I. INTRODUCTION

Overview of the case

Typhoid fever is an acute systemic infection caused by the bacterium Salmonella enterica Typhi. Salmonella entericaserovars Paratyphi A, B and C cause the clinically similar condition, paratyphoid fever. Typhoid and paratyphoid fevers are collectively referred to as enteric fevers. In most endemic areas, approximately 90% of enteric fever is typhoid. Although the organism of typhoid fever is commonly referred to as S. typhi, it should be recognized that typhi represents the serotype.

MANILA (AP) — More than 1,400 people have displayed typhoid symptoms in less than a month in a city near the Philippine capital, prompting authorities to declare a state of calamity, health officials said Wednesday. Extra medical teams have been sent to assist doctors and conduct disease surveillance in Calamba, Health Secretary Francisco Duque said. Of 1,477 people with typhoid symptoms, 436 have been treated in the city's six hospitals and the rest in local community health centers since Feb. 16, said Dr. Dennis Labro, spokesman for the city's health office. Only 37 of those cases have been confirmed with blood tests because the typhoid test is expensive, Labro said.

The outbreak was concentrated in five adjacent villages in Calamba, about 34 miles from Manila, and the salmonella bacteria that caused the illness may have been spread via the water system, based on the speed at which the outbreak grew, he said.

Typically, typhoid symptoms include high-grade fever, stomach cramps, diarrhea or constipation and general malaise. In extreme cases, the small intestine could be perforated, leading to death if left unattended or not treated properly. Labro said the city's 50-bed government-run hospital was so swamped when the outbreak peaked Feb. 25-27 that corridors were used to accommodate patients. The city declared a state of calamity Monday, allowing it to immediately withdraw emergency funds for antibiotics and intravenous drips, he said. The Red Cross and the health department also sent medicine and doctors.

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Objective of the study

As a third year nursing student of Liceo de Cagayan University, within two days

of nursing intervention on a client with Typhoid Fever at Camp Evangelista Station

Hospital, condition of the aforementioned will augment and free of possible

complications from the disorder.

The completion of this case study enables the proponent to do the following:

1. To establish rapport and harmonious communication during the whole course of

the study.

2. To review Patient’s Chart and carry out Medical Orders; thus, relate these

interventions to the alleviation of the Patient’s health condition.

3. To discuss the Anatomy, Physiology and Pathophysiology of the Patient’s health

condition.

4. To identify Patient’s Clinical Manifestations as basis for the Actual and Ideal

Nursing Care Plans.

5. To promote Patient self-care as well as the significant others through Health

Teachings.

6. Demonstrate participation in the delivery of the formulated plan of care.

7. Obtain normal range of temperature and free of any signs and symptoms of

distress.

8. Experience therapeutic environment and relationship with the caregiver, resulting

to optimal recuperation.

Scope and limitation

The case presentation merely covers data that have been gathered through

interview per assessment tool and chart referral on the day of the assessment phase in

loading assigned patients and in the succeeding days of the rotation, in the care

formulated and intervened to its progress as the week’s rotation ended. Thus, it is

limited to the days in the rotation the student nurse interacted with the client in the hope

to gather the necessary data to support the presentation which is not enough to acquire

a bulk of specific details.

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II. HEALTH HISTORY

Patient’s Profile

Client’s Name: Patient A

Age: 23 years old

Address: Cabadbaran, Butuan City

Civil Status: Single

Sex: Male

Nationality: Filipino

Religion: Roman Catholic

Birthday: May 29, 1987

Height: 115.2 cm

Weight: 5’5’’

Allergy: Allergic to Chicken, Crab and Shrimp

Educational Attainment: High School Graduate

Physician: Dra. Cynthia M. Woo

Date of Admission: March 2, 2011

Time of Admission: 9:10 in the evening

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Family Health History

Personal Health History

Past Medical History

History of present health illness

2 weeks prior to admission patient had fever on and of associated with hard

productive cough. Consulted and diagnosed as urinary tract infection and upper

respiratory tract infection, given recalled medications, no relief obtained, so eight days

prior to admission he reconsulted because of in afternoon he experiences rise in

temperature and abdominal pain and then was advised to seek admission.

Chief complains

Prior to admission patient complains of hard productive cough, headache and

abdominal pain. He was consulted and medicated but no relief, so he was reconsulted

again and was advised for admission.

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III. DEVELOPMENTAL DATA

Psychosocial theory (Erick Erikson)

 Young adulthood: 18 to 35

Ego Development Outcome: Intimacy and Solidarity vs. Isolation

Basic Strengths: Affiliation and Love

In the initial stage of being an adult we seek one or more companions and love.

