INTRODUCTION

RATIONALE:
Primary Nursing is a system of nursing care delivery which emphasizes continuity of care and responsibility acceptance by having one registered nurse (RN), often teamed with a licensed practical nurse (LPN) and/or nursing assistant (NA), who together provide complete care for a group of patients throughout their stay in a hospital unit or department. The "primary nurse" is responsible for coordinating all aspects of care for the same group of patients throughout their stay in a given area. June is typically the start of rainy season. It is also the season wherein different

diseases are acquired. One of the common disease during rainy season and can be acquired through flood is leptospirosis. According to the Department of Health (DOH), leptospirosis is caused by a bacterium called Leptospira interrogans. People are infected by this disease through contaminated animal urine that is usually transmitted through flood waters. It can enter the body through lesions in the skin, eyes or mucous membranes. It is estimated that 100-200 Leptospirosis cases are identified annually in the United States. About 50% of cases occur in Hawaii.(from Center for Disease and Control for Prevention).In the Philippines the Latest statistics from the Regional Epidemiology Surveillance Unit (RESU) showed a total of 456 cases and 45 deaths from January 1 to October 15, 2011, which is 221% higher (DOH,2011). In the Davao Region has the most number of leptospirosis cases in Mindanao in the first six months this year, according to the Department of Health (DOH).The disease surveillance report of the DOH from January to June 25, 2012 disclosed that Davao Region recorded 56 cases, a 107.4-percent increase from last years 27 cases.(Mindanao Times,2012). We chose our client _____ who had various clinical signs and symptoms of ___ and

diagnosed with leptospirosis which is the subject for our case analysis because we wanted to gain further insight regarding the disease process of leptospirosis to help us in becoming more effective student nurses. The complexity of his treatment had drawn our curious minds to look deeper into his case. Aside from that, the family of our patient was more than willing to participate in the study and contribute in any way possible so that they could have a better understanding of the said disease. The nursing case analysis of Leptospirosis is significant to nursing research because it will guide researchers who are interested in studying. Furthermore, our gathered data can serve as a baseline data to help the researchers determine new management for this condition 2

and how to intervene using new technology. And, nurses can be newly updated about new findings about the disease process. Through this case analysis, by nursing education we fully hope to understand all the underlying causes and risk factors present in our patient, and all of his physical responses to the entire medical and nursing management rendered during the time of his hospital stay under our care. This includes all the emotional, psychological, physical, and financial impacts his hospitalization and illness had brought on his parents and family. Lastly, for the nursing practice, with the knowledge we gained in this case analysis about leptospirosis us student nurse will be thoughtful and offer them a holistic care.

General Objective Within our 2 weeks rotation in the San Lorenzo Ward of San Pedro Hospital, we, the student nurses of BSN-4A Group 3 will be able to formulate a comprehensive case analysis of a patient with Leptospirosis which will help us in developing more skills and knowledge in nursing. This will provide us further understanding of the nature, process, cause, diagnostic procedures, and management of the disease. Specific Objectives: Within our 2 weeks rotation in the San Lorenzo Ward of San Pedro Hospital, we, the student nurses of BSN-4A Group 3 aims to: a) select a patient that will be our subject for case analysis b) initiate a good therapeutic relationship with our client and her family; c) present an introduction which covers the rationale on selecting such patient, statistics of the case and nursing implications; d) formulate the general and specific objectives that would serve as our guide throughout the study using the principle of SMART- specific, measurable, attainable, realistic, and time-bounded; e) obtain the initial data base and health history which includes her family that will serve as our baseline data; f) h. perform a thorough head to toe assessment;

g) j. gather the results of the actual laboratory and diagnostic examinations that our client underwent; h) l. enumerate and discuss the different drugs administered to our client, its generic name, brand name, classifications, action, indications, drug interactions, the contraindications, ordered doses, adverse reactions, and the nursing responsibilities necessary; i) j) m. relate one of the theories of nursing to our case study n. formulate nursing care plans based on the data gathered;

k) o. present the prognosis of the clients condition; and l) p. enumerate all references used following the APA format.

