in blood are of an 0.27 0.20-0.35 Mr. Raticates they

extremely high levels individual. This test measures

the number of lymphocytes (a type of white blood cell) in 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. 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 may be used as part of the 77 150-400x10 9L

lymphocyte count is within the range. normal

Mr. is

Raticates count the range of for below

platelet normal

which might be indicative risk bleeding.

workup of a bleeding disorder, bone marrow disease, or excessive clotting disorder, to name just a few. The test may used as a monitoring tool for people with underlying conditions or undergoing treatment with drugs known to affect platelets. It may also be used to monitor those being treated for a platelet disorder to determine if therapy is effective.

Nursing Responsibilities: Prior: Explain the procedure. Explain the purpose and what to expect. No food or fluid restrictions. Check the doctor's order.

During: Do not take the blood sample from hand or arm with receiving IVF. The tourniquet should be less on a minute. Do not squeeze the punctured site rightly. Wipe away the first drop of blood. After: Label the specimen. Secure the results. Note for inflammation of punctured site. Document.

C. RENAL FUNCTION TEST DIAGNOSTIC / LABORATORY PROCEDURES

Creatinine DO: 9-20-12 DI: 9-20-12 A creatinine test reveals important information about your kidneys. Creatinine is a chemical waste product that's produced by your muscle metabolism and to a smaller extent by eating meat. Healthy kidneys filter creatinine and other waste products from your blood. The filtered waste products leave your body in your urine. If your kidneys aren't functioning properly, an increased level of creatinine may accumulate in your blood. A serum creatinine test measures the level of creatinine 114.7

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. Raticates Creatinine is within normal range.

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). A creatinine urine test can measure creatinine in your urine. The blood urea nitrogen (BUN) test measures the level of urea nitrogen in a sample of the patient's blood. Urea is a substance that is formed in the liver when the body breaks down protein. Urea then circulates in the blood in the form of urea nitrogen. In healthy people, most urea nitrogen is filtered out by the kidneys and leaves the body in the urine. If the patient's kidneys are not functioning properly or if the body is using large amounts of protein, the BUN level will rise. If the patient has severe liver disease, the

5.8

1.7-8.3

Mr. Raticates BUN level is within normal range.

BUN will drop. The BUN level may be checked in order to assess or monitor: the presence or progression of kidney or liver disease. blockage of urine flow. mental confusion. Patients with kidney failure are sometimes disoriented and confused. abnormal loss of water from the body (dehydration). recovery from severe burns. The body uses larger than normal amounts of protein following serious burns.

III.

ANATOMY AND PHYSIOLOGY

Renal System

The kidneys are bean-shaped organs which help the body produce urine to get rid of unwanted waste substances. When urine is formed, tubes called ureters transport it to the urinary bladder, where it is stored and excreted via the urethra. 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, bean-shaped organs towards the back of the abdomen (belly). They lie behind a protective sheet of tissue within the abdomen. The kidneys perform many vital functions which are important in everyday life. For example, they help us get rid of waste products by making urine and excreting it from the body. A special system of tubes within the kidneys allow substances such as sodium (salt) and chloride to be filtered. The kidneys regulate the amount of water in the body. Humans produce about 1.5 litres of urine a day. However, if we drink more water, we may produce more urine. On hot days, if we get dehydrated and sweat more, we may produce less urine. This is why it's very important to drink lots of water on hot summer days.

The kidneys also produce renin (a hormone important in regulating blood pressure) and erythropoietin (helps produce red blood cells). Located in the lower part of our bellies, the right kidney is slightly lower in position than the left, allowing room for the liver. The kidneys are reddish brown in colour and measure about 10 cm in length, 5 cm width and 2.5 cm thick. On the side of the kidney with the smaller curve is an opening called the hilum, where blood vessels, nerves, and the ureters enter the kidney. On one end of the ureters is a funnel-shaped expansion, called the renal pelvis, where urine collects. The ureters carry urine to the bladder; they are 2530 cm long tubes lined withsmooth muscle. The muscular tissue helps force urine downwards. The ureters enter the bladder at an angle, so urine doesn't flow up the wrong way. The kidney can be divided into two distinct regions. There is an outer red-brown part (cortex) and inner lighter coloured part (medulla). The cortex is made up of special units called corpuscles, nephrons, and a system of straight and curvy collecting tubules supplied by many blood vessels. In the outer part of the kidney, there are many nephrons which act as filtering units. Each nephron is supplied by a ball of small blood vessels, called glomeruli. A diagram of a single glomerulus is seen below. 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, where water, salt and nutrients are reabsorbed.

