COLLEGE OF NURSING

RELATED LEARNING EXPERIENCE

LEPTOSPIROSIS

A Case Study
Presented to the Faculty of
the
College of Nursing

In Partial Fulfillment
Of the Requirement for the Subject
RELATED LEARNING EXPERIENCE

Presented by:

Macalinao, Hanna Yumi

B.

Presented to:

Prof. Archito L. Dela Cruz. MAN,RN

OCTOBER 2024

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CHAPTER I. THE PROBLEM AND ITS SETTINGS

OBJECTIVE OF THE CASE
a. General 3
b. Specific 3
INTRODUCTION
a. What is a case study? 3
b. Introduction about the case 4
c. Incidence 4
d. Theoretical Framework 5
e. Review of Related Literature and Studies 6
CLIENT’S PROFILE 6
SUBJECTIVE DATA COLLECTION 7
a. Comprehensive Nursing Health History 8
b. Gordon’s Functional Health History 8
ACTIVITIES OF DAILY LIVING 10
OBJECTIVE DATA COLLECTION.
GENERAL SURVEY
a. Physical Appearance 12
b. Behavior 13
c. Body Measurements 13
d. Physical Examination 15
CHAPTER II. CASE DISCUSSION AND PRESENTATION
a.Case Discussion 17
b.Review of anatomy and physiology 19
c. Pathophysiology 22
d. Clinical manifestation 23
e. Risk factors 23
f. Prevention 24
g. Complications 25
h. Laboratory findings 26
i. Diagnostic/radiology findings 26
j.Medical management 27
CHAPTER III. NURSING MANAGEMENT
Problem identification, analysis and priorization. 29
Nursing care plan 31
Implications of the case 41
Bibliography 44

OBJECTIVES OF THE CASE 2

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CLIENT’S PROFILE
a. Name: V.N
b. Address: Carranglan, Nueva Ecija
c. Age: 52 years old
d. Gender: Male
e. Religion: Roman Catholic
f. Occupation: Farmer
g. Marital Status : Single
h. Number of Children : N/A
i. Reason for Seeking Care : High fever, muscle
pain, jaundice
j. Date of Admission : October 4, 2024
k. Ethnicity : Filipino
l. Educational Attainment : High School Graduate
m. Admitting History : The patient presents with a high
fever (39.5°C) and muscle pain that began three days
prior to admission. He also reports jaundice, which
has developed over the past two days. Notably, the
patient has a recent wound on his left foot from
working in a rice field, where he was exposed to
muddy water, increasing his risk of leptospirosis.
He denies any history of travel or contact with sick
animals but acknowledges that he often works in wet
conditions during the rainy season.
n. Admitting Diagnosis : Leptospirosis
o. Final Diagnosis : Leptospirosis

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SUBJECTIVE DATA COLLECTION

A. COMPREHENSIVE NURSING HEALTH HISTORY
a. History of Present illness

V. N, a 52-year-old male farmer from Carranglan,

Nueva Ecija, presented with high fever, muscle pain,
and jaundice, which began five days prior to
admission. The patient reported a gradual onset of
symptoms, initially feeling fatigued and developing a
low-grade fever. The fever spiked to 39.5°C two days
later, accompanied by generalized muscle pain,
particularly in the calves and lower back, as well as
severe headaches.
V. N also noted yellowing of his skin and eyes over
the past two days. He has a recent wound on his left
foot, sustained while working in a flooded rice field,
which may have exposed him to contaminated water.
Despite home remedies for the fever, his symptoms
persisted, prompting him to seek medical attention.
Upon admission on September 29, 2024, the patient was
diagnosed with leptospirosis based on clinical
presentation and
laboratory findings.
b. History of Past illness
The patient does not have any significant past medical
history. No previous hospitalizations, surgeries, or
chronic illnesses were reported.

c. Family History
N/A

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B. GORDON’S FUNCTIONAL HEALTH PATTERNS

a. Health Perception-Health Management Pattern

V. N perceives his overall health as generally good until

the recent onset of leptospirosis symptoms. He has managed
minor illnesses at home with over-the-counter medications but
sought medical help when his fever and other symptoms
worsened. He understands the importance of timely medical
intervention and is compliant with prescribed treatment.

