INTRODUCTION

Typhoid fever

Typhoid fever, also known as enteric fever, or commonly just typhoid,[1] is an illness caused by the bacterium
Salmonella enterica serovar Typhi. Common worldwide, it is transmitted by the ingestion of food or water
contaminated with feces from an infected person.[2] The bacteria then perforate through the intestinal wall and are
phagocytosed by macrophages. Salmonella Typhi then alters its structure to resist destruction and allow them to
exist within the macrophage. This renders them resistant to damage by PMN's, complement and the immune
response. The organism is then spread via the lymphatics while inside the macrophages. This gives them access to
the reticuloendothelial system and then to the different organs throughout the body. The organism is a Gram-
negative short bacillus that is motile due to its peritrichous flagella. The bacteria grows best at 37 °C/99 °F – human
body temperature.

Symptoms

Typhoid fever is characterized by:

• a sustained fever as high as 40 °C (104 °F),

• profuse sweating,
• gastroenteritis, and
• Non bloody diarrhea.
• Less commonly a rash of flat, rose-colored spots may appear.[3]

Classically, the course of untreated typhoid fever is divided into four individual stages, each lasting approximately
one week. In the first week, there is a slowly rising temperature with relative bradycardia, malaise, headache and
cough. A bloody nose (epistaxis) is seen in a quarter of cases and abdominal pain is also possible. There is
leukopenia, a decrease in the number of circulating white blood cells, with eosinopenia and relative lymphocytosis, a
positive diazo reaction and blood cultures are positive for Salmonella Typhi or Paratyphi. The classic Widal test is
negative in the first week.

In the second week of the infection, the patient lies prostrated with high fever in plateau around 40 °C (104 °F) and
bradycardia (Sphygmo-thermic dissociation), classically with a dicrotic pulse wave. Delirium is frequent, frequently
calm, but sometimes agitated. This delirium gives to typhoid the nickname of "nervous fever". Rose spots appear on
the lower chest and abdomen in around 1/3 patients. There are rhonchi in lung bases. The abdomen is distended and
painful in the right lower quadrant where borborygmi can be heard. Diarrhea can occur in this stage: six to eight
stools in a day, green with a characteristic smell, comparable to pea-soup. However, constipation is also frequent.
The spleen and liver are enlarged (hepatosplenomegaly) and tender and there is elevation of liver transaminases. The
Widal reaction is strongly positive with antiO and antiH antibodies. Blood cultures are sometimes still positive at
this stage.

In the third week of typhoid fever a number of complications can occur:

• Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but is usually
non-fatal.
• Intestinal perforation in distal ileum: this is a very serious complication and is frequently fatal. It may occur
without alarming symptoms until septicaemia or diffuse peritonitis sets in.
• Encephalitis
• Metastatic abscesses, cholecystitis, endocarditis and osteitis

The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the patient is delirious
(typhoid state). By the end of third week the fever has started reducing (defervescence). This carries on into the
fourth and final week.

Complications: (occurs in 10-15% of cases)

• Gastrointestinal Bleeding (2-10% of cases)
• Bowel perforation
• Typhoid encephalopathy
Diagnosis

Diagnosis is made by blood, bone marrow or stool cultures and with the Widal test (demonstration of salmonella
antibodies against antigens O-somatic and H-flagellar). In epidemics and less wealthy countries, after excluding
malaria, dysentery or pneumonia, a therapeutic trial time with chloramphenicol is generally undertaken while
awaiting the results of Widal test and blood cultures.[4]

Treatment

Typhoid fever in most cases is not fatal. Antibiotics, such as ampicillin, chloramphenicol, trimethoprim-
sulfamethoxazole, Amoxicillin and ciprofloxacin, have been commonly used to treat typhoid fever in developed
countries. Prompt treatment of the disease with antibiotics reduces the case-fatality rate to approximately 1%.

