College of Nursing
Fairview, Quezon City
A Case Study on
Leptospirosis
In Partial Fulfilment
Of the Requirement in
Out Patient Department
Related Learning Experience
Table of Contents
Case Summary………………………………………………………...............…..……...4 I. Introduction……………………………………………………..........……......5 II. Patient’s Profile……………………………………….............….……………7 III. Pathophysiology………………………………………...........………………..8
IV. Nursing Care Plan…………………………..................................……….10 * Nursing Physical Assessment.................................................10 * Related Treatments................................................................10 * Nursing Care Goal.................................................................10 * Nursing Diagnosis.................................................................11 * Nursing Intervention.............................................................12 IV. Drug Study……………………………………………………..........……….14
VI. Evaluation.....................................................................................13
VII. Recommendation...........................................................................13
Case Summary
Leptospirosis is caused by infection of the bacteira genus Leptospira, and affects humans as well as other mammals, birds, amphibians, and reptiles. A patient is suspected to acquire leptospirosis when experiencing symptoms for about 1-2 weeks after exposure to the urine of the carrier animals. In this case, Ms. Angeline Dara Damaderio has experienced it. She is 11 years old, a resident of Blk. 4 Lot. 7 Phase 4Tayuman, Manila. She experienced fever for 2 days with headaches and muscle pain. She also has a body temperature of 39 degrees centigrade and a pulse rate of 115 bpm. Last August 8, 2011 Monday, she went to the Out Patient Department of OSSAM with her father for a check-up. We met her there and we took some information about her.