I.

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

II. Patient’s Profile

Patients name: Patient D
Age: 37
Sex: Male
Address: Purok 8, dalipuga, iligan city
Marital Status: Married
Occupation: seaman
Religion: Roman Catholic
Admission date and time: November 28, 2010 at 4:45pm
Attending Physician: Dr. Estrada
Initial Diagnosis: Acute bronchitis/ Typhoid Fever
Chief Complaint: Fever

III. Nursing History

Initial Diagnosis: Acute bronchitis/ Typhoid Fever

Chief Complaint: Fever

History of Present Illness

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

Past History

Childhood Illnesses
Did not suffer any childhood illnesses

Childhood Immunization Status

Patient did not remember his immunization status

Allergies
No known allergies to food, drugs, animals and other environmental agents

Accidents and injuries

Patient had experienced motor vehicle injury when he was still 13 years old

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

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

Social Data

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

IV. Physical Assessment

Initial vital signs:

T = 38.1˚C
PR = 82bpm
RR = 22cpm
 BP = 130/70mmHg

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

Body Part Technique Actual Finding Interpretation

Assessed Used

Skin Inspection Skin color is fair and even Normal

Palpation Skin is warm and dry Normal due to
aging

HEENT Head Normocephalic Normal

Inspection Evenly distributed hair, with Normal
gray hair, no dandruff, lesions
Palpation nor infection Normal
Sinuses non-tender
Eyes
Inspection Normal
Symmetrical eyelids Normal
Pinkish conjuctiva Normal
PERRLA

No discharges Normal
Nose Airways patent on both nares Normal

No discharges Normal
Ears

Mouth, Mouth Has complete set of teeth Normal

Pharynx and Lips violet and dry Normal
Neck Pharynx Tongue at midline (smoker)
Gums and mucosa pink Normal
Normal
Neck Tonsils not inflamed
Neck symmetrical with full Normal
ROM Normal
Trachea at midline Normal
Cardiovascular AuscultationHas audible heart sound Normal
Inspection Apical pulse at 5th ICS MCL Normal
Heart is pumping well with a Normal
pulse rate of
81 bpm from the normal rate
of 60-100 beats per minute

Extremities Inspection Skin fair in color with no Normal

presence of marks/ scars Normal (due to
Skin dry aging)
Skin intact Normal
Palpation Nails convex curved Normal
Pink nail beds Normal
Normal capillary refill <3 sec.
Skin warm to touch Normal
Bounding pulses Normal
Fair muscle strength Normal
 Full active ROM

Abdomen Inspection Abdomen is rounded in shape Normal

when sitting down and flat in
supine position
The rest of the abdomen in of Normal
same color with no abrasion
Ausculation Bowel sounds are 1-5 bowel Normal
sound per minute
Bowel and Genitals were not assessed
Urine due to patient’s refusal.
Excretion Patient was able to urinate Normal
atleast 7x since admitted
Patient defecates every other
day since admitted Abnormal

Gordon’s Functional Health Pattern

Functional Prior to During Interpretation
Health Hospitalization Hospitalization
Pattern
Health He engages in He was more inclined He manages his
Perception – simple exercises to bed rest due to health well since his
Health such as walking easy fatigability but realization. He now
Management and jogging. He engages in ROM takes a higher regard
Pattern also follows exercises. He eats of health and has
medication hospital meals and become more aware
regimen. fruits. He closely of lifestyle changes
listens to the doctor’s significances.
and nurse’s health
advices.

Nutritional –
Metabolic
Pattern Patient has loss of
a. number of appetite due to
meals per day 3 full meals a day disease process
b. appetite with good appetite 3 meals a day he has
c. glass of loss of appetite since
water per day admitted but eats
meals that is served
by the dietary
6 - 8 glasses of department
water a day

