Typhoid Fever Case

8/8/2019 Typhoid Fever Case

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Angeles University Foundation

Angeles City, Philippines

College of Nursing

A Case Study on

TYPHOID FEVER

Submitted by:

Castro, Kimberlee M.

Diaz, Raymoncler B.

Garcia, Coco Chanel G.

Santiago, Antonio Miguel O.

Vitug, Shaneen Jenica M.

BSN III 1, Group 1

Submitted to:

Marthia C. Dizon, R.N., M.N.

August 23, 2010

A.Y. 2010 2011


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I. Introduction

There are three wicks you know to the lamp of a man's life: brain, blood, and breath.

Press the brain a little, its light goes out, followed by both the others. Stop the heart a minute,

and out go all three of the wicks. Choke the air out of the lungs, and presently

the fluid ceases to supply the other centres of flame,

and all is soon stagnation, cold, and darkness.

-Oliver Wendell Holmes, Sr.

Health is an essential part of a person, it is the fuel which gives every

individual the physical drive needed to conquer a day. Without it no man can

survive, a deficiency in health impairs the normal functioning of a person, it

becomes a hindrance. Health pertains to the persons body systems as a whole,

it is not achieved if even only one body system is impaired, a good heart with

weak lung still does not signal health, there should be harmony and balance

between the systems to achieve ultimate health.

Typhoid fever

Typhoid fever, also known as typhoid, is a common worldwide illness, transmitted

by the ingestion of food or water contaminated with the feces of an infected

person, which contain the bacterium Salmonella typhi. The bacteria then

perforate through the intestinal wall and are phagocytosed bymacrophages.

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. Typhoid fever remains a serious disease especially difficult to treat

in developing countries. Salmonella typhi, the bacteria causing typhoid fever,


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have become resistant to several antibiotics increasing the difficulty of treating

the disease. ( http://knowledge-storage.com/medicine/37-medicine/109-

typhoid-fever)

In order to provide an updated assessment of the burden of typhoid fever

in Asia, the World health Organization conducted a population-based

surveillance in 5 asian countries namely: China, India, Indonesia, Pakistan and

Vietnam. The age groups under surveillance were selected as those judged by

local officials to be the most appropriate targets for typhoid vaccination: 560

year-olds in the Chinese site; all ages in the Indian and Indonesian sites; 215year-olds in the Pakistani site; and school-aged children and adolescents (518

years) in the Vietnamese site. The statistics revealed the following:

A total of 441 435 persons in the targeted age groups were under surveillance

for one year, during which 21 874 fever episodes lasting 3 days were detected

and 475 persons had blood culture-confirmed S. typhi. The overall incidence offever lasting 3 days for the five sites combined was 49.6 per 1000 person-years,

ranging from 12.4 to 184.9 for the sites in China and Pakistan, respectively. The

incidence of typhoid ranged from 15.3 cases per 100 000 person-years among

those aged 560 years in China to 451.7 cases per 100 000 person-years among

215 year-olds in Pakistan. Overall, the S. typhi isolation rate (prevalence) was

23.1 per 1000 cultured febrile episodes and ranged from 5.0 (Vietnamese site) to

33.1 per 1000 (Indonesian site)

A total of 42 typhoid cases required hospitalization: 6 (40% of all cases) in China,

2 (2%) in India, 26 (20%) in Indonesia, 3 (2%) in Pakistan, and 5 (28%) in Vietnam


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(P


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animals. If the O-acetyl pectin conjugate proves successful, it will be evaluated

in children ages 5 to 14 years old and in infants, toward using it with routine

vaccines for infants.( http://clinicaltrials.gov/ct/show/NCT)

The study states that a another vaccine has been developed which

resembles the first vaccine, the Vi polysaccharide vaccine. The new vaccine is

said to have a more potent effect on children as compared to that of the Vi

vaccine. The new vaccine is called the exoprotein A. If the evaluation of this

vaccine is of success then this vaccine could be used as a routine vaccine for

children to prevent typhoid fever.

The group chose, typhoid fever since it is a very common and serious

problem affecting several people especially young children. The group

understood the seriousness of the matter since children at a very young age

have developing immune systems that could be compromised because of

typhoid fever and may lead to the deterioration of their health. The group sawthis case as an opportunity to gain more knowledge about the disease and with

it enhances our abilities to take care of such patients with typhoid fever. This

case will open our minds to the disease, not only the pathophysiology, but also

to the ways on how this condition can be managed and how people could

prevent this condition from occurring.


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II. NURSING ASSESSMENT

1. Personal Data

To secure confidentiality, the patient would be referred as Nella

throughout the study. Fe, the mother of Nella and Ver, the eldest sister of Nella

are the primary source of information. Nella is a 7 year old girl and a naturally

born Filipino citizen affiliated to the Adventist religion who lives in a barangay in

Angeles City along with her parents and four siblings. She was born last January

7, 2010 via Caesarean Section at Dr. Amando Garcia Medical Center. She is theyoungest among five siblings. Nella was admitted last August 8, 2010 at around

11am at Ospital ning Angeles with complaints of having high fever with a

temperature of 39.4C, difficulty of walking cause of body weakness, headache

and abdominal pain upon admission and likewise the day beforeadmission to

the hospital. The admitting diagnosis is T/C Typhoid Fever and was discharged

on August 12, 2010 with a final diagnosis of Typhoid Fever.

2. Pertinent Family History

Nella a 7 year old girl, comes from a nuclear family composed of seven

members the father, mother and five children. Her parents Mrs. Fe and Mr. Tay

have no history of Typhoid Fever, her four other siblings has likewise no history of

Typhoid Fever. Mrs. Fe has five children the first one is Ver who is 22 years old, thesecond one is 17 years old, the third one is 12 years old, the fourth one is 10 years

old and last is Nella. She delivered the first four through normal spontaneous

delivery and the last which is Nella was delivered via Caesarean Section.


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Nella lives in a barangay which has easy accessibility to the hospital. Her

father, Mr. Tay work as an automotive mechanic to sustain the needs of their

family. While her mother, Mrs. Fe work as a housekeeper. Both of them earned

money of an estimated amount of Php 6,000 per month. And her eldest sister

Ver, who is a call center agent earns money of Php 9,000 per month with a total

of Php 15,000 per month. Their income suffices the daily needs of the family. The

breakdown of their expenses is as follows: food 500 per day, water 300 per

month, electricity 500 per month, and grocery 2,000 per month. These would

all amount to 3,300 php per month. The remaining from the salary is used for

other expenses, such as medical emergencies and for the four children who

were still at school. In terms of insufficiency, concerning financial needs, theywould ask help from their relatives. The family is affiliated to the Adventist

Community and they serve well to their religion. At present, they live in a single-

storied house or what they call as bungalow, which is made up of cement walls

that is thrice as big as the private rooms in the hospital. Her mother describes

their community as a peaceful one and her neighbours are hospitable.

According to her eldest sister, if ever they have extra food, they put it in their

refrigerator for storage. Moreover, the mother also puts the uneaten food inside

the rice cooker for the food to be hot. The drinking water of the family comes

from the faucet supplied by NAWASA. They drink unboiled water. However,

mother sometimes buys distilled water for them.

The family of Nella do not rely on cultural practices when it comes to their

health, they do not believe in albularyos they readily consult for medical

assistance like going to the health center or hospital. However, they use some

medications like Tempra if one of the children is suffering from fever like what


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they did to Nella and Solmux if someones suffering from cough but admitted

that they never used herbal medicines. They have a Kapampangan culture

which means most of their diet is mostly high in salt and fat since they are known

for cooking food increasing the risk in acquiring disease of the heart and kidney

problems. Morever, Nella has good habits which is conducive to health

maintenance like taking a bath everyday, brushing teeth at all times and taking

supplemental like Multivitamins but also stop two years ago. Regarding Nellas

behaviour, she is fond of eating street foods like fish balls especially when she is

at school, she also admitted that she always eats siopao at school which she

knows is not that cleaned and student nurses had also observed that she is fond

of biting her nails when she was doing nothing and student nurses haveobserved that Nella is fond of biting her nails when she is doing nothing.

Regarding the Nellas activities of daily living, she usually wakes up at six

oclock in the morning and she would be eating breakfast with her siblings than

dress up for school. Then she will be heading to school picked up by her service.

By seven oclock in the morning up to twelve oclock in the noon she was in theschool. By one oclock in the afternoon she was already in their house and she

would be doing all her homework and study, after doing school stuffs she would

be playing in the computer or just watch the television up to six oclock in the

evening then by eight oclock in the evening she would be sleeping already.

