PUBLIC HEALTH NURSING PRATICUUM (NRS 508)

A CASE STUDY ON A PATIENT WITH TYPHOID FEVER

SUBMITTED TO:

DEPARMENT OF NURSING SCIENCE,

FACULTY OF MEDICAL SCIENCE,

UNIVERSITY OF JOS.

IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD

OF BACHELOR OF NURSING SCIENCE (BNSc) DEGREE.

SUBMITTED BY:

CHUKWUKA HENRY

UJ/2005/MD/0176

MARCH, 2012

DEDICATION

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This work is dedicated to my Dad, Sir C.Y Chukwuka, my Mum, Lady

Emelda Chukwuka and my siblings; Gerald, Cyprian, and Cynthia for your

support and love. And also to my friends; Peace Nelson, Oche, Stephen

and Obetta, you guys are the best.

ACKNOWLEDGMENT

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I would like to acknowledge Mr. J.D Goshit, under whose supervision I am

undertaking this case study. The matron and entire staff of Bukuru P.H.C,

for supplying data and permitting me to use the hospital records. My group

members, thank you for helping out in the care of my client. I also

acknowledge Martha, for a wonderful typing and compilation job.

TABLE OF CONTENTS

Title page - - - - - - - - - i

iii

Dedication - - - - - - - - - ii

Acknowledgement - - - - - - - - iii

Table of contents - - - - - - - - iv

CHAPTER ONE

INTRODUCTION

Objective/Purpose of cases study - - - - - 1

Client’s Particulars - - - - - - - 2

CHAPTER TWO

LITERATURE REVIEW

Anatomy and Physiology review Gastrointestinal System - 3

Typhoid Fever - - -- - - - - 4

Theoretical Framework - - - - - - 7

CHAPTER THREE

NURSING PROCESS AND MANAGEMENT OF MISS. ESTHER MATHEW

Nursing Assessment - - - - - -- 9

Medical Management - - - - - - 10

Nursing Management - - - - - - 11

Nursing Diagnosis and Care Plan - - - - - 13

Advice on Discharge - - - - - - 13

Evaluation - - - - - - - - 14

Recommendation - - - - - -- - 14

Conclusion - - - - - - - - 14

References - - - - - - - - 15

Nursing Care plan for Miss. Esther Matthew - - - 16

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CHAPTER ONE

INTRODUCTION

Typhoid fever otherwise known as enteric fever is an acute illness

associated with fever caused by the Salmonella typhi bacteria.

Salmonella typhosa is a short, gram negative rod that is flagellated and

actively motile. Contaminated food or water is the common medium of

contagion.

Typhoid fever is characterized by:

- A slow progressive fever as high as 400c (1040f)

- Profuse sweating

- Gastro-enteritis

- Non-bloody diarrhea

- Rash made up of flat, rose coloured spots.

Common causes of transmission are flying insects most specifically

flies feeding on faeces 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 through 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 vaccines

are also available as preventive measure. Typhoid is only transmitted from

human to human

The discovery of oral rehydration therapy provided a simple way to

prevent many of the deaths of diarrheal diseases in general. Treatment of

choice is by use of a fluoroquinolone such as ciprofloxacin, otherwise a

third generation cephalosporin such a ceftriaxone or cefotaxime is the

first choice.

Objective/Purpose of Case Study

The following are the objectives of study to student nurse, client and

significant others;

1

The students nurse will be able to:

1. acquire knowledge, attitude and skills about the care for community

patients with typhoid fever.

2. Make thorough nursing assessment of the client to be able to come

up with an apposite plan of care.

3. Explain the pathophysiology of typhoid fever

4. Recognize the possible symptoms of typhoid fever manifested by the

patient.

5. List ways of preventing typhoid fever.

6. Render appropriate nursing care, medicate properly and accurately

the prescribed medication.

The patient and significant others will be able to:

(1) Understand awareness of the disease.

(2) Identify risk factors, causes and Recognize own symptoms of typhoid

fever.

(3) Learn and understand why laboratory examinations are being done.

(4) Show proper diet and exercise and stress its importance in

promoting health and preventing further complications.

(5)Display proper hygiene techniques and stress its importance in

promoting health and preventing further complication.

Client’s Particulars

It was on 30th January 2012 when our team was exposed to our first

community posting. I observed that within the period of posting 60% of

client where diagnosed with typhoid fever. This led me to carry out an

assessment on Gyel community, investigating sanitation, hygiene and

water supply.

