Leprosy: A Case Presentation

CASE PRESENTATION: LEPROSY

I. INTRODUCTION

A.BACKGROUND OF THE STUDY

Leprosy has been a public health problem in the Philippines for several decades. The disease is unequally distributed throughout the country. In 1987, in the provinces of Ilocos Norte and Ilocos Sur, Abra, Sulu, Palawan, Cebu and La Union, Pangasinan and Metro Manila, the prevalence rate ranged from 0.40 to 3.01 per thousand populations. In other provinces, the prevalence rate is lower than 0.40/1000 population. The National Prevalence Rate as of 1998 was 0.65/1000. (Community Health Nursing Services in the Philippines, 9th edition, page 215)

The nationwide implementation of Multi-Drug Therapy (MDT) since 1988 has resulted in the decrease in the prevalence rate of leprosy. The prevalence rate of the disease declined from 7.2/10,000 population in 1986 to 1.2/10,000 population in 1997. Since then, the treatment of leprosy has shifted from institutional care to that of home treatment

Leprosy (Hansen’s disease; Hansenosis; Lepra; Leontiasis) is a chronic disease with an insidious onset, transmitted from man to man, affecting the skin, mucous membranes and nervous tissue, and eventually producing deformities. This chronic, mildly, infectious disease is caused by rod-shaped bacilli, Mycobacterium Leprae or leprosy bacilli or Hansen’s bacillus.

B.RATIONALE FOR CHOOSING THE CASE

Most of our patient assignments are Non-Hansen patient, meaning they are not affected with the Mycobacterium Leprae. Since our focus is Patient Care Management and we are in a Leprosarium, we choose the case of Hansen patient or patient affected with the Mycobacterium Leprae because it would help us to have a focus study regarding this case—more nursing care would be given. Added to that, we choose the client because of the fact that she is cooperative in the sense that she always try to answer the questions asked in her full knowledge and try to verbalize anything that she wants to say.

C.LEARNING OBJECTIVES

(1) To explore patient’s past health history prior to Leprosy(2) To review the body system involve in Leprosy (anatomy

and physiology)(3) To review the disordered function of the body related to

Leprosy (pathophysiology)(4) To review the laboratory results and compare it to normal

and the implication of the abnormal(5) To make a list of nursing problems(6) To prioritize listed nursing problems(7) To make Nursing Care Plan for prioritized problem(8) To make a health teaching to the client and other potential

candidates regarding about Leprosy

II.CLINICAL SUMMARY

A.GENERAL DATA

Name: V.C.Age: 25 years oldBirth date: January 24, 1979Birth place: CebuSex: FemaleNationality: FilipinoReligion: Roman CatholicCivil Status: SingleAddress: Caloocan CityWard/Accommodation/Service: Female Ward/Charity/MedicinePatient Category: Non regular HansenDate Admitted: November 13, 2006Time Admitted: 3:00pm

B. HISTORY OF PRESENT ILLNESS

The client stated that she is having difficulty walking to different areas of the hospital because she experiences shortness of breath. She verbalized, “Dito sa kama ko hanggang diyan sa kubeta hinihingal na ako”, “Simula nung napasok na ako dito ganyan na yung nararamdaman ko”.

The client was admitted at Dr. Jose N. Rodriguez Memorial Hospital, Tala, Caloocan City last November 13, 2006 at around 3 o’ clock in the afternoon

C. PAST MEDICAL HISTORY

--When asked about the client’s perception on how does that disease got into her. The client states that “Sa kuya ko, kasi mas nauna syang nagkaroon ng ganito….” “Sa aming magkakapatid kami yung close talaga, inaalagaan ko rin kasi yun” “That time, may sugat ako”

1. Childhood Illnesses--The client verbalized, “Nagka-asthma ako nung grade 1

hanggang gade 5”

2. Immunizations--According to the client, “Wala akong bakuna”

3. Allergies--The client stated that she doesn’t have any allergies

4. Accidents--According to the client, "Nahulog ako sa hagdanan nung

mga 2 years old ako”

5. Hospitalization-- The client verbalized, “Na-ospital ako nang 1-2 years, dahil

dun sa aksidente”

6. Medicines --Her medicine are part of MDT (Multi Drug Therapy)—

Rifampicin, Dapsone and Clofazimine

7. Foreign Travel--According to the client she doesn’t have travels outside the

country.

8. Operation--According to the client, she doesn’t gone any operations

D. FAMILIAL HISTORY

-- According to the client, diabetes and hypertension are common in her family specifically from her father’s side and kidney disease from her mother’s side.

