I. Introduction

I. Introduction Typhoid fever was not well understood in the ancient world, probably because its symptoms are not primarily diarrheal, but rather systemic and non-specific. It was only in the mid-19th century that physicians began to distinguish it from typhus and malaria. Typhoid or enteric fever is an ancient disease, which has afflicted mankind since human populations grew large enough to contaminate their water and food supplies. Practicality has always been an attribute of the typical Filipino. It is a trait that has been embedded into the very fabric of our lives as we bid to make the best out of what we have. We exploit and utilize our resources to the maximum possible extent in an effort to limit whatever goes to waste as a result of our actions. Kyle is one example of a very practical person. Everyday before going to school in his hometown of Malugong T’boli, South Cotabato, he chooses to make the nearby river useful and chooses to bathe in it rather than use the water that his father had fetched from the community reservoir. Unfortunately for him, other “practical” persons (and even animals) also exhibit practicality by using the river as a site for disposing bodily waste, turning the natural body of water into a medium for spread of infection and disease. One week prior to admission, Kyle began to have persistent fever then after few days he started to vomit everything that he eats. Initially, they thought that it was caused by mosquito bite. Unbeknownst to him and his family, Kevin had contracted an infection from his daily swimming sessions in the river. He was taken to the Davao Medical Center on November 24, 2007 when he was no longer able to tolerate the symptoms especially the vomiting episodes. After undergoing laboratory tests and diagnostic exams, Kevin was diagnosed of having Typhoid fever. In the United States alone, about 400 cases of typhoid fever occur each year, and 70% of these are acquired while traveling internationally. Typhoid fever is still common in the developing world, where it affects about 12.5 million persons each year. In the Philippines, the Department of Health estimated that in the year 2002 alone, there were 13,661 cases of typhoid and paratyphoid fever in the country, of which 990 were reported from Region11. Typhoid is now regarded as a disease of history by many people living in developed countries. However, WHO estimates that globally there are still more than 17 1

million typhoid cases annually and that these infections areassociated with about 600 000 deaths. Our group was able to handle the case of Kyle when we were assigned for duty at the Pediatric Ward of the Davao Medical Center on November 9, 2007. After we were given consent by his parents, we decided to take Kevin’s case as a subject for study in order to expand our knowledge regarding his disease and be able to collect additional data that we deem necessary for us to progress in our quest to become effective nurses in the future.

2

II. OBJECTIVES -During our four weeks of exposure in the clinical area, from November 15December 1, 2007, the group will be able to achieve the following: General Objectives: 1. To be able to choose a case study for our case presentation. 2.

To have a case study related to our concepts in lecture regarding communicable diseases and oxygenation.

3. To be able to apply our learning’s from our lectures to our case study. 4. To learn further regarding on our concepts in lecture. Specific Objectives: 1. To gather enough and credible data for our case study and be able to prevent it. 2. To be able to establish rapport to our patient and his family in order to gain their cooperation for the interview and therapeutic processes. 3. To be able to know our patients Family background and Health history in order to trace past and present health condition. 4. To be able to assess our patients developmental stages in life into three theories namely: Havighurts, Freud, Erikson, or Piaget. 5. To be able to define Typhoid fever along with the patients complete diagnosis in at least three sources from any medical surgical textbooks. 6. To be able to assess our patient physically and cephalocaudally.

3

7. To be able to discuss and explain about the Anatomy and Physiology of the specific body systems involved in our clients diagnosis. 8. To be able to present the etiology of Typhoid fever with scientific basis. 9. To be able to trace the Pathophysiology of Typhoid fever. 10. To be able to show and explain the Doctors Order for our client. 11. To be able to illustrate and explain each Diagnostic Exam undergone by our patient along with its important information’s. 12. To be able to present and explain the different drugs of our patient. 13. To be able to present at least 3 nursing theories related and applicable to the case of the patient. 14. To be able to formulate and present at least 5 nursing care plans in relation to our clients existing health conditions. 15. To be able to cite our recommendations for this case study and health teachings for our patients Health condition. 16. To be able to formulate the discharge plan applicable and needed by our patient in M.E.T.H.O.D pattern. 17. To be able to justify the prognosis of our client concerning his present condition. 18. To be able to present the list of all the references we used in coming up with our Case Study.

4

III. PATIENTS DATA Patient’s code name: “Kyle” Age: 8 years old Nationality: Filipino Civil status: Single Occupation: Student Ward: Pedia Room: IMCU Bed no. : 4 Religion: Roman Catholic Educa’l attainment: grade 1 Date of admission: November 24, 2007 V/S on admission: T: 39. 8’ C

CR: 145 bpm

RR: 34 cpm

BP: 90/70 mmhg

Chief Complaints: Fever Admitting diagnosis: Enteric Fever t/c Typhoid fever Final diagnosis: Thyphoid fever r/o intestinal perforation Source of information: Patients Chart

5

IV. HEALTH HISTORY Family Health history There is no history of any diseases in the family of Kyles Mother, the Gaway clan. However, in the paternal line, a history of Heart diseases and Hypertension is present. Marilou, his father’s eldest sibling and Robert Nelson, the fifth of the six siblings has hypertension and heart disease while Anabelle, the second sibling and Gladys, the youngest among has hypertension. Meanwhile, Wilfredo, Kyle’s father did not acquire any from the two disease nor have any disease.

Effects and expectations of the illness to self and family Of course, the first effect of Kyle being ill is that both of his parents and as well as his lola and younger sibling, of which he is the eldest, they worry so much of Kyle. The effect was emotional. His father became so worried and problematic. He said that he can’t sleep very well because he is too concerned for his child. Also, there was a big effect on financial, the family needs to spend a lot of money for the medications which is so expensive but they are so thankful that there is the “Lingap” which helped them in their hospital finances. Her mother is also worried that she would always call from Jeda for Kyle. Also Kyle’s brothers misses him so much and so is he that he will always cry and wants to see his siblings who are in South Cotabato. Kyle is a grade 1 student from Malugong Elementary school. There was a big effect on his studies because he has been absent for about 3 weeks but with the permission from his teacher because Kyle is a very diligent student. Also, because of the sickness Kyle sufferes both mental, physiological and emotional. He wasn’t able to do his usual routines at home like playing with his playmates, watching TV and swimming in the pool when he was still not sick. These are very important for a child of 8 years old.

6

The Family expects a lot that Kyle would recover from the illness and that he would go back to his old strength and go to school and do his usual routines. The Family expects that they will become more careful in their diets or in the food hygiene in order to prevent having the disease because hospitalization is expensive.

Past Health History a. History of past illness Kyle haven’t had any kind of diseases or illnesses since he was a baby until this year. The only illnesses that he will have are just mild fever, coughs and colds but nothing more severe.

b. History of present illness Kyles lifestyle is so active. Before going to school, he takes a bath in the Malugong River which is near their house. Then, as a child, he loves to eat junk foods like Mr. chips and drink sodas. He has a good academic performance in school. As what his father says he would sometimes be the leader in some schoolworks. When he arrives from school he play’s with his playmates from the neighborhood. If not playing outside and not swimming in the river with friends and especially if its weekend he watches cartoons from morning till evening. His usual diet are vegetables but eats slowly and his favorite foods are pork sausage, salted foods and okras. He always skips breakfast especially during schooldays because he wokes up late in the morning so there are no time for it and then he usually have a dinner heavier than his lunch.

7

On the month of November Kyle got sick. He had a fever for eight day. Usually the fevers are high and is lowered by taking paracetamol which offered a temporary relief then followed by loss of appetite. There are no medical consultation made. There was an onset of soft and watery stools for five days but still no consultation done and no meds given. The patient had anorexia and will vomit everything that he will swallow along with his fever and diarrhea and this prompted his father to consult medical help at Davao Medical Center.

