STI COLLEGE SOUTHWOODSLot 2A Maduya, Carmona, Cavite

COLLEGE OF HEALTH CARE

T/C Typhoid Fever; Post VP Shunt 2 Hydrocephalus and

2 Meningocele 2008

Presented By:Capistrano, Reggie

Foroneas, KarenNono, Ma. Franine Alyssa

Sobrevega, Reysie

BSN 3rd year Level-Group 3

Presented To:Herald Clarence Ambayec, R.N

March 18, 2010Division of Labor

Part of the Case Study_ Person to Discuss

A. Introduction = Marcus Dale Belisario

B. Biographical Data = Marcus Dale Belisario

C. Nursing History = Marcus Dale Belisario

D. Current Health Status = Reggie Capistrano

E. Psychological Development = Reysie Sobrevega

F.Physical Examination = Ma. Franine Alyssa Nono

G. Laboratory Examination = Karen Foroneas

H. Medical Plan of Care = Karen Foroneas

I. Anatomy and Physiology = Reggie Capistrano

J. Pathophysiology = Marcus Dale Belisario

K. Drug Study = Ma. Franine Alyssa Nono

L. Nursing Care Plan = Karen Foroneas

M. Discharge Plan of Care = Reysie Sobrevega

N. Health Teaching Plan = Reysie Sobrevega/Reggie Capistrano

O. Summary of Clients Status as of Last Day Contact = Reysie Sobrevega

INTRODUCTION:

Typhoid fever, also known as enteric fever, bilious fever, Yellow Jack or commonly just

typhoid, is an illness caused by the bacterium Salmonella enterica serovar Typhi. Common

worldwide, it is transmitted by the ingestion of food or water contaminated with feces from an

infected person. The bacteria then perforate through the intestinal wall and are phagocytes by

macrophages. Salmonella Typhi then alters its structure to resist destruction and allow them

to exist within the macrophage. This renders them resistant to damage by PMN's, complement

and the immune response. The organism is then spread via the lymphatic while inside the

macrophages. This gives them access to the Reticulo-Endothelial System and then to the

different organs throughout the body. The organism is a Gram-negative short bacillus that is

motile due to its peritrichous flagella. The bacterium grows best at 37 °C/99 °F – human body

temperature.

Salmonella Typhi lives only in humans. Persons with typhoid fever carry the bacteria in their

bloodstream and intestinal tract. In addition, a small number of persons, called carriers,

recover from typhoid fever but continue to carry the bacteria. Both ill persons and carriers

shed S. Typhi in their feces (stool). You can get typhoid fever if you eat food or drink

beverages that have been handled by a person who is shedding S. Typhi or if sewage

contaminated with S. Typhi bacteria gets into the water you use for drinking or washing food.

Therefore, typhoid fever is more common in areas of the world where handwashing is less

frequent and water is likely to be contaminated with sewage.

Typhoid fever is characterized by a sustained fever as high as 40 °C (104 °F), profuse

sweating, gastroenteritis, and non-bloody diarrhea. Less commonly a rash of flat, rose-colored

spots may appear.

Classically, the course of untreated typhoid fever is divided into four individual stages, each

lasting approximately one week. In the first week, there is a slowly rising temperature with

relative bradycardia, malaise, headache and cough. A bloody nose (epistaxis) is seen in a

quarter of cases and abdominal pain is also possible. There is leukopenia, a decrease in the

number of circulating white blood cells, with eosinopenia and relative lymphocytosis, a

positive diazo reaction and blood cultures are positive for Salmonella Typhi or Paratyphi. The

classic Widal test is negative in the first week.

In the second week of the infection, the patient lies prostrated with high fever in plateau

around 40 °C (104 °F) and bradycardia (Sphygmo-thermic dissociation), classically with a

dicrotic pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This

delirium gives to typhoid the nickname of "nervous fever". Rose spots appear on the lower

chest and abdomen in around 1/3 patients. There are rhonchi in lung bases. The abdomen is

distended and painful in the right lower quadrant where borborygmi can be heard. Diarrhea

can occur in this stage: six to eight stools in a day, green with a characteristic smell,

comparable to pea-soup. However, constipation is also frequent. The spleen and liver are

enlarged (hepatospleenomegaly) and tender and there is elevation of liver transaminases.

Blood cultures are sometimes still positive at this stage.

In the third week of typhoid fever a number of complications can occur:

Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very

serious but is usually non-fatal.

Intestinal perforation in distal ileum: this is a very serious complication and is

frequently fatal. It may occur without alarming symptoms until septicaemia or diffuse

peritonitis sets in.

Encephalitis

Metastatic abscesses, cholecystitis, endocarditis and osteitis

The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the

patient is delirious (typhoid state). By the end of third week defervescence commences that

prolongs itself in the fourth week.

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.

Typhoid can only spread in environments where human feces or urine are able to come into

contact with food or drinking water. Careful food preparation and washing of hands are

therefore crucial to preventing typhoid.