GENOGRAM

Father

Hx of DM & HPN

Sister(14 years old)

Brother(16 years old)



Brother(24 years old)with Leprosy

Patient(25 years old)

Mother

Hx of Kidney Disease

E. PHYSICAL ASSESSMENT

BODY PARTS

NORMS ACTUAL FINDINGS

INTERPRETATION AND ANALYSIS

Skin Varies from light to deep brown; from ruddy pink; from yellow overtones to olive(pg. 538, Fundamentals of Nursing by Kozier, 7th edition)

Skin lesions all over the body.Loss of sensation on the skin lesions.

Not normal.The cardinal signs of leprosy are the ff:--Loss of sensation on the skin lesions.--Enlargement of peripheral nerves.--Presence of leprosy bacilli in the skin smear.Loss of sensation can cause further damage to skin.

F. PATTERNS OF FUNCTIONING

a. Psychological Health

1. Coping Pattern According to the client, the people significant to her are her

parents, siblings and relatives. When in times that the client feel stressed the client just tends to be quiet.

ANALYSIS: Coping maybe described as dealing with problems and situations, or contending with them successfully. Coping strategies varies among individuals and are often related to the individual’s perception of stressful events. A person’s coping strategies often change with a reappraisal of a situation. (Fundamentals of Nursing by B. Kozier, 7th edition, p 1020) INTERPRETATION: Effective Coping Pattern

2. Interaction PatternAccording to the client the people in her family are her father,

step-mother and siblings. She said that she usually express her feelings and thoughts to other indirectly but most of the times verbally. According to her she doesn’t find ways to blame others for something she did. Then after the client verbalized, “Sa aming magkakapatid mas kadikit ko yung sumunod sa’kin.”

ANALYSIS: Interaction patterns involve ways of expressing affection, love, sorrow, anger and other feelings and thought in most significant family in person and life. Openness of communication with all family members develops the family’s ability to function as a cooperative, growth producing unit. (Fundamentals of Nursing by B. Kozier, 7th edition, p 671) Illness limits an individual psychosocial world. As a result of sickness, the ability to interact w/ others becomes limited of effects on personl stamina, social activity and mobility. (Charlotte Eliopoulos, Assesment of Older Adult 2nd edition p. 131)INTERPRETATION: Effective/ Normal Interaction Pattern

3. Cognitive PatternThe highest formal education of the client was High school

graduate.

ANALYSIS: Changes in the cognitive function of middle adults are rare except with trauma or illness. The middle aged adults are able to continue learning new skills and can reflect on the past and current experience and can imagine, anticipate, plan and hope. (Fundamentals of Nursing by Potter and Perry, 3rd edition, Vol.1 p 821) Formal thinking is not entirely related to chronological age, and its expression varies among individual. (Craven, RF. FUN 4th edition p. 278)INTERPRETATION: Proper cognitive pattern

4. Self ConceptAccording to the client, after the signs and symptoms are

visible, she became depress. “Pumunta ako sa albularyo tapos ang ginawa lang sa akin ay pinausukan ako tapos napansin

parang dumami ung mga sugat” She also added that in 3 months regimen, “Tanggap ko na rin naman at nagproprogress naman ang kalagayan ko eh.”

ANALYSIS: Self concept is an individual’s perception of self. It includes self esteem (an individual’s perception of self worth) and body image (perception of physical self). Self concept influences individual’s health behaviors in that people think highly themselves will tend to take care of themselves. On the other hand, a person with a negative self concept will engage in reckless or self destructive behaviors that endanger health. Persons with a low self concept frequently ignore their own needs because they are perceived to be less important than the needs of other people. (Nursing Fundamentals by R. Daniels p 854) Interest in appearance it begins to wane and intensifies when the external physical changes, it accompany advancing age become noticeable. Middle age adults realize he/she is growing older. Reasonable concern for one’s health and appearance is compatible w/ sound mental health. The person accepts physical attributes that cannot be altered and then attends other matters. (Mattie Collins. Communication in Health Care p. 16-17)INTERPRETATION: Healthy Self Concept

5. Emotional PatternThe client is a quiet type person. When in times that the

client feel stressed the client just tends to be quiet.

ANALYSIS: Cooperative or friendly, expressive feelings appropriate to the situation, verbalizes positive things regarding others and the future. Express positive coping mechanism. (Nurses Handbook of Health Assessment, Janet Weber, pg. 513) Emotional states such as depression and anger affect a client’s perception and degree of risk taking behavior. These emotional states alter a client’s thinking pattern and reaction time (Nursing Fundamentals by R. Daniels p 874). The developmental crisis according to Erickson is Generativity vs. Self StagnationINTERPRETATION: Effective Emotional Pattern

6. Family Coping PatternsThe client verbalized, “Sinabi ko sa kanila ung kalagayan ko

ngayon.” She also added that she was supported by her family thru texting.

