University of the Cordilleras College of Nursing I. General Profile/Information Name: Age: Birth Date: Sex: Civil Status: Address: Religion: Nationality: GSC 14 y/o June 11, 1995 Male Child Carael, Dagupan City, Pangasinan Roman Catholic Filipino

Date and Time of Admission: April 22, 2010/ 10:30 am Admitting Diagnosis: T/C enteric fever

II. Chief Complaint/s On and off fever for one month III. History of Present Illness Condition started one month prior to admission when patient developed on and off fever with no accompanying signs and symptoms. The patient self medicated with chloramphenicol for three weeks and paracetamol from the onset of fever. On April 18,2010, the patient consulted at private clinic and was advised to continue chloramphenicol and given with rapidol. Condition persisted hence admitted. IV. Past Medical History There is no previous hospitalization. The patient sometimes has coughs and colds but he does self medication for management. Fever is also a common illness experienced by the patient and he usually takes paracetamol to relieve it. The patient has no known allergies to drugs and foods. V. Social and Environmental History The patient is the third child among the 7 children. His father is a fisherman while his mother is a housewife. The place of the patient is situated near coastal waters. They have fishing as their main source of income thus; the patient is exposed in contaminated water. According to the mother of the patient, they boil their drinking water but we found out that they dont continue to boil it for at least 15 minutes. The mother also stated that the patient is fond of eating street foods especially fishballs, kikiams and palamig bought from street vendors. VI. Family History The patient has no family history of hypertension, diabetes mellitus and asthma. The client is the third child out of six. His father is a farmer and so as his mother. VII. Physical Examination A. General Survey

Client is groomed and changes his clothes every time he perspires. He is conscious, coherent and shows good attitude towards nursing interventions. He is weak in appearance but not irritable and has poor skin turgor. B. HEENT Head- Patient`s head is symmetrical and no noted abnormalities. Eyes- Client`s eyes are reactive to light, he can open and dilate both. His eyelashes are well distributed, with parallel eye movement. His pupils are round, regular, and 35mm equal in both eyes. No mass upon palpation and with pale palpebral conjunctiva. Ears-Ears are symmetrical with same color of patient`s face. Smooth in texture and both in same color. No discharges were noted and able to respond to soft and loud verbals. Nose-Client can distinguish different kind of smell such as; fragrance, foul odor, sour smell and others. He can inhale and exhale thoroughly and clearly. No discharges and deformity were noted. Throat-No obstruction were noted and can easily swallow foods and drinks. C. Respiratory System The patients respiration is normal which is 24 cycles per minute characterized by regular breathing pattern. Lung expansion is symmetrical. There are no presence of adventitious sounds like crackles, wheezes, pleural friction rub and stridor upon auscultation.

D. Cardiovascular System His pulse rate is normal which is 90 beats per minute which is in children is 60 100 beats per minute. He is not in any cardiovascular distress and his pulse is in regular rhythm. He has a low hemoglobin count which is 107 g/dL and the normal hemoglobin count for male is 140 170 g/dL prior to hemoglobin test done on April 22, 2010. He also has a low level of hemotacrit count which is 35 vol % while the normal hematocrit count is 40 50 vol % in which is done in CBC (complete blood count) prior to admission. E. Gastrointestinal System The physician Dr. S. ordered a DAT diet (Diet as Tolerated) for the patient because of his illness but he has a good appetite. He has normal patterns of intake of fluid which is 6-8 glasses of water a day. He perspires once in a while and urinates for at least 45ml/hr. No constipation, diarrhea and abnormal bowel sound noted. He has a regular bowel movement characterized by brown semi-solid stool. Clients abdomen is flat, soft and tender. F. Genito-Urinary System There is no presence of bladder distension and tenderness. The bladder when palpated is firm. There is no presence of lumps or masses. The patient has no difficulty in urinating and the urine is amber in color. He urinates for about three times a day. He voids when he feels the urge to urinate. According to his urinalysis there is presence of pus cells which shows infection. G. Musculo-skeletal System He moves slowly and needs assistance in performing activities of daily living because of body weakness felt by the patient. Muscle tone is symmetrical. Joints can move to its full potential.