b. Cognitive- Perceptual Pattern

V. N demonstrates normal cognitive functioning for his

age. He is alert, oriented, and able to communicate
effectively. However, he reports difficulty concentrating due
to severe headaches and fatigue caused by his illness. His
vision and hearing are intact, with no significant sensory
deficits.

c. Self –Perception- Self- Concept Pattern

V. N expresses frustration and concern over his physical

condition, particularly the weakness and jaundice caused by
leptospirosis. He feels uncomfortable with his current
appearance due to the yellowing of his skin and eyes, which has
affected his self-esteem temporarily. He is worried about his
ability to return to work as a farmer.

d. Role-Relationship Pattern

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As a single man with no children, V. N's primary role is

that of a farmer, supporting himself through agricultural
work. His illness has disrupted his ability to fulfill his
role, which causes him concern, particularly as it affects his
livelihood. His relationships with his siblings remain
supportive, though he tends to manage his health
independently.

e. Sexuality-Reproductive Pattern

V. N reports no current issues related to his sexuality

or reproductive health. He describes his sexual health as
satisfactory and appropriate for his age, with no significant
changes or concerns during the illness.

f. Value- Belief Pattern

V. N holds strong spiritual beliefs as a Roman Catholic,

relying on his faith for comfort and hope during his illness.
His values are rooted in hard work and resilience, which guide
his decisions regarding health and recovery. He believes in
the importance of seeking medical care when necessary,
especially in critical situations like his current illness.

g. Nutritional –Metabolic Pattern

V. N’s illness has affected his appetite, leading to

reduced food intake. He reports nausea and a lack of desire
to eat, mainly consuming liquids and soft foods like soup and
porridge. He is aware of the importance of maintaining
hydration, particularly given his fever and risk of
dehydration.

h. Elimination Pattern

V. N reports regular bowel movements but has noticed a

decrease in urination since his symptoms began. He also
reports increased sweating due to his fever but no vomiting.
His condition is being monitored closely for any signs of
dehydration or renal impairment.

i. Activity-Exercise Pattern

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Prior to his illness, V. N was very active, engaging in

physical labor as a farmer. However, since the onset of his
symptoms, he has been mostly bedridden due to extreme fatigue,
muscle pain, and weakness. He expresses frustration with his
inability to continue his regular activities.

j. Sleep-Rest Pattern

V. N has experienced difficulty sleeping due to his

fever, muscle pain, and headaches. He reports waking
frequently during the night and feeling fatigued throughout
the day. His sleep quality has been poor since the onset of
his illness, contributing to his overall discomfort and
prolonged recovery.

C. ACTIVITIES OF DAILY LIVING

Katz Index of Independence in Activities of Daily Living

Activities Independence Dependence
Points (0 or (1 Point) (0 point)
0)
NO supervision, WITH supervision,
direction or direction,
personal personal
assistance. assistance or
total care.
BATHING (1 POINT) Bathes (O POINT) Need
Points: 1 self completely or help with bathing
needs help in more than one part
bathing only a of the body,
single part of the getting in or out
body such as the of the tub or
back, genital area shower. Requires
or disabled total bathing.
extremity.

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DRESSING (1 POINT) Get (0 POINT) Needs

Points: 1 clothes from help with dressing
closets and self or needs to be
drawers and puts completely
on clothes and dressed.
outer garments
complete with
fasteners. May
have help tying
shoes.
TOILETING (1 POINT) Goes to (0 POINT) Needs
Points: 1 toilet, gets on help transferring
and off, arranges to the toilet,
clothes, cleans cleaning self or
genital area uses bedpan or
without help. commode.
TRANSFERRING (1 POINT) Moves in (0 POINT) Needs
Points: 1 and out of bed or help in moving
chair unassisted. from bed to chair
Mechanical or requires a
transfer aids are complete transfer.
acceptable.
CONTINENCE (1 POINT) (0 POINT) Is
Points: 1 Exercises complete partially or
self-control over totally incontinent
urination and of bowel or
defecation. bladder.
FEEDING (1 POINT) Gets (0 POINT) Needs
Points: 1 food from plate partial or total
into mouth without help with feeding
help. or requires
Preparation of parenteral
food may be done feeding.
by another person.
TOTAL POINTS: SCORING: 6 – High (patient very
independent)
0 – Low (patient
dependent)