ANALYSIS: Family coping mechanisms are the behaviors families use to deal with stress or changes imposed from either within or without. (Fundamentals of Nursing by B. Kozier, 7th edition, p 193) Because chronic illness lasts longer than acute illness, it can influence the family to a greater extent. People with chronically ill children, parents, or other family members may express negative feelings about themselves such as guilt, inadequacy, failure, rejection and helplessness. The family may be in denial initially as members struggle with the shock of the illness. (Fundamentals of Nursing by Craven and Hirnle, 4th

edition, p 1282)INTERPRETATION: Effective Family Coping Pattern

b. Socio Cultural Health

1. Cultural patternAccording to the client, the social values she was brought up

to were respect, sense of responsibility, fear of God. The traditions in her family are Christmas, Birthday, New Year and Holy week.

ANALYSIS: The value placed on children and elders within a society is culturally derived. (Fundamentals of Nursing by Craven and Hirnle, 4th edition, p212) The family passes on patterns of daily living and lifestyles to offspring. Cultural rules, values, and beliefs give people a sense of being stable and able to predict others (Fundamentals of Nursing by Kozier, 7th edition p 178). A relief system that the member of the culture holds, consciously and unconsciously as absolute truth. This guides the everyday behavior and makes it routine. Cultural norms can influence a client’s belief about what constitutes illness and personal responsibility. (Craven and Hirule, FON p. 326 and 366) INTERPRETATION: Proper Cultural Pattern

2. Significant relationshipAccording to the client, her family and her girlfriend are the

significant persons in her life. They have harmonious relationship with her family and relatives

ANALYSIS: Family influences on health care because health is defined uniquely by each client’s culture. Family is often major care givers of their relatives. Lack of social support from family or significant others results in psychological and spiritual isolation, which negatively impacts a person’s physiological state. Thus, it is important to help clients identify, strengthen, and use their social support systems. Sometimes, families need guidance to optimize health behaviors. (Nursing Fundamentals by R. Daniels p849-851)INTERPRETATION: Effective Significant Relationship

3. Recreational PatternThe client verbalized, “Bago ako maospital puro barkada

talaga ako”. But because of her hospitalization, her recreational activities are listening to radio, watching TV and sometimes socialization with the patients in and out of the ward

ANALYSIS: Leisure time is important for normal social development and adjustment (Nursing assessment and Health Promotion by Murray and Zentner, 5th edition, p 386)INTERPRETATION: Proper Recreational Pattern

4. EconomicAccording to the client, she was not financially supported by

her family. The hospital accommodates all the needs of the patients regarding about her basic needs

ANALYSIS: Financial resources increase the ability to provide the necessary commodities for health and well being. (Nursing Fundamentals by R. Daniels p 855)INTERPRETATION: Adequate Economic Finances

c. Spiritual Pattern

1. Religious beliefs and practicesAccording to the client, praying is her religious practice since

she is at the hospital.

ANALYSIS: In middle age, people tend to be less dogmatic about religious beliefs and religion often offers more comfort to the middle aged person than it did previously. People in this age group often relies on spiritual beliefs to help them deal with illness, death and tragedy (Fundamentals of Nursing by Kozier, 7th edition p 400)INTERPRETATION: Proper practice of religious beliefs

2. Values and valuingAccording to the client God and family and her girlfriend are

the most important persons in her life.

ANALYSIS: Values can be described as the outcome of an individual‘s effort to apply universal moral laws to his everyday life. Values are more personal, and provide meaning and direction. (Fundamentals of Nursing practice by Narrow and Buschle, 2nd edition p 84)INTERPRETATION: Proper valuing

F. PATIENT’S CONCEPT OF HEALTH, ILLNESS AND HOSPITALIZATION

The ideal health status is one in which people are successful in achieving their full potential regardless of any limitations they might have. The person with a chronic illness or disability may still be able to achieve a desirable level of wellness. The key to wellness is to function at the highest potential within the limitations over which there is no control.

The client views her role as a sick person as a vulnerable person who seek help and proper care. She expects support and proper care management and calmness to those people who care for her. She said that her illness should be treated with the help of medicines and proper care management. She wants to know the things that are necessary for her and health promotion.

She also added that within 3 months of regimen, she already accepted what she is now. She verbalized that after discharge, “Hindi na ako maglalakwatsa, wala na ring ang inom-inom.”

