I.

OBJECTIVES
GENERAL OBJECTIVE:
 To learn and understand the case of a patient diagnosed with Leptospirosis

SPECIFIC OBJECTIVES:
 Describe and explain Leptospirosis
 To review the history of past and present illness as well as its physical assessment
 To review the anatomy and physiology of the organs involved
 To trace the pathophysiology of Leptospirosis
 Interpret the laboratory results and diagnostic procedures done with the patient and
specific nursing responsibilities before during and after the procedure
 Enumerate the different medications administered for the condition, their indications
and specific nursing responsibilities
 Formulate significant nursing diagnosis with their significantly related nursing care
plans.

II. INTRODUCTION
Leptospirosis is a disease that is caused by spirochete bacteria in the genus Leptospira. There
are 10 pathogenic species, and more than 250 pathogenic serovars. While leptospirosis occurs
worldwide, it is more common in tropical or sub-tropical climates. Outbreaks tend to occur
after heavy rainfall or flooding in endemic areas, especially areas with poor housing and
sanitation conditions. Leptospirosis are spread by the urine of infected animals (rodents, dogs,
livestock, pigs, horses, wildlife). The bacteria can survive for weeks to months in urine-
contaminated water and soil.

People can be infected through » Direct contact with the urine or reproductive fluids from
infected animals » Contact with urine-contaminated water (floodwater, rivers, streams,
sewage) and wet soil » Ingestion of food or water contaminated by urine or urine-contaminated
water. Transmission occurs through mucous membranes, conjunctiva, and skin cuts or
abrasions. Human-to-human transmission is very rare but has been documented through sexual
intercourse and breastfeeding. Transmission has also rarely occurred through animal bites.
Other high risk activities can include direct contact with animals and activities that can lead to
skin abrasions and water or soil exposure, such as clearing brush, trekking, and gardening or
wadding into floods.
Data from the Public Health Division of Epidemiology Surveillance Bureau of the Department of
Health recorded a total of 337 cases of the disease across the country from January to March
25, 2017, including fatalities.

This compares to 201 cases reported during the same time in 2016.

Leptospirosis cases rise by 60% in NCR. In a press briefing held at San Lazaro Hospital in Manila,
Health secretary Francisco Duque III said that a total of 234 leptospirosis cases were recorded
compared to years 146 cases, covering January to June 29.

Out of the 234 cases, 38 led to deaths. As of July 2, 2018 there were 22 cases recorded in San
Lazaro Hospital.

Early treatment may decrease the severity and duration of disease. In patients with a high
clinical suspicion of leptospirosis, initiating antibiotic treatment as soon as possible without
waiting for laboratory results is recommended.
III. ANATOMY AND PHYSIOLOGY
What are kidneys?

The kidneys are two bean-shaped organs in the renal system.

They help the body pass waste as urine. They also help filter
blood before sending it back to the heart.

The kidneys perform many crucial functions, including:

 maintaining overall fluid balance
 regulating and filtering minerals from blood
 filtering waste materials from food, medications, and
toxic substances
 creating hormones that help produce red blood cells,
promote bone health, and regulate blood pressure

Liver is a roughly triangular organ that extends across the entire

abdominal cavity just inferior to the diaphragm. Most of the
liver’s mass is located on the right side of the body where it
descends inferiorly toward the right kidney. The liver is made of
very soft, pinkish-brown tissues encapsulated by a connective
tissue capsule. This capsule is further covered and reinforced by
the peritoneum of the abdominal cavity, which protects the liver
and holds it in place within the abdomen.

The liver is the largest organ in the body, normally weighing about 1.5kg (although this can
increase to over 10kg in chronic cirrhosis). The liver is the main organ of metabolism and energy
production; its other main functions include:

 Bile production
 Storage of iron, vitamins and trace elements
 detoxification
 conversion of waste products for excretion by the kidneys

The liver is functionally divided into two lobes, right and left. The external division is marked on
the front of the liver by the falciform ligament, which joins the coronary ligament at the
superior margin of the liver.
What Is the Function of Liver in Human Body?

