A Case Study on Typhoid Fever

A Case Study OnTyphoid Fever

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In partial Fulfillment of the CourseRequirement in Nursing Care Management

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Presented to the Faculty ofSan Lorenzo Ruiz College of Nursing

Ormoc City

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Submitted by:

Busa, Ana MarieEcho Class 2010

Introduction

Typhoid fever, also known as “Tipos” (in laymen’s term), is one of the most

common worldwide illness most specifically in third world country such as ours, this is a

question of sanitation since this disease is transmitted through ingestion of food or water which

is improperly prepared and contaminated with the feces of an infected person, that contains the

bacterium Salmonella enterica, serovar Typhi. The said bacteria perforates through the intestinal

wall and grows best at 37 °C/99 °F – human body temperature.

Typhoid fever is characterized by:

a slowly progressive fever as high as 40 °C (104 °F)

profuse sweating, gastroenteritis

nonbloody diarrhea.

less commonly, a rash of flat, rose-colored spots may appear.

Common causes of transmission are flying insects most specifically flies feeding

on feces that may occasionally transfer the bacteria through poor hygiene habits and public

sanitation conditions. A person may become an asymptomatic carrier of typhoid fever, suffering

no symptoms, but capable of infecting others. Diagnosis is made by any blood, bone marrow or

stool cultures and the Widal test. Sanitation and hygiene are the critical measures that can be

taken to prevent typhoid. Typhoid does not affect animals and therefore transmission is only

from human to human. The rediscovery of oral rehydration therapy in the 1960s provided a

simple way to prevent many of the deaths of diarrheal diseases in general. Where resistance is

uncommon, the treatment of choice is a fluoroquinolone such as ciprofloxacin otherwise; a third-

generation cephalosporin such as ceftriaxone or cefotaxime is the first choice.

The student nurse personally chose this case study because as one of the persons

living in a developing country, where handwashing and proper sanitation are not well practiced

by some people, are at risk of acquiring typhoid fever. Moreover, the student felt that this study

is important to her because this usually inflicts children particularly toddlers in which his son is.

This study will help the nursing profession by providing information about the

proper management and care for patients with Typhoid fever. It will also educate the people,

especially those with Typhoid Fever and vulnerable individuals to seek medical care in order to

prevent the illness. It will increase awareness about the importance of having a healthy lifestyle

and clean environment. This study will elaborate the inter relatedness of environment, life style

habits and acquiring Typhoid Fever.

Through this, the student nurse would be able to formulate a plan of care for the

patient and formulate a health teaching plan to lay a foundation and minimize difficulties in the

future. This study is not limited to the patients with Typhoid Fever only, but it is for all people

who are interested in Typhoid Fever.

The student nurse expects a lot from this case study, even if she couldn’t really

tackle the deepest part of the illness, she expect to gain more knowledge about the disease. The

student nurse also expects to raise concern and awareness to everyone that typhoid fever is a

communicable disease in which everyone is at risk of acquiring. However, it is greatly

preventable with enough knowledge and understanding about the disease and with proper

practicing handwashing and sanitation in our respective homes. The treatments and the different

psychotherapy are important factors that she also wants to know as part of her job as a student

nurse. From this study, she expect to have a better understanding about typhoid fever, learn

skills especially with the care of these patients as well as nursing responsibilities that are

involved in this care.

Objectives

GENERAL OBJECTIVES:

After 3 days of giving holistic nursing care to the patient, the student nurse will be

able to acquire knowledge, attitude and skills about the care for pediatric patients with typhoid

fever.

SPECIFIC OBJECTIVES:

After 8 hours of giving holistic nursing care to the patient, the student-nurse will

be able to:

1. make thorough nursing assessment of the patient to be able to come up with an

apposite plan of care.

2. explain the pathophysiology of Typhoid fever

3. identify the causes of Typhoid fever.

4. recognize the possible symptoms of Typhoid fever as manifested by the patient.

5. develop an individualized plan considering client characteristics or the situation and

setting a specific, measurable, attainable, realistic and time bounded plan that reflect

the onset, date of problem identified.

6. list ways on preventing Typhoid fever.

7. site the importance of preventions, medication compliance and positive attitude to

early healing.

8. render appropriate nursing care to the patient to promote wellness and optimum level

of functioning.

9. medicate properly and accurately the prescribed medications and to be able to identify

its action and drug information.

10. endorse proper health behaviors in relevance to her care and age through play therapy

GENERAL OBJECTIVES:

After 3 days of giving holistic nursing care or student nurse-patient-significant

others interaction, the patient as well as the significant others will be able to acquire knowledge,

attitude, and skills in the proper management with typhoid fever.

SPECIFIC OBJECTIVES:

After 8 hours of giving holistic nursing care, the patient and the significant others

will be able to:

1. understand awareness of the disease.

2. identify the risk factors of typhoid fever

3. explain the causes of typhoid fever

4. recognize own symptoms of typhoid fever.

5. learn and understand why laboratory examinations are being done.

6. know and understand the treatments of typhoid fever.

7. demonstrate proper management with the signs and symptoms manifested.

8. enumerate drugs or medications necessary with the care through understanding of drug

information and precautions regarding its use.

9. show proper diet and exercise and stress its importance in promoting health and

preventing further complications.

10. display proper hygiene techniques and stress its importance in promoting health and

preventing further complications.

