NURSING CARE PLAN 1

Patient’s initials: R.T. Age:62 yrs.old Date:05/15/23

Doctor:Dr.Abegail Q.Chu Hospital no.: FM3
Diagnosis/Impression:Thypoid fever

Assesssment Nursing Diagnosis Scientific Basis Goal Statement/Desired

Outcomes
Subjective Ineffective Fever is the most Goal Statement
cues: thermoregulation: common sign of a After 8hrs of deliberate
“Init napud Fever secondary to systemic response nsg.intervention,the patient
balik ako infection to injury and it is will be able to lowered
paminaw.”as most likely caused temperature as maintain
verbalized by Status by endogenous body temperature within
the patient. actual pyrogens released normal range
from neutrophils
Objective Level of priority and macrophages , Desired Outcomes
cues: Medium a specialized form 1. Verbalized
-body of understanding of individual
temperature Functional Health factors and appropriate
leukocytes.These
of 38.5C Pattern interventions
substances reset
-absence of Nutritional- 2. Demonstrate techniques
the hypothalamic
sweating metabolic pattern and behaviors to correct
thermostat which
-Flushed skin controls body underlying condition or
-skin warm to temperature and situation
touch produce fever 3. Maintain body
-teary eyes temperature within normal
-dry and limits
cracked lips
Source:
Brunner&Suddarth Soure:
’s Medical Surgical Marilyn E. Doenges,Mary
Nursing Frances Moorhouse,Alice C.
Murr “Nursespocket
Guide.”14th Ed.p.784
 Intervention Rationale Evaluation

Independent After 8hrs of deliberate

1. Note extremes of -as this can directly impact nsg.intervention,
age ability to maintain or regulate
2. Obtain history body temperature The goal is
concerning present -thermoregulation is a met
symptoms,correlate controlled process that
with previous maintains the body’s core Patient was able to
episodes or family temperature in the range at 1. Verbalized understanding
history,and diagnostic which most biochemical of individual factors and
studies processes work best appropriate interventions
3. Identify indivial -thermoregulation is affected 2. Demonstrate techniques
factors or underlying in two ways:endogenous and behaviors to correct
condition factors and exogenous underlying condition or
4. Maintain ambient factors situation
temperature in -to prevent or compensate 3. Maintain body
comfortable range for client’s heat production temperature within normal
5. Review causative or or heat loss limits
related factors and -provides information about
risk factors,if what ,if any ,measures can be
appropriate,with implemented to protect
clients/SO client from harm or limit
potential for problems
associated with ineffective
thermoregulation
Dependent
1. initiate emergent -to restore or maintain body
and/or immediate temperature within normal
interventions range
2. Administer -to restore or maintain body
fluids,electrolytes,and and organ function
medications,as
appropriate
3. Provide oral and -allows for review of
written information instructions for early
concerning client’s interventions and
disease implementation of preventive
processes,current or corrective measures
therapies,and
postdischarge
precautions regarding
hypothermia or
hyperthermia,as
appropriate to
situation -to identify potential internal
Collaborative causes of temperature
1. monitor laboratory imbalances
studies -measures could include use
2. Review home of heating pads,ice
management of bag,radiant heaters or fans
temperature
-measures could include use
fluctuation in special
of heating pads,ice
 NURSING CARE PLAN 3
Patient’s initials: R.T. Age:62 yrs.old Date:05/15/23
Doctor:Dr. Abegail Q. Chu Hospital no.: FM3
Diagnosis/Impression: Thypoid fever

Assesssment Nursing Diagnosis Scientific Basis Goal Statement/Desired

Outcomes
Subjective Impaired comfort Impaired comfort Goal Statement
cues: related to acute pain is a After 8hrs of deliberate
“Sakit ako secondary to typhoid multidimensional nsg.intervention,the patient
iyan.”as fever diagnosis used to will be able to verbalize a
verbalized by describe the feeling of improved comfort
the patient. Status physical , and relaxed
actual emotional ,social ,
Objective Cultural and Desired Outcomes
cues: Level of priority spiritual challenges 1. Engage in behaviors or
-facial Medium a patient lifestyle changes to increase
grimace encounters.Acute level of ease
-pain scale of Functional Health 2. Verbalize sense of
pain maybe related
6/10 Pattern comfort or contentment
to spasm of the
-restlessness Cognitive-
lower esophageal
-sighing perceptual pattern
sphincter,possibly
-worried evidenced by
reports of
Vital Signs: substernal
BP: 120/90 pressure,recurrent
RR:20 heartburn or
HR:92 gastric fullness
TP:36.1
O2:98 Soure:
Marilyn E. Doenges,Mary
Source:
Frances Moorhouse,Alice C.
F.A.Davis
Murr “Nursespocket
Company.
Guide.”14th Ed.p.867
mhmedical
Dictionary,23e
 Intervention Rationale Evaluation

Independent After 8hrs of deliberate

1. Provide age- -to provide nsg.intervention,
appropriate measures nonpharmacological pain
2. Discuss concerns manangement The goal is
with the client and -this helps to determine the met
active listen to identify client’s specific needs and
underlying issues ability to change own Patient was able to
3. Determine the situation 1. Engage in behaviors or
client is managing -lack of control maybe lifestyle changes to increase
pain components related to other other issues level of ease
4. Determine type of -help client ti identify the 2. Verbalize sense of
discomfort focus of discomfort comfort or contentment

Dependent
1. Discuss -to promote ease and
intervention/activities relaxation and to refocus
2. Establish realistic attention
goals activity -this enhances commitment
3. Provide information to promoting optimal
about condition, outcomes
health risk factor -give the client choices for
factor accessing and applying
4. Discuss potential information
complication and the -timely recognition and
possible need for intervention can promote
medical follow-up or wellness
alternative therapies
Collaborative -timely recognition and
1. Collaborate intervention can promote
mothers when client wellness
expresses interest -promote physical stability
2. Collaborate in
treating -to determine possible
3. Review medications changes or to reduce side
4. Assist the client to effects
use and modify -to make the best use of
medication regimen pharmacological pain

Source:
Source: Marilyn E. Doenges,Mary
Marilyn E. Frances Moorhouse,Alice C.
Doenges,Mary Frances Murr “Nursespocket
Moorhouse,Alice C. Guide.”14th Ed.p.136-140
Murr “Nursespocket
Guide.”14th Ed.p.868-
869
 NURSING CARE PLAN 2
Patient’s initials: R.T. Age:62 yrs.old Date:05/15/23
Doctor:Dr.Abegail Q.Chu Hospital no.: FM3
Diagnosis/Impression: Thypoid fever
Assesssment Nursing Diagnosis Scientific Basis Goal Statement/Desired
Outcomes
Subjective Diarrhea related to This is Goal Statement
cues: ingestion of characterized by After 8hrs of deliberate
Sige ko ug suspected initial symptoms of nsg.intervention,the patient
kalibang .”as contaminated food nausea and will be able to verbalize
verbalized by as evidenced by vomiting followed relieved or reduction in the
the patient. loose,yellowish stool by abdominal frequency of stools and
cramps and returned to normal
Objective Status diarrhea which is consistency.
cues: actual accompanied by
-weakness fever.The diarrhea Desired Outcomes
-pale and dry Level of priority varies from loose 1. Reestablish and maintain
skin Medium watery stools to normal pattern of bowel
-watery stools bloody purulent functioning
-stool exam Functional Health 2. Verbalize understanding
cholera like stools.
results Pattern of causative factors and
-dry or Elimination Pattern rationale for treatment
cracked lips regimen
-hyperactive 3. Demonstrate appropriate
bowel sounds behavior to assist with
resolution of causative
factors

Source:
Oxford Textbook of Soure:
Medicine Volume Marilyn E. Doenges,Mary
3 By: David A Frances Moorhouse,Alice C.
Warrell p.661 Murr “Nursespocket
Guide.”14th Ed.p.241
 Intervention Rationale Evaluation

Independent After 8hrs of deliberate

1. Ascertain onset and -acute diarrhea caused by nsg.intervention,
pattern of viral,bacterial,or parasitic
diarrhea,noting infections lasts from few days The goal is
whether acute or up to a week met
chronic
2. Note the client’s -Diarrhea in an infant or Patient was able to
age young child and older or 1. Reestablish and maintain
3. Note reports of debilitated client can cause normal pattern of bowel
abdominal or rectal complications of dehydration functioning
pain associated with and electrolyte imbalances. 2. Verbalize understanding
episodes -pain is often present with of causative factors and
4. Auscultate inflammatory bowel rationale for treatment
abdomen disease,irritable bowel regimen
5. Determine recent syndrome,and mesenteric 3. Demonstrate appropriate
exposure to different ischemia behavior to assist with
or foreign -for presence,location,and resolution of causative
environments,change characteristics of bowel factors
in drinking water or sounds
food intake,and -that may help identify
similar illness of causative environmental
others factors
6. Note reports of -these are signs/symptoms of
thirst,less frequent or dehydrations and need for
absent urination,dry rehydrations
mouth and
skin,weakness,light-
headedness,and
headaches

Dependent
-to allow for bowel rest and
1. Restrict solid food reduced intestinal workload
intake,as indicated -to avoid foods or substances
2. Provide for changes that precipitate diarrhea
in dietary intake -when diarrhea is associated
3. Adjust strength or with tube feedings
rate enteral tube
feedings,change
-therapies can include
formula,as indicated
treatment of fever,pain,and
4. Assist in treatment
infectious or toxic
of underlying
agents;rehydrations;oral
conditions and
refeeding and so forth
complications of
diarrhea -to decrease gastrointestinal
5. Administer motility and minimize fluid
antidiarrheal losses
medications,as
indicated -to restore normal bowel
6. Recommend flora
products such as
DRUG THERAPEUTIC RECORD 1
Drug/Dose/ Classification Indication/ Nursing Evaluation
Frequency/ / Contraindication/ Consideration/
Route Mechanism Adverse Reaction Patient Teaching
of action
Drug: Classification: Indication: Nursing -assess oral
Cefixime antibiotic - dosage in renal consideration: cavity for
impairment obtain CBC,renal white
Dose: Mechanism -dosage in hepatic functions tests patches on
400mg of action: impairment -questions for mucous
Binds to hypersensitiviy membranes
Frequency: bacterial cell Contraindication: to cefixime or ,tongue(thr
Once daily membranes,i -history of other ush)
nhibits cell hypersensitivity/anaph cephalosporins,p -monitor
Route: wall ylactic reaction to enicillins daily
PO synthesis.The cefixime,cephalospori pattern of
rapeutic ns Patient bowel
effect:Bacteri Teaching: activity,sto
cidal Adverse Reaction: -continue ol
-antibiotic-associated medication for consistency
colitis,other full length of -monitor
superinfections(abdo treatment;do renal
minal cramps,severe not skip doses function
watery -may cause GI tests for
diarrhea,fever)may upset(may take evidence of
result from altered with food or nephrotoxic
bacterial balance in GI milk) ity
tract.Nephrotoxicity -report -be alert for
may occur ,esp.in pts persistent superinfecti
with preexisting renal diarrhea ons:fever,v
disease.Pts with omiting,dia
history of penicillin rrhea,anal/
allergy are at increase genital
risk for developing a pruritus,ora
severe hypersensitivity l mucosal
reaction(severe changes
pruritus,angioedema,b
ronchospasm,anaphyl
axis)

DRUG THERAPEUTIC RECORD 2

Drug/Dose/ Classification Indication/ Nursing Evaluation
Frequency/ / Contraindication/ Consideration/
Route Mechanism Adverse Reaction Patient Teaching
of action
Drug: Classification: Indication: Nursing -assess oral
Ceftriaxone antibiotic -dosage in renal consideration: cavity for
impairment obtain CBC,renal white
Dose: Mechanism -dosage in hepatic function tests patches on
1gm of action: impairment -questions for mucous
Frequency: -Binds to history of membrane
Every 8hrs bacterial cell Contraindication: allergies,particul s,tongue(th
membranes,i -history of arly rush)
Route: nhibits cell hypersensitivity/anaph cephalosporins,p -monitor
IV wall ylactic reaction to enicillins daily
synthesis.The ceftriaxone,cephalospo pattern of
rapeutic rins Patient bowel
effect:Bacteri -do not administer Teaching: activity,sto
cidal with calcium- -discomfort may ol
containing IV occur with IM consistency
solutions,including injection -monitor
continuous calcium- -doses should be renal
containing infusion evenly spaced function
such as parenteral -continue tests for
nutrition due to risk of antibiotic evidence of
precipitation of therapy for full nephrotoxi
ceftriaxone-calcium length of city
salt treatment -be alert
for
Adverse Reaction: superinfecti
-peptic ulcer,GI ons:fever,v
bleeding ,gastritis ,seve omiting,dia
re hepatic reaction rrhea,anal/
occur rarely genital
pruritus,ora
l mucosal
changes

DRUG THERAPEUTIC RECORD 3

Drug/Dose/ Classification Indication/ Nursing Evaluation
Frequency/ / Contraindication/ Consideration/
Route Mechanism Adverse Reaction Patient Teaching
of action
Drug: Classification: Indication: Nursing -monitor
Carvedilol antihyperten -hypertension consideration: BP for
sive -hearfailure -assess BP,apical hypertensi
Dose: -left ventricular pulse on,respirati
6.25mg Mechanism dysfunction immediately ons for
of action: -dosage in renal before drug is dyspnea.
Frequency: -possesses impairment admitted -take
BID nonselective -dosage in hepatic -received full standing
beta-blocking impairment medication systolic BP
Route: and alpha- history and 1hr after
PO adrenergic Contraindication: screen for dosing as
blocking -hypersensitivity to interactions guide for
activity.cause carvedilol.Bronchial tolerance
s vasodilation asthma or related Patient -assess
bronchospastic Teaching: pulse
conditions,cardiogenic -full therapeutic quality,reg
shock,decompensated effect of BP may ularity rate
HF requiring take 1-2wks -monitor
intravenous inotropic -contact lens for
therapy,severe hepatic wearers may bradycardia
impairment,second or experience -monitor
third degree AV decrease EKG for
block,severe lacrimation cardiac
bradycardia,or sick -take with food arrhythmia
sinus syndrome -compliance s
with therapy
Adverse Reaction: regimen is
-overdose may essential to
produce profound control
bradycardia,hypotensi hypertension
on,bronchospasm,card -report excessive
iact fatigue,prolonge
insufficiency,cardiogeni d dizziness
c shock,cardiac arrest -monitor
-abrupt withdrawal BP ,pulse before
may result in taking
diaphoresis,palpitation medication
s,headache,tremors.
DRUG THERAPEUTIC RECORD 4
Drug/Dose/ Classification Indication/ Nursing Evaluation
Frequency/ / Contraindication/ Consideration/
Route Mechanism Adverse Reaction Patient Teaching
of action
Drug: Classification: Indication: Nursing -evaluate
Esomepraz proton pump -erosive esophagitis consideration: for
ole inhibitor -gastroesophageal -assess therapeutic
reflux disease(GERD) epigastric/abdo response
Dose: Mechanism -treatment of NSAID- minal pain -question if
40mg of action: induced gastric ulcers -question history GI
-converted -zollinger-ellison of hepatic discomfort,
Frequency: to active syndrome impairment,path nausea,diar
Once daily metabolites -duodenal ulcer caused ologic bone rhea occur
that by helicobacter pylori fractures -monitor
Route: rreversibly -heartburn for occult
IV bind Patient
-dosage in renal blood
to,inhibit impairment Teaching: -observe
enzymes on -dosage in hepatic -report for
surface of impairment headache hemorrhag
gastric -take atleast 1hr e in pts
parietal Contraindication: before eating with peptic
cells.Inhibits -hypersensitivity to -if swallowing ulcer
hydrogen ion esomeprazole,other capsules is
transport proton pump inhibitors difficult,open
into gastric capsules and mix
lumen Adverse Reaction: pellets with
- 1tbsp
pancreatitis,hepatotoxi applesauce.Swal
city,interstitial low immediately
nephritis occur rarely without chewing

DRUG THERAPEUTIC RECORD 5

Drug/Dose/ Classification Indication/ Nursing Evaluation
Frequency/ / Contraindication/ Consideration/
Route Mechanism Adverse Reaction Patient Teaching
of action
Drug: Classification: Indication: Nursing -assess BP
amlodipine - -hypertension consideration: -assess for
antihyperten -CAD -assess baseline peripheral
Dose: sive,antiangi -renal impairment renal/hepatic edema
5mg nal -hepatic impairment tests.BP,apical behind
pulse medial
Frequency: Mechanism Contraindication: malleolus
Once daily of action: -hypersensitivity to Patient -assess skin
-inhibits amlodipine Teaching: for flushing
Route: calcium -do not abruptly -question
PO movement Adverse Reaction: discontinue for
across -overdose may medication headache,a
cardiac and produce excessive -compliance sthenia
vascular peripheral with therapy
smooth vasodilation,marked regimen is
muscle cell hypotension with essential to
membranes reflex tachycardia control
syncopy hypertension
-avoid tasks that
require
alertness,motor
skills until
response to drug
is established
-do not ingest
grapefruit
products

DRUG THERAPEUTIC RECORD 6

Drug/Dose/ Classification Indication/ Nursing Evaluation
Frequency/ / Contraindication/ Consideration/
Route Mechanism Adverse Reaction Patient Teaching
of action
Drug: Classification: Indication: Nursing -maintain
Losartan - -hypertension consideration: hydration
Dose: antihyperten -diabetic nephropathy -obtain -assess for
50mg sive -renal impairment BP ,apical pulse evidence of
-hepatic impairment immediately upper
Frequency: Mechanism before each respiratory
Once daily of action: Contraindication: dose,in addition infection,co
-blocks -hypersensitivity to to regular ugh
Route: vasoconstrict losartan monitoring -monitor
PO or,aldosteron -concomitant use of -question for BP,pulse
e-secreting aliskiren in pts with possibility of -assist with
effects of diabetes pregnancy ambulation
angiotensin -assess if dizziness
II,inhibiting Adverse Reaction: medication occurs
binding of -overdosage may history -monitor
angiotensin II manifest as daily
to AT1 hypertension and Patient pattern of
receptor tachycardia. Teaching: bowel
-bradycardia occurs -female pt of activity,sto
less often childbearing age ol
-institute supportiveshould take consistency
measures measure to
avoid pregnancy
-report
pregnancy as
soon as possible
-avoid tasks that
require
alertness,motor
skills until
response to drug
is established
-report any signs
of infection
-do not take OTC
cold
preparations,nas
al decongestants
-limit salt intake
DRUG THERAPEUTIC RECORD 7
Drug/Dose/ Classification Indication/ Nursing Evaluation
Frequency/ / Contraindication/ Consideration/
Route Mechanism Adverse Reaction Patient Teaching
of action
Drug: Classification: Indication: Nursing -monitor
Metronidaz - -amebiasis consideration: daily
ole antibacterial, -anerobic infection -obtain baseline pattern of
antiprotozoal -intra-abdominal CBC,LFT bowel
Dose: infection -question for activity,sto
500mg -pseudomembranous history of ol
Mechanism colitis hypersensitivity consistency
Frequency: of action: -bacterial vaginosis to -monitor
TID -disrupts -rosacea metronidazole,o I&O
DNA,inhibitin -renal impairment ther -assess for
Route: g nucleic acid -hepatic impairment nitroimidazole urinary
PO synthesis derivatives problems
Contraindication: -be alert to
-hypersensitivity to Patient neurologic
metronidazole Teaching: symptoms
-pregnancy -urine maybe -assess for
-use of disulfiram red-brown or rash ,urtica
within 2weeks dark ria
-use of alcohol during -avoid -monitor
therapy or within alcohol,alcohol0 for onset of
3days of discontinuing containing superinfecti
metronidazole preparations for ons
atleast 48hrs
Adverse Reaction: after last done
-oral therapy may -avoid tasks that
result in furry require
tongue,glossitis,cystitis alertness,motor
,dysuria,pancreatitis,pe skills until
ripheral neuropathy response to drug
-seizures occur is established
occasionally

DRUG THERAPEUTIC RECORD 8

Drug/Dose/ Classification Indication/ Nursing Evaluation
Frequency/ / Contraindication/ Consideration/
Route Mechanism Adverse Reaction Patient Teaching
of action
Drug: Classification: Indication: Nursing -evaluate
Omeprazol -proton -active duodenal ulcer consideration: for
e pump -symptomatic GERD -evaluate for therapeutic
inhibitor -erosive esophagitis therapeutic response
Dose: -pylori duodenal ulcer response -question if
40mg Mechanism -gastric ulcer -question if GI GI
of action: -OTC use frequent discomfort,naus discomfort,
Frequency: -inhibits heartburn ea,diarrhea nausea,diar
Once daily hydrogen- -renal impairment occurs rhea occurs
potassium -hepatic impairment
Route: adenosine Patient
PO triphosphata Contraindication: Teaching:
se,an enzyme -hypersensitivity to -report
on the omeprazole,other headache,onet
surface of proton pump inhibitor of black,tarry
gastric -concomitant use with stools,diarrhea,a
parietal cells. products containing bdominal pain
rilpivirine -avoid alcohol
-swallow
Adverse Reaction: capsules
- whole,do not
pancreatitis ,hepatotox chew,crush,diss
icity,interstitial olve,or divide
nephritis occur rarely -take before
-may increase risk of eating
C.difficile infection

DRUG THERAPEUTIC RECORD 9

Drug/Dose/ Classification Indication/ Nursing Evaluation
Frequency/ / Contraindication/ Consideration/
Route Mechanism Adverse Reaction Patient Teaching
of action
Drug: Classification: Indication: Nursing -
Paracetam - -fever consideration: medication
ol antipyretics,a -mild pain -not to exceed s taken at
nalgesics with ordered
Dose: Contraindication: recommended dose,date
500mg Mechanism -hypersensitivity to dose,acute and time.
of action: paracetamol poisoning with Desired
Frequency: -anytipyretic -anemia liver damage effects
TID action results -hepatic or severe may result obtained
from renal disease
Route: inhibition of Patient
PO prostaglandi Adverse Reaction: Teaching:
n in the - -give with full
central leucopenia,neutropeni glass of water
nervous a,hemolytic -with food or
system,may anemia,drowsiness,na milk to decrease
block pain usea,vomiting,abdomi gastric
impulses nal symptoms
peripherally pain,hepatotoxicity,ras -increase fluids
that occur in h,urticaria -monitor VS
response to -avoid usage of
inhibition of multiple
prostaglandi preparations
n synthesis containing
acetamenophen

3.12 HEAD-TO-TOE ASSESSMENT

Name: Rama,Trinidad Age:62 years old
Diagnosis: Thypoid Fever Sex:Female
Physician:Dr.Abegail Q.Chu

PHYSICAL ASSESSMENT
Body Part Inspection Palpation Percussion Auscultation
 Head Head is Hard and smooth N/A N/A
symmetric.in w/o lesions
midline;round;e
rect
 Hair Evenly Smooth,symmetricall N/A N/A
distributed; a bit y distributed
of white of
white/gray hair
 Scalp No dandruff,no symmetric N/A N/A
lesion
 Forehead Symmetrical Strong temporal N/A N/A
pulse
 Face symmetrical Smooth;no N/A N/A
nodules/masses
present
 Eyes “sunsetting” No lumps N/A N/A
eye,watery around,preorbital
color of the eye area,no eye
is black .Eyelids- bumps;no
fully cover eye inflammation
when close and
partially raise
when
open,placement
in eye socket-
normally placed.
 Brows Coarse,hair is No lumps,no N/A N/A
evenly nodules,no rashes
distributed present
 Lashes Present on both N/A N/A N/A
lids;evenly
distributed
 Lids No nodule No eyelid bumps,no N/A N/A
observed,no lumps,not
 lesions,no edematous
edema
o (upper) No nodule No nodules N/A N/A
observed
o (lower) No nodule No nodules N/A N/A
observed
 Sclerae The sclerae is N/A N/A N/A
white in color
and the
palpebral
conjunctiva
appears pink
 Cornea Lustrous surface N/A N/A N/A
and crystal
clear,allowing a
crisp and lucid
view of the iris
 Iris Round,similar N/A N/A N/A
black-brown
color where
pupil is centrally
located
 Pupil Pupils are N/A N/A N/A
equal,round and
reactive to light
and
accommodation
 Muscle Both eyes with N/A N/A N/A
function coordinated
movements
with parallel
alignment
 Muscle Eyes aligned N/A N/A N/A
balance with
coordinated
movements
when looking
upward and
downward
 Visual No lenses,20/20 N/A N/A N/A
acuity vision,able to
read newsprint
or magazines
 Periphera When looking N/A N/A N/A
l vision straight
ahead ,client
can see objects
in the periphery
 nose Conforms to No pain noted,firm N/A N/A
face;external and stable
nose is structures;no hard
symmetrical masses or lumps
with no palpated;no
discoloration,sw malformations or
elling or foreign
malformation;n bodies;patient can
o polyps breath through the
noted;nasal nose normally when
mucosa is the other nares is
pinkish red with occluded
no
discharged/blee
ding
 Frontal No swelling;no No pain reported No sinus pain N/A
sinuses malformations upon palpation;no noted.Nose
noted tenderness;no is patent
masses with good air
flow
 Maxillary No swelling,no No pain reported Percussion N/A
sinuses malformations upon palpation;no note is
noted tenderness;no typanitic,indi
masses cating a
normal
content of air
 Mouth Normally No pain reported N/A N/A
symmetrical,slig upon palpation,no
htly pink in lumps,no
color,smooth,an inflammation/swellin
d slightly dry,no g
growths,lumps
or undesirable
discoloration of
the tissue
 Lips Pink,dry,presenc No growths,lumps or N/A N/A
e of some cracks discoloration of the
and peelings tissue
 Gums Dark pink in No swelling/no N/A N/A
color with no gingivitis;no pain
swelling or reported
bleeding
 Teeth Yellowish in N/A N/A N/A
color
 Tongue Central Patient can portrude N/A N/A
position,pink tongue straight out
and with no deviation
moist,smooth,la noted,pink
teral margins,no color,smooth texture
lesions with no masses or
noted,raised abnormal tissue
papillae growth
 Frenulum Midline with Lingual frenulum,no N/A N/A
moistness,pink lesions or
in color masses/overgrowth
of tissue
 Hard Whitish in Firm to palpations N/A N/A
palate color,with a firm towards the anterior
texture and and lateral to the
irregular midline while more
transverse compressible
rugae towards the
posterior and medial
to the apices of the
teeth
 Soft Slightly less N/A N/A N/A
palate vascular than
the
oropharynx;pink
in color
 Uvula No redness;not Using a tongue blade N/A N/A
swollen;light pressed down on
pink,smooth patient’s
and upwardly tongue,uvula in the
movable midline and rise
along the soft palate
 Tonsils No swelling or N/A N/A N/A
lesions
 Ears Equal size,ear No masses;no N/A N/A
canal is skin- nodules upon
colored palpation art the
 back of the ears and
pinna
o (external) No odor or Recoils easily;no N/A N/A
discharge tenderness,no lumps
o (internal) Small amount of N/A N/A N/A
cerumen
 Auditory Patient correctly N/A N/A N/A
acuity replies to word
through whisper
test
 Neck Neck and back No masses or N/A N/A
have no nodules present
deformities
 Lymph Symmetrically,n No masses or N/A N/A
nodes o enlargement nodules present
 Trachea At N/A N/A N/A
midline;correct
position
 Throid N/A Rises freely with N/A N/A
gland swallowing;no
enlargement
 Chest Regular No pain reported;no Resonance Good air
anterior breathing masses or crepitus heard entry,equal
without throughout bilaterally,no
distress;regular lungs on adventitious
rise and fall of anterior sounds
chest;RR within thorax throughout
normal limits all lobes on
anterior
thorax
 Lungs No visible No pain;no Resonance Equal
deformities,suc tenderness to heard bilateral air
h a barrel indicate trauma throughout entry,no
chest,regular lungs on adventitious
rise and fall of anterior sounds
chest;RR within thorax throughout
normal limits all lobes on
anterior
thorax
 Heart No cardiac Absent vibratory Dullness to Regular rate
impulses sensations percussion and rhythm
observed from the without a
against chest sternum to murmur
 wall the left of
the sternum
 Chest Regular No Equal tactile Good air
posterior breathing pain,temperatures fremitus entry,equal
without distress warm to touch,equal bilaterally,no
bilaterally,no adventitious
moisture,masses,swe sounds
lling,or deformities audible
throughout
all lobes
 Diaphrag Normal No Rest of the No
matic diaphragmatic masses;nodules/tend lung fields hyperresona
excursion excursion,no erness are resonant nce
hyperinflation,n
o difficulty of
movement of
the thoracic
diaphragm
during
breathing
 Abdomen No bluish Abdomen is slightly Dullness No altered
discoloration of hard ,assemetrically /burborgymi bowel
the and tender sounds over sounds
umbilicus(cullen the
’s signs)or stomach,epig
flanks(grey astric
turner’s sign);no area,and
visible lesions or upper
scars midline
 Liver No gross No tenderness;no Tympany Tympany
symmetrically guarding movement sound sound on the
across the right over
abdomen;no the liver
caput
medusa(cluster
of swollen veins
in your
abdomen)or
spider
angiomata
noted
 Spleen N/A enlargement Tympany N/A
 KIdney Laboratory work enlargement Tympany N/A
 of
patient(urinalysi
s-indicates all
within normal
limits)
 Upper Symmetric;no No tenderness,no N/A N/A
extremiti tremors;extremi masses/swelling,no
es ties are without contractures(patient
tenderness or is able to flex and
erythema extend wrist with no
pain reported
o (Muscle Both arms no N/A N/A N/A
tone) contractures(pa
tient can flex
and extend
wrist and elbow
without
assistance)
o (Muscle Full range of Smooth coordinated N/A N/A
strength) motion without movement
resistance
o (Reflexes) Patient has Patient extends arms N/A N/A
relaxed with palms up and
arms;reflexes eyes closed
are not difficult
to elicit
 Lower Symmetric;no No tenderness,no N/A N/A
extremiti tremors;extremi masses/swelling,no
es ties are without contractures(patient
tenderness or is able to flex and
erythema extend legs with no
pain reported
o (Muscle Both knee and Smooth coordinated N/A N/A
tone) ankle no movement
contractures(pa
tient can flex
and extend
without
assistance)
o (Muscle Full range of Smooth coordinated N/A N/A
strength) motion without movement
resistance
o (Reflexes) Plantar flexion Flexion of all toes N/A N/A
 and dorsiflexion present
of toes present
 Gait ,bala Good physical Smooth coordinated N/A N/A
nce and mobility and movement
coordina posture
tion