She never sleeps in the afternoon that she rather plays or watched T.V. than

sleeping.


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A. Pertinent Family Health-Illness History

Paternal Side Maternal S

Grandfather

Heart Attack

Grandmother

65 y/o * 47 y/o *

Father 63 y/o

HPN

Grandfather

DM

46 y/o *

Mother

44 y/o

1 = 22 y/o 2 = 17 y/o 3 = 12 y/o 4 = 10 y/o

42 y/o *


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Family Health-Illness History

Legend:

= deceased

*= did not specify any illness or disease

1= 1st sibling

2=2nd sibling

3=3rd sibling

4=4th sibling

5=5th sibling

There are no significant influences of the diseases/ illnesses of Nellas

grandparents and parents to his present condition which is Typhoid Fever.

Except for the diet of the family which most likely contributes to the said

condition of Nella.


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3. Personal History

Mrs. Fe, has no specific habits during her pregnancies to her five children. All

she does is to make her self-healthy for baby to come out very healthy too. She

attends her prenatal check ups with her doctor regularly to make sure her

baby is healthy and never misses one. She had also completed her vaccines

needed for pregnancy, which is TT1 to TT5. Regarding the obstetric history of Mrs.

Fe she had Gravida 7, Para 5, Term 5, Preterm 0, Abortion 2, Living 5, and

Multiple pregnancies 0. According to her, she undergone DIC twice, the first one

is when she was diagnosed with ectopic pregnancy, and two months after she

undergone again. Nella was born via Caesarean section at Dr. Amando Garcia

Medical Center at exact 9th month. She was born without any complications to

herself and to her mother.

According to Ver, Nellas eldest sister, Mrs. Fe have breast fed Nella from the

day she was born until she reaches one year old. She never fed Nella with

formula milk for she knows that breast feeding is much healthier than formula

milks. Not only Nella was fed like that with the five children, but also the other

four. After they reach one year old, she fed them with soft diet like lugaw.

Nella is already vaccinated with 1 BCG, 3 OPV, 3 DPT, 3 Hepa B and measles

at Lourdes Sur East Health Center. Her mother, Mrs. Fe makes sure that Nella was

vaccinated on schedule and goes to the health center to avoid the

preventable diseases. But Mrs. Fe could not remember the exact dates she was

vaccinated.


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Theories of Growth and Development (Client-centered)

Erik Ericson

Psychosocial Development

Industry VS Inferiority

(6 12 years old)

During school age, children learn how to do things well. When they are

absorbed in a project, children ask, Am I doing a good job? Am I doing this

right? When they are encouraged in their efforts to do practical tasks or make

practical things and are praised and rewarded for the finished results, their sense

of industry grows. Parents who see their childrens efforts at making and doing

things as merely busy work or who dont show appreciation for their childrens

efforts may cause them to develop a sense of inferiority rather than pride and

accomplishment.

Jean Piaget

Cognitive development

Concrete Operational Thought

(7 12 years old)

Concrete operations include systematic reasoning. Uses memory to learn

broad concepts and subgroups of concepts. Classifications involve sorting

objects according to attributes such as color; seriation, in which objects are

ordered according to increasing or decreasing measures such as weight;

multiplication, in which objects are simultaneously classified and seriated using

weight. Child is aware of reversibility, an opposite operation or continuation of

reasoning back to a starting point (follows a route through a maze and then

reverses steps). Understands conversation, sees constancy despite


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transformation (mass or quantity remains the same even if it changes shape or

position). Good activity for this period: collecting and classifying natural objects

such as native plants, sea shells, etc.

Sigmund Freud

Psychosexual development

Latent Stage

(6 12 years old)

Freud saw the school age period as a latent phase, a time in which

childrens libido appears to be diverted into concrete thinking. He saw nodevelopments as obvious as those in earlier periods appearing during this time.

In here, childs personality development appears to be nonactive or dormant.

They should also help the child have positive experiences so his or her self

esteem continues to grow and the child prepares for the conflicts of

adolescence.

Anna FreudEgo Psychology

Defense mechanisms are psychological strategies brought into play by

various entities to cope with reality and to maintain self-image. Healthy persons

normally use different defenses throughout life. Ego defense mechanism

becomes pathological only when its persistent use leads to maladaptive

behavior such that the physical and/or mental health of the individual isadversely affected. The purpose of the Ego Defense Mechanisms is to protect

the mind/self/ego from anxiety, social sanctions or to provide a refuge from a

situation with which one cannot currently cope. 6 12 years old children shows

fear of separateness with their parents where they experience anxiety. They also


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have fear of the loss of an object they loved, and the fear of being punished

when they have done something wrong.

4. Family Health-Illness History

History of Past Illness

According to Nellas eldest sister, Nella never had any illness when she

was a baby. The time she had been sick was just last year, because of fever

cause by cough and colds. She was brought to a doctor that time and was

prescribed with some medications but she can barely recall it all she knows they

let Nella drink Tempra for her fever. She never had chicken pox, measles and

any other illness or sickness except for what was mentioned above. And

according to Nellas eldest sister, this was the first time Nella was admitted to the

hospital.

5. History of present illness

Nellas fever started at August 5, 2010 Thursday, they thought that she only

got wet in the rain and thought that she only had a simple fever. Then the next

day she still has fever which the temperature increases at 39.04C, they havent

let her go to school and just gave her a bed rest and gave herTempra to lessen

her fever. After that her fever would be decreasing up to 38C, then she would

be complaining of headache then the next morning she has a high fever again.

All they just do is gave her some medicines and then gave her some tepid

sponge bath.


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By August 8, 2010, her parents decided to bring her to the hospital

because of high fever, sudden abdominal pain, headache and body

weakness. She was diagnosed with Typhoid Fever. In her stay in the hospital,

Nella had experienced diarrhea. According to Ver, she defacates 5 7 times at

night with 2 3 cups of soft-watery stool per episode. During her stay also, she

manifested cough and colds.


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6. Physical Examination (IPPA Cephalocaudal Approach)

August 08, 2010 (lifted from the chart)

Vital Signs:

T- 38.5C/axilla PR- 86bpm RR- 21cpm Weight- 21kg.

HEENT:

y Pink Palpebral Conjunctiva

y Icteric Conjunctiva

Chest and Lungs:

y Symmetrical chest expansion

y No rales, no retractions

y Clear breath sounds

Heart:

y

Adynamic precardiumy No murmur

Abdomen:

y Flat, Normal abdominal bowel sounds, nontender, soft

Genitalia:

y Not examined

Extremities:

y Grossly normal, no edema, no cyanosis


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August 09, 2010 (first nursing-patient interaction)

Vital Signs:

T- 36.3C/axilla PR- 108bpm RR- 28cpm Wt- 21kg

General Appearance and Mental Status:

Conscious, awake; oriented to time and place and aware of self and

environment; responds to external stimuli; attentive, cooperative,

demonstrates continuity of ideas; wears clean clothes (white t-shit and green

pajamas)

General Appearance

o Attitude is cooperative

o Speech is understandable, slow paced, speaks tagalog and

kapampangan and exhibits thought association

o Appears weak with slow movement

Heado Skull is round in shape and has normal contour with no palpated

depressions

o Hair has fine strands, scalp is oily but no masses palpated

o Facial features are symmetrical with no noted abnormalities

o Hair evenly distributed and skin is intact

o With straight, long and black hair

o No dandruff was observed or any abnormal skin growth

Eyes

o Pupils are equally round and reactive to l ight, (+) PERRLA

o Pink palpebral conjunctiva and icteric sclera


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o Eyebrows are symmetrically aligned

o Eyelashes are short, evenly distributed and curled slightly outward

o No discharges present

o Cornea is transparent, smooth and shiny

o Details of the iris are visible, dark brown in color

o Sclera appears white

o Skin around the eyes is intact

o Eyes move in consensus

Ears

o

Ears are symmetrical and aligned with the outer canthus of the eye withno lesions noted

o Color is same as facial skin

o Pinna recoils after being folded

o Absence of difficulty in hearing

o No cerumen was noted in both ears

Noseo Nose has no discharge, no lesions, not occluded & with patent airway

o Nose is not tender, without masses or any displacement of bone and

cartilage noted upon palpation


o Normal size for the face

o Absence of difficulty in breathing and no nasal flaring on both nostrils was

observedo Able to breathe clearly and identify mild aromas presented to her

Throat and Mouth

o Throat & mouth have no sores and swellings or inflammation


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o Teeth complete in number, yellowish, and slightly shiny

