A Case Study On Typhoid Fever

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In partial Fulfillment of the Course Requirement in Nursing Care Management

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Presented to the Faculty of San Lorenzo Ruiz College of Nursing Ormoc City

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Submitted by: Busa, Ana Marie Echo Class 2010

Introduction Typhoid fever, also known as Tipos (in laymens term), is one of the most common worldwide illness most specifically in third world country such as ours, this is a question of sanitation since this disease is transmitted through ingestion of food or water which is improperly prepared and contaminated with the feces of an infected person, that contains the bacterium Salmonella enterica, serovar Typhi. The said bacteria perforates through the intestinal wall and grows best at 37 C/99 F human body temperature. Typhoid fever is characterized by: a slowly progressive fever as high as 40 C (104 F) profuse sweating, gastroenteritis nonbloody diarrhea. less commonly, a rash of flat, rose-colored spots may appear. Common causes of transmission are flying insects most specifically flies feeding on feces that may occasionally transfer the bacteria through poor hygiene habits and public sanitation conditions. A person may become an asymptomatic carrier of typhoid fever, suffering no symptoms, but capable of infecting others. Diagnosis is made by any blood, bone marrow or stool cultures and the Widal test. Sanitation and hygiene are the critical measures that can be taken to prevent typhoid. Typhoid does not affect animals and therefore transmission is only from human to human. The rediscovery of oral rehydration therapy in the 1960s provided a simple way to prevent many of the deaths of diarrheal diseases in general. Where resistance is uncommon, the treatment of choice is a fluoroquinolone such as ciprofloxacin otherwise; a thirdgeneration cephalosporin such as ceftriaxone or cefotaxime is the first choice. The student nurse personally chose this case study because as one of the persons living in a developing country, where handwashing and proper sanitation are not well practiced by some people, are at risk of acquiring typhoid fever. Moreover, the student felt that this study is important to her because this usually inflicts children particularly toddlers in which his son is. This study will help the nursing profession by providing information about the proper management and care for patients with Typhoid fever. It will also educate the people, especially those with Typhoid Fever and vulnerable individuals to seek medical care in order to

prevent the illness. It will increase awareness about the importance of having a healthy lifestyle and clean environment. This study will elaborate the inter relatedness of environment, life style habits and acquiring Typhoid Fever. Through this, the student nurse would be able to formulate a plan of care for the patient and formulate a health teaching plan to lay a foundation and minimize difficulties in the future. This study is not limited to the patients with Typhoid Fever only, but it is for all people who are interested in Typhoid Fever. The student nurse expects a lot from this case study, even if she couldnt really tackle the deepest part of the illness, she expect to gain more knowledge about the disease. The student nurse also expects to raise concern and awareness to everyone that typhoid fever is a communicable disease in which everyone is at risk of acquiring. However, it is greatly preventable with enough knowledge and understanding about the disease and with proper practicing handwashing and sanitation in our respective homes. The treatments and the different psychotherapy are important factors that she also wants to know as part of her job as a student nurse. From this study, she expect to have a better understanding about typhoid fever, learn skills especially with the care of these patients as well as nursing responsibilities that are involved in this care.

Objectives GENERAL OBJECTIVES: After 3 days of giving holistic nursing care to the patient, the student nurse will be able to acquire knowledge, attitude and skills about the care for pediatric patients with typhoid fever. SPECIFIC OBJECTIVES: After 8 hours of giving holistic nursing care to the patient, the student-nurse will be able to: 1. make thorough nursing assessment of the patient to be able to come up with an apposite plan of care. 2. explain the pathophysiology of Typhoid fever 3. identify the causes of Typhoid fever. 4. recognize the possible symptoms of Typhoid fever as manifested by the patient. 5. develop an individualized plan considering client characteristics or the situation and setting a specific, measurable, attainable, realistic and time bounded plan that reflect the onset, date of problem identified. 6. list ways on preventing Typhoid fever. 7. site the importance of preventions, medication compliance and positive attitude to early healing. 8. render appropriate nursing care to the patient to promote wellness and optimum level of functioning. 9. medicate properly and accurately the prescribed medications and to be able to identify its action and drug information. 10. endorse proper health behaviors in relevance to her care and age through play therapy

GENERAL OBJECTIVES: After 3 days of giving holistic nursing care or student nurse-patient-significant others interaction, the patient as well as the significant others will be able to acquire knowledge, attitude, and skills in the proper management with typhoid fever.

SPECIFIC OBJECTIVES: After 8 hours of giving holistic nursing care, the patient and the significant others will be able to: 1. understand awareness of the disease. 2. identify the risk factors of typhoid fever 3. explain the causes of typhoid fever 4. recognize own symptoms of typhoid fever. 5. learn and understand why laboratory examinations are being done. 6. know and understand the treatments of typhoid fever. 7. demonstrate proper management with the signs and symptoms manifested. 8. enumerate drugs or medications necessary with the care through understanding of drug information and precautions regarding its use. 9. show proper diet and exercise and stress its importance in promoting health and preventing further complications. 10. display proper hygiene techniques and stress its importance in promoting health and preventing further complications.