STI COLLEGE SOUTHWOODS

Lot 2A Maduya, Carmona, Cavite

COLLEGE OF HEALTH CARE

PATIENT’S HISTORY

A. Biographical Data

Name: Baby Pops

Age: 2 years old and 5 months Gender: Male Status: Pedia

Address: San Pablo City, Laguna

Dialect/Language Spoken: Tagalog and English

Chief Complaint: On and off fever x 6 days with poor oral intake

Admitting Diagnosis: T/C Typhoid Fever; Post VP Shunt 2 Hydrocephalus, 2 Meningocele

B. NURSING HISTORY

1. History of Present Illnesses

Last January 16, 2010 Baby Pops experience a fever with 39C consistent of 6

days and self medicated by his mother and given Paracetamol syrup p.o without

any consultation to the doctor. Then 6 days of fever the mother decided to go to

the hospital and having consultation, when they arrived to the hospital and

consulted by the doctor, the mother advised to admit Baby Pops.

2. Family History

Male: Female: Patient:

3. Childhood Illnesses

According to the mother, Baby Pops had only a cough and colds and fever.

4. Hospitalization History

First Admission

When Baby pops was 9 months old and diagnosed Pneumonia at PPL San Pablo,

Laguna

Second Admission

When Baby Pops was 1 year old and 4months and admitted at the PGH Manila

December 11, 2008 Lumbuscral Myelomeningocele

December 24, 2008 Inserting VP Shunt

-No abnormality

-Hirshprung disease-Diabetes

-Hydrocephalus-Lumbuscral Myelomeningocele

C. CURRENT HEALTH STATUS

A. Activity

Frequency and regularity of exercise: Baby Pops always wants to bend, to crawl

and to play basketball with his dad.

Duration and Length of Exercise: “Malimit” o “Maya’t maya” is how his mother

describes the duration of his exercise. While if his playing

basketball, he plays at least 2 hours

Limitation of Activity: Baby Pops mother limited him to walk and to play with

relatives especially his cousins, causing him to be tease.

Any Complaints and Discomfort: Baby Pops doesn’t have any discomfort or

complaints related to the activity.

B. Rest

Usual no. of hours of sleep and rest at night/at day time: At night, Baby Pops

usually sleeps 10 hours and while in day time, he usually

sleeps at around 10:30am-1:30pm but sometimes, kit

depends on the environment.

No. of hours of sleep and rest to feel rested: Usually, Baby Pops sleeps 4 hours to

feel rested.

Change in sleep/rest pattern: Baby Pops doesn’t have any changes in sleeping, but

sometimes it depends on the situation.

Discomfort or difficulty going to sleep: He doesn’t have any discomfort going to

sleep but sometimes he get easily destructed when stranger

hold his IV line or touch him, because his mother and his

grandmother can only touch him.

Remedy done with the comfort: The only remedy done with this discomfort was

“yapos lang ng nanay ang gusto niya”, said by the mother.

No. pillows use when sleep: He had 4 pillows when sleeping; 1 for the head, 1 on

each side and a hotdog pillow to embrace.

C. Nutritional Metabolic Pattern

Food Preference: Baby Pops loves to eat rice and “bulanglang” a kind of mixed

vegetables, that popular in Bisaya.

Volume and type of fluid taken per day: He drinks 18oz of milk twice a day, with

“sabaw ng buko and mais”

Source of drinking water: The mother gets water for Baby Pops on a Wilkins mineral

water

Medication used (if any): At home, the mother gives multivitamins like Growee and

Propan TLC, for protection and for rapid growth.

D. Elimination Pattern

i. Bladder

Frequency and amount of urination per day: Baby Pops usually uses 2

(XL) diapers a day.

Color and odor of urine: He had light yellow color urine and with aromatic

odor which indicates of the normal findings.

Any discomfort of urination: The child also doesn’t have any complaints

in urination.

ii. Bowel

Frequency of bowel movement: Baby Pops usually defecate 1 or 2 times

a day.

Consistency and color of stools: Baby Pops had a soft stool and scanty

odor and slightly brownish color as alleged.

Changes in bowel elimination: After surgery, he had experienced bowel

movement difficulty.

E. Fluids and Electrolytes

Skin turgor: Baby Pops was found to have a normal skin turgor when pinched,

within 1-2 seconds skin returns to normal prior to the

assessment.

Condition of mucous membrane: Baby Pops mucous membrane was good with

some mild pinkish mucous membrane.

Edema: There were no evident edemas observed on the pt. face and on the lower

and upper extremities.

K, Ca, Na, and supplementation: The present fluid supplement upon assessment

was D5IMB solution.

F. Senses

There are no disturbances or difficulty aside from touch, he just got easily

destructed and disturbed when somebody holds or touch him.

G. Skin Integrity

Pigmentation: Baby Pops had fair skin pigmentation.

Temperature: He was cold to touch due to expose and direct air thru window.

Smooth (+) Rough (-) Soft (+) Dry (-)

H. Neurologic Function

Level of Consciousness: Baby Pops was conscious and coherent.

Orientation: Baby Pops easily becomes irritable when he sees stranger going close

to him.

Gait: Baby Pops had disturbances due to his plantar flexion of foot.

Posture: He had a plantar flexion of foot.