As we try to find mutually satisfying relationships, primarily through marriage and

friends, we generally also begin to start a family, though this age has been pushed back

for many couples who today don't start their families until their late thirties. If negotiating

this stage is successful, we can experience intimacy on a deep level.

If we're not successful, isolation and distance from others may occur. And when we

don't find it easy to create satisfying relationships, our world can begin to shrink as, in

defense, we can feel superior to others.

Our significant relationships are with marital partners and friends.

Psychosexual theory (Sigmund Freud)

The fifth stage of psychosexual development is the genital stage that

spans puberty and adult life, and thus occupies most of the life of a man and of a

woman; its purpose is the psychological detachment and independence from the

parents. The genital stage affords the person the ability to confront and resolve his or

her remaining psychosexual childhood conflicts. As in the phallic stage, the genital

stage is centered upon the genitalia, but the sexuality is consensual and adult, rather

than solitary and infantile. The psychological difference between the phallic and genital

stages is that the ego is established in the latter; the person’s concern shifts from

primary-drive gratification (instinct) to applying secondary process-thinking to gratify

desire symbolically and intellectually by means of friendships, a love relationship, family

and adult responsibilities.

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Cognitive development theory (Jean Piaget)

Formal operational stageThe formal operational period is the fourth and final of the periods of cognitive

development in Piaget's theory. This stage, which follows the Concrete Operational

stage, commences at around 11 years of age (puberty) and continues into adulthood. In

this stage, individuals move beyond concrete experiences and begin to think abstractly,

reason logically and draw conclusions from the information available, as well as apply

all these processes to hypothetical situations. The abstract quality of the adolescent's

thought at the formal operational level is evident in the adolescent's verbal problem

solving ability. The logical quality of the adolescent's thought is when children are more

likely to solve problems in a trial-and-error fashion. Adolescents begin to think more as

a scientist thinks, devising plans to solve problems and systematically testing solutions.

They use hypothetical-deductive reasoning, which means that they develop hypotheses

or best guesses, and systematically deduce, or conclude, which is the best path to

follow in solving the problem. During this stage the adolescent is able to understand

such things as love, "shades of gray", logical proofs and values. During this stage the

young person begins to entertain possibilities for the future and is fascinated with what

they can be. Adolescents are changing cognitively also by the way that they think about

social matters. Adolescent Egocentrism governs the way that adolescents think about

social matters and is the heightened self-consciousness in them as they are which is

reflected in their sense of personal uniqueness and invincibility. Adolescent egocentrism

can be dissected into two types of social thinking, imaginary audience that involves

attention getting behavior, and personal fable which involves an adolescent's sense of

personal uniqueness and invincibility.

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Moral stages (Kohlgberg)

 Postconventional Morality

Stage 5. Social Contract and Individual Rights. At stage 4, people want to keep society

functioning. However, a smoothly functioning society is not necessarily a good one. A

totalitarian society might be well-organized, but it is hardly the moral ideal. At stage 5,

people begin to ask, "What makes for a good society?" They begin to think about

society in a very theoretical way, stepping back from their own society and considering

the rights and values that a society ought to uphold. They then evaluate existing

societies in terms of these prior considerations. They are said to take a "prior-to-society"

perspective.

Stage 5 respondents basically believe that a good society is best conceived as a social

contract into which people freely enter to work toward the benefit of all They recognize

that different social groups within a society will have different values, but they believe

that all rational people would agree on two points. First they would all want certain

basic rights, such as liberty and life, to be protected. Second, they would want

some democratic procedures for changing unfair law and for improving society.

Stage 6: Universal Principles. Stage 5 respondents are working toward a conception of

the good society. They suggest that we need to (a) protect certain individual rights and

(b) settle disputes through democratic processes. However, democratic processes

alone do not always result in outcomes that we intuitively sense are just. A majority, for

example, may vote for a law that hinders a minority. Thus, Kohlberg believes that there

must be a higher stage--stage 6--which defines the principles by which we achieve

justice.

Kohlberg's conception of justice follows that of the philosophers Kant and Rawls, as well

as great moral leaders such as Gandhi and Martin Luther King. According to these

people, the principles of justice require us to treat the claims of all parties in an impartial

manner, respecting the basic dignity, of all people as individuals. The principles of

justice are therefore universal; they apply to all. Thus, for example, we would not vote

for a law that aids some people but hurts others. The principles of justice guide us

toward decisions based on an equal respect for all.