 The liver is an essential organ that has many functions in the body, including making
proteins and blood clotting factors, manufacturing triglycerides and cholesterol,
glycogen synthesis, and bile production.
 The liver is a large organ that sits on the right hand side of the belly.
 The liver is the body's largest internal organ.
 Many different disease processes can occur in the liver, including infections such
as hepatitis, cirrhosis (scarring), cancers, and damage by medications or toxins.
 Symptoms of liver disease can include
o jaundice,
o abdominal pain and swelling,
o confusion,
o bleeding,
o fatigue, and
o weight loss.
 Alcohol can be toxic to the liver (hepatotoxic), especially in high doses, and long-
term alcohol abuse is a common cause of liver disease.
 The liver is involved in metabolizing many toxins, including drugs and medications,
chemicals, and natural substances.
IV. PATIENTS PROFILE
LAST NAME, FIRST, MIDDLE SERVICE ATTENDING
B.I.Q ADULT DEP PHYSICIAN
MALE DR. XX
AGE/SEX DATE OF BIRTH STATUS NATIONALITY RELIGION
31/MALE DECEMBER 30, SINGLE FILIPINO IGLESIA NI CRISTO
1986
HOME ADDRESS OFFICE ADDRESS
TONDO MANILA
FATHER’S NAME
D.Q

MOTHER’S NAME
B.Q
CHIEF COMPLAINT:
FEVER AND BODY PAIN

ADMITTING DIAGNOSIS ADMISSION

LEPTOSPIROSIS DATE:AUGUST 1, 2018
TIME: 1:20 PM

HISTORY OF PRESENT ILLNESS

4 Days prior to admission the patient had fever and chills accompanied by headache and
abdominal pain and knee pain on both knees and self-medicated with biogesic 2x a day. 3 days
PTC still with the above symptoms the patient has generalized weakness, eye pain, and calf
tenderness hence seek for consult.

PAST MEDICAL/PERSONAL AND SOCIAL HISTORY

(+) Hospitalization (2009 ulcer)
(-) Asthma, TB, DM, HPN
(+) alcohol intake occasionally
(+) 3 sticks a day
V. PHYSICAL ASSESSMENT

PARAMETERS ACTUAL FINDINGS INTERPRETATION

SKIN (+) Yellowish ABNORMAL
(-) Cyanosis
(+) wound left foot
HEAD (+) normocephalic NORMAL
HAIR (+) Evenly distributed NORMAL
(+) yellowish ABNORMAL
EYES (-) Discharges
(-) Vision Impairment
(+) Patent NORMAL
NOSE (-) discharges
EARS (-) Discharge NORMAL
(-) Hearing impairment
(-) Ulcers ABNORMAL
MOUTH (+) Pale lips
(+) has some decay on some teeth
NECK (-) Mass NORMAL
CHEST (+) normal chest expansion NORMAL
(+) Soft ABNORMAL
ABDOMEN (-) Tenderness
(-) Mass
(+) Pain
EXTREMITIES (-) gross deformities ABNORMAL
(+) calf tenderness

IV. GORDON’S FUNCTIONAL HEALTH PATTERN

PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION

Patient doesn’t have regular He showed interest in having

HEALTH check-ups and when he is
PERCEPTION having high fever he rest for a
while and self-medicate.
Patient ate 3 times a day and
NUTRITIONAL usually ate vegetable.
knowledge of his illness.
Willing to accept and listen to any
health teaching.
Patients’ doctor ordered him normal
diet.
METABOLIC
Patient consumed 1 litre of
water per day.
Bowel habits: Patient usually Patient noticed that his bladder habit
ELIMINATION defecates every day. is lesser than the normal.

Bladder habits: He voids 4-5

times a day.
ACTIVITY- Patient exercises when there is The patient is in bed rest.
EXERCISE a time because he works.