o Dental caries were observed over her front teeth's enamel and whitish

plaque were noted over her molars

o Buccal Mucosa- dry, smooth and light pink in color

o Tongue- pink in color, rough-surfaced, moist, no lesions, and aligned at the

center of the mouth

o Lips are dry, pink in color

o No lesions in his lips and mouth, was able to purse his lips, protrude and

move tongue from side to side, up and down

o Gag reflex was elicited

o

Palate appears pale; soft palate is smooth and light pink, hard palate islighter pink with more irregular texture

o Uvula- positioned at the midline of the soft palate

o Oropharynx- pink in color, smooth, with no discharge

o Tonsils- pink in color, not inflamed or swollen

o Pale gums

Necko Neck is centered and aligned with the head

o Able to move the neck without much effort from side to side, up and

down and even in rotation

o No palpable lymph nodes

o Trachea is movable and aligned at the center

o Thyroid gland not visible upon inspection and ascends while swallowing

o Arteries and veins not distended

Chest

- symmetrical

BREASTS


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o No lesions

o No abnormal swelling or presence of masses

Cardiovascular

o Absence of chest pain and murmurs

o Normal heart rhythm and regular rate

o Veins are not visibly distended

o No presence of sound/bruit heard upon auscultation

o Adynamic precardium

Respiratoryo Chest is symmetric; Anteroposterior to transverse diameter ratio is 1:2

o Chest expansions are symmetrical

o Absence of rales on both lung fields (clear breath sounds)

o Spine vertically aligned

o Spinal column is straight; left and right shoulders and hips are the same

height

o Regular respiratory rhythm & normal respiratory rate: 28cpm

Skin

o Skin is dry and has good skin turgor

o Exhibits a fair complexion

o No masses were observed and palpated all over his body

o (-) Edemao (-) Jaundice, (-) cyanosis

o Some blemishes on her lower extremities

-> NAILS


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o Pale in color

o Capillary refill is less than 3 seconds

o (-) Schamroths test

o Untrimmed and dirty

Gastrointestinal

o Skin is fair

o Abdomen is soft and flat

o (+) Bowel sounds 4/min, (+) flatus, (+) bowel movement

o (-) Organomegaly

o

Non tender abdomen

Extremities

o Some blemishes were noted over the patient's legs

o No edema noted on both upper and lower extremities, without numbness

and tingling sensation

o Grossly nomal

o (-) edema, (-) cyanosis

Genitourinary

o No tenderness

o Not examined

August 10, 2010 (second nursing-patient interaction)

Vital Signs:

T- 35.4C/axilla PR- 72bpm RR- 15cpm Wt- 21kg


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General Appearance and Mental Status:

Conscious, awake; oriented to time and place and aware of self and

environment; responds to external stimuli; attentive, cooperative,

demonstrates continuity of ideas; wears clean clothes (blue t-shit and pink

pajamas)

General Appearance

o Attitude is cooperative

o Speech is understandable, speaks tagalog and kapampangan and

exhibits thought associationo Appears weak

Head

o Skull is round in shape and has normal contour with no palpated

depressions

o Hair has fine strands, scalp is oily but no masses palpated

o Facial features are symmetrical with no noted abnormalitieso Hair evenly distributed and skin is intact

o With straight, long and black hair

o No dandruff was observed or any abnormal skin growth

Eyes

o Pupils are equally round and reactive to l ight, (+) PERRLA

o Pink palpebral conjunctiva and anicteric sclerao Eyebrows are symmetrically aligned

o Eyelashes are short, evenly distributed and curled slightly outward

o No discharges present

o Cornea is transparent, smooth and shiny


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o Details of the iris are visible, dark brown in color

o Sclera appears white

o Skin around the eyes is intact

o Eyes move in consensus

Ears

o Ears are symmetrical and aligned with the outer canthus of the eye with

no lesions noted


o Pinna recoils after being folded

o

Absence of difficulty in hearingo No cerumen was noted in both ears

Nose

o Nose has no discharge, no lesions, not occluded & with patent airway

o Nose is not tender, without masses or any displacement of bone and

cartilage noted upon palpation

o Color is same as facial skino Normal size for the face

o Absence of difficulty in breathing and no nasal flaring on both nostrils was

observed

o Able to breathe clearly and identify mild aromas presented to her

Throat and Mouth

o Throat & mouth have no sores and swellings or inflammationo Teeth complete in number, yellowish, and slightly shiny

o Dental caries were observed over her front teeth's enamel and whitish

plaque were noted over her molars

o Buccal Mucosa- moist, smooth and light pink in color


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o Tongue- pink in color, rough-surfaced, moist, no lesions, and aligned at the

center of the mouth

o Lips are slightly dry, pink in color

o No lesions in his lips and mouth, was able to purse his lips, protrude and

move tongue from side to side, up and down

o Gag reflex was elicited

o Palate appears pale; soft palate is smooth and light pink, hard palate is

lighter pink with more irregular texture

o Uvula- positioned at the midline of the soft palate

o Oropharynx- pink in color, smooth, with no discharge

o

Tonsils- pink in color, not inflamed or swollen

o Pale gums

Neck

o Neck is centered and aligned with the head

o Able to move the neck without much effort from side to side, up and

down and even in rotation

o No palpable lymph nodeso Trachea is movable and aligned at the center

o Thyroid gland not visible upon inspection and ascends while swallowing

o Arteries and veins not distended

Chest

- symmetrical

BREASTS

o No lesions

o No abnormal swelling or presence of masses

Cardiovascular


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o Absence of chest pain and murmurs

o Normal heart rhythm and regular rate

o Veins are not visibly distended

o No presence of sound/bruit heard upon auscultation

Respiratory

o Chest is symmetric; Anteroposterior to transverse diameter ratio is 1:2

o Chest expansions are symmetrical

o Absence of rales on both lung fields (clear breath sounds)

o Spine vertically aligned

o

Spinal column is straight; left and right shoulders and hips are the sameheight

o Regular respiratory rhythm & normal respiratory rate: 23cpm

o Productive cough, unable to expectorate

Skin

o Skin is dry and has good skin turgoro Exhibits a fair complexion

o No masses were observed and palpated all over his body

o (-) Edema

o (-) Jaundice, (-) cyanosis

o Some blemishes on her lower extremities

-> NAILSo Capillary refill is less than 2 seconds

o (-) Schamroths test

o Untrimmed and dirty fingernails


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Gastrointestinal

o Skin is fair

o Abdomen is soft and flat

o (+) Bowel sounds 4/min, (+) flatus, (-) bowel movement

o (-) Organomegaly

o Non tender abdomen

Extremities

o Some blemishes were noted over the patient's legs

o No edema noted on both upper and lower extremities, without numbness

and tingling sensationo Grossly nomal

o (-) edema, (-) cyanosis

Genitourinary

o No tenderness

o Not examined


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7. DIAGNOSTIC AND LABORATORY PROCEDURES

A. TYPHIDOT

Diagnostic/Lab

Procedure

Date Ordered

Date result(s) in

Indication/Purpose Results Nor

Valu

Typhidot August, 08, 2010 This procedure is a

test for igG &igM

detection of

typoid .

IgM: Positive

IgG: Positive

IgM

Neg

IgG

Neg


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Nursing Responsibilities:

BEFORE THE PROCEDURE:

o Check the doctors order

o Determine the prescribed test and other restrictions prior to the test

o Get the laboratory requisition slip

o Explain to the patient what the procedure to be done is

DURING THE PROCEDURE:

o Explain to the patient what test should be done.

o Prepare all the equipments to be used

After:

y Answer any questions or address any concerns voiced by the patient or family.

y Evaluate test results in relation to the patients symptoms and other test performe


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B. Complete Blood Count

Diagnostic/

Laboratory

Procedure

Date Order/Date Results In

Indications orPurposes

Results

Normal Val

(Units Used

the Hospita

Complete

Blood Count

(CBC)August,08,2010

A procedure

done to count

the blood

components

such as the RBC

and WBC. It also

shows thehemoglobin and

hematocrit

count. It was

done to assess

anemia,

infection, fluid

status and other

blood

abnormalities.

WBC =3.8 5-10x109/L

Hgb. = 131 120-160mg

Hct = 0.41 0.37- 0.47 L/

Lymphocytes =

0.51

0.10-0.40 %


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RBC=4.79 4.2-5.4 x 10

Platelet Count =

275

150-400X10

Segmenters = 0.49 0.45-0.65 %


BEFORE THE PROCEDURE:

o Check the doctors order

o Determine the prescribed test and other restrictions prior to the test

o Get the laboratory requisition slip

o Explain to the patient what the procedure to be done is


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o Explain to the patient that she may feel slight discomfort from the ne

tourniquet

o Inform the patient that this requires a blood sample

o

Explain that this test evaluates the blood for the presence/absence of inbodys defense against infection, the number and condition of RBCs in

possible bleeding tendencies, blood type and the presence/absence of a

o Inform the patient how the procedure is performed, the equipment to be

that she may eat and drink before collection of the specimen.