ANALYSIS: The patients expect the nurse to be thoughtful, understanding and accepting of him. Patients are critical of behavior that is primitive or judgmental. He expects the nurse to orient him in the health agency. Nearby everyone is afraid of the unknown and to be left alone without orientation can be a frightening experience. He also expects the nurse to provide an explanation of his care. Health practitioners who ignore this aspect of care are often referred to as cruel and unkind (Fundamentals of Nursing, 7th edition, pp. 277-278)

G.LABORATORY AND DIAGNOSTIC EXAMINATION

DIAGNOSTI

C EXAM

NORMS ACTUAL RESULTS


Urinalysis Reference ValuesColor: light straw to dark amberAppearance: clearOdor: aromaticpH: 4.5-8.0Specific Gravity: 1.005-1.030Protein: 2-8 mg/dl; negative reagent strip test; traceGlucose: negativeKetones: negative(Handbook of Laboratory and Diagnostic Test

Actual FindingsColor: YellowAppearance: clearOdor: aromaticpH: acidicSpecific Gravity: 1.030Protein: negativeGlucose: negativeMicroscopic Examination:RBC: 0-1/hpfPus: 0-3/hpfEpithelial cells: positiveUrates: positive

Interpretation: The urine color, pH, specific gravity and microscopic examination (epithelial cells and urates) are not normal while the appearance, protein, glucose are normal.Analysis:

Color of the urine changes can results from diet, drugs and many diseases (pg. 395, Diagnostic Test). When water loose from the body exceeds water intake, the kidneys need to consume water making the urination more concentrated with waste products and subsequently dark in

DIAGNOSTI

C EXAM



with Nursing Inplication, 5th edition, pg. 343)

Microscopic Examination:RBC: 0-2/high power fieldWBC: 0-5/high power fieldEpithelial cells: 0-5/high power field(Handbook of Diagnostic Test, 3rd edition, pg. 329)

color. Yellow colored urine is possible of pyuria, and infection. (Medical Surgical Nursing by Bare and Smeltzer pg.1263). A normal pH is 7. A pH < 7 indicates acid urine and > 7 indicates alkaline urine. Acid urine ph is associated with renal tuberculosis, pyrexia, phenylketonuria, alkaptonuria and acidosis. (Diagnostic Tests, A Prescriber’s Guide to Selection and Interpretation by Lippincott Williams and Wilkins, p.395) Due to carbohydrate malabsorption, fat malabsorption and disaccharides deficiency. (A Manual of Laboratory and Diagnostic Tests, 7th edition by Lippincott William and Wilkins, p.279)Normally, freshly voided urine has a faint odor owing to the presence of volatile acids. It is not generally offensive. Fresh urine from most persons has

DIAGNOSTI

C EXAM



a characteristic aromatic odor (pg. 396, Diagnostic Test). Specific gravity is an indication of the relative proportions of dissolved solid components to the total volume of the specimen and reflects the relative degree of concentration or dilution of the specimen. (www.intensivecaring.com) In a healthy renal and urinary tract system, urine contains no protein or only trace amount (pg. 191, A Manual of Laboratory and Diagnostic Test). Sugar, usually absent from the urine, may appear under normal conditions (pg. 329, Handbook of Diagnostic Test, 3rd edition)

A high number of white blood cells in the urine is usually a symptom of urinary tract infection. A large number of cells from tissue lining (epithelial cells) can indicate damage to the small

http://www.intensivecaring.com/

http://www.intensivecaring.com/

DIAGNOSTI

C EXAM



tubes that carry material into and out of the kidneys. (www.healthatoz.com)

Hematology

Reference Values:WBC: 5 – 10 x 109 g/LNeutrophils: 0.40-0.60Lymphocytes: 0.20-0.40(Diagnostic Testing and Nursing Implications, 4th

edition)

Actual Findings:WBC: 12.6Neutrophils: 0.71

Interpretation: Not normalAnalysis:

Increased. Leukocytosis, an increase in circulating leukocytes in all types. When this does occur, it is usually, it is usually a result of hemoconcentration.(A Manual of Laboratory and Diagnostic Tests, 7th edition by Lippincott William and Wilkins, p.49)

Increase in Neutrophils: severe bacterial disease, diabetic acidosis, infarctions, increase in acute, severe inflammation, malignancies (Diagnostic Testing and Nursing Implications, 4th edition)

I. IMPRESSION/DIAGNOSIS

The admitting diagnosis is Hansen’s disease

J. ANATOMY AND PHYSIOLOGY

The skin is the body’s largest organ, covering the entire body. In addition to serving as a protective shield against heat, light, injury, and infection, the skin also:

a. regulates body temperatureb. stores water and fatsc. is a sensory organd. prevents water losse. prevents entry of bacteria