The inner part of the kidney (the medulla) is a continuation of the specialized nephrons in the kidney. A small blood vessel network called the vasa recta supplies the medulla. Each kidney is supplied by the renal arteries, which

give off many smaller branches to the surrounding parts of the kidneys. Renal veins drain the kidney. Bladder The bladder is a pyramid-shaped organ which sits in the pelvis (the bony structure which helps form the hips). The main function of the bladder is to store urine and, under the appropriate signals, release it into a tube which carries the urine out of the body. Normally, the bladder can hold up to 500 mL of urine. The bladder has three openings: two for the ureters and one for the urethra (tube carrying urine out of the body). The bladder consists of smooth muscles. The main muscle of the bladder is called the detrusor muscle. Muscle fibres around the opening of the urethra forms a ring-like muscle that controls the passage of urine. When we want to urinate, stretch receptors in the bladder are activated, which send signals to our brain and tell us that the bladder is full. The ring-like muscle relaxes and the detrusor muscle contracts, allowing urine to flow. The blood supply of the bladder is from many blood vessels. Some of these blood vessels are named: the vesical arteries, the obturator, uterine, gluteal and vaginal arteries. In females, a venous network drains blood from the bladder arteries into the internal iliac vein. Nervous control of the bladder involves centres located in the brain andspinal cord. Urethra The male urethra is 1820 cm long, running from the bladder to the tip of the penis. The male urethra is supplied by the inferior vesical and middle rectal arteries. The veins follow these blood vessels. The nerve supply is via the pudendal nerve. The female urethra is 46 cm long and 6 mm wide. It is a tube running from the bladder neck and opening into an external hole located at the top of the vaginal opening. As the female urethra is shorter than the male urethra, it is more likely to get infections from bacteria in the vagina. The female urethra is supplied by the internal pudendal and vaginal arteries.

Liver The liver is a reddish brown organ with four lobes of unequal size and shape. A human liver normally weighs 1.441.66 kg (3.23.7 lb), and is a soft, pinkish-brown, triangular organ. It is both the largest internal organ (the skin being the largest organ overall) and the largest gland in the human body. It is located in the right upper quadrantof the abdominal cavity, resting just below the diaphragm. The liver lies to the right of the stomach and overlies the gallbladder. It is connected to two large blood vessels, one called the hepatic artery and one called the portal vein. The hepatic artery carries blood from the aorta, whereas the portal vein carries blood containing digested nutrients from the entire gastrointestinal tract and also from the spleen and pancreas. These blood vessels subdivide into capillaries, which then lead to a lobule. Each lobule is made up of millions of hepatic cells which are the basic metabolic cells. Lobules are the functional units of the liver. Cell types Two major types of cells populate the liver lobes: parenchymal and nonparenchymal cells. 80% of the liver volume is occupied by parenchymal cells commonly referred to as hepatocytes. Non-parenchymal cells constitute 40% of the total number of liver cells but only 6.5% of its volume. Sinusoidal endothelial cells, Kupffer cells and hepatic stellate cells are some of the non-parenchymal cells that line the hepatic sinusoid.

Blood flow The supply, liver gets a dual blood vein supply from the hepatic blood drained portal from

vein and hepatic arteries. Supplying approximately 75% of the liver's blood the hepatic portal carries venous the spleen, gastrointestinal tract, and its associated organs. The hepatic arteries supply arterial blood to the liver, accounting for the remainder of its blood flow. Oxygen is provided from both sources; approximately half of the liver's oxygen demand is met by the hepatic portal vein, and half is met by the hepatic arteries. Blood flows through the liver sinusoids and empties into the central vein of each lobule. The central veins coalesce into hepatic veins, which leave the liver. Biliary flow The term biliary tree is derived from the arboreal branches of the bile ducts. The bile produced in the liver is collected in bile canaliculi, which merge to form bile ducts. Within the liver, these ducts are called intrahepatic (within the liver) bile ducts, and once they exit the liver they are consideredextrahepatic (outside the liver). The intrahepatic ducts eventually drain into the right and left hepatic ducts, which merge to form the common hepatic duct. The cystic duct from the gallbladder joins with the common hepatic duct to form the common bile duct. Bile can either drain directly into the duodenum via the common bile duct, or be temporarily stored in the gallbladder via the cystic duct. The common bile duct and the pancreatic duct enter the second part of the duodenum together at the ampulla of Vater. Surface anatomy Peritoneal ligaments Apart from a patch where it connects to the diaphragm (the so-called "bare area"), the liver is covered entirely by visceral peritoneum, a thin, doublelayered membrane that reduces friction against other organs.