INITIAL DATABASE

PHYSICAL ASSESSMENT

Physical Assessment General Survey The assessment was performed last June 28, 2013. Upon assessment, our client was in a well disposition. He was lying on bed awake, conscious and coherent and not in respiratory distress. He was oriented to person, place, and time and talks coherently. With an IVF of cc per hour infusing well at left metacarpal vein at cc level. He was dressed with a clean hospital gown. He has an ectomorphic body structure. His skin was flushed and was covered with rashes. He was relaxed and with coordinated movements. No body odor noted and he was very cooperative.

Vital signs

Normal Values Temperature Respiratory Rate 36.5-37.7 C 16-20 varies Cardiac Rate 70-80 varies Pulse Rate 70-80 varies Blood Pressure 110/70-130/90 mmHg bpm and bpm and cpm and

Actual Findings

Skin Upon inspection, the skin was flushed and was covered with rashes. His skin was warm to touch and the whole body including his extremities was inflamed. The skin is soft and dry and no pallor noted. The skin is uniform in color. Upon palpation, there was no edema noted.

Nails Upon inspection nails are well-trimmed, clean and pinkish nail beds. Fingertips are calloused. Epidermis surrounding the nails is intact. He has capillary refill time of 2 seconds.

Skull, Scalp, Hair Hair is evenly distributed over scalp. His hair is black in color, straight, and dry. Head is generally round, with prominences in the frontal and occipital area. No tenderness or masses noted upon palpation. Scalp is lighter in color than the complexion. Free from lice, nits and dandruff. Facial structures are symmetrical. No involuntary muscle movements and able to move facial muscles at will. Able to puff cheeks, smile, elevate eyebrows, frown.

Eyes, Eyelashes, Eyebrows Eyebrows are symmetrical and in line with each other. It is black in color and is evenly distributed. Eyelashes are evenly distributed and are curled outward. Eyes are evenly placed and in line with each other. It is none protruding and has an equal palpebral fissure. Lacrimal gland is non palpable and no tenderness noted upon palpation. Both bulbar and palpebral conjunctivas are pinkish in color. No ulcers noted upon inspection. Sclera is white in color and no yellowish discoloration. Some capillaries are visible. The cornea is clear and transparent. It looks smooth with no irregularities in the surface. Corneal reflex is present. The iris is dark brown in color. Pupil is equally round, reactive to light and accommodation. It is 3mm in size. It constricts briskly when light is directed to the eye, both directly and consensual. Pupils dilate when looking at distant objects and constricts when looking at nearer objects.

Ears The earlobes are bean shaped, parallel, and symmetrical. The pinna is parallel with the outer canthus of the eye. Its skin is in the same color as the complexion. No lesions noted upon inspection. The auricles have firm cartilage upon palpation. The pinna recoils when folded. There is no pain or tenderness upon palpating the auricles. The ear
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canal has some cerumen upon inspection. No discharges or lesions noted at the ear canal.

Nose Nose is in the midline. No discharges and nasal flaring noted. Both nares are patent. No bone and cartilage deviations noted upon palpation. No tenderness noted. Nasal septum in the midline and is not perforated. Nasal mucosa is pink in color. No tenderness noted upon palpating frontal and maxillary sinuses.

Mouth and Oropharynx His lips are symmetrical pink in color and dry. Mucosa and palate are also pink, free of bleeding, discharges, swelling, retractions and lesions. He has a set of 30 teeth. The gums are pink. The tongue is located at the center, pink in color freely movable and with saliva present. Tonsils are dark pink and swelling is not noted. The hard palate is light pink; uvula is positioned in midline of soft palate. Uvula moves upward and backwards when asked to say ah. Gag reflex is present.

Neck Upon inspection, neck and trachea is at midline. Thyroid and lymph nodes are not palpable. Jugular veins are not distended. Voice is clear and well-modulated. Muscle strength is normal; the patient is able to perform range of motion exercises in the neck.

Chest and Lungs Chest is symmetrical. Chest wall is intact. Spinal alignment is normal with no bulges, tenderness, and lesions noted. Patient is not in respiratory distress. Skin is intact and uniform in temperature. Respiratory excursion measures 3 centimeters and tactile fremitus is symmetrical upon palpation. Adventitious breath sounds such as wheezes and crackles are not heard upon auscultation.

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Heart There was no abnormal, pulsation, lifts or heaves visible on the aortic, pulmonic, and tricuspid area. Upon auscultation in all four anatomic sites, S1 and S2 sounds can be heard at all sites. He has a regular cardiac rate and rhythm. Upon auscultation, presence of distinct heart soundsAortic, pulmonic, tricuspid and apical, noted.

