CASE

PRESENTATI
ON
(TYPHOID FEVER)
GROUP A:
Eden Pamittan
Leonides Ramonette Israel
Elynor reboredo
Blesilda Elaine Obligado
Dianne Aglado
Adelna Faye Tamayo
Rhea Lugo
 General Objectives:
To have a case study related to our concepts in lecture regarding communicable
diseases. To be able to apply our learning’s from our lectures to our case study. To learn
further regarding on our concepts in lecture.

Specific Objectives:

1. To gather enough and credible data for our case study and be able
to prevent it.
2. To be able to establish rapport to our patient and his family in
order to gain their cooperation for the interview and therapeutic
processes.
3. To be able to know our patients Family background and Health
history in order to trace past and present health condition.
4. To be able to assess our patients developmental stages in life into
three theories namely: Havighurts, Freud, Erikson, or Piaget.
5. To be able to define Typhoid fever along with the patients complete
diagnosis in at least three sources from any medical surgical
textbooks.
6. To be able to assess our patient physically and cephalocaudally.
7. To be able to discuss and explain about the Anatomy and
Physiology of the specific body systems involved in our clients
diagnosis.
8. To be able to present the etiology of Typhoid fever with scientific
basis.
9. To be able to trace the Pathophysiology of Typhoid fever.
10. To be able to show and explain the Doctors Order for our client.
 11. To be able to illustrate and explain each Diagnostic Exam
undergone by our patient along with its important information’s.
12. To be able to present and explain the different drugs of our
patient.
13. To be able to present at least 3 nursing theories related and
applicable to the case of the patient.
14. To be able to formulate and present at least 5 nursing care plans in
relation to our clients existing health conditions.
15. To be able to cite our recommendations for this case study and
health teachings for our patients Health condition.
16. To be able to formulate the discharge plan applicable and needed
by our patient in M.E.T.H.O.D pattern.
17. To be able to justify the prognosis of our client concerning his
present condition.
18. To be able to present the list of all the references we used in
coming up with our Case Study.

INTRODUCTION:
Typhoid fever is an acute illness associated with fever caused by the Salmonella
typhi bacteria. It can also be caused by Salmonella paratyphi, a related bacterium that
usually causes a less severe illness. The bacteria are deposited in water or food by a human
carrier and are then spread to other people in the area.

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 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.
First stage

Once signs and symptoms do appear, you're likely to experience:

 Fever, often as high as 103 or 104 F (39 or 40 C)

 Headache

 Weakness and fatigue

 A sore throat

 Abdominal pain

 Diarrhea or constipation

 Rash

Children are more likely to have diarrhea, whereas adults may become severely
constipated. During the second week, you 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.

Second stage
If you don't receive treatment for typhoid fever, you may enter a second stage during which
you become very ill and experience:

 Continuing high fever

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

 Considerable weight loss

 Extremely distended abdomen

The typhoid state

By the third week, you may:

 Become delirious

 Lie motionless and exhausted with your eyes half-closed in what's known as the
typhoid state
Life-threatening complications often develop at this time

Cause:

Typhoid fever is another of the infectious diseases which is to be ascribed to a

specific virus or poison. Yet the present state of our knowledge would indicate that the
disease is not directly communicated by contact of the sick with the well individual. The
disease seems capable of manifesting itself with out previous exposure to this disease ;yet it
is unquestionable that the excretions — the stools — of a typhoid fever patient may be the
means of disseminating the disease among healthy people. The contagion is conveyed in the
water of wells and cisterns, as has been amply demonstrated by observations upon the
German and Austrian soldiery, as well as by cases in civil life. City physicians
are well aware that typhoid fever is specially apt to occur in those dwellings in which,
however elegant the general appointments, the sewerage is defective, as indicated by the
odor from the traps. Typhoid fever, while occurring during all seasons of the year, is
especially frequent in the fall, at which time it may amount almost to an epidemic. The
average mortality varies extremely, being of course greater during epidemics; at these
times there may be one fatal result in three or four. At other times, however, the average
mortality is rarely more than one in six or seven.

DIAGNOSTIC AND LABARATORY EXAMS:

1. Medical and travel history .Your doctor is likely to suspect typhoid fever based on
your symptoms and your medical and travel history. But the diagnosis is usually confirmed
by identifying S. typhi in a culture of your blood or other body fluid or tissue.

2. Blood or body fluid or tissue culture .For the culture, a small sample of your
blood, stool, urine or bone marrow is placed on a special medium that encourages the
growth of bacteria. In 48 to 72 hours, the culture is checked under a microscope for the
presence of typhoid bacteria. A bone marrow culture often is the most sensitive test for S.
typhi.

3. Antibody and antigen testing .Your doctor may recommend other tests to help
diagnose typhoid fever, such as:

 Enzyme-linked immunosorbent assay (ELISA). This blood test looks for an antigen
that's specific to typhoid bacteria. An antigen is any substance, such as a virus,
bacterium, toxin or foreign protein that triggers an immune system response in your
body. An ELISA test can identify if you carry the disease, but not whether you have
an active infection.

 Fluorescent antibody test. This test checks for antibodies to S. typhi. Antibodies are
proteins produced by your immune system in response to harmful substances
(antigens). Each antibody is unique and defends your body against a single antigen.
  New diagnostic tests include those for immunoglobulin M (IgM) and
immunoglobulin G (IgG) antibodies, with rapid results (2 minutes to 3 hours). The
Typhidot-M test has a specificity of 75% and a sensitivity of 95%. The Tubex test is
rapid and detects the O9 antigen.

 The classic Widal test is rarely used because of its low sensitivity and specificity.

 Blood, urine, and stool cultures are still frequently used to isolate S typhi, but the
yield is only about 70%. The duodenal string test may be used to culture bile.

 CBC may reveal anemia and thrombocytopenia.

 Liver function test results are commonly elevated.

 Renal dysfunction may occur, but chronic renal failure has not been reported.

COMPLICATIONS:

Intestinal bleeding or perforation. The most serious complication of typhoid fever —

intestinal bleeding or perforation — may develop in the third week of illness. About 5
percent of people with typhoid fever experience this complication. Intestinal bleeding is
often marked by a sudden drop in blood pressure and shock, followed by the appearance of
blood in your stool.A perforated intestine occurs when your small intestine or large bowel
develops a hole, causing intestinal contents to leak into your abdominal cavity and
triggering signs and symptoms such as severe abdominal pain, nausea, vomiting and
bloodstream infection (sepsis). This life-threatening emergency requires immediate medical
care. Other, less common complications
Other possible complications include:

 Inflammation of the heart muscle (myocarditis)

 Pneumonia

 Inflammation of the pancreas (pancreatitis)

 Kidney or bladder infections

 Infections of the spine (osteomyelitis)

 Infection and inflammation of the membranes and fluid surrounding your brain and
spinal cord (meningitis)

 Psychiatric problems such as delirium, hallucinations and paranoid psychosis

With prompt treatment, nearly all people in industrialized nations recover from typhoid.
Without treatment, some people may not survive complications of the disease.

NURSING MEDICAL MANAGEMENT:

Typhoid fever is treated with antibiotics which kill the Salmonella bacteria. Prior to
the use of antibiotics, the fatality rate was 20%. Death occurred from overwhelming
infection, pneumonia, intestinal bleeding, or intestinal perforation. With antibiotics and
supportive care, mortality has been reduced to 1%-2%. With appropriate antibiotic
therapy, there is usually improvement within one to two days and recovery within seven to
10 days.Several antibiotics are effective for the treatment of typhoid fever.
Chloramphenicol was the original drug of choice for many years. Because of rare serious
side effects, chloramphenicol has been replaced by other effective antibiotics. The choice of
antibiotics needs to be guided by identifying the geographic region where the organism was
acquired and the results of cultures once available. (Certain strains from South America
show a significant resistance to some antibiotics.) If relapses occur, patients are retreated
with antibiotics.The carrier state, which occurs in 3%-5% of those infected, can be treated
with prolonged antibiotics. Often, removal of the gallbladder, the site of chronic infection,
will cure the carrier state.

STATISTICS:

PATIENT’S PROFILE:
 NAME: F. PRINCIPE
 AGE: 45 Y/O
 GENDER: MALE
 CIVIL STATUS: M,ARRIED
 ADDRESS: STO. TOMAS, ISABELA
 BIRTH DATE:
 BIRTH PLACE: CENTRO STO. TOMAS, ISABELA
 OCCUPATION: FARMER AND COOK
 RELIGION: ROMAN CATHOLIC
 C/C: FEVER, CHILLS, BODY PAIN
 DATE OF ADMISSION: NOVEMBER 19, 2009
 TIME OF ADMISSION:4 PM
 DATE OF DISCHARGE:
 FINAL DIAGNOSIS:
 ATTENDING PHYSICIAN: DR. ALBERT B. DE LEON
 CONSULTANT:
 CLINICAL DIAGNOSIS:
 SOURCE OF INFORMATION:

  NURSING HISTORY:
 Chief Complaint: Fever, chills and abdominal pain
 History of present illness:
 According to the patient, they were flooded before experiencing fever, chills, and
abdominal pain blank days PTA and after drinking water.
 History of past illness:
 The patient had an asthma attack and a motor accident.
 Social history:
 The patient is a smoker and he can consume 2 packs of cigarettes in a day. He is
also a drinker and can consume 2 bottles of red horse and 1 bottle of matador.
 Family history:her’s side,
 On the patient’s mother side,has a history of diabetes and on father’s side, a
history of colon cancer and heart disease.

 GORDON’S 11 FUNCTIONAL PATTERN:

 Before Hospitalization 

1) Health Perception-Health  >For him, health is vital to 
Management Pattern every individual. He considers
health as the ability to
perform activities of daily
living. He believes that being
healthy can create/build
improvement in every
individual’s life.

 2) nutrition  >He usually takes his meal 

three times a day and prefers
to eat grilled foods. He drinks
7-9 glasses of water every
day.
 3)elimination  >He defecates once everyday 
with dark browned stool. He
urinates 4-5 times a day with
yellow amber in color.
 4)exercise  >His exercise is walking 3 
kilometers every day and he
also considers his activity of
daily living.

 5)sleep  >he sleeps 5-6hours a day. He

said that he easily asleep
when he drinks alcohol. He
sleeps at 10 or 11 pm and
wakes up at 4- 5 am. He
doesn’t have a nap time.

 6)cognitive  >He speaks clearly, loudly and 

passionate. Therefore,
everyone could definitely
understand him.