The peritoneum folds

back

on

itself

to

form

the falciform

ligament and

the right and left triangular ligaments. These "lits" are in no way related to the true anatomic ligaments in joints, and have essentially no known functional importance, but they are easily recognizable surface landmarks. An exception to this is the falciform ligament, which attaches the liver to the posterior portion of the anterior body wall. Lobes Traditional gross anatomy divided the liver into four lobes based on surface features. The falciform ligament is visible on the front (anterior side) of the liver. This divides the liver into a left anatomical lobe, and a right anatomical lobe. If the liver is flipped over, to look at it from behind (the visceral surface), there are two additional lobes between the right and left. These are the caudate lobe (the more superior) and the quadrate lobe (the more inferior). From behind, the lobes are divided up by the ligamentum

venosum and ligamentum teres (anything left of these is the left lobe). The transverse fissure(or porta hepatis) divides the caudate from the quadrate lobe, and the right sagittal fossa, which the inferior vena cava runs over, separates these two lobes from the right lobe. Each of the lobes is made up of lobules; a vein goes from the centre, which then joins to the hepatic vein to carry blood out from the liver. On the surface of the lobules, there are ducts, veins and arteries that carry fluids to and from them. Functional anatomy The central area where the common bile duct, hepatic portal vein, and hepatic artery proper enter is the hilum or "porta hepatis". The duct, vein, and artery divide into left and right branches, and the portions of the liver supplied by these branches constitute the functional left and right lobes.

The functional lobes are separated by an imaginary plane (historically called Cantle's line) joining the gallbladder fossa to the inferior vena cava. The plane separates the liver into the true right and left lobes. The middle hepatic vein also demarcates the true right and left lobes. The right lobe is further divided into an anterior and posterior segment by the right hepatic vein. The left lobe is divided into the medial and lateral segments by the left hepatic vein. The fissure for the ligamentum teres also separates the medial and lateral segments. The medial segment is also called the quadrate lobe. In the widely used Couinaud (or "French") system, 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. The caudate lobe is a separate structure which receives blood flow from both the right- and left-sided vascular branches. The liver has a multitude of important and complex functions. Some of these functions are to:

Manufacture (synthesize) proteins, including albumin (to help maintain the volume of blood) and blood clotting factors

Synthesize, store, and process (metabolize) fats, including fatty acids (used for energy) and cholesterol

Metabolize and store carbohydrates, 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, D, E, and K.

Eliminate, by metabolizing and/or secreting, the potentially harmful biochemical products produced by the body, such as bilirubin from the breakdown of old red blood cells, and ammonia from the breakdown of proteins

Detoxify,

by

metabolizing

and/or

secreting,

drugs,

alcohol,

and

environmental toxins.

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)

Dog s

Rodents, wild animals

Infected urine or carcasses

Ingestion of contaminated food and water

Man

Entry through eyes, nose and broken skin

Asymptomatic

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

Blood Culture

CSF and urine culture, Agglutination test Death

B C

Leptospirosis

Complications: Pneumonia Optic Neuritis Peripheral neuritis

B. SYNTHESIS OF THE DISEASE (BOOK-CENTERED)

b.1. Definition of the disease Leptospirosis, also known as Weils disease, Mud fever, Canicola fever, Flood fever, Swineherds Disease, and Japanese Seven Days fever is a disease that is caused by pathogenic spirochetes of the genus Leptospira. It is considered the most common zoonosis in the world. 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. Leptospirosis is distributed worldwide (sparing the Polar Regions) but is most common in the tropics. It was first described by Adolf Weil in 1886 when he reported an acute infectious disease with enlargement of spleen, jaundice and nephritis.

