1 BACKGROUND OF THE STUDY INTRODUCTION Typhoid fever, otherwise known as enteric fever, is an acute illness associated with fever

caused by the Salmonella typhi bacteria. Salmonella 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, known as typhoid psychosis. A characteristic feature of typhoid psychosis 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

2 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. 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, Asubunit (Vi PS) vaccine administered by the intramuscular route and a live attenuated S. Typhistrain (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

3 recognition and treatment of complications are strategies to avert the possibility of death. We choose this topic since it catches our interest from the time being we were able to handle patient having typhoid fever. It gives us the motivation to look for the things that governs such disease. Typhoid fever as our case study allows us to find for ways to contribute something for the alleviation of the condition of its victims may it be in our own little ways perhaps. May this case study serves as advent to understand more fully the existence of such disease and the proper interventions needed to be rendered upon to address such condition looking to a new perspective of life.

OBJECTIVES General This case study aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of typhoid Fever. This also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills. Specific To raise the level of awareness of patient on health problems that he may encounter. To facilitate patient in taking necessary actions to solve and prevent the identified problem on his own. To help patient in motivating him to continue the health care provided by the health workers.

4 To render nursing care and information to patient through the application of the nursing skills.

NURSING HEALTH HISTORY

BIOGRAPHIC DATA Case # xxx-xx-xx

5 Patients name: Sex: Address: Nationality: Civil Status: AJV Male Age: Birthday: 13 years old April 21, 1996

Muzon, City of San Jose del Monte, Bulacan Filipino Single Religion: Roman Catholic

Chief Complaint: Admitting Diagnosis: Date of Admission: Date of Discharge: Admitting Physician: Final Diagnosis:

Abdominal Pain, difficulty in urinating and fever t/c Typhoid Fever December 14, 2010 @1:00 pm December 20, 2010 @ 2:00 pm Dr. Lim Typhoid Fever

HISTORY OF PRESENT ILLNESS Five days prior to admission persistent to consult at OPD. The patient had an intermittent fever associated with abdominal pain and weakness. A few hours to admission still the above signs and symptoms remain but already have (+) rose spots and was diagnosed with Typhoid Fever.

PAST MEDICAL HISTORY According to the patient he has no experienced of being hospitalized, only when one time he experience fever and his mom gave paracetamol tablet. FAMILY MEDICAL HISTORY

6 According to the patients mother the only disease that the family has genetically is the Hypertension on the fathers side and no similar incident of typhoid fever noted.

SOCIAL ECONOMIC HISTORY Recent Stress: Support System: Economic condition: Eating habits: Back and Neck Pain Mother, Father and four Siblings Class C Eats chicken, process foods, vegetables, fruits and seldom eats salty, oily, and sweet foods. Food preferences: Area population: Environmental Sanitation: Housing: Water supply: Meat, Fish, process food, vegetables, and fruits Populated area Poor Sanitation Made of scrap woods and cements NAWASA

7 GORDONS FUNCTIONAL HEALTH PATTERNS PATTERNS OF FUNCTIONING BEFORE DURING HOSPITALIZATION HOSPITALIZATION ANALYSIS

Health Perception Health Management

Patient AJV does not want any consultations or even go for checkups because he thinks that he is healthy and there is nothing wrong with him. He maintains a healthy body by playing with his friends and helping in household chores. He easily gets bored when he is not doing anything. he has started playing basketball and since he was 10 years old up to present. He is not allergic to any food or drug. His family has a history of hypertension.

Patient AJV considered himself a not healthy person due to present condition. He is expecting to recover from his present condition with the help of the health care providers attending to his needs. All of the medications prescribed to patient AJV are available

Patient AJV cannot function normally like before because of his confinement and his hospital condition. His body image changed due to his condition.

Nutritional Metabolic Management

Patient AJVs life before his pre confinement stage was normal, he can eat whatever he wants. He eats

During hospitalization, the patient in on Strict Aspiration Precaution (SAP) diet. He said he

Patient AJVs nutritional and metabolic status has been changed due to his confinement

8 fruits like mango and bananas, fish and meats. But most of the time. He always eats meat. loses his appetite due to uncomfortable feeling. and her medical health condition. His pre confinement status is totally affected.