Nursing Assessment

Personal History

Patient’s Profile

Name: Mr. Marlou W. Miao

Age: 3 years old

Civil Status: Single

Religion: Roman Catholic

Date of Admission: July 17, 2010

Room Number: P2

Complaints: Fever, Cough

Impression/Diagnosis: Typhoid fever

Physician: Dr. Neda Labtic

Family/Individual Information, Social and Health History

Mr. Miao, Marlou W. is a Filipino and was born on April 26, 2007. He is the

youngest child of Ms. Melinda Miao, his mother died right after delivery due to some

complications. He lives at Lomboy, Sherwood Albuera, Leyte together with his grandparents and

aunty who looks after him, his other brother lives at another house with his father. He usually

plays outside their house together with his brother and neighbor. He sometimes forgets to wash

her hands prior to eating.

7 days prior to admission, Mr. Miao had an intermittent fever (38-39°C), with no

abdominal pain and no nausea and vomiting, condition was tolerated. The next day, patient still

has fever accompanied by productive cough, yellow phlegm, difficult to expectorate and with

abdominal pain. Patient was then brought by her mother to a private medical doctor and was

prescribed by some medications. Fever was then decreased but still with persistent cough. Patient

was told to come back after 5 days. After 5 days, patient still has fever and the private doctor

requested a Salmonella test, after the test went positive, the doctor made a request for admission

at Ormoc Sugarcane Planters Association-Farmers Medical Center.

A case of Mr. Marlou W. Miao, 3 years old male was admitted at OSPA-FMC on

July 17, 2010 for fever of about 7 days already. On admission, his Salmonella test revealed

positive for salmonella typhi anti-09 antibodies.

Level of Growth and Development

Normal Development at particular stage

A. Physical

Two year old children lose the baby look. Toddlers are usually chubby, with

relatively short legs and a large head. The face appears small when compared to the skull; but as

the toddlers grows, the face seems to grow from under the skull and appears better proportioned.

Toddlers have a pronounced lumbar lordosis and a protruding abdomen. The abdominal muscles

develop gradually with growth, and the abdomen flattens.

Weight: two years old can be expected to weight approximately four times their

birth weight. The weight gain is about 2 kg (5 lbs) between 1 year and 2 years and about 1-2 kg

(2-5 lbs) between 2 and 3 years. The 3 year old weighs about 13.6 kg (30 lbs).

Height: between ages 1 and 2 years, the average growth in height is 10-12 cm (4-

5 in), and between ages 2 and 3 years, it slows to 6 to 8 cm (2 ½ to 3 ½ in).

Head Circumference: The head circumference of the toddler increases on an

average about 2.5 cm (1 in), and by 24 months the head is four-fifths of the average adult size.

The brain is 70% of its adult size by the time the infant is 2 years old.

Sensory Abilities: visual acuity is fairly well established at 1 year; average

estimates of acuity for the toddler are 20/70 at 18 months and 20/40 at 2 years of age.

Accommodation to near and far objects is fairly well developed by 18 months and continues to

mature with age. At 3 years of age the toddler can look away from a toy prior to reaching out and

picking it up. This ability requires the integration of visual and neuromuscular mechanisms. The

senses of hearing, taste, smell, and touch become increasingly developed and associated with

each other. Hearing in the 3 year old is at adult levels. The taste buds of the toddler are sensitive

to natural flavors of food, and the 3-year old prefers familiar odors and tastes. Touch is a very

important sense and a distressed toddler is often soothed by tactile sensations.

Motor abilities: fine muscle coordination and gross motor skills improve during

toddlerhood. At 2 years, toddlers can hold a spoon and put it into the mouth correctly. They are

able to run; their gait is steady; and they can balance on one foot; by 3 years, most children are

toilet trained, although they still may have the occasional accident when playing or during the

night. (Source: Kozier, 2004)

B. Cognitive

According to Piaget, the toddler completes the 5th and 6th stages of the

sensorimotor phase and starts the preconceptual phase at about 2 years of age. In the 5 th stage, the

toddler solves problems by a trial-and-error process. By stage 6, toddlers can solve problems

mentally. (Source: Kozier, 2004)

During Piaget’s preconceptual phase, toddlers develop considerable cognitive and

intellectual skills. They learn about the sequence of time. They have some symbolic thought.

Concepts start to form in late toddlerhood. A concept develops when child learns words the

represent classes of objects or thoughts. (Source: Kozier, 2004)

C. Moral

According to Kohlberg, the first level of moral development is the

preconventional when children respond to labels of “good” or “bad”. During the second year of

life, children begin to know that some activities elicit affection and approval. They also

recognize that certain rituals, such as repeating phrases from prayers, also elicit approval. This

provides children with feelings of security. By 2 years of age, toddlers are learning what attitudes

their parents hold about moral matters. (Source: Kozier, 2004)

D. Psychosexual (Freud)

Anal: anus and rectum are the center of pleasure. This stage occurs during toilet

training. Fixation at the anal stage can result in obsessive compulsive personality traits, such as

obstinacy, stinginess, cruelty and temper tantrums. (Source: Kozier, 2004)

E. Psychosocial (Erikson)

Erikson sees the period from 18 months to 3 years as the time when the central

developmental task is autonomy versus shame and doubt. Toddlers begin to develop their sense

of autonomy by asserting themselves with the frequent use of the word “no.” They are often

frustrated by restraints to their behavior and between ages 1 and 3 may have temper tantrums.

Children learn to develop sense of self through their immediate social

environment, in which their parents play a significant role. If children’s social interactions with

their parents are negative, the children may begin to see themselves as bad.

Although children like to explore the environment, they always need to have a

significant person nearby. Parents need to know that young children experience acute separation

anxiety, the fear and frustration that comes with parental absences. Abandonment is their greatest

fear. (Source: Kozier, 2004)

F. Spiritual Development

According to Fowler, the toddler’s stage of spiritual development is

undifferentiated. Toddlers may be aware of some religious practices, but they are primarily

involved in learning knowledge and emotional reactions rather than establishing spiritual beliefs.

