I.

INTRODUCTION

Typhoid fever , otherwise known as enteric fever, is an acute illness associated with
fever caused by the Salmonella typhi bacteria. S. 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, know as ‘typhoid psychosis’. A characteristic feature of typhoid psychosis
is 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 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, a
subunit (Vi PS) vaccine administered by the intramuscular route and a live attenuated S typhi
strain (Ty21a) for oral immunization. (http://www.medicinenet.com/typhoid_fever/article.htm)

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.

In the U.S., about 400 cases of typhoid fever are reported each year, giving an annual
incidence of less than 0.2 cases/100,000 population, which is similar to that in Western Europe
and Japan. The WHO has estimated that at least 12.5 million cases occur annually worldwide.
(http://www.who.int/)

Typhoid fever is ranked 10th in the leading causes of morbidity in the Philippines with a
rate of 19.5/100,000 population and an almost equal prevalence between male and female.
(http://www.doh.gov.ph/)

I chose this topic out of interest and curiosity regarding the disease. Through the research,
I may gain vast knowledge and understanding about the contents of the disease. I may be able
provide optimum nursing care to my clients suffering from the said condition.

OBJECTIVES

Nurse-centered

General Objectives:

 To become successful in promoting and rendering effective nursing care

Specific Objectives:

 To promote ideas related to Typhoid fever.

 To improve the knowledge in delivering nursing care plan.

 To understand more about the patients health problem condition

 To become more aware about the health problem condition.

Client-centered

General Objectives:

 To maintain and improve the received knowledge to prevent the disease

and to promote health

Specific Objectives:

 To receive the proper nursing care plan

 To maintain the health teachings that the patient learns

 To help client on how to cope up with his case.

 To guide the client and family in preventing disease

 To provide health through health teaching for the patient and family

II. NURSING PROCESS

A. ASSESSMENT

1. Personal Data

a. Demographic data

Name : Child X
Age : 2 years old
Sex : Female
Civil Status : Single
Role/ Position in the Family : Daughter
Religion : Roman Catholic
Date of Birth : October 2008
Place of Birth : Tarlac City
Nationality : Filipino
Place of Admission : Tarlac Provincial Hospital (TPH)
Date of Admission : July 12, 2010
 Attending Physician : Dr. Agas
Chief Complaint : On and off fever
Admitting Diagnosis : Typhoid Fever

b. Environmental Status

Child X is currently residing at Murcia Concepcion, Tarlac. The house of the family is
small and concrete. There are nine persons occupying the house. Their source of water supply
and drinking water is from a deep well. They usually drink the water without boiling. They
dispose their garbage through burning.

c. Lifestyle

According to the patient’s mother, her daughter usually sleeps at eight o’clock in the
evening and wakes up at nine o’clock in the morning. She also stated that at noon her daughter
takes 2-3 hours nap. Child X frequently plays in the afternoon with the neighbors in their
barangay. When it comes to feeding, the mother feeds her child with a normal diet.
 2. Family History of Health and Illness

Paternal Side Maternal Side

65 60 69 63

39 37 34 38 35 31 28 24
22

6 2
 LEGEND

-Male -Male with Hypertension

-Female -Female with Hypertension

-Patient -Male with Diabetes

- points to patient
 3. History of Past Illness

According to the patient’s mother, her daughter received one dose of BCG, three
doses of DPT, three doses of OPV and three doses of Hepa B for her immunization. She
claimed that her daughter has had no measles, chickenpox or had any form of injury prior
to admission. The common illnesses that child X experienced are cough, common colds
and fever. Her mother also stated that child X had no allergies to drugs, foods, insects and
other environmental agents. This was the first time that child X was hospitalized.

4. History of Present Illness

Six days prior to admission, Child X developed colds associated with low grade
fever. Her mother gave paracetamol and carbocistine for treatment.

Three days prior to admission, due to unrelenting cough and on and off fever,
Child X was consulted and was subsequently admitted to a hospital in Capas.

Due to the persistence of the condition of Child X, she was later transferred at
Tarlac Provincial Hospital for treatment.
 5. Physical Assessment

July 16, 2010

BODY PART METHOD OF NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

ASSESSMENT

Skull Inspection The head should be normocephalic and Normocephalic Normal

symmetrical.
Palpation Absence of masses Normal

Hair Inspection Hair varies from dark black to pale blond Hair is thin Normal
base on the amount of melanin present.
As melanin production diminishes, hair
turns gray. Hair color may also be
chemically changed. Hair may feel thin,
straight, coarse, thick, or curly.

Face Inspection Face should be smooth and has no Smooth but pale Due to fever & colds
involuntary movements looking
Eyes Inspection Both eyes should move smoothly and Pale conjunctiva Due to dehydration caused
symmetrically in each six fields of gaze by fever and colds
and converge on the held object as it
moves towards the nose a few bits of
nystagmus with extreme lateral gaze can
be normal.

Nose Inspection It is located symmetrically in the midline (-) mucus secretion Normal
of the face and is without swelling,
bleeding, lesions, or masses.

Mouth The lip and membrane should be pink

and moist with no evidence of lesions or
Lips Inspection Dry and pale lips Due to dehydration caused
inflammation.
by fever and colds
The adult normally has a 32 teeth, it
should be white and smooth edge, in
proper alignment, and without caries.
Teeth & gums Inspection Gums is pink in color
The tongue is in the midline of the Normal
mouth. The dorsum of the tongue should
be pink, moist, rough, and without
lesions. The tongue is symmetrical and
moves freely. It should be moist and
Tongue Inspection without lesions. Moves freely, no
 tenderness Normal

Ears Inspection The ear should match the flesh color of Color same as facial Normal
the rest of the patient’s skin and should skin; symmetrical;
be positioned centrally and in proportion auricle aligned with
to the head. The top of the ear should outer canthus of eye,
cross an imaginary line drawn from the about 10’ from
outer cantus of the eye to the occiput. ventricle
Cerumen should be moist and not
obscure the tympanic membrane. There
should be no foreign bodies, redness,
drainage, deformities, nodules, or lesions.