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IV. MEDICAL MANAGEMENT

Medical orders

March 2, 2011 (1:30PM) Rationale► Please admit

►TPR q shift

►DAT > avoid dark colored foods

► CBC, U/E, S/E MBS, Dengue Rapid test

► PCM 500mg q4° PO PRN for fever

► Ambroxol/Bromihexine i tab TID x 10 days

► Cephalexin 500g i cap TID x 10 days

► Start D5 LR iL at 30 gtts/min

► For confinement

►To obtain baseline data and monitor changes in vital signs. Vital signs are indicators of a change in condition.

► Darkens stool and may misinterpret results.

► For confirmatory diagnostic.

► Anti-pyretic. Used for the relief of fevers aches, and pains associated with many parts of the body

► Mucolytics. All forms of tracheobronchitis, emphysema with bronchitis pneumoconiosis, chronic inflammatory pulmonary conditions, bronchiectasis, brnchitis with bronchospasm asthma.

► Anti-infective. Common infections that are treated with cephalexin include infections of the middle ear, tonsils, throat, larynx(laryngitis), bronchi (bronchitis) and pneumonia. It also is used for treating urinary tract, skin, and bone infections..► Isotonic solution. Used for treatment of hypovolemia, burns, fluid loss as bile or diarrhea, and for acute blood loss replacement.

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March 2, 2011 (9:10PM) Rationale(+) Abdominal pain

► Buscopan i tab NOW then TID

► Increase oral fluid intake(+) Vomiting

► Metochlopramide i tab PRN for vomiting

► Anti-motility agent. To prevent nausea and vomiting from motion sickness

► For fluid replacement and rehydration.

► Gastrointestinal agent. To facilitate intubation of small bowel; symptomatic treatment of gastro esophageal reflux.

March 4, 2011 (9:00AM) Rationale► D/C Ambroxol

► Omiprazole 20mg i tab OD

► Increase oral fluid intake

(+) Tarry stools and Vomiting

► D5 NM iL at 30 gtts/min

► Gastrointestinal agent. Treatment for duodenal and gastric ulcer.

► For fluid replacement and rehydration.

► Hypertonic solution. For maintenance of daily fluid and electrolyte requirements.

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Diagnostic results

(March 2, 2011)Dengue IgA Rapid testResult: “POSITIVE”Method: Solid Phase Immunochromatography

URINALYSIS (March 2, 2011)

Color: Dark Yellow WBC: 0 – 2/hpfTransparency: Slightly hazy RBC: Sugar: Negative Amorphous: RareAlbumin: (+) Mucus threads: ModerateSpecific gravity: 1.030pH: 6.0Others: Fine Granular test: 0 – 2/hpf

HEMATOLOGY (March 2, 2011)

WBC: 14,600 1cumm (5,000 – 10,000) Neutrophil: 79 (50 – 70)Hgb: 13.6 gm% (M: 14 – 16 F: 12 – 15) Lymphocytes: 21 (20 – 40)Hct: 41.0 vol% (M: 40 – 54 F: 37 – 47)Platelet count: 294,000/cumm (150,000 – 400,000)Malarial smear: No malarial parasites seen

FECALYSIS (March 3, 2011)Color: Dark brown WBC: 2 – 4/hpfCharacteristic: SoftParasites found: No Ova or Parasites seen

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VII. ANATOMY and PHYSIOLOGY

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 thedigestive 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 food down 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).

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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, diarrhea, 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. 

Individual components of the gastrointestinal system

Oral cavityThe 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. The tongue, a strong muscular organ, manipulates the food bolus to come in contact with the teeth. It is also the sensing organ of the mouth for touch, temperature and taste using its specialised sensors known as papillae.Insalivation refers to the mixing of the oral cavity contents with salivary gland secretions. The mucin (a glycoprotein) in saliva acts as a lubricant. The oral cavity also plays a limited role in the digestion of carbohydrates. The enzyme serum amylase, a component of saliva, starts the process of digestion of complex carbohydrates. The final function of the oral cavity is absorption of small molecules such as glucose and water, across the mucosa. From the mouth, food passes through the pharynx and oesophagus via the action of swallowing.

Salivary glandsThree pairs of salivary glands communicate with the oral cavity. Each is a complex gland with numerous acini lined by secretory epithelium. The acini secrete their contents into specialised ducts. Each gland is divided into smaller segments called lobes. Salivation occurs in response to the taste, smell or even appearance of food. This occurs due to nerve signals that tell the salivary glands to secrete saliva to prepare and moisten the mouth. Each pair of salivary glands secretes saliva with slightly different compositions.

