Case Scenario:: Is An Eye Finding Occurring Early in

CASE SCENARIO:
Diego, 54-year-old male came in due to body pains.
2 days PTA, patient had body malaise with associated bilateral lower extremity pain, abdominal pain, epigastric burning 5/10 radiating to chest, continuous,
undocumented fever, LBM of 10 episodes. No other associated symptoms noted.
Patient self-medicated with Ibuprofen, Loperamide, Paracetamol which provided no relief. No consult done
During interim, progression of symptoms, now with difficulty in ambulation and DOB.
This prompt consult and hence admission.
PMHx: PE:
• No comorbids noted. No COVID vaccine • Patient is awake, conscious, coherent, ambulatory, in
cardiorespiratory distress
FMHx: • BP: 120/60, 118 bpm, 48 cpm, 38.0, 90% o2 sat at room air
• (+) heart failure - maternal • (+) conjunctival suffusion, is an eye finding occurring early in
leptospirosis, which is caused by Leptospira interrogans.
• (+) CVD - paternal
pink palpebral conjunctivae, no nasoaural discharge,
• No other heredofamilial diseases noted
no cervicolymphadenopathies, no neck vein distention
• Symmetric chest expansion, (+) macular rashes at anterior chest,

PSHx:
no retractions, no lagging, clear breath sounds
• 15 pack year smoker
• Adynamic precordium, a condition where the precordium (the area of
• Alcoholic beverage drinker, 10SD once a week for 30 years the chest over the heart) moves too much (is hyper dynamic) due to
• History of illicit drug use, last intake >20 yrs ago some pathology of the heart.
• Currently works as construction worker normal rate and regular rhythm, no murmurs appreciated
• ROS: Unremarkable • Flat, normoactive bowel sounds, nontender abdomen
• Grossly normal extremities, no cyanosis, no edema, (+) tenderness on

palpation of calf and thigh, (+) purpuric rash at bilateral leg
Laboratory
1. CBC 3. Clinical Chemistry:
WBC: 11.47 Normal 5 to 10 K/uL BUN: 28.61 Normal 10 to 20 mg/dL
RBC: 4.44 Normal 4 to 5.5 M/uL Crea: 646.37 Normal 61.9 to 114.9 µmol/L
HGB: 121 MALE 138 to 172 grams per liter g/L BCR: 10.9 Normal 10% IS or below
HCT: 35.8 MALE 42 to 52 (hemoconcentrated) eGFR: 8 mL/min/1.73m2 100 to 130 mL/min/1.73m2
PLT: 16 Normal 140 to 400 K/uL CrCl: 13 mL/min 110 to 150mL/min
They are measured in thousands per cubic milliliter (K/uL) of blood Creatinine clearance (CrCl) is the volume of blood plasma cleared of
creatinine per unit time. It is a rapid and cost-effective method for the
Neutrophils: 92.3 measurement of renal function.
Lymphocytes: 5.3 AST: 55.94 (1.39x elev)
Monocytes: 2.2 ALT: 28.64
Eosinophils: 0.2 TB: 73.42
B1: 76.07
2. Coagulation Factors B2: 2.67
PT: 14.8 Normal 11 to 13.5 seconds LDH: 311.47
Higher than that means your blood is taking longer than normal to clot CRP: 23.87
and may be a sign of many conditions, including: Bleeding or clotting
disorder
% Act: 73.03 The activated clotting time (ACT) is a test that is used 4. ABG
primarily to monitor high doses of unfractionated (standard)
heparin therapy. Normal range for ACT is 70-120 sec Fully compensated
INR: 1.15 Metabolic acidosis
aPTT: 25.8 Normal 30-40 seconds With adequate oxygenation
L ow activated partial thromboplastin time (aPTT) in a blood test

mean? A low activated partial thromboplastin time (aPTT) show that 5. CXR: Bilateral mid to lower lung pneumonia: Cardiomegaly, Tortous aorta
blood is clotting faster than normal and that increases the risk to
develop a blood clot.
Diagnosis: Anti HCV The HCV antibody test, sometimes called the anti-HCV test, looks
for antibodies to the hepatitis C virus in blood
✓ Septic Encephalopathy secondary to Leptospirosis
Sepsis-associated encephalopathy (SAE) is a diffuse brain

dysfunction that occurs secondary to infection in the body without ✓ Patient is anuric upon insertion of Foley Catheter. refers to the lack of
overt CNS infection. SAE is frequently encountered in critically ill urine production
patients in intensive care units, and in up to 70% of patients with
severe systemic infection. Not responsive to hydration.
✓ Severe Acute Kidney Injury secondary to sepsis ✓ Plan for emergency IJ catheter insertion and hemodialysis
✓ COVID suspect
o Prescription:
Plans: o Duration: 2 1/2 hrs
o UF: 500 net

