1

BACKGROUND OF THE STUDY

INTRODUCTION
Typhoid fever, otherwise known as enteric fever, is an acute illness
associated with fever caused by the Salmonella typhi bacteria. Salmonella
typhosa is a short, plump, gram negative rod that is flagellated and actively
motile. Contaminated food or water is the common medium of contagion.
The disease follows four stages. The first stage is known as incubation
period, usually 10-14 days in occurrence. In this stage generalization of the
infection occurs. In the second stage, aggregation of the macrophages and
edema in focal areas indicates bacterial localization (embolization) and resultant
toxic injury which disappear after few days. The third stage of disease is
dominated by effects of local bacterial injury especially in the intestinal tract,
mesenteric lymph nodes, spleen, and liver. The fourth stage, or the stage of lysis,
is the stage wherein the infectious process is gradually overcome. Symptoms
slowly disappear and the temperature gradually returns to normal.
The symptoms of typhoid fever include high fever, chills, cough, muscle
pain, weakness, stomach pain, headache and a rash made up of flat, rose-
colored spots. Diarrhea is a less common symptom of a typhoid fever, although it
is a gastrointestinal disease. Sometimes there are mental changes, known as
typhoid psychosis. A characteristic feature of typhoid psychosis plucking at the
bedclothes if patient is confined to bed.
Risk factors for acquiring typhoid fever likely include improper food
handling, eating food from outside sources like carinderia, drinking
2

contaminated water, poor sanitation and even poor hygiene practices. War and
natural disasters as well as weak, non-existent of health care infrastructure may
also contribute. Both genders do have equal chances on acquiring such disease.
Asian, African and Americans are at greatest risks of acquiring the disease since
geographical locations play a part.
Complications of typhoid fever are secondary conditions, symptoms, or
other disorders that are caused by typhoid fever. Complications include
overwhelming infection, pneumonia, intestinal bleeding, and intestinal perforation
may eventually lead to death.
Typhoid fever is one of the most protean of all bacterial diseases thus
laboratory procedures are usually depended on to confirm or disprove suspicion
of such disease. The place of blood culture, serologic studies and bacteriologic
examination feces and urine are useful in establishing the diagnosis.
Agglutination (Widal) for typhoid fever is done to determine antibody response
against different antigenic fractions of organisms.
Typhoid fever is treated with antibiotics which kill the Salmonella bacteria.
Several antibiotics are effective for the treatment of typhoid fever. The choice of
antibiotics needs to be guided by identifying the geographic region where the
organism was acquired and the results of cultures once available. Two new
vaccines are currently licensed and widely used worldwide, Asubunit (Vi PS)
vaccine administered by the intramuscular route and a live attenuated S.
Typhistrain (Ty21a) for oral immunization.
3

In most cases, typhoid fever is managed at home with antibiotics and
bed rest. For hospitalized patients, effective antibiotics, good nursing care,
adequate nutrition, careful attention to fluid and electrolyte balance, and prompt
recognition and treatment of complications are strategies to avert the possibility
of death.
We choose this topic since it catches our interest from the time being we
were able to handle patient having typhoid fever. It gives us the motivation to
look for the things that governs such disease. Typhoid fever as our case study
allows us to find for ways to contribute something for the alleviation of the
condition of its victims may it be in our own little ways perhaps. May this case
study serves as advent to understand more fully the existence of such disease
and the proper interventions needed to be rendered upon to address such
condition looking to a new perspective of life.

OBJECTIVES
General
This case study aims to identify and determine the general health
problems and needs of the patient with an admitting diagnosis of typhoid Fever.
This also intends to help patient promote health and medical understanding of
such condition through the application of the nursing skills.
Specific
To raise the level of awareness of patient on health problems that he may
encounter.
4

To facilitate patient in taking necessary actions to solve and prevent the
identified problem on his own.
To help patient in motivating him to continue the health care provided by the
health workers.
To render nursing care and information to patient through the application of
the nursing skills.

















5

NURSING HEALTH HISTORY

BIOGRAPHIC DATA
Case # xxx-xx-xx
Patients name: AJV Age: 13 years old
Sex: Male Birthday: April 21, 1996
Address: Muzon, City of San Jose del Monte, Bulacan
Nationality: Filipino Religion: Roman Catholic
Civil Status: Single

Chief Complaint: Abdominal Pain, difficulty in urinating and fever
Admitting Diagnosis: t/c Typhoid Fever
Date of Admission: December 14, 2010 @1:00 pm
Date of Discharge: December 20, 2010 @ 2:00 pm
Admitting Physician: Dr. Lim
Final Diagnosis: Typhoid Fever

HISTORY OF PRESENT ILLNESS
Five days prior to admission persistent to consult at OPD. The patient had
an intermittent fever associated with abdominal pain and weakness. A few hours
to admission still the above signs and symptoms remain but already have (+)
rose spots and was diagnosed with Typhoid Fever.