6 - 8 glasses of water
a day

Elimination
Pattern
a. frequency of There is changes in
urination 3-4 times per day 4-7 times per day the frequency of
b. amount of Moderate Moderate urination due to
urine per day Once a day Every other day increase fluid intake
c. frequency of Formed and with the
bowel Formed Moderate administration of IV
movement Moderate fluids, there is also a
d. consistency change in bowel
of the feces movement due to
e. amount insufficient physical
defecated per mobility
day
Activity –
Exercise
Pattern Client is easily
a. exercise Walking ROM exercises fatigued due to
b. fatigability Don’t get tired Easy to get tired present disease
c. ADL easily None condition.
Activities related
to his work
Sleep – Rest Client usually Client usually has Sleep pattern is
Pattern sleeps at 12 short naps and sleepsaltered due to
midnight and more earlier than present disease
wake up at 4 in usual condition.
the morning
Cognitive –
Perceptual
Pattern No significant
a. orientation changes.
b.
responsivenes Oriented to time,
s Oriented to time, place and person
place and person Responds
Responds appropriately to
appropriately to verbal and physical
verbal and stimuli
physical stimuli
Self-Perception Client has high Client still has high No significant
– Self-Concept regard of self regard of self worth changes.
Pattern worth and is a and is a positive
positive thinker. thinker.
Role –
Relationship
Pattern No significant
a. as a brother changes
b. as a With good Still with good
husband relationship with relationship with his
c. a father and his siblings and siblings and provided
grandfather provided support support whenever
whenever needed needed
With good Still with good
relationship with relationship with wife
wife With good
With good relationship with sons
relationship with and daughters as
sons and well as with in-laws
daughters as well and grandchildren
as with in-laws
and grandchildren

Sexual- Patient is not that sexually active since No significant

Reproductive he works abroad and comes for vacation changes
Pattern every 9 months
Coping – Stress In spite of challenges, he is enthusiastic This helps in a
Tolerance of overcoming them. He is a strong better prognosis of
Pattern willed person and his support system his disease
(family and friends) has strong condition.
foundation.
Value – Belief He is a devout Catholic but he doesn’t No significant
Pattern go to church that often, because of his changes
work.

Disease Process

Anatomy and Physiology

Gastr oi n te sti n al syste m
To aid in understanding the disease process, Anatomy and Physiology
provides the
necessary information about the normal function of certain body
components, its structure and
function. Anatomy and physiology are always related. Anatomy is the study
of the structure and
shape of the body and body parts and their relationships to one another.
Physiology is the study
of how the body pars work or function.
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting
from the oral
cavity, where food enters the mouth, continuing through the pharynx,
oesophagus, stomach and
intestines to the rectum and anus, where food is expelled. There are various
accessory organs that
assist the tract by secreting enzymes to help break down food into its
component nutrients. Thus
the salivary glands, liver, pancreas and gall bladder have important functions
in the digestive
system. Food is propelled along the length of the GIT by peristaltic
movements of the muscular
walls.
The primary purpose of the gastrointestinal tract is to break down food into
nutrients, which can be absorbed into the body to provide energy. First food
must be ingested into the mouth to be mechanically processed and
moistened. Secondly, digestion occurs mainly in the stomach and small
intestine where proteins, fats and carbohydrates are chemically broken down
into their basic building blocks. Smaller molecules are then absorbed across
the epithelium of the small intestine and subsequently enter the circulation.
The large intestine plays a key role in reabsorbing excess water. Finally,
undigested material and secreted waste products are excreted from the body
via defecation (passing of faeces). In the case of gastrointestinal disease or
disorders, these functions of the gastrointestinal tract are not achieved
successfully. Patients may develop symptoms of nausea, vomiting, diarrhoea,
malabsorption, constipation or obstruction. Gastrointestinal problems are
very common and most people will have experienced some of the above
symptoms several times throughout their lives.
Basic structure
The gastrointestinal tract is a muscular tube lined by a special layer of cells,
called epithelium. The contents of the tube are considered external to the
body and are in continuity with the outside world at the mouth and the anus.
Although each section of the tract has specialised functions, the entire tract
has a similar basic structure with regional variations
The wall is divided into four layers as follows:
Mucosa
The innermost layer of the digestive tract has specialised epithelial cells
supported by an underlying connective tissue layer called the lamina propria.
The lamina propria contains blood vessels, nerves, lymphoid tissue and
glands that support the mucosa. Depending on its function, the epithelium
may be simple (a single layer) or stratified (multiple layers).
Areas such as the mouth and oesophagus are covered by a stratified
squamous (flat) epithelium so they can survive the wear and tear of passing
food. Simple columnar (tall) or glandular epithelium lines the stomach and
intestines to aid secretion and absorption. The inner lining is constantly shed
and replaced, making it one of the most rapidly dividing areas of the body!
Beneath the lamina propria is the muscularis mucosa. This comprises layers
of smooth muscle which can contract to change the shape of the lumen.
Submucosa
The submucosa surrounds the muscularis mucosa and consists of fat, fibrous
connective tissue and larger vessels and nerves. At its outer margin there is a
specialized nerve plexus called the submucosal plexus or Meissner plexus.
This supplies the mucosa and submucosa.
Muscularis externa
This smooth muscle layer has inner circular and outer longitudinal layers of
muscle fibres separated by the myenteric plexus or Auerbach plexus. Neural
innervations control the contraction of these muscles and hence the
mechanical breakdown and peristalsis of the food within the lumen.
Serosa/mesentery
The outer layer of the GIT is formed by fat and another layer of epithelial cells
called mesothelium.