DURINGT

HE PROCEDURE:

o Explain to the patient what test should be done.

o Prepare all the equipments to be used

o Tell the patient when to insert the needle for her to be prepared

o Do not use hand or arm receiving IV fluid this causes hemodilution. Do no

more than one minute because doing so causes hemoconcentration

o Encourage the patient to remain calm during the test

o Assist the patient if necessary

o Ensure a sterile blood sample from the patient


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AFTER THE PROCEDURE:

o Apply pressure on the puncture site

o Ensure that subdermal bleeding has stopped before removing pressure

o If a hematoma develops at the venipuncture site, apply warm soaks.

Send the blood sample to the laboratory immediately


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C. URINALYSIS

DIAGNOSTIC

LABORATORY

PROCEDURES

DATE ORDERED

DATE

RESULTS(S)

IN

INDICATION(S)

OR PURPOSESRESULTS

NORMAL

VALUES

URINALYSIS August,08,2010 This is a screening

test for abnormalitieswithin the urinary

system that may

manifest through the

urinary tract

COLOR:

yellow

TRANSPARENCY:

s. Turbid

pH:

6.0

Amber

clear

7.35-7.45


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SP. GRAVITY:

1.020

MICROSCOPIC

EXAM

PUS CELLS/HPF

6-8

RBC:

0-1

EPITHELIAL CELLS:

FEW

MUCUS THREADS:

FEW

1.005-

1.035

negative

negative


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ALBUMIN:

Trace

SUGAR:

Negative

negative

negative


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NURSING RESPONSIBILITIES:

Before:

y Inform the patient that the test is used to assist in the diagnosis of renal diseases

inflammatory diseases.

y Obtain a history of the patients genitourinary, surgical procedures and other dia

y Obtain a list of medication the patient is taking.

y Review the procedure with the patient.

y There are no food, fluid or medication restrictions, unless by medical direction.

During:

y Instruct the patient to thoroughly wash his hands, cleanse the meatus, void a sma

y Amount in the toilet and void directly into the specimen container.

y Promptly transport the specimen to the laboratory for processing and analysis.

After:


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y Instruct the patient to report symptoms such as pain related to tissue inflam

during void or alterations in urinary elimination.

y Answer any questions or address any concerns voiced by the patient or family.

y Evaluate test results in relation to the patients symptoms and other test performe


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D. Fecalysis

Diagnostic

Laboratory

Procedures

Date ordered:

Date results in:

Indication or

Purpose

Results Norma

Value

Fecalysis Date Ordered:

August 11,

2010

Date results in:

August 11,

2010

y Help to

diagnose

certain

conditions

affecting the

digestive tract

y Help find the

cause of

symptoms

affecting the

digestive tract

y To determine

the presence of

parasitic worm

in the GI tract of

Color : Brown

Consistency:

Soft

Others:

Bacteria -

many

No Intestinal

parasite seen

Color: brow

Consistency

formed

Bacteria: no


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NURSING RESPONSIBILITIES

Before:

y Check doctors order

y Explain to the SO the purpose and the procedure of fecalysis

y Usual aseptic technique

the patient


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y Try to collect the freshest stool possible

y Take a small piece of stool with the wooden applicator

y Provide clean specimen cup

y

Refer to the other member of the Health Care team

During:

y Collect the stool in a clean specimen cup

y Report the consistency of the stool sample: Formed, semi-formed, soft or wate

y Report the visible presence of blood, mucus or parasites. Look for adult worm

orTrichuris trichuria.

After:

y Immediately label the specimen.

y Remove gloves and wash hands.

y Record the clients name, the test performed and disposition of the specimen


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III. Anatomy and Physiology

ANATOMY AND PHYSIOLOGY OF THE DIGESTIVE

SYSTEM

The digestive tract consists of the digestive tract, a tube extending from the

mouth to the anus, plus the associated organs, which secrete fluids into the

digestive tract. The term gastrointestinal tract technically only refers to the

stomach and intestine but is often used as a synonym for the digestive tract. The

inside of the digestive tract is continuous with the outside environment, where it

opens at the mouth and anus. Nutrients cross the wall of the digestive tract to

enter the circulation.

The digestive tract consists of the oral cavity, pharynx, esophagus, stomach,

small intestine, large intestine, and anus. Accessory glands are associated with


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the digestive tract. The salivary glands empty into the oral cavity and the liver

and pancreas are connected to the small intestine.

Various parts of the digestive tract are specialized for different functions, but

nearly all parts consist of four layers or tunics the mucosa, sub mucosa,

muscularis, and serosa or adventitia.

Digestive Tract Histology

The innermost tunic, the mucosa, consists of mucous epithelium, a loose

connective tissue called the lamina propria, and a thin smooth muscle layer, the

muscularis mucosa. The epithelium in the mouth, esophagus and anus resists

abrasion, and epithelium in the stomach and intestine absorbs and secretes.

The sub mucosa lies just outside the mucosa. It is a thick layer of loose

connective tissue containing nerves, blood vessels, and small glands. An

extensive network of nerve cell processes forms a plexus (network). The plexus is

innervated by autonomic nerves.

The muscularis which in most part of the digestive tube consists of an inner layer

of circular smooth muscle and an outer layer of longitudinal smooth muscle.

Another nerve plexus, also innervated by autonomic nerves, lies between the

two muscle layers. Together the nerve plexuses of the sub mucosa and

muscularis compose the enteric plexus. This plexus is extremely important in the

control of movement and secretion within the tract.

T

he fourth, or outermost, layer of the digestive tract is either a serosa or anadventitia. Some regions of the digestive tract are covered by peritoneum and

other regions are not. The peritoneum, which is a smooth epithelial layer, and its

underlying connective tissue are referred to histologically as the serosa. In

regions of the digestive tract not covered by peritoneum, the digestive tract is


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covered by a connective tissue layer called the adventitia, which is continuous

with the surrounding connective tissue.

Peritoneum and Mesenteries

The body wall of the abdominal cavity and the abdominal organs are covered

with serous membranes. The serous membrane that covers the organs is the

visceral peritoneum, or serosa. The serous membrane that lines the wall of the

abdominal cavity is the parietal peritoneum.

Many of the organs of the abdominal cavity are held in place by connective

tissue sheets called mesenteries. The mesenteries consist of two layers of serous

membranes with a thin layer of loose connective tissue between them. Specific

mesenteries are given names. The mesentery connecting the lesser curvature of

the stomach to the liver and diaphragm is the lesser omentum, and the

mesentery connecting the greater curvature of the stomach to the transverse

colon and posterior body wall is the greater omentum. The greater omentum is

unusual in that it is a long, double fold of mesentery that extends inferiorly from

the stomach before looping back to the transverse colon to create a cavity orpocket, called the omental bursa. Fat accumulates in the greater omentum,

giving it the appearance of a fat-filled apron that covers the anterior surface of

the abdominal viscera. Mesentery is a general term referring to the serous

membrane attached to the abdominal organs. The term is also used specifically

to refer to the mesentery that attaches the small intestine to the posterior

abdominal wall. This mesentery is also called the mesentery proper.

Other abdominal organs lie against the abdominal wall, have no mesenteries,

and are described as retroperitoneal. The retroperitoneal organs include the

duodenum, pancreas, ascending colon, descending colon, rectum, kidneys,

adrenal glands and urinary bladder.


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Oral Cavity

The oral cavity, or mouth, is the first part of the digestive tract. It is bounded by

the lips and cheeks and contains the teeth and tongue.

The lips are muscular structures, formed mostly by the orbicularis oris muscle. The

outer surfaces of the lips are covered by skin. The keratinized stratified epithelium

of the skin becomes thin at the margin of the lips. The color from the underlying

blood vessels can be seen through the thin, transparent epithelium, giving the

lips a reddish-pink appearance. At the internal margin of the lips, the epithelium

is continuous with the moist stratified squamous epithelium of the mucosa in the

oral cavity. The cheeks form the lateral walls of the oral cavity.

The buccinators muscles are located within the cheeks and flatten the cheeks

against teeth. The lips and cheeks are important in the process of mastication, or

chewing. They help manipulate the food within the mouth and hold the food in

place while the teeth crush or tear it. Mastication begins the process of

mechanical digestion, in which large food particles are broken down into

smaller ones.The cheeks also help form words during the speech process.