Breast The skin on breast is uniform in color, smooth, and intact and has no signs of redness or edema. Breast is in equal in size and symmetry. Nipple and areola is dark brown in color. No lumps or masses are palpable. No tenderness upon palpation.

Abdomen Skin is uniform in color, no lesions noted. Contour is flat. No masses noted upon palpation with smooth and consistent tension. No muscle guarding. The umbilicus is concave in shape and is located in the midline of the abdomen. It has normal bowel sounds: LUQ: 20, LLQ: 19, RUQ: 21, RLQ: 19.

Musculoskeletal system Bones are symmetrical in length. No deformities, tenderness or swelling were noted upon inspection and palpation during assessment. Patient was able to move freely the extremities fully and within the normal range of motion. Muscle strength is also within the full strange of motion when applied with resistance.

Genitourinary system Patient reported that pubic hair is normal and evenly distributed. There were no swelling, masses and other abnormalities noted.

Upper and Lower Extremities Both extremities are equal in size. Have the same contour with prominences of joints. No involuntary movements. No edema noted. Skin color is uniform. Skin of both extremities is warm to touch. Both extremities can perform range of motion exercises.
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No crepitus noted on joints. And can counter act gravity and against resistance on ROM.

Cranial Nerves Cranial Nerve I - Olfactory Response - Client is able to identify different smell of the perfume, coffee, and mango with each nostril separately and with eyes closed. II Optic - Client was able to read newspaper that was given to him, with no difficulty seeing the words. III - Occulomotor - His eyes were able to follow the direction of the pen. Pupils are equally round reactive to light and accommodation. Pupils constrict when looking at near object, dilate when looking at a distant object. Pupils converge when the penlight is moved towards the nose.

IV - Trochlear

- Both eyes are able to follow the penlight as it moves.

V - Trigeminal

- Client was able to elicit corneal reflex. Client perceives light touch and superficial pain bilaterally. Client was able to determine sharp and blunt objects using the tip of the pen and the blunt end of the
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pen respectively. VI - Abducens - Both eyes move in coordination following the six cardinal fields of gaze. VII - Facial - Client was able to perform various facial expressions such as puffing of cheeks, frowning, elevating the eyebrows, and smiling. VIII - Vestibulocochlear - Able to hear spoken words on both ears. He was able to hear the ticking sound of the wrist watch. IX - Glossopharyngeal - Gag reflex is present and patient is able to swallow. Speech is clear. X - Vagus - Clients voice is clear and wellmodulated. No hoarseness of voice noted XI - Accessory - Able to shrug trapezius muscles against resistance. He is able to turn head side to side against force. Muscle strength is uniform.

XII - Hypoglossal

- Client can protrude tongue. He can move his tongue side to side, up and down.

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Leptospirosis

Physical Examination Findings Temperature 40 C and above Tachycardia Hypotension Transient petechial eruptions Warm and flushed skin Conjunctival suffusion Muscle stiffness and rigidity Uveitis Present Present

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DIAGNOSTIC EXAMS

15

Laboratories and Diagnostic Exams (ACTUAL) I. Complete Blood Count

Complete Blood Count provides a fairly complete evaluation of all formed elements in blood. It can supply a great deal of the information necessary to diagnose a hematologic disorder, help to identify disease states not directly related to hematopoietic system, and help to evaluate the stages and prognosis of certain diseases. It helps to detect the abnormality of the component of the blood that shows underlying diseases in the patient condition before performing a surgery or operation.

Blood Component

Rationale

Results

Interpretati on

Nursing Responsibilitie s

6/22 6/25

6/27 PRETEST:

Hemoglobin

It

the 147 (N) determination of the number of red and

is

157 (N)

158 (N)

Inrcrease: dehydration. Polcythemia ,

1.