Skin Inspection Normally, the skin is uniform whitish Smooth Normal

pink or brown color depending on the
A rash of flat, rose- A rash of flat, rose-colored
patient’s race. Exposures to sunlight
colored spots were spots is indicative of
result to increase in pigmentation of sun
noted on chest area having typhoid fever.
expose areas. Dark skin persons may
normally have a freckling of the gums,
tongue borders, and lining of the cheeks.

Neck Inspection The muscle of the neck is symmetrical Muscles equal size;
with the head in the central position. The head centered
Normal
patient able to move the head through a
Not palpable
full range of motion without complain of
 -Lymph nodes Palpation discomfort or noticeable limitation. The Lobes may not be Normal
muscle should be symmetrical without palpated
-Thyroid Palpation
palpable masses or spasm.
gland
Normal

Thorax and Inspection The shape of the thorax in a normal adult Symmetrical Normal
Lungs is elliptical; the anteroposterior diameter
is less than the transverse diameter at
Palpation approximately a ratio of 1:2.Moves Chest wall intact, no Normal
symmetrically on breathing with no tenderness
obvious masses. No fail chest which is
Resonance heard upon
Percussion suggestive of rib fracture. No chest Normal
percussion
retractions must be noted as this may
suggest difficulty in breathing. No
Auscultation bulging at the ICS must be noted as this Normal
No adventitious sounds
may obstruction on expiration, abnormal
heard upon auscultation
masses, or cardiomegaly. The spine
should be straight, with slightly curvature
in the thoracic area. There should be no
scoliosis, kyphosis, or lordosis. Breathing
maybe diaphragmatically of costally.
Expiration is usually longer the
inspiration.
Abdomen Inspection In the normal state, the abdominal Flat abdominal contour Normal
 contour is flat or rounded. The abdomen Audible bowel sounds
should be symmetrical bilaterally. There
Auscultation Tympany over the Normal
should be no abdominal scars present.
stomach and gas filled
Percussion The abdomen should be uniform in color Normal
bowels
and pigmentation.

Palpation
No tenderness
Normal

Upper and Inspection Both extremities are equal in size. Have Symmetrical Normal
Lower the same contour with prominences of
Palpation (-) Tenderness Normal
extremities joints. No involuntary movements. No
edema. Color is even. Temperature is
warm and even. Has equal contraction.
Can perform complete range of motion.
 6. Laboratory and diagnostic procedures

Analysis and
Diagnostic/
Date ordered/ Interpretation of
laboratory Indication/ Purpose Result
date done results (related to the
procedures
disease)

Typhidot July 12, 2010 The Typhidot test was developed by a Malaysian Salmonella TYPHI There is presence IgG
scientist for the quick diagnosis of typhoid fever and antibodies and
IgG Pos
has recently been introduced commercially. This test absence of IgM
utilizes the principle of antigen-antibody reaction. It IgM Neg antibodies resulting to
costs less than a blood culture, and results are much positive typhoid
faster. They can be obtained within the same day as fever.
the examination.
Diagnostic/Laboratory Date Indications/ Result Analysis and interpretation of results
Procedure Ordered/Done
Purposes

Hematology 7/12/10 This test is used to evaluate WBC 18.1 G/L White blood cells are high to combat
anemia, leukemia, reaction to invading pathogens.
inflammation and infections, (4.1-10.9 GL)
peripheral blood cellular HGB 115 g/L
characters, State of hydration
and dehydration, (120-180 g/L)
Polycythemia, Hemolytic
HCT .355 L/L
disease of the newborn, to
manage chemotherapy (.370-.510 L/L)
decisions.

Nursing responsibilities prior to, during and after the procedure.

Prior Explain the procedure to the patient and why it is necessary.

During Make the patient relax during the procedure

After Apply pressure to the site to promote blood coagulation

 1. Anatomy and Physiology

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.

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 feces). 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 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:

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 fibers
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.

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.

Insalivation 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.

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.
Immunoglobins are secreted help to fight microorganisms and a-amylase proteins start to break
down 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 more
viscid (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.

Esophagus

The esophagus 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 esophagus is made up of inner circular and outer longitudinal layers of muscle that
are supplied by the esophageal nerve plexus. This nerve plexus surrounds the lower portion of
the esophagus. The esophagus functions primarily as a transport medium between compartments.

Stomach

The stomach is a J shaped expanded bag, located just left of the midline between the esophagus
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 cardia which surrounds the cardial orifice where the
esophagus 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.

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 approximately
6m 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.

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).

The rectum is the final 15cm of the large intestine. It expands to hold fecal 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
summarised 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 travels from the intestinal system. It detoxifies several metabolites including
the breakdown of bilirubin and oestrogen. 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 gall
bladder 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 the Islets of Langerhans. The Islets produce insulin, glucagon and other substances and
these are the areas damaged in diabetes mellitus. The exocrine (secretrory) 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.
 2. PATHOPHYSIOLOGY

Book Based

Salmonella Typhi

Small Intestines

Multiplication in intestinal
and mesenteric lymphoid follicles

Transient bacteraemia

Multiplication in
RETICULOENDOTHELIAL SYSTEM

Bile Septicemia
(onset of symptoms, blood culture positive)

Reinfection of intestinal Generalized infection

Lymphoid follicles (e.g. liver, kidney, marrow)

Excretion in urine and feces

(blood culture may now be negative as organisms now mainly intracellular)
Client Based

Salmonella Typhi

Small Intestines

Multiplication in intestinal
and mesenteric lymphoid follicles

Transient bacteraemia

Multiplication in
RETICULOENDOTHELIAL SYSTEM

Bile Septicemia
(Child X suffered from on and off fever,
cough and resulted positive for blood
culture)

Reinfection of intestinal Generalized infection

Lymphoid follicles (e.g. liver, kidney, marrow)

Excretion in urine and feces

(blood culture may now be negative as organisms now mainly intracellular)
 B. PLANNING
ASSESSMENT
S=Ø
O =warm to touch
= pale and weak in
appearance.
= restless and irritable
= febrile with temp= 37.9º
= WBC – 18.1g/L
= with ongoing IVF of 0.3%
NaCl 500 ml received at
100 ml level and regulated
at 37-38 microdrops per
minute located at left arm,
PLANNING
Within 30 minutes to 1 hour of
appropriate nursing
intervention, the client will be
able to maintain core
temperature within normal
range.
IMPLEMENTATION EVALUATION
Independent: After 30 minutes to 1 hour of
appropriate nursing
• Perform TSB to lower
intervention, the client shall be
body temperature
able to maintain core
temperature within normal
• Maintain hydration range.
status to avoid loss of
body fluids.
• Monitored vital signs
specifically temperature
for baseline data.
• Increase fluid intake to
prevent heat-induced
hyperthermia and
dehydration
 intact and infusing well.

