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I. INTRODUCTION A.

Overview of the study Typhoid fever , otherwise known as enteric fever, is an acute illness associated with fever caused by the Salmonella typhi bacteria. S. typhosa is a short, plump, gram negative rod that is flagellated and actively motile. Contaminated food or water is the common medium of contagion. The disease follows four stages. The first stage is known as incubation period, usually 10-14 days in occurrence. In this stage generalization of the infection occurs. In the second stage, aggregation of the macrophages and edema in focal areas indicates bacterial localization (embolization) and resultant toxic injury which disappear after few days. The third stage of disease is dominated by effects of local bacterial injury especially in the intestinal tract, mesenteric lymph nodes, spleen, and liver. The fourth stage, or the stage of lysis, is the stage wherein the infectious process is gradually overcome. Symptoms slowly disappear and the temperature gradually returns to normal. The symptoms of typhoid fever include high fever, chills, cough, muscle pain, weakness, stomach pain, headache and a rash made up of flat, rosecolored spots. Diarrhea is a less common symptom of a typhoid fever, although it is a gastrointestinal disease. Sometimes there are mental changes, know as typhoid psychosis. A characteristic feature of typhoid psychosis is plucking at the bedclothes if patient is confined to bed. Risk factors for acquiring typhoid fever likely include improper food handling, eating food from outside sources like carinderia, drinking contaminated water, poor sanitation and even poor hygiene practices. War and natural disasters as well as weak, non existent of health care infrastructure may also contribute. Both genders do have equal chances on acquiring such disease. Asian, African and Americans are at greatest risks of acquiring the disease since geographical locations play a part. Page 1

Complications of typhoid fever are secondary conditions, symptoms, or other disorders that are caused by typhoid fever. Complications include overwhelming infection, pneumonia, intestinal bleeding, and intestinal perforation may eventually lead to death. Typhoid fever is one of the most protean of all bacterial diseases thus laboratory procedures are usually depended on to confirm or disprove suspicion of such disease. The place of blood culture, serologic studies and bacteriologic examination feces and urine are useful in establishing the diagnosis. Agglutination (Widal) for typhoid fever is done to determine antibody response against different antigenic fractions of organisms. Typhoid fever is treated with antibiotics which kill the Salmonella bacteria. Several antibiotics are effective for the treatment of typhoid fever. The choice of antibiotics needs to be guided by identifying the geographic region where the organism was acquired and the results of cultures once available. Two new vaccines are currently licensed and widely used worldwide, a subunit (Vi PS) vaccine administered by the intramuscular route and a live attenuated S typhi strain (Ty21a) for oral immunization. In most cases, typhoid fever is managed at home with antibiotics and bed rest. For hospitalized patients, effective antibiotics, good nursing care, adequate nutrition, careful attention to fluid and electrolyte balance, and prompt recognition and treatment of complications are strategies to avert the possibility of death. I choose this topic since it catches my interest from the time being I was able to handle patient having typhoid fever. It gives me the motivation to look for the things that governs such disease. Typhoid fever as my case study allows me to find for ways to contribute something for the alleviation of the condition of its victims may it be in my own little ways perhaps. May this case study of mine serves as advent to understand more fully the existence of such disease and the Page 2

proper interventions needed to be rendered upon to address such condition looking to a new perspective of life. B. Objectives and Purpose of the Study This study generally aims to investigate the condition of a client and further understand the extent of the case. Specifically the student nurse sought to: Perform Physical Assessment, Data Base and History Taking that Solidifies the present diagnosis of the client. Identify Signs and Symptoms associated with the disorder. Identify priority nursing problems which will be the basis of the care plan. Develop Plan of Care and Implement nursing interventions relevant and suitable to the case. Evaluate the effectiveness of the interventions and detect any progress or regression of the clients disease condition. The purpose of the study is to gather significant data to broaden our knowledge of the disease process and to improve my abilities as future healthcare provider. This is done to be able to aid in the recovery process of the client. Moreover this case study will enable me to apply the acquired skills we have obtained in the classroom set-up. C. Scope and Limitation of the Study The scope of the study consists of one Medical Male ward client of the JRB Hospital. Significant others was interviewed specially his mother to know more about the client and his condition. The time period for which the study was conducted and completed, was constrained and limited to a span of 1 week. The first assessment done was last November 28, 2011, at around 8:00 am. Then continuous assessment was done in the span of my duty in the said ward from November 28 29, 2011.The said assessment dates were maximized to gather

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of information including profile, data base, history of present illness, chart data and many others.

