PUBLIC HEALTH NURSING PRATICUUM (NRS 508) A CASE STUDY ON A PATIENT WITH TYPHOID FEVER
SUBMITTED TO: DEPARMENT OF NURSING SCIENCE, FACULTY OF MEDICAL SCIENCE, UNIVERSITY OF JOS.
IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF BACHELOR OF NURSING SCIENCE (BNSc) DEGREE.
SUBMITTED BY: CHUKWUKA HENRY UJ/2005/MD/0176
MARCH, 2012 i
DEDICATION This work is dedicated to my Dad, Sir C.Y Chukwuka, my Mum, Lady Emelda Chukwuka and my siblings; Gerald, Cyprian, and Cynthia for your support and love. And also to my friends; Peace Nelson, Nel son, Oche, Stephen and Obetta, you guys are the best.
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ACKNOWLEDGMENT I would like to acknowledge Mr. J.D Goshit, under whose supervision I am undertaking this case study. The matron and entire staff of Bukuru P.H.C, for supplying data and permitting me to use the hospital records. My group members, thank you for helping out in the care of my client. I also acknowledge Martha, for a wonderful typing and compilation job.
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TABLE OF CONTENTS Title page
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Dedication
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Acknowledgement -
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Table of contents
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CHAPTER ONE INTRODUCTION
Objective/Purpose of cases study -
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Client’s Particulars
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CHAPTER TWO LITERATURE REVIEW
Anatomy and Physiology review Gastrointestinal System
Typhoid Fever
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Theoretical Framework
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CHAPTER THREE NURSING PROCESS AND MANAGEMENT OF MISS. ESTHER MATHEW
Nursing Assessment
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Medical Management
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Nursing Management
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Nursing Diagnosis and Care Plan -
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Advice on Discharge -
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Evaluation
Recommendation
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Conclusion
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References
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Nursing Care plan for Miss. Esther Matthew
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CHAPTER ONE 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, gram negative rod that is flagellated and actively motile. Contaminated food or water is the common medium of contagion. Typhoid fever is characterized by: -
A slow progressive fever as high as 400c (1040f)
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Profuse sweating
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Gastro-enteritis
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Non-bloody diarrhea
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Rash made up of flat, rose coloured spots. Common causes of transmission are flying insects most specifically flies
feeding on faeces that may occasionally transfer the bacteria through poor hygiene habits and public sanitation conditions. A person may become an asymptomatic carrier of typhoid fever, suffering no symptoms, but capable of infecting others. Diagnosis is made through blood, bone marrow or stool cultures and the widal test. Sanitation and hygiene are the critical measures that can be taken to prevent typhoid. Typhoid vaccines are also available as preventive measure. Typhoid is only transmitted from human to human The discovery of oral rehydration therapy provided a simple way to prevent many of the deaths of diarrheal diseases in general. Treatment of choice is by use of a fluoroquinolone such as ciprofloxacin, otherwise a third generation cephalosporin such a ceftriaxone or cefotaxime is the first choice. Objective/Purpose of Case Study The following are the objectives of study to student nurse, client and significant others; The students nurse will be able to: 1.
acquire knowledge, attitude and skills about the care for community patients with typhoid fever. 1
2.
Make thorough nursing assessment of the client to be able to come up with an apposite plan of care.
3.
Explain the pathophysiology of typhoid fever
4.
Recognize the possible symptoms of typhoid fever manifested by the patient.
5.
List ways of preventing typhoid fever.
6.
Render appropriate nursing care, medicate properly and accurately the prescribed medication.
The patient and significant others will be able to: (1)
Understand awareness of the disease.
(2)
Identify risk factors, causes and Recognize own symptoms of typhoid fever.
(3)
Learn and understand why laboratory examinations are being done.
(4)
Show proper diet and exercise and stress its importance in promoting health and preventing further complications. (5) Display proper hygiene techniques and stress its importance in promoting health and preventing further complication.
Client’ s Particulars It was on 30 th January 2012 when our team was exposed to our first community posting. I observed that within the period of posting 60% of client where diagnosed with typhoid fever. This led me to carry out an assessment on Gyel community, investigating sanitation, hygiene and water supply. Patients name is Miss Esther Matthew and her mother is Mrs. Matthew. She is a native of Berom from Gyel district. She is fourteen years old at present she is in primary six. She was seen by Mr Dung (consulting CHEW) laboratory examination and made a diagnosis of Typhoid fever.
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who requested for
CHPATER TWO LITERATURE REVIEW Anatomy and Physiology Review 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. 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 breakdown 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.
Diagram showing organs of GIT.
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Peyer’s Patches Numerous lymph nodes are found in the mucosa at irregular intervals throughout the length of the small intestine. The smaller ones are known as solitary lymphatic follicles, and about 20 or 30 larger nodes situated towards the distal end of the ileum are called aggregated lymphatic follicles (Peyer’s patches). These lymphatic tissues, packed with defensive cells are strategically placed to neutralize ingested antigens (Ross and Wilson, 2006).
Section of small intestine showing Peyer’s patches .
Typhoid Fever Definition Typhoid fever, otherwise known as enteric fever, is an acute illness associated with progressive fever, gastroenteritis, non-bloody diarrhea, profuse sweating transmitted by the ingestion of food or water contaminated with the faeces of an infested person, which contain the bacterium Salmonella typhi (Wikipedia, 2011). Causes, Transmission and Risk Factors Typhoid fever is caused by a bacterium Salmonella typhi. The bacteria may be spread through poor hygiene habits, and public sanitation conditions, and sometimes also by flying insects feeding on faeces. Risk factors include living in developing country, poor sanitation, poor toileting habits, poor drainage, improperly prepared food, areas with wells as sources of drinking water, eating food from outside sources, 4
war and natural disasters, as well as weak or non-existent of health care infrastructure. Epidemiology World health organization identifies typhoid as a serious public health problem. Its incidence is highest in children and young adults between 5 and 19 years old. Both genders have equal chances of acquiring the disease.
Asian, African and
American are at greatest risk of acquiring disease since geographic location plays a part. Clinical Manifestation The disease follows four stages: (a)
First stage is known as incubation period, usually 10-14 days in occurrence. In this stage generalization of the infection occurs.
(b)
Second stage: In the second stage aggregation of the macrophages and edema in focal areas indicates bacterial localization (embolization) and resultant toxin injury which disappear after few days.
(c)
Third Stage: This stage of disease is dominated by effects of local bacterial injury especially in the intestinal tract, mesenteric lymph nodes, spleen, and liver
(d)
Fourth Stage: This is also referred to as the stage of lysis. It is the stage in which infections process is gradually overcome. Symptoms slowly disappear and the temperature gradually returns to normal.
The symptoms of typhoid fever include: -
high progressive fever
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chills, cough,
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muscle pain
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weakness
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stomach pain
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headache
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rash made up of flat, rose-colored spots
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non-bloody diarrhea (less common symptom) 5
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Sometimes there are mental changes, known as typhoid psychosis.
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Profuse sweating.
Pathophysiology Typhoid fever is a bacteremia in which the organism gains access to the blood stream through the bowel, principally through the infected peyer’s patches of lymphoid tissue in the lower portion of the ileum. The first week these patches are swollen; the second week they form sloughs, which are often bile coloured; the third week the sloughs separate and leaves an ulcerative surface, which then starts to heal by granulation. Since the organism reaches all parts of the body through the blood stream, almost all organs at time may show pathologic changes being those due to toxemia and high fever. Commonly, however, the heart liver, spleen, muscle and mesenteric lymph glands may be either red or swollen, or else broken down into messy matter. The urine may be milky in appearance with the peculiar opalescence, which is due to the presence of millions of typhoid bacilli in it. The causative organism invades the blood stream by way of lymphatic tissues and is carried to all parts of the body. Early symptoms may vary, may be vague with headaches, anorexia and malaise. As the disease progresses, there are joint pains, abdominal discomfort, vomiting and usually constipation although there may be diarrhea, cough and bronchitis occur in about 50% of the cases. During the first week, the body temperature rise in step ladder pattern until it reaches about 104 0f. Temperature drops at the end of third week due to lysis. The temperature is irregular, with two (2) remissions in the morning. (smeltzer and Bare, 2004). Diagnosis Diagnosis is made through the following: 1.
Clinical manifestation/presentation: The presenting signs and symptoms can be used to make diagnosis.
2.
Blood test: This include complete blood count and differential white blood cell count
3.
Bone marrow 6
4.
Stool cultures: Colour, consistency and mucus
5.
Widal test: Demonstrates salmonella antibodies against antigens.
6.
Urinalysis: Colour, albumin, sugar, transparency, PH, specific gravity
Prevention Typhoid fever can be prevented through: -
Good sanitation and hygiene
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Good toileting habits
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Proper drainage
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Chlorination of drinking water obtained from wells.
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Food should be properly prepared
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Vaccination in endemic areas.
Treatment (1) Administer Antibiotics: This include fluoroquinolone (ciprofloxacin), third generation cephalosporins (ceftriaxone or cefataxime) and cotrimoxazole (2) Administer Analgesic: Acetaminophen ( has both analgesic and antipyretic effects) (3) Rehydration: This include oral rehydration therapy or intravenous infusion (pediatric saline) Complication The complication of typhoid fever includes: (1)
Overwhelming infection due to systemic spread
(2)
Intestinal bleeding
(3)
Pneumonia due to systemic spread
(4)
Intestinal perforation due to penetration into Peyer’ s patches.
(5)
Death resulting from intestinal perforation
Theoretical Framework The following nursing theories/models form theoretical framework for this case study: 1.
Pender’s Health promotion model
2.
Nightingale’s Environment t(1)
Pender’s Health Promotion Model 7
The health promotion model was designed by Nola J. Pender to be a “contemporary counterpart to models of health protection”. It defines health as a positive dynamic state rather than simply the absence of disease. Health promotion is directed at increasing a patient’s level of well -being. Pender’s model focuses on three areas: -
Individual characteristics and experiences
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behavior specific cognitions and affect behavioural outcome.
The health promotion model makes four assumptions: i.
Individuals seek to actively regulate their own behaviour.
ii.
Individuals,
in
all
their
biopsychosocial
complexity,
interact
with
the
environment, progressively transforming the environment as well as being transformed over time. iii.
Health professionals, such as nurses, constitute a part of the interpersonal environment, which exerts influence on people though their life span.
iv.
Self-initiated recognition of the person environment interactive patterns is essential to changing behaviour.
Health promotion behaviour is directed towards attaining a positive health outcome such as optimal well-being, personal fulfillment and productive living. (2)
Nightingale’s Environment Theory As the founder of modern nursing, Florence Nightingale’s Environment Theory
changed the face of nursing practice. The focus of nursing in this model is to alter the patient’s environment in order to affect health, as identified in the theory are: fresh air, pure water, sufficient food supplies, efficient drainage, cleanliness of patient and environment, and light. A nurse’s role in patient’s recovery is to alter the environment in order to gradually create the optimal conditions for the patient’s body to heal itself.
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CHAPTER THREE NURSING PROCESS AND MANAGEMENT OF MISS ESTHER MATTHEW Nursing Assessment 1) History taken (a)
Personal History
Patients Profile Name: Age:
Miss Esther Matthew 14 years old
Marital Status:
Single
Sex:
Female
Religion:
Christianity
Address:
Gyel
Local Government:Jos South Next of Kin:
Mrs. Esther
Relationship:
Mother
Address: Occupation: Admission No:
Gyel Students 0300/12
Date of Admission: 6th Feburary, 2012 Complaints:
Fever, cough
Diagnosis:
Typhoid Fever
Base Live Vitals: Temp 37.50c, Respiration:
28cpm,
Pulse:
81bpm
Blood Pressure:
90/70mmttg
Informant:
Mrs. Matthew
(b)
Family History Miss Esther Matthew is the 2 nd child among five siblings (3 girls and 2 boys).
The eldest is 17 years and currently working as a farmer. Mr. Matthew is her Father who is also a farmer. Mrs. Esther who is the informant admits that there is no history 9
of any familial disease in both families. She also admitted that the family relationship is strong and stable. She seldom quarrels with her husband and ensures that all her children are on the right track. (c)
Life Style When asked about play, eating habits and life st yle of her daughter “Mrs.
Mathew, verbalized the following -
Miss Esther Mathew is socially interactive in nature.
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Patient loves eating (fruit, vegetable)
(e)
Past Health History Patient has experienced cough common cold, chicken pox in the past. Patient
has no known allergies to food and drugs. (f)
History of Present illness She experienced fever and chills for about 9 days ago, Headache, lethargy, fatigue,
body weakness and pain within same period. Patient also experienced diarrhea. (2)
Physical Assessment Cephalocaudal assessment shows the following
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Skin felt warm and had few abrasions
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Head, eyes were normal
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Ears: cerumen was detected
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Lips: were dry, cracking of lips noted
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Chest : Normal
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Upper and love extremities: nails untrimmed and somewhat dirty.
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Vital Signs: Baseline data;
Temperature: 37.5, Resp: 28cmp, BP: 90/75mmhg, Pulse: 81bpm. Weight: 30kg, Urine: Glucose:-ve, Protein:-ve Medical Management The following drugs were ordered by the consultant: (1)
Capsule Ciprofloxacin 500mg bd x 5/7
(2)
Tab paracetamol 500mg tds x 3/7
(3)
Tab vitamin C 200mg tds x 3/7
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Drug Study Ciprofloxacin Name of Drug:
Ciprofloxaxin
Brand Name:
Ciprotab
Classification:
Antibiotics
Group:
Fluoraquinolone
Dose and Frequency: 500mg bd Mechanism of Action: Binds to 50s ribosomal subunit which interfers with or inhibits protein synthesis. Indication:
Infections caused by S. typhi
Contraindications: Hypersensitivity, renal disease, severe hepatic disorder Adverse Effect:
Anemia, Nausea, vomiting, diarrhea, abdominal pain, itching, rashes, headaches.
(2)
Paracetamol
Name of Drug:
Acetaminophen
Brand Name:
Paracetamol
Classification:
Non-opiod analgesic, anti-pyretic.
Dose and Frequency:
500mg tds or PRN.
Mechanism of Action:
Blocks
pain
impulses,
relieves
fever
by acting
on
hypothalamic heat-regulating centre. Indications:
Mild pain or fever
Contraindication:
Hypersensitivity
Adverse Effect:
Anemia, leukopaenia, liver damage, jaundice, rash, itching.
Nursing Management of Miss Esther Matthew The following are interventions taken to improve the health of Miss Esther Mathew. (1)
Admission and Bed Rest: Patient is admitted for some hours and given adequate bed rest. This is to reduce metabolic consumption and oxygen demand (to conserve energy).
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(2)
Observation: -
Observe patients vital signs: Temperature, pulse rate, blood pressure and respiratory rate.
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Feel patients skin for warmness and dryness.
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Observe lips and mouth for dryness.
(3)
Nutrition -
Ensure adequate diet to meet increase metabolic demands
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Encourage intake of balanced fiber and bulk in diet to improve consistency of stool and facilitate passage through colon.
(4)
Reducing Hyperthermia -
Monitor patient’s vital signs to serve as baseline for future comparism.
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note presence/absence of sweating, to assess degree of hyperthermia
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Initiate tepid sponging: This facilitates heat loss through conduction and evaporation.
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(5)
Undress and remove extra linens, to facilities heat loss by radiation. Administer prescribed paracetamol 500mg as antipyretic Alleviating pain due to insertion or intravenous line
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Determine possible pathophysiology/pscyhologic causes of pain, to assess etiology, precipitating/ contributing factors
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(6)
Encourage verbalization of feelings about pain Administer analgesics as indicated Advice in discharge
(7)
Resolving vomiting/fluid volume depict -
Prepare and administer oral rehydration solution Administer intravenous fluid of normal saline to alternate 5% dextrose solution Monitor and record patients intake and output
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Nursing Diagnosis and Case Plan A nursing care plan outlines the nursing case to be provided to a patient. Case study. Miss Esther Mathew, a 14 year old girl was brought to the ward by her mother Mrs. Matthew with complains of fever for 9 days associated with chills, vomiting and weakness. A diagnosis of Typhoid fever was made following laboratory tests. After insertion of intravenous line for fluid replacement, she complained of acute pain around the area of insertion. Nursing diagnosis for above case study includes: (1)
Acute pain related to presence of traumatized tissue evidenced by grimacing and verbalization.
(2)
Hyperthermia related to disease process evidenced by temperature of 39 0c
(3)
Fluid volume deficit related to vomiting
(4)
Self-care deficit (partial) related to general weakness of the body evidenced by inability to perform activities of daily living.