DIAGNOSTIC TEST NORMAL RESULT SIGNIFICANCE

VALUE
1. Routine Urinalysis
(Chemical analysis)
ph 5.0-8.0 6.0 Normal
Specific Gravity 1.005-1.035 1.010 Normal
Glucose Negative Trace
Negative Negative Normal
Ketones
Negative Negative Normal
Blood
Negative Negative Normal
Leukocyte Esterase
Negative Negative Normal
Nitrate
0.2-2.0mg/dL 0.2mg/dL Normal
Urobilinogen
Negative Negative Normal
Bilirubin
(Urine flow Cytometry) Normal
10.30/uL 0-11/uL
RBC Normal
2.40/uL 0-17/uL
WBC Normal
2.30/uL 0-11/uL
Epithelial Cells Normal
28.40/uL 0-278/uL
Bacteria
RARE
Mucus threads
RARE
Amorphous Urates
2. Salmonella Typhi(TUBEX
Test) <2 4 Weak positive
(Semi-Quantitative Method)

TSH 0.30-5.00uIU/ 0.35uIU/m Normal

mL
FT4 10.6- 12.27pmol/L Normal
(Quantitative Method) 19.4pmol/L

3. Clinical chemistry section

HBAIC(glycoscylated
Hemoglobin) 4.3%-6.4% 5.4% Normal

Potassium 3.5-5.1mmol/L 3.60mmol/L Normal

Creatinine 0.52-1.04mg/dL 0.64mg/dL Normal
Fasting Blood Sugar 74-106mg/dL 136.4mg/dL High Fasting
Blood Sugar

Total Cholesterol 0-240mg/dL 112mg/dL Normal

Triglycerides 0-200mg/dL 80mg/dL Normal

HDL Cholesterol 40-60mg/dL 28mg/dL Low HDL

Cholesterol
LDL Cholesterol 55-150mg/dL 68.00mg/dL Normal
 SGPT/ALT 0-35U/L 35U/L Normal
Blood Uric Acid 2.5-6.2mg/dL 5.1mg/dL Normal
Amylase 30-110 U/L 63 U/L Normal
Lipase 23-300 U/L 81 U/L Normal
Magnesium 1.9-2.5 mg/dL 1.7 mg/dL Low magnesium
4. Complete Blood Count
Hemoglobin 12.3-15.3g/dL 14.3g/dL Normal
Hematocrit 35.9-44.6% 42.O% Normal
White Blood Cells 4.4-11.0 10/uL 19.9 10/uL Normal
Neutrophil 40-70% 89% High Neutrophil
Basophil 0-1% 0 High Basophil
Eosinophils 0-5% 0 Normal
Monocyte 0-8% 5 Normal
Lymphocyte 20-40% 6 Low lymphocyte
Red Blood Cells 4.50-5.10 10/uL 4.78 10/uL Normal

Mean Corpuscular 80-96fL 88fL Normal

Volume(MCV)
Mean Corpuscular HGB.(MCH) 27.5-33.2pg 29.9pg Normal
Mean CorpuscularHGB.CONC.
33.4-35.5% 34.0% Normal
(MCHC)
5.9-9.9fL 9.2fL Normal
Mean Platelet Volume(MPV)
14.0-18.0% 11.7% Low RDW
Red cell distribution
width(RDW) 150-450 10/uL 273 10/uL Normal
Platelet Count

5. Blood Gas Analysis

At 37 Degree Celsius
ph 7.35-7.45 7.46 Alkalosis
pco2 35-45mmHg 26.6 Low pCO2
po2 80-105mmHg 75 Normal
At 39.5 Degree Celsius
7.35-7.45 7.42 Normal
pH
35-45mmHg 29.7 Low pCO2
pCO2
81-105mmHg 89 Normal
Po2
Calculated Data 135- 135 Normal
Na 155mmol/L

3.6-5.5mmol/L 2.9 Low Ca++

K+ Normal
1.12-
Ca++ 1.12
1.32mmol/L

40-54% 40 Normal
Hct
HCO3 22.0- 18.7 Low HCO3
26.0mmol/L
TCO2 23-27mol/L 20 Low TCO2

(-2)- Low BE(ecf)

BE(ecf) (+3)mmol/L -5

So2 95-98% 96 Normal

A Case Study On
Thypoid Fever
-----------------------------------------------------------------------------

In Partial Fulfillment of the Course

Requirement in Medical Nursing

-------------------------------------------------------------------------------
Submitted to the Faculty of
San Lorenzo Ruiz College of Nursing
Ormoc City
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Submitted by:
Mendaros,Mea
Batch Papa