Individual components of the gastrointestinal system

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

The small intestine performs the majority of digestion and absorption of

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

The large intestine is horse-shoe shaped and extends around the small
intestine like a frame. It consists of the appendix, caecum, ascending,
transverse, descending and sigmoid colon, and the rectum. It has a length of
approximately 1.5m and a width of 7.5cm.
The caecum is the expanded pouch that receives material from the ileum and
starts to compress food products into faecal material. Food then travels along
the colon. The wall of the colon is made up of several pouches (haustra) that
are held under tension by three thick bands of muscle (taenia coli).
The rectum is the final 15cm of the large intestine. It expands to hold faecal
matter before it passes through the anorectal canal to the anus. Thick bands
of muscle, known as sphincters, control the passage of faeces.
The mucosa of the large intestine lacks villi seen in the small intestine. The
mucosal surface is flat with several deep intestinal glands. Numerous goblet
cells line the glands that secrete mucous to lubricate faecal matter as it
solidifies. The functions of the large intestine can be summarised as:
1. The accumulation of unabsorbed material to form faeces.
2. Some digestion by bacteria. The bacteria are responsible for the formation
of intestinal
gas.
3. Reabsorption of water, salts, sugar and vitamins.
Liver
The liver is a large, reddish-brown organ situated in the right upper quadrant
of the abdomen. It is surrounded by a strong capsule and divided into four
lobes namely the right, left, caudate and quadrate lobes. The liver has
several important functions. It acts as a mechanical filter by filtering blood
that travels from the intestinal system. It detoxifies several metabolites
including the breakdown of bilirubin and oestrogen. In addition, the liver has
synthetic functions, producing albumin and blood clotting factors. However,
its main roles in digestion are in the production of bile and metabolism of
nutrients. All nutrients absorbed by the intestines pass through the liver and
are processed before traveling to the rest of the body. The bile produced by
cells of the liver, enters the intestines at the duodenum. Here, bile salts break
down lipids into smaller particles so there is a greater surface area for
digestive enzymes to act.
Gall bladder
The gallbladder is a hollow, pear shaped organ that sits in a depression on
the posterior surface of the liver's right lobe. It consists of a fundus, body and
neck. It empties via the cystic duct into the biliary duct system. The main
functions of the gall bladder are storage and concentration of bile. Bile is a
thick fluid that contains enzymes to help dissolve fat in the intestines. Bile is
produced by the liver but stored in the gallbladder until it is needed. Bile is
released from the gall bladder by contraction of its muscular walls in
response to hormone signals from the duodenum in the presence of food.
Pancreas
Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the
stomach. Its head communicates with the duodenum and its tail extends to
the spleen. The organ is approximately 15cm in length with a long, slender
body connecting the head and tail segments. The pancreas has both exocrine
and endocrine functions. Endocrine refers to production of hormones which
occurs in the Islets of Langerhans. The Islets produce insulin, glucagon and
other substances and these are the areas damaged in diabetes mellitus. The
exocrine (secretrory) portion makes up 80-
85% of the pancreas and is the area relevant to the gastrointestinal tract.
It is made up of numerous acini (small glands) that secrete contents into
ducts which eventually lead to the duodenum. The pancreas secretes fluid
rich in carbohydrates and inactive enzymes. Secretion is triggered by the
hormones released by the duodenum in the presence of food. Pancreatic
enzymes include carbohydrases, lipases, nucleases and proteolytic enzymes
that can break down different components of food. These are secreted in an
inactive form to prevent digestion of the pancreas itself. The enzymes
become active once they reach the duodenum