Identify

the patient, and check the requisition form with the patients

Male: 140 180 g/L Female: 120 160 g/L

white cells per cubic millimeter blood. of Decreased: renal failure, anemia, Lymphosarc oma,and malnutrition and as a side effect of chemothera

identification bracelet 2. Explain

the purpose for the laboratory and diagnostic test to the patient and significant others 3. Inform
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py

patient that the test requires blood sample taken with the use of the syringe 4. Obtain

health history of the patients complaints, including a list of known allergies 5. list of medications the patient is taking including herbs and nutritional supplements 6. Note any Obtains a

recent procedure that could interfere with test results such as pretest fasting to follow the correct period of time 7. Inform the

significant others that the specimen

17

collection takes approximately 510 minutes 8. Check

vital signs of the patient 9. Inform the

patient who will perform the venipuncture and when and note that transient discomfort may be felt from the needle puncture and pressure of the tourniquet 10. The

patient maybe seated or in the supine position. The patients arm is in extension, with easy access to the antecubital fossa

DURING THE TEST:

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1.

Ensure

that the blood is not taken from the hand or arm that has intravenous line. Hemodilution with intravenous fluids causes a false decrease in the values of some test 2. Inspect

the antecubital fossae of both arms to select the best vein for the venipuncture 3. Ask the

patient to open and close hand a few times to help make the veins more visible 4. Cleanse

the skin with 70% alcohol, and allow it to air-dry 5. Provide

support to the
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family during the test

POSTTEST: 1. Instruct

the patient to continue compression of the puncture site for 2 to 5 minutes or until bleeding stops 2. Assess the patients arm to ensure that subdermal bleeding has ceased. Apply an adhesive bandage as needed 3. If a

hematoma develops at the site, apply warm compress 4. If a

hematoma is large, monitor pulses distal to the site

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5.

Monitor

patients intake and output and vital signs after the tests 6. Evaluate

test results in relation to patients symptoms and other test performed 7. Determine

if the test was correctly performed according to appropriate procedure 8. Check

other signs of on infection and inflammation such as redness, swelling, heat, and pain in the infected site 9. Tell

patient to report any unusualities or changes

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observed after the procedure. Erythrocytes Male: 4.5 5.0 Female: 4.0 5.0 The RBC of
4.74 (N) 5.25 (high) 5 (N)

Increase: polycythemi a, dehydration, living at high altitude

erythrocyte count detects

the number of RBC in micro liter of whole blood. Erythrocytes mediate exchange oxygen the of and

Decrease: lack of needed supplement s or hormones for erythrocyte production and bone marrow suppression

carbon dioxide between lungs and tissue, the transportation of oxygen, and excretion of

carbon dioxide.

Mean Corpuscular Hemoglobin (MCH) 27.0-33.0

This helps to determine if (N) the patient is having anemia.

31 29.9 (N) 31.7 (N)

Increase: macrocytic anemia Decrease: microcytic anemia

Mean Corpuscular Volume (MCV)

This

helps
93.9 if (N) 88 (N) 92.4 (N)

Increase: macrocytic anemia Decrease:

22

determine

the patient is having anemia.

80-96

microcytic anemia

Mean Corpuscular Volume

This

helps
34.1 (N) 34.3 (N)

Increase: macrocytic anemia Decrease: hypochronic anemia

determine

if 33 the patient is (N)

Concentration having anemia. (MCHC) 32-36 Leukocytes 5.0 10.0 10^9/L Measurement of total number 7.8 of circulating (N) leukocytes an is
3.9 (low) 5.4 (N)

Increase: infection such as urinary tract infection Decrease: Bone marrow depression may result from viral infection of

important in

procedure the

diagnosis

and prognosis of the disease process, because specific patterns leukocytes response can of

from toxic reaction

be expected in different types of Since leukocytes are affected by so many diseases, it

23

diseases.

serves

as

useful guide to the severity of the disease

process. Neutrophils 0.55 0.65 % Neutrophils

78 (high determines the )

Increase:
o.21 (low) .45 (N)

count

Risk for bacterial infection, stress response Decrease: Infection

presence infection.

of

Neutrophils are body's first line of against infection. They are the ones which initiate defense

phagocytosis. Lymphocytes 0.25 0.40 % Important humoral cell and .10 mediated (low)
.66 (high) .43 (high)

Increase: Infectious mononucleo sis Decrease: acute viral infection

immunity, lymphocytes are produced

in the lymph nodes, spleen, thymus, tonsils, lymphoid tissue of the gut. Together and

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with neutrophils, they make up the majority of white cells in the peripheral blood.

Monocyctes 0.02 0.06 %

Monocytes are the body's

.10 (high) .10 (high)

Increase: chronic infections Decrease: aplastic anemia

.10 second line of (high defense. This )

would help in the determination if there is

chronic infection especially the if value

increases.