Throughout the body, the skin’s characteristics (thickness, color, texture) vary. For instance, the head contains more hair follicles than anywhere else, while the soles of the feet contain none. In addition, the soles of the feet and the palms of the hand are much thicker. The skin is made up of the following layers, with each layer performing specific functions:

a. epidermisb. dermisc. subcutaneous fat layer

Epidermis The epidermis is the thin outer layer of the skin and consists of three parts:

a. stratum corneum (horny layer)--this layer consists of fully mature keratinocytes which contain fibrous proteins (keratins). The outermost layer is continuously shed. The stratum corneum prevents the entry of most foreign substances as well as the loss of fluid from the body.b. keratinocytes (squamous cells)--this layer just beneath the stratum corneum, contains living keratinocytes, which mature and forms stratum corneumc. basal layer--the basal layer is the deepest layer of the epidermis, containing basal cells. Basal cells continually divide, forming new keratinocytes that replace the cells that are shed from the skin’s

surfacesThe epidermis also contain melanocytes, which are cells that produces melanin (skin pigment)

Dermis The dermis is the middle layer of the skin. The dermis contains the following

d. blood vesselse. lymph vesselsf. hair folliclesg. sweat glandsh. collagen bundlesi.fibroblastsj.nerves

The dermis is held together by a protein called collagen, made by fibroblasts. This layer also contains pain and touch receptors

Subcutaneous Fat Layer

The subcutis is the deepest layer of skin. The subcutis, consisting of network of collagen and fat cells, helps conserve the body’s heat and protects the body from injury by acting as shock absorber

K. PATHOPHYSIOLOGY/SCHEMATIC DIAGRAM OF THE DISEASE

A chronic intracellular infectious disease unique to man, usually it is not fatal. The manifestations of the disease depend on the resistance of the host. Types:

1. Tuberculoid—host is highly resistant, clinical abnormalities limited to a few peripheral nerves and adjacent skin areas, tuberculoid granuloma2. Lepromatous—host lacks resistance, all tissues affected, form cell granuloma3. Borderline—between tuberculoid and lepromatous

The earliest clinically detectable lesions of Leprosy involve the skin and show histologic association with sebaceous glands and hair follicles. From the onset, small cutaneous nerve fibers are involved. With bacillary multiplication, contigous skin areas, including autonomic nerve fibers, dermal appendages, and blood vessels, are invaded.

Lymphohematogenous dissemination of bacilli is probably an early phenomenon. As infection spreads along sensory nerves, motor fibers within parent nerve trunks are damaged. Leprosy

bacilli are unable to penetrate directly into the nervous system proximal to the dorsal root ganglions; central nervous system infection does not occur.

When there is dense proliferation of leprosy bacilli, as in lepromatous leprosy, bacteremia is virtually continuous, and bacilli are easily demonstrable in many organs. Yet there is little systematic reaction, and tissue destruction occurs mainly in cool, superficial locations; the skin (except in folds); peripheral nerves in subcutaneous loci, oral and nasopharyngeal mucous membranes (not enteric or vaginal); the testes (not the ovaries); and the anterior third of the eye.

The clinical manifestations are the indeterminate (1) lesion, which may be the initial manifestation, shows as ordinary-looking skin changes, such as pale oval or rounded macules, papulonodules, wheals or circinate patches. They may be found in the malar area, extremities or buttocks. There may be only one or a few lesions which may appear and disappear, undergo spontaneous healing, or gradually progress through the borderline (BB) form towards the tuberculoid (BT) or lepromatous (BL) forms. The lesions are usually anesthetic but this may be later manifestations. They may be depigmented or erythomatous. Sensory disturbances as paresthesias, numbness and formication may also be found. There may also be thickening or superficial nerve trunks, especially the ulnar, as well as lymphadenopathy, anhindrosis, ichthyosis and limb weakness. The foregoing manifestations may be seen in any of the clinical forms, particularly in the tuberculoid (TT) which is also characterized by a definite tendency towards healing. Damage in the following nerves is associated with characteristic impairments in leprosy:o Ulnar and median - Clawed hando Posterior tibial - Plantar insensitivity and clawed toeso Common peroneal - Foot dropRadial cutaneous, facial, and greater auricular nerves Infiltration

by bacteria may lead to destruction of nasal cartilage (lepromatous form), ocular involvement, and diffuse thickening of the skin. Advanced cases involve the loss of eyebrows and lashes, but these deformities are less common.

