PNO NONESCOST: College of Nursing NCM 103 Care for Client with Problems in Fluids and Electrolytes, Oxygenation,

n, Cardiovascular, Digestive and Endocrine System

Medical Case Presentation on Typhoid Fever t/c Hepatitis

Presented to: Andrea Marie A. Boherom, RN, MN Jan Leynard D. Camposagrado, RN, MN Maria Theresa M. Espartero, RN, MN Level III Clinical Instructors Christine A. Garzon, RN, MN

Presented by: BSN III A

INTRODUCTION Nature was design to cater various forms of relationships to maintain ecological balance but at some point in time, one element harms another for in this life, only the fittest will survive and eventually, reign this land. Moreover, if humans are talkative creature when it comes to their needs, what more are those tiny constituents of life? Indeed, small things make good instrument for pricking the eye. Worse, bacteria cant be seen by the naked eye. Truth is they are everywhere. In fact, they are as close to you as the air you breathe. They are even inside you waiting for the exact and proper time for predation without you knowing it. Exactly what happened to Mary Mallon, a cook who made herself famous in America during the early 1900s as the first person to be identified as a healthy carrier of typhoid fever. Poor Mary, she was quarantined till she died at age of 69. Typhoid fever is more than just a fever. In fact, it is a systemic infection having complications ranging from respiratory infections such as pneumonia to kidney failure. The word typhoid came from the Salmonella species that caused it --- the S. typhi. With more than 22 million cases and 216,000 related deaths worldwide, enteric fever, as what it is also called, has continued also to affect vulnerable communities in the Philippines. Moreover, here in Negros Occidental, the case has risen by 60 percent in Negros Occidental with 365 cases from January to March this year; most concern areas are Calatrava, Kabankalan City and San Carlos City. (Flutracker.com, 2012) With clinical manifestations that could predispose individuals to more serious pathologic condition, it is very alarming especially that this can easily be transmitted through fecal-oral route and that improper food handling is one of the major causal factor. We, the BSN III-A, chose this case due to its high prevalence rate during our ward exposure and that the common notion of patients is that this is just an ordinary fever caused by a specific bacteria species. As the trend on board exam covers topics about community health nursing, our case could match it with the community settings since water services and sanitation in the environment are the factors where the disease could be taken from. This is like a challenge and a call for us as healthcare provider to show now how effective are we when it comes to health teaching, as one of the instruments to prevent this problem to affect the community. The continual threat from waterborne outbreaks brings an increase in the number of affected population and as long as environmental degradation goes on unabated in our cities, these diseases will continue to haunt us. So calm your nerves and listen for nurses are also not immune to this condition.

OBJECTIVES General Objective: Within 4 hours of case presentation, the group will be able to facilitate learning in the delivery of the case presentation about a client with typhoid fever t/c hepatitis to the class and the panel. Specific Objectives: Within 4 hours of case presentation, the group will be able to: Knowledge 1. Enumerate the factors that predisposed client to typhoid fever t/c hepatitis to the class. 2. Discuss with the class the anatomy and physiology of the digestive system. 3. Discuss with the class the significant laboratory results related to clients health condition. 4. Explain the pathophysiology of the clients disease condition to the class. 5. Present to the class the medications given to the client, its classification, indication, route, dosage, its mechanism of action and side effects evidently. Skills 1. Provide an environment conducive for learning (e.g. establishment of adequate light and ventilation, providing enough seats and use of LCD projector). 2. Perform roles assigned to us in reporting the case of the client with typhoid fever t/c hepatitis respectively. 3. Present accurate and reliable data to the class and the panellists for the achievement of the desired goals for the client. 4. Provide the class and panelists a time to raise questions and clarifications for further understanding of the case presented. 5. Note all corrections and suggestions made by the class and clinical instructors to improve the presentation. Attitude 1. Maintain the established good working relationship within the group. 2. Display confidence in presenting the case. 3. Maintain confidentiality of the clients records althroughout the case presentation. 4. Provide an honest answer to the questions of the class and panellists. 5. Accept comments, suggestions and corrections of the panelists positively.

GENERAL DATA OF THE CLIENT A. Clients Clinical Data Name: G. M. Address: Prk. Paglaum, Brgy. Zone 2, Cadiz City Gender: Male Age: 29 y/o Marital Status: Single Date of Birth: March 3, 1983 Place of Birth: Purok Paglaum, Brgy. Zone 2, Cadiz City Nationality: Filipino Religion: Roman Catholic Educational Attainment: HS undergraduate (3rd year) Occupation: Fisherman B. Admission Data Date of Admission: September 23, 2012 Time of Admission: 3:30 PM Chief Complaint: on and off fever Diagnosis: Typhoid Fever t/c hepatitis Attending Physician: Dr. S Vital signs upon admission: Temperature: 36 OC Pulse Rate: 66 beats per minute Respiratory Rate: 20 cycles per minute Blood Pressure: 110/80 mmHg Weight (prior to admission): 50 kg (upon admission): 43.4 Height: 55 BMI (prior to admission): 19.5

(upon admission): 16.9

Vital signs during shift: October 2,2012 ( 12nn) Temperature: 38.3 0C Pulse Rate: 83 beats per minute Respiratory Rate: 29 cycles per minute Blood Pressure: 100/80 mmHg PAIN SCALE: 7 of 10 GENERAL APPEARANCE Upon assessment, patient was awake, conscious and coherent as of place, time and date, lying on bed in supine position. Intravenous fluid is PNSS 1 L regulated at 80 cc/hour on the left hand. He is a thin person with noticeable bony prominences (weighs 43.4 kg. upon admission). Right upper quadrant protrusion of the abdomen and jaundice of the sclera of the eyes were noted. PAST MEDICAL HISTORY Patient claimed that he has no previous hospitalization ever since he was a child HISTORY OF PRESENT ILLNESS o Seven months prior to hospitalization (February 2012), patient G.M. went to Roxas City to work as a fisherman. Sometimes he stays for a week together with his fellow fishermen at the sea. They utilize a drum as a container for their drinking water, they cook rice and most of the times they have fish for their viand, either cooked or eaten raw. o One month prior to hospitalization (August 23), he started having fever. After few days of intermittent fever, he was alarmed and decided to go to Roxas City Health Center for consultation. There, he was required to undergo x-ray and the doctor diagnosed him having pneumonia. He was given medications for that condition.

o Three weeks prior to hospitalization (August 28), he returned home to Cadiz City. Hes still having intermittent fever and still taking his medications for pneumonia. That same day he started feeling pain on the right upper quadrant of his abdomen. Five days later, his mother decided to let him have another check-up at Don Bernardo Benedicto Cadiz Emergency Clinic. Complete Blood Count (CBC) was done to check if he has dengue hemorrhagic fever. The result was negative. Also, he was diagnosed with Urinary Tract Infection. He completed 5 days of medications for infection. Because of his mothers belief of faith healers, they also consulted one for such. o Two weeks prior to hospitalization, his fever still persists so they decided to have another check-up to a private doctor. His CBC findings tell that he has an infection. He was given medications for 4 days but was unable to comply on the last day. o Still unconvinced about his condition, he went to Cadiz District Hospital for consultation. He had low hemoglobin count according to the CBC conducted. He was then advised to secure 1 pack of whole blood and return to the hospital for BT. o Patient G.M. was brought to the hospital September 23 by his mother when he complained of on and off fever which started almost a month ago. o October 1, 2012 when the patient undergone blood transfusion (#1 whole blood, type O positive) PERSONAL AND SOCIAL HISTORY Patient claimed that he consumes 2-3 cigarette sticks/day and involves in drinking sessions 2-3 times a week, per drinking session they can consumed 3-4 bottles of liquor. His usual diet is composed of bread and coffee at breakfast, rice, vegetable soup and fish for lunch while rice and fish for dinner. He sparingly includes canned foods and noodles in his diet. His daily activities includes going with his father to fish and socializing with his friends in the community and sometimes doing household chores. The patient takes a bath every day, brushes his teeth twice a day and does nail care as necessary. His form of exercise is brisk walking and doing his work. At the hospital, his 24 hour diet recall mainly consists of rice and hotdog in the morning, rice and tinolang isda for lunch rice and vegetable soup for dinner. Due to weakness he seldom interacts with other patient. PRESENT COMPLAINT Patient complains of on and off fever with continuous right upper quadrant pain and decreased intensity when he changes position.

FAMILY HISTORY DISEASE HYPERTENSION DIABETES MELLITUS ASTHMA PATERNAL (+) (-) (-) PHYSICAL ASSESSMENT HEENT: Head: Ears Eyes Light yellowish sclera Pupils are equally round reactive to light and accommodation eyelids are intact with no lesions no edema or tenderness over lacrimal gland Symmetrical auricle aligned with outer canthus of eye auricle mobile, firm and not tender pinna recoils after it is folded able to hear different voice tones No tenderness palpated Absence of nodule or mass with symmetrical facial features and movements Hair is equally distributed MATERNAL (-) (-) (-)

Nose Throat RESPIRATORY: RR= 29 cpm (October 2, 2012) With vesicular breath sounds auscultated on both lung fields Symmetrical chest wall expansion No palpable lymph nodes Nose is symmetrical and straight, without nasal discharges, non-tender, with no lesions nasal septum is intact and located in the midline

CARDIOVASCULAR: Capillary refill of 3 seconds Pulse rate of 86 bpm. Intravenous fluid is PNSS 1 L regulated at 80 cc/hour on the left hand

MUSCULOSKELETAL: Smooth coordinated muscle movements No swelling and tenderness of joints noted

INTEGUMENTARY: Pallor (toes and fingernails) Skin warm to touch Diaphoretic Flushed skin No abrasions or lesions noted Fair skin turgor

GASTROINTESTINAL: Tenderness or the RUQ abdomen Swelling of the RUQ abdomen Is evident Abdominal girth: o o Oct. 4 73 cm Oct. 5 69.4 cm Small volume, lumpy stools Measurement of liver: enlarged size o o Midclavicular 13 cm Midsternal 11 cm

Tenderness on the RUQ noted (7 out of 10 on pain scale) He verbalized no pain upon defecation

Hypoactive bowel sounds heard on auscultation (3/min)

GENITOURINARY Has no bladder distention He verbalized no pain upon urination Voids 2-3 times a day to a dark- yellow urine approximately 650- 800 ml/day for the four-day shift.

NEUROLOGIC: Cranial Nerve Assessment CN I (Olfactory): Patient is able to recognize the smell of a citrus fruit and coffee. CN II (Optic): Patient recognizes the color of the student nurses uniform. CN III (Oculomotor): Pupils equally round and reactive to light and accommodation CN IV (Trochlear): Both eyeballs were moving bilaterally CN V (Trigeminal): Patient was able to open his mouth and move jaw side to side CN VI (Abducens): Both eyeballs were moving bilaterally CN VII (Facial): Patient can slightly smile, frown, raise and lower the eyebrows CN VIII (Vestibulocochlear): Hearing was active and can respond to sounds like voices of the people around. CN IX (Glossopharyngeal) : Patient has no difficulty in swallowing CN X (Vagus): Patient has no difficulty in swallowing

CN XI (Spinal accessory): Patient was able to shrug his shoulders CN XI (Hypoglossal): Patient was able to stick his tongue out without any difficulties

ANATOMY AND PHYSIOLOGY

If a human adults digestive tract were stretched out, it would be 6 to 9 m (20 to 30 ft) long. In humans, digestion begins i n the mouth, where both mechanical and chemical digestion occur. The mouth quickly converts food into a soft, moist mass. The muscular tongue pushes the food against the teeth, which cut, chop, and grind the food. Glands in the cheek linings secrete mucus, which lubricates the food, making it easier to chew and swallow. Three pairs of glands empty saliva into the mouth through ducts to moisten the food. Saliva contains the enzyme ptyalin, which begins to hydrolyze (break down) starcha carbohydrate manufactured by green plants. Once food has been reduced to a soft mass, it is ready to be swallowed. The tongue pushes this mass called a bolusto the back of the mouth and into the pharynx. This cavity between the mouth and windpipe serves as a passageway both for food on its way down the alimentary canal and for air passing into the windpipe. The epiglottis, a flap of cartilage, covers the trachea (windpipe) when a person swallows. This action of the epiglottis prevents choking by directing food from the windpipe and toward the stomach. A. The Esophagus The presence of food in the pharynx stimulates swallowing, which squeezes the food into the esophagus. The esophagus, a muscular tube about 25 cm (10 in) long, passes behind the trachea and heart and penetrates the diaphragm (muscular wall between the chest and abdomen) before reaching the stomach. Food advances through the alimentary canal by means of rhythmic muscle contractions (tightenings) known as peristalsis. The process begins when circular muscles in the esophagus wall contract and relax (widen) one after the other, squeezing food downward toward the stomach. Food travels the length of the esophagus in two to three seconds. A circular muscle called the esophageal sphincter separates the esophagus and the stomach. As food is swallowed, this muscle relaxes, forming an opening through which the food can pass into the stomach. Then the muscle contracts, closing the opening to prevent food from moving back into the esophagus. The esophageal sphincter is the first of several such muscles along the alimentary canal. These muscles act as valves to regulate the passage of food and keep it from moving backward. B. The Stomach The stomach, located in the upper abdomen just below the diaphragm, is a saclike structure with strong, muscular walls. The stomach can expand significantly to store all the food from a meal for both mechanical and chemical processing. The stomach contracts about three times per minute, churning the food and mixing it with gastric juice. This fluid, secreted by thousands of gastric glands in the lining of the stomach, consists of water, hydrochloric acid, an enzyme called pepsin, and mucin (the main component of mucus). Hydrochloric acid creates the acidic environment that pepsin needs to begin breaking down proteins. It also kills microorganisms that may have been ingested in the food. Mucin coats the stomach, protecting it from the effects of the acid and pepsin.

About four hours or less after a meal, food processed by the stomach, called chyme, begins passing a little at a time through the pyloric sphincter into the duodenum, the first portion of the small intestine. C. The Small Intestine Most digestion, as well as absorption of digested food, occurs in the small intestine. This narrow, twisting tube, about 2.5 cm (1 in) in diameter, fills most of the lower abdomen, extending about 6 m (20 ft) in length. Over a period of three to six hours, peristalsis moves chyme through the duodenum into the next portion of the small intestine, the jejunum, and finally into the ileum, the last section of the small intestine. During this time, the liver secretes bile into the small intestine through the bile duct. Bile breaks large fat globules into small droplets, which enzymes in the small intestine can act upon. Pancreatic juice, secreted by the pancreas, enters the small intestine through the pancreatic duct. Pancreatic juice contains enzymes that break down sugars and starches into simple sugars, fats into fatty acids and glycerol, and proteins into amino acids. Glands in the intestinal walls secrete additional enzymes that break down starches and complex sugars into nutrients that the intestine absorbs. Structures called Brunners glands secrete mucus to protect the intestinal walls from the acid effects of digestive juices. The small intestines capacity for absorption is increased by millions of fingerlike projections called villi , which line the inner walls of the small intestine. Each villus is about 0.5 to 1.5 mm (0.02 to 0.06 in) long and covered with a single layer of cells. Even tinier fingerlike projections called microvilli cover the cell surfaces. This combination of villi and microvilli increases the surface area of the small intestines lining by about 150 times, multiplying its capacity for ab sorption. Beneath the villis single layer of cells are capillaries (tiny vessels) of the bloodstream and the lymphatic system. Th ese capillaries allow nutrients produced by digestion to travel to the cells of the body. Simple sugars and amino acids pass through the capillaries to enter the bloodstream. Fatty acids and glycerol pass through to the lymphatic system. D. The Large Intestine

A watery residue of indigestible food and digestive juices remains unabsorbed. This residue leaves the ileum of the small intestine and moves by peristalsis into the large intestine, where it spends 12 to 24 hours. The large intestine forms an inverted U over the coils of the small intestine. It starts on the lower righthand side of the body and ends on the lower left-hand side. The large intestine is 1.5 to 1.8 m (5 to 6 ft) long and about 6 cm (2.5 in) in diameter. The large intestine serves several important functions. It absorbs waterabout 6 liters (1.6 gallons) dailyas well as dissolved salts from the residue passed on by the small intestine. In addition, bacteria in the large intestine promote the breakdown of undigested materials and make several vitamins, notably vitamin K, which the body needs for blood clotting. The large intestine moves its remaining contents toward the rectum, which makes up the final 15 to 20 cm (6 to 8 in) of the alimentary canal. The rectum stores the feceswaste material that consists largely of undigested food, digestive juices, bacteria, and mucusuntil

elimination. Then, muscle contractions in the walls of the rectum push the feces toward the anus. When sphincters between the rectum and anus relax, the feces pass out of the body. IV. REGULATION OF THE DIGESTIVE PROCESS The body coordinates the various steps of digestion so that the process proceeds smoothly and cells obtain a steady supply of nutrients and energy. The central nervous system and various glands control activities that regulate the digestive process, such as the secretion of enzymes and fluids. For example, the presence of food in the esophagus, stomach, or intestines triggers peristalsis. Food entering the stomach also stimulates the central nervous system to initiate the release of gastric juice. And as hydrochloric acid passes from the stomach, the small intestine produces secretin, a substance that simulates secretion of pancreatic juice.

HEPATOBILIARY SYSTEM The liver is the second largest organ of the body, weighing 1200 to 1500 grams, or 4-5% of body weight. It is located in the right upper abdominal quadrant, or the right hypochondriac and epigastric regions, behind the lower ribs. The falciform ligament divides the liver anatomically into two unequal lobes: right and left. Two additional smaller lobes, the quadrate and caudate lobes are more visible in cross section. Physiologically though, the division is equal, following the fossa for gall bladder and inferior vena cava. There is no evidence for difference in functionsamong the four anatomical lobes.The gall bladder is a saccular organ located posterior to the liver that functions to store bile. It has a mean capacity of 30-50 mL. Mucosal folds, called the spiral valves of Heister, maintain patency of the cystic duct to allow passage of bile. Presence of fats in the duodenum stimulate the gall bladder to contract.

Blood Supply To Liver The liver receives blood from two sources: oxygenated arterial blood from the hepatic artery, and portal blood draining from the lower GI via the portal vein. The two vessels drain into hepatic sinusoids and then flow towards the central vein. Small central veins come together to form three hepatic veins that return blood to the heart through the inferior vena cava.

Blood Supply To Bile Ducts The right hepatic artery supplies the bile ducts by dividing into a rich capillary plexus that would drain into the sinusoids. Hepatocytes then act for the directional exchange of compounds between bile and blood. Biliary Flow Bile is synthesized and secreted by hepatocytes into the canaliculi. Afterwhich, bile flows into progressively larger ducts until bile reaches the duodenum via the greater duodenal papilla (of Vater):Terminal ductules (canals of Hering), surrounded by 3-6 ductal epithelial cells: perilobular ducts ->interlobular bile ducts surrounding portal vein-> septal ducts ->lobar ducts -> 2 hepatic ducts -> common hepatic duct + cystic duct -> common bile duct +pancreatic duct ->ampulla of Vate.

LABORATORY STUDY Patient Name: M.G. Age/Sex: 29 y/o; M Room/Ward: Male Medical Ward HEMATOLOGY (9/23/12) Normal Values Hemoglobin 136-163 g/L Result Implication Nursing Consideration Chief Complaint/s: on and off fever Admitting Diagnosis: Typhoid fever t/c hepatitis Attending Physician: Dr. S

54 g/L

below normal range: mild anemia, decreased oxygen-carrying capacity of the blood

Encourage patient to increase intake of iron-rich foods like green leafy vegetables. Instruct patient to eliminate iron-busting foods in the diet such as caffeinated beverages, chocolate and foods that are high in calcium. Encourage client to have adequate time for rest and sleep to conserve energy. Administer intravenous fluid as prescribed (PNSS 1 L) to promote optimal blood flow, organ perfusion and function. Encourage ambulation and necessary position changes to promote circulation and prevent tissue injury. Advise client to have adequate time for rest to conserve energy. Perform tilt test to obtain potential and degree of activity intolerance. Have client perform range of motion exercises to prevent deconditioning that results from inactivity.

Hematocrit

0.40-0.48g/L

0.18g/L

Below normal range: anemia, increased breakdown of cells

RBC

4.0-5.0x10/L

2.1g/L

below normal range: anemia

Advise client to eat foods high in folate, Vitamin B12 and iron such as organ meats and beans to promote erythropoeisis. Limit activity to clients tolerance to conserve energy.

 Regulate intravenous fluid flow rate accurately to expand circulating blood volume. Encourage ambulation and necessary position changes to promote circulation and prevent tissue injury. WBC 5.010.0x10/L 14.6x10/L Above normal range: infection Encourage client to increase intake of Vitamin C-rich foods such as citrus fruits. Promote nail care: keep fingernails clean, short, and well manicured to eliminate rough edges or hangnails, which can harbor microorganisms. Educate client about proper hand hygiene to prevent crosscontamination. Promote appropriate nutritional intake because a balanced diet supplies proteins and vitamins necessary to build or maintain body tissues. Monitor laboratory values. Encourage client to increase intake of Vitamin C-rich foods such as citrus fruits. Educate client about proper hand hygiene to prevent crosscontamination.

Platelet count

150350x10/L

516x10/L

Above normal range: infection

Differential count Neutrophils 0.55-0.65 0.66 Slight increase Lymphocytes Monocytes 0.25-0.40 0.02-0.08 0.25 0.05 Within normal range Within normal range Stress the importance of proper hygiene to prevent crosscontamination. Advise client to have daily bath. Monitor clients visitors for respiratory illnesses. Offer masks and tissues to client or visitors who are coughing or sneezing to limit exposures, thus protecting client from cross-

Eosinophils

0.01-0.06

0.04

Within normal range

contamination. Monitor vital signs as these are indicators of any alterations inside the body. Stress proper hand hygiene.

X- RAY (9/28/2012) Results Nursing considerations Radiographic evaluation shows a veil of haziness at the lower portion of the right hemithorax. Trachea is in the midline. Cardiac shadow is not enlarged. Pulmonary vasculature are not prominent Hemidiaphragms are not distinct and intact Right costrophenic sulcus is obscured The rest of the visualized osseous and soft tissue structures are unremarkable. mild pleural effusion, right hemithorax Monitor respirations and breath sounds, noting rate and sounds as these are indicative of respiratory distress and/or accumulation of secretions. Encourage client to increase his oral fluid intake because hydration can liquefy secretions. Provide opportunities for rest; limit activities to level of respiratory tolerance to prevent fatigue.