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ParotidsThe parotid glands are large, irregular shaped glands located under the skin on the side of the face. They secrete 25% of saliva. They are situated below the zygomatic arch (cheekbone) and cover part of the mandible (lower jaw bone). An enlarged parotid gland can be easier felt when one clenches their teeth. The parotids produce a watery secretion which is also rich in proteins. Immunoglobins are secreted help to fight microorganisms and a-amylase proteins start to break down complex carbohydrates.

SubmandibularThe submandibular glands secrete 70% of the saliva in the mouth. They are found in the floor of the mouth, in a groove along the inner surface of the mandible. These glands produce a more viscid (thick) secretion, rich in mucin and with a smaller amount of protein. Mucin is a glycoprotein that acts as a lubricant.

SublingualThe sublinguals are the smallest salivary glands, covered by a thin layer of tissue at the floor of the mouth. They produce approximately 5% of the saliva and their secretions are very sticky due to the large concentration of mucin. The main functions are to provide buffers and lubrication.

OesophagusThe oesophagus is a muscular tube of approximately 25cm in length and 2cm in diameter. It extends from the pharynx to the stomach after passing through an opening in the diaphragm. The wall of the oesophagus is made up of inner circular and outer longitudinal layers of muscle that are supplied by the oesophageal nerve plexus. This nerve plexus surrounds the lower portion of the oesophagus. The oesophagus functions primarily as a transport medium between compartments.

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StomachThe 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 intestineThe 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.

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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 intestineThe 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.

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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.

LiverThe 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 bladderThe 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.

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PancreasFinally, 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.

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PATHOPHYSIOLOGY

Definition:Acute gastroenteritis: Gastroenteritis (also known as gastro, gastric flu, tummy bug in some countries, and stomach flu, although unrelated to influenza) is inflammation of the gastrointestinal tract, involving both the stomach and the small intestine (see also gastritis and enteritis) and resulting in acute diarrhea.Typhoid fever: a life-threatening illness caused by the bacterium Salmonella typhi.

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Predicposing factors:Geographical area- tropical islands like PhilippinesYoung adult (19 – 45 years old.)

Precipitating factors:Washing of hands inadequately.Sharing of food from the same plate.Drinking unpurified water.Eating from outside sources (carenderia)

Ingestion of foods or fluids contaminated with Samlmonella typhi bacteria.

Bacteria will enter the stomach and survive a pH as low as 1.5

Bacteria invades the Payer’s patches of the intestinal wall in the small intestines where it attach (incubation period is first 7-14 days after ingestion

Bacteria will inject toxins known as the effecter proteins into the intestinal wall.

DiagnosticsHematology:Neutrophils:79 (50 – 70)

Perforation and destruction of mucosal lining of the intestinal wall can lead to persistent inflammation

Signs and SymptomsEpigastric pain; pain scale of 8/10

The bacteria are within the macrophages and survive.

Bacteria spread via the lymphatics while inside the macrophages.

Ulceration and bleeding in the mucosal lining and leads to necrosis

DiagnosticsFecalysis: Dark brownRBC: 2 – 4/hpf (0 – 1)

Bacteria induced macrophage a poptosis, breaking out into the bloodstream and cause systemic infection

Typhoid feverSigns and SymptomsFebrile; Temp – 39.7°cWarmth to touchHeadache; pain scale of 4/10Body weakness

Tissue damage and inflammation causes loss of absorption due to damaged villi causing an increase in water, electrolytes, mucus, blood and serum to be pulled into the intestine.

Abdominal spasm is induce to limit mucosal injury adding in stimulation of increased peristalsis.

Signs and SymptomsAbdominal pain; pain scale 8/10Abdominal guardingFacial grimaceTachypnea; RR 21 cpm

Acute Gastrointeritis

Signs and SymptomsDiarrhea; 4x/daySoft watery stoolsHyperactive bowel soundsEpigastric pain; pain scale 8/10

Macrophages and intestinal epithelial cells then attract T cells and neutrophils with interleukin 8, causing inflammation of the intestinal wall.

X. ASSESSMENT (Nursing Review Chart II)

Vital signs:Temp.: 39.2°c Pulse: 74 bpm Respi:21 cpm BP:110/70 Height: 5’ 5” Weight: 70 kgs.