L. DRUG STUDY

GENERIC NAME BRAND NAME

ACTION CLASSIFICATION INDICATION CONTRAINDICATIO

N

SIDE EFFECTS/ ADVERSE

REACTIONS

NURSING RESPONSIBILITY

RIFAMPIN Rifadin, Rimactane, Rofact

antiinfective; antibiotic; antituberculosis agent

Semisynthetic derivative of rifamycin B, an antibiotic derived from Streptococcus mediterranei, with bacteriostatic and bactericidal actions. Inhibits DNA-dependent RNA polymerase activity in susceptible bacterial cells, thereby suppressing RNA synthesis.

Primarily as adjuvant with other antituberculosis agents in initial treatment and retreatment of clinical tuberculosis; as short-term therapy to eliminate meningococci from nasopharynx of asymptomatic carriers of N. meningitidis when risk of meningococcal meningitis is high.

Hypersensitivity to rifampin; obstructive biliary disease; meningococcal disease; intermittent rifampin therapy; lactation. Safe use during pregnancy (category C) or in children <5 y is not established.

CNS: Fatigue, drowsiness, headache, ataxia, confusion, dizziness, inability to concentrate, generalized numbness, pain in extremities, muscular weakness. Special Senses: GI: Heartburn, epigastric distress, nausea, vomiting, anorexia, flatulence, cramps, diarrhea, Body as a Whole: Hypersensitivity (fever, pruritus, urticaria, skin eruptions, soreness of

Assessment & Drug Effects Lab tests: Periodic liver function tests are advised. Closely monitor patients with hepatic disease. Check prothrombin time daily or as necessary to establish and maintain required anticoagulant activity when patient is also receiving an anticoagulant. Patient & Family Education Do not interrupt prescribed dosage regimen. Hepatorenal reaction with flu-like syndrome has occurred when therapy has been resumed following



N


REACTIONS


mouth and tongue, eosinophilia, hemolysis), flu-like syndrome. Urogenital: Hemoglobinuria, hematuria, acute renal failure, light-chain proteinuria, menstrual disorders, hepatorenal syndrome, (with intermittent therapy). Respiratory: Hemoptysis. Other: Increasing lethargy, liver enlargement and tenderness, jaundice, brownish-red or orange discoloration of skin, sweat, saliva,

interruption. Be aware that drug may impart a harmless red-orange color to urine, feces, sputum, sweat, and tears. Report onset of jaundice, hypersensitivity reactions, and persistence of GI adverse effects to physician. Use or add barrier contraceptive if using hormonal contraception. Concomitant use of rifampin and oral contraceptives leads to decreased effectiveness of the contraceptive and to menstrual disturbances (spotting, breakthrough bleeding). Keep drug out of reach of children.



N


REACTIONS


tears, and feces;

DAPSONE Avlosulfon , DDS

antiinfective; antileprosy (sulfone) agent

Sulfone derivative chemically related to sulfonamides, with bacteriostatic and bactericidal activity similar to that group. Interferes with bacterial cell growth by competitive inhibition of folic acid synthesis by susceptible organisms.

Drug of choice for treatment of all forms of leprosy (unless organism is shown to be dapsone resistant). Used in dapsone-sensitive multibacillary leprosy (with clofazimine and rifampin) and in dapsone-sensitive paucibacillary leprosy (with rifampin, clofazimine, or ethionamide). Also used prophylactically in contacts of

Hypersensitivity to sulfones or its derivatives; advanced renal amyloidosis, anemia, methemoglobin reductase deficiency. Safe use during pregnancy (category C) or lactation is not established.

Body as a Whole: Hypersensitivity (cutaneous reactions); erythema multiforme, exfoliative dermatitis, allergic rhinitis, urticaria, fever, infectous mononucleosis-like syndrome. CNS: Headache, nervousness, insomnia, vertigo; paresthesia, muscle weakness. CV: Tachycardia. GI: Anorexia, nausea, vomiting, abdominal pain; toxic

Assessment & Drug Effects Monitor for therapeutic effectiveness that may not appear for leprosy until after 3–6 mo of therapy. Skin lesions respond well; recovery from nerve involvement is usually limited. Lab tests: Perform baseline then weekly CBC during the first month of therapy, at monthly intervals for at least 6 mo, and semiannually thereafter. Determine periodic dapsone blood levels. Perform liver function tests in patients who complain of malaise, fever, chills, anorexia,



N


REACTIONS


patients with all forms of leprosy except tuberculoid and indeterminate leprosy. Used for treatment of dermatitis herpetiformis.