Changes in facial: He also had a downward deviation of the eye (sun setting).

Role Function Mode

Type of family structure: Their family structure was extended.

How many members in the family: They were composed of 5 family members.

Who is the bread winner: The present breadwinner in their family was the father and

the grandmother.

Who is the decision maker: Also, when it comes to decision making it was the father

and the grandmother, who decides in their family.

How does the family feel about the illness: The family feels sad but very supportive,

when it comes to Baby Pops’ hospitalization.

D. PSYCHOLOGICAL DEVELOPMENT

PSYCHOSEXUAL

(Freud)

PSYCHOSOCIAL

(Erickson)

COGNITIVE

(Piaget)

INTERPERSON

AL

(Sullivan)

MORAL

(Kohlberg)

SPIRITUAL

(Fowler’s)

Anal: 18 mos.-

3yrs. Old

-pleasure is

through

elimination or

retention of

Autonomy vs.

Shame and

Doubt: 18

mos.- 3yrs. old

-Impulsitivity,

determination

and compulsion

-curious to

Pre-

operational:

2-4yrs. Old

-no cause and

effect

reasoning,

Childhood:

18 mos. –

6yrs old

-learn to delay

need

gratification

Level1: Pre-

conventional

Stage 1: Age

2-3 years old

-punishment or

obedience

(heteronymous

Stage 1:

Initiative-

Projective

Faith:

Toddler/

Pre-

school

-No

spiritual

feces

-behaviors:

control of

holding on and

letting go.

-develop

concepts of

power,

punishment,

ambivalence,

concern with

cleanliness or

being dirty.

Baby Pops was

a 2years and 5

months old

child, he still

uses diaper, he

can already

control his feces

even his in the

hospital. The

resolution of the

patient was

Shame and

Doubt, due to

anxiety with

strangers.

everything that

their body

secretes

- significant

relation: Parents

Baby Pops is a 2

years old, he

already have the

authority to

command what

he wants to do

even it is

dangerous. And

he also wants to

be beside of his

mother.

egocentrism;

use of

symbols;

magical

thinking

Baby Pops was

able to imitate

different

activities

demonstrated

to him such as

throwing the

ball, asking

him to run

after you,

hides and

seeks an

example of

mental

representation

.

Baby Pops

doesn’t have

control in his

defecation,

would have a

hard time

developing his

so called

sense of

power as he

attempts to

control

himself and

his

environment.

This sense of

power can

also be used

to please the

mother. He

also learns to

interact with

the other child

to play and

build to have

friends.

morality)

-a child does

the right

things because

a parent tells

him or her to

avoid

punishment.

Baby Pops

knows how to

be an obedient

child to his

mother. But

sometimes,

the child

learns not to

follow the task

that given to

him. And a

punishment

will be given to

him.

concept

but

involves

parents on

religion

and

spiritual

beliefs.

Baby Pops

already

knows how

to pray and

always go

to church

every

Sunday

with his

parents

but he

doesn’t

know very

well about

the

concept of

religion

and

spiritual

beliefs that

his parents

taught to

him.

E. PHYSICAL EXAMINATION

Date performed: January 22, 2010 No. of hospital Days: 2 days

1. Vital signs :

a. Temperature: 36.4C

b. Pulse Rate: 103bpm

c. Respiratory Rate: 25cpm

2. Regional Examination:

Regions of the bodyMethods of Assessment

(IPAP)Results

a. Hair Inspection Short, slightly oily hair

b. Head

Inspection

Palpation

Oblong shape, open anterior

fontanel at the frontal area,

(+) VP Shunt tube located at

the right temporal, (-) mass,

(+) scar at least 1 inch at

the right occipital area.

c. Face

Inspection

Symmetrical, with slight

bulging at the top of head,

downward deviation of eyes.

d. Eyes

Inspection

“Sunsetting” eye, watery

color of the eye is black,

constricted, (eyes do not

follow in response to head

movement) can focus on

objects 7-8 inches away, can

follow up to midline,

Eyelids-fully cover eye when

close and partially raise

when open (blink reflex

present), placement in eye

socket-normally placed.

e. NoseInspection

Flat nose, smooth, (-)

distress, (-) nasal flaring

f. Mouth and pharynx

Inspection

Lip color-normally pinkish,

open evenly when cry, soft

and hard palate intact,

tongue slightly heart shape,

freely movable and does not

protrude, milk teeth present,

but upper teeth in front are

decayed.

g. Neck

Inspection

Symmetric, flexible and

movement of the head

equally to both sides,

supported by pillows when

eating, (+) lymph nodes

h. Chest wall ( Anterior) Inspection Symmetric, clavicles

Auscultation

straight, (-) fractures, heart

rate heard at the mid

clavicular space at fourth

intercostal space (103bpm),

(-)murmur

i. Chest wall (Posterior)