EENT:[ ] impaired vision [ ] blind [x] pain[ ] reddened [ ] drainage [ ] gums [ ] Hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth Assess eyes, ears, nose,throat for abnormalities. [ ] no problem

RESPIRATORY:[ ] asymmetric [ ] tachypnea[ ] apnea [ ] rales [x] cough[ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi[x] sputum [ ] diminished [ ] dyspnea[ ] orthopnea [ ] labored [ ] wheezing[ ] pain [ ] cyanoticAssess resp. rate, rhythm,pulse blood breath sounds, Comfort [ ] no problem

CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia[ ] numbness [ ] diminished pulses[ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] painAssess heart sound, rate, rhythm, pulse, blood pressure, circulation, fluid retention, comfort[x]no problem

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GASTROINTESTINAL TRACT:[ ] obese [ ] distention [ ] mass[ ] dysphagia [ ] rigidity [x] painAssess abdomen, bowel habits, swallowing bowel sounds, Comfort [ ] no problem

GENITO-URINARY AND GYNE:[ ] pain [ ] urine color [ ] vaginal bleeding[ ] hematuria [ ] discharge [ ] nocturiaAssess urine frequency,control, color,odor, Comfort, gyne bleeding, discharge [x] no problem

NEURO:[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethargic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] gripAssess motor, function, sensation, LOC, Strength, grip, gait, coordination, Speech [x] No problem

MUSCULOSKELETAL AND SKIN:[ ] appliance [ ] stiffness [ ] itching [ ] petechiae [x] hot [ ] drainage[ ] prosthesis [ ] swelling [ ] lesion[ ] poor turgor [ ] cool [ ] deformity[ ] wound [ ] rash [ ] skin color [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic [x] moistAssess mobility, motion, gait, alignment, joint function, skin color, texture, turgor, integrity [ ] no problem

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SUBJECTIVE OBJECTIVECommunication:[ ] hearing loss        Comments: Hearing is good. Client [ ] visual changes is responsive and hears [x] denied              clearly when talked to.

 [ ] glasses                     [ ] languages[ ] contact lens             [ ] hearing aide R      LPupil size: 2-3mm    [ ] speech difficultiesReaction: Pupil Equally Round and Reactive to Light and Accommodation

Oxygenation: [ ] dyspnea             Comments : “Dili man hinuon ko ga- [x] smoking history lisud ug ginhawa pero [x] cough                   naa lang koy ubo karon [ ] denied   na gahi na nay plema” As verbalized by the client.

 Resp.           [ ] regular       [x] irregularDescribe: Patient has fast breathing

R: R lung is symmetrical to left lungL: L lung is symmetrical to right lung.

Circulation:[ ] chest pain            Comments: Patient did not [ ] leg pain          experience any of [ ] numbness of such.extremities          [x]denied

 Heart Rhythm   [x] regular      [] irregularAnkle Edema: None

Pulse    Car.      Rad.        DP.        FEM*R :               + 74 bpm + not obtain   L :       + 74 bpm + not obtain    

Comments: All pulse sites are palpable.*If applicable

Nutrition:Diet : Diet as tolerated – Avoid dark colored foods.[ ] N     [ ] V             Comments: Patient did not Character: experience any of such.[ ] recent change in   Eat fairly. weight, appetite      [ ] swallowing                    difficulty        [x] denied                

  [ ] dentures                      [x] none                   Full            Partial         W/ Patient Upper         [ ]                [ ]                   [ ] Lower         [ ]                [ ]                   [ ]

Elimination:Usual bowel pattern    [ ] urinary frequency4 times a day   3-4 times a day[ ] constipation                    [ ] urgency    remedy                           [ ] dysuria     none [ ] hematuria   Date of Last BM             [ ] incontinence     03/03/11 [ ] polyuria[x] Diarrhea                        [ ] foley in place    character : Watery; Dark brown  [ ] denied     

Comments: Bowel sounds: hyper- Bowel sounds are active bowel sounds hyperactive per Abdominal distention auscultation . Present [ ] yes [x] no     Urine:(consistency, odor) Slightly hazy and dark yellow with aromatic odor.

MGT. of Health & Illness:[x]alcohol 1 bottle occasional [x]smoking :10-15 sticks/day    [ ] denied (amount, frequency)[ ] SBE: N/A Last Pap Smear: N/A LMP: N/A

Briefly describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present)..

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SUBJECTIVE OBJECTIVESkin Integrity:[ ] dry                      Comments: Patient skin was fine[ ] itching                   soft in complexion and[ ] other                   with good turgor. No[x] denied                  lesions found.

 [ ] dry                  [ ] cold                  [ ] pale[ ] flushed                 [ ] warm [ ] moist                    [ ] cyanotic*rashes, ulcers, decubitus (describe size, location, drainage) No rashes and ulcers noted, patient has no Problem in skin integrity.

