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 15-
December 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 life-
threatening. 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 by the cells. Chemical
digestion, through a process called
hydrolysis, uses water and 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:

factor actual rationale

Genes X Salmonella typhi is shed
only in human feces and is
transmitted via the fecal-
oral route of infection. It is
therefore a non-hereditary
disease.
Age X 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.
Sex X Both sexes can acquire
typhoid fever through the
ingestion of contaminated
food or water.
Socio-Economic Status 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

34

Precipitating Factors:
Environment  The family at the moment
Unsanitary food handling  The Family does practice
Ingestion of Contaminated  Kyle is always swimming
Foods.
needs in order for the living
to be more comfortable and
to buy all the medicines
needed.
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
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.
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 fecal-
oral 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  The father said that there are

food a lot of food flies, rats and
cockroaches in their kitchen
that must have contaminated
the prepared food.

36
 X. Symptomatology

symptoms actual rationale

1. Fever  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.
2. Burning Micturition X Not Present.
3. Gastroenteritis  S.typhi, which is present within
his stomach, elicits an
inflammatory reaction as the body
tries to combat the infection.
4. Diarrhea  Diarrhea is one of the body’s
methods of releasing infectious
bacteria before it gets a chance to
proliferate.
5. Headache X Not Present.
6. Abdominal Pain  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.
7. Body Ache X Not Present.
8. Dry Cough  Bacteria can reach the lungs as
contaminated blood enters the

37
 lungs for oxygenation. This elicits
a response in the form of
unproductive cough,
9. Constipation X Not Present.
10. Anorexia  Fever causes decreased
functioning of the taste buds.
Frequent vomiting may also cause
loss of appetite.
11. Vomiting  Vomiting is a result of reflux of
gastric contents due to the
inflamed intestinal lining.
12. Hepatomegaly  The liver is one site for bacterial
multiplication in cases of typhoid
fever, and this causes the liver to
increase in volume.
13. Toxemia  Typhoid fever is often associated
with bacteria within the blood
stream which can be considered
as toxins.
14. Splenomegaly X Not Present.
15. Ileus X Not Present.
16. Intestinal Perforation X Not Present.
17. Gastrointestinal X Not Present.
Bleeding
18. Typhoid X Not Present.
Encephalopathy
19. Leukocytosis  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.
20. Rose Spots X Not Present.
21. Endocarditis X Not Present.

38
XI. Pathophysiology

39
Predisposing Factors: Precipitating Factors:

o Genes o Environment
o Age S.typhi is shed in o Unsanitary Food
o Sex human feces Handling
o Socio-economic o Ingestion of
Status Contaminated
Contamination of food 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
Constant exposure to
bacteria
Macrophages from Peyer’s
patches engulf bacteria
Inflammation

S.typhi injects effector

proteins into macrophage
Necrosis

Normal cellular activities are

diverted
Intestinal Bowel
bleeding perforation
Bacteria survives and
multiplies within
macrophage -Blood in vomitus
-Abdominal pain
-Gastroenteritis

Macrophages carrying bacteria

accumulate in Peyer’s patches Bacteria passes through thoracic
duct and enters the bloodstream

Phagocytes undergo lyses and release

bacteria into nearby lymphatic ducts Primary Bacteremia
(Asymptomatic)

Bacteria disseminate to regional lymph

nodes
40
 Bacteria spread to other cells of
Bacteria is shed into the blood reticuloendothelial system (including
stream spleen, liver, and gallbladder)

-Fever
-Headache Secondary Bacteremia
-Abdominal Pain Bacterial growth
within spleen and liver

Infection spreads to other

systems
-Splenomegaly
-Hepatomegaly

-Endocarditis
Changes brought about by sepsis
-Renal Failure
accumulate in the heart, brain, and
-Brain Infxn
kidneys

IF NOT
IF TREATED:
TREATED:

Overwhelming Antibiotic Therapy

sepsis

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

41
XII. Doctor’s Order

42
 Date Order Rationale Remarks
11/25/07 >Pls. admit to SVI, level 2, red2 DONE
>DAT except for DCF
>Dxs:
• CBC, platelet count >To assess the patient for
infection, anemia and any DONE
disorders.

• UA >To assess for any

abnormalities within the
urinary system as well as for DONE
systemic problems that may
manifest symptoms through
the urinary tract.

• Blood GS/CS
• Urine GS/CS

• Typhidot IgM and IgB >To detect Typhoid fever and

any other salmonella DONE
infection.

>IVF: D5LR 1L to run @56cc/h >To prevent patient from

dehydration and maintain DONE
adequate electrolyte and fluid
balance.

>Meds: Ranitidine 20mg/ IVTT >To relief Patient’s DONE

q8h prn for abdominal pain, abdominal pain.