 7)self perception  >He said that he loves himself 

and considers himself a good
citizen and a strong and
responsible husband and
father.

 8)social  >he has a good relationship 

w/ his family. He stands as the
bread winner of the family. He
has a good relationship w/ his
neighbors as well.
 9)spiritual  >He is a Roman Catholic 
follower. They go to mass
once a month but he has a
strong faith in God.
 10)sexual pattern  >He and his wife are still 
active. They perform it 3x a
week. They are blessed w/ 3
children;2 girls and 1 boy.
  Many skin conditions can be treated with phototherapy, including:

 Pruritus (itchiness). Phototherapy may be beneficial in many different forms of pruritus, particularly those
associated with diabetes, liver disorders, uremic pruritus (itchiness due to kidney problems), and itchiness
without an identifiable cause.

 11 coping-stress pattern  > He use to drink alcohol to 

 Atopic dermatitis. Dermatitis (inflammation of the skin) with intense itching, relieve
often due to the stress
an allergic he feels. He
reaction.
Phototherapy has been used in the treatment of atopic dermatitis for decades. also enjoys playing w/ her
It is most helpful in chronic,
moderate cases of the disease and may reduce the need for potent corticosteroids. However, many
grandchildren.
treatment exposures may be required to control the condition and recurrence rates are high and rapid,
requiring frequent maintenance sessions.

 Seborrheic dermatitis. Dermatitis marked by oily scales, crusty yellow patches and itching. Phototherapy
may be very effective in severe cases of seborrheic dermatitis, but flares may occur, requiring further
treatment.

 Psoriasis. A skin disease characterized by raised, red patches of skin often covered with silvery scales.
Phototherapy is frequently used to help manage many types of psoriasis, although the erythrodermic and
pustular varieties may be more difficult to treat. It may be combined with other therapies (e.g., anthralin,
vitamin D analogs, retinoids).

 Vitiligo. Patches of skin lacking pigmentation (color). Phototherapy may cause repigmentation of the skin by
stimulating the production of melanocytes. Doses of ultraviolet light must be tended to more carefully than in
other disorders because of increased photosensitivity associated with the condition.

 Generalized lichen planus. A skin condition marked by flat, shiny, violet papules. Phototherapy may provide
an effective alternative to corticosteroids in the treatment of generalized lichen planus. Complete remissions
may occur, although it may require many sessions and not all patients respond.

 Alopecia areata. Patches of hair loss. Certain forms of phototherapy (topical or systemic psoralens plus
ultraviolet A [PUVA] light) may help to regrow hair. However, the response varies from patient to patient.

 Urticaria pigmentosa. A skin disease with brownish papules that sting when touched. Phototherapy may
relieve the itching and stinging and may flatten and reduce lesions. In many cases, even long-term
symptoms (e.g., migraines, flushing) decrease gradually as treatment is continued. Recurrences are
 Conditions treated with phototheraPhototherapy is prescribed
primarily to treat seasonal affective disorder (SAD), a mood
disorder characterized by depression in the winter months,
and is occasionally employed to treat insomnia and jet lag.
The exact mechanisms by which the treatment works are not
known, but the bright light employed in phototherapy may
act to readjust the body's circadian (daily) rhythms, or
internal clock. Other popular theories are that light triggers
the production of serotonin, a neurotransmitter believed to
be related to depressive disorders, or that it influences the
body's production of melatonin, a hormone derived from
serotonin that may be related to circadian rhythms. py

 Functions of the Urinary System

 One of the major functions of the Urinary system is the process of excretion. Excretion
is the process of eliminating, from an organism, waste products of metabolism and
other materials that are of no use. The urinary system maintains an appropriate fluid
volume by regulating the amount of water that is excreted in the urine. Other aspects
of its function include regulating the concentrations of various electrolytes in the body
fluids and maintaining normal pH of the blood. Several body organs carry out
excretion, but the kidneys are the most important excretory organ. The primary
function of the kidneys are to maintain a stable internal environment (homeostasis) for
optimal cell and tissue metabolism. They do this by separating urea, mineral salts,
toxins, and other waste products from the blood. They also do the job of conserving
water, salts, and electrolytes. At least one kidney must function properly for life to be
maintained.

 Six important roles of the kidneys are:

 Regulation of plasma ionic composition. Ions such as sodium, potassium, calcium,

magnesium, chloride, bicarbonate, and phosphates are regulated by the amount that the
kidney excretes.

 Regulation of plasma osmolarity. The kidneys regulate osmolarity because they have
direct control over how many ions and how much water a person excretes.

 Regulation of plasma volume. Your kidneys are so important they even have an
effect on your blood pressure. The kidneys control plasma volume by controlling how
much water a person excretes. The plasma volume has a direct effect on the total blood
volume, which has a direct effect on your blood pressure. Salt(NaCl)will cause
osmosis to happen; the diffusion of water into the blood.

 Regulation of plasma hydrogen ion concentration (pH). The kidneys partner up

with the lungs and they together control the pH. The kidneys have a major role
because they control the amount of bicarbonate excreted or held onto. The kidneys
 help maintain the blood Ph mainly by excreting hydrogen ions and reabsorbing
bicarbonate ions as needed.

 Removal of metabolic waste products and foreign substances from the plasma.
One of the most important things the kidneys excrete is nitrogenous waste. As the liver
breaks down amino acids it also releases ammonia. The liver then quickly combines
that ammonia with carbon dioxide, creating urea which is the primary nitrogenous end
product of metabolism in humans. The liver turns the ammonia into urea because it is
much less toxic. We can also excrete some ammonia, creatinine and uric acid. The
creatinine comes from the metabolic breakdown of creatine phospate (a high-energy
phosphate in muscles). Uric acid comes from the break down of nucleotides. Uric acid
is insoluble and too much uric acid in the blood will build up and form crystals that
can collect in the joints and cause gout.

 Secretion of Hormones The endocrine system has assistance from the kidney's when
releasing hormones. Renin is released by the kidneys. Renin leads to the secretion of
aldosterone which is released from the adrenal cortex. Aldosterone promotes the
kidneys to reabsorb the sodium (Na+) ions. The kidneys also secrete erythropoietin
when the blood doesn't have the capacity to carry oxygen. Erythropoietin stimulates
red blood cell production. The Vitamin D from the skin is also activated with help
from the kidneys. Calcium (Ca+) absorption from the digestive tract is promoted by
vitamin D.

 CC: Chapter Check: Name the role of the kidneys and how they work?


 [edit] Organs in the Urinary System

 [edit] Kidneys And Their Structure


 The kidneys are a pair of bean shaped, reddish brown organs about the size of your
fist.It measures 10-12 cm long. They are covered by the renal capsule, which is a
tough capsule of fibrous connective tissue. Adhering to the surface of each kidney is
two layers of fat to help cushion them. There is a concaved side of the kidney that has
 a depression where a renal artery enters, and a renal vein and a ureter exit the kidney.
The kidneys are located at the rear wall of the abdominal cavity just above the
waistline, and are protected by the ribcage. They are considered retroperitoneal, which
means they lie behind the peritoneum. There are three major regions of the kidney,
renal cortex, renal medulla and the renal pelvis. The outer, granulated layer is the
renal cortex. The cortex stretches down in between a radially striated inner layer. The
inner radially striated layer is the renal medulla. This contains pyramid shaped tissue
called the renal pyramids, separated by renal columns.

 [edit] Renal Vein

 The renal veins are veins that drain the kidney. They connect the kidney to the inferior
vena cava. Because the inferior vena cava is on the right half of the body, the left renal
vein is generally the longer of the two. Unlike the right renal vein, the left renal vein
often receives the left gonadal vein (left testicular vein in males, left ovarian vein in
females). It frequently receives the left suprarenal vein as well.

 Renal Artery
 The renal arteries normally arise off the abdominal aorta and supply the kidneys with
blood. The arterial supply of the kidneys are variable and there may be one or more
renal arteries supplying each kidney. Due to the position of the aorta, the inferior vena
cava and the kidneys in the body, the right renal artery is normally longer than the left
renal artery. The right renal artery normally crosses posteriorly to the inferior vena
cava. The renal arteries carry a large portion of the total blood flow to the kidneys. Up
to a third of the total cardiac output can pass through the renal arteries to be filtered by
the kidneys.

 Ureters
 The ureters are two tubes that drain urine from the kidneys to the bladder. Each ureter
is a muscular tube about 10 inches (25 cm) long. Muscles in the walls of the ureters
send the urine in small spurts into the bladder, (a collapsible sac found on the forward
part of the cavity of the bony pelvis that allows temporary storage of urine). After the
urine enters the bladder from the ureters, small folds in the bladder mucosa act like
valves preventing backward flow of the urine. The outlet of the bladder is controlled
by a sphincter muscle. A full bladder stimulates sensory nerves in the bladder wall that
relax the sphincter and allow release of the urine. However, relaxation of the sphincter
is also in part a learned response under voluntary control. The released urine enters the
urethra.

 Urinary Bladder
 The urinary bladder is a hollow, muscular and distendible or elastic organ that sits on
the pelvic floor (superior to the prostate in males). On its anterior border lies the pubic
symphysis and, on its posterior border, the vagina (in females) and rectum (in males).
The urinary bladder can hold approximately 17 to 18 ounces (500 to 530 ml) of urine,
however the desire to micturate is usually experienced when it contains about 150 to
200 ml. When the bladder fills with urine (about half full), stretch receptors send nerve
impulses to the spinal cord, which then sends a reflex nerve impulse back to the
 sphincter (muscular valve) at the neck of the bladder, causing it to relax and allow the
flow of urine into the urethra. The Internal urethral sphincter is involuntary. The
ureters enter the bladder diagonally from its dorsolateral floor in an area called the
trigone. The trigone is a triangular shaped area on the postero-inferior wall of the
bladder. The urethra exits at the lowest point of the triangle of the trigone. The urine in
the bladder also helps regulate body temperature. If the bladder becomes completely
void of fluid, it causes the patient to chill.

 Urethra



 Female urethra (labeled at bottom right.)



 Male Sphincter urethrae muscle - The male urethra laid open on its anterior (upper)
surface. (Region visible, but muscle not labeled.)
  The urethra is a muscular tube that connects the bladder with the outside of the body.
The function of the urethra is to remove urine from the body. It measures about 1.5
inches (3.8 cm) in a woman but up to 8 inches (20 cm) in a man. Because the urethra is
so much shorter in a woman it makes it much easier for a woman to get harmful
bacteria in her bladder this is commonly called a bladder infection or a UTI. The most
common bacteria of a UTI is E-coli from the large intestines that have been excreted in
fecal matter. Female urethra

 In the human female, the urethra is about 1-2 inches long and opens in the vulva
between the clitoris and the vaginal opening.

