ILOILO DOCTORS’ COLLEGE

COLLEGE OF NURSING

PRESENTED BY:
(Shiares P. Luig)
Typhoid Fever

CLINICAL INSTRUCTOR:
Ms. Adame C. Arnaez
 ILOILO DOCTORS’COLLEGE
COLLEGE OF NURSING

Case Scenario

Typhoid Fever

This is a case of a 29 year old man was admitted to the hospital because of fatigue, anorexia, malaise,
headache, fever and difficulty of concentrating. On physical examination he appeared tired and thin. His
temperature was 40°C. 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. Laboratory test: WBC ct. 4, 600/mm³; aspartate-
aminotransferase, 790U/L; lactate dehydrogenase , 1,562U/L. He also had roseola spots distributed on
the trunk. 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. Since the isolated Salmonella was sensitive in vitro to fluoroquinolones, this drug
was administered and broad spectrum antibiotics, such as the tetracyclines and chloramphenicol, was
given as well and the patient was discharged as cured.
 I. Introduction and Objectives
Introduction:

Typhoid fever is an acute illness associated with fever caused by the Salmonella enterica serotype
Typhi bacteria. It can also be caused by Salmonella  paratyphi, a related bacterium that usually causes a less
severe illness. The bacteria are deposited in water or food by a human carrier and are then spread to other
people in the area. The incidence of typhoid fever in the United States has markedly decreased since the
early 1900s, when tens of thousands of cases were reported in the U.S. Today, less than 400 cases are
reported annually in the United States, mostly in people who have recently traveled to Mexico and South
America. This improvement is the result of better environmental sanitation. India, Pakistan, and Egypt are
also known as high-risk areas for developing this disease. Worldwide, typhoid fever affects more than 21
million people annually, with about 200,000 people dying from the disease.

Typhoid fever is contracted by drinking or eating the bacteria in contaminated food or water. People
with acute illness can contaminate the surrounding water supply through stool, which contains a high
concentration of the bacteria. Contamination of the water supply can, in turn, taint the food supply. The
bacteria can survive for weeks in water or dried sewage. About 3%-5% of people become carriers of the
bacteria after the acute illness. Others suffer a very mild illness that goes unrecognized. These people may
become long-term carriers of the bacteria -- even though they have no symptoms -- and be the source of
new outbreaks of typhoid fever for many years.

After the ingestion of contaminated food or water, the Salmonella bacteria invade the small
intestine and enter the bloodstream temporarily. The bacteria are carried by white blood cells in
the liver, spleen, and bone marrow, where they multiply and reenter the bloodstream. People develop
symptoms, including fever, at this point. Bacteria invade the gallbladder, biliary system, and the lymphatic
tissue of the bowel. Here, they multiply in high numbers. The bacteria pass into the intestinal tract and can
be identified in stool samples. If a test result isn't clear, blood or urine samples will be taken to make a
diagnosis.

Typhoid fever is treated with antibiotics which kill the Salmonella bacteria. Prior to the use of

antibiotics, the fatality rate was 20%. Death occurred from overwhelming infection, pneumonia, intestinal
bleeding, or intestinal perforation. With antibiotics and supportive care, mortality has been reduced to 1%-
2%. With appropriate antibiotic therapy, there is usually improvement within one to two days and recovery
within seven to 10 days.

Objectives:

General Objectives

At the end of the study, students will be able to analyze the effects of Typhoid fever on the
holistic well-being of a person as well as to expand their knowledge and provide accurate nursing care
and implement proper nursing intervention.

Specific Objectives

At the end of this case presentation, student’s will be able to:

 Knowledge

 Recognize the signs and symptoms of patient’s condition

 Discuss what is Typhoid fever
 Discuss the anatomy and physiology, pathophysiology and possible complications of this
condition.
Skills

 Implement a nursing care plan in managing patient’s condition

 Document patient’s condition, nursing intervention and evaluation correctly and accurately
 Apply both dependent and independent nursing intervention, management and treatment
towards treating patients with acute typhoid fever.
Attitude

 Establish rapport with patient and her family

 Recognize patient’s needs using holistic approach

II. Patient’s Data

Biographic Data
a. Name: Not stated
b. Age: 29 years old
c. Sex: Male
d. Marital Status: Married
e. Occupation: N/A
f. Religion: N/A
g. Attending Physician: N/A

Chief Complaints
 Admitted to the hospital because of fatigue, anorexia, malaise, headache, fever and
difficulty of concentrating.