hepatitis, cholestatic jaundice Hematologic: In patient with or without G6PD deficiency; dose-related hemolysis, Heinz body formation, Skin: Drug-induced lupus erythematosus, phototoxicity. Special Senses: Blurred vision, tinnitus.

nausea, vomiting, and have jaundice. Dapsone therapy is usually suspended until etiology is identified. Monitor severity of anemia. Nearly all patients demonstrate hemolysis. Manufacturer states that Hgb level is generally decreased by 1–2 g/dL; reticulocytes increase by 2%–12%; RBC life span is shortened; and methemoglobinemia occurs in most patients receiving dapsone. Monitor temperature during first few weeks of therapy. If fever is frequent or severe, leprosy reactional state



N


REACTIONS


should be ruled out. Report cyanotic appearance or mucous membranes with brownish hue to physician as possible methemoglobinemia.Patient & Family Education Report symptoms of leprosy that do not improve within 3 mos or get worse to physician. Report the appearance of a rash with bullous lesions around elbows and other joints promptly. Report symptoms of peripheral neuropathy with motor loss (muscle weakness) promptly.

CLOFAZIMINE Lamprene antiinfective; Exerts a slow Chiefly in Pregnancy GI: Assessment &



N


REACTIONS


antileprosy agent

bactericidal effect on Mycobacterium leprae (Hansen's bacillus). Binds preferentially to DNA of all mycobacteria and inhibits their growth. Its antiinflammatory action (precise mechanism unknown) controls erythema nodosum leprosum reactions. Bacterial killing is not detectable in biopsy tissue from leprosy patient until 50 d after start of therapy.

multiinfective therapy of multibacillary leprosy (with dapsone, rifampin, ethionamide) to prevent development of drug resistance.

(category C), lactation, children <12 y.

Abdominal nausea, vomiting, diarrhea, Drowsiness, fatigue, headache, giddiness, dizziness, Skin: Pink-brown skin discoloration, ichthyosis, dryness, rash, pruritus, phototoxicity, erythema nodosum leprosum (lepra) reaction.

Drug Effects Assess for serious adverse effects (e.g., pain in bones and joints, GI bleeding, diminished vision). Reactions are usually reversible but may require months or years to diminish. Lab tests: Periodic WBC with differential, serum electrolytes, serum albumin, and liver function tests. Drug-induced reddish-brown discoloration of skin, cornea, conjunctiva, and body fluids (including tears, sweat, sputum, urine, and feces) occurs in 75–90% of patients within a few weeks of treatment. Skin discoloration may



N


REACTIONS


take months or years to disappear after drug is discontinued. Monitor for the onset of tender, erythematous nodules with lymphadenopathy, joint swelling, epistaxis, iritis which suggests a type 2 leprosy reactional state. Dosage may be increased to 200 mg/d. After reactive episode is controlled, dosage is tapered to 100 mg/d as soon as possible. Patient should remain under medical surveillance during the episode. Patient & Family Education Adhere strictly to established drug regimen. No drug dosage



N


REACTIONS


should be omitted, increased, or decreased without advice of physician. Report promptly bone and joint pain; GI bleeding, colicky abdominal pain, nausea, vomiting, diarrhea; diminished vision. Minimize use of soap, avoid applying it directly to dry skin, and thoroughly rinse it off.

V. NURSING PROCESS

A.PROBLEM LIST

RATE NURSING PROBLEMS IDENTIFIED

JUSTIFICATION

1 Ineffective Breathing pattern related to excessive mucus secretion.

According to Abraham Maslow Hierarchy of needs, physiologic needs come in priority.This is an actual problem that requires immediate attention. It is the chief complaint of the patient and the other nursing problems occur in relation to the presence of this problem.

2 Impaired skin integrity related to presence of skin lesion.

Further damage to skin may cause other infections.This is an actual problem which is an effect of the prioritized problem above. Interventions are available and possible for this problem

3 Anxiety (Mild) related to changes in health status.

Sudden change in her way of living.