8

V. DEVELOPMENTAL DATA Moral Development Theory (Lawrence Kohlberg) Moral development, a complex process not fulkly understood, involves learning what ought to be and what ought to be done. It is more than imprinting that parent’s rule and virtues or values of children. The term “moral” means “relating to right and wrong”. The terms Morality, Moral behavior, and Moral Development nedd to be distinguished from each other. Morality refers to the requirements necessary for people to live in a societry; Moral behavior is the way a person perceives those requirements and responds to them; Moral development is the pattern of change in moral behavior with age. At the meantime, the children lives with their lola at Malugong and their Father lives their temporarily. Kyle, as a child perceives punishment as the sign that he dis something wrong or what he’s doing is wrong. He avoids punishment and consequences which are either set by his father or authorities and so he does things that he thinks are right by which he can’t be punished. He follows what his Lola, mother and Father wants him to do as having good grades at school and being a good and unbully child. Also, He does what he wants to do or what interest him which tells that what his doing is actually right(at his own view of what is right). Like he goes to swimming in the river, play with playmates and watch TV a lot. This is his routine and what he likes to do and also his father doesn’t prohibit him from doing so.

9

Psychosocial Development (Erik Erikson) This theory refers to the development of personality. Personality is a complex that is difficult to define. It can be considered as the outward (interpersonal) expression of the inner(intrapersonal) self. It compasses a person’s temperament, feeling, character traits, independence, self-esteem, self-concept, behavior, ability to interact with others and ability to adapt to life changes. The patient is an eight-years old child. He belongs in the stage of Industry vs. Inferiority. Industry here refers to purposeful or meaningful activity. It's the development of competence and skills, and a confidence to use a 'method', and is a crucial aspect of school years experience. Erikson described this stage as a sort of 'entrance to life'. A child who experiences the satisfaction of achievement - of anything positive - will move towards successful negotiation of this crisis stage. A child who experiences failure at school tasks and work, or worse still who is denied the opportunity to discover and develop their own capabilities and strengths and unique potential, quite naturally is prone to feeling inferior and useless. Engaging with others and using tools or technology are also important aspects of this stage. It is like a rehearsal for being productive and being valued at work in later life. Inferiority is feeling useless; unable to contribute, unable to cooperate or work in a team to create something, with the low self-esteem that accompanies such feelings Kyle is a productive student at school and an active child in the village. He has a lot of friends and plays with them after school or on weekend when it does not interrupt in his school works. He enjoys playing and swimming with his friends. He doesn’t miss his schooldays and he doesn’t want to be absent in school. After playing and watching TV during schooldays, he would now study his lessons for school. Kyle knows when to do things and has his method of doing it by setting his priorities and what needs to be attended first and whats more important. He is confident in his self as evidenced by being a good leader at school. He also have a positive comments from his teachers.

10

Cognitive Theory (Jean Piaget) This theory refers to the manner in which people learn to think, reason, and use language. It involves a person’s intelligence, perceptual ability, and ability to process information. Cognitive development represents a progression of mental abilities from illogical to logical thinking, from simple to complex problem solving, and from understanding concrete iseas to understand abstract concepts. Our Patient, Kyle is on Concrete Stage. During this stage, accommodation increases. The child develops an ability to think abstractly and to make rational judgements about concrete or observable phenomena, which in the past he needed to manipulate physically to understand. In teaching this child, giving him the opportunity to ask questions and to explain things back to you allows him to mentally manipulate information. Our patient is a grade 1 student from Malugong Elementary highschool in South Cotabato. His favorite subjects are Math and Filipino. He likes to read short stories like Fables and Filipino folklores. He is practical. He thinks for what is important and what could he done. He follows his therapeutic regime i.e. NPO in which after knowing, he does not insists on eating or drinking because it was the instruction. He knows how to reason and answers question concretely and coherently. He follows our instructions or what we tells him to do like, when he was lying on bed, we asked him to sit in order for us to auscultate his lungs eventhough he has body malaise. We also observed that he knows how to reason for things while were conversing with him. As what we observed, Kyle is a smart boy. He knows what he should do and what to say and reasons. At his age, He could comprehend his present condition and follows instructions given to him by the medical staffs.

11

DEFINITION OF COMPLETE DIAGNOSIS Typhoid Fever r/o Intestinal Perforation Typhoid Fever Typhoid fever is a bacterial infection of the intestinal tract and occasionally the bloodstream. It is an uncommon disease with only 30-50 cases occurring in New York each year. Most of the cases are acquired during foreign travel to underdeveloped countries. The germ that causes typhoid is a unique human strain of Salmonella called Salmonella typhi. Outbreaks are rare Source: http://www.health.state.ny.us/diseases/communicable/typhoid_fever/fact_sheet.htm

An acute illness associated with fever caused by the Salmonellae Typhi bacteria. The bacteria is deposited in water or food by a human carrier, and is then spread to other people in the area. The incidence of the illness in the United States has markedly decreased since the early 1900's. This improvement is the result of improved environmental sanitation. Mexico and South America are the most common areas for U.S. citizens to contract typhoid fever. India, Pakistan and Egypt are also known high risk areas for developing this disease. Source: http://www.medicinenet.com/typhoid_fever/article.htm

Typhoid fever is a potentially life-threatening illness that is caused by the bacteria Salmonella typhi (S. typhi). Persons with typhoid fever carry the bacteria in their bloodstream and intestinal tract and can spread the infection directly to other people by contaminating

12

food or water. Anyone can get typhoid fever if they drink water or eat food contaminated with the S. typhi bacteria. Travelers visiting developing countries are at greatest risk for getting typhoid fever. Typhoid fever is still common in the developing world, where it affects about 12.5 million persons each year. Source: http://health.utah.gov/epi/fact_sheets/typhoid.pdf

Intestinal Perforation

a hole that passes through the small intestine or large bowel which can be caused by a variety of illnesses, including appendicitis, diverticulitis, ulcer disease, Crohn's disease, and less commonly, infections of the bowel, Perforation of the intestine leads to leakage of intestinal contents into the abdominal cavity. Source: http://www.nlm.nih.gov/medlineplus/ency/article/000235.htm

A perforation is a hole in the wall of the digestive tract. A perforation may occur anywhere in the digestive tract and may occur when, a craterlike sore (ulcer) erodes through the wall of the stomach or a section of intestine, an infection in the appendix erodes through the wall of the appendix, an infection of an abnormal pouch or sac in the intestine (diverticulum) erodes through the wall of a section of the bowel, a swallowed object punctures the digestive tract. A perforation of the digestive tract can be lifethreatening. It can cause severe pain and bleeding. The material inside the intestines can leak into the hollow space of the abdomen (abdominal cavity) and cause an infection (peritonitis). Source: http://www.everettclinic.com/kbase/frame/not36/not36453/frame.htm

13

This surgical emergency involves rupture of the wall of the intestine. intestinal perforation results in severe abdominal pain intensified by movement. Later symptoms include fever and chills.

Source: http://www.medhelp.org/HealthTopics/H.html

14

VII. PHYSICAL ASSESSMENT 1. Vital signs BP: 110/90 (sitting) TEMP: 39. 7’ C RR: 42 bpm (shallow and fast) PR: 112 bpm

2. General Survey Weight remains the same since admission, 17 kg. The head circumference is . He appears to have signs of distress, pain and anxiety and talks limitedly. He is conscious, alert, coherent and oriented. He is ectomorphic, well developed and looks according to age. He is poorly nourished as evidenced by very thin body structure, dry skin and reported that he only eats a little and his usual diet is vegetables but his favorite is pork sausage and salted foods. However at the onset of his symptoms, he started to loss his appetite. His emotional state is that he appears to be worried, restless and has grimaced face and also cries due to homesickness.

3. Skin Texture of skin is smooth and is hot to touch. Turgor is good. Scars and allergies are noted on both lower legs. Pitting edema is noted on both arms and feet. Pallor is present on palms and soles of feet.

4. Head Configuration of the head is normocephalic with fontanels closed and no masses or lesions are present. Facial movements are symmetrical. Hair is evenly distributed and scalp is clean.

15

5. Eyes Lids are symmetrical but swelling. Edema is evident on both periorbital regions but more severe on the right side. No lesions. Conjunctiva is pale in color and sclera is anicteric but light red in color. Visual acuity is glossy normal and peripheral vision is intact and full.