 Men have a longer urethra than women. This means that women tend to be more
susceptible to infections of the bladder (cystitis) and the urinary tract.

 Male urethra

 In the human male, the urethra is about 8 inches long and opens at the end of the head
of the penis.

 The length of a male's urethra, and the fact it contains a number of bends, makes
catheterisation more difficult.


The urethral sphincter is a collective name for the muscles used to control the flow
of urine from the urinary bladder. These muscles surround the urethra, so that when
they contract, the urethra is closed.

 There are two distinct areas of muscle: the internal sphincter, at the bladder neck and

 the external, or distal, sphincter.

 Human males have much stronger sphincter muscles than females, meaning that they
can retain a large amount of urine for twice as long, as much as 800mL, i.e. "hold it".

 Nephrons
 A nephron is the basic structural and functional unit of the kidney. The name nephron
comes from the Greek word (nephros) meaning kidney. Its chief function is to regulate
water and soluble substances by filtering the blood, reabsorbing what is needed and
excreting the rest as urine. Nephrons eliminate wastes from the body, regulate blood
volume and pressure, control levels of electrolytes and metabolites, and regulate blood
pH. Its functions are vital to life and are regulated by the endocrine system by
hormones such as antidiuretic hormone, aldosterone, and parathyroid hormone.

 Each nephron has its own supply of blood from two capillary regions from the renal
artery. Each nephron is composed of an initial filtering component (the renal
 corpuscle) and a tubule specialized for reabsorption and secretion (the renal tubule).
The renal corpuscle filters out large solutes from the blood, delivering water and small
solutes to the renal tubule for modification.

 Glomerulus
 The glomerulus is a capillary tuft that receives its blood supply from an afferent
arteriole of the renal circulation. The glomerular blood pressure provides the driving
force for fluid and solutes to be filtered out of the blood and into the space made by
Bowman's capsule. The remainder of the blood not filtered into the glomerulus passes
into the narrower efferent arteriole. It then moves into the vasa recta, which are
collecting capillaries intertwined with the convoluted tubules through the interstitial
space, where the reabsorbed substances will also enter. This then combines with
efferent venules from other nephrons into the renal vein, and rejoins with the main
bloodstream.


Afferent/Efferent Arterioles

 The afferent arteriole supplies blood to the glomerulus. A group of specialized cells
known as juxtaglomerular cells are located around the afferent arteriole where it
enters the renal corpuscle. The efferent arteriole drains the glomerulus. Between the
two arterioles lies specialized cells called the macula densa. The juxtaglomerular cells
and the macula densa collectively form the juxtaglomerular apparatus. It is in the
juxtaglomerular apparatus cells that the enzyme renin is formed and stored. Renin is
released in response to decreased blood pressure in the afferent arterioles, decreased
sodium chloride in the distal convoluted tubule and sympathetic nerve stimulation of
receptors (beta-adrenic) on the juxtaglomerular cells. Renin is needed to form
Angiotensin I and Angiotensin II which stimulate the secretion of aldosterone by the
adrenal cortex.

 Glomerular Capsule or Bowman's Capsule

 Bowman's capsule (also called the glomerular capsule) surrounds the glomerulus
and is composed of visceral (simple squamous epithelial cells) (inner) and parietal
(simple squamous epithelial cells) (outer) layers. The visceral layer lies just beneath
the thickened glomerular basement membrane and is made of podocytes which send
foot processes over the length of the glomerulus. Foot processes interdigitate with one
another forming filtration slits that, in contrast to those in the glomeruluar
endothelium, are spanned by diaphragms. The size of the filtration slits restricts the
passage of large molecules (eg, albumin) and cells (eg, red blood cells and platelets).
In addition, foot processes have a negatively-charged coat (glycocalyx) that limits the
filtration of negatively-charged molecules, such as albumin. This action is called
electrostatic repulsion.

 The parietal layer of Bowman's capsule is lined by a single layer of squamous

epithelium. Between the visceral and parietal layers is Bowman's space, into which the
filtrate enters after passing through the podocytes' filtration slits. It is here that smooth
 muscle cells and macrophages lie between the capillaries and provide support for
them. Unlike the visceral layer, the parietal layer does not function in filtration. Rather,
the filtration barrier is formed by three components: the diaphragms of the filtration
slits, the thick glomerular basement membrane, and the glycocalyx secreted by
podocytes. 99% of glomerular filtrate will ultimately be reabsorbed.

 The process of filtration of the blood in the Bowman's capsule is ultrafiltration (or
glomerular filtration), and the normal rate of filtration is 125 ml/min, equivalent to ten
times the blood volume daily. Measuring the glomerular filtration rate (GFR) is a
diagnostic test of kidney function. A decreased GFR may be a sign of renal failure.
Conditions that can effect GFR include: arterial pressure, afferent arteriole
constriction, efferent arteriole constriction, plasma protein concentration and colloid
osmotic pressure.

 Any proteins that are roughly 30 kilodaltons or under can pass freely through the
membrane. Although, there is some extra hindrance for negatively charged molecules
due to the negative charge of the basement membrane and the podocytes. Any small
molecules such as water, glucose, salt (NaCl), amino acids, and urea pass freely into
Bowman's space, but cells, platelets and large proteins do not. As a result, the filtrate
leaving the Bowman's capsule is very similar to blood plasma in composition as it
passes into the proximal convoluted tubule. Together, the glomerulus and Bowman's
capsule are called the renal corpuscle.

 Proximal Convoluted Tubule (PCT)

 The proximal tubule can be anatomically divided into two segments: the proximal
convoluted tubule and the proximal straight tubule. The proximal convoluted tubule
can be divided further into S1 and S2 segments based on the histological appearance
of it's cells. Following this naming convention, the proximal straight tubule is
commonly called the S3 segment. The proximal convoluted tubule has one layer of
cuboidal cells in the lumen. This is the only place in the nephron that contains cuboidal
cells. These cells are covered with millions of microvilli. The microvilli serve to
increase surface area for reabsorption.

 Fluid in the filtrate entering the proximal convoluted tubule is reabsorbed into the
peritubular capillaries, including approximately two-thirds of the filtered salt and
water and all filtered organic solutes (primarily glucose and amino acids). This is
driven by sodium transport from the lumen into the blood by the Na+/K+ ATPase in
the basolateral membrane of the epithelial cells. Much of the mass movement of water
and solutes occurs in between the cells through the tight junctions, which in this case
are not selective.

 The solutes are absorbed isotonically, in that the osmotic potential of the fluid leaving
the proximal tubule is the same as that of the initial glomerular filtrate. However,
glucose, amino acids, inorganic phosphate, and some other solutes are reabsorbed via
secondary active transport through cotransport channels driven by the sodium gradient
out of the nephron.
 ] Loop of the Nephron or Loop of Henle



 The Nephron Loop or Loop of Henle.
 The loop of Henle (sometimes known as the nephron loop) is a U-shaped tube that
consists of a descending limb and ascending limb. It begins in the cortex, receiving
filtrate from the proximal convoluted tubule, extends into the medulla, and then
returns to the cortex to empty into the distal convoluted tubule. Its primary role is to
concentrate the salt in the interstitium, the tissue surrounding the loop.

 Descending limb
 Its descending limb is permeable to water but completely impermeable to salt, and
thus only indirectly contributes to the concentration of the interstitium. As the filtrate
descends deeper into the hypertonic interstitium of the renal medulla, water flows freely
out of the descending limb by osmosis until the tonicity of the filtrate and interstitium
equilibrate. Longer descending limbs allow more time for water to flow out of the filtrate,
so longer limbs make the filtrate more hypertonic than shorter limbs.
 Ascending limb
 Unlike the descending limb, the ascending limb of Henle's loop is impermeable to
water, a critical feature of the countercurrent exchange mechanism employed by the loop.
The ascending limb actively pumps sodium out of the filtrate, generating the hypertonic
interstitium that drives countercurrent exchange. In passing through the ascending limb,
the filtrate grows hypotonic since it has lost much of its sodium content. This hypotonic
filtrate is passed to the distal convoluted tubule in the renal cortex.
 Distal Convoluted Tubule (DCT)
 The distal convoluted tubule is similar to the proximal convoluted tubule in structure
and function. Cells lining the tubule have numerous mitochondria, enabling active
transport to take place by the energy supplied by ATP. Much of the ion transport taking
place in the distal convoluted tubule is regulated by the endocrine system. In the
presence of parathyroid hormone, the distal convoluted tubule reabsorbs more calcium
and excretes more phosphate. When aldosterone is present, more sodium is reabsorbed
and more potassium excreted. Atrial natriuretic peptide causes the distal convoluted
tubule to excrete more sodium. In addition, the tubule also secretes hydrogen and
ammonium to regulate pH. After traveling the length of the distal convoluted tubule,
only 3% of water remains, and the remaining salt content is negligible. 97.9% of the
water in the glomerular filtrate enters the convoluted tubules and collecting ducts by
osmosis.

 Maintaining Water-Salt Balance

 It is the job of the kidneys to maintain the water-salt balance of the blood. They also
maintain blood volume as well as blood pressure. Simple examples of ways that this
balance can be changed include ingestion of water, dehydration, blood loss and salt
ingestion.

 Reabsorption of water
 Direct control of water excretion in the kidneys is exercised by the anti-diuretic
hormone (ADH), released by the posterior lobe of the pituitary gland. ADH causes the
insertion of water channels into the membranes of cells lining the collecting ducts,
allowing water reabsorption to occur. Without ADH, little water is reabsorbed in the
collecting ducts and dilute urine is excreted. There are several factors that influence
the secretion of ADH. The first of these happen when the blood plasma gets too
concentrated. When this occurs, special receptors in the hypothalamus release ADH.
When blood pressure falls, stretch receptors in the aorta and carotid arteries stimulate
ADH secretion to increase volume of the blood.