Dependent:

• Provide high-calorie
diet to meet increased
Diagnosis: Hyperthermia
metabolic demands.
related to infection

Collaborative:

Scientific Explanation:
• Prepare and administer
Body temperature elevated medication care of the
above normal range. clinical instructor as
ordered by the doctor
To prevent further
complications
 ASSESSMENT
S=Ø
O =grimace noted
= pale and weak in
appearance
= restless and irritable
= with guarding behavior
= with ongoing IVF of 0.3%
NaCl 500 ml received at
100 ml level and regulated
at 22-23 microdrops per
minute located at left arm,
intact and infusing well.
PLANNING
Within 1 hour of appropriate
nursing intervention, the client
will be able to report physical
and psychological well being as
evidenced by absence of
grimace and guarding behavior.
IMPLEMENTATION EVALUATION
Independent: After 1 hour of appropriate
nursing intervention, the client
• Determine possible
shall be able to report physical
pathophysiologic/
and psychological well being as
psychologic causes of
evidenced by absence of
pain. To assess etiology
grimace and guarding behavior.
precipitating
contributing factors.
• Encourage verbalization
of feelings about pain.
To assist client to
explore methods to
control/ alleviate pain.
• Encourage us of
relaxation techniques
such as deep breathing
exercises. To assist
client to explore
methods to control/
alleviate pain

Diagnosis: Acute Pain r/t
presence of traumatized tissue
resulting from insertion of IV
Scientific Explanation:
Unpleasant sensory and
emotional experience arising
Dependent:
from actual or potential tissue
damage or described in terms
of such damage.
• Encourage participation
in diversional activities
like socialization or
listening to music. To
assist client to explore
methods to control/
alleviate pain
• Provide patient with a
quiet environment and
calm activities. To
assist client to explore
methods to control/
alleviate pain
• Instruct patient to
position affected arm
properly. To promote
comfort.
• Instruct patient to not
use affected arm
unnecessarily. To
 prevent complications

Collaborative:

• Administer analgesics
as indicated. Inhibits
prostaglandin synthesis
by decreasing an
enzyme needed for
biosynthesis.
 ASSESSMENT
S = “Ilang araw na syang di
dumudumi” as verbalized by
the SO.
O =Dry skin
=Absence of sweating
=Needs assistance upon
getting up in bed
=Refused to ambulate or to do
ROM exercises
=Slowed movement
=presence of flatus
=Defecates 4-5 times per
week
Diagnosis: Risk for
Constipation r/t insufficient
physical activity
PLANNING
Within 6 hours of appropriate
nursing interventions, the
patient will be able to verbalize
understanding of risk factors
and appropriate interventions/
solutions to individual
situation.
IMPLEMENTATION EVALUATION
Independent: After 6 hours of appropriate
nursing interventions, the
• Auscultate abdomen for patient shall be able to
presence, location, and verbalize understanding of risk
factors and appropriate
characteristics of
interventions/ solutions to
bowels sounds. Reflects individual situation.
bowel activity.
• Ascertain client’s usual
elimination pattern. To
assess client’s
individual risk factors/
needs.
• Encourage intake of
balanced fiber and bulk
in diet. To improve
consistency of stool and
facilitates passage
through colon
• Promote increase in
fluid intake unless
contraindicated. To
promote moist/ soft

Scientific Explanation:
At risk for a decrease in normal
frequency of defecation
accompanied by difficult or
incomplete passage of stool, or
Dependent:
passage of excessively hard,
dry stool.
Collaborative:
stool.
• Encourage participation
in activity/ exercise
within limits of own
ability. To stimulate
contractions of
intestines.
• Instruct patient to
respond to urge to
defecate. To promote
comfort and prevent
complications.
• Instruct client and SO to
ascertain frequency,
color, consistency of
stool once defecated.
• Advise patient to have
elimination diary if
appropriate. To help
monitor bowel pattern.
• Notify physician for
unusualities. For
prompt management
 ASSESSMENT
S=Ø
O =Slowed movement
=Body weakness noted
=Refused to ambulate or to
do ROM exercises
=Needs assistance upon
getting up/ out in bed
=Prefers to lie down on bed
Diagnosis: Impaired Physical
Mobility r/t to reluctance to
initiate movement
Scientific Explanation:
Limitation in independent,
PLANNING IMPLEMENTATION EVALUATION
Within 4 hours of appropriate Independent: After 4 hours of appropriate
nursing interventions, the nursing interventions, the
patient will be able to verbalize • Determine degree of patient will be able to verbalize
willingness to and demonstrate mobility. To assess willingness to and demonstrate
participation in activities. functional ability participation in activities.
• Assess nutritional status
and energy level. To
identify causative/
contributing factors.
• Ascertain client’s
perception of activity/
exercise needs. To
identify causative/
contributing factors.
• Have client reposition
self on regular schedule
as indicated. To
promote optimal level
of functioning.
• Instruct in use of
siderails upon
positioning. To promote
purposeful physical movement
of the body or of one or more
extremities.
Dependent:
safety.
• Schedule activities with
adequate rest periods
during the day. To
prevent/ reduce fatigue.
• Encourage client to
participate in self care
activities. Enhances
self- concept and sense
of independence.
• Identify energy-
conserving techniques
for ADL’s. Limits
fatigue, maximizing
participation.
• Instruct patient to
promote / have
ambulation as
necessary. To prevent
skin breakdown and
maximizes energy
production.
• Instruct patient to eat
nutritious foods and
drink adequate fluid
intake. Promotes well
being and maximizes
energy production.
 ASSESSMENT
S = “Kanina pa nya
sinusubukan matulog” as
verbalized by the SO.
O = Yawning noted
= Finds way to promote sleep
like turning on the electric fan
=Slowed movement
=Doesn’t practice afternoon
naps
=Sleeps 6-8 hours a day
Diagnosis: Readiness for
Enhanced Sleep
Scientific Explanation:
PLANNING IMPLEMENTATION EVALUATION
Within 4 hours of appropriate Independent: After 4 hours of appropriate
nursing interventions, the nursing interventions, the
patient will be able to verbalize • Listen to client’s reports patient shall be able to
of sleep quantity and
understanding on ways to verbalize understanding on
promote sleep. quality. Reveals client’s ways to promote sleep.
expectations and
experiences.
• Obtain feedback from
client and SO about
usual bedtime, desired
rituals and routine.
Helps identify
circumstances that are
known to interrupt
sleep patterns.
• Note client’s report of
potential for alteration
for habitual sleep time.
To determine usual
sleep pattern and
provide comparative
baseline data.
• Arrange care as
necessary. To provide
A pattern of natural, periodic for uninterrupted
suspension of consciousness periods for rest.