b.2. 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.3. Signs and Symptoms 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 day2 types: Anicteric (without jaundice) return of fever of a lower degree with rash,conjunctival asepticmeningitis) 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. injection, headache, meningeal manifestations like disorientation,convulsions & signs of meningeal irritations (with CSF finding of

PATHOPHYSIOLOGY (CLIENT-CENTERED)

Predisposing Factor: Dirty environment, seasons, males,

Rodents, wild animals

Infected urine or carcasses

Man

Entry through eyes, nose and broken skin

Incubates for 6 days

Profileration and widespread dissemination

Septic stage: Febrile, chills, abdominal tenderness, calf pain

Leptospirosis

B.SYNTHESIS OF THE DISEASE (CLIENT-CENTERED)

b.1. Definition of the disease Leptospirosis, also known as Weils disease, Mud fever, Canicola fever, Flood fever, Swineherds Disease, and Japanese Seven Days fever is a disease that is caused by pathogenic spirochetes of the genus Leptospira. It is considered the most common zoonosis in the world. 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. Leptospirosis is distributed worldwide (sparing the Polar Regions) but is most common in the tropics. It was first described by Adolf Weil in 1886 when he reported an acute infectious disease with enlargement of spleen, jaundice and nephritis.

b.2. Predisposing or Precipitating Factors Factors that may put an individual at risk for acquiring Leptospirosis includes the following:

Sex: Male Season: Rainy months

b.3. Signs and Symptoms 1st stage: Septicemic/ Leptospiremic Phase (4 7 days) - onset of high remittent fever, chills, abdominal tenderness and calf pain.

V. PATIENT AND HIS CARE A. MEDICAL MANAGEMENT a. Intravenous Fluids

MEDICAL MANAGEMENT OR TREATMENT

DATE ORDERED DATE PERFORMED DATE or D/C CHANGED

GENERAL DESCRIPTION

INDICATIONS OR PURPOSES

CLIENTS RESPONSE TO THE TREATMENT

PNSS 1L

Date Ordered: September 20, 2012 Date Consumed: September 20-21, 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 had no untoward reaction to the treatment. The patient was able to tolerate the infusion.

NURSING RESPONSIBILITIES: Before: Check for the doctors order. Explain the procedure to the patient/SO with its purpose and importance. Wash hands and observe other appropriate infection control procedures. Provide client privacy. Always observe and check for the correct type of IVF as well as the clarity of the fluid. During: Be sure to clean the site of entry with cotton and alcohol in a circular motion. Ensure appropriate infusion flow. Adhere to standard precautions, then regulate flow rate as per doctors order. After: Check and observe the puncture site for bleeding, edema, or thrombophlebitis. Make sure that the IVF is patent and properly regulated. Check regularly. Document relevant data.

b. Indwelling Foley Catheter

MEDICAL MANAGEMENT OR TREATMENT

DATE ORDERED DATE PERFORMED DATE or D/C CHANGED

GENERAL DESCRIPTION

INDICATIONS OR PURPOSES

CLIENTS RESPONSE TO THE TREATMENT

Indwelling Foley Catheter

Date Ordered: September 20, 2012 Date Performed: September 20, 2012

A Foley catheter is a thin, sterile tube inserted into the bladder to drain urine. It is held in place with a balloon at the end, which is filled with sterile water to prevent the catheter from being removed from the bladder.

An indwelling Foley Catheter is performed as a diagnostic procedure and for therapeutic purposes. As a diagnostic procedure, it is used to collect uncontaminated urine specimen and for urine output monitoring. For therapeutic purposes, it is indicated for Acute urinary retention, Chronic obstruction causing hydronephrosis, intermittent bladder decompression for neurogenic bladder and for Chronically bed-ridden patients for hygiene.

The patient tolerated the procedure and had drainage of yellowish colored urine.