COGNITIVE Patient does not have any There is no change in his five senses
PERCEPTUAL hearing and vision problems. He and was able to response coherently.
can communicate with others
and make decisions on his own.
He is able to see, feel, hear and
smell.
SLEEP REST Patient mostly sleeps 3 hrs a The patient stated that he is having a
day He usually sleeps at 3 a.m. 7-8 hours of sleep every day.
and woke up at 6 a.m.

SELF Patient described himself as a He never thinks negative thoughts

PERCEPTION/SELF totally fit and he is comfortable that will make him sad while
CONCEPT of what he looks like. recovering with his sickness.

ROLE Patient was very close to his Patient is showing good relationship
RELATIONSHIP family. to his friends and family.

COPING STRESS The patient stated that The patient doesn’t experience stress
TOLERANCE whenever he experience stress in the hospital because he has an
he is out with friends. adequate rest.

VALUE-BELIEF Patient religion is Iglesia ni There are no change with his

Cristo always goes to church religious belief he believes that God
every Thursday and sunday help him recover faster.
with his family.
VII. COURSE IN THE WARD
August 1,2018
At 1:10AM , patient was transferred to adult ward with chief complained of fever.
Secured consent for admission and management. With IVF of PNSS 1Lx500cc regulated at
125cc/hr. Diet as tolerated. Laboratory as follows, CBC with APC,U/A, Leptocheck ,BUN crea,
serum electrolyte(Na,K,Cl). Medication as follows; Penicillin G 1.2 mu every 6 hours,
Paracetamol 500mg/tab every 4 hours. Referred accordingly, Vital signs every 4 hours.
At 3AM , fast drip the remaining IVF. IVF#2 PNSS1L fast drip for one hour. IVF#3 PNSS1L
250cc/hr, Patient was put on salt diet. Medication as follows Penicillin G every 6hours,
Hyanocortisone 250mg TIV. Paracetamol 500mg every 4 hours and Omeprazole 40mg TIV OD.
VS every 4hours

August 2,2018 (DUTY)

 Received patient awake and conscious, with IVF of PNSS regulated to 120cc/hr.
Follow up laboratory results ; leptocheck,(Ig G, IgM, NS1), CBC. Input and Output monitoring
every hour without retention. Medication as follows; Furosemide 40mg IV now then reassess if
urine output is less than 30cc/hr, physician ordered that if there is still no urine output start
D5W 250cc + 80mg Furosemide x 12 hours with BP precaution. VS every 4 hours.

August 3, 2018 (DUTY)

Received the patient awake and conscious, still with continuous IVF. Vital signs
monitored every 4 hours. Did health teaching about nutrition and proper handwashing also
with proper waste management.

VIII. LABORATORY RESULTS

HEMATOLOGY
TEST NAME 08-01-18 08-02-18 INTERPRETATION
HEMOGLOBIN (120-140) ↓ 119.0 ↓ 118.0 Generalized body weakness, fatigue,
pallor, dizziness.

HEMATOCRIT (0.38-0.48) ↓ 0.33 ↓ 0.32 Decreased production of RBCs.

RBC (4.5-5.9) ↓ 3.68 ↓ 3.61 Body malaise, headache, pallor,
dizziness.
WBC (5.0-10.0) ↑ 12.28 ↑ 14.21 Risk for infection
NEUTROPHILS (0.45-0.65) ↑ 96.4 ↑ 95.5 Risk for infection
LYMPHOCYTES (0.25-0.65) ↑ 2.4 ↑ 3.1 Risk for infection
EOSINOPHILS (0.02-0.04) ↓ 0.1 ↓ 0.0 BELOW NORMAL
MONOCYTES (0.02-0.06) 0.3 0.6 NORMAL
 RDW (11.6-14.6) 12 12 NORMAL
PLATELETS (150-160) ↓ 52 ↓ 56 BELOW NORMAL
BASOPHILS (0.00-1.0) 0.2 0.2 NORMAL
MCV (80-100) 89.4 87.3 NORMAL