6. Ears Has normoset of external pinnae and are symmetrical. Hearing is symmetrical with cerumen on the external canal but without discharges and foul smell.

7. Nose Septum is midline. No discharges, no lesions and masses. Both are patent.

8. Mouth Lips are cracked and dry with presence of bleeding lesions. Mucosa and gums are pale in color and tongue is at midline and intact speech. Cavities are present on molars and premolars on both upper and lower teeth.

9. Pharynx Uvula is at midline with mucusa pinkish in color. Tonsils are not inflamed.

10. Neck Trachea is at midline. No tenderness at cervical lymph nodes upon palpation and thyroid is not enlarged.

16

11. Chest and Lungs Breathing is irregular and is having shallow and fast breathing with use of accessory muscles. Lung expansion is symmetrical with no adventitious lung sounds upon auscultation.

12. Heart Palpitation is present. Bleeding tendencies for lesions on lips and gastrointestinal tract. There is a presence of a heart sound upon palpation.

13. Breast and axillae Both breast are equal in shape and symmetrical. Surface is smooth and no dimpling, edema or retractions. No masses and tenderness.

14. Abdomen By inspection, there are presence of visible veins but no lesions and scars. Abdomen is globular in configuration with absent bowel sounds upon auscultation. Tenderness is evident during palpation with presence of guarding behavior. Abdominal pain is felt on the left hypochondriac region.

15. Back and extremities Peripheral pulses are symmetrical. nail beds pale in color. ROM full and symmetrical and muscle tone is equally strong and symmetrical muscle size with coordinated gait.

17

VIII. ANATOMY δ 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. TheDigestiveProcess: 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.

18

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.

19

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

20

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.

Functions of the Digestive System The digestive system includes the digestive tract and its accessory organs, which process food into molecules that can be absorbed and utilized by the cells of the body. Food is broken down, bit by bit, until the molecules are small enough to be absorbed and the waste products are eliminated. The digestive tract, also called the alimentary canal or gastrointestinal (GI) tract, consists of a long continuous tube that extends from the mouth to the anus. It includes the mouth, pharynx, esophagus, stomach, small intestine, and large intestine. The tongue and teeth are accessory structures located in the mouth. The salivary glands, liver, gallbladder, and pancreas are major accessory organs that have a role in digestion. These organs secrete fluids into the digestive tract. Food undergoes three types of processes in the body: •

Digestion

•

Absorption

•

Elimination

Digestion and absorption occur in the digestive tract. After the nutrients are absorbed, they are available to all cells in the body and are utilized by the body cells in metabolism.

21

The digestive system prepares nutrients for utilization by body cells through six activities, or functions. Ingestion. The first activity of the digestive system is to take in food through the mouth. This process, called ingestion, has to take place before anything else can happen. Mechanical Digestion. The large pieces of food that are ingested have to be broken into smaller particles that can be acted upon by various enzymes. This is mechanical digestion, which begins in the mouth with chewing or mastication and continues with churning and mixing actions in the stomach. Chemical

Digestion

The

complex

molecules of carbohydrates, proteins, and fats are transformed by chemical digestion into smaller molecules that can be absorbed and

utilized

digestion, hydrolysis,

by

through uses

the a water

cells.

Chemical

process and

called

digestive

enzymes to break down the complex molecules. Digestive enzymes speed up the hydrolysis process, which is otherwise very slow. Movements. After ingestion and mastication, the food particles move from the mouth into the pharynx, then into the esophagus. This movement is deglutition, or swallowing. Mixing movements occur in the stomach as a result of smooth muscle contraction. These repetitive contractions usually occur in small segments of the digestive tract and mix the food particles with enzymes and other fluids. The movements that propel the food particles through the digestive tract are called peristalsis. These are rhythmic waves of contractions that move the food particles through the various regions in which mechanical and chemical digestion takes place.

22

Absorption. The simple molecules that result from chemical digestion pass through cell membranes of the lining in the small intestine into the blood or lymph capillaries. This process is called absorption. Elimination. The food molecules that cannot be digested or absorbed need to be eliminated from the body. The removal of indigestible wastes through the anus, in the form of feces, is defecation or elimination. General Structure of the Digestive System The long continuous tube that is the digestive tract is about 9 meters in length. It opens to the outside at both ends, through the mouth at one end and through the anus at the other. Although there are variations in each region, the basic structure of the wall is the same throughout the entire length of the tube. The wall of the digestive tract has four layers or tunics: •

Mucosa

•

Submucosa

•

Muscular layer

•

Serous layer or serosa

The mucosa, or mucous membrane layer, is the innermost tunic of the wall. It lines the lumen of the digestive tract. The mucosa consists of epithelium, an underlying loose connective tissue layer called lamina propria, and a thin layer of smooth muscle called the muscularis mucosa. In certain regions, the mucosa develops folds that increase the surface area. Certain cells in the mucosa secrete mucus, digestive enzymes, and hormones. Ducts from other glands pass through the mucosa to the lumen. In the mouth and anus, where thickness for protection against abrasion is needed, the epithelium is stratified squamous tissue. The stomach and intestines have a thin simple columnar epithelial layer for secretion and absorption.

23

The submucosa is a thick layer of loose connective tissue that surrounds the mucosa. This layer also contains blood vessels, lymphatic vessels, and nerves. Glands may be embedded in this layer. The smooth muscle responsible for movements of the digestive tract is arranged in two layers, an inner circular layer and an outer longitudinal layer. The myenteric plexus is between the two muscle layers. Above the diaphragm, the outermost layer of the digestive tract is a connective tissue called adventitia. Below the diaphragm, it is called serosa. Organs of the Digestive System At its simplest, the digestive system is a tube running from mouth to anus. Its chief goal is to break down huge macromolecules (proteins, fats and starch), which cannot be absorbed intact, into smaller molecules (amino acids, fatty acids and glucose) that can be absorbed across the wall of the tube, and into the circulatory system for dissemination throughout the body.

24

Regions of the digestive system can be divided into two main parts: the alimentary tract and accessory organs. The alimentary tract of the digestive system is composed of the mouth, pharynx, esophagus, stomach, small and large intestines, rectum and anus. Associated with the alimentary tract are the following accessory organs: salivary glands, liver, gallbladder, and pancreas.

Mouth The mouth, or oral cavity, is the first part of the digestive tract. It is adapted to receive food by ingestion, break it into small particles by mastication, and mix it with saliva. The lips, cheeks, and palate form the boundaries. The oral cavity contains the teeth and tongue and receives the secretions from the salivary glands.

Lips and Cheeks The lips and cheeks help hold food in the mouth and keep it in place for chewing. They are also used in the formation of words for speech. The lips contain numerous sensory receptors that are useful for judging the temperature and texture of foods. Palate The palate is the roof of the oral cavity. It separates the oral cavity from the nasal cavity. The anterior portion, the hard palate, is supported by bone. The posterior portion, the soft palate, is skeletal muscle and connective tissue. Posteriorly, the soft palate ends in a

25

projection called the uvula. During swallowing, the soft palate and uvula move upward to direct food away from the nasal cavity and into the oropharynx. Tongue The tongue manipulates food in the mouth and is used in speech. The surface is covered with papillae that provide friction and contain the taste buds.

Teeth A complete set of deciduous (primary) teeth contains 20 teeth. There are 32 teeth in a complete permanent (secondary) set. The shape of each tooth type corresponds to the way it handles food. Pharynx and Esophagus Pharynx The pharynx is a fibromuscular passageway that connects the nasal and oral cavities to the larynx and esophagus. It serves both the respiratory and digestive systems as a channel for air and food. The upper region, the nasopharynx, is posterior to the nasal cavity. It contains the pharyngeal tonsils, or adenoids, functions as a passageway for air, and has no function in the digestive system. The middle region posterior to the oral cavity is the oropharynx. This is the first region food enters when it is swallowed. The opening from the oral cavity into the oropharynx is called the fauces. Masses of lymphoid tissue, the palatine tonsils, are near the fauces. The lower region, posterior to the larynx, is the laryngopharynx, or hypopharynx. The laryngopharynx opens into both the esophagus and the larynx.