Patients name is Miss Esther Matthew and her mother is Mrs.

Matthew. She is a native of Berom from Gyel district. She is fourteen years

old at present she is in primary six. She was seen by Mr Dung (consulting

CHEW) who requested for laboratory examination and made a diagnosis

of Typhoid fever.

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CHPATER TWO

LITERATURE REVIEW

Anatomy and Physiology Review Gastrointestinal System

To aid in understanding the disease process, Anatomy and

physiology provides the necessary information about the normal function

of certain body components, its structure and function. The

gastrointestinal tract (GIT) consists of a hollow muscular tube starting from

the oral cavity, where food enters the mouth, continuing through the

pharynx, esophagus, stomach and intestines to the rectum and anus,

where food is expelled. There are various accessory organs that assist the

tract by secreting enzymes to help breakdown food into its component

nutrients. Thus the salivary glands, liver, pancreas and gall bladder have

important functions in the digestive system. Food is propelled along the

length of the GIT by peristaltic movements of the muscular walls.

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Diagram showing organs of GIT.

Peyer’s Patches

Numerous lymph nodes are found in the mucosa at irregular

intervals throughout the length of the small intestine. The smaller ones are

known as solitary lymphatic follicles, and about 20 or 30 larger nodes

situated towards the distal end of the ileum are called aggregated

lymphatic follicles (Peyer’s patches). These lymphatic tissues, packed with

defensive cells are strategically placed to neutralize ingested antigens

(Ross and Wilson, 2006).

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Section of small intestine showing Peyer’s patches.

Typhoid Fever

Definition

Typhoid fever, otherwise known as enteric fever, is an acute illness

associated with progressive fever, gastroenteritis, non-bloody diarrhea,

profuse sweating transmitted by the ingestion of food or water

contaminated with the faeces of an infested person, which contain the

bacterium Salmonella typhi (Wikipedia, 2011).

Causes, Transmission and Risk Factors

Typhoid fever is caused by a bacterium Salmonella typhi. The

bacteria may be spread through poor hygiene habits, and public sanitation

conditions, and sometimes also by flying insects feeding on faeces. Risk

factors include living in developing country, poor sanitation, poor toileting

habits, poor drainage, improperly prepared food, areas with wells as

sources of drinking water, eating food from outside sources, war and

natural disasters, as well as weak or non-existent of health care

infrastructure.

Epidemiology

World health organization identifies typhoid as a serious public

health problem. Its incidence is highest in children and young adults

between 5 and 19 years old. Both genders have equal chances of acquiring

the disease. Asian, African and American are at greatest risk of acquiring

disease since geographic location plays a part.

Clinical Manifestation

The disease follows four stages:

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(a) First stage is known as incubation period, usually 10-14 days in

occurrence. In this stage generalization of the infection occurs.

(b) Second stage: In the second stage aggregation of the macrophages

and edema in focal areas indicates bacterial localization

(embolization) and resultant toxin injury which disappear after few

days.

(c) Third Stage: This stage of disease is dominated by effects of local

bacterial injury especially in the intestinal tract, mesenteric lymph

nodes, spleen, and liver

(d) Fourth Stage: This is also referred to as the stage of lysis. It is the

stage in which infections process is gradually overcome. Symptoms

slowly disappear and the temperature gradually returns to normal.

The symptoms of typhoid fever include:

- high progressive fever

- chills, cough,

- muscle pain

- weakness

- stomach pain

- headache

- rash made up of flat, rose-colored spots

- non-bloody diarrhea (less common symptom)

- Sometimes there are mental changes, known as typhoid psychosis.

- Profuse sweating.

Pathophysiology

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

the blood stream through the bowel, principally through the infected

peyer’s 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 coloured; the third week the sloughs separate and

leaves an ulcerative surface, which then starts to heal by granulation.

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Since the organism reaches all parts of the body through the blood stream,

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 matter.

The urine may be milky in appearance with the peculiar

opalescence, which is due to the presence of millions of typhoid bacilli in it.

The causative organism invades the blood stream 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 there 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 1040f.

Temperature drops at the end of third week due to lysis. The temperature

is irregular, with two (2) remissions in the morning. (smeltzer and Bare,

2004).

Diagnosis

Diagnosis is made through the following:

1. Clinical manifestation/presentation: The presenting signs and

symptoms can be used to make diagnosis.