Nursing Assessment Personal History Patients Profile Name: Mr. Marlou W. Miao Age: 3 years old Civil Status: Single Religion: Roman Catholic Date of Admission: July 17, 2010 Room Number: P2 Complaints: Fever, Cough Impression/Diagnosis: Typhoid fever Physician: Dr. Neda Labtic Family/Individual Information, Social and Health History Mr. Miao, Marlou W. is a Filipino and was born on April 26, 2007. He is the youngest child of Ms. Melinda Miao, his mother died right after delivery due to some complications. He lives at Lomboy, Sherwood Albuera, Leyte together with his grandparents and aunty who looks after him, his other brother lives at another house with his father. He usually plays outside their house together with his brother and neighbor. He sometimes forgets to wash her hands prior to eating. 7 days prior to admission, Mr. Miao had an intermittent fever (38-39C), with no abdominal pain and no nausea and vomiting, condition was tolerated. The next day, patient still has fever accompanied by productive cough, yellow phlegm, difficult to expectorate and with abdominal pain. Patient was then brought by her mother to a private medical doctor and was prescribed by some medications. Fever was then decreased but still with persistent cough. Patient was told to come back after 5 days. After 5 days, patient still has fever and the private doctor requested a Salmonella test, after the test went positive, the doctor made a request for admission at Ormoc Sugarcane Planters Association-Farmers Medical Center. A case of Mr. Marlou W. Miao, 3 years old male was admitted at OSPA-FMC on July 17, 2010 for fever of about 7 days already. On admission, his Salmonella test revealed positive for salmonella typhi anti-09 antibodies.

Level of Growth and Development Normal Development at particular stage A. Physical Two year old children lose the baby look. Toddlers are usually chubby, with relatively short legs and a large head. The face appears small when compared to the skull; but as the toddlers grows, the face seems to grow from under the skull and appears better proportioned. Toddlers have a pronounced lumbar lordosis and a protruding abdomen. The abdominal muscles develop gradually with growth, and the abdomen flattens. Weight: two years old can be expected to weight approximately four times their birth weight. The weight gain is about 2 kg (5 lbs) between 1 year and 2 years and about 1-2 kg (2-5 lbs) between 2 and 3 years. The 3 year old weighs about 13.6 kg (30 lbs). Height: between ages 1 and 2 years, the average growth in height is 10-12 cm (45 in), and between ages 2 and 3 years, it slows to 6 to 8 cm (2 to 3 in). Head Circumference: The head circumference of the toddler increases on an average about 2.5 cm (1 in), and by 24 months the head is four-fifths of the average adult size. The brain is 70% of its adult size by the time the infant is 2 years old. Sensory Abilities: visual acuity is fairly well established at 1 year; average estimates of acuity for the toddler are 20/70 at 18 months and 20/40 at 2 years of age. Accommodation to near and far objects is fairly well developed by 18 months and continues to mature with age. At 3 years of age the toddler can look away from a toy prior to reaching out and picking it up. This ability requires the integration of visual and neuromuscular mechanisms. The senses of hearing, taste, smell, and touch become increasingly developed and associated with each other. Hearing in the 3 year old is at adult levels. The taste buds of the toddler are sensitive to natural flavors of food, and the 3-year old prefers familiar odors and tastes. Touch is a very important sense and a distressed toddler is often soothed by tactile sensations. Motor abilities: fine muscle coordination and gross motor skills improve during toddlerhood. At 2 years, toddlers can hold a spoon and put it into the mouth correctly. They are able to run; their gait is steady; and they can balance on one foot; by 3 years, most children are

toilet trained, although they still may have the occasional accident when playing or during the night. (Source: Kozier, 2004)

B. Cognitive According to Piaget, the toddler completes the 5th and 6th stages of the sensorimotor phase and starts the preconceptual phase at about 2 years of age. In the 5th stage, the toddler solves problems by a trial-and-error process. By stage 6, toddlers can solve problems mentally. (Source: Kozier, 2004) During Piagets preconceptual phase, toddlers develop considerable cognitive and intellectual skills. They learn about the sequence of time. They have some symbolic thought. Concepts start to form in late toddlerhood. A concept develops when child learns words the represent classes of objects or thoughts. (Source: Kozier, 2004) C. Moral According to Kohlberg, the first level of moral development is the preconventional when children respond to labels of good or bad. During the second year of life, children begin to know that some activities elicit affection and approval. They also recognize that certain rituals, such as repeating phrases from prayers, also elicit approval. This provides children with feelings of security. By 2 years of age, toddlers are learning what attitudes their parents hold about moral matters. (Source: Kozier, 2004) D. Psychosexual (Freud) Anal: anus and rectum are the center of pleasure. This stage occurs during toilet training. Fixation at the anal stage can result in obsessive compulsive personality traits, such as obstinacy, stinginess, cruelty and temper tantrums. (Source: Kozier, 2004) E. Psychosocial (Erikson) Erikson sees the period from 18 months to 3 years as the time when the central developmental task is autonomy versus shame and doubt. Toddlers begin to develop their sense of autonomy by asserting themselves with the frequent use of the word no. They are often frustrated by restraints to their behavior and between ages 1 and 3 may have temper tantrums.

