I.

INTRODUCTION

Typhoid fever is an acute systemic bacterial disease resulting from infection with Salmonella typhi. The organism is a Gram-negative short bacillus that is motile due to its peritrichous flagella. The bacterium grows best at 37 C/99 F human body temperature. The organism gains access to the body through ingestion of food or water that has been contaminated by infected feces or urine. Since it is eliminated in the stools and urine of patients, the organism can find its way into food and water through sewage, flies and the hands of the carriers handling raw fruits, vegetables and other food. And other source of infection is the ingestion of oysters and shellfish harvested from polluted water. And we consider the five Fs factors which are the Feces, Flies, Fumites, Food, and Fingers which can be a way in getting the disease. Most of the affected and at risk of the disease are those clients with an age of 30 years old. And most of the carriers of the bacteria are those clients with an age of 50 yeas old and above especially women. The onset of typhoid fever is gradual. During the first week of having the disease, the signs and symptoms include fever, anorexia, myalgia, malaise, and headache. The patient may not seek health care at this time since these are non specific symptoms. But at the end of the first week, rose spot (a cluster of pink lesions that initially blanch with pressure) may be found on the chest and abdomen. Without therapy, the temperature rises steadily reaching its highest level, usually 40 0C 41 0C. During this period of rising temperature, most patients suffer with a severe headache and a non productive cough. During the second week, if the patient is not treated, the signs and symptoms of the disease already include fever (40 0C specifically in the evening) accompanied with chills and delirium, diaphoresis, weakness, abdominal pain, diarrhea, and cough (crackles). And during the third week, the signs and symptoms include persistent fever and body weakness. The impact of this disease falls sharply with the application of modern sanitation techniques.

II. OBJECTIVES
1. To be able to know what is typhoid fever is all about. 2. To be aware on how we can get the bacteria of the disease. 3. To know how the bacteria Salmonella typhi penetrate our body and its life cycle inside our body that lead to the occurrence of the disease. 4. To be aware of the signs and symptoms of the disease. 5. To know about the appropriate nursing intervention, medical management, promotive and preventive management of the disease.

III. PATIENTS PROFILE / PERSONAL DATA

Name: Age: Sex: Address: Birthday: Religion: Civil Status: Chief Complaint: Date Admitted: Admitting Physician: Admitting Diagnosis: Ward: Arvin Tipon Arellano 12 Male Pagsanaan Norte, Magsingal, Ilocos Sur January 14, 1998 Roman Catholic Child Fever June 16, 2010 Dr. Guerrero Typhoid Fever Pedia ward

IV. MEDICAL HISTORY OF PAST AND PRESENT ILLNESS

Past
The patient had been already hospitalized once when he was still 10 years old due to allergic reaction. His face became swollen and was admitted and treated at Magsingal District Hospital. He has no history of any surgical procedure and no record of any communicable diseases. The patient always chooses OTC over the counter drugs first before considering going to the hospital.

Present
The condition of the patient started about one week prior to admission as on and off fever. Paracetamol was given which afforded temporary relief. Few hours prior to admission, patient had chill episodes thus consult were done. He was admitted at Magsingal District Hospital on June 16, 2010 and was diagnosed to have a typhoid fever. His drugs were Ceftriaxone, Paracetamol, Cotrimoxazole, Cefotaxime, and Gentamycin. During his hospitalization, he was given Bisacodyl due to his zero bowel movement. After a week of confinement, his parents decided to have him a HAMA (Home against Medical Advice). Two days after he was discharged, he was again admitted at Gabriela Silang Government Hospital due to fever and shortness of breath. He undergone a CT scans procedure and was diagnosed to have an Otitis Media at the left ear and a pus on his head. After a day upon his admission he was transferred at Metro Vigan Coop. Hospital and had a final diagnosis of Left Cerebellar Abscess with Obstructive Hydrocephalus secondary to Chronic Otitits Media at the left ear. He had his first surgical operation on June 27, 2010 for his left cerebellar abscess and was scheduled (no specific date) to have his next and last operation for his chronic Otitis Media and was advised by his physician to stay at the hospital for six weeks after his last operation.