>Chloramphenicol >Use to treat infetction DONE

565mg/IVTT q8h specifically salmonella
species.

>VSq4h with BP monitoring, >To monitor the patient’s

WOF unusualities: bleeding and condition and monitor for any DONE
hypotension, refer unusualties in the patient such
bleeding and hypotension.
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
9:45pm abnormalities in the patient’s
VS.

>I&OqS > To determine if the kidneys

function is now affected
because Typhoid fever is
complicated by Acute 43
Oliguric Renal Failure.
 XIII. Diagnostic and Laboratory Exams

Date Diagnostic Exam Rationale Normal Result Clinical significance Nursing

value considerations
11/24/07 COMPLETE BLOOD The CBC requires
COUNT a sample of blood
• Hgb To evaluate 135-175 L71 g/L Increased: collected from a
blood loss, • Congenital heart disease vein. The nurse or
erythropoietic • Hemoconcentration phlebotomist
ability, • Congestive heart failure inserting the needle
anemia, and • Chronic obstructive should clean the
response to pulmonary disease skin first. The
therapy. • Dehydration tourniquet should
Decreased: be removed from
the arm as soon as
• Anemia
the blood flows. If
• Hemolysis a fingerstick is
• Severe hemorrhage used to collect the
• Cancer blood, care must be
• Kidney disease taken to wipe away
• Chronic hemorrhage the first drop, and
• Nutritional deficiency not to squeeze the
• Lymphoma finger excessively
• Hemoglobinopathies as this causes the
blood to be diluted
by tissue fluid.
Many drugs affect
the results by
• Hct To evaluate 0.40- L0.20 Increased: causing increased
blood loss, 0.52 • Congestive heart disease or decreased RBC,
anemia, blood • Hemoconcentration WBC, and/or
replacement • Severe dehydration platelet production.
therapy, and Medications should
• Shock
fluid balance, be taken into
• Severe diarrhea
and screens account when
Decreased:
red blood cell interpreting results.
status. Also to • Anemia
evaluate • Cirrhosis Discomfort or
dehydration • Hemolytic reaction bruising may occur
and • Dietary deficiency at the puncture site.
hypervolemia. • Malnutrition Applying pressure
• Hemorrhage to the puncture site
until the bleeding
Increased: stops helps to
• RBC count To evaluate L2.78x10 • Congenital heart disease reduce bruising;
anemia and 4.20- ^6/uL • Polycythemia warm packs relieve
other 6.10 vera/hemoconcentration discomfort. Some
conditions • Cor pulmanale people feel dizzy or
affecting red faint after blood

44
 blood cells. • Pulmonary fibrosis has been drawn and
• Severe diarrhea should be treated
Decreased: by resting awhile.
• Hemorrhage
• Hemolysis
• Anemia
• Chronic illness
• Organ failure
• Dietary deficiency

• WBC count To evaluate a

number of
conditions 5.19x10^ Increased:
and 5.0-10.0 3/uL • Infection
differentiates • Stress
causes of • Inflammation
alterations in • Tissue necrosis
the total • Trauma
WBC count • Hemorrhage
including • Malignancies(particularly
inflammation, gastrointestinal, live,
infection, bone, and metastasis)
tissue • Toxins
necrosis, and • Serum sickness
or leukemic Decreased:
neoplasm.
• Drug toxicity
• Overwhelming infection
• Autoimmune disease
• Dietary deficiency
• Bone marrow failure or
depression
• Drug toxicity
Differential count
• neutrophils
Increased:
55-75 64 • 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
 tularemia
• SLE
• Aplastic anemia

• Lymphocytes Increased:
20-35 29 • 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
• Monocytes Increased:
2-10 7
• 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.

• Eosinophils Increased:
1-6 L0 • 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 0-1 0 Increased:

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

To assist in • An abnormally low

• Platelet Count the diagnosis 150-400 L125 platelet level
of bleeding (thrombocytopenia) is a
disorders 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 Rationale Normal Result Clinical significance Nursing
value considerations
11/25/07 COMPLETE BLOOD The CBC
COUNT requires a
• Hgb To evaluate 135-175 L59 g/L Increased: sample of blood
blood loss, • Congenital heart disease collected from a
erythropoietic • Hemoconcentration vein. The nurse
ability, • Congestive heart failure or phlebotomist
anemia, and • Chronic obstructive inserting the
response to pulmonary disease needle should
therapy. • Dehydration clean the skin
Decreased: first. The
tourniquet
• Anemia
should be
• Hemolysis removed from
• Severe hemorrhage the arm as soon
• Cancer as the blood
• Kidney disease flows. If a
• Chronic hemorrhage fingerstick is
• Nutritional deficiency used to collect
• Lymphoma the blood, care
• Hemoglobinopathies must be taken to
wipe away the
first drop, and
not to squeeze
the finger
• Hct To evaluate 0.40- L0.17 Increased: excessively as
blood loss, 0.52 • Congestive heart disease this causes the
anemia, blood • Hemoconcentration blood to be
replacement • Severe dehydration diluted by tissue
therapy, and fluid. Many
• Shock
fluid balance, drugs affect the
• Severe diarrhea
and screens results by
Decreased:
red blood cell causing
status. Also to • Anemia increased or
evaluate • Cirrhosis decreased RBC,
dehydration • Hemolytic reaction WBC, and/or
and • Dietary deficiency platelet
hypervolemia. • Malnutrition production.
• Hemorrhage Medications
should be taken
Increased: into account
• RBC count To evaluate L2.36x10^6/uL • Congenital heart disease when
anemia and 4.20- • Polycythemia interpreting
other 6.10 vera/hemoconcentration results.
conditions • Cor pulmanale
affecting red • Pulmonary fibrosis Discomfort or
blood cells. bruising may
• Severe diarrhea
occur at the
Decreased:
puncture site.
• Hemorrhage
Applying
• Hemolysis pressure to the
• Anemia puncture site
• Chronic illness until the
• Organ failure bleeding stops
• Dietary deficiency helps to reduce
bruising; warm
packs relieve
discomfort.
Some people feel
• WBC count To evaluate a dizzy or faint
number of 5.18x10^3/uL Increased: after blood has
conditions • Infection been drawn and
and 5.0-10.0 • Stress should be treated
differentiates • Inflammation 49 by resting
causes of • Tissue necrosis awhile.
alterations in • Trauma
the total
• Hemorrhage
Date Diagnostic exam Rationale Normal Result Clinical significance Nursing.
Value Considerations
11/26/07 URINALYSIS urinalyses are Patients do not
A. Physical performed for have to fast or
Examination: several reasons: change their
• Color • general Yellow food intake
evaluation • Urine may be cloudy before a urine
• Appearance of health Clear Slightl (turbid) because it test. They
• diagnosis cloudy contains red or white should,
of blood cells, bacteria, however,
metabolic fat, mucus, digestive avoid intense
or fluid (chyle), or pus athletic
systemic from a bladder or training or
diseases kidney infection. heavy physical
that affect work before
kidney the test
function because it may
• diagnosis result in small
of amounts of
endocrine blood in the
disorders. urine.
Twenty-
four-hour Increased: Normal
• Reaction/pH urine 4.6-6.5 6.5 • Respiratory urine is a clear
studies are alkalosis straw-colored
often • Metabolic alkalosis liquid. It has a
ordered • Urinary tract slight odor. It
for these infection contains some
tests • Renal tubular crystals, a
• diagnosis acidosis small number
of diseases Decreased: of cells from
or • Metabolic acidosis the tissues that
disorders • Diabetes mellitus line the
of the bladder, and
• Diarrhea
kidneys or transparent
• Respiratory
urinary (hyaline)
acidosis
tract casts. Normal
• monitoring urine does not
of patients contain sugars,
with yeast cells,
diabetes protein,
ketones,
bacteria, or
parasitic
1.016- 1.020 Increased:
• Specific organisms.
1.022 • Gylcosuria and
gravity
proteinuria
The time of
• Fever
day a urine
• Diarrhea
sample is
• Dehydration collected can
• Decreased renal make a
blood flow difference in
Decreased: the appearance
• Diabetes insipidus of the
• Renal failure specimen.
• Diuresis Some foods
• Overhydration and medicines,
• Glomerulonephritis including red
beets,
asparagus, and
B. Chemical negative Trace penicillin, can
examination: affect the
• Albumin negative Negativ color or smell
e of urine.
• Sugar 50
Although most
color
C. Microscopic variations are
0-5 harmless, they
exam:
 Date Diagnostic Exam Rationale Normal Result Clinical significance Nursing
value considerations
11/28/-7 Serology It is a dot ELISA Positive control gives blue
• Typhidot kit which detects IgM + colour dots,
IgM and IgG - blood culture positive for
antibodies against IgG + salmonella agglutinating
S. Typhi. It uses a bodies, indicative of
specific antigen on salmenonella infection
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.

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 POOR FAIR GOOD JUSTIFICATION
1.Onset of  The progression of thypoid fever
illness 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
circulation.
2. Duration of  As of the writing of this study, the
illness 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
 help sooner.
3. Precipitating  Health teachings were given to the
factors patient and his family regarding the
causes of the disease. The precipitating
factors of this case were highly
modifiable and so we gave this
parameter a “good” rating.
4. Attitude and  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
good.
5. Family  Kyle’s family is very supportive as
Support 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
the disease.
6. Age  Tyhpoid fever does not affect a specific
age group. It can be acquired by anyone
who accidentally ingests the S.typhi
bacteria.
7. Environment  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