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Leptospirosis Case

The document provides information about a case study on leptospirosis submitted by a nursing student. It includes an introduction describing leptospirosis, the patient profile, history, Gordon's functional health patterns assessment, anatomy/physiology, related literature, pathophysiology, and laboratory results. The patient is a 31-year-old male stockman admitted to the ICU with fever and diagnosed with leptospirosis likely from contact with contaminated soil/water through his occupation.

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0% found this document useful (0 votes)
824 views29 pages

Leptospirosis Case

The document provides information about a case study on leptospirosis submitted by a nursing student. It includes an introduction describing leptospirosis, the patient profile, history, Gordon's functional health patterns assessment, anatomy/physiology, related literature, pathophysiology, and laboratory results. The patient is a 31-year-old male stockman admitted to the ICU with fever and diagnosed with leptospirosis likely from contact with contaminated soil/water through his occupation.

Uploaded by

Jp Rectra
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© © All Rights Reserved
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You are on page 1/ 29

EMILIO AGUINALDO COLLEGE

1113- 1117 San Marcelino St., Ermita, Manila

CASE STUDY IN
LEPTOSPIROSIS

SUBMITTED BY:
Ciryl P. Amoto
BSN LEVEL IV

SUBMITTED TO:
Ariel Ortuoste, RN, MAN
Clinical Instructor
ICU Rotation
CONTENTS

I. INTRODUCTION
II. PATIENT PROFILE
III. PATIENT HISTORY
IV. GORDON’S LEVEL OF HEALTH FUCTIONING
V. ANATOMY AND PHYSIOLOGY
VI. RELATED LITERATURE
VII. PATHOPHYSIOLOGY
VIII. LABORATORY RESULTS
IX. COURSE IN THE WARD
X. NCP
XI. DRUG STUDY
I. INTRODUCTION

Leptospirosis is a relatively rare bacterial infection that affects people and animals. It can pass

from animals to humans when an unhealed break in the skin comes in contact with water or

soil where animal urine is present.

Several species of the Leptospira genus of bacteria cause leptospirosis. It can progress to
conditions such as Weil’s disease or meningitis, which can be fatal.

The condition does not usually pass from one person to another.

The bacteria can enter the body through open wounds, the eyes, or mucous membranes.
Animals that transmit the infection to humans include rats, skunks, opossums, foxes, and
raccoons.

Leptospirosis is more common in tropical areas, where the World Health Organization
(WHO) estimate that it affects 10 or more people in every 100,000 each year.

In temperate climates, it probably affects between 0.1 and 1 per 100,000 people. In an
epidemic, it can affect 100 or more in every 100,000 people.

People traveling to tropical areas have a greater risk of exposure.


II. PATIENT PROFILE

 Ward: ICU
 Date of Admission: February 21,2020 7:40am
 Patient’s Name: G. S. G.
 Address: N/A
 Age: 31 years old
 Gender: Male
 Birthdate: September 2, 1989
 Educational Status: N/A
 Religion: Roman Catholic
 Nationality: Filipino
 Civil Status: Married
 Occupation: Stockmen
 Health Care Financing:
 Informant: Mother
 Reliability: Chart

Admission Data:
1. Chief Complaint: Fever
2. Initial Diagnosis: Leptospirosis
3. Final Diagnosis: Leptospirosis
4. Attending Physician: Lou Jorel P. Tia M.D
III. PATIENT HISTORY

 CHIEF COMPLAINT
 PAST MEDICAL HISTORY
-N/A
 FAMILY HISTORY with GENOGRAM

Father Mother (HPN, TB)

Patient G.G Sister Sister Brother

PERSONAL/ SOCIAL HISTORY


Substance use: Smoker, Non alcoholic, No history of drug
abuse
IV. GORDON’S FUNCTIONAL HEATLH PATTERN

LEVEL OF BEFORE DURING ANALYSIS/


FUNCTIONING HOSPITALIZATION HOSPITALIZATION INFERENCE
Patient does not
Health exercise and barely Patient continues to
takes any medication, Compliance with comply with medical
Perception/Health is a heavy smoker, medical treatment treatment and
Management doesn’t go to medication regimen
checkups
Patient’s source of Patient continues to
Patient likes to eat
Nutritional any kind of food and
nutrition is food given comply with medical
Metabolic Pattern by nutritionist and treatment and
drinks water always
fluid is via IV and PO continues nutrition

Patient continues
Elimination Urine is green and Urine is yellow and
elimination via
Pattern poops everyday reddish, stool is soft
catheter

Walks to his work Unable to perform Patient status is weak.