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According to the Katz Index of Independence in Activities

of Daily Living, the client still has the ability to
perform common living activities with independence and
asks for assistance minimally. The client have a total
score of 6 points in the table since the client is still
able to bathe, dress, use the toilet, transfer herself,
manage continence, and feed herself. However, the client
still needs minimal assist due to muscle weakness and
limited mobility associated with the disease.

OBJECTIVE DATA COLLECTION

GENERAL SURVEY
A. PHYSICAL APPEARANCE
V. N, a 52-year-old male, presents with clear signs of
illness and moderate distress. He appears uncomfortable
due to muscle pain, particularly in the calves and lower
back, often grimacing during movement. His skin has a
noticeable yellow tint, indicative of jaundice, while his
facial features reflect fatigue and pallor. Despite this,
he remains alert and oriented, responding appropriately,
though his speech is soft and labored.

Physically, he has a well-proportioned body structure but

appears slightly thinner due to decreased appetite. A
healing wound on his left foot shows mild inflammation,
likely related to the leptospirosis infection. V. N’s
mobility is significantly limited; he moves slowly and
requires assistance to get in and out of bed, favoring
sitting or lying down to minimize discomfort and avoid
exacerbating his symptoms.

B. BEHAVIOR
V. N displays a subdued mood and flat affect, indicative
of his discomfort and anxiety about his health. His speech
is soft and deliberate, often punctuated by pauses due to
fatigue and ongoing pain. He is dressed in clean, casual
clothing appropriate for the hospital, though it appears
slightly rumpled, reflecting his decreased energy levels.

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His personal hygiene is acceptable, but he may not

maintain his usual standards due to his illness. V. N
maintains appropriate eye contact during conversations,
although he occasionally looks away when discussing his
discomfort. Overall, his behavior shows a struggle to
cope with significant physical and emotional stress.

C. BODY MEASUREMENTS
The patient stands at a height of 5'7" and weighs 75 kg.
This results in a BMI of approximately 25.9, placing him
in the overweight category according to standard BMI
classifications. This indicates that the patient carries
more weight than is typically considered ideal for his
height. Such a weight classification may have implications
for his overall health and recovery, particularly in the
management of his symptoms and complications associated
with leptospirosis. Maintaining a healthy weight can be
critical in reducing the risk of further health issues and
aiding in the recovery process.

C. Vital Signs

Date Blood Temperat Pulse Respirato Oxygen

Pressure ure Rate ry Rate Saturatio
n
10/09/2024

4:00PM 110/70 36.7 82 18 96%

8:00PM 120/60 36.8 76 17 100%
10/10/2024

4:00PM 100/50 36.6 72 19 98%

8:00PM 90/70 36.9 80 19 96%

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D. PHYSICAL EXAMINATION (CEPHALOCAUDAL) (Discussion after

the table)

Date Organ Method Normal Actual Interpretation

assessed findings findings And analysis (with
reference)

10/09/24 Head Inspection, Symmetrical, Mild Tenderness could

Palpation no lumps, no tenderness indicate early signs
tenderness on of dehydration or
palpation, muscle strain.
no visible (Hinkle &
deformities Cheever, 2020)

10/09/24 Eyes Inspection Clear, Mild redness Redness may suggest

sclera of irritation or
white, conjunctiva; infection; scleral
pupils slight icterus indicates
equal and scleral potential liver
reactive icterus involvement.(Lewis et
to light al.,
2020)
10/09/24 Abdomen Inspection, Soft, Mild Tenderness may
Auscultation nontender, epigastric suggest
no masses, tenderness, gastrointestinal
bowel bowel sounds involvement related
sounds present to the infection.
present

Extremities Inspection, No edema, Mild Petechiae may

Palpation, full range petechiae on indicate
Percussion of motion, lower thrombocytopenia;
no extremities; wound on left foot
tenderness left foot may be the portal of
wound noted entry for infection.

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Skin Inspection, Warm, Jaundice Jaundice indicates

Palpation dry, noted on liver dysfunction;
intact, skin, rash may be
no rashes generalized associated with the
rash present exanthematous phase
of leptospirosis..
(Lewis et al., 2020)

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CHAPTER II: CASE DISCUSSION AND PRESENTATIONS

A. CASE DISCUSSION

Leptospirosis is a zoonotic infection caused by the

spirochete bacteria Leptospira, commonly transmitted to
humans through exposure to contaminated water or soil,
particularly in tropical and subtropical regions (Haake
& Levett, 2020). This case focuses on V. N, a 52-year-
old male farmer who presented with symptoms typical of
leptospirosis, including high fever, muscle pain, and
jaundice. His occupational exposure, especially through
contact with flooded rice fields where he sustained a
wound on his left foot, is a significant risk factor for
infection. The presence of scleral icterus and jaundice
indicates liver involvement, while mild epigastric
tenderness suggests potential gastrointestinal distress,
which can occur due to the systemic effects of the
disease (Costa et al., 2021).

Management of leptospirosis involves prompt

antibiotic therapy, typically with doxycycline or
penicillin, and supportive care to address complications
such as dehydration and renal failure (Munoz-Zanzi et
al., 2019). In V. N's case, early recognition of his
symptoms and appropriate interventions are crucial for
improving his outcomes and reducing the risk of severe
complications. Monitoring liver function, renal
parameters, and platelet counts is essential in guiding
treatment decisions and ensuring effective management of
his condition. This case underscores the importance of
timely medical intervention in patients with
leptospirosis to prevent progression to severe illness.

References

Haake, D. A., & Levett, P. N. (2020). Leptospirosis

in humans. Current Topics in Microbiology and
Immunology, 387, 65-97.

Costa, F., Hagan, J. E., Calcagno, J., Kane, M.,

Torgerson, P., Martinez-Silveira, M. S., ... & Ko, A. I.

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(2021). Global morbidity and mortality of leptospirosis:

A systematic review. PLOS Neglected Tropical Diseases,
14(9), e0008500.

Munoz-Zanzi, C., Mason, M. R., Encina, C., Astroza, A.,

& Romero, A. (2019). Leptospirosis prevention: Reducing
high-risk exposures through environmental interventions.
BMC Public Health, 19(1), 774.

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B. REVIEW OF ANATOMY AND PHYSIOLOGY

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1. Kidneys:

The kidneys are essential organs that filter blood to

remove waste products, excess salts, and toxins, playing
a crucial role in maintaining the body's homeostasis.
They regulate fluid and electrolyte balance by adjusting
the volume and concentration of urine produced, ensuring
that the body maintains the right levels of hydration and
essential minerals like sodium and potassium. Through the
nephrons, the functional units of the kidneys, they also
help regulate blood pressure by controlling the volume of
blood and releasing hormones like erythropoietin, which
stimulates red blood cell production.

2. Liver:

The liver is a vital organ responsible for metabolizing

nutrients absorbed from the digestive tract and
detoxifying harmful substances that enter the
bloodstream. It synthesizes important proteins,
including those necessary for blood clotting and immune
function, while also producing bile, which is essential
for the digestion and absorption of fats in the
intestine.
Additionally, the liver plays a role in regulating blood
glucose levels by converting excess glucose into glycogen
for storage and releasing it back into the bloodstream
when needed, thereby maintaining energy balance in the
body.

3. Heart:

The heart is a muscular organ that functions as the

central component of the cardiovascular system,
continuously pumping blood throughout the body to
deliver oxygen and essential nutrients to tissues while
removing carbon dioxide and metabolic waste products. It
consists of four chambers—two atria and two ventricles—
that work in a coordinated manner to ensure efficient
circulation. The heart also regulates blood flow and
pressure through its rhythmic contractions, adapting to
the body's varying demands during physical activity,
rest, and stress.

