I. Introduction Typhoidfever , otherwise known as enteric fever, is an acute illness associated with fever caused by the Salmonella typhi bacteria. S. typhosa is a short, plump, gram negative rod that is flagellated and actively motile. Contaminated food or water is the common medium of contagion. The disease follows four stages. The first stage is known as incubation period, usually 10- 14 days in occurrence. In this stage generalization of the infection occurs. In the second stage, aggregation of the macrophages and edema in focal areas indicates bacterial localization (embolization) and resultant toxic injury which disappear after few days. The third stage of disease is dominated by effects of local bacterial injury especially in the intestinal tract, mesenteric lymph nodes, spleen, and liver. The fourth stage, or the stage of lysis, is the stage wherein the infectious process is gradually overcome. Symptoms slowly disappear and the temperature gradually returns to normal. The symptoms of typhoid fever include high fever, chills, cough, muscle pain, weakness, stomach pain, headache and a rash made up of flat, rose-colored spots. Diarrhea is a less common symptom of a typhoid fever, although it is a gastrointestinal disease. Sometimes there are mental changes, know as ‘typhoid psychosis’. A characteristic feature of typhoid psychosis is plucking at the bedclothes if patient is confined to bed. Risk factors for acquiring typhoid fever likely include improper food handling, eating food from outside sources like carinderia, drinking contaminated water, poor sanitation and even poor hygiene practices. War and natural disasters as well as weak, non existent of health care infrastructure may also contribute. Both genders do have equal chances on acquiring such disease. Asian, African and Americans are at greatest risks of acquiring the disease since geographical locations play a part. Complications of typhoid fever are secondary conditions, symptoms, or other disorders that are caused by typhoid fever. Complications include overwhelming infection, pneumonia, intestinal bleeding, and intestinal perforation may eventually lead to death. Typhoid fever is one of the most protean of all bacterial diseases thus laboratory procedures are usually depended on to confirm or disprove suspicion of such disease. The place of blood culture, serologic studies and bacteriologic examination feces and urine are useful in establishing the diagnosis. Agglutination (Widal) for typhoid fever is done to determine antibody response against different antigenic fractions of organisms. Typhoid fever is treated with antibiotics which kill theSalmonella bacteria. Several antibiotics are effective for the treatment of typhoid fever. The choice of antibiotics needs to be guided by identifying the geographic region where the organism was acquired and the results of cultures once available. Two new vaccines are currently licensed and widely used worldwide, a subunit (Vi PS) vaccine administered by the intramuscular route and a live attenuated S typhi strain (Ty21a) for oral immunization. In most cases, typhoid fever is managed at home with antibiotics and bed rest. For hospitalized patients, effective antibiotics, good nursing care, adequate nutrition, careful attention to fluid and electrolyte balance, and prompt recognition and treatment of complications are strategies to avert the possibility of death.

II. Patient’s ProfilePatients name: Patient DAge: 37Sex: MaleAddress: Purok 8, dalipuga, iligan cityMarital Status: MarriedOccupation: seaman

Religion: Roman CatholicAdmission date and time: November 28, 2010 at 4:45pmAttending Physician: Dr. EstradaInitial Diagnosis: Acute bronchitis/ Typhoid FeverChief Complaint: Fever

III. Nursing History

Initial Diagnosis: Acute bronchitis/ Typhoid FeverChief Complaint: Fever

History of Present Illness

2 weeks prior to admission there is onset of fever with cough, 4days (+) LBM w/c stopped because patient took up loperamide

Past History

Childhood IllnessesDid not suffer any childhood illnesses

Childhood Immunization StatusPatient did not remember his immunization status

AllergiesNo known allergies to food, drugs, animals and other environmental agents

Accidents and injuriesPatient had experienced motor vehicle injury when he was still 13 years old

Past hospitalizationPatient was admitted at Mindanao Sanitarium and Hospital last 1983 for motor vehicle accident, he had a closed reduction on his right wrist

Family HistoryPatient had positive heredofamilial history of hypertension as his father side and some of his siblings are already diagnosed with hypertension

Social Data

Patient eats a well balanced diet; he also smokes 20 sticks of cigar per day.Patient is a college graduate with the degree of Bachelor of Science in Marine Transportation.He works as a seaman, and comes back to the Philippines for vacation every 9months, he works and provide for his family.He lives in a typical rural area.