Activity- Exercise
everyday as his form any activity due to Doesn’t participate in
Pattern of work. fatigue any activity
Client’s perception of
quality and quantity
Sleep- Rest Always lacks sleep
Tends to sleep more of sleep is well. Has
Pattern and feels unrested
no specific time of
sleep
Client’s vision and
Cognitive hearing still the same.
Has no difficulty in Decreased in
Perceptual seeing cognitive functions.
Cognitive functions
Pattern decreased due to
hospitalization.
Self- Perception Most of the time feels Client’s perception
Hoping for better about self is still the
and Self- Concept good about herself. days to come. same most of the
Pattern Doesn’t lose hope.
time, felt good.

Role- Lives with extended Client’s isn’t alone


S/O accompany
family. Doesn’t most of the time.
Relationship belong to any social
patient throughout
Satisfied with the
Pattern hospitalization.
groups. support of the family.
Client’s usual manner
Patient doesn’t use Sleeping is the
of handling stress,
any medications in client’s way of
Coping Stress available support
coping with stress. handling stress. S/O is
Tolerance systems, has the
Smokes to relieve self helpful also with
ability to control or
from stress client.
manage situations.
Client’s religious
Wants to have longer
Value- Belief Doesn’t go to mass affilation is
life and always stay
Pattern but prays everyday important, doesn’t
faithful to religion.
lose hope in life.

V. ANATOMY AND PHYSIOLOGY


VI. RELATED LIRERATURE
VII. PATHOPHYSIOLOGY

Causative Agent:
 Contact with soil, water or plants
that have been contaminated by
animal urine.

Enters human body through abraded


skin or through mucous membrane.

Leptospirosis enters the Causes damage to the inner


bloodstream lining of bloodvessels

Spread to all organs of the body

Ischemic Ischemic Ischemic Ischemic


damage to liver damage to damage to damage to
kidney meninges muscles

LEPTOSPIROSIS
VIII. LABORATORY RESULTS

HEMATOLOGY

Name: G.G Age/Sex: M/29 Date:02-26-20


Hospital no.: 86889 Sample: Ward:
Physician: Palma M.D

Component Result Reference Range

Hemoglobin 98 M= 130-180 g/dl F= 125-165


Hematocrit 0.29 M=0.42-0.48 F=0.37-0.42
9
WBC 14.6 5-10 x 10 /L
RBC 3.23 4.2-5.4 x 1012 /L
MCV 86.4 75.0- 90.0 fl
MCH 30.4 25.0-32.0 pg
MCHC 35.2 32.0-36.0 g/DL
Platelet 85 150-400 x 109 / L

Differential
Count
Neutrophil 0.84 0.36-0.66
Lymphocytes 0.12 0.22-0.40
Monocyte 0.04 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY

Name: G.G Age/Sex: M/29 Date:02-25-20


Hospital no.: 86889 Sample: Ward:
Physician: Palma M.D

Component Result Reference Range

Hemoglobin 104 M= 130-180 g/dl F= 125-165


Hematocrit 0.27 M=0.42-0.48 F=0.37-0.42
WBC 14.8 5-10 x 109/L
RBC 3.33 4.2-5.4 x 1012 /L
MCV 81.1 75.0- 90.0 fl
MCH 31.0 25.0-32.0 pg
MCHC 35.8 32.0-36.0 g/DL
Platelet 77 150-400 x 109 / L

Differential
Count
Neutrophil 0.62 0.36-0.66
Lymphocytes 0.38 0.22-0.40
Monocyte 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY

Name: G.G Age/Sex: M/29 Date:02-24-20 9am


Hospital no.: 86889 Sample: Ward:
Physician: Palma M.D

Component Result Reference Range

Hemoglobin 111 M= 130-180 g/dl F= 125-165


Hematocrit 0.31 M=0.42-0.48 F=0.37-0.42
WBC 11.0 5-10 x 109/L
RBC 3.62 4.2-5.4 x 1012 /L
MCV 85.4 75.0- 90.0 fl
MCH 30.6 25.0-32.0 pg
MCHC 35.8 32.0-36.0 g/DL
Platelet 41 150-400 x 109 / L