Elimination Pattern

Bowel

Bowel

Bowel
There was a change in the frequency, consistency and amount of stool.

Patient AJV defecates two times a day without experiencing discomforts, usually morning and afternoon. Stool is brown in color and is well-formed.

Patient defecates once a day but not every day. Stool is soft, is minimal in amount, and is brown in color

Bladder

Bladder Bladder Patient AJV voids usually 6-8 times a day. Urine is yellow in color. No pain Patient voids 10There was a when voiding. 12 times a day with change in the pain and frequency, and discomfort. amount.

Activity, Leisure In the morning, Patient AJVs During Patient and Recreation Patient AJVs daily activity in the AJVs Pattern activities include hospital is eating confinement in collection of water and sleeping. the hospital, for the days use. In there is the afternoon after limitation in his launch, Patient AJV activities of daily

9 go out and play basketball or swimming on the so called carabao beach living and a disruption in his leisure and recreation pattern.

Sleep and Rest Pattern

Patient AJV puts himself to sleep by watching primetime television programs. He does not have usual time of sleep. He sleeps for long period of time. He feels rested when sleeping and he thinks that his energy is sufficient for his activities.

Patient AJV has a difficulty in sleeping. He don't feel rested and comfortable even though he had a long period of sleep, he still feels weak.

Patient AJV sleeps and rest pattern was changed when he was admitted due to his condition. His usual routine of watching television programs to put himself to sleep changed because he doesnt need to do anything to fall asleep.

Cognitive Perceptual Pattern

Patient AJV is still a high school student from Sto. Rosario National High School in San Jose Del Monte Bulacan. He can read and write. he can speak and easily be understood by

Patient AJV present condition, does not affect his communicating skills. Patient is still able to read and write at present.

There was a no change in cognitive and perceptual pattern in terms of writing and speaking

10 others.

Self Perception /SelfConcept Pattern

Patient AJV is a friendly person; he loves to socialize with his friends in their neighborhood. he considered himself as a holistic human being as long as hes complete, healthy and his family is always there for him

He doesnt consider himself as a holistic person. He has many regrets in his life. He thinks that he can't function well than before.

Due to his present condition, there is a change to the level of patient selfperception and self-concept because he can't accept that he cant function the same way like before.

Role Relationship

He was able to do This time his role Due to his his responsibilities as a patient is not condition he is as a son and fully met not aware of brother performing his real role in this field.

Sexuality and Reproductive Pattern

He doesnt think of the things like having a girlfriend and getting married.

Same

Due to his youthful mind, it is still not his priority in life.

Coping and Stress Tolerance

When he is The recent Due to his anxious, patient hospitalization was condition, AJV wants to be a unusual patient AJV alone. He does not experience for does not have

11 show his emotions. When he is stressed, he prefers to rest and sleep. When it comes to problem, he let his self think immediately for a solution. patient AJV, there any outlet to have been many divert his changes occurred feelings. that made it difficult for his to adjust.

Values Belief Pattern

Patient AJV is a During Due to his Roman Catholic. hospitalization the hospitalization, According to the patient wasnt able the patients client, he goes to to go to church. routine in going the mass every to the church Sunday in Bulacan was altered for with her family. a while.

PHYSICAL ASSESSMENT Date assessed: December 14, 2010 Measurements Weight 41 Findings

12 Height Level of Consciousness Body Build Posture and Gait 38.6 kgs Conscious and coherent Medium Erect posture, active purposeful stride

General assessment: conscious and coherent Initial Vital Signs: T: 37.5oC, RR: 24cpm, BP: 90/70mmHg, PR: 97bpm Body Part Technique Normal Findings Actual Findings
The head circumferen ce measures 50 cm, round in shape. The scalp is free from inflammatio n and is lighter in color of that of the complexion of the skin.

Analysis/ Interpretation

Head

Inspection

Generally round, with prominences in the frontal and occipital area.

Head circumference is according to his age on development.

Hair and Scalp

Inspection Palpation

Dark black to
pale blonde; may turn gray or white; may be chemically changed Terminal hair

Hair appears black Even distribution of hair No infestation

Hair grows according to his age.

