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.

 Nursing Care Plan

SCIENTIFIC NURSING
CUES PROBLEM RATIONALE EVALUATION
REASON INTERVENTION

Subjective: Hyperthermia Leptospirosis is a  Monitor vital  To evaluate Goal met.

biphasic disease signs the effects or Patient’s
“Mainit ang that begins with especially degrees of temperature
pakiramdam ko flu-like symptoms temperature. hyperthermia. return to normal
ngayon”, as (fever, chills, range from 38 to
verbalized by the myalgias, intense 37 oCelsius.
client. headache).  Provide tepid  To lower down
sponge bath. body
Objective: temperature
by cooling the
 Febrile, body surface
Temp.: 38oC of the patient.
 Skin warm to  Remove
touch excess  To promote
 Dry skin clothing or surface cooling
 Poor skin change clothes of the body
turgor to comfortable
ones.

 To reduce
 Maintain metabolic
bedrest. demands.

 To replace
Source: fluid loss and
Handbook of  Once to support
Common permitted, circulating
Communicable encourage to volume and
and Infectious increase intake tissue
Diseases of fluid at least perfusion.
(Navales, D.) 2L/day.
 To reduce or to
 Administer return to
prescribed normal body
meds, temperature.
Paracetamol.
 Nursing Care Plan
Date: October 10, 2009

Name: D.D.

Age: 32 years old

Medical Diagnosis: Leptospirosis

Nursing Diagnosis: Fluid volume deficit related to active fluid volume loss

as manifested by decreased urine output, poor skin turgor, and dry skin, and

high specific gravity.

Short Term Goal: After rendering nursing interventions, patient will

achieve fluid volume at a functional level as evidence by good skin turgor,

stable vital signs, and normal specific gravity.

Long Term Goal: At the end of hospitalization the patient will maintain fluid

volume at a functional level.

 Nursing Care Plan

SCIENTIFIC NURSING
CUES PROBLEM RATIONALE EVALUATION
REASON INTERVENTION

Subjective: Fluid volume Symptoms of  Note possible  To assess Goal partially met.
deficit leptospirosis conditions that causative/ After rendering
“Tatlong beses na include vomiting may lead to precipitating nursing
akong nagsusuka and diarrhea deficits e.g. factors. interventions,
at limang beses which often diarrhea, patient urinated
ng nagtatae” as causes vomiting. 20cc/hr but still
verbalized by the dehydration. with poor skin
client.  Monitor vital  To evaluate turgor and dry
signs degree of fluid skin.
Objective: especially BP loss.
and note
 Poor skin physical signs
turgor e.g. dry skin,
 Dry skin poor skin  To be accurate
 Specific turgor. in replacement
Gravity: needs.
1.022  Monitor urine
output and  To return the
measure body’s fluid
amount. and
electrolytes
 Administer level to
fluid and normal.
electrolytes as
indicated.  To correct/
replace fluid
loss.
Source:
 Once
permitted,
Handbook of
increase fluid
Common
intake at least  Because this
Communicable
2L/day. beverages
and Infectious
 Nursing Care Plan
Diseases tend to be
(Navales, D.)  Limit intake of diuretics that
alcoholic or will help more
caffeinated for fluid loss.
beverages.  To prevent
injury from
 Provide dryness
frequent oral
and eye care.

Date: October 11, 2009

Name: D.D.

Age: 32 years old

Medical Diagnosis: Leptospirosis

Nursing Diagnosis: Impaired urinary elimination r/t disease process.

Short Term Goal: After rendering nursing interventions, patient will be able

to urinate at least 30cc per hour.

 Nursing Care Plan
Long Term Goal: At the end of hospitalization the patient will be able to

achieve normal elimination pattern.

NURSING SCIENTIFIC NURSING

CUES RATIONALE EVALUATION
PROBLEM REASON INTERVENTION
 Nursing Care Plan

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

Date: October 11, 2009

Name: D.D.

Age: 32 years old

Medical Diagnosis: Leptospirosis

Nursing Diagnosis: Mild Anxiety related to change in health status as

evidenced apprehension and restlessness.

Short Term Goal: After rendering nursing interventions the patient will

appear relaxed and report anxiety is reduced to a manageable level.

Long Term Goal: At the end of hospitalization the patient will be free from

anxiety.
Nursing Care Plan
 CUES
NURSING
PROBLEM
SCIENTIFIC
REASON
NURSING
INTERVENTION
Nursing
RATIONALE Care Plan
EVALUATION

Subjective: Mild anxiety Due to acquisition of Independent:

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

Date: October 10, 2009

Name: D.D.

Age: 32 years old

 Nursing Care Plan
Medical Diagnosis: Leptospirosis

Nursing Diagnosis: Disturbed body image related to presence of jaundice

as evidence by elevated bilirubin levels.

Short Term Goal: After rendering nursing interventions, patient will

verbalize understanding of body changes.

Long Term Goal: At the end of hospitalization the patient will verbalize

acceptance of self in the present situation.

 Nursing Care Plan

NURSING SCIENTIFIC
CUES INTERVENTIONS RATIONALE EVALUATION
PROBLEM REASON

Subjective: Disturbed The severe form of  Observe emotional  This may indicate After rendering
body image leptospirosis changes. acceptance or non- nursing interventions,
“Sabi nila results to hepatic acceptance of patient verbalized
naninilaw ako” as impairment which situation. understanding of
verbalized by the causes elevated  Encourage body changes.
patient. bilirubin levels. verbalization about  Provides opportunity
Bilirubin gives a concerns of disease to identify fears and
Objective: yellow color to the process, future misconceptions and
skin and sclera expectations. deal with them
 icteric sclera which is known as directly.
 yellow skin jaundice.
 Discuss situation.
color (jaundice) Explain relationship  To help the patient
 Total Bilirubin: between nature of understand the cause
513.0 disease and of his change in
mmol/L symptoms. appearance.

 Assist patient/SO to
cope with change in  Patient may present
appearance; suggest unattractive
clothing that does appearance as a result
not emphasize of jaundice. Providing
altered appearance, support can enhance
e.g., use of red, self-esteem and
blue, or black promote patient sense
clothing. of control.
Source:
Handbook of  Assist with grooming
Common needs as necessary.  Maintaining
Communicable appearance enhances
and Infectious  Involve patient in self-image.
Diseases (Navales, planning care and
D.) scheduling activities  Enhances feelings of
competency /self-
worth, encourages
independence and
participation in
therapy