Interpretation

Impression

PROBLEM LISTING Patient Name: M.G. Age/Sex: 29 y/o; M Room/Ward: Male Medical Ward CUES: Subjective: Client verbalized, Gapalangluya lang ko pirme. Basta, daw kakapoy bala haw. Gasakit akun kilid kag kung kis-a gakautod akon tulog. Ga abot- abot japon akun hilanat kag galingin akon ulo. Objective: Facial grimace noted Guarding behaviour and protective gestures noted Frequent position changes to avoid pain noted Sleep disturbance (e.g. eyes lack luster, beaten look) Skin is warm to touch Chills noted Diaphoretic Jaundice of the sclera noted Body weakness noted Weak peripheral pulses Capillary refill: 2 seconds Pallor Infrequent passage of stool Small volume, lumpy stools Chief Complaint/s: on and off fever Admitting Diagnosis: Typhoid fever t/c hepatitis Attending Physician: Dr. S

Stool frequency during shift 10/2/2012: 0 10/3/2012: 0 Vital signs: Temperature: 38.5 0C Pulse Rate: 86 bpm Respiratory Rate: 33 cpm Blood Pressure: 100/80 mmHg Pain Scale: 7/10 (dull pain) 10/4/2012: 1 10/5/2012: 1 Intake: 950 cc Output: 480 cc

10/03/2012 Intake: 1,050 cc Output: 350 cc

Intake and Output: 10/02/2012 10/05/2012 Intake: 600 cc Output: 800 cc

10/04/2012 Intake: 840 cc Output: 480 cc

Blood chemistry: Hemoglobin= 54g/L Hematocrit= 0.18g/L RBC= 2.1g/L WBC= 14.6x10/L Platelets= 516x10/L

PHYSIOLOGIAL PROBLEM RANK ACTUAL Acute pain r/t liver cell damage by Salmonella typhi endotoxin POTENTIAL Risk for impaired skin integrity r/t limited position changes brought about by abdominal discomfort Risk for imbalance nutrition: less than body requirements r/t increased metabolic demand brought about by the process of infection Risk for injury r/t abnormal blood profile AEB low hemoglobin and hematocrit count. ACTUAL

BEHAVIORAL POTENTIAL Risk for impaired social interaction r/t limited physical mobility and discomfort in social situations. Risk for ineffective role performance r/t altered state of wellness.

PAIN

Sleep deprivation r/t physical discomfort brought about by RUQ pain

FEVER

Ineffective thermoregulation; Hyperthermia r/t adaptive response to bacterial infection 2 typhoid fever

Powerlessness r/t increased metabolic demand brought about by the process of infection

LOW AND HEMOGLOBIN HEMATOCRIT COUNT DISTURBED SLEEPING PATTERN

Ineffective tissue perfusion r/t Low hemoglobin and hematocrit count

Restlessness r/t decreased carrying capacity the blood AEB low hemoglobin and hematocrit count

Risk for acute confusion r/t decreased oxygen supply to the brain.

Fatigue r/t inadequate rest and sleep

Risk for Activity intolerance r/t inadequate rest and sleep

Fatigue r/t inadequate rest and sleep

Risk for anxiety r/t disturbance in sleeping pattern

DIZZINESS

Impaired physical mobility r/t below normal blood profile

Risk for falls r/t difficulty with gait secondary to low hemoglobin and hematocrit count

Self care deficit r/t generalized body weakness

Risk for situational low self esteem r/t present physical illness

NURSING CARE PLAN FOR ELEVATED BODY TEMPERATURE Patient Name: M.G. Age/Sex: 29 y/o; M Room/Ward: Male Medical Ward General Objective: To facilitate the maintenance of regulatory mechanisms and function. Cues Subjective: Client verbalized, Ga abot- abot japon akun hilanat kag galingin akon ulo. Objective: Skin is warm to touch Chills noted Diaphoretic Body weakness noted Nursing Diagnosis Ineffective Thermoregulation: Hyperthermia r/t adaptive response to bacterial infection 2o to typhoid fever Expected Outcome Within 32 hours of nursing intervention, patient will be able to: 1. Maintain body temperature within normal range (36.5 37.50 C 2. Be free of chills. 3. Demonstrate techniques to promote maintainance of normal temperature. Nursing Intervention Independent: 1. Assess temperature every 30 minutes. Notify physician of significant changes. 2. Monitor cardiac rate and rhythm. Vital signs provide more accurate indication of core temperature. Rationale Evaluation After 32 hours of nursing intervention, goals were met as evidenced by: Chief Complaint/s: on and off fever Admitting Diagnosis: Typhoid fever t/c hepatitis Attending Physician: Dr. S

Dysrhythmias are common due to electrolyte imbalance and a. clients temperature of 37. dehydration and direct effect of 1 0 C at last day of shift (Oct. hyperthermiaon blood and 5, 2012) cardiactissues. b. absence of chills -Fluid rescuscitation may be necessary to prevent dehydration. c. clients other vital signs within normal range

Vital signs: Temperature: 38.5 0C Pulse Rate: 86 bpm Respiratory Rate: 33 cpm Blood Pressure:

3. Monitor clients fluid intake and output.

4. Perform tepid sponge bath and check temperature 30 minutes after.

Tepid sponge bath is a form of evaporative cooling.

100/80 mmHg

5. Encourage client to have adequate rest periods.

To conserve energy and prevent fatigue.

Intake and Output: 10/02/2012 Intake: 950 cc Output: 480 cc

6. Encourage client to eat foods high in calorie such as white bread and cookies. 7. Cover clients extremities with blankets during episodes of chills.

To meet increasing metabolic demands.

To reduce shivering.

10/03/2012 Intake: 1,050 cc Output: 350 cc

Dependent: 1. Administer IVF as ordered: PNSS 1L x 120 gtts/min To meet increasing metabolic demands and replace losses References: NANDA Nursing Diagnosis 12th Edition by Doenges, et. al. Nursing Care Plans by 6th Edition by Gulanick and Myers

10/04/2012 Intake: 840 cc Output: 480 cc

10/05/2012 Intake: 600 cc Output: 800 cc Hemoglobin= 54g/L Hematocrit= 0.18g/L RBC= 2.1g/L WBC= 14.6x10/L 2. Administer antipyretic as prescribed: Paracetamol 500 mg 1 tab q4h To reduce elevated body temperature to normal.