Inspection

Auscultation

(-) fracture, spine is aligned,

(-) murmur. At the midline of

lumbar area (+) scar 1 ½

inch long due to lumboscral

myelomeningocele

j. Breast and Axilla

Inspection

Nipple are prominent, well

formed and symmetrical

place

k. Heart

Auscultation

103bpm, apical pulse and

respiratory rate identified,

normal rhythm

l. Abdomen

Inspection

Auscultation

(-)kidney and spleen

enlargement, (+)

burborgymi sounds (18p/m),

globular, , (-) masses

m. Skin and nails

Inspection

Skin- (-)dry, (+) smooth

Nails- short nails with some

dirt at the “singit” inside

nails

n. Anus and Rectum

Inspection

(+)patent anus, (-)rashes,

(-)hemorrhoids

BM- 1x

o. Extremities (lower)

*include ROM and

muscle strengthInspection

Palpation

Rating: 5 normal, there is an

active resistance with simple

motion

-equal in length, five

fingers on each feet, but the

both foot is in plantar flexion

(equinus)

p. Extremities (upper)

*include ROM and

muscle strength

Inspection

Palpation

Rating: 5 normal, there is an

active resistance with simple

motion, complete fingers on

both hands

q. Urinary Inspection Color- light yellow

Transparency- turbid

Specific Gravity- 1.005

Reaction- acid

Albumin- ++

Sugar- negative

Pus Cell- TNTC

RBC- 2-4hpf

Bacteria- +

Epithelial Cell- few

Crystals- Amorphous

Urates(+)

Void- 2 diapers per day

r. Genitals Inspection (-) hernia

s. Musculoskeletal

Inspection

- (-) weakness, equal size on

both side of the body,

smooth and coordinated

movements

- (+) equinus (plantar flexion

of foot)

- no tenderness, swelling of

joints

- (+) gait problems

t. Hematology Based on laboratory Refer to Lab results

If applicable please include Neuromuscular Vital signs / assessment

F. LABORATORY EXAMINATION

Date and

Type of

Examination

Purpose of

the

examinatio

n to the

patient’s

case

Normal

Values

Results of

the

examination

Interpretation

Nursing

responsibiliti

es

(before,

during ,

after)

1-22-10

Urinalysis

-to detect

normal

versus

abnormal

urine

component

Color:

yellow-

straw/amber

Transparen

cy: clear

Color: light

yellow

Transparen

cy: turbid

All of the results

in the urinalysis

that are

significant is the

presence of pus

cells

Before: Check the

chart of the pt. And carried out doctor’s order

During: Explain the

Hematology

-to detect

glycosuria

-to aid in the

diagnosis of

a renal

failure

- to check

the blood

component

for any

abnormality

Specific

Gravity:

1.010-1.020

Reaction:

4.5-8.0

Albumin:

Negative

Sugar:

Negative

Pus Cell:

3-4

RBC: 1-2

Bacteria:

Negative

Epithelial

Cells:

Negative

Crystals:

Negative

HGB- (110-

165 g/L)

HCT- (0.35-

0.50 g/L)

Specific

Gravity:

1.005

Reaction:

acidic

Albumin:

++

Sugar:

Negative

Pus Cell:

too numerous

to count

RBC: 2-4

Bacteria:

Positive

Epithelial

Cells: few

Crystals:

amorphous

Urates:

Negative

HGB- (94.6

g/L)

HCT- (0.26

g/L)

The urine of the

patient was

diluted due to

less specific

gravity

CSF was

composed of

protein

Due the VP shunt

the patient have

Due to his

hydrocephalus

and the VP Shunt

Due to the

decrease

procedure to the pt. And its importance.

Assist client with the urine collection as needed

Obtain history of excess amount of certain foods such as carrots, rhubarb

After: Provide

Comfort to the pt. After the procedure.

Wait for the

result

Before:

Check for

CBC order

Carry Out

Doctors

TYPHIDOT

- to check

the volume

of RBC’s in

the blood

To

determine

the

presence of

Salmonella

typhi which

is the

causative

agent of

typhoid

fever

Platelet

count- (150-

450 x 10

g/L)

WBC- (5.0-

10.0 x 10

g/L)

Differential

count-

Segmenter

s- (43.0-

76%)

Lymphocyt

es- (17-

48%)

Leukocytes

- (4.0-

10.0%)

IgM:

Negative

IgG:

Negative

Platelet

count- (226

x 10 g/L)

WBC- (12.0 x

10 g/L)

Differential

count-

Segmenter

s- (60.7%)

Lymphocyte

s- (32.7%)

Leukocytes-

(6.6%)

IgM: Positive

IgG:

Negative

pressure in his

VP Shunt

An increase in

WBC which

signifies a

current infection

Implication for

the presence of

IgM antibodies

includes previous

infection or

relapsed or re-

infection,

therefore; it is

important that

interpretation be

made together

with the clinical

symptoms to

diagnosed if the

Order

During

Explain

the

procedure

to the pt.

and what

is to be

withdrawn

from the

blood.

Assess

client for

signs/symp

toms of

allergies

such as

tearing,

runny nose

and rashes

After

Wait for

the result

Before:

Check for

CBC order

Carry Out

Doctors

Order

During

Explain

the

procedure

to the pt.

and what

is to be

withdrawn

patient is

currently having

typhoid fever.

from the

blood.