MCH (27-31) ↑ 32.3 ↑ 32.7 Not having enough folic acid

MCHC (32.0-36.0) ↑ 36.2 ↑ 37.5 RBCs are smaller than usual and have
decreases level of hemoglobin

COAGULATION
COMPONENTS RESULT INTERPRETATION
(08-01-18)
PT 11.70 NORMAL
(9.9-12.9)
%ACTIVITY 105.90
INR 0.97
TT 20.7 BELOW NORMAL
(28-38)

CHEMISTRY TEST
August 1. 2018 SI UNIT CONVENTIONAL UNIT
RESULT NORMAL RESULT NORMAL
RANGE RANGE
Blood Urea Nitrogen ↑ 21.40 mmol/L 3.2-7.1 59.96 mg/dL 9-20
Creatinine ↑ 542.00 umol/L 71-133 6.13 mg/dL 0.8-1.5
Total Bilirubin ↑ 192.00 umol/L 3-22 11.23 mg/dL 0.2-1.3
Direct Bilirubin ↑ 123.00 umol/L 0-5 7.19 mg/dL 0.0-0.3
Indirect Bilirubin ↑ 22.00 umol/L 0-19 1.29 mg/dL 0.0-1.1
Sodium ↓ 125.00 mmol/L 137-145 125.00mEq/L 137-145
Potassium 3.80 mmol/L 3.5-5.1 3.80 mmol/L 3.5-5.1
SGOT/AST 42.00 U/L 17-59 42.00 U/L 17-59
SGPT/ALT ↑ 123.00 U/L 21-72 123.00 U/L 21-72
ARTERIAL BLOOD GAS (08-01-18)

TEST NAME RESULT REFERENCE RANGE

pH 7.465 7.35-7.45
pCO2 ↑ 25.0 35-45

pO2 87 80-105
SO2 97 95-98

HCO3 ↓ 17.6 22-26

(08-02-18)

EXAMINATION DONE METHOD RESULT

Leptospira IgG/IgM ICT/LOT NO. 16ADC001E IgG: POSITIVE

IgM: POSITIVE

IX. PATHOLOGY AND PHYSIOLOGY

Risk factors
 Dirty environment
 Seasons
 Males
 Wadding to flood
• Skin and eyes are • Calf tenderness • Fever • Fatigue
yellowish • Urinary retention
• Abdominal pain

X. DRUG STUDY
DRUG NAME ACTION RATIONAL SIDE EFFECTS CONTRAINDICATIO NURSING
E N RESPONSIBILITIE
S
Use to It - Fever Contraindicated in - Monitored VS
Omeprazole treat decreases - Stomach patients with
certain the pain known - Monitored for
Brand name: stomach amount of - Nausea and hypersensitivity to abdominal pain
Prilosec and acid your vomiting any component of
esophagu stomach - Mild the formulation. - Evaluated fluid
TIV OD s makes. diarrhea I&O
problems - Headache
CLASSIFICATIO such as
N: acid NO MANIFESTED
Proton pump reflux, SIDE EFFECTS TO
inhibitor ulcers. THE PATIENT.
 DRUG NAME ACTION RATIONALE SIDE EFFECTS CONTRAINDICATIO NURSING
N RESPONSIBILITIES
A loop Treats fluis - Chest pain Contraindicated in -Assessed patient
Furosemide diuretic retention - Chills patients with anuria tinittus or pain
that also treat - Fever and in patients with
Brand name: prevents high blood - Headache a history of - Monitored Vital
lasix body from pressure. - Sore throat hypersensitivity to signs
absorbing - Unusual furosemide.
40mg. IV too much tiredness or -Monitored I&O
salt. This weakness
CLASSIFICATION allows the
: salt to NO MANIFESTED
Diuretics instead be SIDE EFFECTS TO
passed in THE PATIENT.
your urine.