Differential
Count
Neutrophil 0.75 0.36-0.66
Lymphocytes 0.21 0.22-0.40
Monocyte 0.04 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY

Name: G.G Age/Sex: M/29 Date:02-23-20 9am


Hospital no.: 86889 Sample: Ward:
Physician: Palma M.D

Component Result Reference Range

Hemoglobin 102 M= 130-180 g/dl F= 125-165


Hematocrit 0.29 M=0.42-0.48 F=0.37-0.42
WBC 15.5 5-10 x 109/L
RBC 3.35 4.2-5.4 x 1012 /L
MCV 86.7 75.0- 90.0 fl
MCH 30.4 25.0-32.0 pg
MCHC 35.0 32.0-36.0 g/DL
Platelet 18 150-400 x 109 / L

Differential
Count
Neutrophil 0.84 0.36-0.66
Lymphocytes 0.14 0.22-0.40
Monocyte 0.02 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY

Name: G.G Age/Sex: M/29 Date:02-22-20 9pm


Hospital no.: 86889 Sample: Ward:
Physician: Palma M.D

Component Result Reference Range

Hemoglobin 91 M= 130-180 g/dl F= 125-165


Hematocrit 0.26 M=0.42-0.48 F=0.37-0.42
WBC 17.3 5-10 x 109/L
RBC 3.01 4.2-5.4 x 1012 /L
MCV 88.1 75.0- 90.0 fl
MCH 30.3 25.0-32.0 pg
MCHC 34.4 32.0-36.0 g/DL
Platelet 12 150-400 x 109 / L

Differential
Count
Neutrophil 0.85 0.36-0.66
Lymphocytes 0.15 0.22-0.40
Monocyte 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY

Name: G.G Age/Sex: M/29 Date:02-22-20 9am


Hospital no.: 86889 Sample: Ward:
Physician: Palma M.D

Component Result Reference Range

Hemoglobin 101 M= 130-180 g/dl F= 125-165


Hematocrit 0.29 M=0.42-0.48 F=0.37-0.42
WBC 15.5 5-10 x 109/L
RBC 3.29 4.2-5.4 x 1012 /L
MCV 88.2 75.0- 90.0 fl
MCH 30.7 25.0-32.0 pg
MCHC 34.8 32.0-36.0 g/DL
Platelet 12 150-400 x 109 / L

Differential
Count
Neutrophil 0.89 0.36-0.66
Lymphocytes 0.11 0.22-0.40
Monocyte 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY

Name: G.G Age/Sex: M/29 Date: 02-21-20 9pm


Hospital no.: 86889 Sample: Ward:
Physician: Palma M.D

Component Result Reference Range

Hemoglobin 102 M= 130-180 g/dl F= 125-165


Hematocrit 0.30 M=0.42-0.48 F=0.37-0.42
WBC 12.4 5-10 x 109/L
RBC 3.43 4.2-5.4 x 1012 /L
MCV 88.9 75.0- 90.0 fl
MCH 29.8 25.0-32.0 pg
MCHC 33.8 32.0-36.0 g/DL
Platelet 14 150-400 x 109 / L

Differential
Count
Neutrophil 0.93 0.36-0.66
Lymphocytes 0.07 0.22-0.40
Monocyte 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY

Name: G.G Age/Sex: M/29 Date: 02-21-20 1pm


Hospital no.: 86889 Sample: Ward:
Physician: Palma M.D

Component Result Reference Range

Hemoglobin 106 M= 130-180 g/dl F= 125-165


Hematocrit 0.32 M=0.42-0.48 F=0.37-0.42
WBC 2.2 5-10 x 109/L
RBC 3.57 4.2-5.4 x 1012 /L
MCV 88.3 75.0- 90.0 fl
MCH 29.6 25.0-32.0 pg
MCHC 33.5 32.0-36.0 g/DL
Platelet 14 150-400 x 109 / L

Differential
Count
Neutrophil 0.87 0.36-0.66
Lymphocytes 0.13 0.22-0.40
Monocyte 0.02 0.04-0.08
Eosinophil 0.06 0.01-0.04
Basophil 0.0-0.01
HEMATOLOGY