IV. Physical Assessment

Initial vital signs: T = 38.1˚C

PR = 82bpm RR = 22cpmBP = 130/70mmHg

General Appearance

The patient is conscious, coherent and is not in distress. He looks according to age and is calm and engaging. One can see that he is well nourished and practices good hygiene.

Body Part Assessed Technique Used

Actual Finding Interpretation

Skin Inspection Palpation

Skin color is fair and even Skin is warm and dry

NormalNormal due to aging

HEENT Head Inspection

Palpation

EyesInspection

Nose

Ears

Normocephalic Evenly distributed hair, with gray hair, no dandruff, lesions nor infectionSinuses non-tender

Symmetrical eyelidsPinkish conjuctiva PERRLA

No dischargesAirways patent on both nares

No discharges

NormalNormal

Normal

NormalNormalNormal

NormalNormal

Normal

Mouth, Pharynx and Neck

Mouth

Pharynx

Neck

Has complete set of teethLips violet and dryTongue at midlineGums and mucosa pink

Tonsils not inflamedNeck symmetrical with full ROMTrachea at midline

NormalNormal (smoker)NormalNormal

NormalNormalNormal

Cardiovascular AuscultationInspection

Has audible heart soundApical pulse at 5th ICS MCLHeart is pumping well with a pulse rate of 81 bpm from the normal rate of 60-100 beats per minute

NormalNormalNormal

Extremities Inspection Palpation

Skin fair in color with no presence of marks/ scarsSkin drySkin intactNails convex curvedPink nail bedsNormal capillary refillSkin warm to touchBounding pulsesFair muscle strength Full active ROM

NormalNormal (due to aging)NormalNormalNormal<3 sec.NormalNormalNormal

Abdomen Inspection Abdomen is rounded in shape Normal

Ausculation

when sitting down and flat in supine positionThe rest of the abdomen in of same color with no abrasionBowel sounds are 1-5 bowel sound per minute

Normal

Normal

Bowel and Urine Excretion

Genitals were not assessed due to patient’s refusal.Patient was able to urinate atleast 7x since admittedPatient defecates every other day since admitted

Normal

Abnormal

Gordon’s Functional Health PatternFunctional Health Pattern

Prior to Hospitalization

During Hospitalization Interpretation

Health Perception – Health Management Pattern

He engages in simple exercises such as walking and jogging. He also follows medication regimen.

He was more inclined to bed rest due to easy fatigability but engages in ROM exercises. He eats hospital meals and fruits. He closely listens to the doctor’s and nurse’s health advices.

He manages his health well since his realization. He now takes a higher regard of health and has become more aware of lifestyle changes significances.

Nutritional – Metabolic Pattern a. number of meals per day b. appetite c. glass of water per day

3 full meals a day with good appetite

6 - 8 glasses of water a day

3 meals a day he has loss of appetite since admitted but eats meals that is served by the dietary department

6 - 8 glasses of water a day

Patient has loss of appetite due to disease process

Elimination Pattern a. frequency of urination b. amount of urine per day c. frequency of bowel movement d. consistency of the feces e. amount defecated per day

3-4 times per day Moderate Once a day

Formed Moderate

4-7 times per day Moderate Every other dayFormed Moderate

There is changes in the frequency of urination due to increase fluid intake and with the administration of IV fluids, there is also a change in bowel movement due to insufficient physical mobility

Activity – Exercise Pattern a. exercise b. fatigability c. ADL

Walking Don’t get tired easily Activities related to his work

ROM exercises Easy to get tired None

Client is easily fatigued due to present disease condition.

Sleep – Rest Pattern

Client usually sleeps at 12 midnight and wake up at 4 in the morning

Client usually has short naps and sleeps more earlier than usual

Sleep pattern is altered due to present disease condition.

Cognitive – Perceptual Pattern a. orientation b. responsiveness

Oriented to time, place and person Responds appropriately to verbal and physical stimuli

Oriented to time, place and person Responds appropriately to verbal and physical stimuli

No significant changes.

Self-Perception – Self-Concept Pattern

Client has high regard of self worth and is a positive thinker.

Client still has high regard of self worth and is a positive thinker.

No significant changes.

Role – Relationship Pattern a. as a brother b. as a husbandc. a father and grandfather

With good relationship with his siblings and provided support whenever needed With good relationship with wife With good relationship with sons and daughters as well as with in-laws and grandchildren

Still with good relationship with his siblings and provided support whenever needed Still with good relationship with wifeWith good relationship with sons and daughters as well as with in-laws and grandchildren

No significant changes

Sexual-Reproductive Pattern

Patient is not that sexually active since he works abroad and comes for vacation every 9 months

No significant changes

Coping – Stress Tolerance Pattern

In spite of challenges, he is enthusiastic of overcoming them. He is a strong willed person and his support system (family and friends) has strong foundation.