Children learn to develop sense of self through their immediate social environment, in which their parents play a significant role. If childrens social interactions with their parents are negative, the children may begin to see themselves as bad. Although children like to explore the environment, they always need to have a significant person nearby. Parents need to know that young children experience acute separation anxiety, the fear and frustration that comes with parental absences. Abandonment is their greatest fear. (Source: Kozier, 2004) F. Spiritual Development According to Fowler, the toddlers stage of spiritual development is undifferentiated. Toddlers may be aware of some religious practices, but they are primarily involved in learning knowledge and emotional reactions rather than establishing spiritual beliefs. A toddler may repeat short prayers at bedtime, conforming to a ritual, because praise and affection result. This parental response enhances a toddler a sense of security. (Source: Kozier, 2004) 1.3.2 The Ill Person at Particular Stage of Patient Separation Anxiety Children react aggressively to the separation from the parent. They cry and scream for their parents, refuse the attention or anyone else, and are inconsolable in their grief. Children in the toddler stage demonstrate more goal-directed behaviors. For example, they may plead with their parents to stay and physically try to keep the parents with them or try to find parents who have left. They may demonstrate displeasure on the parents return or departure by having temper tantrums; refusing to comply with the usual routine of mealtime, bedtime, or toileting; or regressing to more primitive level of development. Loss of Control When their egocentric pleasures meet with obstacles, toddlers react with negativism, especially temper tantrums. Any restriction or limitation of movement, such as the simple act of making toddlers lie down, can cause forceful resistance and noncompliance. Loss

of control also results from altered routines and rituals. Toddlers rely on consistency and familiarity of daily rituals to provide a measure of stability and control in their complex world of growing and developing. The experience of hospitalization or illness severely limits their sense of expectation and predictability, since practically every detail of the hospital environment differs from that of the home. The principal reaction to such change is regression. Bodily Injury and Pain Toddlers reactions to pain are similar to those seen during infancy, except that the number of variables influencing the individual response is highly complex and varied. In general, children in this age-group continue to react with intense emotional upset and physical resistance to any actual or perceived painful experience. Behaviors indicating pain include grimacing, clenching their teeth or lips, opening their eyes wide, rocking, rubbing, and acting aggressively, such as biting, kicking, hitting or running away. (Source: Kozier, 2004) The ill person at the particular stage of patient: The patient, Mr. Miao is quite cooperative and responds to my questions. Although he is afraid of other health care members that would come near him thinking that they would hurt him through some injections. He manifests this kind of attitude because of his experience during his admission at the emergency room where he was started with an IV line several times due to difficulty in locating his veins and also during extractions of blood for some tests. After that, he makes a face and sometimes cry every time he sees any of the health care members. He would also cling to his aunt most of the time because he is afraid that she might leave him.

SAN LORENZO RUIZ COLLEGE OF ORMOC COLLEGE OF NURSING ORMOC CITY Name: Mr. Marlou W. Miao Room Number: P2 Impression/Diagnosis: Typhoid fever Date of Admission: July 17, 2010 Physician: Dr. Labtic

Diagnostic results Diagnostic Test HEMATOLOGIC EXAM: Date: July 17, 2010 Hemoglobin MCH MCHC Hematocrit WBC Granulocytes Lymphocytes Mid Eosinophils Basophils Monocytes Granulocytes Lymphocytes Mid 1.2 - 8 x 10^9/uL 0.5 5 x 10^9/uL .10 - 1.5 x 10^9/uL 11.5 - 16.5 g/dl 27 - 32 pg 32 - 36 g/dl 41.5 - 50.4 % 5 - 10 x 10^9/uL 35 - 80 % 20 - 40 % 2 - 15 % 10.70 g/dl 27.90 pq 34.80 g/dl 30.7% 10.60x10^9/uL 90.6 % 34.3 % 5.1 % 2% 1% 3% 6.40 x 10^9/uL 3.60 x 10^9/uL .60 x 10^9/uL Normal Normal Normal Decreased, Infection Normal Normal Decreased, Infection Increased, Infection Increased, Infection Normal Normal Normal Value Patients Result Significance

RBC MCV RDWR RDWA Platelet count MPV PDW PCT LPCR MICROBIOLOGY SECTION: SALMONELLA TEST: Date: July 17, 2010

4.8-5 x 10^12/L 80 100 fl 11-16 % 30 160 fl 150 - 450 x 10^12/L 8 11 fl .10 9.99 fl .09 9.99 fl .10 9.99 %

3.83 x 10^12/L 80.10 fl 12.60 % 51.90 fl 337.10 x 10^12/L 6.40 fl 8.40 fl .21 fl 9.10 %

Decreased, Infection Normal Normal Normal Normal Normal Normal Normal Normal

Igm Positive -acute Typhoid Fever

positive typhoid fever

URINALYSIS: Date: July 17, 2010 I. Macroscopic Color Albumin Sugar Transparency pH Specific Gravity II. Microscopic Light straw or yellow Negative Negative Clear 4.0-8.0 1.007-1.030 Yellow Negative Negative Slightly Turbid 6.0 1.080 Normal Normal Normal Normal Normal Increased, Infection

Pus Cells RBC Squamous Cells Bacteria Mucus Threads Crystals Amorphous nitrites STOOL EXAM: Date: July 17, 2010 Color Consistency Mucus Yellow Formed negative

1-2 0-1 few few few

few

Yellow brown Watery Slightly mucoid

Typhoid fever diarrhea intestinal infection; typhoid fever

1. Present Profile of Functional Health Patterns Health Perception/ Health Management Pattern Before admission, Mr. Miao is a healthy active toddler who tries everything under his nose. He is not conscious about health practices such as washing hands before eating. His aunt verbalizes that he is healthy that is without any major illnesses. Upon Marlous admission, he became very attached to his aunty and grandmother. He also becomes very sensitive because of his present condition. Every time a health personnel gets inside his room, he immediately clings to his aunty and cry. He is afraid that the health personnel might inject and hurt him. Marlou has fever and his body temperature ranges from 38-39C. To manage such condition, his aunt performs tepid sponge bath and he has an antipyretic PRN for temperature greater than 38C.