When untreated, typhoid fever persists for three weeks to a month. Death occurs in between 10% and 30% of
untreated cases.
DEMOGRAPHIC DATA
AND NURSING HISTORY
I. DEMOGRAPHIC DATA

Name: Mr. Lalo

Address: Gulab Echague, Isabeela
Gender: Male
Age: 7 y/0
Date of Birth: November 27, 2000
Place Of Birth: Echague, Isabela
Civil Status; Child
Religion: Roman Catholic
Nationality: Filipino
Chief Complaint: on and off fever x 2 weeks
Date of admission: January 14, 2009
Time of admission: 8:10 pm
Admitting diagnosis: typhoid fever
Attending Physician: Dra. CAV

Initial V/S:
Wt: 17.1 kg
T:38.7C

Present History of illness

2 weeks Prior to admission the pt had on and off fever and was rushed to Echague
District Hospital last January 14, 2009 at exactly 8:10 pm and was diagnosed to have typhoid
fever and was given and IVF of D50.3 Nacl I L to run @ 40ugtts/min.
Past Medical History

According to the Mother it was his first time to be hospitalized. His childhood illness are
cough, colds and fever, There are no other serious illnesses.

Family History

The father of Mr. Lalo is hypertensive, whereas her mother doesn’t have any known
serious disease.

11 GORDON’S
PATTERN
Health Perception- Health Management

Since the patient is just 7 years old, he stated that “ dapat laging malusog”as his
perception about health. He was being treated with OTC drugs every time he suffers from
diseases.

Nutritional- Metabolic Pattern

The patent loves to eat vegetables and meat. He also loves to eat junk foods and soft
drinks. He eats on time. And eats at school canteen during school days.

Elimination Pattern

Prior to admission, the patient says he voids atleast 3 x a day, and has a good bowel
movement. But during confinement, he defecates every other day and voids every day.

Activity and Exercise Pattern

Mr. Lalo goes to school every week days. Playing serves as his exercise.

Sleep- Rest Pattern

The patient sleeps at around 7-8 o’clock in the evening prior to admission and wakes up
at around 6 o’clock in the morning to go to school. But during his stay in the hospital, he
experienced disturbed sleeping pattern due to hospital environment.

Cognitive- Perceptual Pattern

The patient is aware with the things that are happening around him. The patient has no
sensory deficits. He can express himself logically and with an air of confidence.

Self- Perception and Self-Concept

Mr. Lalo is aware of what causes his illness. He is complying with the doctor’s order. So
that he will get well.
Role and Relationship

The patient is very friendly to his brothers and friends. He is also a good son of his
parents.

Coping and Stress Tolerance

In time of stress and coping strategies, his parents is always on his side to support him to
whatever problems he encounter.

Values and Belief

The patient is a Roman catholic; He is going to the church every Sunday with his Family.

COURSE IN THE
WARD
DATE/TIME ADMITTING ORDERS INTERPRETATION
1/14/09 >Please admit to ROC >For further management of the
condition of the pt
V/S >Consent for admission >For legality purposes
T:38.7c >TPR q shift and record >for baseline data
Wt:17.1 >DAT DIET >For nourishment
>REQUEST FOR CBC and >For baseline data
Urinalysis

>D50.3Nacl to run for 40 >To facilitate hydration and

ugtts/min. parenteral nourishment. This also
serves asroute for drug
administration

>Ceftriaxone 1 gm IVP q 12 > Haemostatic

ANST(-)
>Paracetamol 1cc IVP now then >Analgesic
PRN if T≥38.5
>Paracetamol 200/5 5mL q 4 >Analgesic
>Refer accordingly
1/16/09 >continue meds. >For management of the
condition
 PHYSICAL
ASSESMENT
 PHYSICAL ASSESSMENT
January 16,2008

Received patient lying on bed conscious and coherent with ongoing IVF of D50.3Nacl regulated at 40
ugtts/min patent and infusing well.