This helps in a better prognosis of his disease condition.

Value – Belief Pattern

He is a devout Catholic but he doesn’t go to church that often, because of his work.

No significant changes

Disease Process

Anatomy and Physiology Gastrointest inal system To aid in understanding the disease process, Anatomy and Physiology provides thenecessary information about the normal function of certain body components, its structure andfunction. Anatomy and physiology are always related. Anatomy is the study of the structure andshape of the body and body parts and their relationships to one another. Physiology is the studyof how the body pars work or function.The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oralcavity, where food enters the mouth, continuing through the pharynx, oesophagus, stomach andintestines to the rectum and anus, where food is expelled. There are various accessory organs thatassist the tract by secreting enzymes to help break down food into its component nutrients. Thusthe salivary glands, liver, pancreas and gall bladder have important functions in the digestivesystem. Food is propelled along the length of the GIT by peristaltic movements of the muscularwalls.The primary purpose of the gastrointestinal tract is to break down food into nutrients, which can be absorbed into the body to provide energy. First food must be ingested into the mouth to be mechanically processed and moistened. Secondly, digestion occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates are chemically broken down into their basic building blocks. Smaller molecules are then absorbed across the epithelium of the small intestine and subsequently enter the circulation. The large intestine plays a key role in reabsorbing excess water. Finally, undigested material and secreted waste products are excreted from the body via defecation (passing of faeces). In the case of gastrointestinal disease or disorders, these functions of the gastrointestinal tract are not achieved successfully. Patients may develop symptoms of nausea, vomiting, diarrhoea, malabsorption, constipation or obstruction. Gastrointestinal problems are very common and most people will have experienced some of the above symptoms several times throughout their lives. Basic structure The gastrointestinal tract is a muscular tube lined by a special layer of cells, called epithelium. The contents of the tube are considered external to the body and are in continuity with the outside world at the mouth and the anus. Although each section of the tract has specialised functions, the entire tract has a similar basic structure with regional variationsThe wall is divided into four layers as follows: Mucosa

The innermost layer of the digestive tract has specialised epithelial cells supported by an underlying connective tissue layer called the lamina propria. The lamina propria contains blood vessels, nerves, lymphoid tissue and glands that support the mucosa. Depending on its function, the epithelium may be simple (a single layer) or stratified (multiple layers). Areas such as the mouth and oesophagus are covered by a stratified squamous (flat) epithelium so they can survive the wear and tear of passing food. Simple columnar (tall) or glandular epithelium lines the stomach and intestines to aid secretion and absorption. The inner lining is constantly shed and replaced, making it one of the most rapidly dividing areas of the body! Beneath the lamina propria is the muscularis mucosa. This comprises layers of smooth muscle which can contract to change the shape of the lumen. Submucosa The submucosa surrounds the muscularis mucosa and consists of fat, fibrous connective tissue and larger vessels and nerves. At its outer margin there is a specialized nerve plexus called the submucosal plexus or Meissner plexus. This supplies the mucosa and submucosa. Muscularis externa This smooth muscle layer has inner circular and outer longitudinal layers of muscle fibres separated by the myenteric plexus or Auerbach plexus. Neural innervations control the contraction of these muscles and hence the mechanical breakdown and peristalsis of the food within the lumen. Serosa/mesentery The outer layer of the GIT is formed by fat and another layer of epithelial cells called mesothelium.