Activity/Safety:[ ] convulsion            Comments: Patient is actively [ ] dizziness         ambulatory.[ ] limited motion of joints       

  Limitation in ability to[ ] ambulate [ ]bathe self            [ ]other                   [x] denied

 [ ] LOC and orientation The patient is oriented to place, time and date.

Gait:            [ ] walker        [ ] cane           [ ] other [ ] steady               [ ] unsteady[ ] sensory and motor losses in face or extremities:

No sensory and motor losses in face or extremities.

[ ] ROM limitations: The patient has normal range of motion.

Comfort/Sleep/Awake:[x] pain               Comment: “Gasakit lage akong tiyan, (Location, nya nagkalibanga pud ko.”frequency)  as verbalized by the [ ] nocturia                 client.[ ] sleep difficulties [ ] denied  

[x] facial grimaces[x] guarding[x] No other signs of pain: Headache [ ] side rail release from signed (60 + years) N/A

Coping:

Occupation: SoldierMember of household: Father, Mother and 2 brothers. Most supportive person: Mother

 Observed non-verbal behavior: The patient is very active and alert during the interview

Person(Phone number): kept confidential

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XI. NURSING MANAGEMENT

Ideal Nursing Management

Nursing Diagnosis: Hyperthermia related to inflammatory response.

Interventions Rationale

INDEPENDENT:

Monitor vital signs

Provide tepid sponge bath

Instruct patient to increase oral fluid intake at least 8 to 10 glasses of water a day.

Instruct patient to do deep breathing exercise.

Encourage patient to do deep breathing exercises

DEPENDENT:

Administer theprescribed medication:

Paracetamol 500mg q4H P.O

This is for baseline comparison.

TSP serves as a non-pharmacologic that helps in lowering the patient’s temperature.

Increasing oral fluids will prevent dehydration.

This will help in reducing metabolic demands and oxygen consumption.

This will promote proper lung expansion.

Prescribed medications such as Paracetamol is a pharmacologic method in reducing fever by directing the action on hypothalamus heat regulating center with consequent peripheral vasodilation, sweating and dissipation of heat.

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Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to increase in gastric motility resulting to frequency in defecation.

Interventions Rationale

INDEPENDENT:

Consult dietitian for further assessment and recommendations regarding food preferences and nutritional support.

Instruct patient to increase oral fluid intake at least 8 to 10 glasses of water a day.

Establish appropriate short- and long-range goals. Depending on the etiological factors of the problem, improvement in nutritional status may take a long time.

Discourage beverages that are caffeinated or carbonated.

DEPENDENT:

Administer theprescribed medication:

Omiprazole 20mg i tab OD

Dietitians have a greater understanding of the nutritional value of foods and may be helpful in assessing specific ethnic or cultural foods.

Increasing oral fluids will prevent dehydration.

Without realistic short-term goals to provide tangible rewards, patients may lose interest in addressing this problem.

These may decrease appetite and lead to early satiety.

Gastrointestinal agent. Treatment for duodenal and gastric ulcer.

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Nursing Diagnosis: Altered comfort: Acute pain related to inflammatory response.

Interventions Rationale

INDEPENDENT:

Perform pain assessment.

Assess vital signs.

Encourage client to position for comfort (shrimp position)

Encourage relaxation techniques and deep breathing exercises.

Provide quite and calm environment.

DEPENDENT:

Administer theprescribed medication:

PCM 500mg q4° PO PRN for pain

To identify level and severity of pain.

Usually altered during pain episodes.

Alleviates pain severity and intensity.

Provide comfort and non-pharmacologic pain management.

Soothes client’s emotions and less stimulating.

Anti-pyretic. Used for the relief of fevers aches, and pains associated with many parts of the body.

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S O A P I ES “Basa akong ate ug gabalik-balik ko sa CR.” As verbalized by the client.

O ►Loose watery stools; 4x/day (Dark brown)►Pain on the epigastric region; pain scale of 8/10►Abdominal gurading►Hyper-active bowel sounds►Lip pallor►Cracked lips►Restlessness► Fever; 39.7°c

A Altered Bowel: Diarrhea related to infections process of bacterial contamination resulting to bowel hyperactivity secondary to fever.

P Long term:

Short term: I 1. Assess consistency of stool and record frequency.

*to obtain baseline data and to determine factors related to occurrence of diarrhea.

2. Auscultate abdomen.*for presence, location, and character of bowel sounds.

3. Evaluate diet history*to help determine type of foods and manner of intake that may have precipitated the disorder.

4. Determine recent exposure to different environment and water/food intake.*to help identify causative environmental factor.