PATHOPHYSIOLOGY: Typhoid Fever (book-centered)

Salmonella Typhi

Survives acidity of the stomach

Invades the Payers

Patches
 Intestinal Wall

Macrophages (Payers Patches)

The bacteria is within the macrophages and survives

Bacteria spread via the lymphatic while inside the macrophages

Access to Reticulo endothelial system, in liver, spleen, gallbladder

and bone marrow

First week: elevation of body temperature

Second week: abdominal pain, spleen enlargement and rose spots

Diagnostic Tests/ Laboratory Results

NORMAL RESUL INTERPRETATION

VALUE T
Complete Blood
Test
WBC M= 5-10x10 10.2 9/L Increased WBC result from bacterial
9/L infections, inflammation
4.6 g/L
RBC M= 4.5- Normal
5.6x10 12/L
HB 122 g/L
M= 140-160 Low levels indicate anemia, bleeding
g/L 0.31 or iron deficiency.
HCT
M= 0.40-0.48 Normal

Differential
Count 0.54
Neutrophils
0.55-0.70 0.41 Normal

Lymphocytes 0.25-0.40 0.05 Lymphocytes increase in many viral

infections
Monocyte 0.01-0.08 Normal
Brand Name/ Indication Action/ Mechanism of Action Side Effects Nursing Precaution
Generic Name
Dose/Dosage/
Frequency
Paracetamol Symptomatic relief Blocks pain impulses, probably Hematologic: •Assess patient’s pain and temperature
500mg 1tab now of pain and fever inhibiting prostaglandin or pain hemolytic anemia, before giving any drugs.
then q 4 PRN for receptor sensitizers. May relieve leukopenia • Assess patient’s drug history and
fever fever by acting on hypothalamic Hepatic: liver calculate daily dosage accordingly.
heat-regulating center damage, jaundice • Be alert for adverse reactions and drug
Metabolic: interactions.
hypoglycemia • Assess patient and family’s knowledge of
Skin: rash, urticaria drug use.
• Tell patient not to use drug for fever
higher than 103 degrees Fahrenheit or lasts
longer than 3 days or recurs.
• Tell the patient to keep track of daily
acetaminophen intake.

 Advise patient to apply patch the night

before a planned trip. Transdermal method
releases a controlled therapeutic amount of
-Spastic states Frequent: Dry mouth drug. Transderm-Scop is effective if applied
Buscopan 1tab -Delirium, Inhibits muscarinic actions of (sometimes severe), 2 or 3 hours before experiencing motion but
now then q 8 preanesthetic acetylcholine on autonomic effectors decreased sweating, is more effective if applied 12 hours before.
sedation and innervated by postganglionic constipation  Instruct patient to remove one patch
obstetric amnesia cholinergic neurons. May effect before applying another
with analgesics neural pathways originating in the  Instruct patient to wash and dry hands
-To prevent nausea inner ear to inhibit nausea and thoroughly before and after applying the
and vomiting from vomiting. transdermal patch (on dry skin behind the
motion sickness ear) and before touching the eye because
pupil may dilate. Tell patient to discard
 patch after removing it and to wash
application site thoroughly.
 Tell patient that if patch becomes
displaced, he should remove it and apply
another patch on a fresh skin site behind
the ear.
 Alert patient to possible withdrawal
signs or symptoms (nausea, vomiting,
headache, dizziness) when transdermal
system is used for longer than 72 hours.
 Advice patient that eyes may be ore
sensitive to light while wearing patch.
Advice patient to wear sunglasses for
comfort
 Urge patient to report urinary hesitancy
or urine retention.

