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38273299-Case-Study-typhoid-Fever

VIEWS: 77 PAGES: 33

									                     STI COLLEGE SOUTHWOODS
                    Lot 2A Maduya, Carmona, Cavite


                     COLLEGE OF HEALTH CARE




  T/C Typhoid Fever; Post VP
  Shunt 2 Hydrocephalus and
     2 Meningocele 2008



                           Presented By:
                         Capistrano, Reggie
                           Foroneas, Karen
                       Nono, Ma. Franine Alyssa
                          Sobrevega, Reysie

                      BSN 3rd year Level-Group 3




                            Presented To:
                     Herald Clarence Ambayec, R.N




                           March 18, 2010
Division of Labor
Part of the Case Study_                                   Person to Discuss



A. Introduction                                       =   Marcus Dale Belisario


B. Biographical Data                                  =   Marcus Dale Belisario


C. Nursing History                                    =   Marcus Dale Belisario


D. Current Health Status                              =   Reggie Capistrano


E. Psychological Development                          =   Reysie Sobrevega


F. Physical Examination                               =   Ma. Franine Alyssa Nono


G. Laboratory Examination                             =   Karen Foroneas


H. Medical Plan of Care                               =   Karen Foroneas


I.   Anatomy and Physiology                           =   Reggie Capistrano


J. Pathophysiology                                    =   Marcus Dale Belisario


K. Drug Study                                         =   Ma. Franine Alyssa Nono


L. Nursing Care Plan                                  =   Karen Foroneas


M. Discharge Plan of Care                             =   Reysie Sobrevega


N. Health Teaching Plan                               =   Reysie Sobrevega/
                                                          Reggie Capistrano


O. Summary of Clients Status as of Last Day Contact   =   Reysie Sobrevega




INTRODUCTION:
Typhoid fever, also known as enteric fever, bilious fever, Yellow Jack or commonly just
typhoid, is an illness caused by the bacterium Salmonella enterica serovar Typhi. Common
worldwide, it is transmitted by the ingestion of food or water contaminated with feces from an
infected person. The bacteria then perforate through the intestinal wall and are phagocytes by
macrophages. Salmonella Typhi then alters its structure to resist destruction and allow them
to exist within the macrophage. This renders them resistant to damage by PMN's,
complement and the immune response. The organism is then spread via the lymphatic while
inside the macrophages. This gives them access to the Reticulo-Endothelial System and then
to the different organs throughout the body. The organism is a Gram-negative short bacillus
that is motile due to its peritrichous flagella. The bacterium grows best at 37 °C/99 °F –
human body temperature.


Salmonella Typhi lives only in humans. Persons with typhoid fever carry the bacteria in their
bloodstream and intestinal tract. In addition, a small number of persons, called carriers,
recover from typhoid fever but continue to carry the bacteria. Both ill persons and carriers
shed S. Typhi in their feces (stool). You can get typhoid fever if you eat food or drink
beverages that have been handled by a person who is shedding S. Typhi or if sewage
contaminated with S. Typhi bacteria gets into the water you use for drinking or washing food.
Therefore, typhoid fever is more common in areas of the world where handwashing is less
frequent and water is likely to be contaminated with sewage.


Typhoid fever is characterized by a sustained fever as high as 40 °C (104 °F), profuse
sweating, gastroenteritis, and non-bloody diarrhea. Less commonly a rash of flat, rose-
colored spots may appear.


Classically, the course of untreated typhoid fever is divided into four individual stages, each
lasting approximately one week. In the first week, there is a slowly rising temperature with
relative bradycardia, malaise, headache and cough. A bloody nose (epistaxis) is seen in a
quarter of cases and abdominal pain is also possible. There is leukopenia, a decrease in the
number of circulating white blood cells, with eosinopenia and relative lymphocytosis, a
positive diazo reaction and blood cultures are positive for Salmonella Typhi or Paratyphi. The
classic Widal test is negative in the first week.


In the second week of the infection, the patient lies prostrated with high fever in plateau
around 40 °C (104 °F) and bradycardia (Sphygmo-thermic dissociation), classically with a
dicrotic pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This
delirium gives to typhoid the nickname of "nervous fever". Rose spots appear on the lower
chest and abdomen in around 1/3 patients. There are rhonchi in lung bases. The abdomen is
distended and painful in the right lower quadrant where borborygmi can be heard. Diarrhea
can occur in this stage: six to eight stools in a day, green with a characteristic smell,
comparable to pea-soup. However, constipation is also frequent. The spleen and liver are
enlarged (hepatospleenomegaly) and tender and there is elevation of liver transaminases.
Blood cultures are sometimes still positive at this stage.


In the third week of typhoid fever a number of complications can occur:


      Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very
       serious but is usually non-fatal.
      Intestinal perforation in distal ileum: this is a very serious complication and is
       frequently fatal. It may occur without alarming symptoms until septicaemia or diffuse
       peritonitis sets in.
      Encephalitis
      Metastatic abscesses, cholecystitis, endocarditis and osteitis


The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the
patient is delirious (typhoid state). By the end of third week defervescence commences that
prolongs itself in the fourth week.


Sanitation and hygiene are the critical measures that can be taken to prevent typhoid.
Typhoid does not affect animals and therefore transmission is only from human to human.
Typhoid can only spread in environments where human feces or urine are able to come into
contact with food or drinking water. Careful food preparation and washing of hands are
therefore crucial to preventing typhoid.
                             STI COLLEGE SOUTHWOODS
                             Lot 2A Maduya, Carmona, Cavite


                              COLLEGE OF HEALTH CARE


PATIENT’S HISTORY
  A. Biographical Data
  Name: Baby Pops
  Age: 2 years old and 5 months                 Gender: Male                Status: Pedia
  Address: San Pablo City, Laguna
  Dialect/Language Spoken: Tagalog and English
  Chief Complaint: On and off fever x 6 days with poor oral intake
  Admitting Diagnosis: T/C Typhoid Fever; Post VP Shunt 2 Hydrocephalus, 2 Meningocele


  B. NURSING HISTORY
     1. History of Present Illnesses
            Last January 16, 2010 Baby Pops experience a fever with 39C consistent of 6
            days and self medicated by his mother and given Paracetamol syrup p.o
            without any consultation to the doctor. Then 6 days of fever the mother decided
            to go to the hospital and having consultation, when they arrived to the hospital
            and consulted by the doctor, the mother advised to admit Baby Pops.


     2. Family History


            Male:         Female:          Patient:

                                                      -Hirshprung
                          -No                         disease
                         abnormality                  -Diabetes




                                                      -Hydrocephalus
                                                      -Lumbuscral
                                                      Myelomeningocele
     3. Childhood Illnesses
            According to the mother, Baby Pops had only a cough and colds and fever.
  4. Hospitalization History
        First Admission
        When Baby pops was 9 months old and diagnosed Pneumonia at PPL San Pablo,
        Laguna
        Second Admission
        When Baby Pops was 1 year old and 4months and admitted at the PGH Manila
               December 11, 2008 Lumbuscral Myelomeningocele
               December 24, 2008 Inserting VP Shunt


C. CURRENT HEALTH STATUS
     A. Activity
     Frequency and regularity of exercise: Baby Pops always wants to bend, to crawl
                           and to play basketball with his dad.
     Duration and Length of Exercise: “Malimit” o “Maya’t maya” is how his mother
                           describes the duration of his exercise. While if his playing
                           basketball, he plays at least 2 hours
     Limitation of Activity: Baby Pops mother limited him to walk and to play with
                           relatives especially his cousins, causing him to be tease.
     Any Complaints and Discomfort: Baby Pops doesn’t have any discomfort or
                           complaints related to the activity.


     B. Rest
     Usual no. of hours of sleep and rest at night/at day time: At night, Baby Pops
                           usually sleeps 10 hours and while in day time, he usually
                           sleeps at around 10:30am-1:30pm but sometimes, kit
                           depends on the environment.
     No. of hours of sleep and rest to feel rested: Usually, Baby Pops sleeps 4 hours to
                           feel rested.
     Change in sleep/rest pattern: Baby Pops doesn’t have any changes in sleeping, but
                           sometimes it depends on the situation.
     Discomfort or difficulty going to sleep: He doesn’t have any discomfort going to
                           sleep but sometimes he get easily destructed when stranger
                           hold his IV line or touch him, because his mother and his
                           grandmother can only touch him.
     Remedy done with the comfort: The only remedy done with this discomfort was
                           “yapos lang ng nanay ang gusto niya”, said by the mother.
     No. pillows use when sleep: He had 4 pillows when sleeping; 1 for the head, 1 on
                           each side and a hotdog pillow to embrace.
C. Nutritional Metabolic Pattern
Food Preference: Baby Pops loves to eat rice and “bulanglang” a kind of mixed
                      vegetables, that popular in Bisaya.
Volume and type of fluid taken per day: He drinks 18oz of milk twice a day, with
                      “sabaw ng buko and mais”
Source of drinking water: The mother gets water for Baby Pops on a Wilkins
                      mineral water
Medication used (if any): At home, the mother gives multivitamins like Growee and
                      Propan TLC, for protection and for rapid growth.


D. Elimination Pattern
       i. Bladder
          Frequency and amount of urination per day: Baby Pops usually uses 2
                      (XL) diapers a day.
          Color and odor of urine: He had light yellow color urine and with
                      aromatic odor which indicates of the normal findings.
          Any discomfort of urination: The child also doesn’t have any complaints
                      in urination.
      ii. Bowel
          Frequency of bowel movement: Baby Pops usually defecate 1 or 2 times
                      a day.
          Consistency and color of stools: Baby Pops had a soft stool and scanty
                      odor and slightly brownish color as alleged.
          Changes in bowel elimination: After surgery, he had experienced bowel
                      movement difficulty.


E. Fluids and Electrolytes
Skin turgor: Baby Pops was found to have a normal skin turgor when pinched,
                      within 1-2 seconds skin returns to normal prior to the
                      assessment.
Condition of mucous membrane: Baby Pops mucous membrane was good with
                      some mild pinkish mucous membrane.
Edema: There were no evident edemas observed on the pt. face and on the lower
                      and upper extremities.
K, Ca, Na, and supplementation: The present fluid supplement upon assessment
                      was D5IMB solution.
  F. Senses
  There are no disturbances or difficulty aside from touch, he just got easily
  destructed and disturbed when somebody holds or touch him.


  G. Skin Integrity
  Pigmentation: Baby Pops had fair skin pigmentation.
  Temperature: He was cold to touch due to expose and direct air thru window.
  Smooth (+)               Rough (-)             Soft (+)                Dry (-)


  H. Neurologic Function
  Level of Consciousness: Baby Pops was conscious and coherent.
  Orientation: Baby Pops easily becomes irritable when he sees stranger going close
                         to him.
  Gait: Baby Pops had disturbances due to his plantar flexion of foot.
  Posture: He had a plantar flexion of foot.
  Changes in facial: He also had a downward deviation of the eye (sun setting).


Role Function Mode
 Type of family structure: Their family structure was extended.
 How many members in the family: They were composed of 5 family members.
 Who is the bread winner: The present breadwinner in their family was the father and
                         the grandmother.
 Who is the decision maker: Also, when it comes to decision making it was the father
                         and the grandmother, who decides in their family.
 How does the family feel about the illness: The family feels sad but very supportive,
                         when it comes to Baby Pops’ hospitalization.
  D. PSYCHOLOGICAL DEVELOPMENT
                                                          INTERPERSON
PSYCHOSEXUAL        PSYCHOSOCIAL          COGNITIVE                             MORAL          SPIRITUAL
                                                                 AL
     (Freud)           (Erickson)           (Piaget)                          (Kohlberg)       (Fowler’s)
                                                            (Sullivan)
Anal: 18 mos.-      Autonomy vs.        Pre-              Childhood:        Level1: Pre-       Stage 1:
3yrs. Old           Shame and           operational:      18 mos. –         conventional       Initiative-
                    Doubt: 18           2-4yrs. Old       6yrs old          Stage 1: Age       Projective
                    mos.- 3yrs. old                                         2-3 years old      Faith:
                                                                                               Toddler/
                                                                                               Pre-
-pleasure is        -Impulsitivity,                                                            school
through             determination       -no cause and     -learn to delay   -punishment
elimination or      and compulsion      effect            need              or obedience       -No
retention of        -curious to         reasoning,        gratification     (heteronymous      spiritual
feces               everything that     egocentrism;                        morality)          concept
-behaviors:         their body          use of            Baby Pops         -a child does      but
control of          secretes            symbols;          doesn’t have      the right          involves
holding on and      - significant       magical           control in his    things because     parents on
letting go.         relation: Parents   thinking          defecation,       a parent tells     religion
-develop                                                  would have a      him or her to      and
concepts of         Baby Pops is a 2    Baby Pops was     hard time         avoid              spiritual
power,              years old, he       able to imitate   developing his    punishment.        beliefs.
punishment,         already have the    different         so called
ambivalence,        authority to        activities        sense of          Baby Pops          Baby Pops
concern with        command what        demonstrated      power as he       knows how to       already
cleanliness or      he wants to do      to him such as    attempts to       be an obedient     knows how
being dirty.        even it is          throwing the      control himself   child to his       to pray
                    dangerous. And      ball, asking      and his           mother. But        and always
Baby Pops was       he also wants to    him to run        environment.      sometimes,         go to
a 2years and 5      be beside of his    after you,        This sense of     the child          church
months old          mother.             hides and         power can         learns not to      every
child, he still                         seeks an          also be used      follow the task    Sunday
uses diaper, he                         example of        to please the     that given to      with his
can already                             mental            mother. He        him. And a         parents
control his feces                       representation.   also learns to    punishment         but he
even his in the                                           interact with     will be given to   doesn’t
hospital. The                                             the other child   him.               know very
 resolution of the                                        to play and                               well about
 patient was                                              build to have                             the
 Shame and                                                friends.                                  concept of
 Doubt, due to                                                                                      religion
 anxiety with                                                                                       and
 strangers.                                                                                         spiritual
                                                                                                    beliefs that
                                                                                                    his parents
                                                                                                    taught to
                                                                                                    him.


    E. PHYSICAL EXAMINATION
           Date performed: January 22, 2010                          No. of hospital Days: 2 days
           1. Vital signs :
                     a.   Temperature:          36.4C
                     b.   Pulse Rate:           103bpm
                     c.   Respiratory Rate:     25cpm
           2. Regional Examination:
                              Methods of Assessment
Regions of the body                                                   Results
                                         (IPAP)
a. Hair                                 Inspection       Short, slightly oily hair
b. Head                                                  Oblong shape, open anterior
                                                         fontanel at the frontal area,
                                        Inspection       (+) VP Shunt tube located at
                                        Palpation        the right temporal, (-) mass,
                                                         (+) scar at least 1 inch at
                                                         the right occipital area.
c. Face                                                  Symmetrical,       with        slight
                                        Inspection       bulging at the top of head,
                                                         downward deviation of eyes.
d. Eyes                                                  “Sunsetting”      eye,    watery
                                                         color of the eye is black,
                                                         constricted,    (eyes     do     not
                                                         follow in response to head
                                        Inspection
                                                         movement)       can     focus     on
                                                         objects 7-8 inches away, can
                                                         follow up to midline,
                                                         Eyelids-fully cover eye when
                                           close     and     partially       raise
                                           when      open      (blink       reflex
                                           present), placement in eye
                                           socket-normally placed.
e. Nose                                    Flat    nose,       smooth,          (-)
                            Inspection
                                           distress, (-) nasal flaring
f. Mouth and pharynx                       Lip    color-normally          pinkish,
                                           open evenly when cry, soft
                                           and     hard       palate        intact,
                                           tongue slightly heart shape,
                            Inspection
                                           freely movable and does not
                                           protrude, milk teeth present,
                                           but upper teeth in front are
                                           decayed.
g. Neck                                    Symmetric,          flexible       and
                                           movement          of      the     head
                            Inspection     equally      to        both      sides,
                                           supported by pillows when
                                           eating, (+) lymph nodes
h.    Chest     wall    (                  Symmetric,                    clavicles
Anterior)                                  straight, (-) fractures, heart
                            Inspection     rate    heard       at     the     mid
                            Auscultation   clavicular      space     at     fourth
                                           intercostal space (103bpm),
                                           (-)murmur
i. Chest wall (Posterior)                  (-) fracture, spine is aligned,
                                           (-) murmur. At the midline
                            Inspection
                                           of lumbar area (+) scar 1 ½
                            Auscultation
                                           inch long due to lumboscral
                                           myelomeningocele
j. Breast and Axilla                       Nipple are prominent, well
                            Inspection     formed       and         symmetrical
                                           place
k. Heart                                   103bpm, apical pulse and
                            Auscultation   respiratory       rate     identified,
                                           normal rhythm
l. Abdomen                  Inspection     (-)kidney          and          spleen
                           Auscultation   enlargement,                     (+)
                                          burborgymi sounds (18p/m),
                                          globular, , (-) masses
m. Skin and nails                         Skin- (-)dry, (+) smooth
                                          Nails- short nails with some
                           Inspection
                                          dirt at the “singit” inside
                                          nails
n. Anus and Rectum                        (+)patent anus, (-)rashes, (-
                           Inspection     )hemorrhoids
                                          BM- 1x
o. Extremities (lower)                    Rating: 5 normal, there is an
*include      ROM    and                  active resistance with simple
muscle strength                           motion
                           Inspection
                                              -equal      in    length,    five
                            Palpation
                                          fingers on each feet, but the
                                          both foot is in plantar flexion
                                          (equinus)
p. Extremities (upper)                    Rating: 5 normal, there is an
*include      ROM    and   Inspection     active resistance with simple
muscle strength             Palpation     motion, complete fingers on
                                          both hands
q. Urinary                                Color- light yellow
                                          Transparency- turbid
                                          Specific Gravity- 1.005
                                          Reaction- acid
                                          Albumin- ++
                                          Sugar- negative
                           Inspection     Pus Cell- TNTC
                                          RBC- 2-4hpf
                                          Bacteria- +
                                          Epithelial Cell- few
                                          Crystals- Amorphous
                                          Urates(+)
                                          Void- 2 diapers per day
r. Genitals                Inspection     (-) hernia
s. Musculoskeletal                        - (-) weakness, equal size on
                           Inspection
                                          both     side    of    the      body,
                                                               smooth           and    coordinated
                                                               movements
                                                               -   (+)          equinus      (plantar
                                                               flexion of foot)
                                                               - no tenderness, swelling of
                                                               joints
                                                               - (+) gait problems
t. Hematology                      Based on laboratory         Refer to Lab results
                          If applicable please include Neuromuscular Vital signs / assessment


    F. LABORATORY EXAMINATION
                Purpose of                                                                           Nursing
                      the                                                                         responsibiliti
 Date and                                          Results of
                examinatio           Normal                                                              es
  Type of                                                the            Interpretation
                    n to the          Values                                                         (before,
Examination                                      examination
                    patient’s                                                                        during ,
                      case                                                                              after)


1-22-10         -to       detect   Color:        Color: light           All of the results        Before:
                                                                                                   Check the
Urinalysis      normal             yellow-       yellow                 in the urinalysis
                                                                                                    chart of the
                versus             straw/amber                          that                are     pt. And
                                                                                                    carried out
                abnormal                                                significant is the
                                                                                                    doctor’s
                urine              Transparen    Transparenc            presence of pus             order
                                                                                                  During:
                component          cy: clear     y: turbid              cells
                                                                                                   Explain the
                -to       detect                                                                    procedure to
                                                                                                    the pt. And
                glycosuria         Specific      Specific               The urine of the
                                                                                                    its
                -to aid in the     Gravity:      Gravity:               patient             was     importance.
                                                                                                   Assist client
                diagnosis of       1.010-1.020   1.005                  diluted       due    to
                                                                                                    with the
                a          renal                                        less          specific      urine
                                                                                                    collection as
                failure                                                 gravity
                                                                                                    needed
                                   Reaction:     Reaction:                                         Obtain
                                                                                                    history of
                                   4.5-8.0       acidic
                                                                                                    excess
                                                                                                    amount of
                                                                                                    certain foods
                                   Albumin:      Albumin:               CSF                 was
                                                                                                    such as
                                   Negative      ++                     composed             of     carrots,
                                                                                                    rhubarb
                                                                        protein
                                                                                                  After:
                                   Sugar:        Sugar:                                            Provide
                                                                                                    Comfort to
                            Negative       Negative                                     the pt. After
                                                                                        the
                                                                                        procedure.
                            Pus Cell:      Pus Cell:                                   Wait for the
                            3-4            too numerous                                 result
                                           to count


                            RBC: 1-2       RBC: 2-4


                            Bacteria:      Bacteria:      Due the VP shunt
                            Negative       Positive       the patient have


                            Epithelial     Epithelial
                            Cells:         Cells: few
                            Negative


                            Crystals:      Crystals:      Due         to        his
                            Negative       amorphous      hydrocephalus
                                                          and the VP Shunt
                                           Urates:
                                           Negative


Hematology   - to   check   HGB- (110-     HGB- (94.6                                 Before:
             the    blood   165 g/L)       g/L)                                           Check for
             component                                                                   CBC order
             for      any   HCT- (0.35-    HCT- (0.26     Due         to        the       Carry Out
             abnormality    0.50 g/L)      g/L)           decrease                       Doctors
             - to   check                                 pressure         in   his      Order
             the volume     Platelet       Platelet       VP Shunt                    During
             of RBC’s in    count-         count- (226                                    Explain
             the blood      (150-450 x     x 10 g/L)                                     the
                            10 g/L)                                                      procedure
                                           WBC- (12.0     An    increase         in      to the pt.
                            WBC- (5.0-     x 10 g/L)      WBC               which        and          what
                            10.0 x 10                     signifies              a       is      to     be
                            g/L)                          current infection              withdrawn
                                                                                         from          the
                            Differential   Differential                                  blood.
                            count-       count-                                        Assess
                            Segmenter    Segmenters                                   client       for
                            s- (43.0-    - (60.7%)                                    signs/symp
                            76%)                                                      toms          of
                                                                                      allergies
                            Lymphocyt    Lymphocyte                                   such          as
                            es- (17-     s- (32.7%)                                   tearing,
                            48%)                                                      runny nose
                                                                                      and rashes
                            Leukocytes   Leukocytes-                               After
                            - (4.0-      (6.6%)                                        Wait       for
                            10.0%)                                                    the result




TYPHIDOT   To               IgM:         IgM: Positive   Implication         for   Before:
           determine        Negative                     the presence of               Check for
           the                                           IgM       antibodies         CBC order
           presence of      IgG:         IgG:            includes previous             Carry Out
           Salmonella       Negative     Negative        infection           or       Doctors
           typhi which                                   relapsed     or     re-      Order
           is        the                                 infection,                During
           causative                                     therefore;     it    is       Explain
           agent       of                                important         that       the
           typhoid                                       interpretation be            procedure
           fever                                         made        together         to the pt.
                                                         with the clinical            and         what
                                                         symptoms            to       is     to     be
                                                         diagnosed if the             withdrawn
                                                         patient              is      from         the
                                                         currently having             blood.
                                                         typhoid fever.            After
                                                                                       Wait       for
                                                                                      the result
      G. MEDICAL PLAN OF CARE
Date of the                                     Responsibility of the       Purpose of the
                    Doctor’s order
   order                                        nurse with the order         given order


1-21-10        -   pls. admit to Pedia ward                               - for admission
                   (Misc) under Dr. Mamasig
               -   Secure Consent               - Ask if the Doctor had   - for legal purposes
                                                already inform her and
                                                had signed the consent
               -   TPR q shift and recorded     - Monitor V/S every 4     -as baseline data
                                                hours
               -   Soft diet                    - Inform the mother the   - To     know     the
                                                proper diet for the       proper nutrition for
                                                patient                   the patient
               -   Labs:                                                  - To further know
                    CBC with platelet          - Executes     as  per    the             other
                                                Doctor’s order            complications to the
                    U/A                        - Refer    to   Medical   disease
                                                Technologists             - To assess for any
                                                                          abnormalities within
                                                                          the urinary system
                                                                          as well as for
                                                                          systemic problems
                                                                          that may manifest
                                                                          symptoms through
                    Typhi dot                                            the urinary tract.
                                                                          -To detect Typhoid
                                                                          fever and any other
               -   Tx                           - Executes     as   per   salmonella
                    D5 0.3 NaCl 500ml x        Doctor’s order            infection.
                   55ugtts/min                  - Carried out
                    Chloramphenicol 300mg
                   TIV
                    (-) ANST every 6 hours
                    Paracetamol     125/5ml
                   every 4 hours p.o
               -   TSB inform PROD of the
                   admission

1-22-10        -   Pls. re-insert IV            - Carried out
               -   Pls. give chloramphenicol
                   IV drip for 15 units
               -   Refer
    8:00 am    -   IVF TF #2 D5IMB 500ml x
                   8 hours

1-23-10        -   Continue meds                - Carried out
               -   TF #3 D5IMB 500ml x 8
                   hours

1-24-10        -   Continue meds                - Carried out
               -   Pls. re-insert IV now
               -   Warm compress on        IV
                   sites
1-25-10   -   IVF TF #4 D5IMB 500 x 8     - Carried out
              hours
          -   Continue meds
          -   Refer

1-26-10   -   IVF TF #5 D5IMB 500 x 8     - Carried out
              hours
          -   Continue meds
          -   Refer

1-27-10   -   IVF TF #6 D5IMB 500 x 8     - Carried out
              hours                       -  executes    as   per
          -   Continue meds               Doctor’s order

1-28-10   -   IVF TF #7 D5IMB 500 x 8     - Carried out
              hours                       -  executes    as   per
          -   To      consume        IV   Doctor’s order
              chloramphenicol; shift to
              cefixime 20mg/ml 2x a
              day
          -   Refer
H. ANATOMY AND PHYSIOLOGY




The Digestive Process:
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.
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.
   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.
   Gallbladder - 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
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.
I. PATHOPHYSIOLOGY
A. Diagram




                                                    Precipitating Factors:
 Predisposing Factor:                                   Environment
     Age: 2years and 5 months old                      Street Foods
     Sex: Male                                         (contaminated)
                                                        Unboiled water
     Genes



                              Salmonella Typhi



                             Enter the G.I tract
                              (jejunum, ileum,
                                   colon)


                             Enters bloodstream
                               via lymphatics
                               (peyer’s patch)


                             Penetrate cell with
                                 little lysis



                             Multiply in lamina
                                   propia




                 Systemic                            Local
                  spread                           Infection



                                     Release of endogenous pyrogens (prostaglandin
                                     E1) from neutrophils and macrophages
                                     (specialized form of leukocytes)


                                      Resetting the thermostatic set
                                      point (prostaglandin E2)



                                      The hypothalamus initiates heat
                                      production behaviors (shivering and
                                      vasoconstriction)


                                                   FEVER
      B. Tabular
                                                         Signs and
                              Signs and
 Definition of the                                    Symptoms                    Evaluation or
                        Symptoms found in
     diseases                                    manifested by the                 comparison
                               the book
                                                          patient


Typhoid Fever
A general infection    Signs and                 Signs and                  These means that the
caused by              Symptoms in book:         Symptoms in                signs and symptoms in
Salmonella typhi, a      Fever                  patient:                   the book about typhoid
gram negative            Anorexia                  fever (6 days)         fever are seen to the
motile and               Diaphoresis               anorexia               patient.
nonspore- forming        Weakness                  constipation
bacillus. It is a        Myalgia                   cough
general infection        Malaise
that primarily           Moist crackles
involves the Peyer’s    Second week:
patches of the small     104F, evening
intestines              chills
                         Delirium
                         Increasing
                        abdominal pain
                         Diarrhea or
                        constipation
                         Maculopapular
                        rash
                         cough


      J. DRUG STUDY
  Name of Drug,
  Classification,                                                       Nursing Responsibility
                           Drug Indication        Drug Action
Route, Frequency                                                        (before, during , after)
   and Dosage
Chloramphenicol            Haemophillus       Inhibits     bacterial       Use      cautiously        in
  (anti-infective)     influenzae              protein     synthesis    patient       with        impaired
R: TIV                     Meningitis         by binding to the        hepatic or renal function,
F: q6 hours                Acute Salmonella   50 sub-unit of the       acute                intermittent
D: 300mg               typhi infection         ribosome;                phorphyria         and      G6PD
                           Bacteremia         bacteriostatic           deficiency;          also     use
                           Other severe                                cautiously         with      other
                       infections caused by                             drugs      that    cause     bone
                       sensitive Salmonella                             marrow        suppression       or
                       species                                          blood disorders
                                                                            Obtain       specimen     for
                                                                        culture and sensitivity test
                                                                   before giving first dose.
                                                                   Therapy        may       begin
                                                                   pending results.
                                                                      Obtain plasma levels
                                                                   maintain levels at 5-20
                                                                   mcg/ml
                                                                      Monitor CBC, platelets,
                                                                   iron   and      reticulocytes
                                                                   before and every 2 days
                                                                   during this therapy. Stop
                                                                   immediately      if   anemia
                                                                   occurred.


  Name of Drug,
  Classification,                                                   Nursing Responsibility
                      Drug Indication          Drug Action
Route, Frequency                                                   (before, during , after)
   and Dosage
   Paracetamol       Mild pain or fever   Thought to produce        Use liquid form for
    (analgesics)                           analgesia by             children and patients
   (antipyretics)                          blocking pain            who have difficulty
R: p.o                                     impulses by              swallowing.
F: q4 hours PRN                            inhibiting synthesis      In children, don’t
D: 4ml                                     of prostaglandin in      exceed five doses in 24
                                           the CNS or of other      hours.
                                           substances that           Tell parents to consult
                                           sensitize pain           prescriber before giving
                                           receptors to             drug to children younger
                                           stimulation. The         than age 2.
                                           drug may relieve          Advise parents that
                                           fever through            drug is only for short-
                                           central action in the    term use; urge them to
                                           hypothalamic heat-       consult prescriber if
                                           regulating center.       giving to children for
                                                                    longer than 5 days or
                                                                    adults for longer than 5
                                                                    days or adults for longer
                                                                    than 10 days.
  Name of Drug,
  Classification,                                                     Nursing Responsibility
                       Drug Indication           Drug Action
Route, Frequency                                                      (before, during , after)
   and Dosage
     Cefixime         Uncomplicated UTI     Cefixime binds to         Check if the patient is
  (anti-infective)   caused by E. coli       one or more of the       allergy to cephalosporins
R: p.o               and proteus mirabilis   penicillin-binding          Use      cautiously      in
F: BID                Otitis media          proteins (PBPs)          patient     with     impaired
D: 2ml               caused by               which inhibits the       hepatic or renal function,
                     Haemophillus            final                    acute             intermittent
                     influenzae              transpeptidation         phorphyria        and     G6PD
                                             step of                  deficiency;        also    use
                                             peptidoglycan            cautiously        with    other
                                             synthesis in bacterial   drugs that cause bone
                                             cell wall, thus          marrow      suppression      or
                                             inhibiting               blood disorders
                                             biosynthesis and            Obtain specimen for
                                             arresting cell wall      culture     and     sensitivity
                                             assembly resulting       test before giving first
                                             in bacterial cell        dose. Therapy may begin
                                             death.                   pending results.
                                                                         Obtain plasma levels
                                                                      maintain levels at 5-20
                                                                      mcg/ml
                                                                       Monitor CBC, platelets,
                                                                      iron and reticulocytes
                                                                      before and every 2 days
                                                                      during this therapy. Stop
                                                                      immediately if anemia
                                                                      occurred.
Nursing Prioritization and Competencies


                                                                                  Date
  NO.            Nursing Diagnosis                Nursing Competencies
                                                                               Identified


        Ineffective Gastrointestinal Tissue            Communication
        Perfusion r/t normactive bowel                Health Teaching
   1    sounds as manifested by burborgymi        Safe and Quality Nursing     Jan.22,2010
        sounds (18p/m)                                      Care
                                                 Ethico-Moral Responsibility
                                                       Communication
        Impaired physical mobility r/t loss of        Health Teaching
   2    integrity of bone structure as            Safe and Quality Nursing     Jan.22,2010
        manifested by plantar flexion of foot.              Care
                                                 Ethico-Moral Responsibility
        Knowledge Deficient r/t typhoid fever          Communication
        as evidenced by unfamiliarity to the          Health Teaching
   3                                                                           Jan.22,2010
        causative factor of the disease           Safe and Quality Nursing
                                                            Care
                                                       Communication
                                                      Health Teaching
        Severe anxiety r/t unfamiliar person
   4                                              Safe and Quality Nursing     Jan.22,2010
        as evidenced by crying
                                                            Care
                                                 Ethico-Moral Responsibility
                                                       Communication
        Risk for infection r/t open anterior
                                                      Health Teaching
        fontanel as manifested by scratching
   5                                              Safe and Quality Nursing     Jan.22,2010
        of the head
                                                            Care
                                                 Ethico-Moral Responsibility
 K. NURSING CARE PLAN
           Cues                                                         Nursing
                              Nursing
(subjective/objectiv                              Objectives         Intervention      Evaluation
                             Diagnosis
             e)                                                     and Rationale


S:                           Ineffective         After 4 hours      - V/S monitored   Goal is met.
“Malimit siya maging         Gastrointestinal    of     nursing     and checked for   After 4 hours
tampulan ng tukso ng         Tissue              intervention       baseline data     of nursing
mga      pinsa niya” as      Perfusion     r/t   the      patient   - Determine       intervention
verbalized        by   the   normactive          will be able to    whether           the patient
patient’s mother             bowel     sounds    decreased          condition is      will be able to
                             as   manifested     burborgymi         permanent or      decreased
O:                           by burborgymi       sounds     from    temporary to      burborgymi
     -   (+) burborgymi      sounds              18p/m to           enhance           sounds from
         sounds              (18p/m)                                acceptance        18p/m to
         (18p/m)                                                    - Establish a
     -   Body malaise                                               patient-nurse
     -   Brownish color                                             relationship to
         of stool                                                   convey an
                                                                    attitude of
                                                                    caring and
                                                                    develop sense
                                                                    of trust
                                                                    - Auscultate
                                                                    bowel sounds to
                                                                    determine
                                                                    problems in
                                                                    abdomen
                                                                    Encourage rest
                                                                    after meals to
                                                                    enhance
                                                                    digestion
          Cues                                                                    Nursing
(subjective/objecti           Nursing Diagnosis          Objectives             Intervention         Evaluation
           ve)                                                              and Rationale


S:                            Impaired       physical    After         5    -    V/S       taken    Goal is met.
“ Malaro siya kaso            mobility r/t loss of       hours        of         and recorded       After 5 hours
hindi     talaga      siya    integrity    of   bone     nursing                 for    baseline    of      nursing
pinapayagan             na    structure             as   intervention            data.              intervention
makipaglaro           dahil   manifested            by   the     patient    -    Provided           the     patient
madali siya mainis at         plantar     flexion   of   will able to            safety      and    was    able     to
sumungin”               as    foot.                      demonstrate             security     for   demonstrate,
verbalized       by    the                               ,                       the safety of      participation
patient’s mother                                         participation           the child          in    activities,
                                                         in    activities   -    Encouraged         command       by
O:                                                       command by              participation      his mother or
     -   limited ROM                                     his     mother          is self care;      relatives.
     -   difficulty      of                              or relatives.           to encourage
         turning side to                                                         self     concept
         side                                                                    and sense of
     -   (+)       plantar                                                       independenc
         flexion of foot                                                         e
     -   Difficulty     to                                                  -    Encouraged
         move                                                                    adequate
                                                                                 intake        of
                                                                                 fluids       and
                                                                                 nutritious
                                                                                 food;         to
                                                                                 promote
                                                                                 well-being
                                                                                 and
                                                                                 maximize
                                                                                 energy
                                                                                 production
                                                                            -    Instructed
                                                                                 proper
                                                                                 hygiene      for
                                                                                 cleanliness
                                                                                        of           the
                                                                                        patient        to
                                                                                        avoid spread
                                                                                        of infection
                                                                               -        Provide quiet
                                                                                        and        calm
                                                                                        environment
                                                                                        to     promote
                                                                                        relaxation


           Cues                                                                          Nursing
                                  Nursing
(subjective/objectiv                                         Objectives                Intervention          Evaluation
                                 Diagnosis
            e)                                                                     and Rationale


S:                             - Knowledge              After    2    hours        -     V/S      taken     Goal           is
“ Hindi     namin alam           Deficient        r/t   of           nursing             and                partially met.
kung       paano        siya     typhoid        fever   intervention                     recorded           After 2 hours
nilagnat    ng     mataas”       as    evidenced        the patient will                 for baseline       of        nursing
as verbalized by the             by                     be      able      to             data.              intervention
patient’s mother                 unfamiliarity to       understand the             -     Explain     to     the       patient
                                 the      causative     related factors                  the relative       will be able to
O:                               factor    of    the    about           the              of     patient     understand
     -   Unfamiliarity to        disease                present illness                  the                the       related
         the      causative                                                              condition of       factors    about
         factor    of   the                                                              the patient        the       present
         disease                                                                   -     Discuss            illness
     -   Restlessness                                                                    related
     -   irritability                                                                    factors
                                                                                         about      the
                                                                                         present
                                                                                         disease
                                                                                   -     Encourage
                                                                                         them        to
                                                                                         read     some
                                                                                         books
                                                                                         about      the
                                                                                         disease and
                                                                                    causative
                                                                                    agent


            Cues                                                                    Nursing
                                         Nursing
(subjective/objectiv                                           Objectives        Intervention          Evaluation
                                        Diagnosis
                e)                                                               and Rationale


S:                                   Severe anxiety r/t   After    4    hours    - V/S                Goal   is   met.
“Madali     siya      matakot        unfamiliar person    of           nursing    monitored           After 4 hours
sa        mga            taong       as evidenced by      intervention            and recorded        of      nursing
ngayonlang                   niya    crying               the patient will        as       baseline   intervention
nakita”     as       verbalized                           be      able      to    data                the     patient
by the patient’s mother                                   develop       sense    - Provide            will be able to
                                                          of trust.               adequate            develop sense
O:                                                                                rest           to   of trust.
     -    crying                                                                  promote
     -    (+)         stranger                                                    relaxation
          anxiety                                                                - Build         a
     -    With       poor    eye                                                  trusting
          contact                                                                 relationship
     -    With extraneous                                                         with          the
          movement                                                                patient        to
     -    (+)               facial                                                promote
          grimace                                                                 rapport.
                                                                                 - Encourage
                                                                                  patient        to
                                                                                  play           to
                                                                                  promote
                                                                                  therapeutic
                                                                                  empathy        to
                                                                                  the patient
                                                                                 - Provide
                                                                                  physical
                                                                                  contact        to
                                                                                  the       patient
                                                                                  as     well   as
                                                                                  being truthful
                                                                                 to        soothe
                                                                                 fears.


             Cues                                                                    Nursing
                                       Nursing
(subjective/objectiv                                         Objectives        Intervention                Evaluation
                                      Diagnosis
                e)                                                             and Rationale


S:                                 Risk for infection   After    4    hours    - monitor       V/S    Goal     is    met.
“     Lagi      niya      gusto    r/t open anterior    of           nursing    every 4 hours         After    4    hours
kamutin yung nasa ulo              fontanel       as    intervention            as        baseline    of           nursing
niya’ as verbalized by             manifested     by    the pt will able        data                  intervention
the                    patient’s   scratching of the    to know what           - soft          diet   the pt was able
grandmother                        head                 are             the     instructed      to    to know what
                                                        intervention to         avoid                 the
O:                                                      prevent         the     restraining           intervention to
      -   afebrile                                      risk              of    and easily to         prevent         the
      -   irritability                                  infection.              swallow               risk of infection
      -   restlessness                                                         - monitored IVF        is.
      -   (+)             open                                                  and IV rates
          anterior                                                             - kept back dry
          fontanel                                                              to        prevent
      -   Scar       on     the                                                 occurrence of
          right side of the                                                     other disease
          head                                                                 - kept
      -   Scratching         of                                                 environment
          the head                                                              well
                                                                                ventilated
                                                                               - emphasized
                                                                                hygiene
                                                                               - provide safety
                                                                                and       security
                                                                                such as
                                                                                      don’t
                                                                                      leave    the
                                                                                      child
                                                                                      unattende
                                                                                      d
                                                                put
                                                                pillows
                                                                each      side
                                                                of the bed
                                                        - monitor         I/O
                                                          to        prevent
                                                          reoccurrence
                                                          of            other
                                                          disease
                                                        - Health
                                                          teaching
                                                          instructed
                                                          such as;
                                                             Hygiene
                                                                measures
                                                                Safety
                                                                measures
                                                                (         tell
                                                                patient
                                                                not         to
                                                                scratch
                                                                site of VP
                                                                shunt)      to
                                                                prevent
                                                                risk        of
                                                                infection
                                                                Diet
                                                                instructed




  L. DISCHARGE PLAN OF CARE
              Key Area                             Plan of Care
1. Nutrition             Continue advice of soft diet as prescribed by the physician,
                         encourage patient to eat nutritious food, and avoid street foods
                         to avoid possible of having typhoid fever.
2. Activity              Encourage patient or instruct mother of daily exercise, avoid
                         sleeping late hours, prevents activity that causes trauma or
                                 injury
3. Self Care / knowledge on      Instructed hygienic measures (e.g. proper hand washing, before
treatments                       and after eating and urinate and defecate, as well as proper
                                 grooming)
4. Medication                    Advise to continue medication as prescribed by the doctor.
5. Follow up check ups           To comeback as prescribed by the doctor. Have a daily
                                 consultation to neuro and physical therapist for the VP Shunt
                                 and for plantar flexion of foot.


  M. HEALTH TEACHING PLAN
                                            Methods of
      Topic              Objective                              Visual aids          Evaluation
                                             Teaching
 1. Choosing Right After 30 mins of          Discussion         - Sample          After 30 mins of
     Foods           discussion the          Explanation        Procedures        discussion the
                     mother of the pt.                                            mother of the pt.
                     will be able to                                              was able to know
                     know the                                                     the importance
                     importance and                                               and
                     understanding,                                               understanding,
                     choosing foods                                               choosing foods
                     to eat                                                       to eat


 2. Importance       After 30 mins of                           - Picture of      After 30 mins of
     of clean and    discussion the          Discussion         nutritious        discussion the
     safe foods      mother of the pt.       Explanation        foods             mother of the pt.
     for the         will able to know                          - List of right   will able to know
     family          the importance                             and affordable    the importance
                     of clean and safe                          foods             of clean and safe
                     foods for the                                                foods for the
                     family                                                       family




 3. Proper Boiling   After 30 mins of                           - Notes of
     of Water        discussion the          Discussion         importance of     After 30 mins of
                     relative of the         Explanation        clean and safe    discussion the
                     pt. will be able                           foods             relative of the pt.
                     to know the                                                  was able to know
                     proper boiling of                                          the proper
                     water to kill the                                          boiling of water
                     microorganism                                              to kill the
                     in the water.                                              microorganism in
                                                                                the water.
  4. Safety and      After 1 hour of     Demonstration     - pictures
     Security of     nursing care and      Explanation     needed for           After 1 hour of
     Child           health teaching                       demonstration        nursing care and
                     the mother of                         such as pillows,     health teaching
                     the pt. will able                     things that          the mother of
                     to know the                           could harm your      the pt. was able
                     safety measures                       child (e.g. knife,   to know the
                     needed by the                         holder and pins)     safety measures
                     child                                                      needed by the
                                                                                child




   N. SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF CONTACT
Date: January 23, 2010
   The condition of the Baby Pops on the last day of duty in the Pedia ward had no signs of
   distress, afebrile and cooperative. He still afraid of strangers especially when touching
   him. Baby Pops was still under observation and possible for MGH the next day.

								
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