NURSING RESPONSIBILITIES: Before: Gather equipment. Explain procedure to the patient Assist patient into supine position with legs spread and feet together Open catheterization kit and catheter Prepare sterile field, apply sterile gloves Check balloon for patency. Generously coat the distal portion (2-5 cm) of the catheter with lubricant Apply sterile drape

During: If female, separate labia using non-dominant hand. If male, hold the penis with the non-dominant hand. Maintain hand position until preparing to inflate balloon. Using dominant hand to handle forceps, cleanse peri-urethral mucosa with cleansing solution. Cleanse anterior to posterior, inner to outer, one swipe per swab, discard swab away from sterile field. Pick up catheter with gloved (and still sterile) dominant hand. Hold end of catheter loosely coiled in palm of dominant hand. In the male, 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, without tension on tubing Place drainage bag below level of bladder

 Evaluate catheter function and amount, color, odor, and quality of urine Remove gloves, dispose of equipment appropriately, wash hands

After: Document size of catheter inserted, amount of water in balloon, patient's response to procedure, and assessment of urine.

B. Drugs Date Ordered, Name Drugs of Date Given, Date D/C Route Dosage, Frequency of and of General Action/ Mechanism of Indication / Action Purpose(s) Clients with Effects Response Side

Administration,

to the Medication Actual

Administration

Generic Name: Penicillin G

Date Ordered: September 20, 2012 Date Given: September 20, 2012

2,000,000 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. It is a natural penicillin antibiotic that is administered intravenously or intramuscularly due to poor oral absorption. Penicillin G may also be used in some cases as prophylaxis against susceptible organisms.

Drug Classes: Antibiotic

For use in the treatment of severe infections caused by penicillin Gsusceptible microorganisms when rapid and high penicillin levels are required.

The patient was able to comply with the drug therapy and did not manifest any side-effects of the drug.

NURSING RESPONSIBILITIES: BEFORE: Verify the doctors order. Assess for previous history of reactions to other cephalosporin or penicillin. Monitor VS. Read the drug label three times before administering. Be cautious enough in preparing drugs amount because exceeding in the prescribed amount may cause toxicity. Reduce the amount of drug with patient having renal or hepatic impairment. Explain the need for the patient to intake all the medicine prescribed

DURING: Maintain aseptic technique throughout the procedure. If the medication is to be infuse through IV push, then inject the drug slowly and be sure that the medication goes directly in vein. Emphasize proper IV administration.

AFTER: Monitor for any side effects or abnormal findings regarding the administered drug. After administering the medication, secure the needle and medication used. Document for any abnormal findings and for the procedure done.

Type of Diet

Date Ordered Date Started Date Changed

General Description

Indication or Purposes

Clients Response and/or reaction to diet

Diet tolerated fluid intake

as Date Ordered: with September

Nearly normal diet Given 20, 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. no food restriction complications and if the 20, with increased oral client of water a day. needs for further lab test. fluid intake of 2-3 L monitoring

Increased oral fluid intake is for hydration purposes.

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. The ordered diet should be monitored. The nurse must reinforce the low salt low fat diet. Continuous monitoring of the clients 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. Check vital signs to obtain baseline data.

Type Activity Exercise

of Date Ordered / Date Started Date Changed General Description

Indication(s) Purpose(s)

or Clients Response to the Activity / Exercise

Designed to improve the To Deep breathing and coughing exercise Date ordered: September 20, 2012 Date Started: September 20, 2012 efficiency decrease breathing, and of the ventilation, 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. gas atelectasis post-op. and

excursion of the diaphragm pneumonia improve exchange oxygenation.

May sit on side of bed, To prevent respiratory Patient sat on bed Ambulation dangle feet, and walk complications as well and has tolerated it thus promoting the patient chose to walk around. around the room and/or as thromboembolism for 2 hours. However, nearby areas. proper circulation.

Nursing Responsibilities for Deep Breathing and Coughing Exercise: Explain the procedure and the purpose of the activity or exercise. Instruct the client to inhale through the nose and exhale through pursed lips. Demonstrate deep breathing exercise to the client, to give the client an illustration of the exercise. Instruct the client to support the incision site using a pillow or his hands. Instruct SO to assist the client perform his normal ADLs. Instruct the client to breathe three times before attempting to expectorate secretions.