Individual components of the gastrointestinal system

Oral cavity The oral cavity or mouth is responsible for the intake of food. It is lined by a stratified squamous oral mucosa with keratin covering those areas subject to significant abrasion, such as the tongue, hard palate and roof of the mouth. Mastication refers to the mechanical breakdown of food by chewing and chopping actions of the teeth.StomachThe stomach is a J shaped expanded bag, located just left of the midline between the oesophagus and small intestine. It is divided into four main regions and has two borders called the greater and lesser curvatures. The first section is the cardia which surrounds the cardial orifice where the oesophagus enters the stomach. The fundus is the superior, dilated portion of the stomach that has contact with the left dome of the diaphragm. The body is the largest section between the fundus and the curved portion of the J. This is where most gastric glands are located and where most mixing of the food occurs. Finally the pylorus is the curved base of the stomach. Gastric contents are expelled into the proximal duodenum via the pyloric sphincter. The inner surface of the stomach is contracted into numerous longitudinal folds called rugae. These allow the stomach to stretch and expand when food enters. The stomach can hold up to 1.5 litres of material. The functions of the stomach include: 1. The short-term storage of ingested food.2. Mechanical breakdown of food by churning and mixing motions.3. Chemical digestion of proteins by acids and enzymes.4. Stomach acid kills bugs and germs.5. Some absorption of substances such as alcohol.Most of these functions are achieved by the secretion of stomach juices by gastric glands in the body and fundus. Some cells are responsible for secreting acid and others secrete enzymes to break down proteins. Small intestine The small intestine is composed of the duodenum, jejunum, and ileum. It averages approximately 6m in length, extending from the pyloric sphincter of the stomach to the ileo-caecal valve separating the ileum from the caecum. The small intestine is compressed into numerous folds and occupies a large proportion of the abdominal cavity. The duodenum is the proximal C-shaped section that curves around the head of the pancreas. The duodenum serves a mixing function as it combines digestive secretions from the pancreas

and liver with the contents expelled from the stomach. The start of the jejunum is marked by a sharp bend, the duodenojejunal flexure. It is in the jejunum where the majority of digestion and absorption occurs. The final portion, the ileum, is the longest segment and empties into the caecum at the ileocaecal junction.

The small intestine performs the majority of digestion and absorption of nutrients. Partly digested food from the stomach is further broken down by enzymes from the pancreas and bile salts from the liver and gallbladder. These secretions enter the duodenum at the Ampulla of Vater. After further digestion, food constituents such as proteins, fats, and carbohydrates are broken down to small building blocks and absorbed into the body's blood stream. The lining of the small intestine is made up of numerous permanent folds called plicae circulares. Each plica has numerous villi (folds of mucosa) and each villus is covered by epithelium with projecting microvilli (brush border). This increases the surface area for absorption by a factor of several hundred. The mucosa of the small intestine contains several specialised cells. Some are responsible for absorption, whilst others secrete digestive enzymes and mucous to protect the intestinal lining from digestive actions. Large intestine

The large intestine is horse-shoe shaped and extends around the small intestine like a frame. It consists of the appendix, caecum, ascending, transverse, descending and sigmoid colon, and the rectum. It has a length of approximately 1.5m and a width of 7.5cm. The caecum is the expanded pouch that receives material from the ileum and starts to compress food products into faecal material. Food then travels along the colon. The wall of the colon is made up of several pouches (haustra) that are held under tension by three thick bands of muscle (taenia coli). The rectum is the final 15cm of the large intestine. It expands to hold faecal matter before it passes through the anorectal canal to the anus. Thick bands of muscle, known as sphincters, control the passage of faeces. The mucosa of the large intestine lacks villi seen in the small intestine. The mucosal surface is flat with several deep intestinal glands. Numerous goblet cells line the glands that secrete mucous to lubricate faecal matter as it solidifies. The functions of the large intestine can be summarised as: 1. The accumulation of unabsorbed material to form faeces. 2. Some digestion by bacteria. The bacteria are responsible for the formation of intestinal gas. 3. Reabsorption of water, salts, sugar and vitamins. Liver The liver is a large, reddish-brown organ situated in the right upper quadrant of the abdomen. It is surrounded by a strong capsule and divided into four lobes namely the right, left, caudate and quadrate lobes. The liver has several important functions. It acts as a mechanical filter by filtering blood that travels from the intestinal system. It detoxifies several metabolites including the breakdown of bilirubin and oestrogen. In addition, the liver has synthetic functions, producing albumin and blood clotting factors. However, its main roles in digestion are in the production of bile and metabolism of nutrients. All nutrients absorbed by the intestines pass through the liver and are processed before traveling to the rest of the body. The bile produced by cells of the liver, enters the intestines at the duodenum. Here, bile salts break down lipids into smaller particles so there is a greater surface area for digestive enzymes to act. Gall bladder The gallbladder is a hollow, pear shaped organ that sits in a depression on the posterior surface of the liver's right lobe. It consists of a fundus, body and neck. It empties via the cystic duct into the biliary duct system. The main functions of the gall bladder are storage and concentration of bile. Bile is a thick fluid that contains enzymes to help dissolve fat in the intestines. Bile is produced by the liver but stored in the gallbladder until it is needed. Bile is released from the gall bladder by contraction of its muscular walls in response to hormone signals from the duodenum in the presence of food. Pancreas Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the stomach. Its head communicates with the duodenum and its tail extends to the spleen. The organ is approximately