H. Integumentary System The patient has dark brown complexion. He has flushed and warm to touch skin. He has poor skin turgor. Upper and lower extremities have minimal scars, lower extremities skin is rough. The patients nails are dirty. He doesnt have dandruff or lice seen on his hair. The patient takes a bath after two days.

VIII.

Diagnostic Examinations DESCRIPTION SIGNIFICANCE RESULTS NORMAL VALUES IMPLICATION OF THE FINDING Decreased -Normal Normal -normal Decreased -normal

DATE OF DIAGNOSTIC PROCED PROCEDURE URE 04/22/10 CBC URINALYSIS

The analysis of urine, the determination of quantity of each type of using physical,chemical blood cell in a given and microscopical tests, to sample of the proportions determine blood, often including the amount of of its normal constituents hemoglobin, alcohol, and to detect the hematocrit, and other drugs, sugarand the proportions of various abnormal constituents. white cells.

The CBC is used as Serves as baseline toa broad screening test determine abnormal to check for such disorders as constituent of the urine to anemia, infection, cause detect any possibleand many fever. of the other diseases.

HemoglobinColor-yellow 107 g/L WBC- 5.0 x 10/L Transparency-51 Hematocrit: Albumin-(+)35 DIFFERENTIAL COUNT: Segmenters: .56 Sugar-(-) Lymphocyte: .32 Specific gravity-1.020 Eosinophils: .03 MICROSCOPIC: Monocyte: .09 epithelial cell-few Platelet count:201 x 10/L Amorphous substance-few Pus cell-1-2 Mucus thread-(-) Crystal(-)

M: 140-170 g/L - yellow color 5-10 -clearx 10/L M: 40-50 vol % - >60 yr. 3.4-4.8 g/dl increase fluid intake >maintain prescribed IV

Body weakness

Activity

Risk for imbalanced nutrition: less than body Vitamins and Minerals: >lysine + Vitamin B complex + iron

Risk for Contamination Medication: Chloramphenic ol

XI.

Treatment and Management A. Drug study Generic Name Classification Dosage Start and Completion of Medication Dosage: 366mg To 38.5oc and 1 tab Q2 for To 38.5 Date started: 04/22/2010 Nonopioid analgesic Mechanism of Action Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that synthesize pain receptors to stimulation. The drug may relieve fever through central actionin the hypothalamic heat regulating center. Side Effects Hematologic: hemolytic anemia, leucopenia, neutropenia, pancytopenia Hepatic: jaundice Metabolic: hypoglycemia Skin: rash, urticaria Nursing Considerations >Use cautiously in patients with long term alcohol use because therapeutic doses cause hepatotoxicity in these patients. >Use liquid form for children and patients who have difficulty swallowing. >Advise parents that drug is only for short-term use; urge them to consult prescriber if giving to children for longer than 5 days or adults for longer than 10 days.

Trade Name

Tylenol

Acetaminophen

Antipyretic

Pentamycetin

Chloramphenicol sodium succinate

Dichloroacetic acid derivative Miscellaneous antiinfectives

Inhibits bacterial Dosage: 500mg 1cap protein synthesis by TID x 14 days binding to the 50s subunit of the Date started: ribosome; 04/24/10 bacteriostatic.

CNS: Confusion, delirium, headache, mild depression, peripheral neuropathy with prolonged therapy EENT: decreased visual acuity GI: diarrhea, glossitis, nausea, vomiting, stomatitis Hematologic: aplastic anemia, thrombocytopenia Hepatic: jaundice

Cefizox

Ceftriaxone sodium

Third generation cephalosporin Anti-infectives

Dosage: 1gm IV q12 Date Started: 04/23/10

Third generation cephalosporin that inhibits cell wall synthesi, promoting osmotic instability; usually bactericidal.

>monitor patient for signs and symptoms of superinfection >Instruct patient and So to notify prescriber if adverse reactions occur, especially nausea, vomiting, diarrhea, fever, confusion, sore throat, or mouth sores. >Instruct patient to report signs and symptoms of superinfection. CNS: fever >Contraindicated in CV: phlebitis, patients thrombophlebitis hypersensitive to GI: diarrhea, colitis, durg or other nausea, anorexia cephalosporins Respiratory: > If large doses are dyspnea given, therapy is Skin: maculopapular prlonged, or patient and erythematous is high risk, monitor rashes, urticaria patient for signs and symptoms of superinfection. >Tell patient and SO to report adverse reactions and signs and symptoms of superinfection

Lysine + Vit. B complex + iron

Vitamins and Minerals tsp BID

Lysine: required in the body for the manufacture of carnitine, which is an amino acid used for the proper metabolism of fats. Lysine has also been found to stimulate the synthesis of cholesterol in the liver. Vit, B complex: Vitamins mainly function as catalysts for reactions within the body. They contain no useful energy, but as catalysts, they serve as essential links and regulators in metabolic reactions that release energy from food

GI: nausea, epigastric pain, vomiting, constipation, black stools, anorexia.

promptly >Instruct patient to report discomfort at the IV site. >Tell patient to notify prescriber about loose stools or diarrhea. > tell patient not to be alarmed for black stools > Instruct patient to notify prescriber if signs and symptoms occur.

Iron: iron is the central atom of the heme group, a metal complex that binds molecular oxygen in the lungs and carries it to all of the other cells in the body that need oxygen to perform their activities B. IV Fluids Name of IV Solution D5LRs 1L x 12o Date Started April 22, 2010 Date Discontinued/ Consumed April 22, 2010 Why is it to be given for 12 or 8 hours duration It contains 5 grams It should be given in a dextrose( 170 calories/L) specific hour because it and 28 mEq Sodium can cause fluid and/or Lactate (provides 9 solute overloading calories/L) which gives resulting in dilution of the patient the right level serum electrolyte of hydration the patients concentrations, over body needed. hydration, congested states, or pulmonary edema. Excess administration may result in metabolic alkalosis. Purpose why is it given to the patient IV Classification Hypertonic

D5NM 1L x 12

o

April 22, 2010

April 23, 2010

The solution is administered by intravenous infusion for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories.

PLRS 1L x 8

o

April 23, 2010

April 23, 2010

For fluid and electrolyte replenishment and caloric supply in a single dose container for intravenous administration. It contains electrolytes such as potassium, calcium, sodium and chloride.

It should be given in a specific hour because it can cause fluid and/or solute overloading resulting in dilution of serum electrolyte concentrations, over hydration, congested states, or pulmonary edema. Excess administration may result in metabolic alkalosis. It should be given in a specific hour because it can cause fluid and/or solute overloading resulting in dilution of serum electrolyte concentrations, over hydration, congested states, or pulmonary edema. Excess administration may result in metabolic alkalosis.

Hypetonic

Isotonic

XII.

Nursing Diagnosis

ASSESSMENT S> Mainit ang pakiramdam ko at masakit ang ulo ko

EXPLANATION OF THE PROBLEM

GOALS AND OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION

O> Temperature39.9 Flushed skin Warm to touch Irritable at times Initial V/S taken as follows: T: 39.9 PR:90 RR:24

Ingestion of foods or fluids contaminated with Salmonella typhi bacteria

STO: After 2 hours of nursing intervention, the temperature of the patient will decrease from 39.9 to 38.

Dx: Monitored vital signs especially temperature. Observe for chills and diaphoresis Fever pattern may aids in diagnosing underlying diseases. Chills often precede during high temperature and is presence of generalized infection.

The temperature of the patient decreases from 39.9 to 38.

Bacteria enter the stomach and survive a pH as low as 1.5 Bacteria invades the Payers patches of the intestinal wall in the small intestines where it attach (incubation period is first 7-14 days after ingestion)

Monitor for signs of deterioration of condition or failure to improve with therapy. Tx:

May reflect inappropriate antibiotic therapy.