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4. Muscles:

Muscles are specialized tissues that facilitate movement

of the body by contracting and relaxing in response to
signals from the nervous system. They provide support for
the skeleton, maintaining posture and stability while
allowing for a wide range of movements, from gross motor
skills like walking to fine motor skills like writing.
Additionally, muscles generate heat as a byproduct of
metabolic processes during contraction, helping to
regulate body temperature and contributing to overall
energy expenditure.

5. Nervous System (Brain and Spinal Cord):

The nervous system is a complex network that controls and

coordinates all bodily functions, processing sensory
information from the environment and initiating
appropriate responses. The brain, as the control center,
processes information, regulates behavior, and integrates
sensory input, while the spinal cord serves as a pathway
for signals between the brain and the rest of the body.
This system is responsible for voluntary actions, such as
moving a limb, as well as involuntary functions, such as
reflex responses and autonomic processes like heart rate
and digestion.

6. Lungs:

The lungs are essential respiratory organs that

facilitate gas exchange, allowing oxygen from the
inhaled air to enter the bloodstream while expelling
carbon dioxide, a metabolic waste product. They consist
of a complex network of airways and alveoli, tiny air
sacs where the actual exchange of gases occurs. The
lungs also play a role in regulating blood pH by
controlling the levels of carbon dioxide in the blood,
and they filter out particulate matter and pathogens
from the air we breathe, contributing to overall
respiratory health.

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C. PATHOPHYSIOLOGY

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I. MEDICAL MANAGEMENT DRUG STUDY

Date Name of Mechanism Indicatio n Contraindic Side Effect Medication Nursing

the Drug of Action ation Card Responsibilities

10/1 a. Generic Inhibits Treatment of Hypersensitivity Allergic Allergic - Asses for

09/24 Name: the bacterial to penicillin or reactions (rash, reactions (rash, allergy before
Penicillin synthesis infections, other beta- hives, hives, administration.
of including lactam anaphylaxis), anaphylaxis),
b. Brand bacterial leptospirosis. antibiotics. gastrointestinal gastrointestinal - Monitor for
Name:
cell walls, upset (nausea, upset (nausea, signs of
Penicillin allergic
leading to vomiting, vomiting,
VK reactions
the diarrhea). diarrhea).
c. Dose/dos destruction -Educate the
age: of the patient on
250mg bacteria. completing full
course of
d. Route: antibiotics.
Oral
- Monitor for
gastrointestinal
upset

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Date Name of Mechanism Indicatio Contraindi Side Medication Card Nursing

the of Action n cation Effect Responsibilitie
Drug s
10/09/ a. Generi Paracetamol Used for Severe Hepatotoxici - Monitor liver
24 c Name: is an the liver ty (in function tests,
Paraceta analgesic relief disease, overdose), especially with
ol and of mild hypersensi skin rash, long-term use.
antipyretic to tivity to anemia
b. Brand that (rare).
moderate paracetamo - Ensure the
Name: inhibits pain and l. patient is aware
Tylenol,
prostaglandi to of the maximum
Panadol
n synthesis reduce daily dose to
c. Dose/dosa in the fever. avoid overdose.
ge: 300mg central
nervous - Administer
d. Route: system and with food or a
Oral works full glass of
peripherally water to
to block minimize
pain impulse gastrointestinal
generation. upset.
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Date Name of Mechanism Indicatio n Contraindi Side Effect Medication Nursing Responsibilitie s
the of cation Card
Drug Action
10/09 a. Gener Inhibits Prevention Hypersensitivity Headache, - Administer before meals
/24 ic Name the proton of gastric to omeprazole or gastrointestinal for optimal effect.
: pump in ulcers in other proton disturbances
Omeprazole gastric patients pump inhibitors (diarrhea,
parietal taking constipation),
cells, NSAIDs, dizziness - Monitor for
b. Brand gastrointestinal
Name: reducing gastritis, or
symptoms
Prilosec the acid-related
(diarrhea,constipation).
production symptoms in
c. of stomach leptospirosis
Dose/dosage acid patients
under - Educate the patient on
40mg antibiotic avoiding irritants like
treatment alcohol, smoking, or
d. Route: spicy foods.
Oral - Monitor for signs of
nutrient malabsorption
(long-term use).

