Nursing Care Plan

 

Nursing Care Plan Date: October 11, 2009 Name:: D.D. Name 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 CUES Subjective: “Mainit ang pakiramdam ko ngayon”, as verbalized by the client.

PROBLEM Hype Hyperrth ther ermi mia a

SCIENTIFIC REASON Lept Leptos ospi piro rosi sis s iis sa biphasic disease that begins with flu-like symptoms (fever, chills, myalgias, intense headache).

NURSING INTERVENTION

RATIONALE



Monitor vital signs especially temperature.

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 To evaluate the effects or degrees of  hyperthermia.

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Provide tepid sponge bath.

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 To lower down body temperature by cooling the

Objective:    

body of thesurface patient.

Febrile, 38oC  Temp.: Skin warm to touch Dry skin Poor skin turgor





Source: Handbook of  Common Communicable and Infectious Diseases (Navales, D.)

Remove excess clothing or change clothes to comfortable ones.

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 To promote surface cooling of the body

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Maintain

 To reduce metabolic

bedrest.

demands.

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Once permitted, encourage to increase intake of fluid at least 2L/day.

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Administer prescribed meds, Paracetamol.

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 To replace fluid loss and to support circulating volume and tissue perfusion.

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 To reduce or to return to normal body temperature.

EVALUATION Goal met. Patient’s temperature return to normal range from 38 to 37 oCelsius.

 

Nursing Care Plan Date: October 10, 2009 Name: D.D. Name: 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

CUES Subjective: “Tatlong beses na akong nagsusuka at limang beses ng nagtatae” as verbalized by the client.

PROBLEM Fluid volume deficit

SCIENTIFIC REASON Symptoms of  leptospirosis include vomiting and diarrhea which often causes dehydration.

NURSING INTERVENTION

 

Poor skin turgor Dry skin Specific Gravity: 1.022

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 To assess causative/ precipitating factors.

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Monitor vital signs especially BP and note physical signs e.g. dry skin, poor skin turgor.

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 To evaluate degree of fluid loss.

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 To be accurate in replacement needs.

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 To return the body’s fluid and electrolytes level to normal.

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To correct/ replace fluid loss.

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Communicable and Infectious

Goal partially met. After rendering nursing interventions, patient urinated 20cc/hr but still with poor skin turgor and dry skin.

Note possible conditions that may lead to deficits e.g. diarrhea, vomiting.



Source: Handbook of  Common

EVALUATION



Objective: 

RATIONALE

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Monitor urine output and measure amount. Administer fluid and electrolytes as indicated.

Once permitted, increase fluid intake at least 2L/day.



Because this beverages

 

Nursing Care Plan Diseases (Navales, D.)

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beverages. 

tend to be diuretics that will help more for fluid loss.

Limit intake of  alcoholic or caffeinated

Provide frequent oral and eye care.

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 To prevent injury from dryness

Date: October 11, 2009 Name:: D.D. Name Age: 32 years old Medical Diagnosis: Leptospirosis Nursing Diagnosis: Impaired urinary elimination r/t disease process.  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.

CUES

NURSING PROBLEM

SCIENTIFIC REASON

NURSING INTERVENTION

RATIONALE

EVALUATION

 

Nursing Care Plan Subjective: ”Kaunti lang iniihi ko,” asclient. verbalized by the

Objective: 

UO: 15cc/hr

Impaired urinary elimination

For baseline data of  Goal partially met. the patient. Patient produced

After the organism gains access to the kidney, it migrates to



Monitor vital signs.

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interstitium, tubules, and renal tubular lumen and cause interstitial nephritis, tubular necrosis and damage and altered capillary permeability.

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Determine client’s usual daily fluid intake.

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 To help determine level of hydration.

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 To help determine level of hydration

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 To determine effectiveness of  management or progression of 

 Note condition of skin

mucous membrane and colour of urine. 

Monitor urine output.

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Administered IVF 1L D5NNM x 12hrs.



Source: Nurse’s Pocket Guide Edition 11 (Doenges et al)

disease. 

For fluid replacement.

Assist with physical examination. 

 To assess causative contributing factors.

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 To increase urine output

Due medication given Furosemide 40mg TIV. 

urine outputof  in the amount 20cc/hr.

 

Nursing Care Plan Date: October 11, 2009 Name:: D.D. Name 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 hospitalization the patient will be free from anxiety.

 

Nursing Care Plan

 

CUES

NURSING PROBLEM

NURSING INTERVENTION

“Kinakabahan ako sa lagay ko ngayon,”

Due Due to to a acq cqui uisi siti tion on of  Independent:  Establish a disease, the therapeutic patient became relationship, uneasy and began

verbalized the patient.

to dread for the unknown.

Subjective:

Mild Mild an anxi xiet ety y

SCIENTIFIC REASON

conveying empathy and unconditional positive regard.

Nursing RATIONALE Care EVAPlan LUATION   To

elicit the trust and comfort of the

Goal met. The patient appears relaxed and

patient

reported anxiety is reduced.

Patient and SO can be affected by the anxiety/uneasin ess displayed by health team members. Honest



Objective:

 Maintain

confident manner (without false reassurance).

restless poor eye contact  

explanations can alleviate anxiety.  Answer

all questions factually. Provide consistent information.

Source: Nurse’s Pocket  Guide Edition 11 (Doenges et al)

   Encourage

patient and SO to communicate with one another, sharing questions and concerns.

 Provide

rest periods/uninterrup ted sleep time, quiet surroundings.

Accurate information about the situation reduces fear and assists patient and SO to deal realistically with situation. 

Sharing information elicits support and comfort and can relieve tension of  unexpressed worries. 

Conserves energy and enhances 

coping abilities.  

Nursing Care Plan

Date: October 10, 2009 Name:: D.D. Name 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. levels. Short Term Goal: After rendering nursing interventions, patient will verbalize understanding of body changes.  Long Term Goal: At the end of hospitalization hospitalization the patient will verbalize acceptance of self in the present situation.

 

Nursing Care Plan CUES Subjective: “Sabi nila naninilaw ako” as verbalized by the patient.

Objective: 

icteric sclera

yellow skin color (jaundice)   Total Bilirubin: 513.0 mmol/L 

NURSING PROBLEM

SCIENTIFIC REASON

Disturbed body image

 The severe form of  leptospirosis results to hepatic impairment which causes elevated bilirubin levels. Bilirubin gives a yellow color to the skin and sclera which is known as

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Observe emotional changes.

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Encourage verbalization about concerns of disease process, future expectations.

 jaundice.

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INTERVENTIONS

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Source: Handbook of  Common Communicable and Infectious Diseases (Navales, D.)

Discuss situation. Explain relationship between nature of  disease and symptoms. Assist patient/SO to cope with change in appearance; suggest clothing that does not emphasize altered appearance, e.g., use of red, blue, or black clothing.

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Assist with grooming needs as necessary.

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Involve patient in planning care and scheduling activities

RATIONALE   This

may indicate acceptance or nonacceptance of  situation.

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Provides opportunity to identify fears and misconceptions and deal with them directly.

  To

help the patient understand the cause of his change in appearance.

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Patient may present unattractive appearance as a result of jaundice. Providing support can enhance self-esteem and promote patient sense of control.

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Maintaining appearance enhances self-image.

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Enhances feelings of  competency /selfworth, encourages independence and participation in

EVALUATION After rendering nursing interventions, patient verbalized understanding of  body changes.