PAST MEDICAL HISTORY
According to the patient he has no experienced of being hospitalized, only
when one time he experience fever and his mom gave paracetamol tablet.
6

FAMILY MEDICAL HISTORY
According to the patients mother the only disease that the family has
genetically is the Hypertension on the fathers side and no similar incident of
typhoid fever noted.

SOCIAL ECONOMIC HISTORY
Recent Stress: Back and Neck Pain
Support System: Mother, Father and four Siblings
Economic condition: Class C
Eating habits: Eats chicken, process foods, vegetables, fruits
and seldom eats salty, oily, and sweet foods.
Food preferences: Meat, Fish, process food, vegetables, and fruits
Area population: Populated area
Environmental Sanitation: Poor Sanitation
Housing: Made of scrap woods and cements
Water supply: NAWASA










7


GORDONS FUNCTIONAL HEALTH PATTERNS

PATTERNS OF
FUNCTIONING
BEFORE
HOSPITALIZATION
DURING
HOSPITALIZATION
ANALYSIS

Health
Perception
Health
Management

Patient AJV does
not want any
consultations or
even go for
checkups because
he thinks that he is
healthy and there is
nothing wrong with
him. He maintains a
healthy body by
playing with his
friends and helping
in household
chores. He easily
gets bored when he
is not doing
anything. he has
started playing
basketball and
since he was 10
years old up to
present. He is not
allergic to any food
or drug. His family
has a history of
hypertension.


Patient AJV
considered himself
a not healthy
person due to
present condition.
He is expecting to
recover from his
present condition
with the help of the
health care
providers attending
to his needs. All of
the medications
prescribed to
patient AJV are
available


Patient AJV
cannot function
normally like
before because
of his
confinement
and his hospital
condition. His
body image
changed due to
his condition.


Nutritional
Metabolic
Management

Patient AJVs life
before his pre
confinement stage
was normal, he can
eat whatever he
wants. He eats
fruits like mango
and bananas, fish
and meats. But
most of the time. He
always eats meat.

During
hospitalization, the
patient in on Strict
Aspiration
Precaution (SAP)
diet. He said he
loses his appetite
due to
uncomfortable
feeling.

Patient AJVs
nutritional and
metabolic status
has been
changed due to
his confinement
and her medical
health condition.
His pre
confinement
status is totally
8

affected.


Elimination
Pattern

Bowel

Patient AJV
defecates two times
a day without
experiencing
discomforts, usually
morning and
afternoon. Stool is
brown in color and is
well-formed.

Bladder

Patient AJV voids
usually 6-8 times a
day. Urine is yellow
in color. No pain
when voiding.


Bowel

Patient defecates
once a day but not
every day. Stool is
soft, is minimal in
amount, and is
brown in color




Bladder

Patient voids 10-
12 times a day with
pain and
discomfort.

Bowel

There was a
change in the
frequency,
consistency and
amount of stool.





Bladder

There was a
change in the
frequency, and
amount.

Activity, Leisure
and Recreation
Pattern

In the morning,
Patient AJVs daily
activities include
collection of water
for the days use. In
the afternoon after
launch, Patient AJV
go out and play
basketball or
swimming on the so
called carabao
beach

Patient AJVs
activity in the
hospital is eating
and sleeping.

During Patient
AJVs
confinement in
the hospital,
there is
limitation in his
activities of daily
living and a
disruption in his
leisure and
recreation
pattern.


Sleep and Rest
Pattern

Patient AJV puts
himself to sleep by
watching primetime
television programs.
He does not have
usual time of sleep.
He sleeps for long
period of time. He

Patient AJV has a
difficulty in sleeping.
He don't feel rested
and comfortable
even though he had
a long period of
sleep, he still feels
weak.

Patient AJV
sleeps and rest
pattern was
changed when
he was admitted
due to his
condition. His
usual routine of
9

feels rested when
sleeping and he
thinks that his
energy is sufficient
for his activities.
watching
television
programs to put
himself to sleep
changed
because he
doesnt need to
do anything to
fall asleep.