13
found in the eyebrows, eyelashes, and scalp, and in axilla and pubic areas after puberty. No signs of infestation or lesions. Seborrhea/dan druff may be present Hair may feel thin, straight, coarse, thick or curly. Shiny and resilient or lesions Hair is thick and shiny

Eyes

Inspection

Symmetrical
with no drooping, infection, tumors or other abnormalities Visual Acuity: 20/20 Sclera: White in lightskinned w/o exudates, lesions or foreign bodies. In dark-skinned, may have brown patches Pupils: equally round, reactive to light and accommodation ; 2-6 mm No tearing, swelling or discharge

Eyes symmetrical Visual acuity of 20/20 Sclera appears white Pupils equally round, reactive to light and accommoda tion; approx. 4 mm No tearing, swelling or discharge

Within normal visual acuity. According his age.

14

Nose

Inspection

Nose in the midline No Discharges. No flaring alae nasi. Both nares are patent. No bone and cartilage deviation noted on palpation. No tenderness noted on palpation. Nasal septum in the mid line and not perforated. The nasal mucosa is pinkish to red in color. (Increased redness turbinates are typical of allergy). No tenderness noted on palpation of the paranasal sinuses.

no obstructions found

With normal and equal distribution of air.

Mouth

Inspection

Breath smells fresh. Lips and membranes pink and moist with no lesions or inflammation. Tongue is

No lesions or sores With good symmetry of found Cracked lips lips and mouth.

15
midline. Pink, moist, rough without lesions. Symmetrical; moves freely. Gums have pale-red strippled surface. No swelling or bleeding.

Neck

Inspection Palpation

Symmetrical with head in central position. Able to move head without discomfort or noticeable limits Muscles should be symmetrical without palpable masses or spasm

no swelling lymph nodes

No indication of swelling of lymph nodes. Signifies normal neck contour.

Skin

Inspection Palpation

Skin is uniform
whitish pink or brown color. No Bleeding. No area of increased. vascularity and ecchymosis. No skin lesions present except for freckles, birthmarks or moles which may be flat or elevated.

Skin is brown No bleeding No area of increased vascularity and ecchymosis No lesions Skin is dry Warm and equal bilaterally Skin sprung back rapidly

Skin may
be dry because of insufficient fluid intake Normal fluid intake should be2500 ml per day

16 Skin is dry with

a minimum of perspiration. Warm and equal bilaterally. Hands and skin slightly cooler than the rest of the body. Skin surfaces non-tender Texture: Smooth, even and firm except where there is significant hair growth/ Skin turgor: When released, should return to original contour rapidly Edema not present when pinched No edema present

Chest

Inspection Palpation Auscultation

Without lesions;
skin intact. Quiet, and effortless breathing No pulsations, masses, thoracic tenderness present. Normal lung tissue produces resonant sound, diaphragm has dull sounds. Bronchial, bronchovesicul ar or vesicular

Uses chest muscle for Equal chest retraction breathing indicates breathing pattern.

17
breath sound

Abdomen

Inspection Auscultation Percussion Palpation

Abdominal contour flat or rounded. Symmetrical . Uniform in color or pigmentation . No abdominal scars. No striae Intermittent gurgling sounds throughout abdominal quadrants. Tympany, predominant sound heard No organ enlargement palpable, or any masses, bulges, or swelling

Abdomin Within normal al abdominal contour flat or contour. rounded. Symmetri cal. Uniform in color or pigmenta tion. No abdomin al scars.

Upper extremities

Inspection

Without lesions, scars or inflammation . Complete fingers

Without Normal upper lesions, scars or extremities inflamma tion.

18

Lower extremities

Inspection

Without lesion, scars No edema Complete number of toes.

Without lesion, scars No edema

Accordi ng to his age. Signifies normal movem ent & findings of extremiti es.