26

Food is forced into the pharynx by the tongue. When food reaches the opening, sensory receptors around the fauces respond and initiate an involuntary swallowing reflex. This reflex action has several parts. The uvula is elevated to prevent food

from

entering

the

nasopharynx.

The

epiglottis drops downward to prevent food from entering the larynx and trachea in order to direct the

food

into

the

esophagus.

Peristaltic

movements propel the food from the pharynx into the esophagus. Esophagus The esophagus is a collapsible muscular tube that serves as a passageway between the pharynx and stomach. As it descends, it is posterior to the trachea and anterior to the vertebral column. It passes through an opening in the diaphragm, called the esophageal hiatus, and then empties into the stomach. The mucosa has glands that secrete mucus to keep the lining moist and well lubricated to ease the passage of food. Upper and lower esophageal sphincters control the movement of food into and out of the esophagus. The lower esophageal sphincter is sometimes called the cardiac sphincter and resides at the esophagogastric junction. Stomach The stomach, which receives food from the esophagus, is located in the upper left quadrant of the abdomen. The stomach is divided into the fundic, cardiac, body, and pyloric regions. The lesser and greater curvatures are on the right and left sides, respectively, of the stomach.

27

Gastric Secretions The mucosal lining of the stomach is simple columnar epithelium with numerous tubular gastric glands. The gastric glands open to the surface of the mucosa through tiny holes called gastric pits. Four different types of cells make up the gastric glands: •

Mucous cells

•

Parietal cells

•

Chief cells

•

Endocrine cells

The secretions of the exocrine gastric glands - composed of the mucous, parietal, and chief cells - make up the gastric juice. The products of the endocrine cells are secreted directly into the bloodstream and are not a part of the gastric juice. The endocrine cells secrete the hormone gastrin, which functions in the regulation of gastric activity. Regulation of Gastric Secretions

28

The regulation of gastric secretion is accomplished through neural and hormonal mechanisms. Gastric juice is produced all the time but the amount varies subject to the regulatory factors. Regulation of gastric secretions may be divided into cephalic, gastric, and intestinal phases. Thoughts and smells of food start the cephalic phase of gastric secretion; the presence of food in the stomach initiates the gastric phase; and the presence of acid chyme in the small intestine begins the intestinal phase. Stomach Emptying Relaxation of the pyloric sphincter allows chyme to pass from the stomach into the small intestine. The rate of which this occurs depends on the nature of the chyme and the receptivity of the small intestine.

Small and Large Intestine Small Intestine The small intestine extends from the pyloric sphincter to the ileocecal valve, where it empties into the large intestine. The small intestine finishes the process of digestion, absorbs the nutrients, and passes the residue on to the large intestine. The liver, gallbladder, and pancreas are accessory organs of the digestive system that are closely associated with the small intestine. The small intestine is divided into the duodenum, jejunum, and ileum. The small intestine follows the general structure of the digestive tract in that the wall has a mucosa with simple columnar epithelium, submucosa, smooth muscle with inner circular and outer longitudinal layers, and serosa. The absorptive surface area of the small intestine is increased by plicae circulares, villi, and microvilli.

29

Exocrine cells in the mucosa of the small intestine secrete mucus, peptidase, sucrase, maltase, lactase, lipase, and enterokinase. Endocrine cells secrete cholecystokinin and secretin. The most important factor for regulating secretions in the small intestine is the presence of chyme. This is largely a local reflex action in response to chemical and mechanical irritation from the chyme and in response to distention of the intestinal wall. This is a direct reflex action, thus the greater the amount of chyme, the greater the secretion.

Large Intestine The large intestine is larger in diameter than the small intestine. It begins at the ileocecal junction, where the ileum enters the large intestine, and ends at the anus. The large intestine consists of the colon, rectum, and anal canal. The wall of the large intestine has the same types of tissue that are found in other parts of the digestive tract but there are some distinguishing characteristics. The mucosa has a large number of goblet cells but does not have any villi. The longitudinal muscle layer, although present, is incomplete. The longitudinal muscle is limited to three distinct bands, called teniae coli, that run the entire length of the colon. Contraction of the teniae 30

coli exerts pressure on the wall and creates a series of pouches, called haustra, along the colon. Epiploic appendages, pieces of fat-filled connective tissue, are attached to the outer surface of the colon. Unlike the small intestine, the large intestine produces no digestive enzymes. Chemical digestion is completed in the small intestine before the chyme reaches the large intestine. Functions of the large intestine include the absorption of water and electrolytes and the elimination of feces. Rectum and Anus The rectum continues from the signoid colon to the anal canal and has a thick muscular layer. It follows the curvature of the sacrum and is firmly attached to it by connective tissue. The rectum and ends about 5 cm below the tip of the coccyx, at the beginning of the anal canal. The last 2 to 3 cm of the digestive tract is the anal canal, which continues from the rectum and opens to the outside at the anus. The mucosa of the rectum is folded to form longitudinal anal columns. The smooth muscle layer is thick and forms the internal anal sphincter at the superior end of the anal canal. This sphincter is under involuntary control. There is an external anal sphincter at the inferior end of the anal canal. This sphincter is composed of skeletal muscle and is under voluntary control.

Accessory Organs The salivary glands, liver, gallbladder, and pancreas are not part of the digestive tract, but they have a role in digestive activities and are considered accessory organs. Salivary Glands Three pairs of major salivary glands (parotid, submandibular, and sublingual glands) and numerous smaller ones secrete saliva into the oral cavity, where it is mixed with food

31

during mastication. Saliva contains water, mucus, and enzyme amylase. Functions of saliva include the following: o

It has a cleansing action on the teeth.

o

It moistens and lubricates food during mastication and swallowing.

o

It dissolves certain molecules so that food can be tasted.

o

It begins the chemical digestion of starches through the action of amylase, which breaks down polysaccharides into disaccharides.

Liver The liver is located primarily in the right hypochondriac and epigastric regions of the abdomen, just beneath the diaphragm. It is the largest gland in the body. On the surface, the liver is divided into two major lobes and two smaller lobes. The functional units of the liver are lobules with sinusoids that carry blood from the periphery to the central vein of the lobule. The liver receives blood from two sources. Freshly oxygenated blood is brought to the liver by the common hepatic artery, a branch of the celiac trunk from the abdominal aorta. Blood that is rich in nutrients from the digestive tract is carried to the liver by the hepatic portal vein. The liver has a wide variety of functions and many of these are vital to life. Hepatocytes perform most of the functions attributed to the liver, but the phagocytic Kupffer cells that line the sinusoids are responsible for cleansing the blood. Liver functions include the following: •

secretion

•

synthesis of bile salts

•

synthesis of plasma protein

•

storage

•

detoxification

32

•

excretion

•

carbohyrate metabolism

•

lipid metabolism

•

protein metabolism

•

filtering

Gallbladder The gallbladder is a pear-shaped sac that is attached to the visceral surface of the liver by the cystic duct. The principal function of the gallbladder is to serve as a storage reservoir for bile. Bile is a yellowish-green fluid produced by liver cells. The main components of bile are water, bile salts, bile pigments, and cholesterol. Bile salts act as emulsifying agents in the digestion and absorption of fats. Cholesterol and bile pigments from the breakdown of hemoglobin are excreted from the body in the bile. Pancreas The pancreas has both endocrine and exocrine functions. The endocrine portion consists of the scattered islets of Langerhans, which secrete the hormones insulin and glucagon into the blood. The exocrine portion is the major part of the gland. It consists of pancreatic acinar cells that secrete digestive enzymes into tiny ducts interwoven between the cells. Pancreatic enzymes include anylase, trypsin, peptidase, and lipase. Pancreatic secretions are controlled by the hormones secretin and cholecystokinin.