Nutritional-Metabolic Pattern Marlou has a big appetite before admission, he usually eats lots of sweets such as candies in between meals and during mealtime he eats vegetables and rice and sometimes dried fish. During his admission here in OSPA-FMC Marlou is on diet as tolerated. His aunty gives him rice, fish, vegetables and some fruits. She also gives him milk. But, Marlou only eats a little because he has decreased in appetite due to his condition. He only eats a maximum of 4 tablespoons per meal. However, he drinks a lot of water. He experiences abdominal pain. Elimination Pattern Marlou defecates once a day and have not encountered problems in urinary elimination prior to admission. He cannot really control hid elimination pattern well that is why he is still wearing diapers and he urinates more often. He can consume 4-5 diapers in one shift. Sometimes, he is constipated because he cannot defecate within 2 days. Activity/ Exercise Pattern Before admission, Marlou is a very active toddler who spends most of the time outside the house playing on the grounds. Now the patients movements seemed weak. He keeps on lying down. Sometimes, he sits up on his bed or asks his aunty to cuddle him. He moves slowly every time he eats or does something. He is assisted by his aunty every time he attempts to sit up. His past time inside his room is just watching other patients since there is no television. Cognitive / Perceptual Pattern Prior and during admission, Marlou still functions and thinks his age. He still enjoys watching cartoon movies and playing. But only during hospitalization that he becomes more attached to his aunty just clinging onto her and expresses tantrums. Rest / Sleep Pattern During admission, sometimes the patients sleep is disturbed due to abdominal pain and feeling of cold whenever he would have fever again. He also wakes up and cries every time a health personnel comes into his room. His sleep and rest are interrupted because he feels anxious whenever someone that she does not know comes near her. Prior to admission, he never had problems with sleep because according to his aunt he enjoys an afternoon nap.

Self perception pattern Before admission the patient thinks he is loved and cared by his aunt and feels secure whenever she is near that is why her aunt stopped schooling just to take care of him. During admission the patient thinks that he really needs more attention from his aunty because he is not feeling very well. He knows that he has an illness and thus he must not be left by his aunty thinking that he would be worse if he is left by her. Role Relationship Pattern Prior and during admission the patient is very close to his aunty and grandmother. He seems very dependent to his aunty and asks his aunties permission every time he wants to do something. He usually doesnt responds to people he doesnt know. You need to gain his trust before he would communicate with you. Coping Stress Tolerance Pattern Before and during admission, his coping mechanism is to cry every time he doesnt feel well, he asks his aunty to cuddle him and puts him to sleep. And when there are things done to him that he doesnt like, he uses crying as a way of coping. Value Belief Pattern The Patients values and beliefs is basically the same before and during admission. He does not pay much attention on praying, though she knows about God. She can recite the Prayer before meals and Prayer before sleep. He goes to mass with his aunty and grandmother every Sundays, but there are times that they cant attend mass due to some uncontrolled circumstances. He doesnt blame God with his hospitalization and he prays with his aunty before he goes to sleep at night.

Pathophysiology and Rationale Normal Anatomy and Physiology of Affected organ The Digestive System The organs of the digestive system together perform a vital function of preparing food for absorption and use by the million of body cells. Most foods when eaten is in a form that cannot reach the cells (because it cannot pass through the intestinal mucosal into the bloodstream) nor could it be used by the cells even if it could reach them. It must, therefore, be modified as both to chemical and physical composition of food so that it can be absorbed and utilized by the cells is known as digestion and is the function of the digestive system. Mouth (Buccal Cavity) The following structures form the buccal cavity: the cheeks (side walls), the tongue and its muscle (floor), and the hard and soft palates (roof). Of these, only the palates and the tongue are important. The palate consists of portions of four bones: two maxillae and two palatines. The soft palate which forms the portion between the mouth and the nasopharynx and is named fauces. Suspended from the midpoint of the posterior of the arch is small cone-shaped process the uvula. Teeth Twenty deciduous teeth, the so called baby teeth, appear early in life and are later replaced by 32 permanent teeth. The name and the numbers of teeth present in both sets are: Name of tooth Central incisors Lateral Incisors Cuspids (Canines) Premolars (Bicuspid) First Molars (Tricuspid) Second Molars Third Molars Total per set deciduous teeth 2 2 2 0 2 2 0 20 Permanent teeth 2 2 2 4 2 2 2 32

The first deciduous tooth erupts usually at the age of 6 months. The rest follow at the rate of 1 or more a month until all 20 have appeared. There is, however, great individual variation in the age at which teeth erupts. Deciduous teeth are shed generally between the ages of 6 and 13 years. The third molars (wisdom teeth) are the last to appear, erupting usually sometimes at the age of 17 years old. Pharynx Food passes from the mouth to esophagus by way of the pharynx Esophagus The esophagus, a collapsible tube about 25cm (10 inches) long, extends from the pharynx to the stomach piercing tho the diaphragm in this descent from the thoracic to the abdominal cavity. It also lies posterior to the trachea and the heart. Stomach Just below the diaphragm, the digestive tube dilates on elongated pouch-like structure, the stomach, the size of which varies according to several factors, notably the gender and amount of distention. In general, the female stomach is usually more slender and smaller than the male stomach. For sometime after a meal, the stomach enlarges because of distention of walls, but as food leaves, the walls partially collapsed, leaving the organ about the size of a large sausage. Sphincter muscle consist of circular fibers so arrange that there is an opening they are contracted. The cardiac sphincter guards the opening of the esophagus into the stomach into the first part of the small intestine (duodenum). Gallbladder The gallbladder is an active storage shed, which absorbs mineral salts and water received from the liver and converts it into a thick, mucus substance called "bile," to be released when food is present in the stomach. The gallbladder is a small, pear-shaped sac which is situated just below the liver and is attached to it by tissues. It stores bile and then releases it when food passes from the stomach to the duodenum (the first part of the small intestine) to help in the process of digestion. Small intestine

