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THYPOID FEVER

A. DEFINITION
Typhoid fever is a systemic infectious disease caused by Salmonella thypi which is
still widely found in various developing countries which are mainly located in tropical and
subtropical regions.This disease is also an important public health problem because its
distribution is closely related to urbanization, population density, environmental health, poor
water sources and sanitation and the low hygiene standards of the food processing industry
(Simanjuntak, CH, 2009).
Thypoid abdominal is an acute small intestinal infection caused by
germs Salmonella Thypi ( which usually affects the digestive tract with symptoms of fever
that lasts more than 7 days, digestive disorders and impaired consciousness (Ari ef, M. 200 9 ).
Typhoid is disease infections that occur in the intestine smooth caused by
salmonella thypii, disease this could transmitted through germs , mouth or water contaminated
by germs sal monellathypii. ( Azis HA 2006) .
Thypoid abdominalis is an acute infectious disease that usually affects the digestive
tract with symptoms of fever that lasts more than one week, disorders of the digestive tract, and
disturbances of consciousness. (Nursalam . 2005)
Typhoid is an acute infection of the small intestine caused by the bacteria salmonella
thypi and salmonella para thypi A, B, C. Synonyms of this disease are Typhoid and
paratyphoid abdominal (Sud oyo, A 200 9 ). Typhoid is an infectious disease in the small
intestine, typhoid is also called paratyphoid fever, enteric fever, typhus and the abdominal
typhus (Seoparman, 2007).
From some of the above understanding it can be concluded that typhoid fever is an
infectious disease of the small intestine caused by salmonella type A, B and C which can be
transmitted through oral, fecal, contaminated food and drinks.

B. ETIOLOGY
Salmonella thypi with Another salmonella Gram-
negative bacteria, have flagella, not capsule , no form spore , facultative anaerob . Has
a somatic (O) antigen consisting from oligosaccharides, flagelarantigen (H) t e rdiri from
the protein and envelope antigen (K) which
is composed from plainaccharide . Have macromolecular lipopolysaccharide complex that fo
rms
an outer layer from Wall cell andnamed endotoxin . Salmonella thypi also can obtain the ass
ociated R-plasmid factor with resistance against multiple antibiotics. ( Nanda Nic-Noc,
2013 )

C. SIGNS AND SYMPTOMS


Signs and symptoms from fever typhoid as following (Nanda NIC-NOC. 2013):
1. Symptoms in children: Incubation between 5-40 days with an average of 10-
14 days .
2. Fever rising to end Sunday first
3. Fever down in the week to four , except fever no handled will causing shock,
Stupor and coma .
4. Rash appears on the day to 7-10 and survive for 2-3 days
5. headache
6. Abdominal pain
7. Bloating
8. Mua l gag
9. Diarrhea
10. Constipation
11. Dizzy
12. Muscle pain
13. Cough
14. Epistaxis
15. Bradikardi
16. Webbed tongue (dirty in the middle , at the edge red and tremors)
17. Hepatomegaly
18. Splenomegaly
19. Meteroismus
20. Mental disorders in the form of samnolen
21. Delirium or psychosis
22. Could arises with symptoms typical especially in infants young as disease fever I
with bro shock and hypothermia .