II. HEALTH HISTORY A. Patients Profile Name of Patient: XY Sex: Male Age: 24 Birthday: August 17, 1988 Birthplace: Baungon, Bukidnon Religion: Roman Catholic Civil Status: Single Educational Attainment: High School Level Number of Siblings: 1 Nationality: Filipino Date Admitted: November 27, 2011 Time Admitted: 10:00 am Informant: Mother Blood Pressure: 100/60 mmHg Temperature: 37.7O C Pulse Rate: 69 bpm Respiration: 21 cpm Attending Physician: Dra. B

B. Past Health History

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According to pt. XY, he had experienced some common childhood illnesses such as measles, chicken pox and mumps when he was in elementary. He had also experienced sore throat, cough, colds, and fever. He managed it through bed rest and sometimes he takes herbal medicine such as oregano for cough and guava leaves if he has wounds. He also took OTC drugs such as paracetamol for fever, biogesic for headache and neozep for colds.. He has no allergy to foods, drugs & animals. He denied any herido familial disease in his family. C. Chief Complains and History of Present Illness Patient XY, a 24 years old male, residing at Baungon, Bukidnon, 3 days PTA he experience high grade fever and productive cough with sputum. He was admitted last November 27 at around 10:00 am @ JRB Hospital Medical Male Ward and was diagnosed by Dra. B that he suffered Typhoid fever

III. DEVELOPMENT DATA A. Erik Eriksons Stages of Psychosocial Development Theory Erikson describes eight developmental stages through which a healthily developing human should pass from infancy to late adulthood. In each stage the person confronts, and hopefully masters, new challenges. Each stage builds on the successful completion of earlier stages. The challenges of stages not successfully completed may be expected to reappear as problems in the future. Each of Erikson's stages of psychosocial development are marked by a conflict, for which successful resolution will result in a favourable outcome and by an important event that this conflict resolves itself around. B. Sigmund Freuds Psychosexual Development Theory According to Freud, people enter the world as unbridled pleasure seekers. Specifically, people seek pleasure through from a series of erogenous zones. These erogenous zones are only part of the story, as the social relations learned Page 5

when focused on each of the zones are also important. Freud's theory of development has 2 primary ideas: One, everything you become is determined by your first few years - indeed, the adult is exclusively determined by the child's experiences, because whatever actions occur in adulthood are based on a blueprint laid down in the earliest years of life (childhood solutions to problems are perpetuated) Two, the story of development is the story of how to handle anti-social impulses in socially acceptable ways. My patient belongs to the genital stage which begins at puberty involves the development of the genitals, and libido begins to be used in its sexual role. However, those feelings for the opposite sex are a source of anxiety, because they are reminders of the feelings for the parents and the trauma that resulted from all that. C.Robert J. Havighursts Developmental Task Theory Havighurst categorized the tasks, in first category are the tasks, which has to be completed in certain period, and the second are the tasks that continue for a long, sometimes for a lifetime.So what happens if the task is not completed in that stage or completed in a later date? Havighurst reply to that it is critical that the tasks should be completed during the appropriate stage, otherwise result will be the failure to achieve success in future tasks. D. Jean Piagets Theory of Development According to Piaget, development is driven by the process of equilibration. Equilibration encompasses assimilation (i.e., people transform incoming information so that it fits within their existing schemes or thought patterns) and accommodation (i.e., people adapt their schemes to include incoming information). My patient belongs to the formal operational stage. 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 Page 6

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.

IV. MEDICAL MANAGEMENT A. DOCTORS ORDER Order November 27, 2011 Please admit pt. to Medical Male Ward under the service of Dra. B Rationale For proper medical management and treatment and for further evaluation For legal purposes and in order for the patient to know all management and treatment to be done Serve as baseline and evaluate abnormality To prevent aspiration DAT except dark colored foods and if not dyspneic Start venodysis w/ IVF PNSS 1L @ 30 gtts/min LABS: -CBC For maintenance of fluid and electrolytes to evaluate level of blood component evaluate urine chemistry Page 7

Secure Consent to care

Monitor or V/S q 4 Monitor I & O q shift

-Urinalysis -Chest x-ray PA -Serum Na+, K+ creatinine determine lung abnormalities evaluate electrolyte imbalance Taken to isolate microorganism that is causing infection