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Chapter III. Nursing Management

Problem Identification, Analysis and Prioritization

NURSING
DIAGNOSIS/CUES TYPE AND RANK JUSTIFICATION
Risk for Risk/Potential The client is at risk for
ineffective ineffective renal
renal perfusion perfusion. It is
related to essential for adequate
infection as kidney functioning, which
evidenced by is critical for
elevated BUN maintaining fluid
and creatinine balance, electrolyte
levels levels, and waste
elimination. This comes
on top priority to ensure
client’s survival and
stability as this can
lead to more serious
complications like fluid
overload and acute kidney
injury, which are very
common serious
complications associating
leptospirosis.

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Hyperthermia Problem focus/ Hyperthermia is a

related Actual critical physiological
to bacterial response to infection and
infection as requires immediate
evidenced by attention to prevent
elevated body complications such as
temperature. dehydration, metabolic
imbalances, and potential
organ dysfunction.
Managing hyperthermia
promptly ensures that the
body maintains
homeostasis, which is
essential for recovery
and the effectiveness of
treatments like
antibiotics.
Acute pain Problem-
related to focused/Actual Pain management is
bacterial essential to improve the
infections in patient's comfort, reduce
the body stress responses, and
promote healing. Although
pain is important to
address, it is secondary
to hyperthermia in terms
of immediacy because
hyperthermia can directly
threaten life if left
unmanaged. Pain control
also aids in improving
patient cooperation with
other necessary
treatments.
B. NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Hyperthermia SMART Independent Independent Parameters

Data: related to - Establish and - Establishing - Adequacy: Assess
"Sobrang bacterial a. Short maintain a rapport whether the
init ang infection term goal: therapeutic enhances trust interventions
pakiramdam as - The rapport with and encourages provided
ko" evidenced patient the patient adherence to sufficient
by elevated will to enhance treatment fluid
Objective body demonstrate communication (Potter & replacement to
Data: temperature. improved and Perry, 2020). correct the
Vital Signs: hydration cooperation. - Ensures early deficit.
(August 14, status with - Measure and detection and - Effectiveness:
2024) moist record all management of Evaluate the
BP: 90/60mmHg mucous fluid intake fluid patient's
PR: 120bpm membranes and output, imbalances hydration
RR: 24bpm and stable ensuring it which is status through
T: 38.8 vital signs aligns with critical in vital signs,
O2Sat: 96 within 12 the patient's dengue urine output,
hours. needs to patients prone and hematocrit
detect any to dehydration levels.
Physical b. Long- imbalances due to - Appropriateness:
Examination: term goal: early. increased Determine if
- The - Regularly capillary the selected
patient assess skin permeability. interventions

31
 - Dry will turgor and - Helps in the were suitable
mucous maintain mucous early for the
membrane adequate membranes for identification patient's
-Skin fluid signs of of dehydration condition.
turgor poor balance dehydration. by evaluating - Efficiency:
with delayed with urine - Provide physical Review the
capillary output of education on signs. timely
refill. at least the - Patient execution of
- Presence 0.5 importance of education interventions
ml/kg/hr, adequate promotes and their
of petechiae
stable fluid intake adherence to ability to
on the and the signs
hematocrit treatment prevent
extremities. levels, and of plans and complications.
no signs of dehydration improves - Acceptability:
shock to enhance overall Consider
Laboratories: within 48 their outcomes. patient and
Complete Blood hours. understanding - Vital signs family
Count (CBC): and monitoring satisfaction
- WBC: cooperation. allows for with the care
3,000/mm³ - Monitor Vital timely provided and
(low) Signs interventions their
- Platelets: Regularly: to prevent understanding
80,000/mm³ Check vital complications of the
(low) signs every 2 like dengue treatment plan.
- Hematocrit: hours, shock
47% focusing on syndrome.
(elevated) temperature,
pulse, and Dependent:
blood

32
Diagnostic pressure, to - IV fluids help
Procedures: detect early maintain
- Chest X- signs of hydration and
ray: No acute fluid prevent
infiltrates, imbalance or hypovolemic
but slight shock. shock, a
pleural severe
effusion Dependent: complication
noted. - Administer of dengue.
isotonic - Reducing fever
fluids (e.g., decreases
0.9% Normal insensible
Saline) fluid losses,
according to helping to
the maintain
healthcare hydration
provider’s status.
orders to
maintain Collaborative:
adequate - A dietitian
hydration and can provide a
electrolyte tailored diet
balance. plan to ensure
- Provide the patient’s
antipyretic hydration and
medications, nutritional
such as needs are met
paracetamol, during
to manage recovery.