D. PATHOPHYSIOLOGY
Salmonella
bacteria enter together food / drink . After being in intestine smooth then hold invasion to net
work lymphoid intestine smooth ( especially Peyer Plaque )
and network lymphoidmesenteric . After causing inflammation and necrose local , germs thro
ugh vessels lymph enter to Flow blood ( happens bakteremi primary) to to the
organs especially liver and lymph . Germs diffagocytewill developing multiply in liver and ly
mph so that these organs enlarged accompanied pain on palpation .
At the end of the incubation period (5-
9 days ) germs back enter in blood ( bacteremia secondary ) and spread to
all body especially into
the gland lymphoid intestine smooth , raises ulcer shapedoval above Peyer Plaque . Ulcer that
could cause bleeding and perforation intestine . During bacteremia this , germs take
out endotoxins that have role help the inflammation process local Where germs thisdevelopin
g.
Fever typhoid caused because of Salmonella Typhosa and
its endotoxin stimulate synthesis and release substance pyrogens by leukocytes in the inflame
d tissue. Substance pyrogen this willcirculating in blood and affect center thermoregulator in
the hypothalamus that gives rise symptoms fever . (PPNI Klaten . 2009)
(Nanda Nic-Noc.2013)
F. DIAGNOSTIC EXAMINATION
According to W idodo , 2007 Supporting the client with typhoid is a laboratory
examination, which consists of:
1. Leukocyte examination
In some literature it is stated that typhoid fever has leukopenia and relative limposistosis
but the fact is that leukopenia is not common. In most cases of typhoid fever, the number of
leukocytes in peripheral blood preparations is at normal limits even sometimes there are
leukocytes even though there are no complications or secondary infections. Therefore
examination of the number of leukocytes is not useful for the diagnosis of typhoid fever.
2. Sgot and Sgot Examination
Sgot and Sgpt in typhoid fever often increase but can return to normal after typhoid healing.
3. Blood culture
If positive blood cultures indicate typhoid fever, but if negative blood cultures do not rule
out typhoid fever. This is because the results of blood cultures depend on several factors:
a. Laboratory inspection techniques
The results of examination of one laboratory are different from other laboratories, this
is due to differences in techniques and culture media used. A good blood collection time
is during a high fever when the bacteremia is taking place.
b. When checking during the course of the disease
Blood culture for salmonella thypi is especially positive in the first week and decreases
in the following weeks. At the time of relapse blood cultures can be positive again.
c. Vaccination in the past
Vaccination against typhoid fever in the past can cause antibodies in the client's blood,
these antibodies can suppress bacteremia so that blood cultures are negative.
4. Treatment with anti-microbial drugs
If the client before blood culture has received antimicrobial drugs, the growth of germs in
culture media is inhibited and the results of culture may be negative.
5. Widal Test
Widal test is an agglutination reaction between antigen and antibody (agglutinin). Aglutinin
which is specific to salmonella thypi found in client serum with typhoid is also found in
people who have been vaccinated. The antigen used in the widal test is a salmonella
suspension that has been turned off and processed in the laboratory. The aim of the widal
test is to determine the presence of agglutinin in the serum of clients who are suspected of
having typhoid. As a result of infection by salmonella thypi, the client makes antibodies or
agglutinin, namely:
a. Aglutinin O, which is made because of the stimulation of the O antigen (derived
from the body of the germ).
b. Aglutinin H, which is made because of the stimulation of H antigen (derived from
the germ flagellum).
c. Aglutinin Vi, which is made because of the stimulation of Vi antigen (derived from
germ hoops)
Of the three agglutinins, only agglutinin O and H determined the titers for
diagnosis, the higher the titer, the bigger the client suffered typhoid.
Widal test is performed to detect antibodies to Salmonella typhi bacteria. Widal
test is said to be valuable if there is a 4-fold widal titer increase (on 5-7 days re-
examination) or widal O titer> 1/320, H> 1/60 (in one examination) titer Gall culture
with bile carr media is a definite diagnosis typhoid fever if the results are positive,
however, if the results of negative cultures do not rule out the possibility of typhoid, for
several reasons, namely the effect of antibiotics, insufficient samples. In accordance
with HR capabilities and the level of travel of typhoid fever, the clinical diagnosis of
typhoid fever is classified as:
1. Possible Case with history and physical examination found symptoms of
fever, gastrointestinal disorders, defecation patterns and hepato /
splenomegaly. Typhoid fever syndrome is incomplete.This diagnosis is only made
in basic health services.
2. Probable Case clinical symptoms have obtained complete or nearly
complete, and supported by an idea which underpins the labora t orium typhoid
fever (widal O titer> 1/160 or H> 1/160 one examination).
3. Definite Case Definitive diagnosis, S. Thypi was found in culture culture or
S.Thypi positives on PCR examination or there was a 4-fold increase in titer (on 5-
7 days re-examination) or widal O titer> 1/320, H> 1/640 ( on examination once) .