MEDS 1. Paracetamol 500 mg; Tab Q4h PRN for 1 > 37.8O 2. Omeprazole 20 mg Tab OD Moderate High Back Rest Refer accordingly November 28, 2011 Continue meds IVF PNSS 1L @ 40 gtts/min Refer accordingly November 29, 2011 Continue meds For UTZ - today Pls follow up results Refer accordingly

B. LABORATORY TEST Property/Constitue nts Color Definition Resul t Yello w Referenc e Value Light straw to dark amber yellow Clear 4.5-8.0 Interpretatio n Normal Clinical significanc e

Transparency PH

It is the

Clear 6.0

Normal Normal Page 8

Specific Gravity

hydrogen concentratio n of the urine. It is a measureme nt of the acid or alkaline status of he urine. it is the measureme nt of the concentratio n of urine

1.010

1.0051.030

Normal

RBC PUS Epithelial Cells Ultrasound Impression: Ascites; Cholecytitis Chest X- Ray Impression: Pneumonia, Right

0-2 36 few

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V. PATHOPHYSIOLOGY & ANATOMY AND PHYSIOLOGY A. PATHOPHYSIOLOGY TYPHOID FEVER

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B. ANATOMY AND PHYSIOLOGY To aid in understanding the disease process, Anatomy and Physiology provides the necessary information about the normal function of certain body components, its structure and function. Anatomy and physiology are always related. Anatomy is the study of the structure and shape of the body and body parts and their relationships to one another. Physiology is the study of how the body pars work or function. The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity, where food enters the mouth, continuing through the pharynx, oesophagus, stomach and intestines to the rectum and anus, where food is expelled. There are various accessory organs that assist the tract by secreting enzymes to help break down food into its component nutrients. Thus the salivary glands, liver, pancreas and gall bladder have important functions in the digestive system. Food is propelled along the length of the GIT by peristaltic movements of the muscular walls.

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The primary purpose of the gastrointestinal tract is to break down food into nutrients, which can be absorbed into the body to provide energy. First food must be ingested into the mouth to be mechanically processed and moistened. Secondly, digestion occurs mainly in the stomach and small intestine where proteins, fats and carbohydrates are chemically broken down into their basic building blocks. Smaller molecules are then absorbed across the epithelium of the small intestine and subsequently enter the circulation. The large intestine plays a key role in reabsorbing excess water. Finally, undigested material and secreted waste products are excreted from the body via defecation (passing of faeces). In the case of gastrointestinal disease or disorders, these functions of the gastrointestinal tract are not achieved successfully. Patients may develop symptoms of nausea, vomiting, diarrhoea, malabsorption, constipation or obstruction. Gastrointestinal problems are very common and most people will have experienced some of the above symptoms several times throughout their lives.

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VI. NURSING REVIEW CHART IV. PHYSICAL ASSESSMENT NURSING SYSTEM REVIEW CHART Name: XY Date: November 28, 2011 Vital Signs: Pulse:69 bpm BP: 100/60

Temp: 37.7

Respi: 21 Head ache Expelled white sputum Fever Productive cough observed With tolerable chest pain upon coughing Flunk pain

EENT [] impaired vision [] blind [x] pain reddened [] drainage [] gums [] hard of hearing [] deaf [] burning [] edema[] lesion teeth [] asses eyes, ears, nose [] throat for abnormality [] no problem RESPIRATION [] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [X] cough [] bradypnea [] shallow [] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [] wheezing [] pain [] cyanotic [] assess resp rate, rhythm, depth, pattern [] breath sounds, comfort []no problem GASTRO INTESTINAL TRACT [] obese [] distention [] mass [] dysphagia [] rigidly[] pain [] asses abdomen, bowel habits, swallowing [] bowel sounds, comfort [X]no problem GENITO-URINARY and GYNE [] pain [] urine color [] vaginal bleeding [] hematuria [] discharge [] nocturia [] assess urine freq., control, color, odor, comfort [] grip, gait, coordination, speech, [X]no problem NEURO [] paralysis [] stuporous [] unsteady [] seizure [] lethargic [] comatose [] vertigo [] tremors [] confused [] vision [] grip [] assess 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 [] atrophy [] pain [] ecchymosis [] diaphoretic [] assess mobility, motion, gait, alignment, joint function [] skin color, texture, turgor, integrity [x] no problem

Fever

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VII. NURSING MANAGEMENT PATIENT XY CUES


S: gahi gyud kayo akong ubo As verbalized by the patient O: cough restlessness expelled white sputum > increase fluid intake >oral fluid intake may liquefy secretion/ enhance expectorant >administer Salbutamol per doctors order 1 neb q 6o >to improve ventilation & facilitate removal of secretions

NURSING DX
Ineffective airway clearance related to increased amount of secretion

OBJECTIVES
At the end of 30 mins the patient will be able to expectorate secretions & improve / maintain airway clearance.