Cognitive
Perceptual
Pattern

Patient AJV is still
a high school
student from Sto.
Rosario National
High School in San
Jose Del Monte
Bulacan. He can
read and write. he
can speak and
easily be
understood by
others.


Patient AJV
present condition,
does not affect his
communicating
skills. Patient is still
able to read and
write at present.


There was a
no change in
cognitive and
perceptual
pattern in terms
of writing and
speaking


SelfPerception
/SelfConcept
Pattern

Patient AJV is a
friendly person; he
loves to socialize
with his friends in
their neighborhood.
he considered
himself as a holistic
human being as
long as hes
complete, healthy
and his family is
always there for him


He doesnt
consider himself as
a holistic person.
He has many
regrets in his life.
He thinks that he
can't function well
than before.


Due to his
present
condition, there
is a change to
the level of
patient self-
perception and
self-concept
because he
can't accept that
he cant function
the same way
like before.


Role
Relationship

He was able to do
his responsibilities
as a son and
brother

This time his role
as a patient is not
fully met

Due to his
condition he is
not aware of
performing his
real role in this
field.
10


Sexuality and
Reproductive
Pattern

He doesnt think
of the things like
having a girlfriend
and getting married.

Same

Due to his
youthful mind, it
is still not his
priority in life.


Coping and
Stress
Tolerance

When he is
anxious, patient
AJV wants to be
alone. He does not
show his emotions.
When he is
stressed, he prefers
to rest and sleep.
When it comes to
problem, he let his
self think
immediately for a
solution.


The recent
hospitalization was
a unusual
experience for
patient AJV, there
have been many
changes occurred
that made it difficult
for his to adjust.


Due to his
condition,
patient AJV
does not have
any outlet to
divert his
feelings.


Values Belief
Pattern

Patient AJV is a
Roman Catholic.
According to the
client, he goes to
the mass every
Sunday in Bulacan
with her family.


During
hospitalization the
patient wasnt able
to go to church.


Due to his
hospitalization,
the patients
routine in going
to the church
was altered for
a while.









11

PHYSICAL ASSESSMENT

Date assessed: December 14, 2010
Measurements Findings
Weight
Height
41
38.6 kgs

Level of Consciousness


Conscious and coherent
Body Build
Posture and Gait
Medium
Erect posture, active purposeful stride

General assessment: conscious and coherent
Initial Vital Signs: T: 37.5
o
C, RR: 24cpm, BP: 90/70mmHg, PR: 97bpm

Body Part Technique Normal Findings Actual
Findings
Analysis/
Interpretation

Head

Inspection


- Generally round,
with prominences
in the frontal and
occipital area.

- The head
circumference
measures 50
cm, round in
shape. The
scalp is free
from
inflammation
and is lighter
in color of that
of the
complexion of
the skin.


Head
circumference
is according to
his age on
development.

Hair and
Scalp

Inspection
Palpation

- Dark black to pale
blonde; may turn
gray or white; may
be chemically
changed
- Terminal hair
found in the

- Hair appears
black
- Even
distribution of
hair
- No infestation
or lesions

Hair grows
according to his
age.
12

eyebrows,
eyelashes, and
scalp, and in axilla
and pubic areas
after puberty.
- No signs of
infestation or
lesions.
- Seborrhea/dandru
ff may be present
- Hair may feel thin,
straight, coarse,
thick or curly.
Shiny and resilient

- Hair is thick
and shiny



Eyes

Inspection

- Symmetrical with
no drooping,
infection, tumors
or other
abnormalities
- Visual Acuity:
20/20
- Sclera:
White in light-
skinned w/o
exudates, lesions
or foreign bodies.
In dark-skinned,
may have brown
patches
- Pupils: equally
round, reactive to
light and
accommodation;
2-6 mm
- No tearing,
swelling or
discharge

- Eyes
symmetrical
- Visual acuity of
20/20
- Sclera appears
white
- Pupils equally
round, reactive
to light and
accommodatio
n; approx. 4
mm
- No tearing,
swelling or
discharge


- Within normal
visual acuity.
- According his
age.

Nose

Inspection

- Nose in the
midline
- No Discharges.
- No flaring alae
nasi.
- Both nares are
patent.
- No bone and
cartilage deviation
noted on
palpation.

- no obstructions
found


With normal
and equal
distribution of
air.
13

- No tenderness
noted on
palpation.
- Nasal septum in
the mid line and
not perforated.
- The nasal mucosa
is pinkish to red in
color. (Increased
redness turbinates
are typical of
allergy).
- No tenderness
noted on palpation
of the paranasal
sinuses.