 Reabsorption of Salt
 The Kidneys also regulate the salt balance in the blood by controlling the excretion
and the reabsorption of various ions. As noted above, ADH plays a role in increasing
water reabsorption in the kidneys, thus helping to dilute bodily fluids. The kidneys
also have a regulated mechanism for reabsorbing sodium in the distal nephron. This
mechanism is controlled by aldosterone, a steroid hormone produced by the adrenal
cortex. Aldosterone promotes the excretion of potassium ions and the reabsorption of
sodium ions. The release of Aldosterone is initiated by the kidneys. The
juxtaglomerular apparatus is a renal structure consisting of the macula densa,
mesangial cells, and juxtaglomerular cells. Juxtaglomerular cells (JG cells, also known
as granular cells) are the site of renin secretion. Renin is an enzyme that converts
angiotensinogen (a large plasma protein produced by the liver) into Angiotensin I and
 eventually into Angiotensin II which stimulates the adrenal cortex to produce
aldosterone. The reabsorption of sodium ions is followed by the reapsorption of water.
This causes blood pressure as well as blood volume to increase.

 Atrial natriuretic hormone (ANH) is released by the atria of the heart when cardiac
cells are streatched due to increased blood volume. ANH inhibits the secretion of renin
by the juxtaglomerular apparatus and the secretion of the aldosterone by the adrenal
cortex. This promotes the excretion of sodium. When sodium is excreted so is water.
This causes blood pressure and volume to decrease.

 Hypernatremia
 An increase in plasma sodium levels above normal is hypernatremia. Sodium is the
primary solute in the extracellular fluid. Sodium levels have a major role in osmolarity
regulation. For excitable cells the electrochemical gradient for sodium across the
plasma membrane is critical for life. Water retention and an increased blood pressure
usually are signs of hypernatremia. If the plasma sodium levels are below normal it is
called hyponatremia. Signs of this are low plasma volume and hypotension.

 Diuretics
 A diuretic (colloquially called a water pill) is any drug that elevates the rate of bodily
urine excretion (diuresis). Diuretics also decrease the extracellular fluid (ECF)
volume, and are primarily used to produce a negative extracellular fluid balance.
Caffeine, cranberry juice and alcohol are all weak diuretics. In medicine, diuretics are
used to treat heart failure, liver cirrhosis, hypertension and certain kidney diseases.
Diuretics alleviate the symptoms of these diseases by causing sodium and water loss
through the urine. As urine is produced by the kidney, sodium and water – which cause
edema related to the disease – move into the blood to replace the volume lost as urine,
thereby reducing the pathological edema. Some diuretics, such as acetazolamide, help
to make the urine more alkaline and are helpful in increasing excretion of substances
such as aspirin in cases of overdose or poisoning. The antihypertensive actions of
some diuretics (thiazides and loop diuretics in particular) are independent of their
diuretic effect. That is, the reduction in blood pressure is not due to decreased blood
volume resulting from increased urine production, but occurs through other
mechanisms and at lower doses than that required to produce diuresis. Indapamide was
specifically designed with this is mind, and has a larger therapeutic window for
hypertension (without pronounced diuresis) than most other diuretics. Chemically,
diuretics are a diverse group of compounds that either stimulate or inhibit various
hormones that naturally occur in the body to regulate urine production by the kidneys.
Alcohol produces diuresis through modulation of the vasopressin system.

 Diseases of the Kidney

 Diabetic nephropathy (nephropatia diabetica), also known as Kimmelstiel-Wilson
syndrome and intercapillary glomerulonephritis, is a progressive kidney disease
caused by angiopathy of capillaries in the kidney glomeruli. It is characterized by
nodular glomerulosclerosis. It is due to longstanding diabetes mellitus, and is a prime
cause for dialysis in many Western countries.


 An image of a kidney stone.
 In medicine, hematuria (or "haematuria") is the presence of blood in the urine. It is a
sign of a large number of diseases of the kidneys and the urinary tract, ranging from
trivial to lethal.

 Kidney stones, also known as nephrolithiases, urolithiases or renal calculi, are solid
accretions (crystals) of dissolved minerals in urine found inside the kidneys or ureters.
They vary in size from as small as a grain of sand to as large as a golf ball. Kidney
stones typically leave the body in the urine stream; if they grow relatively large before
passing (on the order of millimeters), obstruction of a ureter and distention with urine
can cause severe pain most commonly felt in the flank, lower abdomen and groin.
Kidney stones are unrelated to gallstones.

 Case Study I was 34 weeks pregnant when I noticed blood in my urine. I immediately
went to my OBGYN where I was told that I had a bladder infection and given an
antibiotic. The next morning I experienced the most intense pain. I was rushed to the
ER where I was told that I had kidney stones. The doctors explained that there was
nothing they could do as long as I was pregnant. The next 3 weeks of my life were
filled with intense pain and multiple painkillers. After I delivered my baby, CAT scans
were done and I was informed that I had 6 kidney stones. It took three more weeks for
me to pass all of the stones the largest measuring 5 mm. The stones were tested and I
was informed that my body had been building up calcium due to my pregnancy and
this was the cause of the kidney stones. I continued to have kidney pain for 6 months
after passing the stones. I now live my life on a low calcium diet and the hope that my
body will not develop more kidney stones.

 Pyelonephritis When an infection of the renal pelvis and calices, called pyelitis,
spreads to involve the rest of the kidney as well, the result is pyelonephritis. It usually
results from the spread of fecal bacterium Escherichia coli from the anal region
superiorly through the urinary tract. In severe cases, the kidney swells and scars,
 abscesses form, and the renal pelvis fills with pus. Left untreated, the infected kidney
may be severely damaged, but administration of antibiotics usually achieve a total
cure.

 glomerulonephritis Inflammation of the glomerular can be caused by immunologic

abnormalities, drugs or toxins, vascular disorders, and systemic diseases.
Glomerulonephritis can be acute, chronic or progressive. Two major changes in the
urine are distinctive of glomerulonephritis: hematuria and proteinuria with albumin as
the major protein. There is also a decrease in urine as there is a decrease in GFR
(glomerular filtration rate). Renal failure is associated with oliguria (less than 400 ml
of urine output per day).

 Renal Failure Uremia is a syndrome of renal failure and includes elevated blood urea
and creatinine levels. Acute renal failure can be reversed if diagnosed early. Acute
renal failure can be caused by severe hypotension or severe glomerular disease.
Diagnostic tests include BUN and plasma creatinine level tests. It is considered to be
chronic renal failure if the decline of renal function to less than 25%.

 Diabetes Insipidus
 This is caused by the deficiency of or decrease of ADH. The person with (DI) has the
inability to concentrate their urine in water restriction, in turn they will void up 3 to 20
liters/day. There are two forms of (DI), neurogenic, and nephrogenic. In nephrogenic
(DI) the kidneys do not respond to ADH. Usually the nephrogenic (DI) is
characterized by the impairment of the urine concentrating capability of the kidney
along with concentration of water. The cause may be a genetic trait, electrolyte
disorder, or side effect of drugs such as lithium. In the neurogenic (DI), it is usually
caused by head injury near the hypophysisal tract.

 Urinary tract infections (UTI's)

 The second most common type of bacterial infections seen by health care providers is
UTI's. Out of all the bacterias that colonize and cause urinary tract infections the big
gun is Escherichia coli. In the hospital indwelling catheters and straight catheterizing
predispose the opportunity for urinary tract infections. In females there are three stages
in life that predispose urinary tract infections, that is menarche, manipulation between
intercourse, and menopause. However, a small percentage of men and children will get
urinary tract infections. In men it is usually due to the prostate gland growth which
usually occurs in older age men. In children it can occur 3% to 5% in girls and 1% in
boys, uncircumcised boys it is more common than circumcised ones to have a urinary
tract infection, in girls it may be the result of onset of toilet training, some
predispositions for getting urinary tract infection include family history and urinary
tract anomalies. In neonates urinary tract infections is most common when bacteremia
is present.
 Dialysis and Kidney Transplant



 Plugged into dialysis
 Generally, humans can live normally with just one kidney. Only when the amount of
functioning kidney tissue is greatly diminished will renal failure develop. If renal
function is impaired, various forms of medications are used, while others are
contraindicated. Provided that treatment is begun early, it may be possible to reverse
chronic kidney failure due to diabetes or high blood pressure. If creatinine clearance (a
measure of renal function) has fallen very low ("end-stage renal failure"), or if the
renal dysfunction leads to severe symptoms, dialysis is commenced. Dialysis is a
medical procedure, performed in various different forms, where the blood is filtered
outside of the body.

 Kidney transplantation is the only cure for end stage renal failure; dialysis, is a
supportive treatment; a form of "buying time" to bridge the inevitable wait for a
suitable organ.

 The first successful kidney transplant was announced on March 4, 1954 at Peter Bent
Brigham Hospital in Boston. The surgery was performed by Dr. Joseph E. Murray,
who was awarded the Nobel Prize in Medicine in 1990 for this feat.

 There are two types of kidney transplants: living donor transplant and a cadaveric
(dead donor) transplant. When a kidney from a living donor, usually a blood relative,
is transplanted into the patient's body, the donor's blood group and tissue type must be
judged compatible with the patient's, and extensive medical tests are done to determine
the health of the donor. Before a cadaveric donor's organs can be transplanted, a series
of medical tests have to be done to determine if the organs are healthy. Also, in some
countries, the family of the donor must give its consent for the organ donation. In both
cases, the recipient of the new organ needs to take drugs to suppress their immune
system to help prevent their body from rejecting the new kidney.

 Review Questions
 Answers for these questions can be found here
 1.While reading a blood test I notice a high level of creatinine, I could assume from
this that

 A) There is a possibility of a UTI

 B) There is a possibility of diabetes
 C) There is a possibility of kidney failure
 D) There is nothing wrong, this is normal
 2.Direct control of water excretion in the kidneys is controlled by

 A) Anti-diuretic hormone
 B) The medulla oblongata
 C) Blood plasma
 D) Sodium amounts in the blood
 3. Nephrons

 A) Eliminate wastes from the body

 B) Regulate blood volume and pressure
 C) Control levels of electrolytes and metabolites
 D) Regulate blood pH
 E) All of the above
 4. If I am dehydrated, my body will increase

 A) ATP
 B) ADP
 C) Diluted urine
 D) ADH
 5.Which part of the nephron removes water, ions and nutrients from the blood?

 A ) vasa recta
 B ) loop of henle
 C ) proximal convuluted tubule
 D ) peritubular capillaries
 E ) glomerulus
 6.Kidneys have a direct effect on which of the following

 A ) Blood pressure
 B ) How much water a person excretes
 C ) Total blood volume
 D ) pH
 E ) all of the above
 7. Why do substances in the glomerulus enter the Bowman's capsule?