that provides adequate rest, • Explain to patient the

sustains a desired lifestyle, and necessity of
disturbances for
can be strengthened.
hospital procedure like
v/s taking. Allows for
longer periods of
uninterrupted sleep.

• Provide quiet
environment prior to
sleep. To promote
relaxation and
readiness to sleep

• Instruct patient to
practice proper hygiene
practices like washing
of hands and feet before
sleeping. To promote
relaxation and
readiness to sleep.

• Discuss patient’s usual

bedtime rituals,
expectations for
obtaining good sleep
time. Provides
information on client’s
 management of the
situation and identifies
areas that might be
modified.

Dependent:

• Instruct patient to limit

intake of chocolate and
caffeine/ alcoholic
beverages prior to
bedtime. Substances
are known to impair
falling or staying
asleep.

• Instruct patient to limit

fluid intake in evening.
To reduce need for
nighttime elimination.
 C. IMPLEMENTATION

1. DRUGS

Name of Date Route, Dosage, General Action, Indication/Purpose Client

Drug Administere Frequency of Mechanics Action Response to

d Administration Medicine

Generic July 16, 6-7 mL IVP Bacteriostatic • Infections • Pain at IV

Name: 2010 every six hours effect against caused by S. site upon
Chloramphen for 2 weeks susceptible typhi administrat
icol bacteria, prevents ion of
125mg/5ml cell replication. medication

Brand Name:
Eticlob

Generic July 15, 90 mg IVP Blocks pain • Mild pain or • Lightheade

Name: 2010 every four impulses, fever dness
Acetaminoph hours if probably
en temperature is inhibiting
greater than prostaglandin or
37.8C pain receptor
Brand Name: sensitizers. May
relieve fever by
Paracetamol
acting on
hypothalamic
heat-regulating
center.

Nursing responsibilities prior to, during and after the administration

(Students are not allowed to administer drug through IV push)

Prior Verify the Doctor’s order; Check for any drug allergies; Tell the possible side effects;
Check the medication’s name, appearance and expiration date; Check the IV site

During Check the medication; push the medication slowly.

After Check the medication; Report severe diarrhea, skin rashes, inflamed mouth;
monitor for client response

2. MEDICAL MANAGEMENT
Medical Date Cell Indication/Purpose Client
Management Performed/Changed/ Description Response to
/Treatment Discontinued Medicine

IVF: D5 July 12, 2010 – July Hypotonic • Moves into the Normal
0.3NaCl 14, 2010 cell to rehydrate
½L
• Can be helpful
37-38
when cells are
gtts/min
dehydrated.

• May be used for

DKA

• Can be dangerous
to use because of
the sudden shift
from the
intravascular
space to the cells.

3. DIET

TYPE OF DIET DATE INDICATION

Diet As Tolerated (DAT) July 12-14, 2010 This particular diet is only
giver when client can now
tolerate any food she
 desires that is nutritious, if
this will not lead to any
complications and if the
client needs further
monitoring for lab test.

4. ACTIVITY/ EXERCISE

TYPE OF GENERAL INDICATION / PURPOSE CLIENT’S

EXERCISE DESCRIPTION RESPONSE

Deep Act of breathing deep It is generally considered a The patient needs

breathing into one's lungs by healthier and fuller way to support to do these
exercise flexing ingest oxygen[1], and is often exercises and to
one's diaphragm rather used as a therapy feel comfortable.
than breathing shallowly for hyperventilation and anxiet
by flexing one's rib y disorders.
cage. This deep
breathing is marked by
expansion of
the stomach (abdomen)
rather than
the chest when
breathing
 5. NURSING MANAGEMENT

DATE SUBJECTIVE OBJECTIVE ASSESSMEN PLANNING IMPLEMENTATION EVALUATION

CUES CUES T

JULY 15, 2010 • warm to Hyperthermia Within 30 Independent: After 30 minutes

touch related to minutes to 1 to 1 hour of
• Performed TSB
infection hour of appropriate
• pale and to lower body
appropriate nursing
weak in temperature
nursing intervention, the
appearance.
intervention, client shall be
• restless and the client will • Maintained able to maintain
irritable be able to hydration status core temperature
maintain core to avoid loss of within normal
• febrile with
temperature body fluids. range.
temp= 37.9º
within normal

• WBC – range.
• Monitored vital
18.1g/L
signs

• with ongoing specifically

IVF of 0.3% temperature for

NaCl 500 ml baseline data.

received at
100 ml level
• Increased fluid
and regulated intake to
at 37-38 prevent heat-
microdrops induced
per minute hyperthermia
located at left and
arm, intact dehydration
and infusing
well.
Dependent:

• Provided high-
calorie diet to
meet increased
metabolic
demands.