Mouth

Inspection

- Breath smells
fresh.
- Lips and
membranes pink
and moist with no
lesions or
inflammation.
- Tongue is midline.
Pink, moist, rough
without lesions.
- Symmetrical;
moves freely.
- Gums have pale-
red strippled
surface.
- No swelling or
bleeding.


- No lesions or
sores found
- Cracked lips

With good
symmetry of
lips and mouth.

Neck

Inspection
Palpation

- Symmetrical with
head in central
position.
- Able to move
head without
discomfort or
noticeable limits
- Muscles should be
symmetrical
without palpable
masses or spasm

- no swelling
lymph nodes


- No indication
of swelling of
lymph nodes.
- Signifies
normal neck
contour.

Skin

Inspection
Palpation

- Skin is uniform
whitish pink or

- Skin is brown
- No bleeding

- Skin may be
dry because of
14

brown color.
- No Bleeding.
- No area of
increased.
vascularity and
ecchymosis.
- No skin lesions
present except for
freckles,
birthmarks or
moles which may
be flat or
elevated.
- Skin is dry with a
minimum of
perspiration.
- Warm and equal
bilaterally.
- Hands and skin
slightly cooler
than the rest of
the body.
- Skin surfaces
non-tender
- Texture:
Smooth, even and
firm except where
there is significant
hair growth/
- Skin turgor:
When released,
should return to
original contour
rapidly
- Edema not
present
- No area of
increased
vascularity and
ecchymosis
- No lesions
- Skin is dry
- Warm and
equal
bilaterally
- Skin sprung
back rapidly
when pinched
- No edema
present


insufficient
fluid intake
- Normal fluid
intake should
be2500 ml per
day



Chest

Inspection
Palpation
Auscultation

- Without lesions;
skin intact.
- Quiet, and
effortless
breathing
- No pulsations,
masses, thoracic
tenderness
present.
- Normal lung tissue
produces resonant
sound, diaphragm
has dull sounds.
- Bronchial,

- Uses chest
muscle for
breathing


Equal chest
retraction
indicates
breathing
pattern.
15

bronchovesicular
or vesicular breath
sound


Abdomen

Inspection
Auscultation
Percussion
Palpation

- Abdominal
contour flat or
rounded.
- Symmetrical.
- Uniform in color or
pigmentation.
- No abdominal
scars.
- No striae
- Intermittent
gurgling sounds
throughout
abdominal
quadrants.
- Tympany,
predominant
sound heard
- No organ
enlargement
palpable, or any
masses, bulges,
or swelling


- Abdominal
contour flat or
rounded.
- Symmetrical.
- Uniform in
color or
pigmentation.
- No abdominal
scars.


Within normal
abdominal
contour.

Upper
extremities

Inspection

- Without lesions,
scars or
inflammation.
- Complete fingers


- Without
lesions, scars
or
inflammation.

Normal upper
extremities

Lower
extremities

Inspection

- Without lesion,
scars
- No edema
- Complete number
of toes.


- Without lesion,
scars
- No edema

- According to
his age.
- Signifies
normal
movement &
findings of
extremities.





16

Laboratory/ Diagnostic Examination

Blood Chemistry Result
Date Ordered: December 14, 2010
Test Result Reference Range Interpretation
Sodium
129.3 135-140 mEq/l
Can be caused of loss of
sodium through diarrhea or
vomiting
129.3 134-145 mmol/L
Can be caused of loss of
sodium through diarrhea or
vomiting
MISCELLANEOUS
Test Result
Typhidot

Urinalysis
Date Ordered: December 14, 2010
Property/
Constituents
Result Reference Range Interpretation
Color Yellow Light straw to dark
amber yellow

Transparency Clear Clear
PH 5.0 4.5-8.0
Specific Gravity 1.030 1.005-1.030
Protein Negative Qualitative analysis
- Negative
Quantitave analysis
- 10-100mg/24h

Sodium not indicated 135-148 mEq/l
Potassium not indicated 3.5- 5.5 mEq/l

Hematology Complete Blood Count
Date Ordered: December 14, 2010
Test Result Reference Range Interpretation
Hemoglobin 133 120-150g/l
Hematocrit 0.43 0.37-0.47
WBC count 10.8 5-10 x10
9

Platelet Count 220 150-350 mm/hr
17

Differential count
Test Result Reference Range Interpretation
Eosinophil not indicated 0.00-0.06
Lymphocyte 32% 23-35%
Basophil not indicated 0.0-0.1
Monocyte not indicated 4-6%
Neutrophils 68% 50-70%




















18

ANATOMY AND PHYSIOLOGY

THE GASTROINTESTINAL SYSTEM
To aid in understanding the disease process, Anatomy and Physiology
provides the necessary information about the normal function of certain body
components, its structure and function. Anatomy and physiology are always
related. Anatomy is the study of the structure and shape of the body and body
parts and their relationships to one another. Physiology is the study of how the
body pars work or function.
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting
from the oral cavity, where food enters the mouth, continuing through the
pharynx, esophagus, stomach and intestines to the rectum and anus, where food
is expelled. There are various accessory organs that assist the tract by secreting
enzymes to help break down food into its component nutrients. Thus the salivary
glands, liver, pancreas and gall bladder have important functions in the digestive
system. Food is propelled along the length of the GIT by peristaltic movements of
the muscular walls.
19


The primary purpose of the gastrointestinal tract is to break down food
into nutrients, which can be absorbed into the body to provide energy. First food
must be ingested into the mouth to be mechanically processed and moistened.
Secondly, digestion occurs mainly in the stomach and small intestine where
proteins, fats and carbohydrates are chemically broken down into their basic
building blocks. Smaller molecules are then absorbed across the epithelium of
the small intestine and subsequently enter the circulation. The large intestine
plays a key role in reabsorbing excess water. Finally, undigested material and
secreted waste products are excreted from the body via defecation (passing of
faeces). In the case of gastrointestinal disease or disorders, these functions of
the gastrointestinal tract are not achieved successfully. Patients may develop
symptoms of nausea, vomiting, diarrhea, malabsorption, constipation or
obstruction. Gastrointestinal problems are very common and most people will
20

have experienced some of the above symptoms several times throughout their
lives.

Basic structure
The gastrointestinal tract is a muscular tube lined by a special layer of
cells, called epithelium. The contents of the tube are considered external to the
body and are in continuity with the outside world at the mouth and the anus.
Although each section of the tract has specialized functions, the entire tract has a
similar basic structure with regional variations.


The wall is divided into four layers as follows:

21

Mucosa
The innermost layer of the digestive tract has specialized epithelial cells
supported by an underlying connective tissue layer called the lamina propria. The
lamina propria contains blood vessels, nerves, lymphoid tissue and glands that
support the mucosa. Depending on its function, the epithelium may be simple (a
single layer) or stratified (multiple layers).
Areas such as the mouth and esophagus are covered by a stratified
squamous (flat) epithelium so they can survive the wear and tear of passing food.
Simple columnar (tall) or glandular epithelium lines the stomach and intestines to
aid secretion and absorption. The inner lining is constantly shed and replaced,
making it one of the most rapidly dividing areas of the body. Beneath the lamina
propria is the muscularis mucosa. This comprises layers of smooth muscle which
can contract to change the shape of the lumen.
Submucosa
The submucosa surrounds the muscularis mucosa and consists of fat,
fibrous connective tissue and larger vessels and nerves. At its outer margin there
is a specialized nerve plexus called the submucosal plexus or Meissner plexus.
This supplies the mucosa and submucosa.
Muscularis Externa
This smooth muscle layer has inner circular and outer longitudinal layers
of muscle fibres separated by the myenteric plexus or Auerbach plexus. Neural
innervations control the contraction of these muscles and hence the mechanical
breakdown and peristalsis of the food within the lumen.
22

Serosa/mesentery
The outer layer of the GIT is formed by fat and another layer of epithelial
cells called mesothelium.

Individual components of the gastrointestinal system

Oral cavity
The oral cavity or mouth is responsible for the intake of food. It is lined by
a stratified squamous oral mucosa with keratin covering those areas subject to
significant abrasion, such as the tongue, hard palate and roof of the mouth.
Mastication refers to the mechanical breakdown of food by chewing and
chopping actions of the teeth. The tongue, a strong muscular organ, manipulates
the food bolus to come in contact with the teeth. It is also the sensing organ of
the mouth for touch, temperature and taste using its specialized sensors known
as papillae.
In salivation refers to the mixing of the oral cavity contents with salivary
gland secretions. The mucin (a glycoprotein) in saliva acts as a lubricant. The
oral cavity also plays a limited role in the digestion of carbohydrates. The enzyme
serum amylase, a component of saliva, starts the process of digestion of
complex carbohydrates. The final function of the oral cavity is absorption of small
molecules such as glucose and water, across the mucosa. From the mouth, food
passes through the pharynx and esophagus via the action of swallowing.