A toddler may repeat short prayers at bedtime, conforming to a ritual, because praise and

affection result. This parental response enhances a toddler a sense of security. (Source: Kozier,

2004)

1.3.2 The Ill Person at Particular Stage of Patient

Separation Anxiety

Children react aggressively to the separation from the parent. They cry and

scream for their parents, refuse the attention or anyone else, and are inconsolable in their grief.

Children in the toddler stage demonstrate more goal-directed behaviors. For example, they may

plead with their parents to stay and physically try to keep the parents with them or try to find

parents who have left. They may demonstrate displeasure on the parent’s return or departure by

having temper tantrums; refusing to comply with the usual routine of mealtime, bedtime, or

toileting; or regressing to more primitive level of development.

Loss of Control

When their egocentric pleasures meet with obstacles, toddlers react with

negativism, especially temper tantrums. Any restriction or limitation of movement, such as the

simple act of making toddlers lie down, can cause forceful resistance and noncompliance. Loss

of control also results from altered routines and rituals. Toddlers rely on consistency and

familiarity of daily rituals to provide a measure of stability and control in their complex world of

growing and developing. The experience of hospitalization or illness severely limits their sense

of expectation and predictability, since practically every detail of the hospital environment

differs from that of the home. The principal reaction to such change is regression.

Bodily Injury and Pain

Toddlers’ reactions to pain are similar to those seen during infancy, except that

the number of variables influencing the individual response is highly complex and varied. In

general, children in this age-group continue to react with intense emotional upset and physical

resistance to any actual or perceived painful experience. Behaviors indicating pain include

grimacing, clenching their teeth or lips, opening their eyes wide, rocking, rubbing, and acting

aggressively, such as biting, kicking, hitting or running away. (Source: Kozier, 2004)

The ill person at the particular stage of patient:

The patient, Mr. Miao is quite cooperative and responds to my questions.

Although he is afraid of other health care members that would come near him thinking that they

would hurt him through some injections. He manifests this kind of attitude because of his

experience during his admission at the emergency room where he was started with an IV line

several times due to difficulty in locating his veins and also during extractions of blood for some

tests. After that, he makes a face and sometimes cry every time he sees any of the health care

members. He would also cling to his aunt most of the time because he is afraid that she might

leave him.

SAN LORENZO RUIZ COLLEGE OF ORMOCCOLLEGE OF NURSING

ORMOC CITYName: Mr. Marlou W. Miao Room Number: P2

Impression/Diagnosis: Typhoid fever Physician: Dr. Labtic


Diagnostic results

Diagnostic Test Normal Value Patient’s Result Significance

HEMATOLOGIC

EXAM:

Date: July 17, 2010

Hemoglobin

MCH

MCHC

Hematocrit

WBC

Granulocytes

Lymphocytes

Mid

Eosinophils

Basophils

Monocytes

Granulocytes

Lymphocytes

Mid

11.5 - 16.5 g/dl

27 - 32 pg

32 - 36 g/dl

41.5 - 50.4 %

5 - 10 x 10^9/uL

35 - 80 %

20 - 40 %

2 - 15 %

1.2 - 8 x 10^9/uL

0.5 – 5 x 10^9/uL

.10 - 1.5 x 10^9/uL

10.70 g/dl

27.90 pq

34.80 g/dl

30.7%

10.60x10^9/uL

90.6 %

34.3 %

5.1 %

2 %

1 %

3 %

6.40 x 10^9/uL

3.60 x 10^9/uL

.60 x 10^9/uL

Decreased, Infection

Normal

Normal


Increased, Infection


Normal

Normal

Normal

Normal

Normal

RBC

MCV

RDWR

RDWA

Platelet count

MPV

PDW

PCT

LPCR

MICROBIOLOGY

SECTION:

SALMONELLA

TEST:

Date: July 17, 2010

URINALYSIS:

Date: July 17, 2010

I. Macroscopic

Color

Albumin

Sugar

Transparency

pH

Specific Gravity

4.8-5 x 10^12/L

80 – 100 fl

11-16 %

30 – 160 fl

150 - 450 x 10^12/L

8 – 11 fl

.10 – 9.99 fl

.09 – 9.99 fl

.10 – 9.99 %

Light straw or yellow

Negative

Negative

Clear

4.0-8.0

1.007-1.030

3.83 x 10^12/L

80.10 fl

12.60 %

51.90 fl

337.10 x 10^12/L

6.40 fl

8.40 fl

.21 fl

9.10 %

Igm Positive

-acute Typhoid

Fever

Yellow

Negative

Negative

Slightly Turbid

6.0

1.080


Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

positive typhoid fever

Normal

Normal

Normal

Normal

Normal


II. Microscopic

Pus Cells

RBC

Squamous Cells

Bacteria

Mucus Threads

Crystals

Amorphous nitrites

STOOL EXAM:

Date: July 17, 2010

Color

Consistency

Mucus

Yellow

Formed

negative

1-2

0-1

few

few

few

few

Yellow brown

Watery

Slightly mucoid

Typhoid fever

diarrhea

intestinal infection;

typhoid fever

2. Present Profile of Functional Health Patterns

Health Perception/ Health Management Pattern

Before admission, Mr. Miao is a healthy active toddler who tries everything under

his nose. He is not conscious about health practices such as washing hands before eating. His

aunt verbalizes that he is healthy that is without any major illnesses. Upon Marlou’s admission,

he became very attached to his aunty and grandmother. He also becomes very sensitive because

of his present condition. Every time a health personnel gets inside his room, he immediately

clings to his aunty and cry. He is afraid that the health personnel might inject and hurt him.