 A ) the magnetic charge of the Bowman's capsule attracts the substances

 B ) the substances are actively transported into the Bowman's capsule
 C ) blood pressure of the glomerulus is so great that most substances in blood move
into capsule
 D ) little green men force it in with their ray guns
 8. What happens in tubular excretion?

 A ) urine bonds are formed between the wastes

 B ) wastes are diffused from the tubule
 C ) wastes move into the distal convoluted tubule from the blood
 D ) blood pressure forces wastes away from the kidney
 9. The countercurrent exchange system includes_________and_________.

 A ) glomerulus and macula densa

 B ) proximal convoluted tubule and distal convoluted tubule
 C ) loop of Henle and collecting tubule
 D ) afferent arteriole and efferent arteriole
 E ) ureters and bladder
 10. The function of the loop of the nephron in the process of urine formation is:

 A ) reabsorption of water
 B ) production of filtrate
 C ) reabsorption of solutes
 D ) secretion of solutes
 11. Name the six important roles of the kidneys.

 Glossary
 Antidiuretic: lessening or decreasing of urine production or an agent that decreases
the release of urine.

 Catheterisation: a catheter is a tube that can be inserted into a body cavity, duct or
vessel. Catheters thereby allow drainage or injection of fluids or access by surgical
instruments. The process of inserting a catheter is catheterisation. In most uses a
catheter is a thin, flexible tube: a "soft" catheter; in some uses, it is a larger, solid tube:
a "hard" catheter.

 Dehydration: condition resulting from excessive loss of body fluid.

 Diabetes: a general term for a disease characterized by the begining stages and onset
of renal failure. It is derived from the Greek word diabaínein, that literally means
"passing through," or "siphon", a reference to one of diabetes' major symptoms—
excessive urine production.

 Diuresis: secretion and passage of large amounts of urine.

 Diuretic: increasing of urine production, or an agent that increases the production of

urine.
 Erythropoietin: hormone that stimulates stem cells in the bone marrow to produce red
blood cells

 Fibrous Capsule: the kidney's loose connective tissue

 Glomerulus: capillary tuft that receives its blood supply from an afferent arteriole of
the renal circulation.

 Gluconeogenesis: the cycle of producing a glucose form fat or protein; preformed by

the kidney in times of long fasting, initially gluconeogenesis is preformed by the liver

 Juxtaglomerular (JG) cells: Renin-secreting cells that are in contact with the macula
densa and the afferent arterioles of the renal nephron.

 Juxtaglomerular apparatus (JGA): A site of juxtaglomerular cells connecting with

the macula densa where renin is secreted and sensor for control of secretion of
golmerular filtration rate.

 Loop of Henle/ Nephron Loop: u-shaped tube that consists of a descending limb and
ascending limb; primary role is to concentrate the salt in the interstitium, the tissue
surrounding the loop

 Medullary Pyramids or Renal Pyramids: the cone shaped masses in the kidney

 Micturition: another name for excretions

 Nephron: basic structural and functional unit of the kidney; chief function is to
regulate water and soluble substances by filtering the blood, reabsorbing what is
needed and excreting the rest as urine

 Podocytes: filtration membrane, in the visceral layer of the bowman's capsule

 Renal Calculi: kidney stones, solid crystals of dissolved minerals in urine found
inside the kidneys

 Renal Cortex: outer portion of the kidney

 Renal Lobe: each pyramid together with the associated overlying cortex

 Renal Pelvis: a central space, or cavity that transmits urine to the urinary bladder via
the ureter

 Renin: hormone released by the Juxtaglomerular (JG) cells of the kidneys when blood
pressure falls
 TURP: transurethral resection of the prostate. During TURP, an instrument is inserted
up the urethra to remove the section of the prostate that is blocking urine flow. This is
most commonly caused by benign prostatic hyperplasia (BPH). A TURP usually
requires hospitalization and is done using a general or spinal anesthetic. It is now the
most common surgery used to remove part of an enlarged prostate.

 Urethra: a muscular tube that connects the bladder with the outside of the body

 Ureters: two tubes that drain urine from the kidneys to the bladder

 Urine: liquid produced by the kidneys, collected in the bladder and excreted through
the urethra

 Urinary Bladder: a hollow, muscular and distensible or elastic organ that sits on the
pelvic floor

 Urinary System: a group of organs in the body concerned with filtering out excess
fluid and other substances from the bloodstream
 LABARATORY EXAM:
 D  TEST  NORMAL
A
T
E
 1  HEMATOLOGY:  MALE:5-10X
1-
19  WBC 10g/L
-  RBC  4-6X
09 10g/L
 HEMATOCRIT
 PLATELET COUNT  MALE: 40-50
 FEMALE: 38
 48
 150,000-

300,000/cu mm



 11  URINALYSIS: 
-  YELLOW
19  COLOR
-  APPEARANCE AMBER
09
 REACTION  CLEAR
 SPECIFIC GRAVITY  ACIDIC
 PROTEIN  1.0010
 GLUCOSE  NEGATIVE
 RBC’S/HPF  NEGATIVE

 WBC’S/HPF
 EPITHELIAL CELLS
 BACTERIA
 CRYSTAL/LPF
a. AMORPHOUS URATES

 11  FECALYSIS: 
-  BACTERIA  Negative
19  COLOR
-  Brown
 CONSISTENCY
09  BACTERIA 
 RBC  Negative
 PUST CELLS
 PARACITES OR OVA

 11  LABORATORY RESULTS: 
-  BLOOD CHEM. RESULT 
19  70-105mg/dl
-  GLUCOSE FBS
09
 11  MISCELLANEOUS TEST: 
-  Negative
19  TYPHOID IgG/IgM RAPID TEST 
-  RBS  70-160mg/dl
09
 11  DIFFERENTIAL COUNT: 
-  .40-.60
19  SEGMENTERS  .20-.49
-  LYMPHOCYTES  .01-.05
09
 EOSINOPHILS 
 BSMP



 COURSE IN THE WARD:

 Doctor’s order  Rationale  Nur
 11-19-09  
 Please admit to room 301  For proper medical  Admi
under Dr. AdL management 
 secure consent   Expla
  For legal purposes and in secur

order for the patient to 
 start IVF with D5NM X
know all management to 
12hours plus vitamin B- 
be done
 complex ANST   I
  
  
 
  Advice

 DAT and no dark color food dark co

 
 It may alter fecalysis 

 result  secured
 up resu
 lab CBC, 
 UA,F/A,  
  
  CBC-to evaluate blood 
  monito
components for 
 maintenance of body 
 Monitor BP, CR,RR and fluids and electrolytes  measur
Temp. q 4  U/A- to determine 
 And record 
 glucose in the urine  refer to
 Monitor I and O every 8  F/A- to determine 
hours presence of bacteria 
  refer to
  
 Refer result as soon as  Use as a baseline data 
possible   Instruc
 and dr

 Refer for any problem  To know if the patient has a 
 balance intake and output 
 FBS for AM advice NPO   admini
  To check for any problems and IV pus
 complications 
  
 meds:  to determine the proper 
◦ start management  Admin
ceftriaxone(triavex)  efficien
1g slow IV push now  no alteration for the result s/s of d
then q 12 hrs ANST  
  
 Ibuprofen+  
paracetamol(muskelax)   Admin
1 tab PC PRN for fever,  to avoid infection and eff
 headache, and body pain  

 
 Continue   Checke
glimepiride(getryl) 2 mg  for pain reliever line
1 tab OD 30 mins. AC  
   Referr
 11-20-09  
 8 am IVF TF PNSS 1L x  
12 hrs  to lower blood glucose  Admin
  w/ mon
 Problem- 38.8 degree   TSB do
celcius  in char
  for recovery 
   Admin
 Give paracetamol 1  body mechanism to the disease efficien
ampule IM  s/s of d
  
 Continue TSB c/o NAOD  to lower temperature  check f
and student nurse  the IVF
incharge factor a
 aids decrease in temperature
 Continue meds 

 
 for recovery
 11-21-09 

 IVF to consume  monito

 
 for recovery
 

 MGH 

 
 recovered

 Home meds: 

 Ciprofloxaxin 50 mg/ 

tab BID, 6 am-4 pm on  for recovery
a full stomach  Advice

 Glimepiride(getryl) 2 water
 
mg/ tab OD 30 mins AC 
 Ibuprofen + 
  Segreg
paracetamol(muskelax 
) 1 tab TID PRN for disposa
 
fever, headache and
 
body pain
 To replace loss fluid o the body  Instruc
 Increase fluid intake
and balance electrolytes wash u

 
 Advice proper disposal  To avoid contamination to other
of human excretion and 
people  Advice
 secretion  sugar i
  
 Advice segregation of  To avoid contamination  Advice
dirty utensils  sugar i
  
  
 Diabetic diet; 1800  For management of diabetes
calories mellitus
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 Avoid table sugar of all  For management of DM
beverages 
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 ANATOMY AND PHYSIOLOGY:

 Human Digestive System

 The human digestive system is a complex series of organs and glands that
processes food. In order to use the food we eat, our body has to break the food
down into smaller molecules that it can process; it also has to excrete waste.

 Most of the digestive organs (like the stomach and intestines) are tube-like and
contain the food as it makes its way through the body. The digestive system is
essentially a long, twisting tube that runs from the mouth to the anus, plus a few
other organs (like the liver and pancreas) that produce or store digestive
chemicals.
 TheDigestiveProcess:
The start of the process - the mouth: The digestive process begins in the mouth.
Food is partly broken down by the process of chewing and by the chemical action
of salivary enzymes (these enzymes are produced by the salivary glands and
break down starches into smaller molecules).

 On the way to the stomach: the esophagus - After being chewed and swallowed,
the food enters the esophagus. The esophagus is a long tube that runs from the
mouth to the stomach. It uses rhythmic, wave-like muscle movements (called
peristalsis) to force food from the throat into the stomach. This muscle movement
gives us the ability to eat or drink even when we're upside-down.

 In the stomach - The stomach is a large, sack-like organ that churns the food and
bathes it in a very strong acid (gastric acid). Food in the stomach that is partly
digested and mixed with stomach acids is called chyme.

 In the small intestine - After being in the stomach, food enters the duodenum, the
first part of the small intestine. It then enters the jejunum and then the ileum (the
final part of the small intestine). In the small intestine, bile (produced in the liver
and stored in the gall bladder), pancreatic enzymes, and other digestive enzymes
produced by the inner wall of the small intestine help in the breakdown of food.