Collaborative:

• Prepared and
administered
medication care
of the clinical
 instructor as
ordered by the
doctor
To prevent
further
complications
July 16,2010 Nahihirapan • grimace Acute Pain r/t Within 1 hour Independent: After 1 hour of
akong noted pale and presence of of appropriate appropriate
• Determine
huminga weak in traumatized nursing nursing
possible
appearance tissue resulting intervention, intervention, the
pathophysiologi
from insertion the client will client shall be
• restless and c/ psychologic
of IV be able to able to report
irritable causes of pain.
report physical physical and
To assess
• with and psychological
etiology
guarding psychological well being as
precipitating
behavior well being as evidenced by
contributing
evidenced by absence of
• with ongoing factors.
absence of grimace and
IVF of 0.3%
grimace and • Encourage guarding
NaCl 500 ml
guarding verbalization of behavior.
received at 300
behavior. feelings about
ml level and
pain. To assist
regulated at
22-23 client to
microdrops per explore
minute located methods to
at left arm, control/
intact and alleviate pain.
infusing well.
• Encourage us of
relaxation
techniques such
as deep
breathing
exercises. To
assist client to
explore
methods to
control/
alleviate pain

• Encourage
participation in
diversional
activities like
socialization or
 listening to
music. To assist
client to
explore
methods to
control/
alleviate pain

• Provide patient
with a quiet
environment
and calm
activities. To
assist client to
explore
methods to
control/
alleviate pain

Dependent:

• Instruct patient
to position
affected arm
properly. To
promote
 comfort.

• Instruct patient
to not use
affected arm
unnecessarily.
To prevent
complications

Collaborative:

 Administer
analgesics as
indicated. Inhibits
prostaglandin
synthesis by
decreasing an
enzyme needed for
biosynthesis.
July 22,2010 “Ilang araw na • Slowed Risk for Within 6 hours Independent: After 6 hours of
syang di movement Constipation r/t of appropriate appropriate
nursing • Auscultated nursing
dumudumi” as • Body insufficient
interventions, interventions,
abdomen for
verbalized by weakness physical activity the patient will the patient shall
presence,
the SO. noted be able to be able to
verbalize location, and verbalize
• Refused to understanding characteristics understanding of
of risk factors of bowels risk factors and
ambulate or
and appropriate
to do ROM sounds. Reflects
appropriate interventions/
exercises interventions/ bowel activity. solutions to
• Needs solutions to individual
individual • Ascertained situation.
assistance client’s usual
situation.
upon getting elimination
up/ out in pattern. To
assess client’s
bed individual risk
• Prefers to lie factors/ needs.
down on bed • Encouraged
intake of
balanced fiber
and bulk in diet.
To improve
consistency of
stool and
facilitates
passage
through colon

• Promoted
increase in fluid
intake unless
contraindicated.
To promote
 moist/ soft
stool.

• Encouraged
participation in
activity/
exercise within
limits of own
ability. To
stimulate
contractions of
intestines.

Dependent:

• Instructed
patient to
respond to urge
to defecate. To
promote
comfort and
prevent
complications.

• Instructed client
and SO to
ascertain
frequency,
color,
consistency of
 stool once
defecated.

• Advised patient
to have
elimination
diary if
appropriate. To
help monitor
bowel pattern.

Collaborative:

• Notified
physician for
unusualities.
For prompt
management
III. Conclusion

Typhoid fever is a bacterial disease, caused by Salmonella typhi. It is transmitted through

the ingestion of food or drink contaminated by the faeces or urine of infected people.

Salmonella Typhi lives only in humans. Persons with typhoid fever carry the bacteria in
their bloodstream and intestinal tract. In addition, a small number of persons, called carriers ,
recover from typhoid fever but continue to carry the bacteria. Both ill persons and carriers
shed S. Typhi in their feces (stool).

You can get typhoid fever if you eat food or drink beverages that have been handled by a
person who is shedding S. Typhi or if sewage contaminated with S. Typhi bacteria gets into
the water you use for drinking or washing food. Therefore, typhoid fever is more common in
areas of the world where handwashing is less frequent and water is likely to be contaminated
with sewage.

Once S. Typhi bacteria are eaten or drunk, they multiply and spread into the bloodstream.
The body reacts with fever and other signs and symptoms.

Symptoms usually develop 1–3 weeks after exposure, and may be mild or severe. They
include high fever, malaise, headache, constipation or diarrhoea, rose-coloured spots on the
chest, and enlarged spleen and liver. Healthy carrier state may follow acute illness.

Typhoid fever can be treated with antibiotics. However, resistance to common

antimicrobials is widespread. Healthy carriers should be excluded from handling food.

I learnt a lot in dealing with the case. My skills and knowledge regarding the case was
enhanced significantly. I was able to fully understand the concept and the content of the case.
The objectives were reasonably met and I was able to contribute to the health treatment and
recovery of our client.
 IV. RECOMMENDATION

Two basic actions can protect you from typhoid fever:

• Avoid risky foods and drinks

o When you drink water, buy it bottled or bring it to a rolling boil for 1 minute
before you drink it. Bottled carbonated water is safer than uncarbonated water.
o Ask for drinks without ice unless the ice is made from bottled or boiled water.
Avoid popsicles and flavored ice that may have been made with contaminated
water.
o Eat foods that have been thoroughly cooked and that are still hot and steaming.
o Avoid raw vegetables and fruits that cannot be peeled. Vegetables like lettuce are
easily contaminated and are very hard to wash well.
o When you eat raw fruit or vegetables that cannot be peeled, wash them yourself.
o Avoid foods and beverages from street vendors. It is difficult for food to be kept
clean on the street, and many travelers get sick from food bought from street
vendors.
• Get vaccinated against typhoid fever.
 V. Review of Related Literature and Studies

Background

This report is about the investigation of an outbreak of typhoid fever claimed three human lives
and left more than 300 people suffered within one week. The aim of this report is to draw the
attention of global health community towards the areas that are still far from basic human
essentialities.

Methods

A total of 250 suspected cases of typhoid fever were interviewed, out of which 100 were selected
for sample collection on the basis of criteria included temperature > 38°C since the onset of
outbreak, abdominal discomfort, diarrhea, vomiting and weakness. Food and water samples were
also collected and analyzed microbiologically.

Results

Inhabitants of village lived in poor and unhygienic conditions with no proper water supply or
sewage disposal facilities and other basic necessities of life. They consumed water from a nearby
well which was the only available source of drinking water. Epidemiological evidences revealed
the gross contamination of well with dead and decaying animal bodies, their fecal material and
garbage. Microbiological analysis of household and well water samples revealed the presence of
heavy bacterial load with an average total aerobic count 106-109 CFU/ml. A number of Gram
positive and Gram negative bacteria including Escherichia coli, Klebsiella, Bacillus species,
Staphylococcus species, Enterobacter species, and Pseudomonas aeruginosa were isolated. Lab
investigations confirmed the presence of multidrug resistant strain of Salmonella enterica
serovar Typhi in 100% well water, 65% household water samples and 2% food items. 22% of
clinical stool samples were tested positive with Salmonella enterica serover Typhi

Conclusions

This study indicated the possible involvement of well water in outbreaks. In order to avoid such
outbreaks in future, we contacted the local health authorities and urged them to immediately
make arrangements for safe drinking water supply.

Background

Salmonella is most commonly involved bacteria in gastrointestinal tract infections. Its significant
involvement in human mortality and morbidity is a major health concern. In 2006, The World
Health Organization (WHO) estimated incidence of 16 to 33 million typhoid fever cases globally
every year, with 500,000 to 600,000 deaths and case fatality rate of between 1.5 and 3.8% [1].
With more than 80% of global cases, South Asia is the most commonly reported region for the
acquisition of typhoid fever since 1996 to 2005 [2]. The rate of incidence is 110 cases/100, 000
population [3]. There are several hospital based studies carried out in Pakistan that describe high
incidence rate of typhoid fever in children [4,5]. However hospital based data does not reflect the
actual disease status in normal community. Especially in remote areas where people live under
low socioeconomic conditions and without basic necessities of life such as water, food,
electricity and transport, incidence rate is much higher and often associated with small disease
outbreaks.

Consumption of unsafe drinking water and inadequate sanitary conditions also contribute in
increased rate of typhoid fever. In remote places, people usually rely on private and unsafe
drinking water reservoirs for example ground wells are frequently found in these localities and
act as only reservoir of drinking water without proper quality check [6]. According to an estimate
in 2003, water borne infections claim 250,000 deaths each year in Pakistan among which typhoid
fever is the leading cause [7].

In addition with high frequency and easy transmission, typhoid fever outbreaks also accompany
with the threat of multidrug resistance. Multidrug-resistant (MDR) strains of Salmonella;
resistant to chloramphenicol, ampicillin and trimethoprim are commonly observed since two
decades and responsible for numerous outbreaks [8].

This study is based on the investigation of an outbreak of typhoid fever occurred in Nek
Muhammad village, situated 25 kilometer far from metropolitan city of Karachi-Pakistan.
Outbreak of typhoid fever claimed three human lives and left more than 300 people infected
within one week.

Methods

Epidemiological Description of Area

Nek Muhammad village is a remote area situated 25 kilometer far from borders of metropolitan
city of Karachi-Pakistan. The area is not well connected to the city due to less established means
of communication. Approximately 500 poor people, mostly adults between age of 20-45 years
and children under 12 years of age reside in this area with very limited facilities of water, food,
electricity and health care. In October 2004, an outbreak of diarrhea and vomiting with high
grade fever hit this area. Onset of symptoms was rapid and infected more than 300 people within
2 days. Local people contacted Edhi Foundation- an NGO that immediately set up a medical
camp to provide treatment and sent severe cases to local hospitals of Karachi. Due to severity of
symptoms like over dehydration three people lost their lives within 5 days. In order to investigate
the cause of outbreak, a team of microbiologists and medical professionals from Immunology
and Infectious Diseases Research Lab, Microbiology, KU visited the vicinity. We discovered a
well in the locality which was polluted with dead and decaying bodies of birds and amphibians,
their fecal material and garbage. The well was only source of drinking water. The villagers also
informed us about their attempts to clean the well 2 days before the onset of symptoms. We
interviewed the patients and collected various environmental and clinical samples with the help
of Edhi Foundation. The investigation was approved by the Ethical Review Board of the
University of Karachi, Pakistan.
Sample collection and Inclusion Criteria

We gathered information regarding their general health problems, onset of symptoms, daily
activities, education status, age and eating habits through hypothesis generating interviews. A
total of 250 people were interviewed. Due to small population size, we selected 100 patients for
stool sample collection who belonged to different age groups and families and met the criteria of
suspected typhoid fever. Inclusion criteria included temperature > 38°C since the onset of
outbreak, abdominal discomfort, diarrhea, vomiting and weakness. Attack rate was also
calculated on the basis of age. Due to unwillingness of healthy subjects to participate in
investigation process, we were not able to conduct case control study. Stool samples were
collected in clean plastic containers. A pea sized material from each sample was also transferred
to Cary-Blair transport medium. Samples were immediately transported to lab and processed
within 2 hrs of collection.

A total of 10 water samples were collected from contaminated well using five different water
collection buckets. Ninety well water samples, stored for different household purposes including
cooking were also collected from different houses.

Laboratory Investigation of Environmental Samples

Quality assessment of water samples was performed by standard method [9]. Briefly, samples
were processed to determine total aerobic bacterial count by standard Pour Plate technique.
Presence of coliforms and Fecal E. coli was determined by Most Probable Number (MPN) and
membrane filtration methods. In case of food items, 25 grams of each sample was weighed and
transferred to sterile flask containing 100 ml of phosphate buffer saline (PBS). Samples were
homogenized under aseptic conditions. Three 10-fold serial dilutions were prepared from
homogenates to inoculate different culture media.