Ciprofloxacin -Complicated Intra-

500mg 1 tab q 8 Abdominal Infections Ciprofloxacin inhibits DNA enzyme in Nausea Question for history of hypersensitivity to
-Infectious Diarrhea susceptible microorganisms. It Diarrhea Ciprofloxacin or Quinolones.
-Typhoid Fever interferes with bacterial DNA Dyspepsia May be given without regards to meals.
(Enteric Fever) replication. Ciprofloxacin is also Vomiting Preferred dosing time 2 hours after meals.
bactericidal. Constipation Do not administer antacids within 2 hours
Flatulence of Ciprofloxacin.
Confusion Encourage cranberry juice or citrus fruits.
Crystalluria Evaluate food tolerance.
Burning Determine pattern of bowel activity.
Crusting in the corner Check for dizziness, headache, visual
of eye difficulties, and tremors.
Abdominal pain or Observe therapeutic response.
discomfort
Headache
 Rash
Bad taste
Redness of the eyelid
Confusion
Hallucination
Hypersensitivity
reaction
Insomnia
Dry mouth
Paresthesia

Assessment Diagnosis Planning Intervention Rationale

Subjective: Hyperthermia After 5 days of nursing 1. Monitor patient’s vital signs. 1. Serves as baseline data
“init kayo akong paminaw, related to care and management, for future comparison.
sige balik-balik akong hilanat” increased client will: 2. Note chronological and developmental
as verbalized by the client metabolic Be able to manifest age of client. 2. Assess for causative/
rate, illness temperature in normal contributing factor
Objective: range 3. Note presence/ absence of sweating.
• Restlessness. 3. To assess degree of
• V/S taken as 4. Initiate tepid sponge bath. hyperthermia.
follows:
T: 38.1 °C 5. Promotes surface cooling through 4. Facilitates heat through
P: 82 bpm undressing or removing extra linens. conduction and
R: 22 cpm evaporation.
Bp: 130/70 6. Encourage adequate fluid intake.
5. Facilitates heat loss by
7. Encourage adequate bed rest. radiation

8. Instruct patient and SO to report signs 6. To promote heat loss

and symptoms of hyperthermia like flushed and hydration.
skin, increasing respiratory rate and body
temperature. 7. To reduce metabolic
consumption and oxygen
9. Maintain patent airway and pad or raise demands.
side rails upon turning and positioning.
8. To promote wellness
10. Provide high calorie diet unless
contraindicated. 9. To promote safety.

11. Instruct patient and SO to record all 10. To meet increased

sources of fluid loss such as urine, vomiting metabolic demands.
and diarrhea.
11.It potentates fluid and
Collaborative electrolyte losses
12. Administer paracetamol 500mg, 1 tablet 12. Relieves fever by acting
for fever as ordered. in hypothalamic heat
regulating center.
13. Administer replacement fluid and
electrolytes as needed. 13. To support circulating
14. Notify physician for unusualities. volume and tissue
perfusion.

14. For prompt

management.
Assessment Diagnosis Planning Intervention Rationale

Subjective: Risk for Within 6 hours of nursing interventions and 1. Auscultate abdomen for 1. Reflects bowel activity.
“every other day nalang Constipation giving of health teachings, the patient will be presence, location, and
ko makalibang sukad able to verbalize understanding of risk factors characteristics of bowels 2. To identify individual
katong na admit ko” as and appropriate interventions/ solutions to sounds. risk factors/ needs.
verbalized by the client individual situation. 2. Ascertain client’s belief and
practices about bowel 3. To assess client’s
Objective: elimination. individual risk factors/
-Dry skin needs.
-Absence of sweating 3. Ascertain client’s usual
-(+) flatus elimination pattern. 4. To improve
consistency of stool and
4. Encourage intake of facilitates passage
balanced fiber and bulk in through colon.
diet.
5. To promote moist/ soft
5. Promote increase in fluid stool.
intake unless contraindicated.
6. To stimulate
6. Encourage participation in contractions of intestines.
activity/ exercise within limits
of own ability. 7. To promote comfort
and prevent
7. Instruct patient to respond complications.
to urge to defecate.
8. To help monitor bowel
8. Instruct client and SO to
pattern.
ascertain frequency, color,
consistency of stool once
9. For prompt
defecated.
management
9. Advise patient to have
elimination diary if
appropriate

Collaborative:
10. Notify physician for
unusualities.