Laboratory/ Diagnostic Examination Blood Chemistry Result Date Ordered: December 14, 2010 Test Result Reference Range 129.3 Sodium 135-140 mEq/l Interpretation
Can be caused of loss of sodium through diarrhea or vomiting Can be caused of loss of sodium through diarrhea or vomiting

129.3

134-145 mmol/L

MISCELLANEOUS Test Typhidot Result

Urinalysis Date Ordered: December 14, 2010

19 Property/ Constituents Color Transparency PH Specific Gravity Protein Result Yellow Clear 5.0 1.030 Negative Reference Range Light straw to dark amber yellow Clear 4.5-8.0 1.005-1.030 Qualitative analysis Negative Quantitave analysis 10100mg/24h Sodium Potassium
not indicated not indicated

Interpretation

135-148 mEq/l 3.5- 5.5 mEq/l

Hematology Complete Blood Count Date Ordered: December 14, 2010 Test Result Reference Range Hemoglobin Hematocrit WBC count Platelet Count 133 0.43 10.8 220 120-150g/l 0.37-0.47 5-10 x109 150-350 mm/hr Differential count Test Eosinophil Lymphocyte Basophil Result
not indicated

Interpretation

Reference Range 0.00-0.06 23-35% 0.0-0.1

Interpretation

32%
not indicated

20 Monocyte Neutrophils
not indicated

4-6% 50-70%

68%

ANATOMY AND PHYSIOLOGY THE GASTROINTESTINAL SYSTEM

21 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, esophagus, 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.

22

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, diarrhea, malabsorption, constipation or

obstruction. Gastrointestinal problems are very common and most people will

23 have experienced some of the above symptoms several times throughout their lives.

Basic structure The gastrointestinal tract is a muscular tube lined by a special layer of cells, called epithelium. The contents of the tube are considered external to the body and are in continuity with the outside world at the mouth and the anus. Although each section of the tract has specialized functions, the entire tract has a similar basic structure with regional variations.

The wall is divided into four layers as follows:

24 Mucosa The innermost layer of the digestive tract has specialized epithelial cells supported by an underlying connective tissue layer called the lamina propria. The lamina propria contains blood vessels, nerves, lymphoid tissue and glands that support the mucosa. Depending on its function, the epithelium may be simple (a single layer) or stratified (multiple layers). Areas such as the mouth and esophagus are covered by a stratified squamous (flat) epithelium so they can survive the wear and tear of passing food. Simple columnar (tall) or glandular epithelium lines the stomach and intestines to aid secretion and absorption. The inner lining is constantly shed and replaced, making it one of the most rapidly dividing areas of the body. Beneath the lamina propria is the muscularis mucosa. This comprises layers of smooth muscle which can contract to change the shape of the lumen. Submucosa The submucosa surrounds the muscularis mucosa and consists of fat, fibrous connective tissue and larger vessels and nerves. At its outer margin there is a specialized nerve plexus called the submucosal plexus or Meissner plexus. This supplies the mucosa and submucosa. Muscularis Externa This smooth muscle layer has inner circular and outer longitudinal layers of muscle fibres separated by the myenteric plexus or Auerbach plexus. Neural innervations control the contraction of these muscles and hence the mechanical breakdown and peristalsis of the food within the lumen. Serosa/mesentery

25 The outer layer of the GIT is formed by fat and another layer of epithelial cells called mesothelium.

Individual components of the gastrointestinal system

Oral cavity The 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 specialized sensors known as papillae. In salivation 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 esophagus via the action of swallowing.

Salivary glands

26 Three 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 specialized 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.

Parotids The 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.I mmunoglobins

27 are secreted help to fight microorganisms and a-amylase proteins start to breakdown complex carbohydrates. Submandibular The 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 moreviscid (thick) secretion, rich in mucin and with a smaller amount of protein. Mucin is a glycoprotein that acts as a lubricant. Sublingual The 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. Oesophagus The 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.

Stomach

28 The 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 cardiac 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 intestine

29 The small intestine is composed of the duodenum, jejunum, and ileum. It averages approximately6m 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.

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,

30 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 specialized cells. Some are responsible for absorption, whilst others secrete digestive enzymes and mucous to protect the intestinal lining from digestive actions. Large Intestine The 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.

31

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 summarized 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. Liver The 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 estrogen. 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

32 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 bladder The 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 gallbladder by contraction of its muscular walls in response to hormone signals from the duodenum in the presence of food. Pancreas Finally, 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 (secretory) portion makes up 80- 85% of the pancreas and is the area relevant to the gastrointestinal tract.

33 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.

PATHOPHYSIOLOGY OF THE DISEASE

The Pathophysiology of Typhoid Fever is Complex and Occurs through several stages.