Marlou has fever and his body temperature ranges from 38-39°C. To manage such condition, his

aunt performs tepid sponge bath and he has an antipyretic PRN for temperature greater than

38°C.

Nutritional-Metabolic Pattern

Marlou has a big appetite before admission, he usually eats lots of sweets such as

candies in between meals and during mealtime he eats vegetables and rice and sometimes dried

fish. During his admission here in OSPA-FMC Marlou is on diet as tolerated. His aunty gives

him rice, fish, vegetables and some fruits. She also gives him milk. But, Marlou only eats a little

because he has decreased in appetite due to his condition. He only eats a maximum of 4

tablespoons per meal. However, he drinks a lot of water. He experiences abdominal pain.

Elimination Pattern

Marlou defecates once a day and have not encountered problems in urinary

elimination prior to admission. He cannot really control hid elimination pattern well that is why

he is still wearing diapers and he urinates more often. He can consume 4-5 diapers in one shift.

Sometimes, he is constipated because he cannot defecate within 2 days.

Activity/ Exercise Pattern

Before admission, Marlou is a very active toddler who spends most of the time

outside the house playing on the grounds. Now the patient’s movements seemed weak. He keeps

on lying down. Sometimes, he sits up on his bed or asks his aunty to cuddle him. He moves

slowly every time he eats or does something. He is assisted by his aunty every time he attempts

to sit up. His past time inside his room is just watching other patients since there is no television.

Cognitive / Perceptual Pattern

Prior and during admission, Marlou still functions and thinks his age. He still

enjoys watching cartoon movies and playing. But only during hospitalization that he becomes

more attached to his aunty just clinging onto her and expresses tantrums.

Rest / Sleep Pattern

During admission, sometimes the patient’s sleep is disturbed due to abdominal

pain and feeling of cold whenever he would have fever again. He also wakes up and cries every

time a health personnel comes into his room. His sleep and rest are interrupted because he feels

anxious whenever someone that she does not know comes near her. Prior to admission, he never

had problems with sleep because according to his aunt he enjoys an afternoon nap.

Self perception pattern

Before admission the patient thinks he is loved and cared by his aunt and feels

secure whenever she is near that is why her aunt stopped schooling just to take care of him.

During admission the patient thinks that he really needs more attention from his aunty because

he is not feeling very well. He knows that he has an illness and thus he must not be left by his

aunty thinking that he would be worse if he is left by her.

Role Relationship Pattern

Prior and during admission the patient is very close to his aunty and grandmother.

He seems very dependent to his aunty and asks his auntie’s permission every time he wants to do

something. He usually doesn’t responds to people he doesn’t know. You need to gain his trust

before he would communicate with you.

Coping – Stress Tolerance Pattern

Before and during admission, his coping mechanism is to cry every time he

doesn’t feel well, he asks his aunty to cuddle him and puts him to sleep. And when there are

things done to him that he doesn’t like, he uses crying as a way of coping.

Value – Belief Pattern

The Patient’s values and beliefs is basically the same before and during

admission. He does not pay much attention on praying, though she knows about God. She can

recite the Prayer before meals and Prayer before sleep. He goes to mass with his aunty and

grandmother every Sundays, but there are times that they can’t attend mass due to some

uncontrolled circumstances. He doesn’t blame God with his hospitalization and he prays with his

aunty before he goes to sleep at night.

Pathophysiology and Rationale

Normal Anatomy and Physiology of Affected organ

The Digestive System

The organs of the digestive system together perform a vital function of preparing

food for absorption and use by the million of body cells. Most foods when eaten is in a form that

cannot reach the cells (because it cannot pass through the intestinal mucosal into the

bloodstream) nor could it be used by the cells even if it could reach them. It must, therefore, be

modified as both to chemical and physical composition of food so that it can be absorbed and

utilized by the cells is known as digestion and is the function of the digestive system.

Mouth (Buccal Cavity)

The following structures form the buccal cavity: the cheeks (side walls), the

tongue and its muscle (floor), and the hard and soft palates (roof). Of these, only the palates and

the tongue are important. The palate consists of portions of four bones: two maxillae and two

palatines. The soft palate which forms the portion between the mouth and the nasopharynx and is

named fauces. Suspended from the midpoint of the posterior of the arch is small cone-shaped

process the uvula.

Teeth

Twenty deciduous teeth, the so called baby teeth, appear early in life and are later

replaced by 32 permanent teeth. The name and the numbers of teeth present in both sets are:

Name of tooth deciduous teeth Permanent teeth

Central incisors 2 2

Lateral Incisors 2 2

Cuspids (Canines) 2 2

Premolars (Bicuspid) 0 4

First Molars (Tricuspid) 2 2

Second Molars 2 2

Third Molars 0 2

Total per set 20 32

The first deciduous tooth erupts usually at the age of 6 months. The rest follow at

the rate of 1 or more a month until all 20 have appeared. There is, however, great individual

variation in the age at which teeth erupts. Deciduous teeth are shed generally between the ages of

6 and 13 years. The third molars (wisdom teeth) are the last to appear, erupting usually

sometimes at the age of 17 years old.

Pharynx

Food passes from the mouth to esophagus by way of the pharynx

Esophagus

The esophagus, a collapsible tube about 25cm (10 inches) long, extends from the

pharynx to the stomach piercing tho the diaphragm in this descent from the thoracic to the

abdominal cavity. It also lies posterior to the trachea and the heart.

Stomach

Just below the diaphragm, the digestive tube dilates on elongated pouch-like

structure, the stomach, the size of which varies according to several factors, notably the gender

and amount of distention. In general, the female stomach is usually more slender and smaller

than the male stomach. For sometime after a meal, the stomach enlarges because of distention of

walls, but as food leaves, the walls partially collapsed, leaving the organ about the size of a large

sausage. Sphincter muscle consist of circular fibers so arrange that there is an opening they are

contracted. The cardiac sphincter guards the opening of the esophagus into the stomach into the

first part of the small intestine (duodenum).