V. PEARSON ASSESSMENT
Psychosocial June 20, 2010 >Arvin Arellano >12 years old >conscious and coherent >responsive >irritable at times >get dizzy easily upon moving > (+) headache especially when moving >(-) bowel movement >voided three times >diaphoretic only at daytime June 21, 2010 >Arvin Arellano >12 years old >conscious and coherent >responsive >irritable at times >get dizzy easily upon moving > (+) headache especially when moving >he was administered a suppository >(+) bowel movement, once >voided once >diaphoretic only at daytime >lying on the bed at all times >rise up on bed only when to void >has difficulty staying asleep >can not fall back to sleep easily when awaken or disturbed >slept very little >no bed side rails are available >poor room sanitation >poor room ventilation >the patient is aware but weak >vital signs: T 37.6 0C RR 27 cpm Pr 89 bpm >good breathing pattern >productive cough >(-) chest pain upon coughing >poor appetite >decreased oral fluid intake >lesser weight

Elimination

Activity and Rest

Safe Environment

Oxygenation

Nutrition

>lying on the bed at all times >rise up on bed only when to void >has difficulty staying asleep >can not fall back to sleep easily when awaken or disturbed >slept very little >no bed side rails are available >poor room sanitation >poor room ventilation >the patient is aware but weak >vital signs: T 39.5 0C RR 34 cpm Pr 96 bpm >fast breathing pattern >productive cough >(-) chest pain upon coughing >poor appetite >vomits the food upon ingestion >decreased oral fluid intake

VI. DIAGNOSTIC PROCEDURES

A. IDEAL Blood Culture and Sensitivity Test Stool Culture Bone Marrow Aspiration (Anterior Posterior Iliac Crest) Rose Spots Aspiration B. ACTUAL WIDALS TEST 1:80 + + -

Serum Dilution Salmonella A Salmonella B Paratyphoid A Paratyphoid B

1:40 H + -

1:180 + -

1:320 -

PARAMETERS Hemoglobin Hematocrit RBC WBC Different Count Neutrophils Lymphocytes Thrombocytes

HEMATOLOGY RESULTS 120 g/L 37 vol. % 14.0 x 10 q/L 0.78 0 - 22 202 x 10 q/L

NORMAL VALUES 125 160 g/L 35 45 vol. % 4.2 5.6 x 10 q/L 5 10 x 10 q/L

0 15 F 150 350 x 10 q/L

URINALYSIS MACROSCOPE EXAM Color: Yellow orange Character: Turbid Reaction: pA 6.0 Specific Gravity: 1.020 Protein: Positive (+) Sugar: Negative (-) MICROSCOPIC EXAM RBC: 1.2 Pus Cells: 10 15 Casts: Crystals: Uric Acid few Epithelial Cells: Occasional Bacteria: Rare

VII. ANATOMY AND PHYSIOLOGY

DIGESTIVE SYSTEM

VIII. PATHOPHYSIOLOGY
Ingestion of contaminated food caused by the carriers (flies) Invasion of the bacteria to the blood and to the walls of the GI tract Multiplication of the bacteria on the Payers patches Inflammation of the blood vessels of the Payers patches Infection Fever

LIFE CYCLE OF THE SALMONELLA TYPHI

IX. MANAGEMENT
A. MEDICAL SURGICAL NURSING MANAGEMENT
Chloramphenicol, Ampicilin, Amoxicillin or Trimethoprimsulfamethozaxole is used in the treatment of typhoid fever. In the case of my patient his meducations were Ceftriaxone, Paracetamol, Cotrimoxazole, Cefotaxime, and Gentamycin. The fever usually subsides in three to five days following initiation of antibiotic therapy. However, bacteriologic cure is not achieved in all patients. Relapses have occurred and positive stool cultures have been obtained after one course, and even repeated courses, of antibiotic therapy. Thus, while chloramphenicol has reduced the fatality rate of the disease significantly has curtailed the excretion of typhoid bacilli during convalescence it has not reduced the frequency of complications or the incidence of chronic carrier state following typhoid fever.

B. NURSING CARE PLAN

C. PROMOTIVE AND PREVENTIVE MANAGEMENT

The client or patient must always: Provide a good sanitation by: Everyday cleaning of the environment and the house Boiled the water that are going to drink Proper hygiene taking bath everyday Boiled spoon and fork after washing Proper handwashing before eating Avoid street foods Using disinfectant to control flies Proper disposal of garbage Eating shellfish and oyster should be obtained from an approved source Scrupulous cleanliness in the preparation and storage of food Get vaccinated against typhoid fever

XI. DISCHARGE PLAN

MEDICATIONS (Take Home Medication) 1. Cotrimozaxole (Baczole) tablet, 80 mg, twice a day EXERCISE (Activity) >Regular exercise everyday >Non extemporaneous/heavy activities TREATMENT WIDALS TEST 1:80 + + -

Serum Dilution Salmonella A Salmonella B Paratyphoid A Paratyphoid B

1:40 H + -

1:180 + -

1:320 -

PARAMETERS Hemoglobin Hematocrit RBC WBC Different Count Neutrophils Lymphocytes Thrombocytes