INTERVENTIONS
> facilitate maintainace of patient upper airway by proper positioning

RATIONALE
> altered level of consciousness, sedation are some condition that alters pt. to project airways

EVALUATION Goal partially m pt. was able to expectorate secretion which is the white sputum & improve airway clearance

> assist w/ coughing/ deep breathing exercises position changes

> for easy expectoration of secretions

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Patient: Xy CUES S: sakit I ubo As verbalized by the patient O: >C pain scale of 5/10 >grimace noted >irritable >weakness noted NURSING DX Acute pain related to coughing thick mucus secretions OBJECTIVES At the end of 30 mins the patient will be able to demonstrate relief from pain >Instructed to deep breathing excersise >Encourage to have Diversional activities like watching t.v. >Place patient in a comfortable position >Encourage to have adequate bed rest >Provided therapeutic touch Dependent: >Administered Ranitidine as ordered INTERVENTIONS Independent: >monitor v/s RATIONALE > To determine alteration in present condition >Helps relieving pain >To divert attention from and reduce pain felt >To provide Comfort >To have energy >To provide Comfort > Helps in relieving pain EVALUATION > goal partially met, patient demonstrate relief from pain

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Patient: XY CUES S: init kayo akong pamati As verbalized by the patient O: Skin warm to touch Flushed skin Dry, cracked lips Absence of sweating T 38. NURSING DX Hyperthermia r/t underlying disease process OBJECTIVES Within 2 hours of nursing interventions, the patient will be able manifest reduction of core temperature from 39.2 to a normal range of 36.5 C- 37.5 C INTERVENTIONS RATIONALE EVALUATION 1. Monitor patients vital R: Serves as baseline data Goal met. After 1 signs. hour and 45 for future comparison. minutes of nursing R: To assess degree of interventions, the patient was able to hyperthermia. 2. Note presence/ absence manifest reduction of sweating. R: Facilitates heat of core temperature through conduction and from 38.3 to 3. Initiate tepid sponge evaporation. normal range with bath. latest temperature of 36.8 C. R: Facilitates heat loss by 4. Promotes surface radiation cooling through undressing or removing extra linens. R: To promote heat loss 5. Encourage adequate and hydration. fluid intake.

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C. DRUG STUDY
DRUG ORDER Omeprazole 20mg tab OD TRADE/ BRAND NAME Omepron PHARMACOLOGIC ACTION OF DRUG INDICATIONS AND CONTRAINDICATIONS ADVERSE EFFECTS OF THE DRUG DESIRED ACTION ON THE CLIENT Nursing Implications

Gastric acid-pump INDICATIONS: CNS: Headache, Treatment of active inhibitor: Suppresses Short-term treatment of active dizziness, asthenia, benign gastric ulcer gastric acid secretion by duodenal ulcer; First-line therapy in vertigo, insomnia, specific inhibition of the treatment of heartburn or symptoms of apathy, anxiety, hydrogen-potassium gastroesophageal reflux disease paresthesias, dream ATPase enzyme system at (GERD); Short-term treatment of abnormalities the secretory surface of active benign gastric ulcer; GERD, Dermatologic: Rash, the gastric parietal cells; severe erosive esophagitis, poorly inflammation, urticaria, blocks the final step of acidresponsive symptomatic GERD; Long- pruritus, alopecia, dry production. term therapy: Treatment of pathologic skin hypersecretory conditions (Zollinger- GI: Diarrhea, Ellison syndrome, multiple adenomas, abdominal pain, systemic mastocytosis); Eradication of nausea, vomiting, H. pylori with amoxicillin or constipation, dry mouth, metronidazole and clarithromycin; tongue atrophy Prilosec OTC: Treatment of frequent Respiratory: URI heartburn (2 or more days per wk); symptoms, cough, Unlabeled use: Posterior laryngitis; epistaxis enhance efficacy of pancreatin for the Other: Cancer in treatment of steatorrhea in cystic preclinical studies, back fibrosis pain, fever CONTRAINDICATIONS: Contraindicated with hypersensitivity to omeprazole or its components; Use cautiously with pregnancy, lactation.