33

IX Etiology Predisposing Factors: actual

rationale

Genes

factor

X

Age

X

Sex

X

Salmonella typhi is shed only in human feces and is transmitted via the fecaloral route of infection. It is therefore a non-hereditary disease. There is no specific age group within which the disease is most dangerous. However, traditionally the age range considered to be at greatest risk was 5-25 years but typhoid fever can affect any person from any age group who ingests the salmonella typhi bacteria. Both sexes can acquire typhoid fever through the ingestion of contaminated food or water. The Family is not so financially well off. However, the mother is working in Jeda as a Domestic Helper and the father is unemployed. The family’s income is not sufficient to finance all their

Socio-Economic Status



34

needs in order for the living to be more comfortable and to buy all the medicines needed.

Precipitating Factors: Environment



Unsanitary food handling



Ingestion of Contaminated Foods.



The family at the moment lived at a village near a River where Kyle and his siblings usually takes a bath. Also it is where the carabaos are bathing and the father also said that maybe their neighbors defecate there. Typhoid is common in poor andtropical areas of the world where sanitation is inadequate and the water supply not effectively purified. Source:www.ptolemy.ca.pdf The Family does practice good sanitation in handling foods. They dining table is always left uncleaned especially the 3 young sibling are the only one eating together. Also, Unwashed plates are always left in their lavatory until it accumulates. Sometimes left-over foods are also left uncovered in the dining table. Kyle is always swimming the contaminated river. There is a possibility that he ingested water from the

35

river even at minimum amount. S typhi is transmitted via the fecaloral route. The infectious dose is between 105 and 109. The dose is lower if the bacteria are given with sodium bicarbonate, suggesting that a proportion of the ingested bacteria are destroyed by the acid environment in the stomach. Source: www.ptolemy.ca Unsanitary preparation of food



The father said that there are a lot of food flies, rats and cockroaches in their kitchen that must have contaminated the prepared food.

36

X. Symptomatology symptoms 1. Fever

2. Burning Micturition 3. Gastroenteritis

4. Diarrhea

actual 

X 



5. Headache 6. Abdominal Pain

X 

7. Body Ache 8. Dry Cough

X 

rationale Because of the presence of Salmonella typhi on his blood the the body releases pyrogenes which are abnormal proteins. The body increases temperature to increase oxygen uptake which results to increased respiratory rate and renders WBC more aggressive against bacteria and this increases there phagocytic activity. Endotoxins released by the gram-negative bacteria which elicits a antigenic response that results to increased in temperature. Not Present. S.typhi, which is present within his stomach, elicits an inflammatory reaction as the body tries to combat the infection. Diarrhea is one of the body’s methods of releasing infectious bacteria before it gets a chance to proliferate. Not Present. Frequent contact of the stomach lining with the S.typhi bacteria results in constant inflammation, especially in areas of greatest macrophage concentration, which in turn causes tissue necrosis, hence, the abdominal pain. Not Present. Bacteria can reach the lungs as contaminated blood enters the

37

9. Constipation 10. Anorexia

X 

11. Vomiting



12. Hepatomegaly



13. Toxemia



14. Splenomegaly 15. Ileus 16. Intestinal Perforation 17. Gastrointestinal Bleeding 18. Typhoid Encephalopathy 19. Leukocytosis

X X X X

20. Rose Spots 21. Endocarditis

X X

X 

lungs for oxygenation. This elicits a response in the form of unproductive cough, Not Present. Fever causes decreased functioning of the taste buds. Frequent vomiting may also cause loss of appetite. Vomiting is a result of reflux of gastric contents due to the inflamed intestinal lining. The liver is one site for bacterial multiplication in cases of typhoid fever, and this causes the liver to increase in volume. Typhoid fever is often associated with bacteria within the blood stream which can be considered as toxins. Not Present. Not Present. Not Present. Not Present. Not Present. Leukocytes are part of the body’s defenses against infectious diseases. Leukocytosis develops as a result of gastroenteritis and is part of the body’s attempt to combat the infection caused by S.typhi. Not Present. Not Present.

38

XI. Pathophysiology

39

Predisposing Factors: o o o o

Genes Age Sex Socio-economic Status

Precipitating Factors: o Environment o Unsanitary Food Handling o Ingestion of Contaminated Food

S.typhi is shed in human feces Contamination of food and water Ingestion of contaminated food or water by humans S.typhi tries to survive in acidic environment of the stomach Remaining bacteria invade epithelial cells in the intestine Macrophages from Peyer’s patches engulf bacteria

Constant exposure to bacteria Inflammation

S.typhi injects effector proteins into macrophage Normal cellular activities are diverted Bacteria survives and multiplies within macrophage

Macrophages carrying bacteria accumulate in Peyer’s patches

Phagocytes undergo lyses and release bacteria into nearby lymphatic ducts

Necrosis

Intestinal bleeding

Bowel perforation

-Blood in vomitus -Abdominal pain -Gastroenteritis Bacteria passes through thoracic duct and enters the bloodstream

Primary Bacteremia (Asymptomatic)

Bacteria disseminate to regional lymph nodes 40

Bacteria is shed into the blood stream -Fever -Headache -Abdominal Pain

Bacteria spread to other cells of reticuloendothelial system (including spleen, liver, and gallbladder)

Secondary Bacteremia Bacterial growth within spleen and liver Infection spreads to other systems

Changes brought about by sepsis accumulate in the heart, brain, and kidneys IF NOT TREATED:

Overwhelming sepsis

Circulatory Failure

DEATH!

-Splenomegaly -Hepatomegaly -Endocarditis -Renal Failure -Brain Infxn

IF TREATED:

Antibiotic Therapy

-Elimination/ decrease in number of S.typhi -Alleviation of signs and symptoms -Recovery from condition

41

XII. Doctor’s Order

42

Date Order 11/25/07 >Pls. admit to SVI, level 2, red2 >DAT except for DCF >Dxs: • CBC, platelet count

•

UA

• •

Blood GS/CS Urine GS/CS

•

Typhidot IgM and IgB

Rationale

>To assess the patient for infection, anemia and any disorders. >To assess for any abnormalities within the urinary system as well as for systemic problems that may manifest symptoms through the urinary tract.

>To detect Typhoid fever and any other salmonella infection.

>IVF: D5LR 1L to run @56cc/h >To prevent patient from dehydration and maintain adequate electrolyte and fluid balance.

Remarks DONE

DONE

DONE

DONE

DONE

>Meds: Ranitidine 20mg/ IVTT q8h prn for abdominal pain,

>To relief Patient’s abdominal pain.

DONE

>Chloramphenicol 565mg/IVTT q8h

>Use to treat infetction specifically salmonella species.

DONE

>VSq4h with BP monitoring, WOF unusualities: bleeding and hypotension, refer

>To monitor the patient’s condition and monitor for any unusualties in the patient such bleeding and hypotension.

DONE

11/26/07 >Still for UA, blood GS/CS, 9:30am urine GS/CS >Cont. IVF @ SR >Cont. meds >VSq4h

>To monitor patients condition and assess for any abnormalities in the patient’s VS.

>I&OqS

> To determine if the kidneys function is now affected because Typhoid fever is complicated by Acute Oliguric Renal Failure.

9:45pm

43

XIII. Diagnostic and Laboratory Exams Date

Diagnostic Exam

11/24/07

COMPLETE BLOOD COUNT • Hgb

•

•

Hct

RBC count

Rationale

Normal value

Result

To evaluate blood loss, erythropoietic ability, anemia, and response to therapy.

135-175

L71 g/L

To evaluate blood loss, anemia, blood replacement therapy, and fluid balance, and screens red blood cell status. Also to evaluate dehydration and hypervolemia.