G. MANAGEMENT
The principle of management of typhoid fever still adheres to the management trilogy
which includes: rest and care, diet and supportive therapy (both symptomatic and supportive),
and antimicrobial administration. In addition it is also necessary to manage complications of
typhoid fever which include intestinal and extraintestinal complications.
1. Rest and Care
Aim to prevent complications and speed healing. Bed rest with care done entirely in places
such as eating, drinking, bathing, and defecation. The position of the patient being
monitored to prevent dukubitus and orthostatic pneumonia and personal hygiene still need
attention and care.
2. Supporting Diet and Therapy
Maintain adequate calorie and fluid intake.
a. Providing a free diet that is low in fiber in patients without symptoms of meteorism,
and a filter slurry diet in patients with meteorism. This is done to avoid complications
of gastrointestinal bleeding and intestinal perforation. Patient nutrition is also
considered to improve the general condition and accelerate the healing process.
b. Adequate fluid to prevent dehydration due to vomiting and diarrhea.
c. Primperan (metoclopramide) is given to reduce symptoms of nausea and vomiting
with a dose of 3 x 5 ml before each meal and can be stopped whenever the patient has
no nausea anymore.
3. Antimicrobial Giving
Antimicrobial drugs that are often used in managing typhoid are:
In typhoid fever, the drug of choice is chloramphenicol with a dose of 4 x 500 mg per day
can be given orally or intravenously, given up to 7 days free of heat. Chloramphenicol
works by binding to the ribosome unit of the salmonella bacteria, inhibiting its growth by
inhibiting protein synthesis. Chloramphenicol has a negative and positive gram
spectrum. The side effect of using chloramphenicol is that agranulocytosis occurs. While
the loss of use of chloramphenicol is a high recurrence rate (5-7%), long-term use (14
days), and often causes a career.
Tiamfenikol, dosage and effectiveness in typhoid fever is the same as
chloramphenicol which is 4 x 500 mg, and the average fever decreases on days 5 to
6. Hematological complications such as the possibility of aplastic anemia are lower than
chloramphenicol.
Ampisillin and Amoxicillin, the ability to reduce fever is lower than
chloramphenicol, at a dose of 50-150 mg / kgBB for 2 weeks.
Trimetroprim-sulfamethoxazole, (TMP-SMZ) can be used orally or intravenously
in adults at a dose of 160 mg TMP plus 800 mg SMZ twice daily in adults.
Third-generation cephalosforin, namely ceftriaxon with a dose of 3-4 grams in 100 cc
dextrose is given for ½ hour once daily, given for 3-5 days.
Flurokuinolone group (Norfloxacin, ciprofloxacin). Relatively, these classics are
inexpensive, well tolerated, and more effective than previous first-line drugs
(chlorampenicol, ampicillin, amoxicillin and trimethoprim-
sulfamethoxazole). Fluroquinolone has the ability to penetrate good tissue, so it can kill S.
thypi which is in a static stage in the monocytes / macrophages and can reach a higher drug
level in the gallblader than other drugs. This class of drugs can provide a fast therapeutic
response, such as reducing heat complaints and other symptoms in 3 to 5 days. The use of
fluriquinolone drugs can also reduce the likelihood of post-treatment career events.
Combination of 2 antibiotics or more is indicated in certain conditions such as
typhoid toxic, peritonitis or perforation, and septic shock. In pregnant women,
chloramphenicol is not recommended in the third trimester because it causes premature
labor, intrauterine fetal death, and gray syndrome in neonates. Tiamfenikol is not
recommended in the first trimester because it has teratogenic effects. The recommended
medication is ampicillin, amoxicillin and ceftriaxon. (Yudhistira.W.2009)

H. ASSESSMENT
a. Collecting Data
1) Client identity
Includes name, age, gender, address, occupation, ethnicity, religion, marital status,
date of hospital admission, register number and medical diagnosis.
2) Main complaint
The main complaint of typhoid fever is heat or fever that is not descending, abdominal
pain, headache, nausea, vomiting, anorexia, diarrhea and decreased consciousness.
3) Current disease history
Increased body temperature due to the entry of salmonella typhi bacteria into the
body.
4) Past medical history
Have previously suffered from typhoid fever.
5) History of family illness
Has the family ever suffered from hypertension, diabetes mellitus.
6) Health function patterns
a. Nutritional and metabolic patterns
Clients will experience decreased appetite due to nausea and vomiting when
eating so eating only a little doesn't even eat at all.
b. Elimination pattern
Elimination of alvi. Clients can experience constipation due to long bed
rest. While elimination of urine does not experience interference, only the color of
the urine becomes brownish yellow. Clients with typhoid fever increase in body
temperature which results in a lot of sweat coming out and feeling thirsty, so that it
can increase the body's fluid needs.
c. Activity and training patterns
Client activities will be disrupted because they have total bed rest, in order to avoid
complications, all client needs are assisted.
d. Sleep and rest patterns
Sleep and rest patterns are interrupted due to temperature increases body.
e. Pattern of perception and self-concept
Anxiety usually occurs to parents against the condition of the child's disease .
f. Sensory and cognitive patterns
In smell, palpation, feeling, hearing and vision generally do not experience
abnormalities and there is no understanding on the client.
g. Relationship and role patterns
Relationships with other people are disrupted as the client is treated in the hospital
and the client must have a total bed rest.
h. Stress relief patterns
Usually parents will it appears anxious .
7) Physical examination
a. General condition
Obtained client look weak, temperature body increase 38 - 41 0 C,
reddish face.
b. Level of awareness
Impairment can occur (apathy).
c. Respiration system
Respiratory an average increase, rapid and deep breathing with images such as
bronchitis.
d. Cardiovascular system
A decrease in blood pressure, relative bradycardia, low hemoglobin.
e. Integumentary system
Dry skin, turgor kullit decreases, face looks pale, hair is rather dull
f. Gastrointestinal system
Dry lips are cracked, mucosa is dry mouth, tongue is dirty (typical), nausea,
vomiting, anorexia, and constipation, abdominal pain, stomach feels bad, intestinal
peristalsis increases.
g. Musculoskeletal system
The client is weak, feels tired but there is no abnormality.
h. Abdominal system
When palpation is obtained the spleen and liver enlarge with soft consistency and
tenderness in the abdomen. On Percussion has a flatulence and increased
auscultation of intestinal peristalsis.