Tongue

The tongue is a large, muscular organ that occupies most of the oral cavity. The

major attachment of the tongue is in the posterior part of the oral cavity. The

anterior part of the tongue is relatively free. There is an anterior attachment to

the floor of the mouth by a thin fold of tissue called the frenulum.

The tongue moves food in the mouth and, in cooperation with the lips and

cheeks, holds the food in place during mastication. It also plays a major role in

the process of swallowing. The tongue is a major sensory organ for taste, as well

as being one of the major organs of speech.


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Teeth

There are 32 teeth in the normal adult mouth, located in the mandible and

maxillae. The teeth can be divided into quadrantsright upper, left upper, right

lower, and left lower. In adults, each quadrant contains one central and one

lateral incisor; one canine; first and second premolars; and first, second, and

third molars. The third molars are called wisdom teeth because they usually

appear in a persons late teens or early twenties, when the person is old enough

to have acquired some degree of wisdom.

The teeth of adults are permanent, or secondary, teeth. Most of them are

replacements of the 2 primary, or deciduous, teeth.

Each tooth consists of a crown with one or more cusps, a neck and a root. The

center of the tooth is a pulp cavity, which is filled with blood vessels, nerves and

connective tissue, called pulp. The pulp cavity is surrounded by a living, cellular,

bonelike tissue called dentin. The dentin of the tooth crown is covered by an

extremely hard, acellular substance called enamel, which protects the tooth

against abrasion and acids produced by bacteria in the mouth.T

he surface ofthe dentin in the root is covered with cementum, which helps anchor the tooth

in the jaw.

The teeth are rooted within alveoli along the alveolar processes of the mandible

and maxillae. The alveolar processes are covered by dense fibrous connective

tissue and moist stratified squamous epithelium, referred to as the gingival, or

gums. The teeth are held in place by periodontal ligaments, which are

connective tissue fibers that extend from the alveolar walls and are embedded

into the cementum.

Palate and Tonsils


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The palate, or roof of the oral cavity, consists of two parts. The anterior part

contains bone and is called the hard palate, whereas the posterior portion

consists of skeletal muscle and connective tissue and is called the soft palate.

The uvula is a posterior extension of the soft palate. The palate separates the

oral cavity from the nasal cavity and prevents food from passing into the nasal

cavity during chewing and swallowing.

The tonsils are located in the lateral posterior walls of the oral cavity, in the

nasopharynx, and in the posterior surface of the tongue.

There are three pairs of salivary glands the parotid, submandibular, and

sublingual glands. They produce saliva, which is a mixture of serous and mucous

fluids. Saliva helps keep the oral cavity moist and contains enzymes that begin

the process of chemical digestion. The salivary glands are compound alveolar

glands. They have branching ducts with clusters of alveoli, resembling grapes, at

the ends of the ducts.

The largest of the salivary glands, the parotid glands, are serous glands located

just anterior to each ear. Parotid ducts enter the oral cavity adjacent to thesecond upper molars.

The submandibular glands produce more serous than mucous secretions. Each

gland can be felt as a soft lump along the inferior border of the mandible. The

submandibular ducts open into the oral cavity on each side of the frenulum of

the tongue. In certain people, if the mouth is opened and the tip of the tongue

is elevated, saliva can squirt out of the mouth from the ducts of these glands.

The sublingual glands, the smallest of the three paired salivary glands, produce

primarily mucous secretions. They lie immediately below the mucous membrane

in the floor of the oral cavity. Each sublingual gland has 10-12 small ducts

opening onto the floor of the oral cavity.


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Pharynx

The pharynx, or throat, which connects the mouth with the esophagus, consists

of three parts the nasopharynx, oropharynx, and laryngopharynx. Normally only

the oropharynx and laryngopharynx transmit food. The posterior walls of the

oropharynx and laryngopharynx are formed by the superior, middle, and inferior

pharyngeal constrictor muscles.

Esophagus

The esophagus is a muscular tube, lined with moist stratified squamous

epithelium that extends from the pharynx to the stomach. It is about 25

centimeters (cm) long and lies anterior to the vertebrae and posterior to the

trachea within the mediastenum. It passes through the diaphragm and ends at

the stomach. Upper and lower esophageal sphincters, located at the upper

and lower ends of the esophagus, respectively, regulate the movement of food

into and out of the esophagus. The lower esophageal sphincter is sometimes

called the cardiac sphincter. Numerous mucous glands produce thick,

lubricating mucus that coats the inner surface of the esophagus.

Stomach

The stomach is an enlarged segment of the digestive tract in the left superior

part of the abdomen. The opening from the esophagus into the stomach is

called the cardiac opening because it is near the heart. The region of the

stomach around the cardiac opening is called the cardiac region. The most

superior part of the stomach is the fundus. The largest part of the stomach is the

body, which turns to the right, forming a greater curvature on the left, and a

lesser curvature on the right. The opening from the stomach into the small

intestine is the pyloric opening, which is surrounded by a relatively thick ring of


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smooth muscle called the pyloric sphincter. The region of the stomach near the

pyloric opening is the pyloric region.

The muscular layer of the stomach is different from other regions of the digestive

tract in that it consists of three layers an outer longitudinal layer, a middle

circular layer, and an inner oblique layer. These muscular layers produce a

churning action in the stomach, important in the digestive process. The sub

mucosa and mucosa of the stomach are thrown into large folds called rugae

when the stomach is empty. These folds allow the mucosa and sub mucosa to

stretch, and the folds disappear as the stomach is filled.

The stomach is lined with simple columnar epithelium. The mucosal surface forms

numerous, tube-like gastric pits, which are the openings for the gastric glands.

The epithelial cells of the stomach can be divided into five groups. The first

group consists of surface mucous cells on the inner surface of the stomach and

lining the gastric pits. Those cells produce mucus which coats and protect the

stomach lining. They are mucous neck cells, which produce mucous; parietal

cells, which produce hydrochloric acids and intrinsic factors; endocrine cells,

which produce regulatory hormones; and chief cells, which produce

pepsinogen, a precursor of the protein-digesting enzyme pepsin.

Small Intestines

The small intestine is about 6 meters long and consists of three partsthe

duodenum, jejunum, and ileum. The duodenum is about 25 centimeter (the

term duodenum means 12, suggesting that it is 12 inches long). The jejunum is

about 2.5 meter long and makes up two-fifths of the total length of the small

intestine. The ileum is about 3.5 meter long and makes up three-fifths of the small

intestine.


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The duodenum nearly completes a nearly an 18degree arc as it curves within

the abdominal cavity. Part of the pancreas lies within this arc. The common bile

duct from the liver and the pancreatic duct from the pancreas join each other

and empty into the duodenum.

The small intestine is the major site of digestion and absorption of food, which

are accomplished by the presence of a large surface area. The surface of the

small intestine has three modifications that increase surface area about 600-

foldcircular folds, villi, and microvilli. The mucosa and sub mucosa form a series

of circular folds that run perpendicular to the long axis of the digestive tract. Tiny

finger like projections of the mucosa forms numerous villi, which are 0.5-1.5 mm

long. Most of the cells composing the surface of the villi have numerous

cytoplasmic extensions, called microvilli. Each villus is covered by simple

columnar epithelium. Within the loose connective tissue core of each villus is a

blood capillary called lacteal. The blood capillary network and the lacteal are

very important in transporting absorbed nutrients.

The mucosa of the small intestine is simple columnar epithelium with four major

cell types: Absorptive cells, which have microvilli, produce digestive enzymes,

and absorb digested food Goblet cells, which produce a protective mucus

Granular cells, (Paneths cells), which may help protect the intestinal epithelium

from bacteria; Endocrine cells, which produce regulatory hormones. The

epithelial cells are produce within tubular glands of the mucosa, called intestinal

glands, at the base of the villi. Granular and endocrine cells are located in the

bottom of the glands. The sub mucosa of the duodenum contains mucous

glands, called duodenal glands, which open into the base of the intestinal

glands.

The duodenum, jejunum, and ileum are similar in structure except that there is a

granular decrease in the diameter of the small intestine, in the thickness of the


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intestinal wall, in the number of circular folds, and in the number of villi as one

progress through the small intestine. Lymph nodules are common along the

entire length of the digestive tract. Clusters of lymph nodules, called Peyers

patches, are numerous in the ileum. These lymphatic tissues in the intestine help

protect the intestinal tract from harmful micro organisms.

The junction between the ileum and the large intestine is the ileocecal junction.

It has a ring of smooth muscle, the ileocecal sphincter, and an ileocecal valve,

which allows material contained in the intestine to move from the ileum to the

large intestine, but not in the opposite direction.

Secretions of the Small Intestines

Secretions from the mucosa of the small intestine mainly contain mucus, ions

and water. Intestinal secretions lubricate and protect the intestinal wall from the

acidic chime and the action of the digestive enzymes. They also keep the

chime in the small intestine in a liquid form to facilitate the digestive process.

Most of the secretions entering the small intestine are produced by the intestinal

mucosa, but the secretions of the liver and the pancreas also enter the smallintestine and play important roles in the process of digestion.

The epithelial cells in the walls of the small intestine have enzymes bound to their

free surfaces that play a significant role in the final steps of digestion. Peptidases

break the peptide bonds in proteins to form amino acids. Disaccharidases break

down dissacharides, such as maltose and isomaltose, into monosaccharide. The

amino acids and monosaccharides can be absorbed by the intestinal

epithelium.

Mucus is produced by duodenal glands and by goblet cells, which are

dispersed throughout the epithelial lining of the entire small intestine and within

intestinal glands. Hormones released from the intestinal mucosa stimulate liver


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and pancreatic secretions. Secretion by duodenal glands is stimulated by the

vagus nerve, secretin release, and chemical or tactile irritation of the duodenal

mucosa.

Movement of Small Intestines

Mixing and propulsion of chime are the primary mechanical events that occur in

the small intestine. Peristaltic contractions proceed along the length of the

intestine for variable distances and cause the chime to move along the small

intestine. Segmental contractions are propagated for only short distances and

function to mix intestinal contents.

The ileocecal sphincter at the juncture of the ileum and the large intestine

remains mildly contracted most of the time, but peristaltic contractions reaching

the ileocecal sphincter from the small intestine cause the sphincter to relax and

allow movement of chime from the small intestine into the cecum. The ileocecal

valve allows chime to move from the ileum into the large intestine, but tends to

prevent movement from the large intestine back into the ileum.

Absorption in the Small Intestines

A major function of the small intestine is the absorption of nutrients. Most

absorption occurs in the duodenum and jejunum, although some absorption

also occurs in the ileum.

Liver

The liver weighs about 1.36 kilograms and is located in the right upper quadrant

of the abdomen, tucked against the inferior surface of the diaphragm. The

posterior surface of the liver is in contact with the right ribs 5-12. it is divided into

two major lobes, the right and left lobes, separated by a connective tissue

septum, the falciform ligament. Two smaller lobes, the caudate and quadrate,


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can be seen from an inferior view. Also seen from the inferior view is the porta,

which is the gate through which blood vessels, ducts and nerves enter or exit the

liver.

The liver receives blood from two sources. The hepatic artery brings oxygen-rich

blood to the liver, which supplies liver cells with oxygen. The hepatic portal vein

carries blood that is oxygen-poor but rich in absorbed nutrients and other

substances from the digestive tract to the liver. Liver cells process nutrients and

detoxify harmful substance from the blood. Blood exits the liver through hepatic

veins, which empty into the inferior vena cava.

Many delicate connective tissue septa divide the liver into lobules with portal

triads at the corners of the lobules. The portal triads contain three structuresthe

hepatic artery, hepatic portal vein, and hepatic duct. Hepatic cords, formed by

platelike groups of cells called hepatocytes, are located between the center

and the margins of each lobule. The hepatic cords are separated from one

another by blood channels called hepatic sinusoids. The sinusoid epithelium

contains phagocytic cells that help remove foreign particles from the blood.

Blood from the hepatic portal vein and the hepatic artery flows into the sinusoids

and becomes mixed. The mixed blood flows towards the center of each lobule

into a central vein. The central veins from all the lobes unite to form the hepatic

veins, which carry blood out of the liver to the inferior vena cava.

A cleft-like lumen, the bile canaliculus, is between the cells of each hepatic

cord. Bile, produced by the hepatocytes, flows through the bile canaliculi to the

hepatic ducts in the portal triads. The hepatic ducts converge and empty intothe right and left hepatic ducts, which transport bile out of the liver. The right

and left hepatic ducts unite to form a single common hepatic duct. The

common hepatic ducts is joined by the cystic duct from the gallbladder is a

small sac on the inferior surface of the liver that stores and concentrates bile.


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The common bile duct joins the pancreatic duct and opens into the duodenum

at the duodenal papilia. The opening into the duodenum is regulated by a

sphincter.

The liver performs important digestive and excretory functions, store and

processes nutrients, synthesizes new molecules, and detoxifies harmful

chemicals.

The liver secretes about 70mL of bile each day. Bile contains no digestive

enzymes, but it plays an important role in digestion by diluting and neutralizing

stomach acid and by dramatically increasing the efficiency of fat digestion and

absorption. Digestive enzyme cannot act efficient on large fat globules. Bile salts

emulsify fats, breaking the fat globules into smaller droplets, much like the action

of detergent in dish-water. The small droplets are more easily digested by the

digestive enzymes. Bile also contains excretory products such as bile pigments,

cholesterol and fats. Bilirubin is a bile pigment that results from the breakdown of

hemoglobin.

Bile excretion by the liver is stimulated by secretin, which is released from theduodenum. Cholecystokinin stimulates the gall bladder to contract and release

bile into the duodenum. Parasympathetic stimulation through the vagus nerve

also stimulates bile secretion and release.

Most bile salts are reabsorbed in the ileum, and the blood carries them back to

the liver, where they stimulate additional bile salts secretion and are once again

secreted into the bile. The loss of bile salts in the feces is reduced by this

recycling process.

The liver can remove sugar from the blood and store it in the form of glycogen. It

can also store fat, vitamins, copper and iron. This storage function is usually short

term.


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The liver transforms some nutrients into more readily usable substances. Many

ingested substances are harmful to the cells of the body. In addition, the body

itself produces many by-products of metabolism that, if accumulated, are toxic.

The liver is an important line of defense against many of those harmful

substances. It detoxifies them by altering their structure, making their excretion

easier. The liver can also produce its own unique new compounds. Many of the

blood proteins, such as albumin, fibrinogen, globulins, and clotting factors, are

synthesized in the liver and released into the circulation.

Pancreas

Pancreas is a fish-shaped spongy grayish-pink organ about 6 inches (15 cm)

long that stretches across the back of the abdomen, behind the stomach. The

head of the pancreas is on the right side of the abdomen and is connected to

the duodenum (the first section of the small intestine). The narrow end of the

pancreas, called the tail, extends to the left side of the body.

The pancreas makes pancreatic juices and hormones, including insulin. The

pancreatic juices are enzymes that help digest food in the small intestine. Insulincontrols the amount of sugar in the blood.

As pancreatic juices are made, they flow into the main pancreatic duct. This

duct joins the common bile duct, which connects the pancreas to the liver and

the gallbladder. The common bile duct, which carries bile (a fluid that helps

digest fat) connects to the small intestine near the stomach.

The pancreas is thus a compound gland. It is compoundin the sense that it is

composed of both exocrine and endocrine tissues. The exocrine function of the

pancreas involves the synthesis and secretion of pancreatic juices. The

endocrine function resides in the million or so cellular islands (the islets of

Langerhans) embedded between the exocrine units of the pancreas. Beta cells


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of the islands secrete insulin, which helps control carbohydrate metabolism.

Alpha cells of the islets secrete glucagon that counters the action of insulin.

Large Intestines

The colon is made up of 6 parts all working collectively for a single purpose. Their

purpose is ridding the body of toxins that have entered the body from food

sources, environmental poisons, or toxins produced within the body. The colons

role is to transfer nutrients into the bloodstream through the absorbent walls of

the large intestine while pushing waste out of the body. In this process, digestive

enzymes are released, water is absorbed by the stool, and a host of muscle

groups and beneficial microorganisms work to maintain the digestive system.

The colon is approximately 4.5 feet long, 2.5 inches wide, and is a muscular tube

composed of lymphatic tissue, blood vessels, connective tissue, and specialized

muscles for carrying out the tasks of water absorption and waste removal. The

tough outer covering of the colon protects the inner layer of the colon with

circular muscles for propelling waste out of the body in an action called

peristalsis. Under the outer muscular layer is a sub-mucous coat containing thelymphatic tissue, blood vessels, and connective tissue. The innermost lining is

highly moist and sensitive, and contains the villi- or tiny structures providing blood

to the colon.

The colon is actually just another name for the large intestine. The shorter of the

two intestinal groups, the large intestine, consists of parts with various

responsibilities. The names of these parts are the transverse colon, ascending

colon, appendix, descending colon, sigmoid colon, and the rectum and anus.

Transverse Colon


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The transverse, ascending, and descending colons are named for their physical

locations within the digestive tract, and corresponding to the direction food

takes as it encounters those sections. Within these parts of the colon,

contractions from smooth muscle groups work food material back and forth to

move waste through the colon and eventually, out of the body. The intestinal

walls secrete alkaline mucus for lubricating the colon walls to ensure continued

movement of the waste.

The ascending colon travels up along the right side of the body. Due to waste

being forced upwards, the muscular contractions working against gravity are

essential to keep the system running smoothly. The next section of the colon is

termed the transverse colon due to it running across the body horizontally. Then,

the descending colon turns downward and becomes the sigmoid colon,

followed by the rectum and anus.

Ileocecal and Cecum Valves

The ileocecal valve is located where the small and large intestines meet. This

valve is an opening between the small intestine and large intestine allowingcontents to be transferred to the colon. The cecum follows this valve and is an

opening to the large intestine.

Rectum and Anus

The rectum is about eight inches long and serves, basically, as a warehouse for

poop. It hooks up with the sigmoid colon to the north and with the anal canal to

the south.

The rectum has little shelves in it called transverse folds. These folds help keep

stool in place until youre ready to go to the bathroom. When youre ready,


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stool enters the lower rectum, moves into the anal canal, and then passes

through the anus on its way out.

The rectum intestinum acts as a temporary storage facility for feces. As the

rectal walls expand due to the materials filling it from within, stretch receptors

from the nervous system located in the rectal walls stimulate the desire to

defecate. If the urge is not acted upon, the material in the rectum is often

returned to the colon where more water is absorbed. If defecation is delayed for

a prolonged period of time constipation and hardened feces results.

When the rectum becomes full, the increase in intrarectal pressure forces the

walls of the anal canal apart, allowing the fecal matter to enter the canal. The

rectum shortens as material is forced into the anal canal and peristaltic waves

propel the feces out of the rectum. The internal and external sphincter allows

the feces to be passed by muscles pulling the anus up over the exiting feces.


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III. The Patients Illness

A. PATHOPHYSIOLOGY

a.) Book-Centered

Medical Diagnosis

Typhoid fever

Definition

Typhoid fever - is a life-threatening illness caused by the bacterium Salmonella typhi.

Schematic Diagram

Predisposing

y Geographical area Asia, Africa, Latin

America, the Caribbean, and Oceania

y School-aged children and young adults

PrecipitatingWashing of handsDrinking unpurifieEating foods fromEconomic status

Ingestion of foods or fluids contaminated with

Salmonella typhi bacteria

Bacteria enter the stomach and survive a pH as low as

1.5

Bacteria invades the Payers patches of the intestinal

wall in the small intestines where it attach (incubation

period is first 7-14 days after ingestion)


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The bacteria is within the macrophagesand survives

Bacteria spread via the lymphatics while inside

the macrophages

Bacteria will then injects toxins known as the effector

proteins into the intestinal cells and interrupts with

the cellular proteins & lipids & manipulate their

function resulting in phagocytization of the epithelial

cell membrane until it is engulf down into the inferiorpart of the host cells where macrophages is present.

Macrophages & intestinal epithelial cells

then attract T cells & neutrophils with

interleukin 8 (IL-8 causing inflammation of

the intestinal wall)

Perforation and

destruction of mucosa

lining of the intestinal

can lead to persistent

inflammation

The bacteria induced macrophage apoptosis,

breaking out into the bloodstream and cause

systemic infection

Ulceration and bleedin

the mucosal lining and

leads to necrosis

Tissue damage and

inflammation causes lo

of absorption due to

damaged villi causing a

increase in water,

electrolytes, mucus,

blood, and serum to be

pulled into the intestin

from immature crypt c

Diagnostic:

Hematology:

Neutrophils-elevated


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Legend:

- Pathophsiology

- Signs and symptoms

- Diagnostic exams

- Complications

Typhoid Fever

Acute Gastroenteritis

Abdominal spasm is

induced to limit mucosal

injury adding in

stimulation of increased

peristalsis

Complications:

Peritonitis

Pancreatitis

Hepatic and splenic abscesses

Disseminated intravascular

coagulation Myocarditis

Shock

Death

Signs/ symptoms:

Febrile

Warmth to touch

Headache

Body weakness

Rash/ Red spots

Sore throat

Complications:

Bile is infected and typically shed

in the stool and are then available

to infect other hosts


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b.) Client-Centered

Medical Diagnosis

Typhoid fever

Definition

Typhoid fever - is a life-threatening illness caused by the bacterium Salmonella typhi.

Schematic Diagram

Predisposing

y Geographical area tropical islands inthe Pacific (Philippines) and Asia

y Children aged 5-15

Precipitating

y Washing o

y Drinking u

y Eating stre

y Nail biting

y Economic

Ingestion of foods or fluids contaminated with

Salmonella typhi bacteria

Bacteria enter the stomach and survive a pH as low as

1.5

Bacteria invades the Payers patches of the intestinal

wall in the small intestines where it attach (incubation

period is first 7-14 days after ingestion)


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The bacteria is within the macrophages

and survives

Bacteria spread via the lymphatics while inside

the macrophages

Bacteria will then injects toxins known as the effector

proteins into the intestinal cells and interrupts with

the cellular proteins & lipids & manipulate their

function resulting in phagocytization of the epithelial

cell membrane until it is engulf down into the inferior

part of the host cells where macrophages is present.

Macrophages & intestinal epithelial cells

then attract T cells & neutrophils with

interleukin 8 (IL-8 causing inflammation of

the intestinal wall)

Typhoid Fever

Perforation and

destruction of mucosa

lining of the intestinal

can lead to persistent

inflammation

The bacteria induced macrophage apoptosis,

breaking out into the bloodstream and cause

systemic infection

Ulceration and bleedin

the mucosal lining and

leads to necrosis

Tissue damage and

inflammation causes lo

of absorption due to

damaged villi causing a

increase in water,

electrolytes, mucus,

blood, and serum to be

pulled into the intestin

from immature crypt cSigns/ symptoms:

Febrile: T-38.5CWarmth to touch

Headache of 3/10,

body weakness


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Legend:

- Pathophsiology

- Signs and symptoms

- Diagnostic exams

- Complications

Abdominal spasm is

induced to limit mucosal

injury adding in

stimulation of increased

peristalsis

Complications:

Bile is infected and typically shed

in the stool and are then available

to infect other hosts


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B. SYNTHESIS OF THE DISEASE

1. DEFINITION OF THE DISEASE (book-based)

Typhoid fever is acute, generalized infection caused by Salmonella typhi.

The main sources of infection are contaminated water or milk and, especially in

urban communities, food handlers who are carriers.

Typhoid fever is contracted by the ingestion of the bacteria in

contaminated food or water. Patients with acute illness can contaminate the

surrounding water supply through stool, which contains a high concentration of

the bacteria. Contamination of the water supply can, in turn, taint the food

supply. About 3%-5% of patients become carriers of the bacteria after the acute

illness. Some patients suffer a very mild illness that goes unrecognized. These

patients can become long-term carriers of the bacteria. The bacterium

multiplies in the gallbladder, bile ducts, or liver and passes into the bowel. The

bacteria can survive for weeks in water or dried sewage. These chronic carriers

may have no symptoms and can be the source of new outbreaks of typhoid

fever for many years.

Pathophysiology

After the ingestion of contaminated food or water, the Salmonella

bacteria invade the small intestine and enter the bloodstream temporarily. The

bacteria are carried by white blood cells in the liver, spleen, and bone marrow.

The bacteria then multiply in the cells of these organs and reenter the

bloodstream. Patients develop symptoms, including fever, when the organism

reenters the bloodstream. Bacteria invade the gallbladder, biliary system, and

the lymphatic tissue of the bowel. Here, they multiply in high numbers. The

bacteria pass into the intestinal tract and can be identified for diagnosis in


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cultures from the stool tested in the laboratory. Stool cultures are sensitive in the

early and late stages of the disease but often need to be supplemented with

blood cultures to make the definite diagnosis.

2. PREDISPOSING AND PRECIPITATING FACTORS

Age

According to WHO, most documented typhoid fever cases involve

school-aged children and young adults.

Race

Typhoid fever occurs worldwide, primarily in developing nations

whose sanitary conditions are poor. Typhoid fever is endemic in Asia,

Africa, Latin America, the Caribbean, and Oceania, but 80% of cases

come from Bangladesh, China, India, Indonesia, Laos, Nepal, Pakistan, or

Vietnam. Within those countries, typhoid fever is most common in

underdeveloped areas. Typhoid fever infects roughly 21.6 million people

(incidence of 3.6 per 1,000 population) and kills an estimated 200,000

people every year.

y Work in or travel to areas where typhoid fever is endemic

y Have close contact with someone who is infected or has recently been

infected with typhoid fever

y Have an immune system weakened by medications such as

corticosteroids

y Drink water contaminated by sewage that contains Salmonella typhi

y Low economic status


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y Poor hand washing practice

3. SIGNS AND SYMPTOMS

The symptoms of typhoid appear 10 to 14 days after infection;

. In some cases you may not become sick for as long as two months after

exposure.