Media used for the detection of coliforms and Fecal E. coli included MacConkey's broth, 5%
sheep Blood agar, Nutrient agar, MacConkey's agar and Eosin Methylene Blue agar. Bile Echlin
agar was used to check the presence of fecal Streptococci. In order to find out possible
involvement of Salmonella, Shigella and Campylobacter, samples were inoculated on
Salmonella Shigella (SS), Xylene lactose decarboxylase (XLD) and Campylobacter selective
media.

Lab Investigation of Clinical Samples

Diarrheal stool samples were analyzed microscopically for the presence of ova and parasite(s).
Bacteriological analysis was performed for the detection of Salmonella, Shigella, E. coli O157:
H7, Yersinia, Vibrio cholerae using MacConkey's agar, SS agar, TCBS agar and Sorbitol
MacConkey's agar (Oxoid). Briefly, half pea sized samples were inoculated on culture media
plates and incubated aerobically at 37°C for 48 hours. Samples collected in transport swabs were
used to inoculate Campylobacter selective medium supplemented with 5% Sheep Blood
followed by incubation under microaerophilic environment at 42°C for 48 to 72 hours. Transport
swabs were further immersed in Selenite F broth (Oxoid).
Bacterial isolates from environmental and clinical samples were processed for identification
using standard biochemical reactions such as oxidase, triple sugar iron, indole, sulfide, motility,
citrate and urea hydrolysis. API20E strips (bioMerieux, Inc.) were used for further confirmation.
Antibiotics susceptibility pattern was determined by standard methods [10]. Serotyping was
performed to identify Salmonella strains using Specific antisera (BD).

Results

Epidemiologic Investigation

An outbreak of typhoid fever hit remote area of Nek village in October 2004 typically after 2
days of partial cleaning of reservoir well, the only source of drinking water in the village. Well
cleaning was performed only by physical means. No chemical ingredient was used. The villagers
did not share any common exposure or activity such as food and travel other than well water.
Epidemiological analysis of food items indicated no statistical association with outbreak. Despite
of cleaning attempt, the well was found to be polluted with dead and decaying bodies of birds,
their fecal material and garbage which supported our suspicion regarding its involvement in
disease outbreak. As shown in figure 1, symptoms started after 2 days of well cleaning which can
be assumed as incubation period of the infection. Almost 300 people showed symptoms within 3
days post incubation period. In order to control the infection, 500 mg of Ciprofloxacin was given
per oral 12 hourly as antimicrobial regime. In case of children less than 12 years of age, 10 mg of
drug/kg of body weight was given 12 hourly. Treatment was initiated with intravenous infusion
in case of severely ill patients. Although, treatment measures were initiated after 2 days of
disease onset, symptoms persisted for more than one week in most of individuals and claimed 3
human lives. Among the patients interviewed, 91% reported fever, 65% diarrhea, 98% weakness,
and 42% vomiting and other symptoms as listed in table 1. Analysis of attack rate indicated the
involvement of different age groups ranged from 6 months to 60 years as shown in table 2.

Figure 1. Percent of typhoid patients showing symptoms during the outbreak. (n = 300)

Table 1
Clinical symptoms observed among residents*
Symptoms Number of Residents (n) Percentage (%)
Fever 180 72

Diarrhea 163 65

Vomiting 107 42

Abdominal cramps 100 40

Weakness 245 98

Nausea 180 72

Sore throat or cold 63 25

Stomach Discomfort 205 82

* includes only those individuals who were interviewed (n = 250)

Farooqui et al. BMC Public Health 2009 9:476 doi:10.1186/1471-2458-9-476

Table 2
Involvement of different age groups in disease outbreak
Number of cases Percentag Number of cases selected for
Age*
interviewed (n) e (%) sample collection

≤6
11 4.4 3
months

up to 5
14 5.6 5
year

5-12
30 12 14
years

13-25
35 14 15
years

26-45
115 46 39
years

46-60
24 9.6 9
years

≥ 60
20 8 15
years

* includes only those individuals who were interviewed (n = 250)

Farooqui et al. BMC Public Health 2009 9:476 doi:10.1186/1471-2458-9-476

Lab Investigation of Environmental samples

Water samples tested positive for total coliforms and other fecal indicators. Total viable bacterial
count ranged from 106-109 CFU/ml of water which exceeded the standard limits of untreated
potable water. Total viable count was predominantly constituted with coliform bacteria, however
a number of other Gram positive and Gram negative organisms were also present in addition
with normal environmental flora. Microbiological analysis revealed the presence of Salmonella
enterica serovar Typhi in all well water samples while 65% of household stored water tested
positive. The details are listed in table 3. Food items were loaded with environmental bacteria
but no coliform was detected. Only 2% samples tested positive for Salmonella Typhi. Figure 2
illustrates the presence of a variety of bacteria in water samples for example Escherichia coli. No
O157:H7 serotype and other major gastrointestinal pathogens were observed. Other bacteria
included Klebsiella isolated from 65% samples, Bacillus species (82%), Staphylococcus species
(45%), Enterobacter species(64%), Pseudomonas aeruginosa (85%) and others.

Figure 2. Rate of water samples being contaminated with various bacterial species. Samples
(n = 100). CoNS = Coagulase negative Staphylococci

Table 3
Quality of clinical and environmental samples collected
Samples Samples
No. of Average total Total
positive for positive for
Samples samples viable count* coliform
Salmonella fecal
(n) (CFU/ml or g) Count *^
Typhi (%) indicators# (%)

Clinical 100 - - 22 -
Samples
(feces)

Well water 3 × 106 - 1 ×

10 ≥ 1800 100 100
samples 107

Household
5 × 104 - 4 ×
water 90 ≥ 1800 72 65
107
samples

Cooked Food 2 × 103 - 1 ×

50 0 2 0
samples 104

g = gram, CFU = Colony forming unit, * only for environmental samples, ^ was analyzed by MPN
method, # fecal indicators include fecal E. coli and Fecal Streptococci.
Farooqui et al. BMC Public Health 2009 9:476 doi:10.1186/1471-2458-9-476

Salmonella enterica serovar Typhi strains were found to be resistant to first line therapeutic
drugs i.e. ampicillin, chloramphenicol, co-trimoxazole/trimethoprim, however no ciprofloxacin
and nalidixic acid resistance was observed. Other coliform bacteria were susceptible against a
wide range of commonly used antibiotics including gentamicin, ciprofloxacin, imepenem,
piperacillin/tazobactam, cefuroxime, and ceftriaxone. Ampicillin resistance was prevalent among
75% isolates.