Gallbladder

The gallbladder is an active storage shed, which absorbs mineral salts and water

received from the liver and converts it into a thick, mucus substance called "bile," to be released

when food is present in the stomach. The gallbladder is a small, pear-shaped sac which is

situated just below the liver and is attached to it by tissues. It stores bile and then releases it when

food passes from the stomach to the duodenum (the first part of the small intestine) to help in the

process of digestion.

Small intestine

Chemical digestion of foods begins in the small intestine. The small intestine is

able to process only a small amount of food at one time. The pyloric sphincter controls food

movement into the small intestine from the stomach and prevents the small intestine from being

overwhelmed. Enzymes, produced by the intestinal cells and more importantly by the pancreas

and ducted into the duodenum through the pancreatic duct, complete the chemical breakdown of

foods in the small intestine.

Large intestine

The large intestine is about 5 feet long extends from the ileocecal valve to the anus. Its

major function is to dry out the indigestible food residue by absorbing water and to eliminate this

residue from the body as feces. It frames the small intestine on three sides and has the following

subdivisions: cecum, appendix, colon, rectum, and anal canal. .(Source: Elaine Marieb, Human

Anatomy and Physiology 2006)

PATHOPHYSIOLOGY OF TYPHOID FEVER

SignsNon bloody DiarrheaSlow progressive FeverDecreased AppetiteTransient skin rash (rose spots)Profuse sweatingLeukopeniaPositive Widal test

Predisposing Factors:AgeGenderMedical HistoryGeographical area

Precipitating Factors:contaminated foodsunsanitary food

preparationunsanitary

environment

Ingestion of food or fluids contaminated by S.typhi

Bacteria invades the Payer’s patches of the intestinal wall in the small intestines where it attach (incubation period is first 7-

14 days after ingestion)

Bacteria will then injects toxins known as the effector proteins into the intestinal cells and interrupts with the cellular proteins

& lipids & manipulate their function resulting in phagocytization of the epithelial cell membrane until it is engulf down into the inferior part of the host cells where

macrophages is present.

The bacteria induced macrophage apoptosis, breaking out into the bloodstream and cause systemic infection. The

bacteria induced macrophage apoptosis, breaking out into the bloodstream and cause systemic infection

TYPHOID FEVER

SymptomsBody MalaiseAbdominal PainHeadacheCoughWeakness

Medical Management:

Administration of Analgesics Admonistration of Antipyretics Administration of Antibiotics

(Ceftriaxone)

Nursing Management:

Perform tepid sponge bath

Disease Process of Typhoid Fever

Typhoid fever is a bacteremia in which the organism gains access to the blood

stream through the bowel, principally through the infected peyers patches of lymphoid tissue in

the lower portion of the ileum. The first week these patches are swollen: the second week they

form sloughs, which are often bile colored; the third week the sloughs separates and leaves an

ulcerative surface, which then starts to heal by granulation.

Since the organism reaches all parts of the body through the bloodstream, almost

all organs at time may show pathologic changes being those due to toxemia and high fever.

Commonly, however, the heart, liver, spleen, muscle, and mesenteric lymph glands may be

either red or swollen, or else broken down into messy masses. The muscles are flabby granular.

The urine may be milky in appearance with the peculiar opalescence, which is due to the

presence in it of millions of typhoid bacilli.

The causative organism invades the bloodstream by way of lymphatic tissues and

is carried to all parts of the body. Early symptoms may vary, may be vague with headaches,

anorexia and malaise. As the disease progresses, there are joint pains, abdominal discomfort,

vomiting and usually constipation although they may be diarrhea. Cough and bronchitis occur in

about 50% of the cases. During the first week, the body temperature rise in step ladder pattern

until it reaches about 104. Wherein remains until near the end of the 3rd week, after which it falls

by lysis. The temperature is irregular, with 2 remissions in the morning. (Source: Smeltzer and

Bare,2004)

Classical and Clinical Signs and Symptoms of Typhoid fever

Classical Symptoms Clinical Symptoms Rationale Body Malaise

Decreased Appetite / Anorexia

Fever (intermittent)

Abdominal Pain

Manifested: patient keeps of lying in bed and seldom moves around. He needs his aunty’s assistance whenever she wants to sit up from his bed.

Manifested: patient only eats three spoons to five spoons of food per meal.

Manifested: patient’s temperature fluctuates from 38-39°C to 36°C

Manifested: Abdominal pain of 5/10 pain scale, guarding behavior, facial grimace

Illness can deplete a person’s energy to such degree that it becomes difficult for the person to deal with day-to day life. (Source: Lemone & Burke, Medical surgical Nursing, Chapter 24, page 639)

Loss of appetite occurs as a result of the decreased metabolic rate and the increased catabolism that company immobility (Source: Lemone & Burke, Medical surgical Nursing, Chapter 24, page 640)

The body temperature alternates at regular intervals between periods or subnormal. (Source: Lemone & Burke, Medical surgical Nursing, Chapter 24, page 639)

Abdominal spasm is induced to limit mucosal injury adding in stimulation of increased peristalsis. Perforation and destruction of mucosal lining of the intestinal

Diarrhea Manifested: Consumes

4-5 diapers per shift due to watery stools

wall can lead to persistent inflammation (Source: Monahan, Medical surgical Nursing, Chapter 30, page 1708)

Tissue damage and inflammation causes loss of absorption due to damaged villi causing an increase in water, electrolytes, mucus, blood, and serum to be pulled into the intestine from immature crypt cells (Source: Lemone & Burke, Medical surgical Nursing, Chapter 24, page 639)

Nursing Interventions

Care Guide of Patients with Typhoid Fever

The patient must be isolated until at least 3 negative stool cultures, 24 hours apart and has

been secured. Strict asepsis must be carried out. All stool, urine, and vomitus must be

disinfected unless disposal of in a municipal sewage system. The rectal thermometer

should be taken to conserve the patient’s strength and to avoid chilling the patient.