First stage

Once signs and symptoms do appear, the patient would likely to experience:

y Fever, often as high as 103 or 104 F (39 or 40 C) - body has raised its

temperature to fight an infection or condition

y Headache

y Weakness and fatigue

y A sore throat

y Abdominal pain

y Diarrhea or constipation

y Rose spots in the abdomen- pathognomic sign

Children are more likely to have diarrhea, whereas adults may become severely

constipated. During the second week, the patient may develop a rash of small,

flat, rose-colored spots on your lower chest or upper abdomen. The rash is

temporary, usually disappearing in two to five days.


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Second stage

If the patient doesnt receive treatment for typhoid fever, he/she may enter a

second stage during which you become very ill and experience:

y Continuing high fever

y Either diarrhea that has the color and consistency of pea soup or severe

constipation

y Considerable weight loss

y Extremely distended abdomen

The typhoid state

By the third week, he/she may:

y Become delirious

y Lie motionless and exhausted with eyes half-closed in what's known as the

typhoid state

Life-threatening complications often develop at this time.

TREATMENT

Chloramphenicol is the most effective drug in combating typhoid,

- DOC

DIET

High caloric diet

4. HEALTH PROMOTION AND PREVENTIVE ASPECTS OF THE DISEASE


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1. Wash hands

Frequent hand washing is the best way to control infection. Wash hands

thoroughly with hot, soapy water, especially before eating or preparing food

and after using the toilet. Carry an alcohol-based hand sanitizer for times when

water isn't available.

2. Avoid drinking untreated water.

Contaminated drinking water is a particular problem in areas where typhoid is

endemic. For that reason, drink only bottled water or canned or bottled

carbonated beverages, wine and beer. Carbonated bottled water is safer than

uncarbonated bottled water. Wipe the outside of all bottles and cans before

opening. Ask for drinks without ice. Use bottled water to brush teeth, and try not

to swallow water in the shower.

3. Avoid raw fruits and vegetables.

Because raw produce may have been washed in unsafe water, avoid fruits and

vegetables that can't be peeled, especially lettuce. To be absolutely safe,

avoid raw foods entirely.

4. Choose hot foods.

Avoid food that's stored or served at room temperature. Steaming hot foods are

best. And although there's no guarantee that meals served at the finest

restaurants are safe, it's best to avoid food from street vendors it's more likely

to be contaminated.


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5. Vi polysaccharide vaccines

Typhim Vi is a sterile solution containing the cell surface Vi polysaccharide

extracted from Salmonella typhi Ty2 strain and is for intramuscular use.

According to the approved package insert (PI), Typhim Vi is indicated for active

immunization against typhoid fever for persons two years of age or older. The PI

further states:

"Based on the available efficacy data, vaccination with Typhim Vi may

not be expected to protect 100% of susceptible individuals."

"An optimal reimmunization schedule has not been established.

Reimmunization every two years under conditions of repeated or

continued exposure to the S. typhi organism is recommended at this time."

6. TY21a

Primary vaccination with oral Ty21a vaccine consists of a total of four

capsules, one taken every other day. The capsules should be kept refrigerated

(not frozen), and all four doses must be taken to achieve maximum efficacy.

Each capsule should be taken with cool liquid no warmer than 37 Celsius (98.6

Fahrenheit), approximately one hour before a meal. The vaccine manufacturer

recommends that Ty21a not be administered to infants or children younger than

6 years of age. The vaccine offers between 33 and 78% protection. The vaccine

is most commonly used to protect travelers to endemic countries

To prevent infecting others

If you're recovering from typhoid, these measures can help keep others safe:


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1. Wash hands often.

This is the single most important thing that can do to keep from spreading the

infection to others. Use plenty of hot, soapy water and scrub thoroughly for at

least 30 seconds, especially before eating and after using the toilet.

2. Clean household items daily.

Clean toilets, door handles, telephone receivers and water taps at least once a

day with a household cleaner and paper towels or disposable cloths.

3. Avoid handling food.

Avoid preparing food for others until the doctor says it is no longer contagious. If

he/she works in the food service industry or a health care facility, he/she won't

be allowed to return to work until tests show that he/she is no longer shedding

typhoid bacteria.

4. Keep personal items separate.

Set aside towels, bed linen and utensils for own use and wash them frequently in

hot, soapy water. Heavily soiled items can be soaked first in disinfectant.

NURSING INTERVENTION INDEPENDENT:

Monitor patient temperature degree and pattern.

Observe for shaking chills and profuse diaphoresis


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Wash hands with anti-bacterial soap and after each care of activity and

encourage proper hygiene.

Provide tepid sponge baths and avoid the use of ice water and alcohol.

Monitor for signs of deterioration of condition or failure to improve with

therapy

.COLLABORATIVE

Administer antipyretics as prescribed.-administer antibiotics as prescribed.

*PATIENT- CENTERED

According to the patient, she is fond of eating street foods especially fish

balls and siopao. The main sources of infection caused by salmonella typhi are

contaminated foods and water.

Pathophysiology

The patient ingested a contaminated food or water, the Salmonella

bacteria invade the small intestine and enter the bloodstream temporarily. The

bacteria are carried by white blood cells in the liver, spleen, and bone marrow.

The bacteria then multiply in the cells of these organs and reenter the

bloodstream.

The patient developed symptoms, including fever, when the organismreenters the bloodstream. Bacteria invade the gallbladder, biliary system, and

the lymphatic tissue of the bowel. Here, they multiply in high numbers. The

bacteria pass into the intestinal tract and can be identified for diagnosis in

cultures from the stool tested in the laboratory. Stool cultures are sensitive in the


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early and late stages of the disease but often need to be supplemented with

blood cultures to make the definite diagnosis.

Predisposing and precipitating factors:

Drinking water (water from the faucet) and eating contaminated

food by sewage that contains Salmonella typhi (street foods)

Low economic status

Poor hygiene (biting untrimmed nails as manifested by the patient)

Poor hand washing practice

SIGNS AND SYMPTOMS

The symptoms of typhoid appear 10 to 14 days after infection;

. In some cases you may not become sick for as long as two months after

exposure.

First stage

y Fever, often as high as 103 or 104 F (39 or 40 C) - body has raised its

temperature to fight an infection or condition ( August 8, 2010 )

y Headache due to decreased perfusion in the brain and fever (August 8,

2010 )

y Weakness and fatigue related to decreased absorption of nutrients (

August 8, 2010 )

y Abdominal pain ( August 8, 2010)


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y Diarrhea ( August 9, 2010 )

y Rose spots in the abdomen- pathognomic sign (did not manifest)

Second stage

If the patient doesnt receive treatment for typhoid fever, he/she may enter a

second stage during which you become very ill and experience:

y Continuing high fever ( date manifested)

y Either diarrhea that has the color and consistency of pea soup or severe (

date manifested)

y Considerable weight loss- - did not manifest

y Extremely distended abdomen- did not manifest

The typhoid state:

y Become delirious- did not manifest


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V. The Patient and her care:

A. Medical Management:

a. IVFs

Medical

management:

treatment

Date ordered

Date(s) performed

Date changed/D/C

General description Indication(s)

Or Purpose(s)

PLRS 1L X 10-12 X

8hoursDate ordered:

August 08, 2010

Date(s) performed:

August 08, 2010

It is an isotonic

crystalloid volume

expander that

expands circulating

blood volume. It

approximates the

fluid and electrolyte

composition of

blood and provides

9 cal/L.

PLRS was ordere

for the patient

replace fluid loss.


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Date changed:

August 09. 2010


Prior to:

y Prepare the equipment

y Verify doctors order

y Use strict aseptic technique

y Explain the procedure to the S0 and give formation about the purpose of IVF to b

y Identify the client

y Assess vital signs for baseline data

y Assess skin turgor, allergy to tape

y Check the status or veins to determine appropriate venipuncture site


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During:

y Use the smallest gauge needle possible.

y Check for patency of the tubing

y Spike the solution container

y Cleanse the fluid to be given, make sure it is the same with the prescribed flui

y Partially fill the drip chamber gently with solution.

y Select a suitable vein for venipuncture

Documents

Typhoid Fever Case