0.400.52

L0.20

To evaluate anemia and other conditions affecting red

4.206.10

L2.78x10 ^6/uL

Clinical significance

Increased: • Congenital heart disease • Hemoconcentration • Congestive heart failure • Chronic obstructive pulmonary disease • Dehydration Decreased: • Anemia • Hemolysis • Severe hemorrhage • Cancer • Kidney disease • Chronic hemorrhage • Nutritional deficiency • Lymphoma • Hemoglobinopathies

Increased: • Congestive heart disease • Hemoconcentration • Severe dehydration • Shock • Severe diarrhea Decreased: • Anemia • Cirrhosis • Hemolytic reaction • Dietary deficiency • Malnutrition • Hemorrhage Increased: • Congenital heart disease • Polycythemia vera/hemoconcentration • Cor pulmanale

Nursing considerations The CBC requires a sample of blood collected from a vein. The nurse or phlebotomist inserting the needle should clean the skin first. The tourniquet should be removed from the arm as soon as the blood flows. If a fingerstick is used to collect the blood, care must be taken to wipe away the first drop, and not to squeeze the finger excessively as this causes the blood to be diluted by tissue fluid. Many drugs affect the results by causing increased or decreased RBC, WBC, and/or platelet production. Medications should be taken into account when interpreting results. Discomfort or bruising may occur at the puncture site. Applying pressure to the puncture site until the bleeding stops helps to reduce bruising; warm packs relieve discomfort. Some people feel dizzy or faint after blood

44

• Pulmonary fibrosis • Severe diarrhea Decreased: • Hemorrhage • Hemolysis • Anemia • Chronic illness • Organ failure • Dietary deficiency

blood cells.

•

WBC count

To evaluate a number of conditions and differentiates causes of alterations in the total WBC count including inflammation, infection, tissue necrosis, and or leukemic neoplasm.

5.0-10.0

5.19x10^ 3/uL

Differential count • neutrophils 55-75

64

has been drawn and should be treated by resting awhile.

Increased: • Infection • Stress • Inflammation • Tissue necrosis • Trauma • Hemorrhage • Malignancies(particularly gastrointestinal, live, bone, and metastasis) • Toxins • Serum sickness Decreased: • Drug toxicity • Overwhelming infection • Autoimmune disease • Dietary deficiency • Bone marrow failure or depression • Drug toxicity Increased: • Bacterial infection including osteomyelitis, septicemia, otitis media, gonorrhea, salpingitis, endocarditis, or pneumonia • Parasitic infection • Tissue necrosis Decreased: • Typhoid infection • Brucellosis • Hepatitis • Influenza • Measles • Rubella • Mononucleosis or

45

• • •

Lymphocytes

•

Monocytes

•

Eosinophils

20-35

29

2-10

7

1-6

L0

tularemia SLE Aplastic anemia

Increased: • Viral infection including TB, hepatitis, mumps pertussis, syphilis, rubella,mononucleosis, cytomegalovirus, or other viral illnesses, lymphocytic leukemia, ulcerative colitis • chronic infection or an immune disease Decreased: • defective lymphatic circulation • chronic debilitating conditions such as CHF, renal failure, or advanced TB • Hodgkin’s disease or burns Increased: • TB • Hepatitis • Malaria • Rocky mountain spotted fever • SLE • Monocytic leukemia • Lymphomas • Chronic ulcerative colitis Decreased: • Does not have clinical significance related to disease; it may indicate positive response to prednisone treatment. Increased: • Allergic response • Serum sickness • Parasitic infection including hookworm, roundworm, amebiasis, or trichonosis. • Skin disorder • Neoplastic disorder • Ulcerative colitis • Pernicious anemia • Scarlet fever

46

• Autoimmune disease • Splenectomy Decreased: • Cushing’s syndrome • Trauma • Burns • Shock • Surgery • CHF • Aplastic anemia • Pernicious anemia •

Basophils

•

Platelet Count

To assist in the diagnosis of bleeding disorders

0-1

0

150-400

L125

Increased: • Chronic myelocytic leukemia • Polycythemia vera • Hodgkin’s disease • Ulcerative colitis • Nephrosis • Chronic hemolytic anemia Decreased: • Hyperthyroidism • Pregnancy • Stress response • Anaphylactic reactions • Steroid therapy

•

An abnormally low platelet level (thrombocytopenia) is a condition that may result from increased destruction of platelets, decreased production, or increased usage of platelets. In idiopathic thrombocytopenic purpura (ITP), platelets are destroyed at abnormally high rates. Another cause of a low platelet count is an enlarged spleen. Hypersplenism is characterized by the collection (sequestration) of platelets in the spleen. Disseminated intravascular coagulation (DIC) is a condition in which blood clots occur within blood vessels in a number of tissues.

47

Leukemia and aplastic anemia can result in a low platelet count because of decreased production of platelets in the bone marrow. All of these diseases produce reduced platelet counts. •

Abnormally high platelet levels (thrombocytosis) may indicate either a benign reaction to an infection, surgery, or certain medications; or a disease like polycythemia vera, in which the bone marrow produces too many platelets too quickly.

48

Date

Diagnostic Exam

11/25/07

COMPLETE BLOOD COUNT • Hgb

Rationale

Normal value

Result

To evaluate blood loss, erythropoietic ability, anemia, and response to therapy.

135-175

L59 g/L

0.400.52

L0.17

•

Hct

To evaluate blood loss, anemia, blood replacement therapy, and fluid balance, and screens red blood cell status. Also to evaluate dehydration and hypervolemia.

•

RBC count

To evaluate anemia and other conditions affecting red blood cells.

•

WBC count

To evaluate a number of conditions and differentiates causes of alterations in the total

L2.36x10^6/uL 4.206.10

5.18x10^3/uL 5.0-10.0

Clinical significance

Increased: • Congenital heart disease • Hemoconcentration • Congestive heart failure • Chronic obstructive pulmonary disease • Dehydration Decreased: • Anemia • Hemolysis • Severe hemorrhage • Cancer • Kidney disease • Chronic hemorrhage • Nutritional deficiency • Lymphoma • Hemoglobinopathies

Increased: • Congestive heart disease • Hemoconcentration • Severe dehydration • Shock • Severe diarrhea Decreased: • Anemia • Cirrhosis • Hemolytic reaction • Dietary deficiency • Malnutrition • Hemorrhage Increased: • Congenital heart disease • Polycythemia vera/hemoconcentration • Cor pulmanale • Pulmonary fibrosis • Severe diarrhea Decreased: • Hemorrhage • Hemolysis • Anemia • Chronic illness • Organ failure • Dietary deficiency

Increased: • Infection • Stress • Inflammation • Tissue necrosis • Trauma • Hemorrhage

49

Nursing considerations The CBC requires a sample of blood collected from a vein. The nurse or phlebotomist inserting the needle should clean the skin first. The tourniquet should be removed from the arm as soon as the blood flows. If a fingerstick is used to collect the blood, care must be taken to wipe away the first drop, and not to squeeze the finger excessively as this causes the blood to be diluted by tissue fluid. Many drugs affect the results by causing increased or decreased RBC, WBC, and/or platelet production. Medications should be taken into account when interpreting results. Discomfort or bruising may occur at the puncture site. Applying pressure to the puncture site until the bleeding stops helps to reduce bruising; warm packs relieve discomfort. Some people feel dizzy or faint after blood has been drawn and should be treated by resting awhile.

Date 11/26/07

Diagnostic exam URINALYSIS A. Physical Examination: • Color •

Appearance

•

Reaction/pH

•

Specific gravity

B. Chemical examination: • Albumin •

Rationale urinalyses are performed for several reasons: • general evaluation of health • diagnosis of metabolic or systemic diseases that affect kidney function • diagnosis of endocrine disorders. Twentyfour-hour urine studies are often ordered for these tests • diagnosis of diseases or disorders of the kidneys or urinary tract • monitoring of patients with diabetes

Normal Value

Clinical significance

Yellow Clear

Slightl cloudy

4.6-6.5

6.5

1.0161.022

1.020

negative

Trace

negative

Negativ e

Sugar

C. Microscopic exam:

Result

0-5

•

Urine may be cloudy (turbid) because it contains red or white blood cells, bacteria, fat, mucus, digestive fluid (chyle), or pus from a bladder or kidney infection.