NURSING CARE PLAN FOR ACUTE PAIN Patient Name: M.G. Age/Sex: 29 y/o; M Room/Ward: Male Medical Ward General Objective: To promote good hygiene and physical comfort. CUES Subjective: Client verbalized, Gasakit akun kilid kag kung kis-a gakautod akon tulog. Objective: Facial grimace noted Guarding behaviour and protective gestures noted Frequent position changes to avoid pain noted Sleep disturbance (e.g. eyes lack luster, NURSING DIAGNOSIS EXPECTED OUTCOME NURSING INTERVENTION Independent: 1. . Monitor skin color and temperature and vital signs (e.g. heart rate, blood pressure, respirations) 2. Have client rate the pain he is feeling through pain rating scale. 3 Perform a comprehensive assessment of pain to include location, characteristics, onset, duration, frequency, quality, intensity and precipitating factors of pain. 4. Reduce or eliminate factors that precipitate or increase clients pain experience (e.g. fear, fatigue and lack of These are usually altered in acute pain.. RATIONALE EVALUATION After 32 hours of nursing intervention, goals were met as evidenced by: 1. Clients reports of lower intensity of pain and discomfort after interventions implemented; pain rating is 6. Chief Complaint/s: on and off fever Admitting Diagnosis: Typhoid fever t/c hepatitis Attending Physician: Dr. S

Acute Pain r/t liver cell Within 32 hours of damaged by S. typhi nursing intervention, endotoxin client will be able to: 1. Report pain is diminished from 9 to 6.

Pain is a subjective experience and to assess severity of pain. Pain is a subjective experience and must be described by the client in order to plan effective treatment

2. Demonstrate nonpharmacologic pain management such as music therapy (like calm and soothing musics) and deep breathing.

2. Clients demonstration of use of new strategies to relieve pain and reports their effectiveness. 3. Clients increased interaction with family and friends.

Personal factors can influence pain and pain tolerance and should be reduced or eliminated to enhance overall pain

beaten look) Body weakness noted Abdominal girth: Oct. 4 73 cm Oct. 5 69.4 cm Oct. 6 70.2 cm Oct. 7 70 cm Oct. 8 69 cm Oct. 9 68 cm Oct. 10 70 cm Oct. 11 70 cm Oct. 12 68 cm Vital signs: Temperature: 38.5 0C Pulse Rate: 86 bpm Respiratory Rate: 33 cpm Blood Pressure: 100/80 mmHg Pain Scale: 9/10 (dull pain)

knowledge) by giving him enough information as to why he is feeling pain. 5. Teach client the use of nonpharmacologic techniques (e.g. relaxation, music therapy, distraction) before and after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures. 6. Encourage adequate rest periods. 7. Provide a quiet environment with dim lights and comfortable temperature when possible.

management program.

The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications.

To prevent fatigue. Comfort and a quiet atmosphere promote a relaxed feeling and permit the client to focus on the relaxation technique rather than external distraction.

8. Consider clients willingness and ability to participate, preference, past experiences, and contraindications before selecting a specific relaxation activity.

The client must feel comfortable trying a different approach to pain management. To avoid ineffective strategies, the client should be involved in the planning process.

Research shows that the most 9. Evaluate the effectiveness of common reason for unrelieved pain control measures used pain is failure to routinely assess through ongoing assessment pain and pain relief. Many clients of clients pain experience. silently tolerate pain if not specifically asked about it.

Dependent: 1. Administer analgesics as prescribed: Paracetamol (Biogesic) 1 tab 500 mg q4h To relieve pain.

References: Fundamentals of Nursing 8th Edition by Berman, et.al. Medical-Surgical Nursing 12th Edition by Smeltzer, et. al.

NURSING CARE PLAN FOR LOW HGB AND HCT COUNT Patient Name: M.G. Age/Sex: 29 y/o; M Room/Ward: Male Medical Ward General Objective: To facilitate maintenance of oxygen to all body cells. CUES NURSING DIAGNOSIS Ineffective tissue perfusion r/t Low hemoglobin and hematocrit count EXPECTED OUTCOME NURSING INTERVENTION RATIONALE EVALUATION Chief Complaint/s: on and off fever Admitting Diagnosis: Typhoid fever t/c hepatitis Attending Physician: Dr. S

Subjective: Client verbalized, Gapalangluya lang ko pirme. Basta, daw kakapoy bala haw. Objectives: Body weakness noted Pallor Weak peripheral pulses Capillary refill: 2 seconds

Within32 hours of nursing intervention, client will be able to:

Independent: 1. Monitor Vital signs and quality of pulses. Serves as a baseline data underlying clients condition. To maintain adequacy of systemic circulation.

After 32 hours of nursing intervention, goals were partially met as evidenced by: 1. Clients demonstration of techniques to facilitate optimum circulation such as elevating his legs, active assissted to active range of motion.

1. Demonstrate increased perfusion as individually appropriate (e.g. free of pain or discomfort, peripheral pulses present and strong.

2. Measure capillary refill.

Vital signs: Temperature: 38.5 0C Pulse Rate: 86

2. Demonstrate behaviors and lifestyle changes to improve circulation (e.g. engage in regular exercise,

Malnutrition and weight 3. . Note clients nutritional loss make ischemic tissues and fluid status. more prone to breakdown and dehydration reduces blood volume and compromise peripheral circulation. This ensures adequate 4. Maintain optimal cardiac perfusion of vital organs. output by elevation of limbs to facilitate venous return.

2. Verbalization of understanding about lifestyle changes (e.g stop smoking and drinking too much

bpm Respiratory Rate: 33 cpm

cessation of smoking, etc.)

alcohol) 5. Assist client to do passive Exercise prevents venous range-of-motion stasis and further exercises circulatory compromise. 6. Provide client informations on normal tissue perfusion and possible causes of impairment.

Blood Pressure: 100/80 mmHg

Blood chemistry: Hemoglobin= 54g/L Hematocrit= 0.18g/L RBC= 2.1g/L

Knowledge of causative factors provides understanding for treatments.