2. Blood test: This include complete blood count and differential white

blood cell count

3. Bone marrow

4. Stool cultures: Colour, consistency and mucus

5. Widal test: Demonstrates salmonella antibodies against antigens.

6. Urinalysis: Colour, albumin, sugar, transparency, PH, specific gravity

Prevention

Typhoid fever can be prevented through:

- Good sanitation and hygiene

- Good toileting habits

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- Proper drainage

- Chlorination of drinking water obtained from wells.

- Food should be properly prepared

- Vaccination in endemic areas.

Treatment

(1)Administer Antibiotics: This include fluoroquinolone (ciprofloxacin),

third generation cephalosporins (ceftriaxone or cefataxime) and

cotrimoxazole

(2)Administer Analgesic: Acetaminophen ( has both analgesic and

antipyretic effects)

(3)Rehydration: This include oral rehydration therapy or intravenous

infusion (pediatric saline)

Complication

The complication of typhoid fever includes:

(1) Overwhelming infection due to systemic spread

(2) Intestinal bleeding

(3) Pneumonia due to systemic spread

(4) Intestinal perforation due to penetration into Peyer’s patches.

(5) Death resulting from intestinal perforation

Theoretical Framework

The following nursing theories/models form theoretical framework for

this case study:

1. Pender’s Health promotion model

2. Nightingale’s Environment t(1) Pender’s Health Promotion

Model

The health promotion model was designed by Nola J. Pender to be a

“contemporary counterpart to models of health protection”. It defines

health as a positive dynamic state rather than simply the absence of

disease. Health promotion is directed at increasing a patient’s level of well-

being. Pender’s model focuses on three areas:

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- Individual characteristics and experiences

- behavior specific cognitions and affect behavioural outcome.

The health promotion model makes four assumptions:

i. Individuals seek to actively regulate their own behaviour.

ii. Individuals, in all their biopsychosocial complexity, interact with the

environment, progressively transforming the environment as well as

being transformed over time.

iii. Health professionals, such as nurses, constitute a part of the

interpersonal environment, which exerts influence on people though

their life span.

iv. Self-initiated recognition of the person environment interactive

patterns is essential to changing behaviour.

Health promotion behaviour is directed towards attaining a positive health

outcome such as optimal well-being, personal fulfillment and productive

living.

(2) Nightingale’s Environment Theory

As the founder of modern nursing, Florence Nightingale’s

Environment Theory changed the face of nursing practice.

The focus of nursing in this model is to alter the patient’s

environment in order to affect health, as identified in the theory are: fresh

air, pure water, sufficient food supplies, efficient drainage, cleanliness of

patient and environment, and light. A nurse’s role in patient’s recovery is

to alter the environment in order to gradually create the optimal conditions

for the patient’s body to heal itself.

CHAPTER THREE

NURSING PROCESS AND MANAGEMENT OF MISS ESTHER MATTHEW

Nursing Assessment

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1) History taken

(a) Personal History

Patients Profile

Name: Miss Esther Matthew

Age: 14 years old

Marital Status: Single

Sex: Female

Religion: Christianity

Address: Gyel

Local Government:Jos South

Next of Kin: Mrs. Esther

Relationship: Mother

Address: Gyel

Occupation: Students

Admission No: 0300/12

Date of Admission: 6th Feburary, 2012

Complaints: Fever, cough

Diagnosis: Typhoid Fever

Base Live Vitals: Temp 37.50c,

Respiration: 28cpm,

Pulse: 81bpm

Blood Pressure:90/70mmttg

Informant: Mrs. Matthew

(b) Family History

Miss Esther Matthew is the 2nd child among five siblings (3 girls and 2

boys). The eldest is 17 years and currently working as a farmer. Mr.

Matthew is her Father who is also a farmer. Mrs. Esther who is the

informant admits that there is no history of any familial disease in both

families. She also admitted that the family relationship is strong and

stable. She seldom quarrels with her husband and ensures that all her

children are on the right track.

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(c) Life Style

When asked about play, eating habits and life style of her daughter

“Mrs. Mathew, verbalized the following

- Miss Esther Mathew is socially interactive in nature.

- Patient loves eating (fruit, vegetable)

(e) Past Health History

Patient has experienced cough common cold, chicken pox in the

past. Patient has no known allergies to food and drugs.

(f) History of Present illness

She experienced fever and chills for about 9 days ago, Headache,

lethargy, fatigue, body weakness and pain within same period. Patient also

experienced diarrhea.

(2) Physical Assessment Cephalocaudal assessment shows the following

- Skin felt warm and had few abrasions

- Head, eyes were normal

- Ears: cerumen was detected

- Lips: were dry, cracking of lips noted

- Chest : Normal

- Upper and love extremities: nails untrimmed and somewhat dirty.

- Vital Signs: Baseline data;

Temperature: 37.5, Resp: 28cmp, BP: 90/75mmhg, Pulse: 81bpm. Weight: 30kg, Urine: Glucose:-ve, Protein:-ve

Medical Management

The following drugs were ordered by the consultant:

(1) Capsule Ciprofloxacin 500mg bd x 5/7

(2) Tab paracetamol 500mg tds x 3/7

(3) Tab vitamin C 200mg tds x 3/7

Drug Study

Ciprofloxacin

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Name of Drug: Ciprofloxaxin

Brand Name: Ciprotab

Classification: Antibiotics

Group: Fluoraquinolone

Dose and Frequency: 500mg bd

Mechanism of Action: Binds to 50s ribosomal subunit which interfers

with or

inhibits protein synthesis.

Indication: Infections caused by S. typhi

Contraindications: Hypersensitivity, renal disease, severe hepatic

disorder

Adverse Effect: Anemia, Nausea, vomiting, diarrhea, abdominal pain,

itching, rashes, headaches.

(2) Paracetamol

Name of Drug: Acetaminophen

Brand Name: Paracetamol

Classification: Non-opiod analgesic, anti-pyretic.

Dose and Frequency: 500mg tds or PRN.

Mechanism of Action: Blocks pain impulses, relieves fever by acting

on hypothalamic heat-regulating centre.

Indications: Mild pain or fever

Contraindication: Hypersensitivity

Adverse Effect: Anemia, leukopaenia, liver damage, jaundice, rash,

itching.

Nursing Management of Miss Esther Matthew

The following are interventions taken to improve the health of Miss Esther

Mathew.

(1) Admission and Bed Rest: Patient is admitted for some hours and

given adequate bed rest. This is to reduce metabolic consumption

and oxygen demand (to conserve energy).

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(2) Observation:

- Observe patients vital signs: Temperature, pulse rate, blood pressure

and respiratory rate.

- Feel patients skin for warmness and dryness.

- Observe lips and mouth for dryness.

(3) Nutrition

- Ensure adequate diet to meet increase metabolic demands

- Encourage intake of balanced fiber and bulk in diet to improve

consistency of stool and facilitate passage through colon.

(4) Reducing Hyperthermia

- Monitor patient’s vital signs to serve as baseline for future

comparism.

- note presence/absence of sweating, to assess degree of

hyperthermia

- Initiate tepid sponging: This facilitates heat loss through conduction

and evaporation.

- Undress and remove extra linens, to facilities heat loss by radiation.

- Administer prescribed paracetamol 500mg as antipyretic

(5) Alleviating pain due to insertion or intravenous line

- Determine possible pathophysiology/pscyhologic causes of pain, to

assess etiology, precipitating/ contributing factors

- Encourage verbalization of feelings about pain

- Administer analgesics as indicated

(6) Advice in discharge

(7) Resolving vomiting/fluid volume depict

- Prepare and administer oral rehydration solution

- Administer intravenous fluid of normal saline to alternate 5%

dextrose solution

- Monitor and record patients intake and output

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Nursing Diagnosis and Case Plan

A nursing care plan outlines the nursing case to be provided to a

patient.

Case study.

Miss Esther Mathew, a 14 year old girl was brought to the ward by

her mother Mrs. Matthew with complains of fever for 9 days associated

with chills, vomiting and weakness. A diagnosis of Typhoid fever was made

following laboratory tests. After insertion of intravenous line for fluid

replacement, she complained of acute pain around the area of insertion.

Nursing diagnosis for above case study includes:

(1) Acute pain related to presence of traumatized tissue evidenced by

grimacing and verbalization.

(2) Hyperthermia related to disease process evidenced by temperature

of 390c

(3) Fluid volume deficit related to vomiting

(4) Self-care deficit (partial) related to general weakness of the body

evidenced by inability to perform activities of daily living.

Advice on Discharge

Advice was given in the following key areas

(1) Medication

- Advice patient to take home medication following right durg,

frequency, disease and timing

- Encourage patient to follow drug regimen especially antibiotics, to

prevent resistance

(2) Environment

- Instruct patient to stay in calm, quiet

- Home environment must be free from slipping or accident hazards

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(3) Treatment

- Inform patient to have a follow-check up after 1-2 weeks.