Nursing Responsibilities for Ambulation: Explain the procedure and the purpose of the exercise or activity. Instruct the client to perform the procedure slowly by dangling the legs first before ambulating. Watch closely for signs of orthostatic hypotension like dizziness or lightheadedness upon standing. 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

B. Nursing Management 1. Nursing Care Plan Problem #1: Hyperthermia ASSESSMENT S> Hyperthermia O> the patient may manifest: Seizures Convulsions Increase in respiratory rate (26cpm) Flushed skin, warm to touch Restlessness NURSING DIAGNOSIS SCIENTIFIC EXPLANATION Hyperthermia is an elevation of the body temperature due to failed thermoregulation. It occurs when the body produces or absorbs more heat than it can dissipate. When the elevated body temperature is sufficiently high, hyperthermia is a medical emergency and requires immediate treatment to prevent disability or death. OBJECTIVES Short-term: > After 4 hours of nursing interventions, the patient will be able to maintain core temperature within normal range (36.5C37.5C). Long-term: > After 2-3 days of nursing interventions, the patient will be able to demonstrate behaviors to monitor and promote normothermia. INTERVENTIONS Independent: 1) Establish rapport. 1) To gain trust and cooperation of patient. 2) To obtain baseline data. 3) To make the patient aware of his condition. RATIONALE EXPECTED OUTCOME Short-term: >The patient shall have maintained core temperature within normal range (36.5C37.5C). Long-term: > The patient shall have demonstrated behaviors to monitor and promote normothermia.

2) Monitor and record vital signs. 3) Discuss with the patient why the disease causes the body to increase in temperature. 4) Perform tepid sponge bath.

4) To decrease temperature through evaporation and conduction. 5) To promote

5) Provide

ventilation. 6) Promote bed rest.

heat loss. 6) To reduce metabolic demands/oxygen consumption. 7) To prevent dehydration.

7) Instruct patient to increase fluid intake. 8) Provide high calorie diet.

8) To meet increase metabolic demands. 9) To improve immune system of the patient.

9) Instruct patient to increase intake of protein-rich food and food rich in vitamin C. Dependent: 1) Administer antipyretics orally or rectally as prescribed by the physician.

1) To facilitate fast recovery.

Problem #2: Acute Pain

Nursing Assessment Diagnosis Scientific Explanation Objectives Nursing Interventions Rationale Expected Outcome

S> Patient may verbalize headaches and body pain.

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.) Establish rapport

1.) To gain the trust and cooperation of the patient.

Short-term goal:

> After 4 hours of nursing interventions, the patient will be able to verbalize relief of pain. 3.) Instruct to do deep breathing exercise 2.) Monitor and record VS

> After 4 hours of nursing

2.) To obtain baseline data.

interventions, the patient shall have verbalized relief of

O> pt. may manifest: joint pain body malaise facial grimacing irritability guarding the affected areas

3.) Help in relieving the pain.

pain.

4.) Encourage to Long-term goal: have diversional activities like > After 3 days of nursing interventions, the patient will demonstrate relax body posture and 5.) Place the pt. In comfortable position. watching T.V.

4.) To divert attention from pain and reduce pain felt.

Long-term goal:

> After 3 days of nursing interventions, the

5.) To provide comfort.

patient demonstrated relaxed body posture and

be able to sleep and rest appropriately.

6.) Encourage to have adequate rest. 6.) To regain energy.

adequate sleep and rest appropriately.

7.) Provide therapeutic touch. 7.) Helps in relieving the pain. 8.) Administer Ranitidine as ordered. 8.) To prevent formation of ulcer.

Problem #3: Decreased Cardiac Output

NURSING ASSESSMENT DIAGNOSIS SCIENTIFIC EXPLANATION OBJECTIVES NURSING INTERVENTIONS RATIONALE EXPECTED OUTCOME

S>

Decrease cardiac output to heart

Inability of the heart to keep up with the demands on it, due to increase in the fluid, this situation results to the altered heart rate of the client.

Short-term:

1.) Establish rapport

1.) trust

To gain of the and elicit

Short-term:

O>

The

patient

may

related altered

After 4 hours of nursing interventions, the patient will participate activities reduce in that the 2.) Assess patients general condition

patient SO to

The shall

patient have

manifest: - cyanosis - cough - murmurs - weight gain - altered heart rhythm - difficulty breathing - bradycardia - dry skin - visible use of accessory muscle - presence of crackles on both lungs

rate/rhythm.

quality exchange information. of

been able to participate activities reduce in that the of

2.) the

To gain

workload the heart.

workload of the heart.

knowledge of the patients Long-term:

Long-term:

general condition The patient shall have 3.) Monitor record signs and vital 3.) To been able to display hemodynamic stability. future obtain baseline data for

After 4-5 days of nursing intervention, the patient display will

hemodynamic stability. 4.) Evaluate client report/evidence of fatigue extreme

reference 4.) To for

assess

signs of poor ventricular function

5.) determine cognitive status of the client 5.) For comparison to follow trends

and evaluate response to

interventions

6.) Note

for

the of

6.)