Physical Assessment

Vital signs:

 T - 40 °C

Physical Examination
 Appeared tired and thin
 Liver edge was tender and palpated 3cm below the right costal margin, with diffuse
abdominal tenderness.
III. Past and Present Health History

Past Medical History

 Not stated

Present medical History

 Admitted to the hospital because of fatigue, anorexia, malaise, headache, fever and
difficulty of concentrating.
IV. Pathophysiology
V. Laboratory and Diagnostics

Laboratory Results Normal Values Clinical Significance

Examination
WBC ct. 4, 600/mm³ 4, 500 to 11, 000 cells/ Normal
mm³

Aspartate- 790U/L Male: 10-40 U/L High levels of AST in

aminotransferase Female: 9-25 U/L the blood may
indicate hepatitis,
cirrhosis,
mononucleosis, or
other liver diseases.  In
the second week of
infection of typhoid
fever where the
bacteria cause the
inflammation of the
liver. 
Lactate 1,562U/L. 140 U/L to 280 U/L High levels of LDH
dehydrogenase indicate some form of
tissue damage. High
levels of more than one
isoenzyme may
indicate more than one
cause of tissue
damage. 

Bacterial cultures Positive Positive for Salmonella

(liver’s tissue and typhi
roseola spots)
Blood cultures Negative No signs of bacteria or
yeast in your blood.

 Abdominal CTS showed thickness of the terminal ileum wall and clumped-enlarged mesenteric
lymph nodes in the RLQ.
 Patient had roseola spots distributed on the trunk.
 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

Assessment Nursing Outcomes Nursing Rationale Evaluation

Diagnosis Identification Intervention

Subjective: Short Term: Independent:

Hyperthermia After 6 hours of 1. Establish rapport 1. For the client to Goals met, afte
“Kataas sang akon related to the nursing be comfortable 24 hours of
temperature kg infection of intervention, effective
gapang lamig ako” salmonella the patients’ 2. Assess the 2. To assist in nursing
as verbalized by typhi as temperature patient’s vital creating an intervention,
the patient evidenced by will slightly signs at least accurate the patient’s
clients’ decrease and every 4 hours diagnosis and temperature
temperature of will be able to monitor was on its
40°C verbalize effectiveness of normal limit
comfortability medical form 40°C to
treatment, 37°C, absence
Objective: particularly the of chills was
Rationale: antibiotics and noted, and the
Temp - 40°C Hyperthermia Long Term: fever-reducing patient was
- Weak refers to After 24 hours drugs able to
a group of of nursing verbalized
- roseola heat-related intervention, 3. Remove 3. To regulate the comfortability.
spots conditions the patients’ excessive temperature of
distribute characterized body clothing, the
d on the by an temperature blankets and environment
trunk abnormally will stabilize linens. Adjust and make it
high body within its the room more
- Bacterial temperature. normal limit, temperature comfortable to
cultures of The condition and will be free the patient
the liver’s occurs when form chills.
tissue and the body's 4. Offer a tepid 4. To facilitate the
roseola heat-regulation sponge bath body in cooling
spots system down and to
biopsy becomes provide comfort
were overwhelmed
positive by outside 5. Encourage 5. Monitor the
for factors, causing increase in fluid status of
Salmonella a person's intake hydration as
typhi internal needed;
temperature to monitor the
rise fluid intake
daily; encourage
an increase in
fluid intake; and
collaborate with
other medical
team for IV fluid
 administration.

6. Monitor the
6. Improve amount of
nutritional caloric intake;
intake monitor weight
loss; provide a
comfortable
environment
during meals;
and encourage
an increase in
protein and
vitamin C intake
to meet
nutritional
needs

Dependent:
Administer
medications such as:
7. Tetracycline and
7. Tetracycline and chloramphenicol
Chloramphenicol is used to
treat infections
caused by
bacteria
including
typhoid fever