A> Hyperthermia related to infectious process secondary to Typhoid fever

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

Provided TSB intermittently and avoid the use of ice water and alcohol Changed clothing

May help reduce fever. Use of ice water and alcohol may cause chills and can elevate temperature. To provide comfort To prevent dehydration and Used to reduce fever and to control the spread of infection.

Offered fluids to drink.

Facilitated in giving PRN medications as ordered like Edx:

To prevent fluid loss

ASSESSMENT

EXPLANATION OF THE PROBLEM The patient has elevated body temperature where the body cannot maintain stability within this range by balancing the heat produced by the metabolism with the heat lost to the environment which in turn activates different physical responses designed to cool or warm the body, depending on the circumstances. These responses include: decreasing or increasing the flow of blood from the body's core, where it is warmed, to the surface, where it is cooled; slowing down or speeding up the rate at which the body turns food into energy (metabolic rate); inducing shivering, which generates heat through muscle contraction; and inducing sweating, which cools the body through evaporation which can lead to Fluid volume deficit related to increase metabolic rate secondary to typhoid fever

GOALS AND OBJECTIVES STO: After 3-4 hour of nursing intervention, the patient will be able to have balance intake and output over 24 hours

INTERVENTIONS

RATIONALE

EVALUATION

O Dry skin Weak in appearance Slightly poor skin turgor Dry mucous membrane Poor capillary refill which goes back for about 2-3 seconds Febrile: 39.9C A> Fluid volume deficit related to increase metabolic rate secondary to typhoid fever

Dx> Monitor temperature

Febrile states decrease body fluids through perspiration and increased respiration

STO: Patient was able to have balance intake and output over 24 hours

Observe for excessively dry skin and mucous membranes, decrease skin turgor, slowed capillary refill Assess skin turgor and mucous membranes

Indicates excessive fluid loss or resultant dehydration May indicate signs of dehydration

Tx> Maintain IV flow

Administer medications as ordered (paracetamol for fever)

To facilitate correct administration of fluid To prevent fluid under load and over load To lower the fever to be able to lessen fluid loose

Edx> Encourage to drink prescribed fluid amount Encouraging the patient to increase fluid intake will help the patient and prevent from severe dehydration

Explain the importance of maintaining proper nutrition and hydration

ASSESSMENT

EXPLANATION OF THE PROBLEM

GOALS/ OBJECTIVES STO Dx

EVALUATION INTERVENTION RATIONALE STO: > this aids defining what patient is capable of, which is necessary before setting realistic goals Goal met. After 2-3 hours of nursing interventions the patient is able to do ADL as tolerated

S > nanghihina siya kaya hindi siya masyadong nakakagalaw, as verbalized by the mother After 2-3 hours of nursing interventions the patient will be able to do ADL as tolerated

> Assess patients level of mobility.

>Assessed ability to stand and move about and the degree of assistance necessary

O >alert and awake > febrile ( ) >fatigability noted > weakness noted when positioning >needs assistance in doing ADL >restlessness noted A> Activity Intolerance related to generalized weakness

>To determine current status and needs associated with participation in needs or desired activities

>Assess potential for physical injury with activity

> Injury may be related to falls or overexertion

> Assess emotional response to change in physical status

>Depression over inability to perform required activities can further aggravate the activity intolerance >To provide comparative baseline data > Rest between activities provides time energy conservation and recovery.

> Assessed and monitored V/S Tx > Provided adequate rest periods, especially before meals, other ADLs, and ambulation > Assisted with ADLs

> assisting the patient with ADL allows for conservation of energy. Caregivers should balance providing assistance with

ASSESSMENT O >with sleep disturbances >weak in appearance >fatigue noted >increased food intake >good dentition A>Risk for Imbalanced nutrition less than body requirement related to decrease oral intake as evidenced by lack of interest in food secondary to Typhoid fever

EXPLANATION OF THE PROBLEM Typhoid fever is an infection caused by Salmonella enterica subtype typhi, a bacteria that grows only in the digestive systems and bloodstreams of humans. People infected with S. typhi usually have a fever (thus the term typhoid fever) -sometimes up to 103-104 degrees F. Often they have abdominal pains, loss of appetite, headaches, malaise (feeling lousy) and may feel weak as well which may lead to risk for imbalanced nutrition less than body requirement.