5. Restrict sold foods.*to allow bowel rest

6. Limit caffeine; milk and fibrous foods.*stimulating and promote peristalsis.

7. Encourage into increase in fluid intake.* to replenish and replace lost fluids.

E

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Drug StudyName of Drug

Generic/ Brand

Date Ordered

Classification Dose/ Frequency/

Route

Mechanism of Action

Specific Indication

Contraindication Side Effects Nursing Precaution

Omeprazole 3-04-11 Gastrointestinal agent

20mg i tab OD PO

An antisecretory compound that is a gastric pump inhibitor. Suppresses gastric acidsecretion by inhibiting tha H+, K+- ATPase enzyme system in the parietal cells.

Treatment for duodenal and gastric ulcer. Gastroesophageal reflux disease including severe erosive esophagitis. In combination with clarithromycin to treat duodenal ulcers associated with Helicobacter pylori.

Long-term use for gastroesophageal reflux disease, duodenal ulcers; lactation.

CNS: Headache, dizziness, fatigue.GI: Diarrhea, abdominal pain, nausea, mild transient increases in liver function test.Urogenital: Hematuria, proteinuria.Skin: Rash.

1. Lab tests: Monitor urinalysis for hematuria and proteinuria. Periodic liver function test with prolonged use.

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S O A P I ES “Sakit jud kayo akong tiyan.” As verbalized by the client.

O ►Facial grimace►Abdominal guarding►Pallor►Tachypnea 21cpm►Sweating►Hyperactive bowel sounds►Restless►Frequent defecation; 4x/day►Watery stools; Dark brown►Pain on the epigastric region; pain scale of 8/10

A Acute pain related to irritation of the gastrointestinal tract leading to spasms.

P Long term:

Short term: I 1. Perform pain assessment.

* to identify level and severity of pain.

2. Assess vital signs.*usually altered during pain episodes.

3. Encourage client to position for comfort (shrimp position)*alleviates pain severity and intensity.

4. Encourage relaxation techniques and deep breathing exercises.*provide comfort and non-pharmacologic pain management.

5. Provide quite and calm environment.*soothes client’s emotions and less stimulating.

E

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Drug StudyName of Drug

Generic/ Brand

Date Ordered

Classification Dose/ Frequency/

Route

Mechanism of Action

Specific Indication

Contraindication Side Effects Nursing Precaution

Acetaminophen; Paracetamol

3-02-11 Analgesic: Antipyretic

500mg q4H PRN PO

Produces alnalgesia by unknown mechanism, perhaps by action on peripheral nervous system. Reduces fever by direct action on hypothalamus heat-regulating center with consequent peripheral vasodilation, sweating, and dispiation of heat.

Fever reduction. Temporary relief of mild to moderate pain.

Hypersensitivity to acetaminophen or phenacetin.

Body as a whole: Negligible with recommended dosage; rashChronic ingestion: Neutropenia, pancytopenia, leucopenia, thrombocytopenic purpura and renal damage.

1. Monitor sigs and symptoms of hepatotoxcity, even with moderate acetaminophen doses, especially in individuals with poor nutrition or who have ingested alcohol over prolonged periods, poisoning, usually from accidental ingestion or suicide attempts; potential abuse from psychological dependence.

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Drug StudyName of Drug

Generic/ Brand

Date Ordered

Classification Dose/ Frequency/

Route

Mechanism of Action

Specific Indication

Contraindication Side Effects Nursing Precaution

Metoclopramide

3-02-11 Gastrointestinal agent

10mg i tab TID PRN PO

Potent central dopamine receptor antagonist. Structurally related to procainamide but has little antiarrhytmic or anesthetic activity.

Facilitates intubation of small bowel; symptomatic treatment of gastroesophageal reflux.

Sensitivity or intolerance to metaclopramide; allergy to sulfating agent, history of seizure disorders; concurrent use of drugs that can cause extrapyremidal symptoms, GI obstruction or perforation.

CNS: mild sedation, fatigue, restlessness and headache.Body as a Whole: Glossal or periorbital edema.CV: hypertensive crisis

1. Be aware that during early treatment period, serum aldosterone may be elevated; after prolonged administration periods, it returms to pretreatment level.

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S O A P I ES “Nagkalibanga na sad ko.” As verbalized by the client.

O ►Sweating►Abdominal guarding►Cracked lips►Thirsty►Frequency in defecation; 4x/day►Restless►Watery stools; Dark brown►Pain on the epigastric region; pain scale of 8/10

A Fluid Volume Deficit related to frequency in defecation of watery stools.P Long term:

Short term: I 1. Assess vital signs especially BP.