Assessment Nursing Outcomes Nursing Rationale Evaluation

Diagnosis Identification Intervention
Subjective: Activity Long Term Independent: Goals met, after
“Nakapoy ako kag Intolerance Goal: 1. Establish 1. The gain client’s 3 days of
wala ako gana related to After 3 days of rapport with trust in receiving effective nursing
maghulag ” as mandatory bed nursing the patient the best care. intervention, the
verbalized by the rest secondary intervention, patient was able
patient. to typhoid fever patient will be 2. Monitor V/S 2. Baseline data is to perform some
as evidenced by able to important to help activity level
fatigue and perform determine patient’ tolerance within
body malaise. activity level s current health normal
within normal status and capabilities, and
Objective: Rationale: capabilities evaluate absence of
Typhoid fever is accompanied effectiveness of fatigue was
Fatigue a common by the nursing noted.
cause of febrile absence of intervention
Malaise illness because fatigue. rendered.
of Salmonella 3. Provide
Typhi Infection. assistance to 3. To provide
The presence of Short Term meet their assistance to the
the infection Goal: daily needs client to avoid
will lead to such as food, the onset of
increased in After 24 hours drink, change complications
body of nursing clothes and associated with
temperature intervention, watch oral the movement
which will be patient will be hygiene, hair, who violate
accompanied able to genetalia, program bedrest.
by fatigue. demonstrate and nails.
some
exercises that 4. Involve the
helps to family in the 4. Participation
improve her fulfillment of family is very
condition. ADL. important to
facilitate the
nursing process
and prevent
5. Explain the further
purpose of complications.
bed rest to
prevent 5. Rest decrease
complication intestinal
s and speed mobility also
up the decreases the
healing rate of
process. metabolism and
infection.
 Defining Nursing Objective Nursing Rationale Evaluation
Characteristics Diagnosis Intervention
Subjective: Imbalance Long Term Independent: Goals met
“Grabe akon Nutrition: Less Goal: 1. Establish 1. The gain client’s after providing
pagniwang sang than Body After 2 days rapport with trust in receiving nursing
nagamasakit ako ” as Requirements of nursing the patient the best care. intervention as
verbalized by the related to intervention, evidenced by:
patient. disease process patient will 2. Monitor V/S 2. Baseline data is
secondary to be from important to help “Nagsaka na
typhoid fever as malnutrition determine patient’s ang akon nga
evidenced by accompanied current health kilo kag
thin by the status and evaluate nagmayo na
appearance absence of effectiveness akon pamatyag
Objective: during physical symptoms of of nursing intervention kay wala na
Appears thin on examination. typhoid fever. rendered. ako
physical examination 3. Monitor the nagamasakit“
amount of 3. Knowing the cause as verbalized
Rationale: Short Term nutrients and of the less intake so by the patient.
Typhoid fever is Goal: calories. as to determine
a common appropriate and
cause of febrile After 16 effective
illness because hours of intervention.
of Salmonella nursing 4. Monitor the
Typhi Infection. intervention, weight loss. 4. Cleanliness
The presence of patient will nutrients can be
the infection be able to known through
will lead to demonstrate increased weight
increased in improved 500 g / week.
body health as 5. Monitor the
temperature evidenced by environment 5. A comfortable
which will be intake of during the environment can
accompanied normal meal. reduce stress and
by fatigue. amount of more conducive to
food. eating.
6. Instruct the
patient to 6. Protein and vitamin
enhance the C to meet
protein and nutritional needs.
vitamin C.

7. Provide food
selected. 7. To assist in fulfilling
the nutritional
needs.
 8. Collaboration
with a 8. Helps in the healing
nutritionist to process.
determine the
amount of
calories and
nutrients it
needs
patients.

VII. Drug Study

Drug Name Classification Indications and Side Effects Special Nursing

and Contraindications and Adverse Precautions Responsibilities
Mechanism Effects
of Action
Generic Classification: Indication: Nausea, Tetracycline Monitor the
Name: vomiting, should be effectivenss of the
Tetracycline Antibiotics Tetracycline is used to
diarrhea, loss taken on an drug.
Trade/ Brand treat infections caused
of appetite, empty
Name: by bacteria including
mouth sores, stomach, at
Ala-tet, Mechanism pneumonia and other
black hairy least 1 hour Do not change the
Tetracap of action: respiratory tract
tongue, sore before or 2 establish dose
infections; certain
Dosage: Tetracyclinesin throat, hours after schedule.
hibit protein
infections of skin, eye,
500mg dizziness, meals or
synthesis lymphatic, intestinal,
(250mg) headache, or snacks. Drink
through genital and urinary
rectal a full glass of Do not breast-feed
reversible systems; and certain
Route: discomfort may water with while you are taking
Oral binding to other infections that are
occur. If any of each dose of tetracycline.
bacterial 30 S spread by ticks, lice,
ribosomal
these effects tetracycline. Children younger
Frequency mites, and infected
subunits, which persist or Do not take than 8 years old
and Timing: animals.
prevent binding worsen, tell tetracycline should not take
Q12h
(12:00-12:00) of new your doctor or with food, tetracycline.
incoming pharmacist especially
amino acids
Contraindication:
promptly. dairy
(aminoacyl- diarrhea from an products
tRNA) and thus infection with such as milk,
interfere with Clostridium difficile yogurt,
peptide bacteria. cheese, and
growth.
ice cream.
pseudotumor cerebri, a
condition with high fluid
pressure in the brain.

liver problems.