23

Salivary glands
Three pairs of salivary glands communicate with the oral cavity. Each is a
complex gland with numerous acini lined by secretory epithelium. The acini
secrete their contents into specialized ducts. Each gland is divided into smaller
segments called lobes. Salivation occurs in response to the taste, smell or even
appearance of food. This occurs due to nerve signals that tell the salivary glands
to secrete saliva to prepare and moisten the mouth. Each pair of salivary glands
secretes saliva with slightly different compositions.


Parotids
The parotid glands are large, irregular shaped glands located under the
skin on the side of the face. They secrete 25% of saliva. They are situated below
the zygomatic arch (cheekbone) and cover part of the mandible (lower jaw bone).
An enlarged parotid gland can be easier felt when one clenches their teeth. The
parotids produce a watery secretion which is also rich in proteins.I mmunoglobins
24

are secreted help to fight microorganisms and a-amylase proteins start to
breakdown complex carbohydrates.
Submandibular
The submandibular glands secrete 70% of the saliva in the mouth.
They are found in the floor of the mouth, in a groove along the inner
surface of the mandible. These glands produce a moreviscid (thick)
secretion, rich in mucin and with a smaller amount of protein. Mucin is a
glycoprotein that acts as a lubricant.
Sublingual
The sublinguals are the smallest salivary glands, covered by a thin layer of
tissue at the floor of the mouth. They produce approximately 5% of the saliva and
their secretions are very sticky due to the large concentration of mucin. The main
functions are to provide buffers and lubrication.
Oesophagus
The oesophagus is a muscular tube of approximately 25cm in length and
2cm in diameter. It extends from the pharynx to the stomach after passing
through an opening in the diaphragm. The wall of the oesophagus is made up of
inner circular and outer longitudinal layers of muscle that are supplied by the
oesophageal nerve plexus. This nerve plexus surrounds the lower portion of the
oesophagus. The oesophagus functions primarily as a transport medium
between compartments.


25

Stomach
The stomach is a J shaped expanded bag, located just left of the midline
between the oesophagus and small intestine. It is divided into four main regions
and has two borders called the greater and lesser curvatures. The first section is
the cardiac which surrounds the cardial orifice where the oesophagus enters the
stomach. The fundus is the superior, dilated portion of the stomach that has
contact with the left dome of the diaphragm. The body is the largest section
between the fundus and the curved portion of the J.
This is where most gastric glands are located and where most mixing of
the food occurs. Finally the pylorus is the curved base of the stomach. Gastric
contents are expelled into the proximal duodenum via the pyloric sphincter. The
inner surface of the stomach is contracted into numerous longitudinal folds called
rugae. These allow the stomach to stretch and expand when food enters. The
stomach can hold up to 1.5 litres of material. The functions of the
stomach include:
1. The short-term storage of ingested food.
2. Mechanical breakdown of food by churning and mixing motions.
3. Chemical digestion of proteins by acids and enzymes.
4. Stomach acid kills bugs and germs.
5. Some absorption of substances such as alcohol.

26

Most of these functions are achieved by the secretion of stomach juices by
gastric glands in the body and fundus. Some cells are responsible for secreting
acid and others secrete enzymes to break down proteins.
Small intestine
The small intestine is composed of the duodenum, jejunum, and ileum. It
averages approximately6m in length, extending from the pyloric sphincter of the
stomach to the ileo-caecal valve separating the ileum from the caecum. The
small intestine is compressed into numerous folds and occupies a large
proportion of the abdominal cavity.
The duodenum is the proximal C-shaped section that curves around the
head of the pancreas. The duodenum serves a mixing function as it combines
digestive secretions from the pancreas and liver with the contents expelled from
the stomach. The start of the jejunum is marked by a sharp bend, the
duodenojejunal flexure. It is in the jejunum where the majority of digestion and
absorption occurs. The final portion, the ileum, is the longest segment and
empties into the caecum at the ileocaecal junction.