15cm in length with a long, slender body connecting the head and tail segments. The pancreas has both exocrine and endocrine functions. Endocrine refers to production of hormones which occurs in the Islets of Langerhans. The Islets produce insulin, glucagon and other substances and these are the areas damaged in diabetes mellitus. The exocrine (secretrory) portion makes up 80- 85% of the pancreas and is the area relevant to the gastrointestinal tract. It is made up of numerous acini (small glands) that secrete contents into ducts which eventually lead to the duodenum. The pancreas secretes fluid rich in carbohydrates and inactive enzymes. Secretion is triggered by the hormones released by the duodenum in the presence of food. Pancreatic enzymes include carbohydrases, lipases, nucleases and proteolytic enzymes that can break down different components of food. These are secreted in an inactive form to prevent digestion of the pancreas itself. The enzymes become active once they reach the duodenum

PATHOPHYSIOLOGY: Typhoid Fever (book-centered)

Intestinal Wall

Macrophages (Payers Patches)

The bacteria is within the macrophages and survives

Bacteria spread via the lymphatic while inside the macrophages

Access to Reticulo endothelial system, in liver, spleen, gallbladder and bone marrow

Salmonella Typhi

Survives acidity of the stomach

Invades the Payers Patches

First week: elevation of body temperature

Second week: abdominal pain, spleen enlargement and rose spots

Diagnostic Tests/ Laboratory Results

NORMAL VALUE

RESULT INTERPRETATION

Complete Blood TestWBC

RBC

HB

HCT

Differential CountNeutrophils

Lymphocytes

Monocyte

M= 5-10x10 9/L

M= 4.5-5.6x10 12/L

M= 140-160 g/L

M= 0.40-0.48

0.55-0.70

0.25-0.40

0.01-0.08

10.2 9/L

4.6 g/L

122 g/L

0.31

0.54

0.41

0.05

Increased WBC result from bacterial infections, inflammation

Normal

Low levels indicate anemia, bleeding or iron deficiency.

Normal

Normal

Lymphocytes increase in many viral infectionsNormal

Brand Name/ Generic NameDose/Dosage/ Frequency

Indication Action/ Mechanism of Action Side Effects Nursing Precaution

Paracetamol 500mg 1tab now then q 4 PRN for fever

Buscopan 1tab now then q 8

Symptomatic relief of pain and fever

-Spastic states-Delirium, preanesthetic sedation and obstetric amnesia with analgesics-To prevent nausea and vomiting from motion sickness

Blocks pain impulses, probably inhibiting prostaglandin or pain receptor sensitizers. May relieve fever by acting on hypothalamic heat-regulating center

Inhibits muscarinic actions of acetylcholine on autonomic effectors innervated by postganglionic cholinergic neurons. May effect neural pathways originating in the inner ear to inhibit nausea and vomiting.

Hematologic: hemolytic anemia, leukopeniaHepatic: liver damage, jaundiceMetabolic: hypoglycemiaSkin: rash, urticaria

Frequent: Dry mouth (sometimes severe), decreased sweating, constipation

•Assess patient’s pain and temperature before giving any drugs. • Assess patient’s drug history and calculate daily dosage accordingly. • Be alert for adverse reactions and drug interactions. • Assess patient and family’s knowledge of drug use. • Tell patient not to use drug for fever higher than 103 degrees Fahrenheit or lasts longer than 3 days or recurs. • Tell the patient to keep track of daily acetaminophen intake.

Advise patient to apply patch the night before a planned trip. Transdermal method releases a controlled therapeutic amount of drug. Transderm-Scop is effective if applied 2 or 3 hours before experiencing motion but is more effective if applied 12 hours before. Instruct patient to remove one patch before applying another Instruct patient to wash and dry hands thoroughly before and after applying the transdermal patch (on dry skin behind the ear) and

Ciprofloxacin 500mg 1 tab q 8

-Complicated Intra-Abdominal Infections-Infectious Diarrhea-Typhoid Fever (Enteric Fever)

Ciprofloxacin inhibits DNA enzyme in susceptible microorganisms. It interferes with bacterial DNA replication. Ciprofloxacin is also bactericidal.