GOALS AND OBJECTIVES STO: After 1-2 hours of nursing interventions the client will be able to: a. Verbalize understanding on the importance of proper diet. b. Enumerate foods to be included in his diet LTO: After 2 to 3 days of Nursing interventions, the client will be able To demonstrate changes and maintain proper diet

INTERVENTIONS Dx: Documented actual weight

RATIONALE T o obtain baseline data such as loosing or gaining weight of patient Patients perception of actual intake may differ Proper assessment guide intervention. Determination of type, amount and pattern if food or fluid intake is facilitated Maintaining proper nutrition It serves as a baseline data and awareness of patients own condition To promote nutritional balance

EXPECTED OUTCOME STO: Goal met, if the client is able to verbalize understanding on the importance of a proper diet and can enumerate foods that should be included in his diet LTO: Goal met, if the client is able to demonstrate changes and maintain proper diet.

Obtained nutritional history including family, significant others Determine etiological factors for reduced nutritional intake Tx: Consulted dietician for further assessment and recommendations regarding food preferences and nutritional support for the client Assisted in feeding Edx: Encouraged patients participation in recording daily food intake Discussed possible need for enteral or parenteral nutritional feeding

Assessment O> Febrile: T- 38.3 C > Weak in appearrance > (+) Salmonella Typhi

Explanation of the Problem Salmonella Typhi is transmitted on either water or food, possibly through inadequate hygiene. Transmission by direct contact, oral route. The organism enters the body via the GI tract and gains access to the bloodstream via the lymphatic. Ulceration, hemorrhage, and intestinal perforation may occur in severe cases. Incubation period is usually with fever, headache, and abdominal pain. Untreated prolonged fever is often accompanied by relative bradycardia and prostration. Late in the disease an acute abdomen and leukocytosis.

Objectives STO: 1-2 hours of nursing intervention patient is able to verbalize understanding factors of being a carrier of Salmonella Typhi

Nursing Interventions Dx> Monitored & Recorded V/S > Assess skin integrity

Rationale > to get baseline data

Evaluation STO: Patient verbalizes an understanding of Salmonella Typhi because they were adequately informed and educated

> to determine susceptibility to infection > to determine the awareness of spread/prevention of communicable disease

A> Risk for Contamination R/T ingestion infected food and water 2o Typhoid Fever.

LTO: 2-3 days of nursing intervention patient is able to demonstrate necessary actions to prevent spread of bacteria to family members and community.

>Assess knowledge level to learn and identify barriers to prevent spread of infection. Tx>Performed proper hand hygiene and use appropriate Personal Protection Equipment at all times >Clean all reusable equipment after each use and properly dispose of single use >Monitor visitors

LTO: Patient demonstrates the proper > to prevent infection and techniques to prevent spread of bacteria cross contamination because he does proper hand hygiene and covers mouth when coughing and sneezing. > to prevent spread of contamination

> to prevent exposure of client > to reduce risk of crosscontamination > to maximum antibiotic

> Provide for isolation as indicated

> Due Med given > Informed patient they are a Salmonella Typhi carrier and provide instruction

effectiveness > to help them understan how to prevent crosscontamination > to determine further teaching > to prevent spread of infection > to prevent infection and cross contamination

> Evaluated response to instruction EDx>Demonstrated proper hand hygiene washing > Advised patient to cover mouth when coughing or sneezing. >Advised patient to take Meds as ordered even when feeling better

> to prevent drug resistent

XIII.

Discharge Plan

Diet

Medications

Health Teachings

Activities

> Liquid diet should be given to the patient (milk, barley and fruit juices but orange juice would be more beneficial to the client with typhoid fever)

>Tylenol (Acetaminophen) Dosage: 366mg To 38.5oc and 1 tab every 2 hours for To 38.5 >Pentamycetin (cholaramphenicol sodium succinate) Dosage: 500mg 1cap 3 x a day for 14 days

> Encouraged patient to go for his follow up check up after hospitalization

> Rest is helpful to the patient (complete bed rest)

> Emphasized on the importance of good personal hygiene

> Mobility should be maintained

> Daily medications > Encouraged on complete bed rest to regain energy

> The exclusive diet of orange juice diluted with warm water can be taken for first few days of the treatment with highly beneficial results.