This

presence pulsus paradoxus 7.) Administer

suggest cardiac tamponade 7.) To

oxygen therapy

increase oxygen

8.) Monitor cardiac rhythms

8.)

To

monitor

effectiveness of medications 9.) Schedule activities assessment and 9.) To

maximize sleep periods

Problem #4: Impaired Skin Integrity

Assessment Nursing Diagnosis S> 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. In Leptospirosis, the bacteria called Leptospira may enter open wounds. Upon entering, it may further cause inflammation in the affected part. In not treated promptly, infection may occur. Infection of humans usually Long-term: > After 3 days of nursing intervention, proper skin hygiene and maintenance 3.) Improved Short-term: > After 4 hours of nursing interventions, the patient and SO will be able to verbalize understanding of individual factors that contribute to possibility of infection. 2.) Demonstrated good skin hygiene, e.g., wash thoroughly and pat dry carefully. 2.) Maintaining clean, dry skin provides a barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. Long-term: > Proper skin hygiene and maintenance of skin integrity shall have been demonstrated. 1.) Assessed skin. Noted color, turgor, and sensation. Described and measured wounds and observed changes. .) Establishes comparative baseline providing opportunity for timely intervention. Objectives Interventions Rationale Expected Outcome Short-term: > The patient and SO shall have verbalized understanding of individual factors that contribute to possibility of infection.

occurs where open wounds are immersed in relatively stagnant water contaminated with rat or cattle urine. It can be contracted from contact with any fresh or untreated water including ponds, canals, lakes and rivers, as well as flood waters that are contaminated.

of skin integrity is demonstrated.

3.) Emphasized importance of adequate nutrition and fluid intake.

nutrition and hydration will improve skin condition.

4.) Demonstrated to the family members on how to make a guava decoction to apply to the wound as alternative disinfectant.

4.) Providing the family with alternative solution assists them in optimal healing with less expensive resources.

5.) Instructed family to clip and file nails regularly.

5.) Long and rough nails increase risk of skin damage.

6.) Provided and applied wound dressings carefully. 6.) Wound dressings protect the wound and the surrounding tissues.

Problem #5: Risk for bleeding r/t decreased platelet count

Assessment Nursing Diagnosis S> 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 patients condition because there is a decrease in platelet levels in the blood that would help in clotting. In the presence of thrombocytopenia, there will be increased possibility for various bleeding sites (internal and external) in the body in which due to the spontaneous bleeding, the body Long-term: > After 2 days of nursing interventions, the patient and SO will be able to demonstrate behaviors, 3) Monitor environment for potentially unsafe conditions and modify as needed. 3) To assist client/caregiver to reduce or correct individual risk factors. Short-term: > After 4 hours of nursing interventions, the patient and SO will be able to verbalize understanding of individual factors that contribute to possibility of bleeding. 2) Ascertain knowledge of safety needs/injury prevention and motivation. 2) To prevent injury at home, community, and work setting. Long-term: > The patient and SO shall have demonstrated behaviors, lifestyle changes to reduce risk factors and protect self from bleeding. Independent 1) Assess clients muscle strength, gross and fine motor coordination. 1) To identify risk for falls. Objectives Interventions Rationale Expected Outcome Short-term: > The patient and SO shall have verbalized understanding of individual factors that contribute to possibility of bleeding.

will be receiving inadequate blood to be perfuse in the periphery causing ineffective tissue perfusion and also with the increased in vascular permeability, 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.

4) To prevent errors resulting in client injury, promote client safety, and model safety behaviors for client/SO.

5) Failure to 5) Perform thorough assessments regarding safety issues when planning for client care and/or preparing for discharge from care. 6) Promotes healing and boost the resistance of 6) Encourage intake of foods the body against infection. accurately assess and intervene or refer these issues can place the client at needless risk and creates negligence issues for the healthcare practitioner.

supply.

with high content of Vitamin C. 7) To boost the immune system.