Name: G.G Age/Sex: M/29 Date: 02-21-20 8am


Hospital no.: 86889 Sample: Ward:
Physician: Palma M.D

Component Result Reference Range

Hemoglobin 119 M= 130-180 g/dl F= 125-165


Hematocrit 0.35 M=0.42-0.48 F=0.37-0.42
WBC 10.0 5-10 x 109/L
RBC 4.04 4.2-5.4 x 1012 /L
MCV 87.5 75.0- 90.0 fl
MCH 29.5 25.0-32.0 pg
MCHC 33.7 32.0-36.0 g/DL
Platelet 27 150-400 x 109 / L

Differential
Count
Neutrophil 0.85 0.36-0.66
Lymphocytes 0.15 0.22-0.40
Monocyte 0.04-0.08
Eosinophil 0.01-0.04
Basophil 0.0-0.01
CLINICAL CHEMISTRY

Name: G.G Age/Sex: M/29 Date: 02-21-20 1:26pm


Hospital no.: 86889 DOB:09-02-1190 Ward:
Sample Type: Serum
Sample Character:

Test Full Name Result Units Reference Range

Crea-S Creatine 24.8 umol/L 70.0 to 115.0


(Sarcosinoxidase)

Exam Result Reference Range

Sodium 133.0 135.-148 mmol/L


Potassium 3.47 3.5-5.3 mmol/L
Chloride 100.8 98-106 mmol/L
Leptospira IgG/ IgM

Name: G.G Age/Sex: M/29 Date: 02-22-20 9am


Hospital no.: 86889 Sample: Ward:
Physician: Dela Cruz M.D

Test Result

Leptospira IgG Negative


Leptospira IgM Negative
DENGUE NSI (DENGUE DUO)

Name: G.G Age/Sex: M/29 Date: 02-21-20 8am


Hospital no.: 86889 Sample: Ward: ER
Physician: Dr. Dela Cruz

Test Result

Dengue NSI Negative


Dengue IgM Negative
Dengue IgG Negative
CLINICAL MICROSCOPY- URINALYSIS

Name: G.G Age/Sex: M/29 Date: 02-21-20 8am


Hospital no.: 86889 Sample: Ward: ER
Physician: Dr. Dela Cruz

Physical Examination Microscopic Exam


Color Dark Yellow WBC 25-30/hpf
Transparency Turbid RBC 1-3/hpf
Epithelial Cells
Bacteria
Amorphous +3
Material
Mucus Threads +3

Chemical Examination

Protein +1
Sugar Negative
Specific Gravity 1.030
pH 5.0
IX. COURSE IN THE WARD

February 14, 2020


Doctor’s order:
- For admission in the ward for close monitoring
- Administer PNSS
New medications:
- Paracetamol 300g IV
New orders:
- for CT Scan
X. NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Acute Within 4 INDEPENDENT: After 4 hours of
“Ano yan?” confusion hours of nursing
“bakit?” as related to nursing intervention the
verbalized by the disorientation. intervention goal has not been
patient. the patient met.
will. DEPENDENT:

OBJECTIVE:
Vital signs taken:
BP: 130/90 COLLABORATIVE:
PR: 70
RR: 20
T: 36 C
O2: 97%

SOURCE: NANDA 14 ed.


XI. DRUG STUDY

Generic Name: Classifications Indication: Mechanism Contraindicat Side Nursing


To treat of Action: ion Effects: Responsibilit
Penicillin G A. Chemical: different ies:
Sodium types of Inhibits cell Contraindicat Dizziness Drug may
Natural severe wall ed in px alter normal
Brand Name: Penicillin infections synthesis hypersensitiv colon flora.
Benzylpenicill including during e to drug or Adverse
in Sodium B. strep multiplicatio other Effect: Monitor px
Therapeutic: infections, n penicillin and Neuropat for diarrhea
Dosage: 7.2 meningitis. in those hy and initiate
ml Antibiotic Anthrax, sodium therapeutic
Route: IV pneumonia, restricted Seizures measures as
Frequency: C. Pregnancy gonorrhea, diets. needed.
OD Category: C syphilis. Anxiety Drug may
need to be
Pharmacokinet Confusio stopped.
ics: n Observe px
Onset: closely with
Immediate Depressi large doses
Peak: on and prolong
Immediate therapy,
Duration: Heart bacterial or
Unknown failure fungal
Half Life: 30- superinfectio
60 mins Hemolyti n may occur
c anemia especially in
elderly,
arthralgia debilitated pr
immunosupp
ressed px.
Generic Name: Classifications Indication: Mechanism Contraindicat Side Nursing
of Action: ion Effects: Responsibilit
Ceftriaxone A. Chemical: UTI, ies:
Brand Name: Third Lower Inhibits cell Contraindicat Dizziness
Generation respiratory wall ed in patients Check if the
Rocephin cephalosporins tract, synthesis, hypersensitiv Headach patient is
Dosage 2g: gynecologi promoting e to drug or e allergic to
Route: IV c, bone or osmotic other penicillin or
Frequency: B. joint, intra instability, cephalospori Adverse cephalospori
OD Therapeutic: abdominal, usually n. Reaction n.
Antibiotic skin or skin bactericidal. s:
Pharmacokinet structure Use Monitor
ics: infection cautiously in Fever patient with
Onset: C. Pregnancy septicaemia patients Phlebitis impaired
Immediate Category: B Meningitis hypersensitiv Diarrhea vit.k
Peak: Perioperati e to penicillin Candidia synthesis or
Immediate ve because of sis low vitamin
Duration: prevention possibility of Anaphyla k stores vit.
Unknown cross xis K may be
Half Life: 5 ½ sensitivity chills needed.
to 11hrs with other
beta lactam
antibiotic.