Chemical digestion of foods begins in the small intestine. The small intestine is able to process only a small amount of food at one time. The pyloric sphincter controls food movement into the small intestine from the stomach and prevents the small intestine from being overwhelmed. Enzymes, produced by the intestinal cells and more importantly by the pancreas and ducted into the duodenum through the pancreatic duct, complete the chemical breakdown of foods in the small intestine. Large intestine The large intestine is about 5 feet long extends from the ileocecal valve to the anus. Its major function is to dry out the indigestible food residue by absorbing water and to eliminate this residue from the body as feces. It frames the small intestine on three sides and has the following subdivisions: cecum, appendix, colon, rectum, and anal canal. .(Source: Elaine Marieb, Human Anatomy and Physiology 2006)

Precipitating Factors: Predisposing Factors: contaminated foods Age unsanitary food PATHOPHYSIOLOGY OF TYPHOID FEVER Gender preparation Medical History unsanitary Geographical area environment

Ingestion of food or fluids contaminated by S.typhi

Bacteria invades the Payers patches of the intestinal wall in the small intestines where it attach (incubation period is first 714 days after ingestion)

Bacteria will then injects toxins known as the effector proteins into the intestinal cells and interrupts with the cellular proteins & lipids & manipulate their function resulting in phagocytization of the epithelial cell membrane until it is engulf down into the inferior part of the host cells where macrophages is present.

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

TYPHOID FEVER

Signs Non bloody Diarrhea Slow progressive Fever Decreased Appetite Transient skin rash (rose spots) Profuse sweating

Leukopenia Positive Widal test

Symptoms Body Malaise Abdominal Pain Headache Cough Weakness

Medical Management: Administration of Analgesics Admonistration of Antipyretics Administration of Antibiotics (Ceftriaxone)

Nursing Management: Perform tepid sponge bath

Disease Process of Typhoid Fever Typhoid fever is a bacteremia in which the organism gains access to the blood stream through the bowel, principally through the infected peyers patches of lymphoid tissue in the lower portion of the ileum. The first week these patches are swollen: the second week they form sloughs, which are often bile colored; the third week the sloughs separates and leaves an ulcerative surface, which then starts to heal by granulation. Since the organism reaches all parts of the body through the bloodstream, almost all organs at time may show pathologic changes being those due to toxemia and high fever. Commonly, however, the heart, liver, spleen, muscle, and mesenteric lymph glands may be either red or swollen, or else broken down into messy masses. The muscles are flabby granular. The urine may be milky in appearance with the peculiar opalescence, which is due to the presence in it of millions of typhoid bacilli. The causative organism invades the bloodstream by way of lymphatic tissues and is carried to all parts of the body. Early symptoms may vary, may be vague with headaches, anorexia and malaise. As the disease progresses, there are joint pains, abdominal discomfort, vomiting and usually constipation although they may be diarrhea. Cough and bronchitis occur in about 50% of the cases. During the first week, the body temperature rise in step ladder pattern until it reaches about 104. Wherein remains until near the end of the 3rd week, after which it falls by lysis. The temperature is irregular, with 2 remissions in the morning. (Source: Smeltzer and Bare,2004)

Classical and Clinical Signs and Symptoms of Typhoid fever Classical Symptoms Body Malaise Clinical Symptoms Manifested: patient keeps of lying in bed and seldom moves around. He needs his auntys assistance whenever she wants to sit up from his bed. Rationale Illness can deplete a persons energy to such degree that it becomes difficult for the person to deal with day-to day life. (Source: Lemone & Burke, Medical surgical Nursing, Chapter 24, page 639) Loss of appetite occurs as a result of the decreased metabolic rate and the increased catabolism that company immobility (Source: Lemone & Burke, Medical surgical Nursing, Chapter 24, page 640) The body temperature alternates at regular intervals between periods or subnormal. (Source: Lemone & Burke, Medical surgical Nursing, Chapter 24, page 639) Abdominal spasm is induced to limit mucosal injury adding in stimulation of increased peristalsis. Perforation

Decreased Anorexia

Appetite

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

Fever (intermittent)

Manifested: patients temperature fluctuates from 38-39C to 36C

Abdominal Pain

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

facial grimace

and destruction of mucosal lining of the intestinal wall can lead to persistent inflammation (Source: Monahan, Medical surgical Nursing, Chapter 30, page 1708) Tissue damage and inflammation causes loss of absorption due to damaged villi causing an increase in water, electrolytes, mucus, blood, and serum to be pulled into the intestine from immature crypt cells (Source: Lemone & Burke, Medical surgical Nursing, Chapter 24, page 639)