Antipyretic drug should be administered for fever. The skin must be protected by

frequent turning of the patient and proper positioning, since it is susceptible to skin

infection. Mouth care should be given at regular intervals. The patient should be

encouraged to take adequate fluids by mouth. If fluids are administered parenterally,

caution must be exercised, since overloading the vascular system may lead to

cardiovascular complications. Abdominal distention should be guarded against, since it

thins the intestinal walls and may contribute to hemorrhage or perforation of intestinal

ulcers. Small low enemas may be given and glycerine suppositories or mineral oil to

avoid constipation. All stools must be examined for evidenced of blood and any bright

blood must be reported at once. The patient should be examined for bladder distention

and retention of urine. During acute stage, the patient is drowsy and lethargic and

incontinence may occur. The patient should be in a quiet pleasant surroundings and

visitors reduced to a minimum. (Source: Lemone & Burke, 639)


ORMOC CITYNursing Assessment

Name: Mr. Marlou W. Miao Room Number: P2



BodyPart

PHYSIOLOGIC

I P P AHead:

Hair

Scalp

Forehead

Face

Eyebrow

Eyelash

Eyelids

Conjunctiva

Sclera

Pupils

Black, evenly distributed, shoulder level

White, no dandruff

Smooth, fair skin

No deformities, brown colored skin, dry, good skin turgor

Evenly distributed, black in color, parallel

Slightly curved outward

Intact, able to open and close

Pale pink color, no inflammation, moist, no accumulation of secretions.

White, small veins are visible

Round, reactive to light and accommodation.

Absence of nodules

No tenderness, warm, temporal pulse: 124bpm

No lumps, no tenderness

No masses

External eyes

Nose

Lips

Ears

Gums

Tongue

Uvula

Teeth

Hard palate

Soft palate

Neck

Chest

Abdomen

Parallel, symmetrical

Smooth, proportional to the face

Pink, dry, presence of some cracks and peelings

Symmetrical

Dark pink, no ulceration

Smooth, pinkish, no ulceration

Located at the midline, not inflamed

Yellowish in color

Located anteriorly with ruggae

Posteriorly located, moist, no lesions, no ulcerations

No scars, no lesions, good skin turgor, evenly distributed skin color

No scars, no lesions, no deformities. RR:28 breaths/min

No hairs, no lesions, smooth

No lump, no secretions

Rough

Flexible

No masses

Resistant

Intact to gums

Hard

Carotid pulse:120 bpm

No nodules, no pain

Pain upon palpation (intermittent)

Dull sound on bony prominence; resonant on intercostals spaces.

Resonant on all four quadrants.

Heart rate: 124 bpm

Bowel sounds: Hyperactive bowel sounds14/min every 4

Upper extremities

Equal muscle tone, presence of IVF of #2 D5IMB @ 18cc/hr at the right dorsum of her hand.

Pulse rate: 120bpm axillary temp: 38.5 °C

seconds loud gurgling sounds.

Actual Patient Care


ORMOC CITYName: Mr. Marlou W. Miao Room Number: P2



Nursing Care Plans

Needs/ Problems/

Cues

Nursing Diagnosis

Scientific Basis

Objectives Nursing Actions

Rationale

Physiologic Deficit:1. Altered thermoregulation

Cues:- body temperature of 38.5 °C- flushed skin- skin warm to touch- teary eyes- cracked lips-Positive Salmonella typhi stool exam result

“gitugnaw kuno siya.” As verbalized by the SO.

Altered Thermoregulation: Fever related to on going infection

Fever is the most common sign of a systemic response to injury and it is most likely caused by endogenous pyrogens released from neutrophils and macrophages, a specialized form of leukocytes. These substances reset the hypothalamic thermostat which controls body

After 8 hours of nurse- patient interaction, the patient will be able to:

1. manifest a lowered temperature as evidenced by body temperature from 38.5 °C to 36.5 °C

Measures to:1. decrease body temperature

a. provide dry clothing and bed linens

b. remove excessive clothing and covers.

c. reduce physical activity

d. provide adequate foods and

- to increase heat loss through conduction

- to lower temperature

- to limit heat production

- to meet the increase metabolic demands and

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temperature and produce fever.

Source:Brunner & Suddarth’s Medical Surgical Nursing

fluids

e. provide tepid sponge bath

f. provide oral hygiene

g. provide additional cooling mechanisms like cooling mattress, cold packs

h. administer Paracetamol(tempra syrup) 5ml q4 hours

i. administer Ceftriaxone 500g IVTT q12h

prevent dehydration

- to increase heat loss through conduction

- to keep the mucous membranes moist. They become dry and cracked as a result of excessive fluid loss

- to maintain patient’s comfort

- drugs that reduce the level of fever

-to treat underlying cause

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Physiologic Overload:2. Acute Pain

Cues:-Grimace face-Guarding at the abdominal area-Pain started yesterday (July 17, 2010) accompanied by diarrhea, located at the abdominal area for 8-10 seconds with a pain scale of 5, characterized by colicky pain. It is aggravated by walking and is relieved by bowel movement. It is treated with Paracetamol as pain relief.

“Sakit kuno iyaha tiyan, as verbalized by SO”

Alteration in comfort: Acute Pain related to inflammation of gastric mucosa secondary to Typhoid Fever

Salmomella Gastroenteritis is characterized by initial symptoms of nausea and vomiting followed by abdominal cramps and diarrhea which is accompanied by fever. The diarrhea varies from loose watery stools to bloody purulent cholera like stools.

Source:Oxford Textbook of Medicine volume 3 By:David A Warrell p 661


2. experience increased comfort concerning pain as evidenced by lowered pain intensity from 5/10 to 2/10.

Measures to:2. increase patient’s comfort:

a. Keep at rest in Semi-Fowler’s Position.

b. Encourage verbalization of feelings about pain.

c. Provide Additional Comfort Measures such as touch.

d. Instruct the patient to use diversional activity such as play therapy.

e. use puppets to demonstrate procedures.

-to promote proper lung expansion.

- To alleviate pain by promoting non-pharmacological pain management

-To reduce pain especially when moving.

- Refocuses attention, promotes relaxation and may enhance coping abilities

-to enhance understanding and reduce anxiety or fear level.

-Relief of pain

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f. Administer Paracetamol(tempra syrup) 5ml q4 hours

facilitates cooperation with other therapeutic interventions.

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Physiologic deficit3. Diarrhea

Cues:

-Consumed 3-4 diapers due to watery stools at 100cc per defecation-Stool exam results on p.11-dry lips-hyperactive bowel sounds

“Magsige man siya ug kalibang, as verbalized by the SO”

Fluid Volume Deficit related to diarrhea secondary to Typhoid Fever

Salmomella Gastroenteritis is characterized by initial symptoms of nausea and vomiting followed by abdominal cramps and diarrhea which is accompanied by fever. The diarrhea varies from loose watery stools to bloody purulent cholera like stools.

Source:Oxford Textbook of Medicine volume 3 By:David A Warrell p 661


3. maintain hydration balance. 3. maintain

fluid balance:

a. Assess for the signs of dehydration including skin turgor, oral mucosa, etc.

b. Encourage the client to increase the fluid intake.

c. Monitor I & O and IV fluids q4h

d. Keep a quiet environment and calm activities.

e. Provide health teachings on avoidance of dehydration.conducive for sleeping

- This will provide a data that could be used to evaluate the proper intervention that the client needs.

-To reduce the dryness of the oral mucosa

-To determine if IV fluid and electrolyte replacement are needed

-To reduce stress and anxiety

-To promote awareness on related factors

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ORMOC CITYName: Mr. Marlou W. Miao Room Number: P2Impression/Diagnosis: Typhoid fever Physician: Dr. LabticDate of Admission: July 17, 2010

Drug Therapeutic Record

Drug/ Dose/

Frequency/ Route

Classifications/ Mechanism

of Action

Indications/ contraindications/

side effects

Principles

of

Care

Treatment Evaluation

Ceftriaxone

500g IVTT

q12h

Classification:

Antibiotics

Mechanism of Action:

- binds to 50 S ribosomal sub unit, which interferes with or inhibits protein synthesis promoting osmotic instability usually bactericidal.

Indications:

Uncomplicated gonoccocal vaginitis UTI Lower Respiratory Tract Infection Septicemia Meningitis Peri-operative prevention Acute bacterial otitis media Neurologic complication

Contraindications:

Hypersensitivity to cephalosporins severe renal disease severe hepatic disease minor infections.

Side Effects:

Hema: thrombocytopenia, leucopenia.

Inject deep into large muscle for IM such as gluteus maximus.

Obtain culture may before giving first dose

Before giving drug, ask patient if he is allergic to penicillins/cephalosphorins.

Use cautiously in breastfeeding women

Monitor Vital Signs

Tell patient/SO to report any signs of adverse reactions.

Perform tepid sponge bath for fever.

Increase fluids

Give drug with food

Medications taken at ordered dose,date and time. Desired effects obtained.

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GI: Nausea, vomiting, diarrhea, abdominal pain, colitis, glossitis

CNS: headache, depression, dizziness, fever

CV: phlebitis

Skin: pain, induration, tenderness at injection site, rash, pruritus

Not to exceed with recommended dose.

Paracetamol

(tempra syrup) 5ml q4 hours PRN for T = 38˚C

Classification:

Antipyretics Analgesics

Mechanism of Action:

- antipyretic action results from inhibition of prostaglandin in the Central Nervous System; may block pain impulses peripherally that occur in response to inhibition of prostaglandin synthesis.

Indications:

Fever mild pain

Contraindication:

Hypersensitivity Anemia Hepatic or severe renal disease

Side Effects:

Hema: leucopenia, neutropenia, hemolytic anemia

CNS: drowsiness

GI: nausea, vomiting, abdominal pain, hepatotoxicity,

INTEG: rash urticaria

Not to exceed with recommended dose; acute poisoning with liver damage may result

Use liquid form for children & pts with difficulty in swallowing.

In children,

Give with full glass of water

With food or milk to decrease gastric symptoms.

Increase fluids

Monitor V/S

Avoid usage of multiple preparations containing acetamen

Medications taken at ordered dose,date and time. Desired effects obtained.

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don’t exceed 5 doses in 24 hours.

Carefully check over-the-counter products

Give drug with food

ophen.

Perform Tepid Sponge Bath

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SOAPIE #1

“gitugnaw kuno siya.” As verbalized by the grandmother.