27

The small intestine performs the majority of digestion and absorption of
nutrients. Partly digested food from the stomach is further broken down by
enzymes from the pancreas and bile salts from the liver and gallbladder. These
secretions enter the duodenum at the Ampulla of Vater. After further digestion,
food constituents such as proteins, fats, and carbohydrates are broken down to
small building blocks and absorbed into the body's blood stream.
The lining of the small intestine is made up of numerous permanent folds
called plicae circulares. Each plica has numerous villi (folds of mucosa) and each
villus is covered by epithelium with projecting microvilli (brush border). This
increases the surface area for absorption by a factor of several hundred. The
mucosa of the small intestine contains several specialized cells. Some are
responsible for absorption, whilst others secrete digestive enzymes and mucous
to protect the intestinal lining from digestive actions.
Large Intestine
The large intestine is horse-shoe shaped and extends around the small
intestine like a frame. It consists of the appendix, caecum, ascending, transverse,
descending and sigmoid colon, and the rectum. It has a length of approximately
1.5m and a width of 7.5cm.
The caecum is the expanded pouch that receives material from the ileum
and starts to compress food products into faecal material. Food then travels
along the colon. The wall of the colon is made up of several pouches (haustra)
that are held under tension by three thick bands of muscle (taenia coli).
28

The rectum is the final 15cm of the large intestine. It expands to hold
faecal matter before it passes through the anorectal canal to the anus. Thick
bands of muscle, known as sphincters, control the passage of faeces.


The mucosa of the large intestine lacks villi seen in the small intestine.
The mucosal surface is flat with several deep intestinal glands. Numerous goblet
cells line the glands that secrete mucous to lubricate faecal matter as it solidifies.
The functions of the large intestine can be summarized as:
1. The accumulation of unabsorbed material to form faeces.
2. Some digestion by bacteria. The bacteria are responsible for the formation
of intestinal gas.
3. Reabsorption of water, salts, sugar and vitamins.
Liver
The liver is a large, reddish-brown organ situated in the right upper
quadrant of the abdomen. It is surrounded by a strong capsule and divided into
four lobes namely the right, left, caudate and quadrate lobes. The liver has
several important functions. It acts as a mechanical filter by filtering blood that
29

travels from the intestinal system. It detoxifies several metabolites including the
breakdown of bilirubin and estrogen. In addition, the liver has synthetic functions,
producing albumin and blood clotting factors. However, its main roles in digestion
are in the production of bile and metabolism of nutrients. All nutrients absorbed
by the intestines pass through the liver and are processed before traveling to the
rest of the body. The bile produced by cells of the liver, enters the intestines at
the duodenum. Here, bile salts break down lipids into smaller particles so there is
a greater surface area for digestive enzymes to act.
Gall bladder
The gallbladder is a hollow, pear shaped organ that sits in a depression on
the posterior surface of the liver's right lobe. It consists of a fundus, body and
neck. It empties via the cystic duct into the biliary duct system. The main
functions of the gall bladder are storage and concentration of bile. Bile is a thick
fluid that contains enzymes to help dissolve fat in the intestines. Bile is produced
by the liver but stored in the gallbladder until it is needed. Bile is released from
the gallbladder by contraction of its muscular walls in response to hormone
signals from the duodenum in the presence of food.
Pancreas
Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the
stomach. Its head communicates with the duodenum and its tail extends to the
spleen. The organ is approximately 15cm in length with a long, slender body
connecting the head and tail segments. The pancreas has both exocrine and
endocrine functions. Endocrine refers to production of hormones which occurs in
30

the Islets of Langerhans. The Islets produce insulin, glucagon and other
substances and these are the areas damaged in diabetes mellitus. The exocrine
(secretory) portion makes up 80- 85% of the pancreas and is the area relevant to
the gastrointestinal tract.
It is made up of numerous acini (small glands) that secrete contents into
ducts which eventually lead to the duodenum. The pancreas secretes fluid rich in
carbohydrates and inactive enzymes. Secretion is triggered by the hormones
released by the duodenum in the presence of food. Pancreatic enzymes include
carbohydrases, lipases, nucleases and proteolytic enzymes that can break down
different components of food. These are secreted in an inactive form to prevent
digestion of the pancreas itself. The enzymes become active once they reach the
duodenum.












31

PATHOPHYSIOLOGY OF THE DISEASE


Salmonella Typhi
survives acidity of stomach
invades the Peyer's Patches
intestinal wall
macrophages (Peyer's Patches)
the bacteria is within the macrophages and surves
bacteria spreads via the lymphatic while inside the macrophages
access the Reticulo Endothelial system in liver, spleen, gallbladder, and
bone marrow
First Week: Elevation of body temperature
Second Week: Abdominal pain, spleen enlargement and rose spots
Third Week: Necrosis of the Peyer's Patches
leads to perforation, bleeding
if left untreated, death is imminent
32