✓ Admit to PUI ICU
o BFR: 150
✓ IVF: PNSS 1L to run at 100 cc per hour
o DFR: 500
✓ Diet: NPO temporarily
o HCO3 bath
✓ For transfusion of 8 units platelet concentrate
o Low flux
✓ Diagnostics:
o NSS flushing
o LeptoMAT
o D5050 1 vial on 2nd hour of hemodialysis
The microscopic agglutination test (MAT) is the gold standard for
sero-diagnosis of leptospirosis because of its unsurpassed diagnostic
specificity. It uses panels of live leptospires, ideally recent isolates,
Medications:
representing the circulating serovars from the area where the patient
became infected. 1. Penicillin G 1.5 million units TIV q6
o HBSAg, Hepatitis B surface antigen (HBsAg) is a blood test ordered to 2. Methylprednisolone 1gm in 250cc D5W to run for 4 hours OD for 3 days
determine if someone is infected with the hepatitis B virus
3. Paracetamol 300mg TIV q4 RTC
4. Ranitidine 50mg TIV OD

ACTUAL NCP
ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION
Subjective: Fluid volume Short Term INDEPENDENT Short Term

▪ Body malaise with deficit related to After 8 hours of 1. Monitor vital signs 1. To have a baseline and for After 8 hours of
associated bilateral lower inflammation of nursing detection on the progress of nursing
extremity pain nephrons intervention, the the client’s condition intervention, the
▪ LBM of 10 episodes secondary to client will be able: client
leptospirosis as 2. Maintain a record of I&O 2. To evaluate effectiveness of was able to have
Objective: evidenced by ▪ To have normal accurately and weigh daily resuscitation measures normal pulse rate,
▪ Heart rate: 118 bpm lack of urine pulse rate, temperature and be
▪ Temperature: 38°C production, not temperature and be hydrated
▪ Patient is anuric responsive to hydrated 3. Control humidity and 3. To reduce high fever and
▪ Not responsive to hydration, and ambient air temperature elevated metabolic rate Long Term
hydration low eGFR ▪ Adequate urine Within the hospital
output 4. Change position frequently 4. To reduce pressure on fragile stay, the client was
Clinical Chem: skin and tissues able to maintain
 BUN: 28.61 Long Term fluid volume at a
 Crea: 646.37 Within the hospital 5. Keep fluids within the 5. To improve hydration functional level as
 eGFR: 8 stay, the client will client’s reach and encourage evidenced by
mL/min/1.73m2 be able to maintain frequent intake individually
 CrCl: 13 mL/min fluid volume and adequate urinary
demonstrate 6. Provide lip and eye care 6. To prevent from dryness output
lifestyle changes to
avoid progression of
dehydration DEPENDENT GOAL WAS MET
Assist in administering IV Fluids are necessary to
fluid administration maintain hydration status
COLLABORATIVE
Collaborate with nephrologist To help with the hemodialysis
and patient care technician treatment and evaluating
(PCTs) kidneys to manage condition
REFERENCES:
https://list-nanda-nursing-diagnosis.blogspot.com/2014/09/fluid-volume-deficit-nursing-care-plan.html
https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/leptospirosis/
https://nurseslabs.com/deficient-fluid-volume/
Nursing Diagnosis Handbook an Evidence-Based Guide to Planning 15th Edition pg. 351-355

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CASE SCENARIO:

Diego, 54-year-old male came in due to body pains.

undocumented fever, LBM of 10 episodes. No other associated symptoms noted.

This prompt consult and hence admission.

• No comorbids noted. No COVID vaccine • Patient is awake, conscious, coherent, ambulatory, in

• Symmetric chest expansion, (+) macular rashes at anterior chest,

• ROS: Unremarkable • Flat, normoactive bowel sounds, nontender abdomen

• Grossly normal extremities, no cyanosis, no edema, (+) tenderness on

1. CBC 3. Clinical Chemistry:

WBC: 11.47 Normal 5 to 10 K/uL BUN: 28.61 Normal 10 to 20 mg/dL

HCT: 35.8 MALE 42 to 52 (hemoconcentrated) eGFR: 8 mL/min/1.73m2 100 to 130 mL/min/1.73m2

PLT: 16 Normal 140 to 400 K/uL CrCl: 13 mL/min 110 to 150mL/min

INR: 1.15 Metabolic acidosis

aPTT: 25.8 Normal 30-40 seconds With adequate oxygenation

L ow activated partial thromboplastin time (aPTT) in a blood test

Sepsis-associated encephalopathy (SAE) is a diffuse brain

Plans: o Duration: 2 1/2 hrs

o UF: 500 net

4. Ranitidine 50mg TIV OD

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Fluid volume Short Term INDEPENDENT Short Term

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