7) Instruct client to increase intake of Vitamin C like orange juice or citrus fruits. 8) To prevent the patient in 8) Provide information regarding disease or conditions that increase risk of injury. 9) To prevent dehydration. 9) Instruct patient to increase fluid intake as tolerated. acquiring diseases that can worsen the condition.

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. > Goal met as evidenced by the patient understood and verbalized health teachings given

VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL 1. Clients Daily Progress Chart

Admission Days September 20, 2012 Nursing Problems 1. Hyperthermia 2. Acute pain 3. Decreased Cardiac Output 4. Impaired Skin Integrity

1st Nurse Patient Interaction September 21. 2012

5. Risk

for

bleeding

related

to

decreased platelet count

Vital Signs Temperature

10:00am 38 1:50pm 37.6C

8am 36.4C 12nn

36.5C 5:35pm 36.4C 8pm 36.5C 12mn 37C 4am 36.6C Pulse Rate 10:00am 82bpm 1:50pm 90bpm 4am 36c 8am 96bpm 12nn 97bpm 4pm 85bpm 8pm 87bpm 12mn 90bpm 4am 92bpm Respiratory Rate 10:00am 8am 12mn 36.3C 8pm 36.2C 4pm 36C

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 0.41 5.9 77 0.27 0.68

Blood Chemistry Creatinine: RBS: BUN: Na: 3.68 K: Medical Management IVF D5 LRS 1L 250cc/hr Drugs Penicillin G 2,000,000 IU q4 + 30cc D5Wx 30mins Diet DAT with OFI Activity and Exercise Passive ROM 114.7 5.40 5.8 137

VII. DISCHARGE PLANNING A. General Condition of the Client upon Discharge * Did not observed

B. Method

M- Instructed to take the following medications: Penicillin G 2,000,000IU E- Encouraged to do ambulation T- Encouraged to continue home medication/treatment regimen H- Advised to eat foods rich in protein such as fish, soft meat, and Vitamin C rich foods such as citrus fruits. O-Instructed to return for follow-up check-up on the specified date, time and room number D- Explained appropriate diet

VIII. CONCLUSION Case study is not just a requirement but a fulfilling task. When we were asked to conduct a research about a specific condition, the first thing that came into our minds was how we can accomplish such work. It is a mind opener for us, not just on a specific condition but how student nurses intervene. 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. Seeing a child experience difficulty because of a disease condition is an eye opener. Life is at stake in this profession. Thus, making a mistake or assumption must never be an option. As future nurses, perseverance is always a key to our profession. Not all patients and SO are cooperative enough to accommodate us with this case study. However, it must never be a reason for us to stop from carrying out our duties as a nurse. We learned that we can always find a good case if we persevere. In line with this struggle, 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. Therefore, we should appreciate their kindness of sharing themselves especially their time to us. With all these, it is still a fact that this study provides partial information concerning the specific disease condition the group had chosen. But what makes this piece of work essential to them is that through this, they have been supplied with sufficient knowledge on the basic care that shall be rendered, if not more of the disease. Furthermore this, 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, heard, felt, and shared is one of the greatest treasures that they will surely keep. When youre a nurse you know that every day you will touch a life or a life will touch yours.

IX. BIBLIOGRAPHY Published Sources Book Black, J.M,. et.al. Medical Surgical Nursing: Clinical Management for Positive Outcomes.7th ed. Online Sources http://emedicine.medscape.com/article/220563-clinical http://en.wikipedia.org/wiki/Liver http://www.abs-cbnnews.com/nation/metro-manila/10/19/11/doh-leptospirosiscases-increase-221 http://www.healthline.com/galecontent/blood-urea-nitrogen-test http://www.jmedicalcasereports.com/content/5/1/7http://www.rappler.com/na tion/11003-health-department-warns-of-possible-rise- in-leptospirosiscases http://labtestsonline.org/understanding/analytes/bun/tab/test http://www.scribd.com/doc/17091849/Case-Study-of-Leptospirosis http://www.virtualmedicalcentre.com/anatomy/urinary-system-renal-system/14 http://www.webmd.com/digestive-disorders/picture-of-the-liver