Diarrhea

Manifested: Consumes 45 diapers per shift due to watery stools

Nursing Interventions Care Guide of Patients with Typhoid Fever The patient must be isolated until at least 3 negative stool cultures, 24 hours apart and has been secured. Strict asepsis must be carried out. All stool, urine, and vomitus must be disinfected unless disposal of in a municipal sewage system. The rectal thermometer should be taken to conserve the patients strength and to avoid chilling the patient. Antipyretic drug should be administered for fever. The skin must be protected by frequent turning of the patient and proper positioning, since it is susceptible to skin infection. Mouth care should be given at regular intervals. The patient should be encouraged to take adequate fluids by mouth. If fluids are administered parenterally, caution must be exercised, since overloading the vascular system may lead to cardiovascular complications. Abdominal distention should be guarded against, since it

thins the intestinal walls and may contribute to hemorrhage or perforation of intestinal ulcers. Small low enemas may be given and glycerine suppositories or mineral oil to avoid constipation. All stools must be examined for evidenced of blood and any bright blood must be reported at once. The patient should be examined for bladder distention and retention of urine. During acute stage, the patient is drowsy and lethargic and incontinence may occur. The patient should be in a quiet pleasant surroundings and visitors reduced to a minimum. (Source: Lemone & Burke, 639)

SAN LORENZO RUIZ COLLEGE OF ORMOC COLLEGE OF NURSING ORMOC CITY Nursing Assessment Name: Mr. Marlou W. Miao Room Number: P2 Impression/Diagnosis: Typhoid fever Date of Admission: July 17, 2010 Physician: Dr. Labtic

Body Part Head: Hair

PHYSIOLOGIC I P P A 26

Black, evenly distributed, shoulder level Actual Patient Care White, no dandruff Smooth, fair skin Absence of nodules No tenderness, warm, temporal pulse: 124bpm

Scalp Forehead

Face

No deformities, brown colored skin, dry, good skin turgor Evenly distributed, black in color, parallel Slightly curved outward Intact, able to open and close Pale pink color, no inflammation, moist, no accumulation of secretions. White, small veins are visible Round, reactive to light and accommodation. Parallel, symmetrical Smooth, proportional to the face Pink, dry, presence of some cracks and peelings Symmetrical Dark pink, no ulceration Smooth, pinkish, no ulceration Located at the midline, not inflamed Yellowish in color Located anteriorly with ruggae Intact to gums 26 Hard No lump, no secretions Rough Flexible No masses Resistant No masses No lumps, no tenderness

Eyebrow Eyelash Eyelids Conjunctiva

Sclera Pupils External eyes Nose Lips Ears Gums Tongue Uvula Teeth Hard palate

27 SAN LORENZO RUIZ COLLEGE OF ORMOC COLLEGE OF NURSING ORMOC CITY Name: Mr. Marlou W. Miao Room Number: P2 Impression/Diagnosis: Typhoid fever Date of Admission: July 17, 2010 Physician: Dr. Labtic

Nursing Care Plans Needs/ Problems/ Cues Physiologic Deficit: 1. Altered thermoregula tion Cues: - body temperature of 38.5 C - flushed skin - skin warm to touch - teary eyes - cracked lips -Positive Salmonella typhi stool exam result gitugnaw kuno siya. As verbalized by the SO. Nursing Diagnosis Altered Thermoregul ation: Fever related to on going infection Scientific Basis Fever is the most common sign of a systemic response to injury and it is most likely caused by endogenous pyrogens released from neutrophils and macrophage s, a specialized form of leukocytes. These substances reset the hypothalami c thermostat which controls body temperature and produce fever. Objectives Nursing Actions Rationale

After 8 hours of nursepatient interaction, the patient will be able to: 1. manifest a lowered temperature as evidenced by body temperature from 38.5 C to 36.5 C Measures to: 1. decrease body temperature a. provide dry - to increase clothing and heat loss bed linens through conduction b. remove excessive clothing and covers. c. reduce physical activity d. provide adequate foods and fluids - to lower temperature

- to limit heat production - to meet the increase metabolic demands and prevent dehydration

27

28

Source: Brunner & Suddarths Medical Surgical Nursing

e. provide tepid sponge bath f. provide oral hygiene

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

g. provide - to maintain additional patients cooling comfort mechanisms like cooling mattress, cold packs h. administer Paracetamol (tempra syrup) 5ml q4 hours i. administer
Ceftriaxone 500g IVTT q12h

- drugs that reduce the level of fever

-to treat underlying cause

Physiologic Overload:

Alteration in comfort:

Salmomella Gastroenteri

After 8 hours of nurse-

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29 2. Acute Pain Cues: -Grimace face -Guarding at the abdominal area -Pain started yesterday (July 17, 2010) accompanied by diarrhea, located at the abdominal area for 8-10 seconds with a pain scale of 5, characterized by colicky pain. It is aggravated by walking and is relieved by bowel movement. It is treated with Paracetamol as pain relief. Sakit kuno iyaha tiyan, as verbalized by SO Acute Pain related to inflammation of gastric mucosa secondary to Typhoid Fever tis is characterize d by initial symptoms of nausea and vomiting followed by abdominal cramps and diarrhea which is accompanie d by fever. The diarrhea varies from loose watery stools to bloody purulent cholera like stools. Source: Oxford Textbook of Medicine volume 3 By:David A Warrell p 661 patient interaction, the patient will be able to: 2. experience increased comfort concerning pain as evidenced by lowered pain intensity from 5/10 to 2/10. Measures to: 2. increase patients comfort: a. Keep at rest in SemiFowlers Position. b. Encourage verbalization of feelings about pain. -to promote proper lung expansion. - To alleviate pain by promoting nonpharmacologica l pain management -To reduce pain especially when moving.

c. Provide Additional Comfort Measures such as touch. d. Instruct the patient to use diversional activity such as play therapy. e. use puppets to demonstrate procedures. f. Administer Paracetamol (tempra

- Refocuses attention, promotes relaxation and may enhance coping abilities -to enhance understanding and reduce anxiety or fear level. -Relief of pain facilitates cooperation

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30 syrup) 5ml q4 hours with other therapeutic interventions.