 In the large intestine - After passing through the small intestine, food passes into
the large intestine. In the large intestine, some of the water and electrolytes
(chemicals like sodium) are removed from the food. Many microbes (bacteria like
Bacteroides, Lactobacillus acidophilus, Escherichia coli, and Klebsiella) in the
large intestine help in the digestion process. The first part of the large intestine is
called the cecum (the appendix is connected to the cecum). Food then travels
upward in the ascending colon. The food travels across the abdomen in the
transverse colon, goes back down the other side of the body in the descending
colon, and then through the sigmoid colon.
 The end of the process - Solid waste is then stored in the rectum until it is
excreted via the anus.

 Digestive System Glossary:

anus - the opening at the end of the digestive system from which feces (waste)
exits the body.
Appendix - a small sac located on the cecum.
Ascending colon - the part of the large intestine that run upwards; it is located
after the cecum.
Bile - a digestive chemical that is produced in the liver, stored in the gall bladder,
and secreted into the small intestine.
cecum - the first part of the large intestine; the appendix is connected to the
cecum.
chyme - food in the stomach that is partly digested and mixed with stomach acids.
Chyme goes on to the small intestine for further digestion.
Descending colon - the part of the large intestine that run downwards after the
transverse colon and before the sigmoid colon.
Duodenum - the first part of the small intestine; it is C-shaped and runs from the
stomach to the jejunum.
Epiglottis - the flap at the back of the tongue that keeps chewed food from going
down the windpipe to the lungs. When you swallow, the epiglottis automatically
closes. When you breathe, the epiglottis opens so that air can go in and out of the
windpipe.
Esophagus - the long tube between the mouth and the stomach. It uses rhythmic
muscle movements (called peristalsis) to force food from the throat into the
stomach.
Gall bladder - a small, sac-like organ located by the duodenum. It stores and
releases bile (a digestive chemical which is produced in the liver) into the small
intestine.
Ileum - the last part of the small intestine before the large intestine begins.
Jejunum - the long, coiled mid-section of the small intestine; it is between the
 duodenum and the ileum.
Liver - a large organ located above and in front of the stomach. It filters toxins
from the blood, and makes bile (which breaks down fats) and some blood
proteins.
Mouth - the first part of the digestive system, where food enters the body.
Chewing and salivary enzymes in the mouth are the beginning of the digestive
process (breaking down the food).
Pancreas - an enzyme-producing gland located below the stomach and above the
intestines. Enzymes from the pancreas help in the digestion of carbohydrates, fats
and proteins in the small intestine.
Peristalsis - rhythmic muscle movements that force food in the esophagus from
the throat into the stomach. Peristalsis is involuntary - you cannot control it. It is
also what allows you to eat and drink while upside-down.
Rectum - the lower part of the large intestine, where feces are stored before they
are excreted.
Salivary glands - glands located in the mouth that produce saliva. Saliva contains
enzymes that break down carbohydrates (starch) into smaller molecules.
Sigmoid colon - the part of the large intestine between the descending colon and
the rectum.
Stomach - a sack-like, muscular organ that is attached to the esophagus. Both
chemical and mechanical digestion takes place in the stomach. When food enters
the stomach, it is churned in a bath of acids and enzymes.
Transverse colon - the part of the large intestine that runs horizontally across the
abdomen.

 Functions of the Digestive System

 The digestive system includes the digestive tract and its accessory organs, which
process food into molecules that can be absorbed and utilized by the cells of the
body. Food is broken down, bit by bit, until the molecules are small enough to be
 absorbed and the waste products are eliminated. The digestive tract, also called
the alimentary canal or gastrointestinal (GI) tract, consists of a long continuous
tube that extends from the mouth to the anus. It includes the mouth, pharynx,
esophagus, stomach, small intestine, and large intestine. The tongue and teeth are
accessory structures located in the mouth. The salivary glands, liver, gallbladder,
and pancreas are major accessory organs that have a role in digestion. These
organs secrete fluids into the digestive tract.

 Food undergoes three types of processes in the body:

 Digestion

 Absorption

 Elimination

 Digestion and absorption occur in the digestive tract. After the nutrients are
absorbed, they are available to all cells in the body and are utilized by the body
cells in metabolism.

 The digestive system prepares nutrients for utilization by body cells through six
activities, or functions.

 Ingestion. The first activity of the digestive system is to take in food through the
mouth. This process, called ingestion, has to take place before anything else can
happen.

 Mechanical Digestion. The large pieces of food that are ingested have to be
broken into smaller particles that can be acted upon by various enzymes. This is
mechanical digestion, which begins in the mouth with chewing or mastication and
continues with churning and mixing actions in the stomach.

  Chemical Digestion The

complex molecules of
 carbohydrates, proteins, and
fats are transformed by
chemical digestion into smaller
molecules that can be absorbed
and utilized by the cells.
Chemical digestion, through a
process called hydrolysis, uses
water and digestive enzymes to
break down the complex
molecules. Digestive enzymes
speed up the hydrolysis
process, which is otherwise
very slow.

 Movements. After ingestion and mastication, the food particles move from the
mouth into the pharynx, then into the esophagus. This movement is deglutition,
or swallowing. Mixing movements occur in the stomach as a result of smooth
muscle contraction. These repetitive contractions usually occur in small segments
of the digestive tract and mix the food particles with enzymes and other fluids.
The movements that propel the food particles through the digestive tract are
called peristalsis. These are rhythmic waves of contractions that move the food
particles through the various regions in which mechanical and chemical digestion
takes place.

 Absorption. The simple molecules that result from chemical digestion pass
through cell membranes of the lining in the small intestine into the blood or
lymph capillaries. This process is called absorption.

 Elimination. The food molecules that cannot be digested or absorbed need to be

eliminated from the body. The removal of indigestible wastes through the anus, in
the form of feces, is defecation or elimination.

 General Structure of the Digestive System

  The long continuous tube that is the digestive tract is about 9 meters in length. It
opens to the outside at both ends, through the mouth at one end and through the
anus at the other. Although there are variations in each region, the basic structure
of the wall is the same throughout the entire length of the tube.

 The wall of the digestive tract has four layers or tunics:

 Mucosa

 Submucosa

 Muscular layer

 Serous layer or serosa

 The mucosa, or mucous membrane layer, is the innermost tunic of the wall. It
lines the lumen of the digestive tract. The mucosa consists of epithelium, an
underlying loose connective tissue layer called lamina propria, and a thin layer of
smooth muscle called the muscularis mucosa. In certain regions, the mucosa
develops folds that increase the surface area. Certain cells in the mucosa secrete
mucus, digestive enzymes, and hormones. Ducts from other glands pass through
the mucosa to the lumen. In the mouth and anus, where thickness for protection
against abrasion is needed, the epithelium is stratified squamous tissue. The
stomach and intestines have a thin simple columnar epithelial layer for secretion
and absorption.

 The submucosa is a thick layer of loose connective tissue that surrounds the
mucosa. This layer also contains blood vessels, lymphatic vessels, and nerves.
Glands may be embedded in this layer.

 The smooth muscle responsible for movements of the digestive tract is arranged
in two layers, an inner circular layer and an outer longitudinal layer. The
myenteric plexus is between the two muscle layers.
 Above the diaphragm, the outermost layer of the digestive tract is a connective
tissue called adventitia. Below the diaphragm, it is called serosa.

 Organs of the Digestive System

 At its simplest, the digestive system is a tube running from mouth to anus. Its
chief goal is to break down huge macromolecules (proteins, fats and starch),
which cannot be absorbed intact, into smaller molecules (amino acids, fatty acids
and glucose) that can be absorbed across the wall of the tube, and into the
circulatory system for dissemination throughout the body.


  Regions of the digestive system can be divided into two main parts: the
alimentary tract and accessory organs. The alimentary tract of the digestive
system is composed of the mouth, pharynx, esophagus, stomach, small and large
intestines, rectum and anus. Associated with the alimentary tract are the
following accessory organs: salivary glands, liver, gallbladder, and pancreas.

 Mouth

 The mouth, or oral cavity, is the first part of the

digestive tract. It is adapted to receive food by
ingestion, break it into small particles by mastication,
and mix it with saliva. The lips, cheeks, and palate 
form the boundaries. The oral cavity contains the
teeth and tongue and receives the secretions from the
salivary glands.

 Lips and Cheeks

 The lips and cheeks help hold food in the mouth and keep it in place for chewing.
They are also used in the formation of words for speech. The lips contain
numerous sensory receptors that are useful for judging the temperature and
texture of foods.

 Palate
 The palate is the roof of the oral cavity. It separates the oral cavity from the nasal
cavity. The anterior portion, the hard palate, is supported by bone. The posterior
 portion, the soft palate, is skeletal muscle and connective tissue. Posteriorly, the
soft palate ends in a projection called the uvula. During swallowing, the soft
palate and uvula move upward to direct food away from the nasal cavity and into
the oropharynx.

 Tongue
 The tongue manipulates food in the mouth and is used in speech. The surface is
covered with papillae that provide friction and contain the taste buds.

 Teeth
 A complete set of deciduous (primary) teeth contains 20 teeth. There are 32 teeth
in a complete permanent (secondary) set. The shape of each tooth type
corresponds to the way it handles food.

 Pharynx and Esophagus

 Pharynx
 The pharynx is a fibromuscular passageway that connects the nasal and oral
cavities to the larynx and esophagus. It serves both the respiratory and digestive
systems as a channel for air and food. The upper region, the nasopharynx, is
posterior to the nasal cavity. It contains the pharyngeal tonsils, or adenoids,
functions as a passageway for air, and has no function in the digestive system. The
middle region posterior to the oral cavity is the oropharynx. This is the first
region food enters when it is swallowed. The opening from the oral cavity into the
oropharynx is called the fauces. Masses of lymphoid tissue, the palatine tonsils,
are near the fauces. The lower region, posterior to the larynx, is the
laryngopharynx, or hypopharynx. The laryngopharynx opens into both the
esophagus and the larynx.
 Food is forced into the pharynx by
the tongue. When food reaches the
opening, sensory receptors around
the fauces respond and initiate an 
involuntary swallowing reflex. This
reflex action has several parts. The
uvula is elevated to prevent food
from entering the nasopharynx. The
epiglottis drops downward to prevent
food from entering the larynx and
trachea in order to direct the food
into the esophagus. Peristaltic
movements propel the food from the
pharynx into the esophagus.

 Esophagus
 The esophagus is a collapsible muscular tube that serves as a passageway between
the pharynx and stomach. As it descends, it is posterior to the trachea and
anterior to the vertebral column. It passes through an opening in the diaphragm,
called the esophageal hiatus, and then empties into the stomach. The mucosa has
glands that secrete mucus to keep the lining moist and well lubricated to ease the
passage of food. Upper and lower esophageal sphincters control the movement of
food into and out of the esophagus. The lower esophageal sphincter is sometimes
called the cardiac sphincter and resides at the esophagogastric junction.

 Stomach

 The stomach, which receives food from the esophagus, is located in the upper left
quadrant of the abdomen. The stomach is divided into the fundic, cardiac, body,
and pyloric regions. The lesser and greater curvatures are on the right and left
sides, respectively, of the stomach.
 

 Gastric Secretions
 The mucosal lining of the stomach is simple columnar epithelium with numerous
tubular gastric glands. The gastric glands open to the surface of the mucosa
through tiny holes called gastric pits. Four different types of cells make up the
gastric glands:

 Mucous cells

 Parietal cells

 Chief cells

 Endocrine cells
 The secretions of the exocrine gastric glands - composed of the mucous, parietal,
and chief cells - make up the gastric juice. The products of the endocrine cells are
secreted directly into the bloodstream and are not a part of the gastric juice. The
endocrine cells secrete the hormone gastrin, which functions in the regulation of
gastric activity.

 Regulation of Gastric Secretions

 The regulation of gastric secretion is accomplished through neural and hormonal
mechanisms. Gastric juice is produced all the time but the amount varies subject
to the regulatory factors. Regulation of gastric secretions may be divided into
cephalic, gastric, and intestinal phases. Thoughts and smells of food start the
cephalic phase of gastric secretion; the presence of food in the stomach initiates
the gastric phase; and the presence of acid chyme in the small intestine begins the
intestinal phase.

 Stomach Emptying
 Relaxation of the pyloric sphincter allows chyme to pass from the stomach into
the small intestine. The rate of which this occurs depends on the nature of the
chyme and the receptivity of the small intestine.

 Small and Large Intestine

 Small Intestine
 The small intestine extends from the pyloric sphincter to the ileocecal valve,
where it empties into the large intestine. The small intestine finishes the process of
 digestion, absorbs the nutrients, and passes the residue on to the large intestine.
The liver, gallbladder, and pancreas are accessory organs of the digestive system
that are closely associated with the small intestine.

 The small intestine is divided into the duodenum, jejunum, and ileum. The small
intestine follows the general structure of the digestive tract in that the wall has a
mucosa with simple columnar epithelium, submucosa, smooth muscle with inner
circular and outer longitudinal layers, and serosa. The absorptive surface area of
the small intestine is increased by plicae circulares, villi, and microvilli.

 Exocrine cells in the mucosa of the small intestine secrete mucus, peptidase,
sucrase, maltase, lactase, lipase, and enterokinase. Endocrine cells secrete
cholecystokinin and secretin.

 The most important factor for regulating secretions in the small intestine is the
presence of chyme. This is largely a local reflex action in response to chemical and
mechanical irritation from the chyme and in response to distention of the
intestinal wall. This is a direct reflex action, thus the greater the amount of
chyme, the greater the secretion.


 Large Intestine
 The large intestine is larger in diameter than the small intestine. It begins at the
ileocecal junction, where the ileum enters the large intestine, and ends at the
anus. The large intestine consists of the colon, rectum, and anal canal.

 The wall of the large intestine has the same types of tissue that are found in other
parts of the digestive tract but there are some distinguishing characteristics. The
mucosa has a large number of goblet cells but does not have any villi. The
longitudinal muscle layer, although present, is incomplete. The longitudinal
muscle is limited to three distinct bands, called teniae coli, that run the entire
length of the colon. Contraction of the teniae coli exerts pressure on the wall and
 creates a series of pouches, called haustra, along the colon. Epiploic appendages,
pieces of fat-filled connective tissue, are attached to the outer surface of the colon.

 Unlike the small intestine, the large intestine produces no digestive enzymes.
Chemical digestion is completed in the small intestine before the chyme reaches
the large intestine. Functions of the large intestine include the absorption of water
and electrolytes and the elimination of feces.

 Rectum and Anus

 The rectum continues from the signoid colon to the anal canal and has a thick
muscular layer. It follows the curvature of the sacrum and is firmly attached to it
by connective tissue. The rectum and ends about 5 cm below the tip of the coccyx,
at the beginning of the anal canal.

 The last 2 to 3 cm of the digestive tract is the anal canal, which continues from the
rectum and opens to the outside at the anus. The mucosa of the rectum is folded
to form longitudinal anal columns. The smooth muscle layer is thick and forms
the internal anal sphincter at the superior end of the anal canal. This sphincter is
under involuntary control. There is an external anal sphincter at the inferior end
of the anal canal. This sphincter is composed of skeletal muscle and is under
voluntary control.

 Accessory Organs

 The salivary glands, liver, gallbladder, and pancreas are not part of the digestive
tract, but they have a role in digestive activities and are considered accessory
organs.

 Salivary Glands
 Three pairs of major salivary glands (parotid, submandibular, and sublingual
glands) and numerous smaller ones secrete saliva into the oral cavity, where it is
 mixed with food during mastication. Saliva contains water, mucus, and enzyme
amylase. Functions of saliva include the following:

o It has a cleansing action on the teeth.

o It moistens and lubricates food during mastication and swallowing.

o It dissolves certain molecules so that food can be tasted.

o It begins the chemical digestion of starches through the action of amylase,

which breaks down polysaccharides into disaccharides.

 Liver
 The liver is located primarily in the right hypochondriac and epigastric regions of
the abdomen, just beneath the diaphragm. It is the largest gland in the body. On
the surface, the liver is divided into two major lobes and two smaller lobes. The
functional units of the liver are lobules with sinusoids that carry blood from the
periphery to the central vein of the lobule.

 The liver receives blood from two sources. Freshly oxygenated blood is brought to
the liver by the common hepatic artery, a branch of the celiac trunk from the
abdominal aorta. Blood that is rich in nutrients from the digestive tract is carried
to the liver by the hepatic portal vein.

 The liver has a wide variety of functions and many of these are vital to life.
Hepatocytes perform most of the functions attributed to the liver, but the
phagocytic Kupffer cells that line the sinusoids are responsible for cleansing the
blood.

 Liver functions include the following:

 secretion

 synthesis of bile salts

 synthesis of plasma protein

 storage

 detoxification

 excretion

 carbohyrate metabolism

 lipid metabolism

 protein metabolism

 filtering

 Gallbladder
 The gallbladder is a pear-shaped sac that is attached to the visceral surface of the
liver by the cystic duct. The principal function of the gallbladder is to serve as a
storage reservoir for bile. Bile is a yellowish-green fluid produced by liver cells.
The main components of bile are water, bile salts, bile pigments, and cholesterol.

 Bile salts act as emulsifying agents in the digestion and absorption of fats.
Cholesterol and bile pigments from the breakdown of hemoglobin are excreted
from the body in the bile.

 Pancreas
 The pancreas has both endocrine and exocrine functions. The endocrine portion
consists of the scattered islets of Langerhans, which secrete the hormones insulin
and glucagon into the blood. The exocrine portion is the major part of the gland.
It consists of pancreatic acinar cells that secrete digestive enzymes into tiny ducts
interwoven between the cells. Pancreatic enzymes include anylase, trypsin,
 peptidase, and lipase. Pancreatic secretions are controlled by the hormones
secretin and cholecystokinin.
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 PATHOPHYSIOLOGY:

 Precipitating Factors:
Predisposing
 Factors:
------------------------------------------------------
o Environment
o Status Genes
o Age-- ----------------------------- ↓ o Unsanitary
o Sex Food Handling
S.typhi is shed in o Ingestion of
o Socio-economic human feces
 Contaminated
 Food

 ↓
 Contamination of food
and water

 


Ingestion of contaminated
food or water by humans

S.typhi tries to survive in acidic

environment of the stomach

Remaining bacteria invade

epithelial cells in the intestine

Macrophages from Peyer’s

patches engulf bacteria

S.typhi injects effector

proteins into macrophage

Normal cellular activities are

diverted

Bacteria survives and

multiplies within
macrophage

 Constant exposure to bacteria

Macrophages carrying bacteria accumulate in Peyer’s patches

Inflammation

Necrosis
Phagocytes undergo lyses and release bacteria into nearby lymphatic ducts

Intestinal bleeding
Bowel perforation

Bacteria disseminate to regional lymph nodes

-Blood in vomitus
-Abdominal pain
-Gastroenteritis

Bacteria passes through thoracic duct and enters the bloodstream

Primary Bacteremia
(Asymptomatic)

Bacteria spread to other cells of reticuloendothelial system (including spleen, liver, and gallbladder)

Bacterial growth within spleen and liver

-Splenomegaly
-Hepatomegaly
 Bacteria is shed into the blood
stream

-Fever Secondary Bacteremia

-Headache
-Abdominal Pain

 Infection spreads to other
systems


Changes brought about by sepsis

accumulate in the heart, brain, and -Endocarditis
kidneys -Renal Failure
-Brain Infxn

IF NOT TREATED: IF TREATED:

Overwhelming sepsis Antibiotic Therapy

Circulatory Failure -Elimination/

decrease in number
of S.typhi
 -Alleviation of signs
 and symptoms
 -Recovery from
condition
 DEATH!
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 NURSING CARE PLAN 1:

 ASSESSME  DIAGN  PLANN  INTERVENTI  RA
NT OSIS ING ON AL
 Subjective:  Diarrhea  After 8  >observe stools  >fo
 “masakit r/t hours, for volume, lab
ang tiyan infectiou the frequency, y
ko”as s patient characteristics exa
verbalized processe shall and on
by the s; reestabl precipitating
patient parasites ish and factors.
 maintai  >note reports of
 Objective: n abdominal or
 Hyperacti normal rectal pain
ve bowel pattern associated with
sounds, of episodes
more than bowel  >auscultate
35 times per functio abdomen.
min. ning  >observe for
 7-8x from presence of
watery >35x/mi associated
stools per n to 5- factors such as
day 35x/min fever/chills and
 . bowel abdominal
sounds pain.
 >evaluate diet
history and note
nutritional/fluid
and electrolyte
status.
 >determine
recent exposure
to
different/foreig
n environments
and change in
drinking
water/fluid
intake
 >restrict solid
food intake as
indicated
 >limit caffeine
and high fiber
foods; avoid
milk and citrus
fruits as
appropriate.
 >administer
anti diarrheal
 medications, as
indicated.
 >provide
privacy during
defecation.
 >review
causative
factors and
appropriate
interventions
 > review food
preparation,
emphasizing,
adequate
cooking time
and proper
refrigeration/
storage
 > emphasize
importance of
handwashing
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 NURSING CARE PLAN 2:
 ASSESSME  DIAGNO  PLANN  INTERVENTI  R
NT SIS ING ON A
 Subjective:  Hyperther  After 1  >Instruct  >
 “Nilalagnat mia hour, patient to p
po ako” as related to the increase fluid d
 the patient illness. patient intake. o
stated. will  >Perform tepid  >
 maintai sponge bath as b
 n a needed. e
 Objective: normal  >Encourage o
 BT: 38˚ C range of patient to use c
 Skin warm body light –colored n
to touch tempera clothes.  >
ture as  >promote cool c
manifes environment by c
ted by use of fan or a
decreas opening h
e BT: windows. t
from 38  >Provide t
to 36.5- supplemental i
37.5˚ C. oxygen as b
ordered. t
 >Promote r
surface cooling  >
by undressing l
as permitted by c
the patient. n
 >Encourage 
patient to eat  >
citrus fruits. o
 i
 >Monitor body o
temperature. d
 a
c
o
 >
b
r
a
c
n

f
r
v
w
b
i
s
 >
 a
u
i
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 NURSING CARE PLAN 3:
 ASSESSME  DIAGN  PLANN  INTERVENTI  RA
NT OSIS ING ON E
 Subjective:  Acute  After 4  >Encourage  >E
 “Masakit pain hours, patient to pa
ang tiyan related the verbalize res
ko” as the to illness. patient feelings about ab
patient will the pain. 
verbalized verbaliz  >Assess pain;  >T
 e include wo
 relieved characteristics, co
 Objective: or location, de
 Guarding lessen duration, co
behavior pain as frequency and .
 Moaning manifes quality.  >P
ted by  >Accept su
 irritability
full patients the
coopera description of ca
tion the pain by
toward   >E
the  >Ascertain pa
health patients res
provide knowledge of 
rs. and 
expectations  >T
about the pain pr
management. all
 >Note when the ap
pain usually 
occurs such that 
when he is 
walking, and  >P
other actions
no
that aggravate
ph
the pain.
ca
 >Identify ways
ma
 of minimizing an
the pain such as dis
proper att
positioning, 
massage, use of 
cold or warm co 
press, quiet 
environment,  >V
imaging or ar
musical. alt
 >Monitor vital the
signs of the  >T
patient. pa
 his
 >Discuss with 
the SO’s the 
ways they can 
help the patient

to minimize the
pain and the  Pr
precipitating fat
factors of the
pain.
 >Encourage
patient to have
adequate rest.


 NURSING CARE PLAN 4:

 ASSESSME  DIAGNOS  PLANNI  INTERVENTI 
NT IS NG ON
 Subjective:  Sleep  At the  >Encourage 
 Daytime deprivatio end of patient to
drowsiness n related the shift, restrict foods
and to the rich in caffeine.
lethargy uncomfort patient  >Recommend 
 able sleep will patient to have 
 deprivatio report bedtime snacks.
 n. improve  >Suggest to
 Objective: ment in abstain from
 Irritability, sleep/rest daytime nap. 
pattern.  >Provide quiet 
inability to
concentrate, environment by
slowed closing the
reaction windows and
and apathy avoid making
noise.
 >Encourage 
him to drink
milk before
bedtime.
 >Limit the
visitors. 
 
 >Clustering of 
nursing 
activities.
 > Provide bed
comfort by
preventing bed
sheet from
crumpling. 
 >Discuss to him
the relaxation
techniques and 
musical
therapy.
 >Turn off the
light as
permitted by 
the patient.










 NURSING CARE PLAN 5:

 ASSESSME  DIAGN  PLANNIN  INTERVENTI 
NT OSIS G ON
 Subjective:  Imbalan  At the end  >discuss to the 
 “Isang baso ced of the patient the
o kalahati nutrition shift, the importance of
lang : less patient balancing
kinakain ko than the will calorie intake
na kanin” require verbalize and energy
 ment understan expenditure.
 Objective: related ding of  >Determine the
 Loss of to body and diet of the 
appetite in illness. energy patient. 
eating the needs as  >Identify 
prepared manifested psychological
meal. by eating a significance of
nutrient food to the
dense food patient. 
such as  >Encourage
rice, meet patient to make
and fruits a decision to
if not lead an active
restricted. life and control
food habits. 
 >Discuss eating
habits including
food
preferences. 
 >Encourage SO 
to eat with the
patient.

 >Prevent 
unpleasant
odors or sights.
 >Limit fluids 1 
hour prior to 
meal 


 



 DRUG STUDY1:
 NAME OF  CLASSI  ACTI  INDICA  ADVERSE
DRUG FICATI ON TION REACTIO
ON N
 Generic  Broad  Inhibit  For the  CNS:
name: spectru s treatme  Headache
 Ceftriaxone m bacter nt of dizziness,
 Brand name: antibioti ial cell gram weakness,
 Triavex c wall negative paresthesi
 Dosage: synthe organis fever, chil
sis, ms: seizure
 1 g slow IV
render H.influe  G.I.:
push now ing nzae,  Nausea,
then q 12˚ cell E.coli,
ANST vomiting,
wall E.aeroge diarrhea,
osmoti nes, P. anorexia,
cally mirabilis pain
unstab ,Klebsiel glossitis,
le, la, bleeding;↑
leadin Citrobac AST(SGO
g to ter, ),
cell Enterob ALT(SGP
death acter, , bilirub
Salmone LDH, a
lla, phosphate
Shigella, bdominal
Acinetob pain,
acter, pseudo
B.fragili membran
s, s colitis
Neisseri  G.U.:
a,  Proteinur
Serratia; vaginitis,
gram proritus,
positive BUN,
organis nephrotox
m: ity, ren
S.pneum failure
oniae,  HEMA:
S.pyoge
 Leucopen
nes,
 S.aureus thromboc
;serious openia,
lower agranuloc
respirat osis,
ory anemia,
tract, neutropen
urinary ,
tract, eosinophil
skin, ,
gonococ lymphocy
cal, sis,
intraabd pancytope
ominal a, hemolyt
infection 
s,
septicem
ia,
meningit
is, bone
joint
infection
.
 Generic  Nonste  Inhib  Rheu  CV:
Name:
 Ibuprofen + roidal its matoid  Tachyca
Pracetamol anti prost arthriti dia,
 Brand Name: infala aglan s, peripher
 Muskelax matory din osteo l edema
 Dosage:
 1 tab, TID PC
drug+ synth arthriti palpitati
PRN Analge esis s, ns,
sic , by primar dysrhytm
antipyr decre y ias,
etic asing dysme  CNS:
enzy norrhe  Headach
me a, e,
need gout, dizzines
ed dental drowsin
for pain, ss,
biosy muscu fatigue,
nthes lo tremors,
is; skeleta confusio
analg l n,
esic, disord insomni
anti ers, anxiety,
infla fever. depressi
mma n
tory,  EENT:
anti  Tinnitus
pyret hearing
ic loss,
blurred
vision
 GI:
 Nausea,
norexia,
vomitin
diarrhea
jaundice
cholesta
c
hepatitis
constipa
on,
flatulenc
e,
cramps,
dry
mouth,
peptic
ulcer
 GU:
 Nephrot
xicity:
dysuria,
hematur
 a,
oliguria
azotemi
 HEMA:
 blood
dyscrasi
s,
increase
bleeding
time


 GENERIC  Beta-  Unkn   CNS:
NAME: blocke own.  Dizzine
 Glimepirid r Low ,
e ers asthenia
 Brand gluco headach
name: se  EENT:
 Getryl level,  Changes
 Dosage : possi in
bly accomm
 1 or 2 mg
by dation
PO once
stimu  G.I.:
daily w/
latin  Nausea
first main
g  HEMAT
meal of
relea
day; usual OLOGI
se of
maintenan :
insuli
ce dose is  Leukope
n
1 to 4 mg nia,
from
PO once hemolyt
funct
daily. c anemi
ionin
agranulo
g
pancr cytosis,
thrombo
eatic ytopenia
beta aplastic
cells, anemia,
and pancyto
may enia
lead  HEPATI
to C:
decre  Cholesta
ased ic
sensi jaundice
tivity  METAB
of OLIC:
perip  Hypogly
heral cemia,
tissu dilution
es to hyponat
insuli emia
n.  SKIN:
 Pruritus
erythem
,
urticaria
morbilli
orm,
maculop
pular
eruption
,
photose
sitivity
reaction



 DISCHARGE PLAN:

 Medications:
 Instructed patient to take his home medication in time with the right dose
and right frequency.
 CIPROFLOXAN 50 mg/tab BID 6 am-4 pm on a full
stomach
 GLIMEPIRIDE(GETRYL) 2 mg/ tab 30 mins. AC
 IBUPROFEN + PARACETAMOL(TRIAVEX) 1 tab BID
PRN for fever, headache and body pain
 Exercise:
 Encouraged patient to perform deep breathing exercise to
increase the supply of oxygen in the body. Advised to limit
physical activities especially those activities that are strenuous or
tough to prevent fatigue.
  Treatment:
 Promoted cool environment to facilitate relaxation
 Instructed to get adequate rest and sleep
 Advised to increase oral intake
 Advised SO’s to do tepid sponge bath if his temp is
>37.8 degree Celsius

 Hygiene:
 Advise proper disposal of human excretion and secretion
 Advise segregation of dirty utensils

 OPD:
 Instructed patient to come back on september 04, 2009 at people’s emergency hospital
for his OPD check up.
 Diet:
 instruct patient to eat not more than 1800 cal
 avoid table sugar or all beverages
 Spiritual:
 Advised to continue asking guidance to God and always pray for his wellness.
 Advised to go to mass every Sunday





 

 CASE
PRESENTATI
ON
(TYPHOID
FEVER)


 GROUP A:
 Eden Pamittan
 Leonides Ramonette Israel
 Elynor reboredo
 Blesilda Elaine Obligado
 Dianne Aglado
 Adelna Faye Tamayo
 Rhea Lugo