Increased: • Respiratory alkalosis • Metabolic alkalosis • Urinary tract infection • Renal tubular acidosis Decreased: • Metabolic acidosis • Diabetes mellitus • Diarrhea • Respiratory acidosis

Increased: • Gylcosuria and proteinuria • Fever • Diarrhea • Dehydration • Decreased renal blood flow Decreased: • Diabetes insipidus • Renal failure • Diuresis • Overhydration • Glomerulonephritis

Nursing. Considerations Patients do not have to fast or change their food intake before a urine test. They should, however, avoid intense athletic training or heavy physical work before the test because it may result in small amounts of blood in the urine. Normal urine is a clear straw-colored liquid. It has a slight odor. It contains some crystals, a small number of cells from the tissues that line the bladder, and transparent (hyaline) casts. Normal urine does not contain sugars, yeast cells, protein, ketones, bacteria, or parasitic organisms. The time of day a urine sample is collected can make a difference in the appearance of the specimen. Some foods and medicines, including red beets, asparagus, and penicillin, can affect the color or smell of urine. 50 Although most color variations are harmless, they

Date 11/28/-7

Diagnostic Exam Serology • Typhidot

Rationale It is a dot ELISA kit which detects IgM and IgG antibodies against S. Typhi. It uses a specific antigen on the outer membrane of S.Typhi dotted on nitrocellulose strips and for detecting the resulting antigen antibody complex, peroxidase conjugated anti human IgG and IgM and a chromogenic substrate are employed.

Normal value

Result

IgM

+

IgG

+

Clinical significance

Nursing considerations

Positive control gives blue colour dots, - blood culture positive for salmonella agglutinating bodies, indicative of salmenonella infection

51

XIV. Drug Study

52

XV. Nursing Theories Nightingales Environmental Theory Florence Nightingale, often considered the first nurse theorist, defined nursing over 100 years ago as "the act of utilizing the environment of the patient to assist him in his recovery". She linked health with five environmental factors: pure or fresh air , pure water ,efficient drainage , cleanliness , light, especially direct sunlight. Nightingale's environmental factors attain significance when one considers that sanitation conditions in hospitals of the mid-1800s were extremely poor and that women working in the hospitals were often unreliable, uneducated, and incompetent to care for the ill. In addition to those factors, Nightingale also stressed the importance of keeping the client warm, maintaining a noise-free environment, and attending to the client's diet in terms of assessing intake, timeliness of the food, and its effect on the person. Nightingale set the stage for further work in the development of nursing theories. Her general concepts about ventilation, cleanliness, quiet, warmth, and diet remain integral parts of nursing and health care today.

53

The case of our patient is Typhoid fever. The cause of Typhoid is Salmonella. The mode of acquiring the bacteria and so as the disease itself is through fecal-oral mode of transmission. The bacteria is easily transmitted especially to unsanitary places or objects. In order to provide care for our patient, we need to eradicate it’s reservoir in order to prevent the bacteria’s survival and stop or prevent it’s transmission and so as help the affected clients recover from the infection and also protecting his family. We need to promote and maintain a clean environment conducive for a healthy living and not for bacteria. We need to provide clean water and foods. Proper food handling and washing before and after every procedure done should be well observed and maintained and so as for the patient and family. They should practice having a safe food and safe eating and living environment. Also, we need to provide a well balanced diet for the patient in order to hydrate and fulfill the metabolic demands. Good ventilation and comfort should also be promoted so that our patient will feel quite relaxed and have a happy and healthy disposition. All in all, this sums up to promoting wellness.

Dorothy Johnson Behavioral System (JBS) Model Johnson states that a nurse should use the behavioral system as their knowledge base, comparable to the biological system that physicians use as their base of knowledge. The reason Johnson chose the behavioral system model is the idea that "all the patterned, repetitive, purposeful ways of behaving that characterize each person's life make up an organized and integrated whole, or a system".

Johnson states that by categorizing

behaviors, they can be predicted and ordered. Johnson categorized all human behavior into seven subsystems: Attachment, Achievement, Aggressive, Dependence, Sexual, Ingestive, and Eliminative. Each subsystem is composed of a set of behavioral responses or tendencies that share a common goal. These responses are developed through experience and learning and are determined by numerous physical, biological, psychological, and social factors. Four assumptions are made about the structure and function of each subsystems. These four assumptions are the "structural elements" common to each of the seven Subsystems. The first assumption is "from the form the

54

behavior takes and the consequences it achieves can be inferred what drive has been stimulated or what goal is being sought". The ultimate goal for each subsystem is expected to be the same for all individuals. First, we need to know and study the patient’s behavior with regards to his present condition. What he does and what’s his purpose for doing such act. Is he seeking for something for doing such actions? If so, what is it and why is he doing such action and what thing does he want to achieve. Next, we should set a goal for the patient of what we want to attain for him and that requires his cooperation. Regarding his behavior we nurses needs to assess it if his behavior are appropriate and in favor for his recovery and not detrimental for his health. We as an outside being and could see overt behaviors should note what individual actions the patient is taking for the improvement of one’s recovery. We need to asses his behaviors towards his present condition so that we will also know what type of care is suited for the patient. After doing the above methodology of assessing and taking a role in the patients behavior, we now need to nurture the patients appropriate behaviors through providing an environment favorable for ones actions some of which are approval, attention and recognition and so as physical assistance. Finally each of the subsystems must be stimulated further and be improved continuously in order to enhance growth and prevent stagnation. Now, these systems needs to remain orderly and predictable for the patient to care to be maintained or be at continues cycle.

Jean Watsons Caring Theory Let us concentrate on the Ten Carative Factors by Watson: 1. Formation of a Humanistic-altruistic system of values. 2. Instillation of faith-hope. 3. Cultivation of sensitivity to one's self and to others. 4. Development of a helping-trusting, human caring relationship.

55

5. Promotion and acceptance of the expression of positive and negative feelings. 6. Systematic use of a creative problem-solving caring process. 7. Promotion of transpersonal teaching-learning. 8. Provision for a supportive, protective, and/or corrective mental, physical, societal, and spiritual environment. 9. Assistance with gratification of human needs. 10. Allowance for existential-phenomenological-spiritual forces. With regards to our care for our patien, Kyle, in order to promote his wellness and help him recover from his illness. We could apply Watson’s Caring theory: First, we should establish a loving-kindness relationship to our patient within nursing care consciousness. Second, is being authentically present, and enabling and sustaining a hope and belief and subjective life world of self and one-being-cared- for. Third, Cultivation of one's own spiritual practices and transpersonal self, going beyond ones ego or wants in order to know and attain what is right and what is deemed needed. Fourth, developing and sustaining a helping-trusting, authentic caring relationship or establishing rapport. Fifth, being present and supportive of the expression of positive and negative feelings as a connection with deeper spirit of self and the one-being-cared-for or being open-minded regarding the patient’s feedbacks, thinking, and condition. Sixth, Creative use of self and all ways of knowing as part of the caring process to engage in artistry of caring-healing practices.

56

Seventh, engaging in genuine teaching-learning experience that attends to the patients health care needs. Eight, creating healing environment at all levels, physical, social, emotional, mental, spiritual, and consciousness. Thereby, wholeness, beauty, comfort, dignity, and peace must be enhanced. Ninth, assisting with basic needs, with an intentional caring consciousness, administering ‘human care essentials' and examples of needs maybe according to Maslow’s hierarchy of needs. Tenth, Opening and attending to spiritual-mysterious and existential dimensions of one's own life-death, soul care for self and the one-being-cared-for and so in attending to the patient we should be open-minded regarding the patient’s beliefs.

57

XVI. Nursing Care Plans

58

XVII. Health Teachings 1.

Wash your hands. Frequent hand washing is the best way to control infection.

Wash your hands thoroughly with hot, soapy water, especially before eating or preparing food and after using the toilet. Carry an alcohol-based hand rub for times when water isn't available. 2.

Avoid untreated water. Contaminated drinking water is a particular problem in

areas where typhoid is endemic. For that reason, drink only bottled water or canned or bottled carbonated beverages, wine and beer. Carbonated bottled water is safer than still water is. Wipe the outside of all bottles and cans before you open them. Ask for drinks without ice. Use bottled water to brush your teeth, and try not to swallow water in the shower. 3.