7. Advise client to wear To prevent restriction of non-restrictive clothing. circulation.

To promote peripheral circulation and limit 8. Encourage client to complications associated ambulate when possible with poor perfusion and and elevate legs when tissue injury. sitting and lying down. Dependent: To increase circulating 1. Administer IVF solution as blood volume. prescribed: PNSS 1 L x 120 gtts/min on the left hand.

References: Fundamentals of Nursing 8th Edition by Berman, et.al.

Medical-Surgical Nursing 12th Edition by Smeltzer, et. al.

DRUG STUDY Patient Name: M.G. Age/Sex: 29 y/o; M Room/Ward: Male Medical Ward DRUG CLASSIFICATIO N Antipyretic, analgesics (non-opioid) INDICATION MECHANISM OF ACTION 1.Decreases fever by a hypothalamic effect leading to sweating and vasodilation 2.Inhibits pyrogen effect on the hypothalamicheat-regulating centers 3. Inhibits CNS prostaglandin synthesis Chief Complaint/s: on and off fever Admitting Diagnosis: Typhoid fever t/c hepatitis Attending Physician: Dr. S ADVERSE EFFECT/SIDE EFFECTS GI: GI upset Hematologic: haemolytic anaemia, neutropenia, leukopenia, pancytopenia Hepatic: liver damage, jaundice Metabolic: hypoglycemia Skin: rash, urticaria NURSING CONSIDERATIONS PATIENT TEACHING

1. paracetamol (Biogesic) 500mg, 1 tab., q4h, PO (8AM12NN-4PM-8AM12MN-4AM)

For temporary relief of pain and discomfort from headache and fever. For relieving fever

1. Use cautiously in patients with history of chronic alcohol use because hepatotoxicity has occurred after therapeutic doses.

2. Monitor CBC, liver and renal functions. 2. Instruct patient to take this drug with food or milk to 3. Assess patients pain or minimize GI upset. temperature before therapy and regularly thereafter. 3. Tell the patient that he may report nausea and 4. Monitor skin condition. vomiting, cyanosis, shortness 5. Observe for signs of of breath and abdominal pain hypoglycemia(e.g. weakness) as these are signs of toxicity. 6. Do not give if temperature 4. Advise the patient to avoid alcohol use. is higher than 39.50C. 5. Advise client to take drug with food or milk if

1. Inform client that this drug is not to be used for adults whose fever lasted for more than 3 days and pain which is more than 10 days as toxicity will cause liver damage.

experiencing gastrointestinal distress. 2. cefixime (Zefitas) 200 mg 1 cap BID ,PO (8AM, 6PM) Cephalosporin Treatment of A third uncomplicated generation UTIs, otitis cephalosporin media, that inhibits cellpharyngitis, wall synthesis, tonsillitis, acute promoting bronchitis, acute osmotic exacerbations of instability; usually chronic bactericidal bronchitis, and uncomplicated gonorrhea caused by susceptible strains of specific organisms. CNS: headache, dizziness GI: diarrhea, loose stools, abdominal pain, nausea, vomiting, dyspepsia, flatulence GU: genital pruritus Hematologic: thrombocytopenia, leukopenia Skin: pruritus, rash, urticaria Other: hypersensitivity reactions, anaphylaxis. 1. Auscultate for bowel sounds. 2. Monitor CBC. 3. Have IVF replacement ready in case of diarrhea. 4. Assess skin condition. 2. Monitor for signs and symptoms of infection. 3. Monitor for signs of bleeding. Advise client to be careful so as to avoid bruising. 4. Advise patient to take with meals. 5. Instruct patient to immediately report severe diarrhea, diarrhea containing blood or pus, or severe abdominal cramping. 6. Encourage client to increase oral fluid intake to facilitate excretion but not more than 1.5L. 1. Caution client to ask for support during performing activities.

3. ciprofloxacin (Ciprosa) 500 mg 1 tab BID, PO (8am, 6pm)

Antibacterial

For UTI, skin and tissue infections For Gramnegative bacteria

Bactericidal; interferes with the DNA replication in susceptible bacteria preventing cell reproduction.

CNS: headache, dizziness, insomnia, fatigue, blurred vision CV: arrhythmias, hypotension, angina EENT: dry eyes, eye pain GI: nausea, vomiting, diarrhea, abdominal pain Others: fever, rash

1. Monitor heart rate and rhythm. 2. Auscultate clients abdomen for bowel sounds. 3. Inspect clients skin condition. 4. Monitor vital signs especially BP and temperature. 5. Assess clients eyes and ears for any unusualties. Take into consideration problems with vision and hearing.

1. Photosensitivity could occur. Advise client to avoid excessive exposure to sunlight. 2. Can be taken without meals but encourage client to do so in case gastrointestinal distress occurs. 3. Encourage client to have time for adequate rest and sleep. 4. Instruct client to limit activities as taking this drug will make him prone to developing fatigue. 5. Encourage client to increase oral fluid intake to facilitate excretion of drug.

4. omeprazole (Omeptras) 40 mg 1 cap OD, PO (8AM)

Proton pump inhibitor

To decrease further irritation of the gastric mucosal lining.

Gastric-acid pump inhibitor; suppresses gastric acid secretion at the secretory surface of the gastric parietal cells; blocks the final step of acid production.

CNS: headache, dizziness, insomnia, anxiety, paresthesias

1. Assess for fluid and electrolyte imbalances. 2. Administer drug on empty stomach.

Dermatologic: rash, inflammation, urticaria, 3. Inspect clients skin pruritus, dry skin condition. GI: diarrhea, abdominal 4. Auscultate clients pain, nausea, vomiting, abdomen for bowel sounds. constipation, dry mouth GU: hematuria, dysuria Respi: cough, epistaxis

1. Advise client to increase oral fluid intake, dietary bulk and exercise to relieve constipation. 2. Educate client to avoid foods that can cause gastric irritation: caffeine-containing beverages, alcohol, certain fats, and spices. 3. Instruct client to report pain during difficulty and presence of blood in the urine. 4. Instruct client to increase oral fluid intake or secure hard candies in case of having dry mouth.