Assessment History: Hypersensitivity to omeprazole or any of its components; pregnancy, lactation Physical: Skin lesions; T; reflexes, affect; urinary output, abdominal exam; respiratory auscultation Interventions Administer before meals. Caution patient to swallow capsules wholenot to open, chew, or crush them. Arrange for further evaluation of patient after 8 wk of therapy for gastroreflux disorders; not intended for maintenance therapy. Symptomatic improvement does not rule out gastric cancer, which did occur in preclinical studies. Administer antacids with omeprazole, if needed. Teaching points Take the drug before meals. Swallow the capsules whole; do not chew, open, or crush them. This drug will need to be taken for up to 8 wk (shortterm therapy) or for a prolonged period (> 5 yr in some cases). Have regular medical follow-up visits. These side effects may occur: Dizziness (avoid driving or performing hazardous tasks); headache (request medications); nausea, vomiting, diarrhea (maintain proper nutrition); symptoms of upper respiratory tract infection, cough (do not selfmedicate; consult with your health care provider if uncomfortable). Report severe headache, worsening of symptoms, fever, chills.

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Name of Drug Generic (Brand)


Acetaminophen (Paracetamol)

Classification

Dose Frequency Route


1.2 mL q 4 hr PRN od

Mechanism of Action

Specific Indication

Side Effects

Nursing Implications

antipyretics, nonopioid analgesics

Inhibits the synthesis of Mild pain prostaglandins that Fever may serve as mediators of pain and fever, primarily in the CNS

Hema: hemolytic BEFORE: anemia, ~ Advise parents or caregivers to neutropenia, check concentrations of liquid leukopenia, preparations. Errors have pancytopenia. resulted in serious liver Hepa: jaundice damage. Metabolic: hypoG ~ Assess fever; note presence of GI: HEPATIC associated signs (diaphoresis, FAILURE, tachycardia, and malaise). HEPATOTOXICI DURING: TY ~ Adults should not take (overdose)GU: acetaminophen longer than renal failure 10 days and children not (high longer than 5 days unless doses/chronic directed by health care use). professional. Derm: rash, ~ Advise mother or caregiver to take urticaria. medication exactly as directed and not to take more than the recommended amount. AFTER: ~ Advise patient to consult health care professional if discomfort or fever is not relieved by routine doses of this drug or if fever is greater than 39.5C (103F) or lasts longer than 3 days.

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VIII. REFERRAL AND FOLLOW UP Exercise/Economic Factor Practice deep breathing exercise and coughing exercises. Resume previous activities. Prevent extraneous work. Have a regular physical exercise like brisk walking for 30 minutes daily. For financial insufficiency, there are government drug stores available. The patient may continue his work as a trainee Treatment Follow faithfully the regimen for Typhoid fever, especially the medications. Health Teaching You should practice hand washing regularly. Out patient Follow-up Always have a regular check up at your nearest health center, at least once a week to monitor the progress of the treatment. The client should report immediately to the physician if there is difficulty of breathing, there is productive cough more than 5 days and there is chest pain and experiencing fatigue. Diet. Always drink a lot of water. Also eat fruits and vegetables. Dont escape meals. If there are any food supplements available, consult it with the doctor. Eat vitamin c rich food to strengthen immune systems. Spiritual/Sexual Activities Always pray for the guidance of the Lord. Spiritual health affects the wellness of an individual IX. EVALUATION AND IMPLICATION At the end of my hospital duty, I was able to render care to my patient to help him resolve his health condition. Through observing the patients status, I was able to identify priority problems related to his health. The patient was willing to pursue the medical therapy just to promote health and wellness for the betterment of his condition. We have also made the patients mother realize the importance of completing the course of therapy by taking the medicines prescribed or ordered for his son by his physician. In addition, eating healthy or nutritious foods that were prescribed to him by the health providers was further been explained to her mother especially the benefits she will gain in eating those Page 19

foods. Moreover, this several interventions given to the patient made her body conditioning normal and i can say that our patient has somehow recovered from her illness. X. Bibliography Cuevas F., Public Health Nursing in the Philippines 10th Edition: League of the Philippine Nurses, 2007 Maglaya A., Nursing Practice in the Community 4th Edition : Argonauta Corporation, 2005 Sparks S. and Taylor C., Nursing Reference Manual 3rd Edition Smeltzer C. and Bare B., Medical-Surgical Nursing USA : Lippincott Williams & Wilkins www.nursingcrib.com/typhoidfever www.wikipedia.com/typhoidfever

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