(4) Health Teaching

Inform patient about proper food handling techniques as necessary

- Stress the importance of proper hygiene like hand washing, toileting,

tooth brushing and bathing.

- encourage client to engage in range of motion exercises

- Instruct patient and significant others to drink only purified/boiled

water.

- Advice patient to increase fluid intake for hydration purposes.

- Advise patient to avoid eating foods from outside sources.

(5) Instruct patient to report signs and symptoms of typhoid fever like

high grade fever, diarrhea etc.

Evaluation

The prognosis of Miss Esther is good because she is responding to the

treatment and nursing interventions positively. Improvement has been

noticed in the patient, such as increase food intake, afebrile for days now,

increased activity tolerance and compliance to medication.

Recommendation

As a degree nurse, I will make the following recommendations:

- Water should be boiled or chlorinated (water guard) before use as

drinking water.

- Community should be informed and educated on the prevalence of

typhoid fever and on ways to prevent it.

- Proper sanitation and drainage is needed to prevent such disease.

- Local government should work on building manual borehole at the

rate of one borehole to 15 houses.

- Bukuru express P.H.C should be manned by a generalist physician or

a well trained BNSc nurse to foster better diagnosis and treatment of

typhoid fever and other diseases.

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CONCLUSION

Typhoid fever is one of the most common worldwide illness most

specifically in third world (developing) countries such as ours, this is the

question of sanitation since this disease is transmitted through ingestion of

food or water which is improperly prepared and contaminated with faeces

of an infected person. Gyel community is one of such areas with a high

incidence of typhoid fever.

REFERENCE

Anne W, Allison G. Ross and Wilson Anatomy and Physiology in health and illness 10th editon. Elsevier limited Philadelpia 2006.

Billings, Diane McGovern, Medical-Surgical Nursing. The C.V mosby company y. 11830 westline industrial drive, T.S Louis, Missouri 1987.

Bullock, Barbara . Pathophysiology 4th edition. Lippincott williams and wilkins company, Philadelphia, pennyslvania 2001.

Kozier, Barbara, et al. fundamentals of Nursing 5th edition, Addison longman inc. Singapore 1998.

Rotimi W. Nursing process: an effective tool for qualitative Nursing care 2nd

edition . creative books, Ibadan, Nigeria 2002.

Smeltzer M, Bare, et al. Brunner and suddarth, Textbook of Medical surgical Nursing 12th edition. Lippincott williams and wilkins company, Philadelphia, pennyslvania 2001.

InternetWikipedia. http://en.wikipedia.org/wiki/typhoid_fever.

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Nursing Care plan for Miss. Esther Mathew on 9th Feb. 2012

S/No Nursing diagnosis Nursing objectives

Nursing intervention Rationale Evaluation

1 Acute pain related to presence of traumatized tissue evidenced by grimace and verbalization

Patient will verbalize reduction of pain from a scale 5 to 1. Within 6 hours of intervention

(1)Accept patient’s description of pain

(2)Instruct patient to position affected arm properly

(3)Encourage participation in diversional activities like socialization or listening to music

(4)Administer analgesic as prescribed

(1) Pain is subjective experience and cannot be felt by others

(2) To promote comfort (3) This disrupts the

pain pathway (4) inhibits

prostaglandin synthesis

Patient verbalized reduction of felt pain from a scale of 5 to 1 after 3 hours of intervention

2 Hyperthermia related to disease process evidenced by Temperature of 390c.

Patient’s temperature will reduce by 10c within 1 hour of intervention

(1) expose patient to fresh air environment and fanning

(2) tepid sponge the patient intermittently

(3) Observe and record vital signs every 30mins.

(4) Administer prescribed drug

(1) This increase heat loss by radiation

(2) It increases heat loss by evaporation

(3) To evaluate progress of intervention

(4) relieves fever by acting in hypothalamic heat enter

Patient temperature was reduced by 1ºc within 1 hour of nursing intervention

3 Fluid volume deficit related to vomiting

Patient will not show signs of dehydration like dry lips within 48hrs of intervention

(1) Place patient on nil per oral until vomiting subsides

(2) administer intravenous fluid e.g. N/S alternated with 5% dextrose solution

(3) Monitor and record patients intake and output

(1) It allows intestine to rest.

(2) To replace lost fluid.(3) To assess progress

of intervention

Patient’s fluid volume was restored within 48 hours of nursing intervention

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