33
 fever and
prevent
dehydration
due to
increased
insensible
fluid loss.

Collaborative:
- Work with a
dietitian to
develop a
fluid-rich
diet plan
that includes
easily
digestible
foods and
beverages to
support
hydration and
nutritional
needs.

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 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective Acute pain SMART Independent Independent Parameters

Data: related to - Establish and - Builds trust, Adequacy:
"Napakasakit ng bacterial a. Short term maintain a enhancing - The
ulo at buong infections goal: therapeutic communication and interventions
katawan" as in -After 8 hours rapport with cooperation, which sufficiently
verbalized by the body. of nursing the patient to improves pain addressed the
the patient. interventions, enhance management patient's pain
the patient communication (Bagnasco et al., management
Objective Data: will report a and 2018). needs,
Vital Signs: pain level of cooperation. - Provides objective including
(10 09, 2024) 0/10. - Regularly data to guide medication
BP: 110/70mmHg assess and treatment and administration
PR: 115bpm Long- term document the evaluate and non-
RR: 20bpm goal: patient’s pain intervention pharmacological
T: 38.7 - After 24 hours levels using a effectiveness strategies.
O2Sat: 88 of nursing standardized (Pasero & Effectiveness:
interventions, pain scale (0- McCaffery, 2011). - The patient
the patient 10) to guide - Empowers the successfully
will further patient to manage demonstrated the
Physical demonstrate interventions. pain actively and use of at least
Examination: use of - Instruct the can reduce pain two relaxation
- Facial relaxation patient in perception methods, showing
grimacing skills, other relaxation (McCaffery & effective
- Irritability methods to techniques, Pasero, 2011). integration into
promote such as deep their care
- Tailors care to
comfort and to breathing and routine.
enhance physical
relieve pain. Appropriateness:
Laboratories:

35
Complete Blood guided comfort, - The care plan
Count (CBC): imagery, and potentially was well-suited
- WBC: encourage them reducing pain and for the
3,500/mm³ to practice fostering a patient's
(low) these methods healing needs, focusing
- Platelets: for pain environment on self-
85,000/mm³ relief. (Hadjistavropoulos management and
(low) - Provide et al., 2014). comfort
- Hematocrit: comfort - Improves strategies.
45% (elevated) measures such circulation and Efficiency:
as positioning reduces stiffness, - Educational
pillows for reinforcing the resources and
Diagnostic support, importance of staff time were
Procedures: adjusting room mobility in used
- No any temperature, recovery (Boyer et effectively to
diagnostic or using al., 2018). support the
procedure. warm/cool patient’s
packs as learning and
appropriate. application of
Dependent: pain management
- Provides necessary techniques..
- Promote gentle pain relief; Acceptability:
movements or monitoring ensures - Both the
stretches as safety and patient and
tolerated to effective pain family reported
enhance management (Davis high
comfort and et al., 2015). satisfaction
circulation, - Ensures optimal with the care
while ensuring pain control by provided and

36
 the patient exploring actively
understands alternative adhered to the
the importance strategies when treatment plan,
of pacing pain is indicating
themselves. unmanageable overall
(McCaffery & acceptability.
Pasero, 2011).

Dependent: Collaborative:
- Administer
prescribed - Develops a
analgesics comprehensive
(e.g., mobility plan that
acetaminophen integrates pain
or opioids) as management,
ordered, promoting recovery
monitoring the while minimizing
patient for discomfort
effectiveness (Hernández et al.,
and any side 2016).
effects.

- If pain levels
remain high
despite
interventions,
consult with
the healthcare

37
 provider to
evaluate and
adjust pain
management
medications as
needed.

Collaborative

- Work with
physical
therapists to
develop a safe
mobility plan
that
incorporates
pain
management
strategies and
promotes
rehabilitation
while
minimizing
discomfort.