B.NURSING CARE PLAN

CUES NURSING DIAGNOSI

S

ANALYSIS GOAL AND OBJECTIVES

NURSING INTERVENTIO

N

RATIONALE EVALUATION

Interaction“Hindi naman masakit itong mga sugat ko”“Matagal tagal na rin itong mga sugat ko”

Observation=Presence of skin lesion all over the body=Black color lesions

Impaired skin integrity related to presence of skin lesions all over the body

Immediate cause presence of skin lesions all over the body

Intermediate causeTissue damage

Root causeInvasion of Mycobacterium Leprae

Health ImplicationFurther skin damage will result increased risk of spread of infection and

GoalAfter independent nursing intervention with collaborative nursing intervention, the client will be able to have improved skin integrity as evidenced by:a. Exhibited no further skin breakdownb. Healed skin lesions

ObjectivesAfter 8hour shift the client will be able to:

1. Exhibit no evidence of skin breakdown.

a. Inspect patient’s skin every shift, describe

a. This provides evidence of effectivene

Effectiveness

1. Will the patient exhibit no evidence of skin breakdown?Yes____ No___If no, why?

2. Will the patient able to communicate understanding, verbalizes intent to use


S


NURSING INTERVENTIO

N


risk for other infection. (Nursing Diagnosis Card 9th Edition by Taylor And Sparks, Card 158)

and document skin condition, and report changes.

b. Perform and teach patient prescribed treatment regimen for skin condition involved and monitor progress. Report responses to treatment regimen.

c. Warn

ss of skin regimen.(Nursing Diagnosis Card 9th Edition by Taylor And Sparks, Card 158)

b. To maintain or modify current therapy.(Nursing Diagnosis Card 9th Edition by Taylor And Sparks, Card 158)

c. To avoid spread of infection and

skin protection measures, demonstrates skin inspection technique and performs skin care routine?Yes___ No___If no, Why?

3. Will the patient able to communicate feelings about change in body image? Yes ___ No___If no, why?

EfficiencyWas the interventions done within the time frame?Yes ___ No___If no, why?


S


NURSING INTERVENTIO

N


2. Communicate understanding, verbalizes intent to use skin protection measures,

patient against tampering with wound.

d. Explain therapy to patient.

a. Instruct patient in skin care regimen.

decreased chance of further skin damage.(Nursing Diagnosis Card 9th Edition by Taylor And Sparks, Card 158)

d. To aid compliance.(Nursing Diagnosis Card 9th Edition by Taylor And Sparks, Card 158)

a. To encourage compliance.

AppropriatenessWere the interventions suitable to the client?Yes ___ No___If no, why?

AccessibilityWere the interventions acceptable to the client?Yes ___ No___If no, why?

AdequacyWere the interventions adequate to meet the client’s needs?Yes ___ No___If no, why?


S


NURSING INTERVENTIO

N


demonstrates skin inspection technique and performs skin care routine.

3. Communicates feelings about change in body image.

b. Supervise patient in skin care management.

a. Allow patient to express feelings regarding skin problem.

(Nursing Diagnosis Card 9th Edition by Taylor And Sparks, Card 158)

b. To improve skill of the patient.(Nursing Diagnosis Card 9th Edition by Taylor And Sparks, Card 158)

a. This helps allay anxiety and develops coping skills.(Nursing


S


NURSING INTERVENTIO

N


b. Refer patient to psychiatric liaison nurse, social services, or other support groups.

Diagnosis Card 9th Edition by Taylor And Sparks, Card 158)

b. These provide additional support for patient.(Nursing Diagnosis Card 9th Edition by Taylor And Sparks, Card 158)

C.DISCHARGE PLANNING

MEDICATION

Multi-drug Therapy (Dapsone, Rifampicin and Clofazimine)

EXERCISE

The client should have a daily routine exercises Encourage client to have regular exercise such as performing range of motions exercises. Encourage the client to follow an appropriate exercise program. Exercise is also a useful way to lose weight, ease stress and maintain a feeling of well- being. It is also good for wound healing.

TREATMENT

Medications as prescribed by the physician Educating both patient and family Provides and arranges for provisions of nursing care of patients at home

HEALTH TEACHINGS

Control measures such as immunizations Practice personal hygiene Health education of patients, families, and the community on the nature of the disease, symptomatology and its transmission Advocates healthful living through proper nutrition, adequate rest, sleep, exercise and good environment Health teaching to prevents secondary injury Teach the client that he/she should not fail to complete treatment within the prescribed duration The nurse should give health teachings like information about how to prevent and protect his skin form wounds and lesions. If there’s such, teach how will be the proper way of dressing the wound and taking good care of it.

OUT PATIENT FOLLOW-UP

Refers patient to other health and allied workers

Refers patient to other persons/agencies who can help in his/her physical, mental and social rehabilitation Monthly outpatient follow-up is recommended during treatment, although weekly visits may be necessary if the patient experiences a leprosy reaction.

DIET

Diet as Tolerated

SPIRITUAL TEACHINGS

Mental and emotional support by encouraging self-confidence and self-reliance Providing counseling and guidance

Leprosy: A Case Presentation

Documents

Transcript of Leprosy: A Case Presentation