34 Once, the bacteria (Salmonella Typhi), survives the acidity of the stomach, it reaches the intestine and invades the Payer's patches of the intestinal wall. Payer's patches are the clusters of the cell primarily composed of Macrophages are specialized cells that are essential to kill any bacteria. But, Salmonella Typhi is unaffected by these macrophages but, start survive within the macrophage itself. So, during this asymptomatic incubation period of 7-14 days, the bacteria spread throughout the reticulo endothelial system of liver, spleen, gallbladder, and bone marrow. The first week of symptomatic period is characterized by progressive elevation of temperature. In the second week, the victim may experience abdominal pain, spleen enlargement and notice Rose spots on his skin. The third week is more intense as the bacteria start causing necrosis of the Payer's patches of the intestine which leads to perforation and bleeding. This is the terminal stage, if, left untreated, death is imminent.

MEDICAL INTERVENTIONS Course in the Ward December 14, 2010

35 (Day 1) TIME

1:00 pm

Admitted to pedia with PNSS 1L @30gtts/min inserted @ Right metacarpal vein. With laboratory examinations as follows: Blood CS CBC with platelet UA NA/K Typhidot PPD With medications as follows: Paracetamol 500mg 1tab P.O. q4h PRN for fever Chloramphenicol 500mg 1tab P.O. q6h

4:10 pm

Received pt. on bed on left side lying position Awake and coherent With IVF #1 PNSS 1L @ 900cc level, regulated @ 30gtts/min hooked @ right metacarpal vein, infusing well. Facial grimace, diaphoretic and self-focusing seen Initial Vital Signs taken and recorded as follows: PR: 97bpm

T: 37.5oC 9:30 pm

RR: 24bpm BP: 90/70mmHg Pt. verbalized when asked about discomfort felt. Laboratory results referred to Dr. Lim Due meds given

36 Pt. was weak looking Warm to touched, fluched skin, not diaphoretic Mucous membrane was dry and lips were cracked and dried. Vital Signs taken and recorded as follows: PR: 99bpm

T: 39.2oC

RR: 28bpm BP: 90/70mmHg Paracetamol 500mg 1tab given as ordered.

December 15, 2010 (Day 2)

4:10 pm

Received pt. lying on bed on supine position Awake and coherent With IVF #2 PLR 1L @400cc level, regulated @ 20gtts/mon, hooked @ the right metacarpal vein, infusing well. Vital Signs taken and recorded as follows: T: 37.5oC PR: 71bpm RR: 24bpm BP: 90/60mmHG simula nang maconfine ako dito, hindi pa ako dumudumi, as verbalized by the pt. dry skin without sweating flatulence observed Encouraged the pt. to intake balanced fiber and bulk in diet such as fruits, vegetables, and whole grain.

Due meds given IVF #2 was terminated, followed up with IVF #3 D %NM 1L @ 20gtts/min as ordered.

37 Pt. was warm to touch Flushed skin Dry lips Not diaphoretic Poor skin turgor Slowed movement observed Vital Signs taken and recorded as follows: T: 38oC PR: 91bpm RR: 29bpm BP: 90/70mmHg Paracetamol 500mg 1tab given as ordered. December 16, 2010 (Day 3)

9:30 pm

10:00 pm

4:20 pm

Received pt. lying flat on bed With IVF #3 D5NM 1L @gtts/min, hooked @ the right metacarpal vein @ 50 cc level, infusing well Vital Signs taken and recorded as follows: T: 37.4oC PR: 80bpm RR: 24bpm BP:110/70mmHg Slowed body movements With body weakness

IVF #4 D5NM 1L was followed @ 20 gtts/min Pt. experience flushed skin and drying of lips. Skin warm to touched Poor skin turgor Dry mucous membrane

6:10 pm

10:00 pm December 17, 2010 (Day 4)

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4:00 pm

Received pt. up on bed Awake and coherent With IVF #4 D5NM 1L @ 20 gtts/min, hooked @ right metacarpal vein @ 100cc level, infusing well. Vital Signs taken and recorded as follows: T: 37oC PR: 81bpm RR: 28bpm BP: 90/60mmHg IVF was consumed and terminated as ordered. Due meds given

6:00 pm December 20, 2010 (Day 5)

2:00 pm

MGH with Chloramphenicol continue @ home.