Physiologic deficit

Fluid Volume Salmomella Deficit Gastroenteri

After 8 hours of nurse-

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31 3. Diarrhea Cues: -Consumed 3-4 diapers due to watery stools at 100cc per defecation -Stool exam results on p.11 -dry lips -hyperactive bowel sounds Magsige man siya ug kalibang, as verbalized by the SO related to diarrhea secondary to Typhoid Fever tis is characterize d by initial symptoms of nausea and vomiting followed by abdominal cramps and diarrhea which is accompanie d by fever. The diarrhea varies from loose watery stools to bloody purulent cholera like stools. Source: Oxford Textbook of Medicine volume 3 By:David A Warrell p 661 patient interaction, the patient will be able to: 3. maintain hydration balance. 3. maintain fluid balance: a. Assess for the signs of dehydration including skin turgor, oral mucosa, etc. b. Encourage the client to increase the fluid intake. c. Monitor I & O and IV fluids q4h - This will provide a data that could be used to evaluate the proper intervention that the client needs. -To reduce the dryness of the oral mucosa -To determine if IV fluid and electrolyte replacement are needed -To reduce stress and anxiety

d. Keep a quiet environment and calm activities.

e. Provide -To promote health awareness on teachings on related factors avoidance of dehydration. conducive for sleeping

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32 SAN LORENZO RUIZ COLLEGE OF ORMOC COLLEGE OF NURSING ORMOC CITY Name: Mr. Marlou W. Miao Room Number: P2 Impression/Diagnosis: Typhoid fever Physician: Dr. Labtic Date of Admission: July 17, 2010 Drug Therapeutic Record Drug/ Dose/ Classifications Frequency/ / Mechanism Route of Action Ceftriaxone 500g IVTT q12h Classification: Antibiotics Mechanism of Action: - binds to 50 S ribosomal sub unit, which interferes with or inhibits protein synthesis promoting osmotic instability usually bactericidal. Indications/ contraindications/ side effects Indications: Uncomplicated gonoccocal vaginitis UTI Lower Respiratory Tract Infection Septicemia Meningitis Peri-operative prevention Acute bacterial otitis media Neurologic complication Contraindications: Hypersensitivity to cephalosporins severe renal disease severe hepatic disease minor infections. Side Effects: Hema: thrombocytopenia, leucopenia. Principles of Care Inject deep into large muscle for IM such as gluteus maximus. Obtain culture may before giving first dose Medications taken at ordered dose,date and time. Tell patient/S Desired effects O to report any obtained. signs of adverse reactions. Monitor Vital Signs Perform tepid sponge bath for fever. Treatment Evaluation

Increase Before fluids giving drug, ask Give drug patient if with food he is allergic to penicillin s/cephalo sphorins. Use cautiousl y in breastfee

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33 GI: Nausea, vomiting, diarrhea, abdominal pain, colitis, glossitis CNS: headache, depression, dizziness, fever CV: phlebitis Skin: pain, induration, tenderness at injection site, rash, pruritus ding women Not to exceed with recomme nded dose.

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

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

Indications: Fever mild pain Contraindication: Hypersensitivity Anemia Hepatic or severe renal disease Side Effects: Hema: leucopenia, neutropenia, hemolytic anemia CNS: drowsiness GI: nausea, vomiting, abdominal pain, hepatotoxicity, INTEG: rash urticaria

Not to exceed with recomme nded dose; acute poisoning with liver damage may result Use liquid form for children & pts with difficulty in swallowi ng.

Medications taken at ordered dose,date With food and time. or milk to Desired effects decrease obtained. gastric symptom s. Give with full glass of water Increase fluids Monitor V/S Avoid usage of multiple preparatio ns containin g acetamen ophen.

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34 In children, dont exceed 5 doses in 24 hours. Carefully check over-thecounter products Give drug with food

Perform Tepid Sponge Bath

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35

SAN LORENZO RUIZ COLLEGE OF ORMOC COLLEGE OF NURSING ORMOC CITY Name: Mr. Marlou W. Miao Room Number: P2 Impression/Diagnosis: Typhoid fever Physician: Dr. Labtic Date of Admission: July 17, 2010 SOAPIE #1

gitugnaw kuno siya. As verbalized by the grandmother.

Received patient lying in bed, with an of IVF of #2 D5IMB @ 18cc/hr at the right dorsum of his hand, conscious, and responsive. The patient looks tired and skin is warm to touch. Patient has flushed skin, teary eyes, cracked lips and is shivering. Patients vital signs are: Pulse rate: 120bpm, temp: 38.5 C, RR:28cpm

Altered themoregulation: fever related to on going infection

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

Monitored vital signs qshift; assisted his needs; rendered tepid sponge bath; loosened clothing of patient; encouraged increase fluid intake; administered tempra (antipyretic) as ordered by the physician

Patients temperature lowered from 38.5 C to 37.5 C

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SAN LORENZO RUIZ COLLEGE OF ORMOC COLLEGE OF NURSING ORMOC CITY Name: Mr. Marlou W. Miao Room Number: P2 Impression/Diagnosis: Typhoid fever Physician: Dr. Labtic Date of Admission: July 17, 2010 SOAPIE #2

wala siyay gana mokaon. As verbalized by the grandmother.