Received patient lying in bed, with an of IVF of #2 D5IMB @ 18cc/hr at

the right dorsum of his hand, conscious, and responsive. The patient looks

tired and skin is warm to touch. Patient has flushed skin, teary eyes,

cracked lips and is shivering. Patient’s vital signs are: Pulse rate: 120bpm,

temp: 38.5 °C, RR:28cpm

Altered themoregulation: fever related to on going infection

To report body temperature is lowered from 38.5 °C to 36.5 °C

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Monitored vital signs qshift; assisted his needs; rendered tepid sponge

bath; loosened clothing of patient; encouraged increase fluid intake;

administered tempra (antipyretic) as ordered by the physician

Patient’s temperature lowered from 38.5 °C to 37.5 °C

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SOAPIE #2

“wala siya’y gana mokaon.” As verbalized by the grandmother.

Received patient lying on bed, with an IVF of #2 D5IMB @ 18cc/hr on his

right hand, conscious and responsive. The patient looks tired and ate only

5 tablespoons of her breakfast. Patients vital signs were: temperature: 37

°C, pulse rate: 118 beats per minute, respiration rate of 22 cpm

Altered Nutrition: less than body requirements related to decreased

appetite

To promote optimal nutritional status as evidenced by eating up her entire

meal

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Monitored vital signs; attended patients needs; provided small frequent

feedings; limited activities of patient; offered healthy fruit juices;

organized nursing activities

The patient was eating his fruits and drinking his juices. He was able to

finish eating more half of his lunch.



PLAY THERAPY

Developmental

taskType of Play Objective of Play Framework of Play

Toddler (1-3 Years old)

- leaves and independent behaviors regarding toileting, bathing, feeding, dressing, exert self awareness exercise device

Source:

PARALLEL PLAY

The toddler demonstrate little attention to the feelings of play pattern and frequently grabs desired toys or hates others to keep favorite toy.

After 45 minutes of conduction play therapy, the patient will be able to:

1. develop necessary source of touch

a. provide necessary materials or toys that have different textures (smooth, rough, soft and hard)b. let the child touch the different materials providedc. use different sizes of boxes to use for put in and take out toyd. ask mother to had her cuddle the toddler in her lap

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(Pediatric Nursing by Pot)

2. interact with the environment by responding to various stimuli

3. develop fine motor skills through playing

a. talk to the child in a soft and exciting mannerb. allow child to listen to her heartbeat through the stethoscope

a. prepare variety of objects to handle such as rings, blocks, squeeze toy etc. that the child could lift with one handb. walk with the child in the hallwayc. allow child to run but assist her properly

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Evaluation and Recommendation

The prognosis of the patient is good because he is responding to the treatment and

nursing interventions positively. Improvements have been noticed in the patient, such as increase

food intake, afebrile for 2 days now, increased activity tolerance and compliance of medication

intake. The patient was advised not to eat foods or drinks from unsanitary area or container.

Thus, the student nurse recommends having a continuous care of the client. The

family should support the patient in all aspects since this is the time when the client needs his

family so much. The client should take vitamins and eat lots of fruits and vegetables. Prevention

of any other disease depends on the client himself.

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Evaluation and Implication

Nursing Practice:

Nursing action should be based on standard nursing practice developed through

the basic foundation of biological and psychological sciences. This case study will provide more

emphasis on the treatment of typhoid fever. It is designed to improve and assist individuals to the

performance of nursing care to patient with typhoid fever. The student nurse should have an

attitude of caring characterized by a free and easy environment. This may mean rendering

holistic nursing care effectively and efficiently. It is important to emphasize the good of the

positive aspects in what the patient is capable of doing.

Nursing Education:

This case study will enhance and broaden the knowledge, expertise and ideas

about typhoid fever through the information gathered. It will also contribute to the important

facts when we talk of communicable nursing and will provide a concrete example in the other

related studies during discussion. One can also compare and actual situation with basic

information and may come to appreciate man’s unique being.

Nursing Research:

This case study will enhance research regarding initiating a holistic nursing care

to a patient with typhoid fever. There has always been a need to know more about nursing

measures to be rendered. Through this case study, more works will be instilled towards the

patient with typhoid fever. Researchers may be inspired to continue to research, more

comprehensions and extensive study especially with complications and their response to the care

given.

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Bibliography

Books:

Billings, Diane McGovern. Medical- Surgical Nursing. The C.V. Mosby Company. 11830

Westline Industrial Drive, TS. Louis, Missouri. 1987.

Black, Joyce M. Luckmann and Sorensen’s Medical-Surgical Nursing. 4 th edition. W.B.

Saunders Company. 1993

Bullock, Barbara L. Pathophysiology. 4 th edition. Lippincott Williams and Wilkins Company.

Philadelphia, Pennsylvania. 2001

Holloway, Nancy M. Medical-Surgical Care Planning. 3 rd edition . Springhouse Corporation.

Springhouse, Pennsylvania. 1999

Kozier, Barbara, et al. Fundamentals of Nursing. 5 th edition. Addison Longman Inc. Singapore.

1998

Merch, et al. The Merck Manual. 16 th edition. Merck Research Laboratories. New Jersey.1992

Hockenberry, Marilyn J. Wong’s Essentials of Pediatric Nursing. 7 th edition . Mosby, Elsevier

Inc., Philippines. 2005

Marieb, Essentials of Human Anatomy and Physiology 7 th Edition , Pearson Education Inc., San

Francisco, 2003

Doenges, Moorhouse and Geissler-Murr, Nurrse’s Pocket Guide Diagnoses, Interventions

and Rationale 9 th Ed , Taber’s Publisher, Philadelphia, Pennsylvania, 2004

Internet:

Microsoft® Encarta® Encyclopedia 2002. © 1993-2001 Microsoft Corporation. All rights

reserved.

www.innerbody.com

http://en.wikipedia.org/wiki/Typhoid_fever

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http://www.innerbody.com/

Documents

A Case Study on Typhoid Fever