Eosinophils
0.01 0.05 %

Eosinophils are phagocytic and they destroy .2 antigen - (high ) antibody complexes, attack parasites before they can harm the body and are .02 (N) .01 (N)

Increase: allergies, hypersensiti vity reaction,

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elevated during allergic reactions. This

is important to determine there is if really

allergic reaction from a drug to the patient.

Basophils 0.0 0.005 %

Basophils contain amounts histamine. Their most large of 0

(N) .01 (high) .1 (high)

Increase: Chronic allergies Decreased: Allergies, shock

important role is in immediate hypersensitivit y This important determine reactions. is to if

there is really allergic reaction from a drug patient. Hematocrit Male: 0.40 0.48 Female: 0.37 The hematocrit measures how much space in the blood
0.44 is (N) .46 (N) .44 (N)

to

the

Decrease: anemia, vitamins and minerals

occupied

by

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 0.45

red blood cells. It is useful

deficiencies

when evaluating patient anemia. a for

Thrombocyte s 150 300 10^9/L

Platelets (thormbocytes) are tiny 190 fragments of (N) cells made in the marrow bone that
79 (low) 25 (low)

Increase: acute infections Decrease: thrombocyto penia autoimmune disorder , Folic acid they deficiency, Viral infection

circulate in the blood. Because

are very sticky, they first components to be when activated there are the

has been an injury blood to the

vessels

and begin in formation of a blood clot.

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II.

Urinalysis

Components

Rationale

Results

Interpretati on

Nursing Responsibilitie s

6/22 COLOR: It indicates the of Yellow

6/25 Color Yellow Collect random

Straw colored degree urine yellow

change can specimen of at result diet, and from least 15 ml. drugs many Instruct patient

or concentration. It determines presence of also

diseases such over hydration, diuretic therapy, diabetes mellitus, diabetes insipidus, etc.

to obtain a first as voided morning, midstream catch specimen possible. if

disease state.

Inform patient that he may resume his usual diet and medications, as ordered.

APPEARANC E: Clear

Determine any presence blood of and Clear Clear

Turbid urine may contain red or white cells, bacteria, fat, or chyle and may renal reflect

epithelial cells

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infection. If Cloudy.

Smoky, hazy: Pyuria, bacteriuria, and phosphate in urine

REACTION (7.35-7.45)

Determine the presence disease as also indication kidney dysfunction. of such 5.0 6.5

Normal urine tends to be lower or acidic of

nephrosis, an of

because diet. Alkaline

urine might be indicative of infection.

SPECIFIC GRAVITY 1.005-1.030

Determine the presence disease as also indication kidney dysfunction. of such 1.010 1.010

It the

indicates

concentratio n of the The the

nephrosis, an of

urine. higher

number, the concentrate d the urine is.

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To ALBUMIN (-)

determine of (-) (-)

Increased: Dehydration , proteinuria, altered secretion of antidiuretic hormone Decreased: overhydratio n Proteinuria suggests renal failure or or disease possibly

presence

protein in the urine

multiple myeloma.

Glucose (-)

To

determine (-) (-)

Glycosuria usually indicates diabetes milletus

the sugar level

Pyuria WBC 0- 17 / UL To determine white from vagina, cells the 8 (N) 5 (N) occurs if the presence of leukocytes is abnormal
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especially the

in

or increased which may

presence

of vaginal and cervical infections

appear with infection either upper lower urinary tract or acute glomerulone phritis. with in the or

RBC 0- 11 / UL

To RBC urine

determine in the 6 (N) 5 (N)

Hematuria indicates glomerular damage, tumors which erode the tract kidney trauma, urinary tract stones, renal infarcts, acute tubular necrosis, upper and
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urinary ,

lower urinary tract infections, nephrotoxin s.

Epithelial Cells 0- 17/UL

To

determine 1 (N) 2 (N)

Their presence indicates inflammatio n of the kidney, because such casts will not form except in the kidney.

epithelial cells in the urine

Bacteria 0- 278/ UL

To determine the presence of bacteria in the urine 1 (N) 2 (N)

More than 278/ UL of one organism reflects significant bacteriuria. Multiple organisms reflect contaminati on

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III.