* usually altered in low fluid status.

2. Establish individual fluid needs/replacement schedule.*to continually hydrate and maintain fluid status.

3. Monitor I&O*determine the relativity of intake to output and ensure accuracy of fluid status.

4. Perform serial weights.*to note trends and changes.

5. Assess skin turgor.*dryness indicates poor fluid status.

E

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Referral and Follow-up

Client is advised to return and revisit attending physician after discharge for follow-up check up and retesting. Client may feel better after discharge but reevaluation are needed to note positive and effective recovery of client as well as to identify compliance to discharge medication and independent health teachings. Client is advised with the intake of high caloric and highly nutritive foods to meet the demand of recovery. Likewise is encouraged to freshly and well cooked foods avoiding foods that are cold and leftovers and must also maintain sanitation in food handling and preparation. Regular walks for fresh air in an environment less allergenic and increase oral fluid intake. If despite compliance to discharge teachings and medication manifestation of undesirable outcomes appear client should be returned for another medical reevaluation.

Evaluation and Implication

The entire two days exposure at pediatric ward assigned to a client with Pediatric Community Acquired Pneumonia has thought me a lot of things. That is, understanding the entire pathogenesis of the disorder its affectation and what approach are to be implemented. Thus, consequently an improvement of client’s condition is achieved with the help and assistance of the team of caregivers implementing effective plan of care including active participation of the client and significant other. Therapeutic relationship and communication between the caregivers and the client with the significant others contributed to the achievement of the set goal. Personally my nursing skills and interpersonal relationship with the people I’ve worked with has improved accordingly in the experience of the exposure.

The prognosis for recovery is good for most patients. In the era before effective antibiotics were discovered, about 12% of all typhoid fever patients died of the infection. Now, however, less than 1% of patients who receive prompt antibiotic treatment will die. The mortality rate is highest in the very young and very old, and in patients suffering from malnutrition. The most ominous signs are changes in a patient's state of consciousness, including stupor or coma.

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PATHOPHYSIOLOGY

Definition:Acute gastroenteritis: Gastroenteritis (also known as gastro, gastric flu, tummy bug in some countries, and stomach flu, although unrelated to influenza) is inflammation of the gastrointestinal tract, involving both the stomach and the small intestine (see also gastritis and enteritis) and resulting in acute diarrhea.Typhoid fever: a life-threatening illness caused by the bacterium Salmonella typhi.

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Predicposing factors:Geographical area- tropical islands like PhilippinesYoung adult (19 – 45 years old.)

Precipitating factors:Washing of hands inadequately.Sharing of food from the same plate.Drinking unpurified water.Eating from outside sources (carenderia)

Ingestion of foods or fluids contaminated with Samlmonella typhi bacteria.

Bacteria will enter the stomach and survive a pH as low as 1.5

Bacteria invades the Payer’s patches of the intestinal wall in the small intestines where it attach (incubation period is first 7-14 days after ingestion

Bacteria will inject toxins known as the effecter proteins into the intestinal wall.

DiagnosticsHematology:Neutrophils:79 (50 – 70)

Perforation and destruction of mucosal lining of the intestinal wall can lead to persistent inflammation

Signs and SymptomsEpigastric pain; pain scale of 8/10

The bacteria are within the macrophages and survive.

Bacteria spread via the lymphatics while inside the macrophages.

Ulceration and bleeding in the mucosal lining and leads to necrosis

DiagnosticsFecalysis: Dark brownRBC: 2 – 4/hpf (0 – 1)

Bacteria induced macrophage a poptosis, breaking out into the bloodstream and cause systemic infection

Typhoid feverSigns and SymptomsFebrile; Temp – 39.7°cWarmth to touchHeadache; pain scale of 4/10Body weakness

Tissue damage and inflammation causes loss of absorption due to damaged villi causing an increase in water, electrolytes, mucus, blood and serum to be pulled into the intestine.

Abdominal spasm is induce to limit mucosal injury adding in stimulation of increased peristalsis.

Signs and SymptomsAbdominal pain; pain scale 8/10Abdominal guardingFacial grimaceTachypnea; RR 21 cpm

Acute Gastrointeritis

Signs and SymptomsDiarrhea; 4x/daySoft watery stoolsHyperactive bowel soundsEpigastric pain; pain scale 8/10

Macrophages and intestinal epithelial cells then attract T cells and neutrophils with interleukin 8, causing inflammation of the intestinal wall.