38
 Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Risk for Short-Term Independent: Independent Short-Term
Data: ineffective Goals: Goals:
renal Within 4 hours of 1. Obtain 1. Vital sign
Frequent perfusion nursing client’s is Within 4 hours
urination related to intervention, the baseline significant of proper
but with bacterial client will be vital signs to detect nursing
minimal infection as able to: sudden interventions,
urinary evidenced by health the client
2. Assess the
output elevated BUN  Maintain stable changes. elicits:
skin
and vital signs integrity and
Recurrent creatinine  Maintained
color 2. Skin
headache levels stable
 Promote integrity
hydration via 3. Monitor and color vital
Objective IVF or through intake and may indicate signs
Data: sips of water output health
status of  Improved
BUN: the client hydration
 Diminish 4. Regularly and signs of
headaches monitor BUN liver  Diminished
39.33 mg/Dl headaches
and impairment
Long-Term Goals: creatinine like
Creatinine: levels Long-Term
jaundice.
After 2 weeks, Goals:
2.18 mg/dL
the client will 5. Promote 3. Monitoring
Within a span
Muscle be able to: passive ROM intake and of 2 weeks,
weakness exercises output is the client is
essential to
Decreased ROM Dependent:

39
Yellow-orange  Maintain stable determine able to
vital signs 6. Administer the level of present:
IV Fluids hydration
and the
and
changes in
antibiotics output that
as may tell how
well the
kidney is
functioning.

4. BUN and
creatinine
levels are

40
Implications of the Case to the Following

Areas: Nursing Education

This case study on leptospirosis underscores the

importance of comprehensive nursing education,
particularly in managing the systemic effects of the
disease in a person’s body, and in determining the
significant risks that it can bring to individuals.

Thus, analyzing a case like this allows student-nurses

to explore the disease's nuances, such as its
transmission, clinical manifestations, and potential
complications, thereby deepening their understanding of
infectious diseases and be able to give accurate
information to their clients.

Through these, nurses and student-nurses are able to

define what leptospirosis do in an individual and
practice identifying its key signs and symptoms,
interpreting laboratory results such as elevated BUN and
creatinine levels, and recognize when a client may
require further intervention.

This study may enhance the students in the field of

nursing, particularly in areas of education to even
broaden their understanding of the disease and provide
preventions to decrease the risk of other individuals
from acquiring it.

Nursing Research
41
 The case of mild leptospirosis holds significant
implications for nursing research, offering numerous
avenues for exploration that can enhance patient care and
prevention for others, especially in communities with
high prevalence of leptospirosis cases.

Furthermore, this study may assist in the development

and validation of effective assessment tools for
leptospirosis. Hence, improve therapeutic regimens that
would support the special needs of each client. Thus,
exploring management strategies for mild leptospirosis is
a vital research avenue. Studies could evaluate the
effectiveness of different antibiotic regimens and
supportive therapies, providing evidence-based guidelines
that enhance clinical practice.

Henceforth, nursing research can be able to have

significant contributions in examining control practices
to suppress the infection and transmission to other
organisms. Moreover, by focusing on epidemiology,
assessment tools, management strategies, patient
education, infection control, community health, and long-
term outcomes, nursing research can significantly improve
the understanding and management of leptospirosis.

These efforts not only enhance patient care but also

contribute to broader public health initiatives,
ultimately fostering healthier communities.

Nursing Practice
42
 This study regarding Leptospirosis encompasses various
aspects of nursing practice, including pathophysiology,
symptomatology, assessment, management, prevention, and
even health education. This primarily enhances the
practice of nursing by honing assessment skills to
effectively manage the client.

This enables the nurses to be proficient in conducting

thorough assessments, including taking detailed histories
and monitoring vital signs and laboratory results that
can be able to facilitate in the early diagnosis and
treatment of the disease and prevent further
complications from arising.

Additionally, the study may impose teamwork or

interdisciplinary collaborations that could even
contribute in improving the client’s over-all health
condition and provide outcomes which may be used as a
guide in prevention of the disease, particularly in areas
of high prevalence of leptospirosis cases.

43
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