Avoid raw fruits and vegetables. Because raw produce may have been washed in

unsafe water, avoid fruits and vegetables that you can't peel, especially lettuce. To be absolutely safe, you may want to avoid raw foods entirely. 4.

Choose hot foods. Avoid food that's stored or served at room temperature.

Steaming hot foods are best. And although there's no guarantee that meals served at the

59

finest restaurants are safe, it's best to avoid food from street vendors — it's more likely to be contaminated. 5.

Get Vaccinated- Typhoid fever vaccine. one is injected in a single dose, and the

other is administered orally over a period of days. Neither is 100 percent effective, and both require repeat vaccinations. 6.

Appropriate systems for human waste disposal must be available. S.typhi can

only be shed through human feces. It is therefore of utmost importance that human waste be disposed in a most appropriate manner to avoid spread of bacteria. To prevent infecting others If you're recovering from typhoid or paratyphoid, these measures can help keep others safe: 1.

Wash your hands often. This is the single most important thing you can do to

keep from spreading the infection to others. Use plenty of hot, soapy water and scrub thoroughly for at least 30 seconds, especially before eating and after using the toilet. 2.

Clean household items daily. Clean toilets, door handles, telephone receivers and

taps at least once a day with a household cleaner and paper towels or disposable cloths. 3.

Avoid handling food. Avoid preparing food for others until your doctor says

you're no longer contagious. If you work in the food service industry or a health care facility, you won't be allowed to return to work until tests show that you're no longer shedding typhoid bacteria. 4.

Keep personal items separate. Set aside towels, bed linen and utensils for your

own use and wash them frequently in hot, soapy water. Heavily soiled items can be soaked first in disinfectant.

60

XVIII. DISCHARGE PLAN Medication *Cephalosporins (sef-a-loe-SPOR-ins) are used in the treatment of infections caused by bacteria. They work by killing bacteria or

preventing their growth.

-Cephalosporins may be taken on a full or empty stomach. If this medicine upsets your stomach, it may help to take it with food. * Ampicillin are used to reduce the development of drug-resistant bacteria and maintain the effectiveness of Ampicillin and other antibacterial drugs, Ampicillin should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria. *Ciprofloxacin is used to treat bacterial infections in many different parts of the body. They work by killing bacteria or preventing their growth.

Exercise *Regular exercises aides in achieving and maintaining an optimum level of wellness and health. This may help in avoiding diseases and disorders.

61

Treatment/therapy *Water therapy helps in recovery from the illness.

Hygiene *S.typhi is shed in human feces. Advise the patient to maintain proper hygiene, especially after voiding to avoid spreading the disease. *Advise the patient not to handle food or participate in food preparation. *Educate significant others on importance of sanitary food preparation.

Outpatient 1. Water must be properly filtered and boiled before drinking if it is from an unreliable source. 2.

Food must be properly washed and then cooked

3. One must not eat or drink in suspected unhygienic or unreliable places. 4. Express importance of compliance to prescribed mediations.

Diet Diet: Rich in Carbohydrates, proteins and fats 1. Food must be simple and easy to digest, avoid all kinds of spices on food. 2. Food should be cooked well, but not overcooked as that would make it difficult to digest. 3. If diarrheas develop in typhoid increase fluid intake such as soups, curries, gravies and fruit juice. Vitamin B and C foods must be consumed in order to compensate for the losses of those vitamins. 4. Eggs and milks are suitable proteins that can be consumed during typhoid fever. 5. Vegetables oils and milk products such as butter, cheese, cream and emulsified fats can be consumed. Wheat, rice, potatoes and other foods that are high in carbohydrates are advised

62

XIX. Prognosis CRITERIA 1.Onset of

POOR 

FAIR

illness

GOOD

JUSTIFICATION The progression of thypoid fever includes an incubation period of 2-3 weeks, in which the first week is asymptomatic. This explains why the client sought admission only when symptoms began to appear and the bacteria were already in systemic

2. Duration of illness



circulation. As of the writing of this study, the client has had the illness for almost 3 weeks. He began proper treatment 9 days after the appearance of symptoms, which would suggest that the disease is already

in

its

second

week

of

progression. We rated this parameter fair because proper treatment was given at just the right time, although the patient could have sought professional

63

3. Precipitating



factors

help sooner. Health teachings were given to the patient and his family regarding the causes of the disease. The precipitating factors of this case were highly modifiable and so we gave this

4. Attitude and



parameter a “good” rating. Kyle was very willing to take his

willingness to

medications and he and his family were

take medication

observed to have complied with the treatment regimen being given. As for this reason, we rated this parameter as

5. Family



Support

good. Kyle’s family is very supportive as provided whatever they could to help in their son’s recovery. They also listened intently when health teachings were being given to prevent reoccurrence of

6. Age



the disease. Tyhpoid fever does not affect a specific age group. It can be acquired by anyone who accidentally ingests the S.typhi

7. Environment



bacteria. The family’s house is situated near a river wherein which carabaos bathe and other humans defecate. Kyle is fond of swimming in the river which may cause infection due to the contaminated water.



POOR: Onset of Illness, Environment



FAIR: Duration of Illness, Age

64



GOOD: Precipitating Factors, Attitude & Willingness to Take Medication, Family Support

Computation: Number of categories rated POOR x1 + Number of categories rated FAIR x2 + Number of categories GOOD x3 divided by TOTAL number of categories = score of general prognosis. = 2 + 2(2) + 3(3) = 2+4+9 = 15/7 =

2.1 (Good)

Scoring for general Prognosis: 1 – 1.6 = POOR 1.7 – 2.3 = FAIR 2.4 – 3.0 = GOOD General Prognosis: Based on above criteria, our patient Kyle has a good prognosis.

65

I. References •

Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Geissler-Murr, Nursing Care Plans Guidelines for Individualizing Nursing Care, 6th Edition, Copyright © 2002 F.A. Davis Company

•

Suzanne C. Smeltzer, Brenda G. Bare, Brunner and Suddhart’s Textbook of Maedical-Surgical Nursing, 10th Edition, Copyright by Lippincott William and Wilkins, 2004

•

Barbara Kozier, Glenora Erb, Audrey Berman, Shirlee Snyder, Fundamentals of Nursing, Concepts, Procxess and Practice, 7th Edition, Philippine Edition published by PEARSON EDUCATION SOUTH ASIA LTD., Copyright © 2004

66

•

Marrilynn E. Doenges, Mary Frances Moorhouse, Alice C. Geissler-Murr, Nurse’s Pocket Guide, Diagnoses, Interventions and Rationales, 9th Edition, Copyright © 2004 by F.A. Davis Company

•

Sylvia A. Price, Lorraine M. Wilson, Pathophysiology, Clinical Concepts of Disease Process, 4th Edition, Copyright © 1992 by Mosby-Year Book, Inc.

•

Wilson, Shannon, Stang, Prentice Hall, Nurse’s Drug Guide 2005, Copyright © 2005 by Pearson Education, Inc., Upper Saddle River, NJ 07458

•

Amy M. Karch, 2003 Lippincott’s Nursing Drug Guide, Copyright © 2003 by Lippincott Williams and Wilkins

•

Rick Daniek, Nursing fundamentals, Caring and Clinical Decision Making, Thanson Asian Edition, Copyright © 2004 by Delmar, a division of Thomsom Learning, Copyright © 2002 by F.A. Davis Company

•

Marilyn E. Doenges, Macy Frances Moorhouse, Nurse’s Pocket Guide: Nursing Diagnoses with interventions, 3rd Edition, Copyright © 1991 by F.A. Davis Company

67

•

Edited by: William A. Sodeman, Pathologic Physiology Mechanisms of Disease, Illustrated, 2nd Edition, Copyright, 150, by W.B. Saunders Company

Internet Sources: -

http://www.metagenics.com/ADAM/41/024200.html

-

http://en.wikipedia.org/wiki/Typhoid_fever

-

http://www.ecureme.com/emyhealth/data/Enteric_Fever.asp

68