5. metronidazole 500 mg IVTT q8h x 6wks. (6am, 2pm, 10pm)

Antibacterial Treatment for infection with susceptible anaerobic bacteria

work by entering the bacterial cell, acting on some components and destroying the bacteria.

CNS : headache, dizziness, confusion, irritability, weakness, insomnia

GU : dysuria, incontinence, GI : nausea and vomiting, diarrhea, cramps, anorexia

1. Perform skin test before 1. Advise client to have administering drug. adequate time for rest and sleep. 2. Check IV site for any redness, itchiness and other 2. May cause dizziness or signs of allergic reactions. light-headedness. Caution patient or other activities 3. Solution should be clear to requiring alertness until pale yellow to yellow green. response to medication is Do not use if medication is known. cloudy or containing precipitates.

4. Inform client that urine Local : redness, may turn dark in color. burning, dryness, and skin irritation in the site 5. Monitor fluid and electrolytes.

6. ceftriaxone (Rocephin) 2gms. IVTT x 6wks. OD (8AM)

antibiotic

Treatment for miscellaneous infection

inhibits bacterial cell wall causing cell death

CNS: headache, dizziness, lethargy, GI: nausea and vomiting, diarrhea, flatulence Hypersensitivity : anaphylaxis Rash,redness,urticuria

1. Check IV site if there is any redness, itchiness and other signs of allergic reactions. 2. Protect drug from the light it may alter its effectiveness. 3. Have Vitamin K available in case if hypoprothrombinemia occurs. 4. Contraindicated with allergy to cephalosporins or penicillins. 5. Discontinue if hypersensitivity reaction occurs. 6. Arrange patient for sensitivity test before the therapy.

1. Instruct patient to report severe diarrhea, difficulty breathing, unusual tiredness or fatigue, pain at injection site. 2. instruct patient to report any signs of hypersensitivity like rash, redness, urticuria.

7. lactulose 30ml BID, PO ( 8am, 6pm)

laxative

Treatment for constipation

The drug passes unchanged into the colon where bacteria break it down to organic acids that increase the osmotic pressure in the colon and slightly acidify the colonic contents, resulting in an increase in stool water content, stool softening, laxative action.

1. Give laxative syrup orally GI: transient flatulence, with fruit juice, water, or milk diarrhea, nausea to increase palatability. 2. Do not administer any laxative while using lactulose.

1. Mix the drug in water, juice, or milk to make it more tolerable. 2. Instruct the client to report diarrhea ,severe belching, abdominal fullness. 3. Make sure you have ready access to bathroom, bowel movements will be increased to 2 or 3 times per day. 4. Instruct patient that he may experience these side effects: abdominal fullness, flatulence, belching.

DISCHARGE PLAN Patient Name: M.G. Age/Sex: 29 y/o; M Room/Ward: Male Medical Ward POSSIBLE PROBLEM HYGIENE Hand hygiene Nail care Oral care Daily bath PROMOTIVE: Instruct client to increase consumption of Vit. C rich foods such as citrus fruits. Instruct client to monitor body temperature. To promote hydration Chief Complaint/s: on and off fever Admitting Diagnosis: Typhoid fever t/c hepatitis Attending Physician: Dr. S PATIENT TEACHING RATIONALE

ACTIVITY DIET Diet as tolerated Activity as tolerated Adequate rest and sleep Exercise

Recurrence of Infection
Emphasize the importance of adequate rest and sleep for at least 8- 10 hours. Encourage client to perform frequent daily bath and nail care.

To promote prompt intervention for decreasing temperature. To regain strength and enhance muscle tone Prevent harbouring of microorganism and prevent infection from taking place.

INSTRUCTIONS Follow- up check- up a week after discharge at CDH, OPD

PREVENTIVE: Instruct client to clean surroundings. Discuss the importance of frequent handwashing with the client and Significant others. To prevent further infection To prevent transmission of microorganism

Encourage client to eat Vitamin C rich foods like citrus fruits. Stress the importance of proper food handling

To prevent infection and strengthen immune system To prevent cross contamination.

CURATIVE: Discuss the importance of not taking antibiotics or using left- over drugs unless instructed by health care provider. Explain the importance of strict- compliance with the medications. To prevent overdose and so as not to harm the normal flora of the body. To facilitate full recovery from infection

REHABILITATIVE: Encourage client to have a well- balanced diet. Well balance diet provides the body adequate nutrition to prevent infection. To manage factors that may aggravate the recurrence of infection. To evaluate the effectiveness of the therapy given

Provide knowledge about treatment plans and therapeutic procedures. Advice client to continue seeking attention to her laboratory findings.

LEARNING FACILITATION

It is never easy living a life of accurate routines, comprehensive conversations and having this you-cant-be-wrong set of perspectives. Though many have been called and ironically, many have also been chosen, only few lived to exercise their profession by heart. In a world full of materialistic desires, it takes a pure heart and intention to be really called a nurse. While we are in the process of moulding and unleashing the rare, precious stone in us, it is of utmost respect to recognize the people behind this prestigious making. We would like to grab this moment to put into words what we have in our hearts and minds. We want to show how grateful we are that we finished this case presentation successfully. First, to our Almighty God for guiding and giving us wisdom, to our families who love and supported us, to the clinical instructors who always believed in our capacity and not tired of helping us to achieve our goals. Lastly, to our classmates that work as one whatever odds we encounter. The journey to the nursing world surely is tough but we are wearing our helmets. The journey to the nursing world surely is a climb but rest assured the view would be great. Truth to be told, it is the path that one would never enter without a ready mind and heart. Again, the reason we entered nursing world is because of those who need care, belongingness and love. Bring this thought together with persistence, positivism and diligence and youre on your ride to your big, shining star.