VS

T: 36C

PR: 100 bpm

RR: 31 cpm

General Appearance:

Pt is in semi fowler’s position,

Irritable, weak in appearance, pale looking

Body Parts Method Findings Interpretation

General Appearance Inspection Weak looking d/t decrease hgb in

blood

HEAD Inspection Round normocephalic Normal

SKIN Inspection Brown complexion Normal

HAIR Inspection Evenly distributed normal

LIPS inspection pale d/t decrease hgb in
blood
TEETH Inspection No black stains normal
TONGUE Inspection pale d/t decrease hgb in
blood
GUMS Inspection Pink in color normal
 EYES Inspection Proportionally aligned Normal
eyes and eyebrows

PUPIL Inspection PERRLA size of pupil Normal

2mm

SCLERA Inspection White in color Normal

CONJUNCTIVA Inspection pale d/t decrease hgb in

blood
EARS Inspection Absence of lesions, Normal
discharge

Palpation Absence of lump , Normal

NOSE Inspection No discharges Normal

NECK Inspection No visible nodes, Normal

same as facial skin,
jugular veins not
distended

Palpation Nodes are not Normal

palpable

CHEST Inspection Symmetrical chest Normal

expansion

Auscultation Normal heart rate Normal

and rhythm
ABDOMEN Inspection Uniform skin color Normal

Auscultation bowel sounds Normal

Palpation (-) tenderness Normal

Percussion dull Normal

NAILS Inspection Clean and short Normal
Palpation Capillary refill Normal
3seconds

UPPER AND Inspection Free of lesions, Normal

LOWER absence of edema, no
EXTREMITIES deformities and can
move freely without
any discomfort
LABORATORY
RESULT
CBC RESULT

Parameters REFERENCE RESULTS S.I INTERPRETATION

VALUE UNITS
Hgb Male 140-180g/L 103 Decrease, d/t poor
Female 120-160g/L blood circulation
Hct% Male 40-54g/L 31 Decrease d/t
Female 37-47g/L
WBC x10g/L 5-10x109/L 10.0 Normal
Platelet x10g/L - -
Neutrophil % 55-65 68 Slightly elevated d/t
infection
Lymphocyte % 25-40 31 Normal

JANUARY 16, 2009

Urinalysis

Color Golden Yellow

Transparency clear
pH 6.0
Specific Gravity 1.015
Pus cell 0-1
RBC 0-1
Ephi. cell few
Amorphous few
ANATOMY AND
PHYSIOLOGY
ANATOMY AND PHYSIOLOGY

Human digestive system

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

Most of the digestive organs (like the stomach and intestines) are tube-like and
contain the food as it makes its way through the body. The digestive system is
essentially a long, twisting tube that runs from the mouth to the anus, plus a few other
organs (like the liver and pancreas) that produce or store digestive chemicals.

The Digestive Process:

The start of the process - the mouth: The digestive process begins in the mouth.
Food is partly broken down by the process of chewing and by the chemical action of
salivary enzymes (these enzymes are produced by the salivary glands and break down
starches into smaller molecules).

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

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

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

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

The end of the process - Solid waste is then stored in the rectum until it is excreted
via the anus.

Digestive System Glossary:

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

ETIOLOGIC AGENT PREDISPOSING FACTOR

Salmonella Typhosa - Ingestion of contaminated food and water
Salmonella Typhi - Improper food handling

Invasion of GIT (small intestinal Mucosa)

Proliferation of
phagocytes

Swelling of lymphatic submucosal nodule

Mainly the Peyer’s patches

Bulging into the intestinal lumen

Enlargement of reticuloendothelial and Swollen Ileal lymphoid tissue

lymphoidAnorexia
tissue

Oval ulcer or mucosal ulcer

Increase size of mesenteric lymph
nodes, spleen and liver

Interruption of bowel
Altered lymph flow in blood steam flow
 Bacteria
Abdominal pain

Systemic infection

Death

NURSING CARE
PLAN
DRUG STUDY
 CASE STUDY

BLEEDING PEPTIC
ULCER
PRESENTED BY: