ILOILO DOCTORS’ COLLEGE

COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

NCM 112 RLE

A CASE STUDY ON:

Typhoid Fever

PRESENTED BY:

SERNEO, MADELYN

BSN III – D

MRS. MARIA RAYCHELLE G. LANCERO

COURSE INSTRUCTOR
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

I. INTRODUCTION

i. Typhoid Fever

Typhoid fever, also known as enteric fever, is a potentially fatal multisystemic illness
caused primarily by Salmonella enterica serotype typhi and, to a lesser extent, Salmonella
enterica serotypes paratyphi A, B, and C. Typhoid fever has a wide variety of presentations
that range from an overwhelming multisystemic illness to relatively minor cases
of diarrhea with low-grade fever. It may have responsible for the Great Plague of Athens at
the end of the Peloponnesian War. Untreated typhoid fever may progress to delirium,
obtundation, intestinal hemorrhage, bowel perforation, and death within 1 month of onset.

The Philippines had 2,025 cases of typhoid and paratyphoid fever in 2010, a marked
decrease from the 2003 figure of 16,444 cases. Morbidity is 30.5/100,000 population and
mortality is 1.7/100,000 population. Contaminated food and water or close contact with an
infected person cause typhoid fever. Signs and symptoms usually include:

 High fever

 Headache

 Stomach pain

 Constipation or diarrhea

Most people who have typhoid fever feel better a few days after they start antibiotic
treatment, but a small number of them may die of complications. Vaccines against typhoid
fever are only partially effective. Vaccines usually are reserved for those who may be
exposed to the disease or who are traveling to areas where typhoid fever is common.
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

ii. General Objective:

The study aims to broaden the knowledge of student nurse in terms of effective
nursing management to be able to provide quality care to the patient. At the end of the
study, the student nurse and the audience will be able to expand their knowledge regarding
Typhoid Fever.

Specific Objective

Knowledge

 To define typhoid fever.

 To know the cause and symptoms of the disease.
 To know different methods to diagnose typhoid fever.
 Define and explain the pathophysiology of fever.

Skills

 Implement proper nursing diagnosis and discharge plan.

 To formulate an effective pharmacologic and non-pharmacologic management for a
patient with fevers.
 Provide appropriate nursing intervention for clients care.

Attitude

 Provides professional care.

 Communicate effectively and keep a positive attitude when dealing with patients.
 Establish rapport effectively with the patient and with their family.

II. PATIENT’S DATA

 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

1. Biographic Data
A. Client’s name: n/a
B. Address: n/a
C. Age: 29 y.o
D. Sex: Male
E. Weight: n/a
F. Height: n/a
G. Marital Status: n/a
H. Admitting Impression/ Final Diagnosis (if admitted in the hospital):
Typhoid fever
I. Mode of Admission: n/a
J. Date and Time of Admission (if admitted in the hospital) : n/a

2. Chief Complaint: fatigue, anorexia, malaise, headache, fever and difficulty of

concentrating.

3. Vital signs:
 Temperature: 40°C
 Blood Pressure: n/a
 Pulse Rate: n/a
 Respiratory Rate: n/a
 O2 sat: n/a

4. Physical Assessment:
 The liver edge was tender and palpated 3cm below the right costal margin,
with diffuse abdominal tenderness.
 Abdominal CTS showed thickness of the terminal ileum wall and clumped-
enlarged mesenteric lymph nodes in the RLQ.
 Roseola spots distributed on the trunk.

III. PAST AND PRESENT MEDICAL DATA:

 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

Past History:n/a

Present Medical History: Upon admission patient is suffering from fatigue, anorexia,
malaise, headache, fever, difficulty breathing and
appeared tired and thin.
Lifestyle: n/a

IV. Pathophysiology

Ingest contaminated Food

Ingested bacilli invade small intestinal

mucosa

Taken up by macrophage and

transported to regional lymph node.

S.typhi multiply in the intestinal

lymphoid tissue

Intact with electrolytes and M cells (ileal Peyer’s pathches)

during 1-3 week of intubation period. (diarrhea)

End of incubation period, bacilli enter blood stream

(Bacteraemia Phase) (Onset of typhoid fever)

Bacteria invade the gallbladder, biliary system and

lymphatic tissue of the bowel and multiply in high number.

Then pass into the Intestinal tract.

V. Diagnostic Examination Results:(Stool)

 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

Result Normal Values Significance

Aspartate- High levels of AST in the blood
aminotransferase may indicate hepatitis, cirrhosis,
mononucleosis, or other liver
790U/L 8 to 33 U/L
diseases. High AST levels can also
indicate heart problems or
pancreatitis.
Lactate High levels of LDH indicate some
dehydrogenase 140 units per form of tissue damage. High
1,562U/L liter (U/L) to levels of more than one
280 U/L isoenzyme may indicate more
than one cause of tissue damage.

 Repeated blood cultures were negative.

 Microscopy of a liver showed lobular aggregates of Kupffer’s cells (typhoid nodules).
 Bacterial cultures of the liver’s tissue and roseola spots biopsy were positive for
Salmonella typhi.
 The fecal culture of the patient’s wife was also positive S. typhi and the molecular typing
of the bacterial DNA showed the wife was a silent carrier and main source of the
typhoidic infection.

VI. Nursing care plan

Defining Nursing Outcome Nursing Rationale Evaluation
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

Characteristics Diagnosis Identification Interventions

Subjective: Preoperativ Long Term: Independent: Independent: • Client’s
e: response
Fatigue,  Maint s to
- Document client’s -Useful in defining
anorexia, Imbalanced ain treatmen
nutritional status extent of problem and
malaise, nutrition, weight or t,
display on admission, appropriate choice of
headache, less than teaching,
body weight noting skin interventions.
fever and turgor, current and
requirement gain action
difficulty of , may toward weight and
performe
concentrating. related to desired degree of weight
d.
anorexia goal. loss, integrity of
• Attainme
Objective: and fatigue.  Demo oral mucosa,
nt or
nstrate ability to swallow, progresse
• Fatigue Hypertherm positive presence of
• Anorexia d
ia related to nitrogen bowel tones, and towards
• Body increase in balance, history of nausea, desired
malaise metabolic be free of vomiting, or outcomes
Headache rate. signs of -Helps to identify
• fever
diarrhea. • Modifica
malnutriti specific needs or
• Difficulty of tion to
on, and strengths. plan of
concentrati - Ascertain client’s
display Consideration of care.
ng noted. usual dietary
improved individual preferences
• Temperatu pattern and likes
energy may improve dietary
re: 40°C and dislikes.
level. intake.
• The patient
appeared
to be tired -Useful in measuring
- Monitor intake
and thin Short Term: effectiveness of
and ouput (I&O)
 Maintain nutritional and fluid
and weight
s support.
periodically.
adequate
intake. -Affects dietary choices
 Identifies and can identify areas
- Investigate
ways to for problem-solving to
anorexia, nausea,
increase enhance intake of
and vomiting.
protein nutrients.
Note possible
and correlation to
caloric medications.
intake Monitor
frequency, -Helps conserve
volume, and energy, especially
ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

consistency of when metabolic

stools. requirements are
- Encourage and increased by fever.
provide for
frequent rest -Reduces bad taste left
periods. from sputum or
medications used for
- Provide oral care respiratory treatments
before and after that can stimulate the
respiratory vomiting center.
treatments.
-Maximizes nutrient
- Encourage small, intake without undue
frequent meals energy expenditure
with foods high in from eating large
protein and meals.
carbohydrates.

- Encourage SO to -Creates a more

bring foods from normal social
home and to environment during
share meals with mealtime and helps
client unless meet personal and
contraindicated. cultural preferences.

Dependent:
Dependent:
- Provides assistance
- Refer to in planning a diet
dietitian for with nutrients
adjustments in adequate to meet
dietary client’s metabolic
composition. requirements,
dietary preferences,
and financial
resources
postdischarge.
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

- May help reduce the

- Consult with incidence of nausea
respiratory and vomiting
therapy to associated with
schedule medications or the
treatments 1 to effects of respiratory
2 hours before treatments on a full
or after meals. stomach.

- Low values reflect

malnutrition and
- Monitor
indicate need for
laboratory
change in
studies, such as
therapeutic
blood urea
regimen.
nitrogen (BUN),
serum protein,
and prealbumin
and albumin.
- Fever increases
metabolic needs and
- Administer
therefore calorie
antipyretics, as
consumption.
appropriate.

VII. Drug study

Classification Indications Side Effects and Special Nursing
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

and and
Mechanism of Contraindicati Adverse Effects Precautions Responsibilities
Drug Name Action ons
Chloramphenicol Chloramphen  Monitor I&O
(Anpheclor) may icol ratio or
Generic Name: Classifications: Indications:
cause serious (Ampheclor) pattern:
Chloramphenic chloramphenic Typhoid fever,
and sometimes is Report any
ol ol ; Belongs to meningitis,
fatal adverse contraindicat appreciable
the class of brain
effects such as ed in patients change.
amphenicols. abscesses,
Trade/ Brand depression of with a history  Check
Used in the rickettsial
Name: the bone of temperature
systemic infections &
at least q4h.
other diseases marrow, aplastic hypersensitiv
Anpheclor treatment of Usually
which do not anemia, ity or toxic
infections. chlorampheni
respond to hemolytic reaction to
Dosage: col is
Mechanism of other standard anemia, the drug. It
discontinued
Actions: antimicrobial hypersensitivity should never
50 mg/kg in if temperature
agent. reaction may be given for
divided doses remains
every 6 hr, up Antimicrobial occur especially minor normal for 48
Action: Chlora Contraindicati after topical use. infections or
to 100 mg/kg h.
ons:
in severe mphenicol Gastro-intestinal for  Check the
History of
infections due (Anpheclor) is symptoms prophylaxis. doctor's
hypersensitivit
to moderately a broad- including Repeated order.
spectrum y or toxic nausea, courses and  Observe the
resistant
organisms. antibiotics reaction. vomiting, and prolonged 10 rights of
which acts by Minor diarrhea can treatment medication.
Route: interfering infection, follow oral should be
NPO. Should with bacterial prophylaxis. administration. avoided.
be taken on an protein Disturbances of Routine
empty
synthesis. It is the oral and periodic
stomach.
usually intestinal flora Blood
bacteriostatic may cause examinations
Frequency and
Timing: and is effective stomatitis, are advisable
  against a wide glossitis, and in all
range of Gram- rectal irritation. patients, but
Take 1 hr negative and will not
before or 2 hr Gram-positive warm of
after meals. organisms aplastic
including Salm anemia.
onella
typhi, Haemop
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

hilus
influenzae, Nei
serria
meningitidis, S
treptococcus
pneumonia,
and Bacteriode
s fragilis.

Classification Indications
and and Side Effects and Special Nursing
Drug Name
Mechanism Contraindic Adverse Effects Precautions Responsibilities
of Action ations
Generic Classification Indications: Nausea, abdominal • Check allergies
pain, vomiting,  Tetracyclines • Alert: Check
Name: s: Syphilis, can cause
diarrhea, and expiration date
Chlamydia fetal harm
Tetracycline Broad- anorexia, Using outdated
trachomatis and shouldn’t
spectrum enterocolitis, or deteriorated
Trade/Bran , gonorrhea, be used in
Antiinfectiv hepatotoxicity, drug has been
lymphogran pregnant
d Name: e. flatulence, linked to severe
uloma women.
abdominal cramps, reversible
Sumycin venereum; Tetracyclines
Mechanism epigastric burning, nephrotoxicity
uncommon appear in
Dosage: stomatitis, (Fanconi
of Action: gram- human milk;
hepatitis and syndrome)
250-500 mg positive, the decision
Tetracycline CDAD. • Effectiveness is
gram- to continue or
Route: s are reduced when
negative discontinue
bacteriostati drug is given
PO organisms; breastfeeding
c but may be with milk or
rickettsial should take
Frequency bactericidal other dairy
infections. into account
against products,
and benefits to
certain antacids, or iron
Timing: organisms. Contraindic the mother products
They bind and risks to • For best drug
q6hr ations: the infant.
reversibly to absorption, give
30S and 50S Pregnancy, drug with a full
ribosomal breastfeedin glass of water
subunits, g, on an empty
which children <8 stomach at leas
inhibits yr, 1 hour before o
bacterial hypersensiti 2 hours after
protein vity to meals
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

tetracyclines. • Give drug at

least 1 hour
before bedtime
to prevent
esophageal
irritation or
ulceration
• Use caution
with renal or
hepatic
impairment
• Avoid using in
children
younger than
age 8 because
drug may cause
permanent
discoloration of
synthesis. teeth, enamel
defects, and
bone growth
retardation
• Avoid in
pregnancy due
to toxic effects
on the
developing
fetus (often
related to
retardation of
skeletal
development
and teeth)

VIII. Discharge planning

 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

Medicines:

 Antibiotics are given to fight a bacterial infection. It is important to take all of the

antibiotics to make sure the infection is treated completely. Your healthcare provider will
get bowel movement samples over time to check that treatment is working.

 Take your medicine as directed. Contact your healthcare provider if you think your
medicine is not helping or if you have side effects. Tell him or her if you are allergic to any
medicine. Keep a list of the medicines, vitamins, and herbs you take. Include the amounts,
and when and why you take them. Bring the list or the pill bottles to follow-up visits. Carry
your medicine list with you in case of an emergency.

Manage typhoid:
Signs and symptoms may start to get better in about 4 weeks. You may still be infected even
after treatment. This means you can pass the infection to others. Ask your healthcare
provider about these and other ways to prevent spreading the bacteria until the infection is
gone:

 Ask about going back to work. Your healthcare provider may need to verify that you
are no longer infected before you can work. He or she may need to do this if you handle
food or work in certain care facilities.

 Wash your hands often. Wash your hands several times each day. Wash after you
use the bathroom, change a child's diaper, and before you prepare or eat food. Use soap
and water every time. Rub your soapy hands together, lacing your fingers. Wash the front
and back of your hands, and in between your fingers. Use the fingers of one hand to scrub
under the fingernails of the other hand. Wash for at least 20 seconds. Rinse with warm,
running water for several seconds. Then dry your hands with a clean towel or paper towel.
Use hand sanitizer that contains alcohol if soap and water are not available. Do not touch
your eyes, nose, or mouth without washing your hands first.

 Do not cook or serve food to anyone. Your risk for spreading the bacteria will
increase if someone eats food you handled.

 Clean surfaces often. Use a disinfecting wipe, a single-use sponge, or a cloth you can
wash and reuse. Use disinfecting cleaners if you do not have wipes. You can create a
disinfecting cleaner by mixing 1 part bleach with 10 parts water. In the kitchen, clean
countertops, cooking surfaces, and the fronts and insides of the microwave and refrigerator.
In the bathroom, clean the toilet, the area around the toilet, the sink, the area around the
sink, and faucets. Clean surfaces in the person's room, such as a desk or dresser.
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

 Do not share towels or similar items. Use specific towels, sheets, and eating utensils
or cups. Do not let anyone else use these items. Wash the items often. Use soap and hot
water. If any item is soiled, soak it in disinfectant solution before you wash it.
Prevent typhoid:

 Ask about the typhoid vaccine. You can get the vaccine before you travel to a
country where typhoid is common. You may need the vaccine if you handle typhoid bacteria
or have contact with an infected person. Your healthcare provider will tell you when to get
the vaccine and which vaccine you need. Even after you receive the vaccine, you will need to
be careful about foods and drinks while you travel. You can still get typhoid even after you
receive the vaccine.

 Choose foods carefully when you travel. Do not eat food from street vendors.
Refrigerate food, and only have pasteurized milk or dairy products. Do not eat raw fruits or
vegetables. Peel fruits and vegetables. Do not eat the peelings. Always cook all food
thoroughly, and eat food that is steaming hot.

 Find safe water when you travel. Only drink water that has been treated. Ask for no
ice in your drink, or only have ice made from treated water. Drink bottled water instead of
tap water. You can also boil water for 1 minute before you drink it. Carbonated drinks are
safer than drinks that are not carbonated.

Follow up with your doctor as directed:

You will need tests to make sure you are no longer infected. Write down your questions so
you remember to ask them during your visits.

IX. Review of related studies/ literature

Typhoid Fever
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

Typhoid fever is one of the most common febrile illnesses encountered by the
physicians in Bangladesh. Diagnosis is not difficult but has lately become a challenge due to
changed clinical pattern of the disease, lack of adequate facilities for blood, stool, urine
culture, excessive reliance on nonspecific Widal test and non availability of any reliable rapid
diagnostic tests. Further, the indiscriminate and injudicious use of antibiotics for treating
fever in undiagnosed febrile illnesses early has created problems to the physicians to reach
to a diagnosis later on. This has also led to the emergence of high level resistance to many
of the commonly used antibiotics in our country. Ciprofloxacin is often used empirically for
treating the disease though there is already a high level resistance. In case the organism is
in-vitro sensitive to ciprofloxacin but resistant to nalidixic acid, a much higher dose of drug is
required to maintain the MIC which is 10 times higher than usual. Third generation
cephalosporins (ceftriaxone and cefixime) are still the effective drugs for treating typhoid
fever. The drug needs to be used in proper dose and duration to prevent emergence of
resistance. Azithromycin though advocated by many as an alternative to ciprofloxacin in
resistant cases, has recently lost its credibility due to emergence of resistance. We should
not rely on Widal test in diagnosing typhoid fever. In a suspected case, the patient should
not be prescribed any antibiotic without sending blood sample for culture sensitivity.

Mahmud, A. K., Chowdhury, A. J., Sarker, Z. M., Miah, R. A., Saleh, A. A., Mandal, R. M., &
Dhakal, G. P. (2008). Typhoid Fever. Mymensingh medical journal : MMJ, 17(2), 236–
244.

Typhoid fever infection - Antibiotic resistance and vaccination strategies: A narrative

review

Typhoid fever is a bacterial infection caused by the Gram-negative bacterium

Salmonella enterica subspecies enterica serovar Typhi (S. Typhi), prevalent in many low- and
middle-income countries. In high-income territories, typhoid fever is predominantly travel-
related, consequent to travel in typhoid-endemic regions; however, data show that the level
of typhoid vaccination in travellers is low. Successful management of typhoid fever using
antibiotics is becoming increasingly difficult due to drug resistance; emerging resistance has
spread geographically due to factors such as increasing travel connectivity, affecting those in
endemic regions and travellers alike. This review provides an overview of: the epidemiology
and diagnosis of typhoid fever; the emergence of drug-resistant typhoid strains in the
endemic setting; drug resistance observed in travellers; vaccines currently available to
prevent typhoid fever; vaccine recommendations for people living in typhoid-endemic
regions; strategies for the introduction of typhoid vaccines and stakeholders in vaccination
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

programmes; and travel recommendations for a selection of destinations with a medium or

high incidence of typhoid fever.

Masuet-Aumatell, C., & Atouguia, J. (2021). Typhoid fever infection - Antibiotic resistance
and vaccination strategies: A narrative review. Travel medicine and infectious
disease, 40, 101946. https://doi.org/10.1016/j.tmaid.2020.101946

QUESTIONS:

1. How is typhoid fever spread?

-  Typhoid fever and paratyphoid fever are transmitted commonly through
the consumption of drinking water or food contaminated with the feces of
people who have typhoid fever or paratyphoid fever or of people who are
chronic carriers of the responsible bacteria.
2. What is the usual course of the temperature in typhoid fever?
- Rose spots on the chest of a patient with typhoid fever due to the bacterium
Salmonella typhi. Symptoms of typhoid fever may include a sustained fever
as high as 103 to 104 F (39 to 40 C), weakness, stomach pains, headache, and
loss of appetite.

3. What is the general principle of the Widal test?

- The main principle of widal test is that if homologous antibody is present in
patients serum, it will react with respective antigen in the reagent and gives
visible clumping on the test card and agglutination in the tube. The antigens
used in the test are “H” and “O” antigens of Salmonella Typhi and “H” antigen
of S.

4. How long is typhoid vaccine considered to protect those vaccinated?

 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING

West Avenue, Molo, Iloilo City

5000 Philippines

- Typhoid vaccines lose effectiveness over time. The injectable vaccine requires
a booster every 2 years, and the oral vaccine requires a booster every 5 years. If you
were vaccinated in the past, ask your doctor if it is time for a booster vaccination.

5. What effect does typhoid vaccine considered to protect those vaccinated?

- The vaccine helps protect against typhoid disease, an infection caused by typhoid
bacteria. Typhoid vaccine will give you some protection against the disease (it is
about 50 to 55 percent effective). However, it is also very important to have good
personal hygiene and to take food and drink precautions while you are travelling.