The Pathophysiology of Typhoid Fever is Complex and Occurs through
several stages.
Once, the bacteria (Salmonella Typhi), survives the acidity of the stomach,
it reaches the intestine and invades the Payer's patches of the intestinal wall.
Payer's patches are the clusters of the cell primarily composed of Macrophages
are specialized cells that are essential to kill any bacteria. But, Salmonella Typhi
is unaffected by these macrophages but, start survive within the macrophage
itself.
So, during this asymptomatic incubation period of 7-14 days, the bacteria
spread throughout the reticulo endothelial system of liver, spleen, gallbladder,
and bone marrow.
The first week of symptomatic period is characterized by progressive
elevation of temperature.
In the second week, the victim may experience abdominal pain, spleen
enlargement and notice Rose spots on his skin.
The third week is more intense as the bacteria start causing necrosis of
the Payer's patches of the intestine which leads to perforation and bleeding. This
is the terminal stage, if, left untreated, death is imminent.





33

MEDICAL INTERVENTIONS
Course in the Ward
December 14, 2010
(Day 1)
TIME

1:00 pm













4:10 pm











9:30 pm

Admitted to pedia with PNSS 1L @30gtts/min inserted @
Right metacarpal vein.
With laboratory examinations as follows:
Blood CS
CBC with platelet
UA
NA/K
Typhidot
PPD
With medications as follows:
Paracetamol 500mg 1tab P.O. q4h PRN for fever
Chloramphenicol 500mg 1tab P.O. q6h

Received pt. on bed on left side lying position
Awake and coherent
With IVF #1 PNSS 1L @ 900cc level, regulated @ 30gtts/min
hooked @ right metacarpal vein, infusing well.
Facial grimace, diaphoretic and self-focusing seen
Initial Vital Signs taken and recorded as follows:
T: 37.5
o
C PR: 97bpm
RR: 24bpm BP: 90/70mmHg
Pt. verbalized when asked about discomfort felt.
Laboratory results referred to Dr. Lim
Due meds given

Pt. was weak looking
Warm to touched, fluched skin, not diaphoretic
Mucous membrane was dry and lips were cracked and dried.
Vital Signs taken and recorded as follows:
T: 39.2
o
C PR: 99bpm
RR: 28bpm BP: 90/70mmHg
Paracetamol 500mg 1tab given as ordered.

December 15, 2010
(Day 2)

4:10 pm

Received pt. lying on bed on supine position
34
















9:30 pm



10:00 pm
Awake and coherent
With IVF #2 PLR 1L @400cc level, regulated @ 20gtts/mon,
hooked @ the right metacarpal vein, infusing well.
Vital Signs taken and recorded as follows:
T: 37.5
o
C PR: 71bpm
RR: 24bpm BP: 90/60mmHG
simula nang maconfine ako dito, hindi pa ako dumudumi, as
verbalized by the pt.
dry skin
without sweating
flatulence observed
Encouraged the pt. to intake balanced fiber and bulk in diet
such as fruits, vegetables, and whole grain.

Due meds given
IVF #2 was terminated, followed up with IVF #3 D%NM 1L @
20gtts/min as ordered.

Pt. was warm to touch
Flushed skin
Dry lips
Not diaphoretic
Poor skin turgor
Slowed movement observed
Vital Signs taken and recorded as follows:
T: 38
o
C PR: 91bpm
RR: 29bpm BP: 90/70mmHg
Paracetamol 500mg 1tab given as ordered.
December 16, 2010
(Day 3)

4:20 pm








6:10 pm


10:00 pm

Received pt. lying flat on bed
With IVF #3 D5NM 1L @gtts/min, hooked @ the right
metacarpal vein @ 50 cc level, infusing well
Vital Signs taken and recorded as follows:
T: 37.4oC PR: 80bpm
RR: 24bpm BP:110/70mmHg
Slowed body movements
With body weakness

IVF #4 D5NM 1L was followed @ 20 gtts/min

Pt. experience flushed skin and drying of lips.
Skin warm to touched
Poor skin turgor
35

Dry mucous membrane

December 17, 2010
(Day 4)

4:00 pm







6:00 pm

Received pt. up on bed
Awake and coherent
With IVF #4 D5NM 1L @ 20 gtts/min, hooked @ right
metacarpal vein @ 100cc level, infusing well.
Vital Signs taken and recorded as follows:
T: 37oC PR: 81bpm
RR: 28bpm BP: 90/60mmHg

IVF was consumed and terminated as ordered.
Due meds given
December 20, 2010
(Day 5)

2:00 pm

MGH with Chloramphenicol continue @ home.