I. Diagnosis K eperawatan
1. Hyperthermia and Disease / Increased body metabolism
2. Diarrhea in gastrointestinal inflammation
3. Nutritional imbalance: Less than needed
4. Lack of fluid volume and loss of active fluid
5. Acute pain bd Physical injury agent
(Application-NOC.2013 Nanda NIC)

J. INTERVENTION

No. Dx nursing Aim Intervention

1 Hyperthermia NOC: Thermoregulation NIC: Fever Treatment


and Disease /
Increased body a. Monitor the
metabolism temperature as often
as possible
b. IWL monitor
c. Monitor body
temperature and
temperature
d. TTV monitor
e. Monitor Wbc,
Hb, Hct
f. Monitor fluid
intake and output
g. Collaboration
with antipuretics
h. Collaboration of
IV fluids
i. Compress the
patient with warm
water
j. Give treatment to
overcome the cause of
fever
2 Diarrhea in NOC: Bowel Elimination NIC: Diarhea
gastrointestinal Management
inflammation a. Instruct family to
record the color,
amount, frequency
and consistency of
feces
b. Evaluate
incoming food intake
c. Observe skin
turgot regularly
d. Instruct families
to eat foods low in
fiber, high in protein
and high in calories if
possible
e. Collaboration of
IV fluids
f. Collaboration
of diarrheamedication
3 Disadvantages NOC: Fluid Balance, Hydration NIC: Fluid Management
Lack of fluid
volume and a. Monitor the
loss of active patient's hydration
fluid status
b. Maintain records
of fluid intake and
output
c. TTV monitor
d. Monitor food and
fluid intake and
calculate daily calorie
intake
e. Collaboration of
IV fluids
4 Acute pain in NOC: Pain Control NIC: Pain Management
physical injury
agents After nursing care for 2x24 hours is a. Conduct
expected the client's pain will decrease with comprehensive pain
the results criteria: assessments including
Indicator A Q. location,
1. Know 3 4 characteristics, when
when pain started or duration,
starts frequency, quality,
2. Describe 3 4 intensity and trigger
the cause and factors
effect factors b. Observe
3. Use 3 4 nonverbal reactions
precautions from discomfort
4. Using c. Use therapeutic
recommended 3 5 communication
analgesics techniques to
5. Use determine the client's
available pain experience
resources d. Assess the culture
6. Recognize 3 5 that affects the client's
symptoms of pain response
pain e. Explore the
client's knowledge and
2 4 beliefs about pain
f. Joint evaluation
Information : of clients and health
1: Never demonstrate workers about the
2: Rarely
3: Sometimes ineffectiveness of pain
4: Often control in the past
5: Consistent g. Environmental
controls that can
worsen pain such as
room temperature or
noise
h. Choose and do
pain management
(pharmacology,
nonpharmacology and
interpersonal)
i. Teach about non-
pharmacological
techniques
j. Use pain control
before the pain gets
heavier
5 Nutritional NOC: Nutritional Status NIC: Nutritional
imbalance: less Management
than the body's After done care for 3 x
needs 24hours nutritional status clientwill getting a. Assess for food
better withindicator: allergies
b. Collaborate with
Indicator A Q. nutritionists to
1. Intakae 3 4 determine the
nutrition nutrients needed
2. Liquid 3 4 c. Give sugar
intake sustenance
3. Energy 3 4 d. Give a high-fiber
4. Hydration 3 4 diet to prevent
constipation
Description : e. Monitor the
1. severe deviation from normal range amount of nutrients
2. substantial and calorie content
3. moderate f. Assess the
4. mild patient's ability to get
5. none the nutrients needed
g. Eat a little but
often to prevent
vomiting

Nutrition Monitoring

a. Monitor skin
turgor
b. Monitor nausea
and vomiting

( Nanda NIC-NOC application . 2013)


BIBLIOGRAPHY

Inawati. (2009). Typhoid fever. Wijaya Kusuma Medical Scientific Journal. Special edition. Pp. 31-36.
Nadyah. (2014). Relationship of factors influencing the incidence of typhoid fever in Samata Village,
Somba Opu District, Gowa Regency, 2013. Health Journal , Vol VII, No. 1, 305-321.
Ngastiyah. (2005). Care for sick children . Jakarta: EGC
Wardana, IMTL, et al. (2014). Diagnosis of typhoid fever with
widal examination. Bali: Pathology Clinic Faculty Medical University Udayana / House Sick Ge
neral Sanglah Center