> Log rolling (if patient cannot move)

>Cefizox (ceftriaxone sodium) Dosage: 1gm IV every 12 hours > Lysine + Vit. B complex + iron tsp 2x a day > Encouraged to take in liquids that are rich in Vitamin C (orange juice, lime juice, calamansi juice) > TSB (tepid sponge bath) should be administered when fever is 37.5 C and above

> Avoid raw vegetables and fruits that cannot be peeled. Vegetables like lettuce are easily contaminated and are very hard to wash well.

> Encouraged Significant others on cleaning their surroundings to prevent recurrence of the illness

> Encouraged Significant others to prepare a well prepared foods

> Emphasized on the importance of avoiding street foods that it may also cause

the recurrence of the illness

> Emphasized on the importance of changing his sedentary lifestyle to a healthy one

> Encouraged to boil water for drinking (if it came from the faucet)

> Provided information on the causes of typhoid fever

> Provided information on the bacteria that lies in the body that may result to typhoid fever

>Provided preventive measures like provide adequate fluid and dietary intake, and appropriate clothing

> Provided Community resources, consultants as needed

XIV.

Conclusion and Recommendation

Typhoid fever is a common worldwide, acute illness most commonly caused by Salmonella typhi. It is contracted by the ingestion of the bacteria in contaminated food or water. Patients with acute illness can contaminate the surrounding water supply through stool, which contains a high concentration of the bacteria. As we can see, the spread of the disease is mainly brought about by poor environmental sanitation which concerns food handling, improper waste disposal, drainage system, as well as hand hygiene; all of which are manageable and possible to avoid as threat to peoples health. As we dig in to the pathophysiology of the disease, we recognized that although the disease is not fatal, it could damage the body systems and may in fact lead to complications detrimental to well being. Therefore, given the chance to study this disease and gain knowledge from it is a privilege that we should share not only to our co students but most importantly, to the patients who needs to be enlightened. In this case, we would like to give the following recommendations which in turn will be of great help in alleviating the cases of Typhoid fever.

Carriers of typhoid must not be allowed to work as food handlers to stop the spreadthen we should stop the root cause.

Avoiding risky foods and beverages (especially when traveling in the developing world) is another good typhoid fever prevention strategy - Avoid foods and beverages from street vendors. It is difficult for food to be kept clean on the street, if you drink water, buy it bottled or bring it to a rolling boil for one minute before you drink it, eat foods that have been thoroughly cooked and that are still hot and steaming, When you eat raw fruit or vegetables that can be peeled, peel them yourself. (Wash your hands with soap first.)

Adequate water treatment, waste disposal, and protection of food supply from contamination are important public health measures managing these areas will help lessen the risk of incurring the disease.

Strict hand hygiene the universal precaution never fails to break the chain of any infectious disease. The typhoid vaccine. There are two types of vaccines. One vaccine contains killed Salmonella typhi bacteria. This vaccine is administered by a shot. The other vaccine contains a live but weakened strain of the Salmonella bacteria that causes typhoid fever. This typhoid vaccine is taken by mouth.

University of the Cordilleras College of Nursing Governor Pack Road, Baguio City Philippines 2600

A Case Report: Typhoid Fever

A Case Presentation Presented to the Faculty of the University of the Cordilleras College of Nursing

In Partial Fulfillment of the Requirements in Bachelor of Science in Nursing

By: Antonio, Joseph Christopher Cino, Christine De Vera, Mawee Escala, Monica Hagada, Kim Inagapad, Mhel Florence Masadao, Daphne Yvonne Natividad, Earl John Ngolab, Kirk Lee Wayne Padawil, Pearly Jhane Porto, May Rhezalie BSN 3-6B

May 19, 2010