Stool Exam

Components

Rationale

Results

Interpretati on

Nursing Responsibilitie s

6/26 Color: Brown Brown

6/27

Brown

Consistency: Soft

Soft

Soft

Ova/Parasite

None

(+)

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DRUG STUDY

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RELATED NURSING THEORY

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Nursing Theory

Betty Neumans Systems Model Neuman views the person as an open system consisting of a basic core as a source of energy which represents concentric circles. Each concentric circle is made up of 5 variables mainly: 1. Physiological- refers to the bodily structure and function 2. Psychological- refers to the mental processes, functioning and emotions 3. Sociocultural- refers to relationships; and cultural functions and activities 4. Spiritual- refers to influence of spiritual beliefs and norms 5. Developmental- refers to lifes developmental process Neuman also developed the basic structure of energy resources also commonly known as central core, which is made up of basic survival factors common to all organisms. These are normal temperature range, genetic structure, response pattern, organism strength or weakness, ego structure, and known or commonalities. She views a person as an open system which means that it is dynamic and constantly evolving. Homeostasis, occurs when the amount of energy balances with the amount of energy being used by the system. A homeostatic body system is a dynamic process of input, output, feedback and compensation, which leads to a state of balance. Flexible Lines of Defense

Is the outer boundary to the normal line of defense, the line of resistance, and the core structure. Keeps the system free from stressors and is dependent on the amount of sleep, nutritional status, as well as the quality and quantity of stress an individual experiences. If the flexible line of defense fails to provide adequate protection to the normal line of defense, the lines of resistance become activated.

Normal Line of Defense

Represents clients usual wellness level. Can change over time in response to coping or responding to the environment, which includes intelligence, attitudes, problem solving and coping abilities.
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Example is skin which is constantly smooth and fair will eventually form callous over times.

Lines of Resistance

the last boundary that protects the basic structure Protect the basic structure and become activated when environmental stressors invade the normal line of defense. An example would is that when a certain bacteria enters our system, there is an increase in leukocyte count to combat infection. If the lines of resistance are effective, the system can reconstitute and if the lines of resistance are not effective, the resulting energy loss can result in death. Stressors are capable of producing either positive or negative effect on client system. It is an environmental force that can affect the stability of the system. It may be intrapersonal, interpersonal or extra personal. Stressors may vary and depend on the persons line of defence. When the line of defence fails, its up to the line of resistance to manage. As a part of reaction the persons system can adapt to a stressor, an effect known as reconstitution. It is the increase in energy that occurs in relation to the degree of reaction to the stressor which starts after initiation of treatment for invasion of stressors. Neuman also develop the three preventions:

1. Primary prevention focuses on protecting the normal line of defense and strengthening the flexible line of defense. This occur before the system reacts to a stressor and strengthens the person (primarily the flexible line of defense) to enable him to better deal with stressors and also manipulates the environment to reduce or weaken stressors. Includes health promotion and maintenance of wellness. 2. Secondary prevention focuses on strengthening internal lines of resistance, reducing the reaction of the stressor and increasing resistance factors in order to prevent damage to the central core. This occurs after the system reacts to a stressor. This includes appropriate treatment of symptoms to attain optimal client system stability and energy conservation. 3. Tertiary prevention focuses on readaptation and stability, and protects reconstitution or return to wellness after treatment. This occurs after the system has been treated through secondary prevention strategies. Tertiary prevention offers support to the client and attempts to add energy to the system or reduce energy needed in order to facilitate reconstitution.

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Synthesis: Our patient is yet to be diagnosed with leptospirosis but nonetheless he is exhibiting signs and symptoms of it. He has intermittent fever, petechial rash and has reddish conjunctiva. In relation to this theory, leptospirosis could only be acquired into direct contact with contaminated water into a wound or a break in the skin which means a break in the first line of defence. Now as a defence mechanism the body would exhibit fever, increase in WBC and the likes which is a typical doing of our lines of resistance to combat the bacteria that penetrated to our system. If this happens immediate hospitalization is needed and secondary prevention should take place. In our case it will be a course of antibiotics to treat the infection first-hand and palliative care. If the leptospirosis have been removed out of the system our next priority would be readaptation and rehabilitation in order for our client to recover from the illness so that it would be easy for him to return to homoestatic stability. This theory is best for our client since it views person as an open system meaning it focuses on the well-being of the person therefore we need to regain homeostasis before attending to other factors.

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NURSING CARE PLAN

40

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PROGNOSIS

42

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