DRUG NAME ACTION RATIONALE SIDE EFFECTS CONTRAINDICATIO NURSING

N RESPONSIBILITIE
S
Suppresses It prevents - Anxiety Contraindicated in - Monitored BP.
Hydrocortisone inflammator the release - Dizziness systemic fungal
y and of - Headache infections and - monitored pt.
Brand name: immune substances - Dry mouth patients with response to the
cortef responses. in the body - Irritability known drug.
It is also that causes - hypersensitivity to
250mg. TIV 96 x used to inflammatio NO MANIFESTED products
3 days treat n. SIDE EFFECTS TO constituents.
conditions THE PATIENT.
 CLASSIFICATIO such as
N: allergic
corticosteroid conditions
and skin
conditions.

DRUG NAME ACTION RATIONALE SIDE EFFECTS CONTRAINDICATION NURSING

RESPONSIBILITIES
Reduces the Used to - Fever and Contraindicated in - Watched
Penicillin G developmen prevent/treat chills patients with known out for
t og drug infections - Headache allergy to corn or side effects
1.5 resistant that are - Tachycardi corn products.
bacteria and proven and a - Monitored
CLASSIFICATION: maintain the strongly - Hyperventil Vital signs
Antibiotic effectiveness suspected ation
of other caused by - Diarrhea
antibacterial bacteria.
drugs. NO MANIFESTED
SIDE EFFECTS TO
THE PATIENT.

DRUG NAME ACTION RATIONALE SIDE EFFECTS CONTRAINDICATION NURSING

RESPONSIBILITIES
 Used to To reduce - Bloody or Contraindicated in - Monitored
Paracetamol treat many fever black, tarry patients vital signs
conditions stools hypersensitive to
Brand name: such as - Bloody or drug. - Adviced the
Biogesic headache, cloudy patient to
muscle urine Use cautiously in increase
500mg q4hrs ache, - Diarrhea patients with long
arthritis, term alcohol use
CLASSIFICATIO backache, NO MANIFESTED because therapeutic
N: toothaches, SIDE EFFECTS TO doses cause
Analgesic colds and THE PATIENT. hepatotoxicity.
fever.

DRUG NAME ACTION RATIONALE SIDE EFFECTS CONTRAINDICATION NURSING

RESPONSIBILITIES
It works by For the - Bloody Contraindicated in - Watched
Mefenamic reducing relief of urine patients with chronic out for side
Acid hormones acute pain - Heart burn inflammation or active effects.
that cause - Indigestion ulceration of either - Assessed
Brand name: inflammati - Nausea the upper or lower the patient
Ponstan on and pain - Stomach gastrointestinal tract before and
in the body. bloating and patients with pre- after giving
500mg PRN existing renal disease. the drug
NO MANIFESTED - Assessed
CLASSIFICATIO SIDE EFFECTS TO the drugs
N: THE PATIENT. effectivenes
NSAID s to the
patient.

XI. NURSING CARE PLAN

 Assessment Nursing Planning Background Intervention Rationale Evaluation
Diagnosis knowledge

august
Subjective: Hyperthermi After 1hr of Hyperthermia is • Assessed • to obtain After 1hr of
"patuloy a related to nursing elevated body and baseline data nursing
ang lagnat ongoing intervention temperature due monitored interventions
ng kapatid disease the patient's to failed temperature the patient
ko" as process temperature thermoregulation and cardiac • to promote temperature
verbalized will that occurs when rate body relief has
by the decrease. a body produces and decreased
relative or absorbs more • Promoted comfortability from 38.6 to
heat than it heat loss by 37.0
Objective: dissipates. decreasing • to decrease
external temperature Goal was
T: 38.6 coverings by means met.
P: 89 through
R: 23 • Performed evaporation
BP: 110/70 tepid sponge and
bath conduction

• • to facilitate
Administere fast recovery
d anti-
pyretics
drugs as
prescribed
by the
physician.