Received patient lying on bed, with an IVF of #2 D5IMB @ 18cc/hr on his right hand, conscious and responsive. The patient looks tired and ate only 5 tablespoons of her breakfast. Patients vital signs were: temperature: 37 C, pulse rate: 118 beats per minute, respiration rate of 22 cpm

Altered Nutrition: less than body requirements related to decreased appetite

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

Monitored vital signs; attended patients needs; provided small frequent feedings; limited activities of patient; offered healthy fruit juices; organized nursing activities

The patient was eating his fruits and drinking his juices. He was able to finish eating more half of his lunch.

SAN LORENZO RUIZ COLLEGE OF ORMOC COLLEGE OF NURSING ORMOC CITY Name: Mr. Marlou W. Miao Room Number: P2 Impression/Diagnosis: Typhoid fever Physician: Dr. Labtic Date of Admission: July 17, 2010 PLAY THERAPY

Developmental task Toddler (1-3 Years old) - leaves and independent behaviors regarding toileting, bathing, feeding, dressing,

Type of Play

Objective of Play

Framework of Play

PARALLEL PLAY The toddler demonstrate little attention to the feelings of play pattern and frequently grabs

After 45 minutes of conduction play therapy, the patient will be able to: 1. develop necessary source of touch a. provide necessary materials or toys that have different textures (smooth, rough, soft and hard) b. let the child touch the different

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39 exert self awareness exercise device Source: (Pediatric Nursing by Pot) 2. interact with the environment by responding to various stimuli 3. develop fine motor skills through playing desired toys or hates others to keep favorite toy. materials provided c. use different sizes of boxes to use for put in and take out toy d. ask mother to had her cuddle the toddler in her lap a. talk to the child in a soft and exciting manner b. allow child to listen to her heartbeat through the stethoscope a. prepare variety of objects to handle such as rings, blocks, squeeze toy etc. that the child could lift with one hand b. walk with the child in the hallway c. allow child to run but assist her properly

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40 Evaluation and Recommendation The prognosis of the patient is good because he is responding to the treatment and nursing interventions positively. Improvements have been noticed in the patient, such as increase food intake, afebrile for 2 days now, increased activity tolerance and compliance of medication intake. The patient was advised not to eat foods or drinks from unsanitary area or container.

Thus, the student nurse recommends having a continuous care of the client. The family should support the patient in all aspects since this is the time when the client needs his family so much. The client should take vitamins and eat lots of fruits and vegetables. Prevention of any other disease depends on the client himself.

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41 Evaluation and Implication

Nursing Practice: Nursing action should be based on standard nursing practice developed through the basic foundation of biological and psychological sciences. This case study will provide more emphasis on the treatment of typhoid fever. It is designed to improve and assist individuals to the performance of nursing care to patient with typhoid fever. The student nurse should have an attitude of caring characterized by a free and easy environment. This may mean rendering holistic nursing care effectively and efficiently. It is important to emphasize the good of the positive aspects in what the patient is capable of doing.

Nursing Education: This case study will enhance and broaden the knowledge, expertise and ideas about typhoid fever through the information gathered. It will also contribute to the important facts when we talk of communicable nursing and will provide a concrete example in the other related studies during discussion. One can also compare and actual situation with basic information and may come to appreciate mans unique being.

Nursing Research: This case study will enhance research regarding initiating a holistic nursing care to a patient with typhoid fever. There has always been a need to know more about nursing measures to be rendered. Through this case study, more works will be instilled towards the patient with typhoid fever. Researchers may be inspired to continue to research, more comprehensions and extensive study especially with complications and their response to the care given.

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42 Bibliography Books: Billings, Diane McGovern. Medical- Surgical Nursing. The C.V. Mosby Company. 11830 Westline Industrial Drive, TS. Louis, Missouri. 1987. Black, Joyce M. Luckmann and Sorensens Medical-Surgical Nursing. 4th edition. W.B. Saunders Company. 1993 Bullock, Barbara L. Pathophysiology. 4th edition. Lippincott Williams and Wilkins Company. Philadelphia, Pennsylvania. 2001 Holloway, Nancy M. Medical-Surgical Care Planning. 3rd edition. Springhouse Corporation. Springhouse, Pennsylvania. 1999 Kozier, Barbara, et al. Fundamentals of Nursing. 5th edition. Addison Longman Inc. Singapore. 1998 Merch, et al. The Merck Manual. 16th edition. Merck Research Laboratories. New Jersey.1992 Hockenberry, Marilyn J. Wongs Essentials of Pediatric Nursing. 7th edition. Mosby, Elsevier Inc., Philippines. 2005 Marieb, Essentials of Human Anatomy and Physiology 7th Edition, Pearson Education Inc., San Francisco, 2003 Doenges, Moorhouse and Geissler-Murr, Nurrses Pocket Guide Diagnoses, and Rationale 9th Ed, Tabers Publisher, Philadelphia, Pennsylvania, 2004 Interventions

Internet: Microsoft Encarta Encyclopedia 2002. 1993-2001 Microsoft Corporation. All rights reserved. www.innerbody.com http://en.wikipedia.org/wiki/Typhoid_fever

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