Decreased kidney function

Pregnancy.

Drug Name Classification Indications and Side Effects Special Nursing

and Contraindications and Adverse Precautions Responsibilities
Mechanism Effects
of Action
 Generic Classification: Indication: not enough red Baseline blood Monitor the
Name: blood cells studies should effectivenss of the
Chlorampheni Antibiotics Chloramphenicol is a produced be followed by drug.
col medication used in (aplastic periodic blood
the management and anemia) studies
Trade/ Brand Mechanism treatment of superficial bone marrow approximately
Do not change the
Name: of action: eye infections such as suppression. every two
days during establish dose
Chloromyceti bacterial conjunctivitis,
n, Econochlor, Inhibition of therapy. The schedule.
and otitis externa. It has
Ocu-Chlor  bacterial diarrhea. drug should be
protein also been used for the
discontinued
Dosage: synthesis by treatment of typhoid upon
inflammation Monitor newborns
binding with and cholera. appearance of
of the small for signs of gray
Route: ribosomes. Chloramphenicol is an reticulocytope
intestine and syndrome (also
Oral antibiotic and is in the the colon nia,
called
class of antimicrobials (enterocolitis) leukopenia,
chloramphenicol
Frequency that inhibits protein thrombocytop
and Timing: enia, anemia toxicity in
synthesis.
accumulation or any other newborns), including
Contraindication: of blood study gray/ashen skin
chloramphenic findings color, cyanosis,
hereditary liver ol especially in attributable to respiratory distress,
metabolism disorder. newborns (gray chloramphenic hypotension,
decreased function of syndrome) ol. vomiting, and
bone marrow. hypothermia.
low blood counts due to headache.
bone marrow failure. Report these signs
immediately to the
anemia. nausea.
physician or nursing
decreased blood staff.
platelets. nightmares.
low levels of
granulocytes, a type of
white blood cell.

VIII. Discharge Plan

Home care

 Rest at home for at least the first few days.

 Be sure to take the antibiotic medicines as directed until they are gone or the healthcare
provider tells you to stop, even if you are feeling better. If you don't the infection may come
back and be harder to treat.
 Fever increases water loss from the body. Drink plenty of fluids
 Ask your healthcare provider before taking any over-the-counter medicines. Unless advised by
your healthcare provider, don’t 'take over-the-counter antidiarrheal medicines.
 As symptoms lessen and you feel able, you can gradually return to eating normally. Don't drink
alcohol.
 Washing hands well with soap and water is the best way to prevent the spread of infection.
Wash your hands with plain soap and warm water for at least 20 seconds. Wash under the
fingernails, between the fingers, and up both wrists.
 Don't prepare or serve food for other people until your healthcare provider has determined the
bacteria is no longer present in your body.
 Clean the toilet after each use by the sick person.
 Dispose of soiled linen and towels in a sealed container.
 Before going to countries where typhoid fever is common, see your local public health
department or your healthcare provider about a vaccination. When traveling in these countries,
don't eat raw peeled fruits or vegetables since they may have been prepared with contaminated
water. Drink only bottled, boiled, or treated water.

Follow-up care

 Follow up with your healthcare provider, or as advised. If a stool (diarrhea) sample was taken,
call in 2 days (or as directed) for the results.

IX. Review of Related Studies

 Progress in Typhoid Fever Epidemiology
John A Crump 1

Abstract

Salmonella enterica subspecies enterica serovar Typhi (Salmonella Typhi) is the cause of typhoid fever
and a human host-restricted organism. Our understanding of the global burden of typhoid fever has
improved in recent decades, with both an increase in the number and geographic representation of
high-quality typhoid fever incidence studies, and greater sophistication of modeling approaches. The
2017 World Health Organization Strategic Advisory Group of Experts on Immunization recommendation
for the introduction of typhoid conjugate vaccines for infants and children aged >6 months in typhoid-
endemic countries is likely to require further improvements in our understanding of typhoid burden at
the global and national levels. Furthermore, the recognition of the critical and synergistic role of water
and sanitation improvements in concert with vaccine introduction emphasize the importance of
improving our understanding of the sources, patterns, and modes of transmission of Salmonella Typhi in
diverse settings.

DOI: 10.1093/cid/ciy846