NauseaDiarrheaDyspepsiaVomitingConstipationFlatulenceConfusionCrystalluriaBurningCrusting in the corner of eyeAbdominal pain or

before touching the eye because pupil may dilate. Tell patient to discard patch after removing it and to wash application site thoroughly. Tell patient that if patch becomes displaced, he should remove it and apply another patch on a fresh skin site behind the ear. Alert patient to possible withdrawal signs or symptoms (nausea, vomiting, headache, dizziness) when transdermal system is used for longer than 72 hours. Advice patient that eyes may be ore sensitive to light while wearing patch. Advice patient to wear sunglasses for comfort Urge patient to report urinary hesitancy or urine retention.

Question for history of hypersensitivity to Ciprofloxacin or Quinolones.May be given without regards to meals. Preferred dosing time 2 hours after meals.Do not administer antacids within 2 hours of Ciprofloxacin.Encourage cranberry juice or citrus fruits.Evaluate food tolerance.Determine pattern of bowel activity.Check for dizziness, headache, visual difficulties, and tremors.Observe therapeutic response.

discomfortHeadacheRashBad tasteRedness of the eyelidConfusionHallucinationHypersensitivity reactionInsomniaDry mouthParesthesia

Assessment Diagnosis Planning Intervention Rationale

Subjective: “init kayo akong paminaw, sige balik-balik akong hilanat” as verbalized by the client

Objective:• Restlessness. • V/S taken as follows:

Hyperthermiarelated toincreasedmetabolicrate, illness

After 5 days of nursing care and management, client will:Be able to manifest temperature in normal range

1. Monitor patient’s vital signs.

2. Note chronological and developmental age of client.

3. Note presence/ absence of sweating.

4. Initiate tepid sponge bath.

1. Serves as baseline data for future comparison.

2. Assess for causative/ contributing factor

3. To assess degree of hyperthermia.

T: 38.1 °CP: 82 bpmR: 22 cpmBp: 130/70

5. Promotes surface cooling through undressing or removing extra linens.

6. Encourage adequate fluid intake.

7. Encourage adequate bed rest.

8. Instruct patient and SO to report signs and symptoms of hyperthermia like flushed skin, increasing respiratory rate and body temperature.

9. Maintain patent airway and pad or raise side rails upon turning and positioning.

10. Provide high calorie diet unless contraindicated.

11. Instruct patient and SO to record all sources of fluid loss such as urine, vomiting and diarrhea.

Collaborative

12. Administer paracetamol 500mg, 1 tablet for fever as ordered.

13. Administer replacement fluid and electrolytes as needed.14. Notify physician for unusualities.

4. Facilitates heat through conduction and evaporation.

5. Facilitates heat loss by radiation

6. To promote heat loss and hydration.

7. To reduce metabolic consumption and oxygen demands.

8. To promote wellness

9. To promote safety.

10. To meet increased metabolic demands.

11.It potentates fluid and electrolyte losses

12. Relieves fever by acting in hypothalamic heat regulating center.

13. To support circulating volume and tissue perfusion.

14. For prompt management.

Assessment Diagnosis Planning Intervention Rationale

Subjective: “every other day nalang ko makalibang sukad katong na admit ko” as verbalized by the client

Objective:-Dry skin-Absence of sweating-(+) flatus

Risk for Constipation

Within 6 hours of nursing interventions and giving of health teachings, the patient will be able to verbalize understanding of risk factors and appropriate interventions/ solutions to individual situation.

1. Auscultate abdomen for presence, location, and characteristics of bowels sounds.2. Ascertain client’s belief and practices about bowel elimination.

3. Ascertain client’s usual elimination pattern.

4. Encourage intake of balanced fiber and bulk in diet.

5. Promote increase in fluid intake unless contraindicated.

6. Encourage participation in activity/ exercise within limits of own ability.

1. Reflects bowel activity.

2. To identify individual risk factors/ needs.

3. To assess client’s individual risk factors/ needs.

4. To improve consistency of stool and facilitates passage through colon.

5. To promote moist/ soft stool.

6. To stimulate contractions of intestines.

7. Instruct patient to respond to urge to defecate.

8. Instruct client and SO to ascertain frequency, color, consistency of stool once defecated.

9. Advise patient to have elimination diary if appropriate

Collaborative:10. Notify physician for unusualities.

7. To promote comfort and prevent complications.

8. To help monitor bowel pattern.

9. For prompt management