Advice on Discharge Advice was given in the following key areas (1)
Medication
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Advice patient to take home medication following right durg, frequency,
disease and timing -
Encourage patient to follow drug regimen especially antibiotics, to prevent
resistance (2)
Environment
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Instruct patient to stay in calm, quiet
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Home environment must be free from slipping or accident hazards
(3)
Treatment
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Inform patient to have a follow-check up after 1-2 weeks.
(4)
Health Teaching Inform patient about proper food handling techniques as necessary
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Stress the importance of proper hygiene like hand washing, toileting, tooth brushing and bathing.
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encourage client to engage in range of motion exercises
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Instruct patient and significant others to drink only purified/boiled water.
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Advice patient to increase fluid intake for hydration purposes.
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Advise patient to avoid eating foods from outside sources.
(5)
Instruct patient to report signs and symptoms of typhoid fever like high grade fever, diarrhea etc.
Evaluation The prognosis of Miss Esther is good because she is responding to the treatment and nursing interventions positively. Improvement has been noticed in the patient, such as increase food intake, afebrile for days now, increased activity tolerance and compliance to medication. Recommendation As a degree nurse, I will make the following recommendations: -
Water should be boiled or chlorinated (water guard) before use as drinking water.
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Community should be informed and educated on the prevalence of typhoid fever and on ways to prevent it.
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Proper sanitation and drainage is needed to prevent such disease.
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Local government should work on building manual borehole at the rate of one borehole to 15 houses.
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Bukuru express P.H.C should be manned by a generalist physician or a well trained BNSc nurse to foster better diagnosis and treatment of typhoid fever and other diseases.
CONCLUSION Typhoid fever is one of the most common worldwide illness most specifically in third world (developing) countries such as ours, this is the question of sanitation since this disease is transmitted through ingestion of food or water which is improperly prepared and contaminated with faeces of an infected person. Gyel community is one of such areas with a high incidence of typhoid fever. 14
REFERENCE
Anne W, Allison G. Ross and Wilson Anatomy and Physiology in health and illness 10th editon. Elsevier limited Philadelpia 2006. Billings, Diane McGovern, Medical-Surgical Nursing. The C.V mosby company y. 11830 westline industrial drive, T.S Louis, Missouri 1987. Bullock, Barbara . Pathophysiology 4 th edition. Lippincott williams and wilkins company, Philadelphia, pennyslvania 2001. Kozier, Barbara, et al. fundamentals of Nursing 5th edition, Addison longman inc. Singapore 1998. Rotimi W. Nursing process: an effective tool for qualitative Nursing care 2 nd edition . creative books, Ibadan, Nigeria 2002. Smeltzer M, Bare, et al. Brunner and suddarth, Textbook of Medical surgical Nursing 12th edition. Lippincott williams and wilkins company, Philadelphia, pennyslvania 2001. Internet Wikipedia. http://en.wikipedia.org/wiki/typhoid_fever .
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Nursing Care plan for Miss. Esther Mathew on 9 th Feb. 2012 S/No 1
Nursing diagnosis Acute pain related to presence of traumatized tissue evidenced by grimace and verbalization
Nursing objectives Patient will verbalize reduction of pain from a scale 5 to 1. Within 6 hours of intervention
2
Hyperthermia related to disease process evidenced by Temperature of 390c.
Patient’s temperature will reduce by 10c within 1 hour of intervention
3
Fluid volume deficit related to vomiting
Patient will not show signs of dehydration like dry lips within 48hrs of intervention
Nursing intervention (1) Accept patient’s description of pain (2) Instruct patient to position affected arm properly (3) Encourage participation in diversional activities like socialization or listening to music (4) Administer analgesic as prescribed (1) expose patient to fresh air environment and fanning (2) tepid sponge the patient intermittently (3) Observe and record vital signs every 30mins. (4) Administer prescribed drug (1) Place patient on nil per oral until vomiting subsides (2) administer intravenous fluid e.g. N/S alternated with 5% dextrose solution (3) Monitor and record patients intake and output
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Rationale
Ev
(1) Pain is subjective experience and cannot be felt by others (2) To promote comfort (3) This disrupts the pain pathway (4) inhibits prostaglandin synthesis
Pati red as hou
(1) This increase heat loss by radiation (2) It increases heat loss by evaporation (3) To evaluate progress of intervention (4) relieves fever by acting in hypothalamic heat enter
Pati red hou int
(1) It allows intestine to rest. (2) To replace lost fluid. (3) To assess progress of intervention
Pati res of