After

Wait for

the result

G. MEDICAL PLAN OF CARE

Date of the

orderDoctor’s order

Responsibility of the

nurse with the order

Purpose of the

given order

1-21-10

1-22-10

- pls. admit to Pedia ward (Misc) under Dr. Mamasig

- Secure Consent

- TPR q shift and recorded

- Soft diet

- Labs: CBC with platelet

U/A

Typhi dot

- Tx D5 0.3 NaCl 500ml x 55ugtts/min Chloramphenicol 300mg TIV (-) ANST every 6 hours Paracetamol 125/5ml every 4 hours p.o

- TSB inform PROD of the admission

- Pls. re-insert IV- Pls. give chloramphenicol

IV drip for 15 units

- Ask if the Doctor had already inform her and had signed the consent- Monitor V/S every 4 hours- Inform the mother the proper diet for the patient

- Executes as per Doctor’s order- Refer to Medical Technologists

- Executes as per Doctor’s order- Carried out

- Carried out

- for admission

- for legal purposes

-as baseline data

- To know the proper nutrition for the patient- To further know the other complications to the disease- To assess for any abnormalities within the urinary system as well as for systemic problems that may manifest symptoms through the urinary tract. -To detect Typhoid fever and any other salmonella infection.

8:00 am

1-23-10

1-24-10

1-25-10

1-26-10

1-27-10

1-28-10

- Refer- IVF TF #2 D5IMB 500ml x

8 hours

- Continue meds- TF #3 D5IMB 500ml x 8

hours

- Continue meds- Pls. re-insert IV now- Warm compress on IV

sites

- IVF TF #4 D5IMB 500 x 8 hours

- Continue meds- Refer

- IVF TF #5 D5IMB 500 x 8 hours

- Continue meds- Refer

- IVF TF #6 D5IMB 500 x 8 hours

- Continue meds

- IVF TF #7 D5IMB 500 x 8 hours

- To consume IV chloramphenicol; shift to cefixime 20mg/ml 2x a day

- Refer

- Carried out

- Carried out

- Carried out

- Carried out

- Carried out- executes as per Doctor’s order

- Carried out- executes as per Doctor’s order

H. ANATOMY AND PHYSIOLOGY

The Digestive Process:

The start of the process - the mouth:

The digestive process begins in the mouth. Food is partly broken down by the process

of chewing and by the chemical action of salivary enzymes (these enzymes are produced

by the salivary glands and break down starches into smaller molecules).

On the way to the stomach: the esophagus

After being chewed and swallowed, the food enters the esophagus. The esophagus is a

long tube that runs from the mouth to the stomach. It uses rhythmic, wave-like muscle

movements (called peristalsis) to force food from the throat into the stomach. This muscle

movement gives us the ability to eat or drink even when we're upside-down.

In the stomach

The stomach is a large, sack-like organ that churns the food and bathes it in a very

strong acid (gastric acid). Food in the stomach that is partly digested and mixed with

stomach acids is called chyme.

In the small intestine

After being in the stomach, food enters the duodenum, the first part of the small

intestine. It then enters the jejunum and then the ileum (the final part of the small

intestine). In the small intestine, bile (produced in the liver and stored in the gall bladder),

pancreatic enzymes, and other digestive enzymes produced by the inner wall of the small

intestine help in the breakdown of food.

In the large intestine

After passing through the small intestine, food passes into the large intestine. In the

large intestine, some of the water and electrolytes (chemicals like sodium) are

removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus

acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in the digestion

process. The first part of the large intestine is called the cecum (the appendix is connected

to the cecum). Food then travels upward in the ascending colon. The food travels across

the abdomen in the transverse colon, goes back down the other side of the body in the

descending colon, and then through the sigmoid colon.

The end of the process

Solid waste is then stored in the rectum until it is excreted via the anus.

Digestive System Glossary:

Anus - the opening at the end of the digestive system from which feces (waste) exits

the body.

Appendix – a small sac located on the cecum.

Ascending colon - the part of the large intestine that run upwards; it is located after

the cecum.

Bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and

secreted into the small intestine.

Cecum - the first part of the large intestine; the appendix is connected to the cecum.

Chyme - food in the stomach that is partly digested and mixed with stomach acids.

Chyme goes on to the small intestine for further digestion.

Descending colon - the part of the large intestine that run downwards after the

transverse colon and before the sigmoid colon.

Duodenum - the first part of the small intestine; it is C-shaped and runs from the

stomach to the jejunum.

Epiglottis - the flap at the back of the tongue that keeps chewed food from going

down the windpipe to the lungs. When you swallow, the epiglottis automatically closes.

When you breathe, the epiglottis opens so that air can go in and out of the windpipe.

Esophagus - the long tube between the mouth and the stomach. It uses rhythmic

muscle movements (called peristalsis) to force food from the throat into the stomach.

Gallbladder - a small, sac-like organ located by the duodenum. It stores and releases

bile (a digestive chemical which is produced in the liver) into the small intestine.

Ileum - the last part of the small intestine before the large intestine begins.

Jejunum - the long, coiled mid-section of the small intestine; it is between the

duodenum and the ileum.

Liver - a large organ located above and in front of the stomach. It filters toxins from

the blood, and makes bile (which breaks down fats) and some blood proteins.

Mouth - the first part of the digestive system, where food enters the body. Chewing

and salivary enzymes in the mouth are the beginning of the digestive process

(breaking down the food).

Pancreas - an enzyme-producing gland located below the stomach and above the

intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats and

proteins in the small intestine.

Peristalsis - rhythmic muscle movements that force food in the esophagus from the

throat into the stomach. Peristalsis is involuntary - you cannot control it. It is also what

allows you to eat and drink while upside-down.

Rectum - the lower part of the large intestine, where feces are stored before they are

excreted.

Salivary glands - glands located in the mouth that produce saliva. Saliva contains

enzymes that break down carbohydrates (starch) into smaller molecules.

Sigmoid colon - the part of the large intestine between the descending colon and the

rectum.

Stomach - a sack-like, muscular organ that is attached to the esophagus. Both

chemical and mechanical digestion takes place in the stomach. When food enters the

stomach, it is churned in a bath of acids and enzymes.

Transverse colon - the part of the large intestine that runs horizontally across the

abdomen.

I. PATHOPHYSIOLOGY

A. Diagram

B. Tabular

Predisposing Factor: Age: 2years and 5 months old Sex: Male Genes

Precipitating Factors: Environment Street Foods (contaminated) Unboiled water

Multiply in lamina propia

Salmonella Typhi

Enter the G.I tract(jejunum, ileum,

colon)

Penetrate cell with little lysis

Systemic spread

Enters bloodstream via lymphatics(peyer’s patch)

Local Infection

FEVER

Release of endogenous pyrogens (prostaglandin E1) from neutrophils and macrophages (specialized form of leukocytes)

Resetting the thermostatic set point (prostaglandin E2)

The hypothalamus initiates heat production behaviors (shivering and vasoconstriction)

Definition of the

diseases

Signs and

Symptoms found in

the book

Signs and

Symptoms

manifested by the

patient

Evaluation or

comparison

Typhoid FeverA general infection caused by Salmonella typhi, a gram negative motile and nonspore- forming bacillus. It is a general infection that primarily involves the Peyer’s patches of the small intestines

Signs and Symptoms in book: Fever Anorexia Diaphoresis Weakness Myalgia Malaise Moist cracklesSecond week: 104F, evening chills Delirium Increasing abdominal pain Diarrhea or constipation Maculopapular rash cough

Signs and Symptoms in patient:

fever (6 days) anorexia constipation cough

These means that the signs and symptoms in the book about typhoid fever are seen to the patient.

J. DRUG STUDY

Name of Drug,

Classification,

Route, Frequency

and Dosage

Drug Indication Drug ActionNursing Responsibility

(before, during , after)

Chloramphenicol

(anti-infective)

R: TIV

F: q6 hours

D: 300mg

Haemophillus

influenzae

Meningitis

Acute Salmonella

typhi infection

Bacteremia

Other severe

infections caused by

sensitive Salmonella

species

Inhibits bacterial

protein synthesis

by binding to the

50 sub-unit of the

ribosome;

bacteriostatic

Use cautiously in

patient with impaired

hepatic or renal function,

acute intermittent

phorphyria and G6PD

deficiency; also use

cautiously with other

drugs that cause bone

marrow suppression or

blood disorders

Obtain specimen for

culture and sensitivity test

before giving first dose.

Therapy may begin

pending results.

Obtain plasma levels

maintain levels at 5-20

mcg/ml

Monitor CBC, platelets,

iron and reticulocytes

before and every 2 days

during this therapy. Stop

immediately if anemia

occurred.

Name of Drug,

Classification,

Route, Frequency

and Dosage

Drug Indication Drug ActionNursing Responsibility

(before, during , after)

Paracetamol

(analgesics)

(antipyretics)

R: p.o

F: q4 hours PRN

D: 4ml

Mild pain or fever Thought to produce

analgesia by

blocking pain

impulses by

inhibiting synthesis

of prostaglandin in

the CNS or of other

substances that

sensitize pain

receptors to

stimulation. The

drug may relieve

fever through

central action in the

hypothalamic heat-

regulating center.

Use liquid form for

children and patients

who have difficulty

swallowing.

In children, don’t

exceed five doses in 24

hours.

Tell parents to consult

prescriber before giving

drug to children younger

than age 2.

Advise parents that

drug is only for short-

term use; urge them to

consult prescriber if

giving to children for

longer than 5 days or

adults for longer than 5

days or adults for longer

than 10 days.

Name of Drug,

Classification,

Route, Frequency

and Dosage

Drug Indication Drug ActionNursing Responsibility

(before, during , after)

Cefixime

(anti-infective)

R: p.o

F: BID

D: 2ml

Uncomplicated UTI

caused by E. coli and

proteus mirabilis

Otitis media

caused by

Haemophillus

influenzae

Cefixime binds to

one or more of the

penicillin-binding

proteins (PBPs)

which inhibits the

final

transpeptidation

step of

peptidoglycan

synthesis in

bacterial cell wall,

thus inhibiting

biosynthesis and

arresting cell wall

assembly resulting

in bacterial cell

death.

Check if the patient is

allergy to cephalosporins

Use cautiously in

patient with impaired

hepatic or renal function,

acute intermittent

phorphyria and G6PD

deficiency; also use

cautiously with other

drugs that cause bone

marrow suppression or

blood disorders

Obtain specimen for

culture and sensitivity

test before giving first

dose. Therapy may begin

pending results.

Obtain plasma levels

maintain levels at 5-20

mcg/ml

Monitor CBC, platelets,

iron and reticulocytes

before and every 2 days

during this therapy. Stop

immediately if anemia

occurred.

Nursing Prioritization and Competencies

NO. Nursing Diagnosis Nursing CompetenciesDate

Identified

1

Ineffective Gastrointestinal Tissue

Perfusion r/t normactive bowel sounds

as manifested by burborgymi sounds

(18p/m)

Communication

Health Teaching

Safe and Quality Nursing

Care

Ethico-Moral Responsibility

Jan.22,2010

2

Impaired physical mobility r/t loss of

integrity of bone structure as

manifested by plantar flexion of foot.

Communication

Health Teaching

Safe and Quality Nursing

Care

Ethico-Moral Responsibility

Jan.22,2010

3

Knowledge Deficient r/t typhoid fever

as evidenced by unfamiliarity to the

causative factor of the disease

Communication

Health Teaching

Safe and Quality Nursing

Care

Jan.22,2010

4Severe anxiety r/t unfamiliar person as

evidenced by crying

Communication

Health Teaching

Safe and Quality Nursing

Care

Ethico-Moral Responsibility

Jan.22,2010

5

Risk for infection r/t open anterior

fontanel as manifested by scratching

of the head

Communication

Health Teaching

Safe and Quality Nursing

Care

Ethico-Moral Responsibility

Jan.22,2010

K. NURSING CARE PLAN

Cues

(subjective/

objective)

Nursing

DiagnosisObjectives

Nursing

Intervention

and Rationale

Evaluation

S: Ineffective After 4 hours - V/S monitored Goal is met.

“Malimit siya maging

tampulan ng tukso ng

mga pinsa niya” as

verbalized by the

patient’s mother

O:

- (+) burborgymi

sounds (18p/m)

- Body malaise

- Brownish color

of stool

Gastrointestina

l Tissue

Perfusion r/t

normactive

bowel sounds

as manifested

by burborgymi

sounds (18p/m)

of nursing

intervention

the patient

will be able to

decreased

burborgymi

sounds from

18p/m to

and checked for

baseline data

- Determine

whether

condition is

permanent or

temporary to

enhance

acceptance

- Establish a

patient-nurse

relationship to

convey an

attitude of

caring and

develop sense

of trust

- Auscultate

bowel sounds to

determine

problems in

abdomen

Encourage rest

after meals to

enhance

digestion

After 4 hours

of nursing

intervention

the patient

will be able to

decreased

burborgymi

sounds from

18p/m to

Cues

(subjective/

objective)

Nursing Diagnosis Objectives

Nursing

Intervention

and Rationale

Evaluation

S:

“ Malaro siya kaso

hindi talaga siya

Impaired physical

mobility r/t loss of

integrity of bone

After 5 hours

of nursing

intervention

- V/S taken

and

recorded for

Goal is met.

After 5 hours

of nursing

pinapayagan na

makipaglaro dahil

madali siya mainis at

sumungin” as

verbalized by the

patient’s mother

O:

- limited ROM

- difficulty of

turning side to

side

- (+) plantar

flexion of foot

- Difficulty to

move

structure as

manifested by

plantar flexion of

foot.

the patient

will able to

demonstrate

,

participation

in activities

command by

his mother

or relatives.

baseline

data.

- Provided

safety and

security for

the safety of

the child

- Encouraged

participation

is self care;

to encourage

self concept

and sense of

independenc

e

- Encouraged

adequate

intake of

fluids and

nutritious

food; to

promote

well-being

and

maximize

energy

production

- Instructed

proper

hygiene for

cleanliness

of the

patient to

avoid spread

of infection

- Provide quiet

and calm

environment

to promote

intervention

the patient

was able to

demonstrate,

participation

in activities,

command by

his mother or

relatives.

relaxation

Cues

(subjective/

objective)

Nursing

DiagnosisObjectives

Nursing

Intervention

and Rationale

Evaluation

S:

“ Hindi namin alam

kung paano siya

nilagnat ng mataas”

as verbalized by the

patient’s mother

O:

- Unfamiliarity to

the causative

factor of the

disease

- Restlessness

- irritability

- Knowledge

Deficient r/t

typhoid fever

as evidenced

by

unfamiliarity to

the causative

factor of the

disease

After 2 hours of

nursing

intervention

the patient will

be able to

understand the

related factors

about the

present illness

- V/S taken

and

recorded

for baseline

data.

- Explain to

the relative

of patient

the

condition of

the patient

- Discuss

related

factors

about the

present

disease

- Encourage

them to

read some

books

about the

disease and

causative

agent

Goal is

partially met.

After 2 hours

of nursing

intervention

the patient

will be able to

understand

the related

factors about

the present

illness

Cues

(subjective/

objective)

Nursing

DiagnosisObjectives

Nursing

Intervention

and Rationale

Evaluation

S:

“Madali siya matakot

sa mga taong

Severe anxiety r/t

unfamiliar person

as evidenced by

After 4 hours of

nursing

intervention

- V/S

monitored

and recorded

Goal is met.

After 4 hours

of nursing

ngayonlang niya

nakita” as verbalized

by the patient’s mother

O:

- crying

- (+) stranger

anxiety

- With poor eye

contact

- With extraneous

movement

- (+) facial

grimace

crying the patient will

be able to

develop sense

of trust.

as baseline

data

- Provide

adequate

rest to

promote

relaxation

- Build a

trusting

relationship

with the

patient to

promote

rapport.

- Encourage

patient to

play to

promote

therapeutic

empathy to

the patient

- Provide

physical

contact to

the patient

as well as

being truthful

to soothe

fears.

intervention

the patient

will be able to

develop sense

of trust.

Cues

(subjective/

objective)

Nursing

DiagnosisObjectives

Nursing

Intervention

and Rationale

Evaluation

S:

“ Lagi niya gusto

kamutin yung nasa ulo

niya’ as verbalized by

the patient’s

Risk for infection

r/t open anterior

fontanel as

manifested by

scratching of the

After 4 hours of

nursing

intervention

the pt will able

to know what

- monitor V/S

every 4 hours

as baseline

data

- soft diet

Goal is met.

After 4 hours of

nursing

intervention

the pt was able

grandmother

O:

- afebrile

- irritability

- restlessness

- (+) open

anterior

fontanel

- Scar on the

right side of the

head

- Scratching of

the head

head are the

intervention to

prevent the

risk of

infection.

instructed to

avoid

restraining

and easily to

swallow

- monitored IVF

and IV rates

- kept back dry

to prevent

occurrence of

other disease

- kept

environment

well

ventilated

- emphasized

hygiene

- provide

safety and

security such

as

don’t

leave the

child

unattende

d

put

pillows

each side

of the bed

- monitor I/O

to prevent

reoccurrence

of other

disease

- Health

teaching

instructed

such as;

to know what

the

intervention to

prevent the

risk of infection

is.

Hygiene

measures

Safety

measures

( tell

patient

not to

scratch

site of VP

shunt) to

prevent

risk of

infection

Diet

instructed

L. DISCHARGE PLAN OF CARE

Key Area Plan of Care

1. Nutrition Continue advice of soft diet as prescribed by the physician,

encourage patient to eat nutritious food, and avoid street foods

to avoid possible of having typhoid fever.

2. Activity Encourage patient or instruct mother of daily exercise, avoid

sleeping late hours, prevents activity that causes trauma or

injury

3. Self Care / knowledge on

treatments

Instructed hygienic measures (e.g. proper hand washing, before

and after eating and urinate and defecate, as well as proper

grooming)

4. Medication Advise to continue medication as prescribed by the doctor.

5. Follow up check ups To comeback as prescribed by the doctor. Have a daily

consultation to neuro and physical therapist for the VP Shunt

and for plantar flexion of foot.

M. HEALTH TEACHING PLAN

Topic ObjectiveMethods of

TeachingVisual aids Evaluation

1. Choosing Right

Foods

After 30 mins of

discussion the

mother of the pt.

Discussion

Explanation

- Sample

Procedures

After 30 mins of

discussion the

mother of the pt.

2. Importance

of clean and

safe foods

for the

family

3. Proper Boiling

of Water

4. Safety and

Security of

Child

will be able to

know the

importance and

understanding,

choosing foods

to eat

After 30 mins of

discussion the

mother of the pt.

will able to know

the importance

of clean and safe

foods for the

family

After 30 mins of

discussion the

relative of the

pt. will be able to

know the proper

boiling of water

to kill the

microorganism

in the water.

After 1 hour of

nursing care and

health teaching

the mother of

the pt. will able

to know the

safety measures

needed by the

child

Discussion

Explanation

Discussion

Explanation

Demonstration

Explanation

- Picture of

nutritious

foods

- List of right

and affordable

foods

- Notes of

importance of

clean and

safe foods

- pictures

needed for

demonstration

such as pillows,

things that

could harm your

child (e.g. knife,

holder and pins)

was able to know

the importance

and

understanding,

choosing foods

to eat

After 30 mins of

discussion the

mother of the pt.

will able to know

the importance

of clean and safe

foods for the

family

After 30 mins of

discussion the

relative of the pt.

was able to know

the proper

boiling of water

to kill the

microorganism in

the water.

After 1 hour of

nursing care and

health teaching

the mother of

the pt. was able

to know the

safety measures

needed by the

child

N. SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF CONTACT

Date: January 23, 2010

The condition of the Baby Pops on the last day of duty in the Pedia ward had no signs of

distress, afebrile and cooperative. He still afraid of strangers especially when touching

him. Baby Pops was still under observation and possible for MGH the next day.