HEMATOLOGY RESULTS 120 g/L 37 vol. % 14.0 x 10 q/L 0.78 0 - 22 202 x 10 q/L

NORMAL VALUES 125 160 g/L 35 45 vol. % 4.2 5.6 x 10 q/L 5 10 x 10 q/L

0 15 F 150 350 x 10 q/L

URINALYSIS MACROSCOPE EXAM Color: Yellow orange Character: Turbid Reaction: pA 6.0 Specific Gravity: 1.020 Protein: Positive (+) Sugar: Negative (-) MICROSCOPIC EXAM RBC: 1.2 Pus Cells: 10 15 Casts: Crystals: Uric Acid few Epithelial Cells: Occasional Bacteria: Rare

HEALTH TEACHINGS The client or patient must always: Provide a good sanitation by: Everyday cleaning of the environment and the house Boiled the water that are going to drink Proper hygiene taking bath everyday Boiled spoon and fork after washing Proper handwashing before eating Avoid street foods Using disinfectant to control flies Proper disposal of garbage Eating shellfish and oyster should be obtained from an approved source Scrupulous cleanliness in the preparation and storage of food OUT PATIENT (FOLLOW UP CHECK UP) >After one week that the patient has discharge, he is advised by the physician to have his follow up check up DIET > Avoid eating of street foods and raw vegetables > Eating shellfish and oyster should be obtained from an approved source > Drink plenty of water > Avoid popsicles and flavored ice that may have been made with contaminated water

XII. SUMMARY AND COPY OF UPDATES

Typhoid Fever By Dr. Gary Sy October 20, 2009 Typhoid fever is a life threatening illness caused by the bacterium Salmonella typhi. Typhoid fever or enteric fever is a condition in which there is an insidious fever, a typical course of temperature, marked abdominal symptoms. Salmonella typhi lives in humans. Persons with typhoid fever carry the bacteria in the bloodstreams and intestinal tract. In addition, a small number of persons, called carriers, recover from typhoid fever but continue to carry the bacteria. Both ill persons and carriers shed Salmonella typhi in their stools.

Update:
Typhoid fever outbreak updates in real, Quezon Philippines As an update on the Typhoid Fever Outbreak in Real, Quezon (Philippines), there are already more than 100 confirmed cases of typhoid fever in the town and the river (which is the primary source of drinking water of the people there) has already been inspected by DOH officials. It was clear from video footages that the river is contaminated because the net used in filtering dirt was already damaged. On the other hand, even if the net was still in good condition, its filtering capabilities are limited and bacteria can still pass through it. Hence, this improvised filter is not reliable. For a related outbreak in the Philippines, please read the article titled Cholera Outbreak in Misamis Oriental, Philippines Affects Hundreds which has already affected almost a thousand individuals in Misamis Oriental.

XIII. BIBLIOGRAPHY BOOKS: Medical/Surgical Nursing 6th Edition (Brunner/Suddarth) Nurses Pocket Guide 8th Edition (Doenges et.al) Nursing Care Plans 7th Edition (Doenges et.al) INTERNET http://www.google.com
http://www.nlm.nih.gov/medlineplus/druginfo/mteds/a684026.html
http://www.jpsimbulan.com/2008/11/18/typhoid-fever-update-in-real-quezonphilippines/

Republic of the Philippines University of Northern Philippines Tamag, Vigan City

COLLEGE OF NURSING CASE STUDY GRADING SHEET PARAMETERS Introduction and Objectives Personal Data Nursing History of Past and Present Illness PEARSON Assessment Diagnostic Procedures a. Ideal b. Actual Anatomy and Physiology Pathophysiology a. Algorithm b. Explanation Management a. Medical and Surgical b. Promotive and Preventive c. NCP with Evaluation Drug Study Discharge Plan Updates Organization/Bibliography TOTAL PERCENTAGE 5 5 5 10 ACTUAL GRADE

15

15 5 5 20 10 10 5 5 100

REMARKS:________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _____________________________________________.

Mrs. Mignone Antonette T. Tipon, R.N. CLINICAL INSTRUCTOR

Republic of the Philippines University of Northern Philippines Tamag, Vigan City

College of Nursing

Case Study on Typhoid Fever

In Partial Fulfillment of the Requirements in the Subject R.L.E.

Prepared by: Charmaine C. Cortez BSN III Delphinium

Prepared to: Mrs. Mignone Antonette T. Tipon, R.N. Clinical Instructor