Assessment Nursing Background Planning Intervention Rationale Evaluation

Diagnosis knowledge
August 2,
2018 • Acute • Leptospirosis • After 1 hour • Established • To gain trust • After 1 hours
pain related is a bacterial of nursing rapport. and of nursing
Subjective: to bacterial disease that interventions, cooperation. interventions,
“Napakasakit infections in affects humans the patient • Assessed the the patient
ng ulo at the body. and animals. It will report of pain, • To provide was able to
buong is caused by demonstrate including base line demonstrate
katawan ko” bacteria of the use of location and information. use of
as verbalized genus relaxation intensity. relaxation
by the patient. Leptospira. In skills, other • Help reduce skills, other
humans it methods to • Applied local muscle methods to
Objective: causes a wide promote massage gently tension. promote
• Facial range of comfort and to affected comfort and to
•Grimacing symptoms, and relieve pain. areas. • Enhances relieve pain.
• Irritability some infected patient sense
• Guarding persons may • Explored of control like
behaviour. have no alternative pain deep
symptoms at relieve measures breathing
V/S taken as all. Symptoms such as: exercise to
follows: of leptospirosis Relaxation and relieve pain.
include high deep breathing
T: 38.6 fever, severe exercise. • Prevents
P: 89 headache, joint stiffness
R: 23 chills, muscle • Encouraged and possible
BP: 110/70 aches, and range of motion contracture
vomiting and exercises. formation.
may include
jaundice • Maintained • Dehydration
(yellow skin and adequate fluid increases
eyes), red eyes, intake. sickling and
abdominal pain, corresponding
diarrhea, or a • Administered pain.
rash. medication as
prescribed by • Analgesics
the physician. reduces pain
(Mefenamic) and promote
rest and
comfort.
Assessment Nursing Background Planning Intervention Rationale Evaluation
Diagnosis knowledge

August 2,
2018 Activity A state in After 10 •Established • To gain trust
After 10
intolerance which a minutes of Rapport and minutes of
Objective: related to person has nursing cooperation ofnursing
•Weak in generalize insufficient interventions • Provided the patient. interventions
appearance d physical or the patient safety the patient
weakness. psychological will be able measures, • To enhance was able to:
•cannot energy to to: assisted to self-concept -identify
perform perform -identify learn safety and sense of techniques
activity of desired techniques measures. independence. to enhance
daily living activities. to enhance activity
alone activity • Instructed • To relieve tolerance
tolerance to do deep pain and to -participate
•with -participate breathing promote willingly in
limited willingly in exercises relaxation necessary
range of necessary or desired
motion or desired •assessed •adequate activities.
activities. nutritional energy
• V/S taken status reserves are
as follows: required for
activity.
T: 38.6 •Encourage
P: 89 d range of • Prevents
R: 23 motion joint stiffness
BP: 110/70 exercises. and possible
contracture
formation
XII. RECOMMENDATION
Medication
 Omeprazole TIV once a day
 Furosemide 40mg once a day
 Hydrocortisone 250mg TIV three times a day
 Paracetamol 500mg q4hrs
 Mefenamic acid 500mg PRN

Environment
 Clean and safe environment.
 Avoid wading, swimming, bathing, swallowing, or submersing head in potentially
contaminated freshwater (rivers, streams) especially after periods of heavy rainfall
or flooding.
 Avoid contact with floodwater, avoid stagnant water and do not eat food
contaminated with floodwater.
 If exposure cannot be avoided, wear appropriate personal protective equipment
(PPE) (rubber boots, waterproof coveralls/ clothing, gloves).

Treatments
 Instructed the client to do follow up check ups.

Health Teachings
 Cover open wounds with waterproof dressings.
 Treat unsafe or potentially contaminated drinking water by boiling or chemically
treating. Keep rodent populations (rats and mice) or other animal pests under
control.
 Do not eat food that may have been exposed to rodents and possibly contaminated
with their urine.

Diet
 Increase fluid intake up to 3000 ml/day
 Eat whole foods like fruits and vegetables
 Food to be avoided: milk, dairies, tea and coffee, ice creams and sweets, Eggs,
peanuts and likes,

Spiritual
 Encourage Prayer depending on belief.