Generic Name: Classifications Indication: Mechanism Contraindicat Side Nursing


Clopidogrel of Action: ion Effects: Responsibilit
A. Chemical: Reduction ies:
Brand Name: Platelet of Inhibits Hypersensiti Dizziness
Saphlopid aggregation artheroscler platelet vity to Assess
inhibitor otic events aggregation pathologic Fatigue patient for
Dosage 75mg: in patient at by bleeding symptoms of
Route: P.O B. risk for irreversibly Headach stroke
Frequency: Therapeutic: such events inhibiting e peripheral
OD Antiplatelet including the binding vascular
recent MI, of ATP to disease
Pharmacokinet acute platelet Adverse during
ics: C. Pregnancy coronary receptor. reactions: therapy
Category: B syndrome Monitor
Onset: within stroke or GI patient for
24 hrs peripheral bleeding signs of
Peak: 3-7 days vascular Drug thrombocyto
Duration: 5 disease. rash with penic
days eosinophi purpura.
Half Life: 6hrs lia Monitor
Neutrope bleeding
nia time during
Thrombo therapy
cytopenia Monitor
purpura CBC with
differential
and platelet
count during
therapy.

Generic Name: Classifications Indication: Mechanism Contraindicat Side Nursing


Potassium of Action: ion Effects: Responsibilit
Chloride A. Chemical: Treatment/ ies:
prevention Maintain Hyperkalemi Diarrhea
Brand Name: Mineral and of acid base a severe renal Assess for
K-lyte electrolyte potassium balance and impairment Flatulenc signs and
depletion. electrophysi e symptoms of
B. ologic hypokalemia
Dosage:600mg Therapeutic: balance of Nausea and
Route: PO supplements the cell. hyperkalemia
Frequency:TI Activation Vomiting
D in many Monitor
C. Pregnancy enzymatic Abdomin serum
Pharmacokinet Category: C reactions, al pain potassium
ics: essential to before and
Onset: transmission Adverse periodically
unknown of nerve Reaction: during the
Peak: 1-2hrs impulses, therapy
Duration: contraction Arrhyth
Unknown of cardiac, mia Monitor
Half Life: skeletal and renal
Unknown smooth Confusio function
muscle n serum
gastric bicarbonate
secretion GI and pH.
renal ulceratio
function n
tissue
synthesis paralysis
and
carbohydrat
e
metabolism
Generic Name: Classifications Indication: Mechanism Contraindicat Side Nursing
of Action: ion Effects: Responsibilit
Omeprazole A. Chemical: ies:

Brand Name:

B.
Available Therapeutic:
Dosage:
Route:
Frequency:
C. Pregnancy
Pharmacokinet Category:
ics:
Onset:
Peak:
Duration:
Half Life:

REFERENCES:
https://www.ahajournals.org/doi/10.1161/STROKEAHA.114.006320
https://www.mayoclinic.org/diseases-conditions/stroke/symptoms-
causes/syc-20350113
https://www.healthline.com/health/cerebrovascular-accident#diagnosis
https://www.slideshare.net/ReihchelleBayad/gordons-
11functionalhealthpatterns
https://www.scribd.com/doc/36707103/Anatomy-and-Physiology-CVA

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