Lab Investigation of Clinical Samples

Due to initiation of antibiotic treatment prior to sample collection, we decided to collect stool
samples instead of blood culture to increase the chances of pathogen recovery. Moreover,
majority of patients were not ready to participate in blood sample collection. Salmonella Typhi
was isolated as sole pathogen from clinical samples. A total of 22 samples were found positive
with MDR strains of Salmonella Typhi. However, the number of positive samples is under
representing the actual number due to antibiotic treatment. Attack rate in different age groups
was also calculated on the basis of bacteriological analysis as listed in Table 4. The data
represents the recovery of organisms from every age group which is in agreement with
symptoms observed. No other significant pathogen including Shigella, E. coli O157: H7,
Yersinia, Vibrio cholerae and Campylobacter was isolated from stool samples. No evidence of
protozoal and parasitic involvement was observed by microscopy.

Table 4
Recovery of Salmonella enterica serovar Typhi from different age groups
No. of samples tested positive for Percentag
Age
Salmonella Typhi e*
≤ 6 months1 33

up to 5
1 20
year

5-12 years 2 14

13-25
3 20
years

26-45
13 33
years

46-60
2 22
years

≥ 60 years 0 0

*Percentage is calculated on the basis of samples collected from respective group

Farooqui et al. BMC Public Health 2009 9:476 doi:10.1186/1471-2458-9-476

Discussion

Drinking safe and healthy water is the right of every human being. Unsafe drinking water and
inadequate sanitary conditions increase the risk of various public health hazards such as typhoid
fever. On the basis of literature reviews and surveys, WHO estimates the involvement of
diarrheal diseases in 39% of total water, sanitation and hygiene related disease burden
worldwide. In Pakistan, 13.6% of total deaths are due to water sanitation and hygiene [11].
Disease magnitude is higher and unquantifiable in some remote areas where people usually rely
on private water reservoirs like ground wells without any quality assessment. Most of the wells
are not up to the mark of safe drinking water [12,13] what we observed in Nek Muhammad
village.

In this study, laboratory findings, clinical symptoms and epidemiological evidences link the
presence of Salmonella enterica serovar Typhi in contaminated well water with illness. We were
not able to perform DNA fingerprinting of Salmonella Typhi which was required to confirm
bacteriological findings. Moreover, no genotypic characterization of E. coli and detection of viral
pathogens were performed due to limited funds which can be considered as main limitations of
our study.

The disease is not new for the region. There are several reports regarding the prevalence of
Salmonella Typhi in different geographical locations of Pakistan [4,5], and [14] for example in
1998, Luby et al reported the prevalence of typhoid in Karachi, resulted from high-dose
exposures from multiple sources [15]. On the contrary the affected area in our study has never
been reported for typhoid burden before. Involvement of MDR Salmonella Typhi strain is
another health aspect to consider. Since two decades, MDR S. Typhi strains have been
responsible for numerous outbreaks in several South Asian countries including Pakistan, India,
and Bangladesh [8]. Rapid spread of MDR infection in small community like Nek Muhammad
Village can provide a niche for the spread of antibiotic resistant strain among larger population.

Grossly contaminated and uncovered well, consumption of un-boiled water, poor sanitary and
domestic hygiene conditions indicated the vulnerability of individuals. Moreover, inadequate
well cleaning by local people disturbed the ecology of the natural source which increased the
bio-load of well water and resulted in the addition of major diarrheal pathogens.

In order to prevent such outbreaks at global level, recently WHO introduced several household
water interventions (HWST) including solar disinfection, bleach addition, boiling and use of low
cost ceramic filters. The program not only benefits poor communities at individual level but will
also lead to a benefit of up to US$60 for every US$ 1 invested [16]. Despite of large scale global
efforts, situation cannot be easily controlled in rural areas like Nek Muhammad Village where
majority of the inhabitants live in very poor economical conditions that doesn't allow them to
boil or treat water. We, therefore advised them to at least filter the water through several layers
of clean, fine cotton clothe before drinking till the time they get proper arrangement. Later, a
local NGO transported safe drinking water tankers to the vicinity. We also contacted local health
authorities to immediately set up teams to visit the suburb and educate people about proper
method of well cleaning as well as make arrangements for supplying safe drinking water. The
incidence was publicized in media but no foreign health watchdogs were informed formally.

Pakistan is the country of growing geographical importance in these days. Provision of good
quality life is not only better for the country but also important for the world community.
Although, provision of quality education and poverty alleviation programs are government
priorities, it is important to keep continuous vigilance in remote areas where people still live
under inhumane conditions and provide them basic necessities of life. Reach and experience of
local NGOs to such areas can be very helpful to bring up strong and sustained health reforms.

Conclusions

Our study presented the link of contaminated well water with the outbreak of typhoid fever in a
remote village which claimed three human lives and left more than 300 people suffered within
one week. In order to avoid such incidences in future, we contacted the local health authorities
and urged them to immediately make arrangements for safe drinking water supply.
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Incorporated.

Unpublished materials

• http://en.wikipedia.org/wiki/Typhoid_fever
• http://www.cdc.gov/ncidod/dbmd/diseaseinfo/typhoidfever_g.htm
• http://www.cdc.gov/ncidod/dbmd/diseaseinfo/typhoidfever_g.htm#how
• http://www.who.int/topics/typhoid_fever/en/
 A Clinical Case Study Presented to
Tarlac State University
College of Nursing
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines 2300

In partial fulfillment on the requirements in the subject

NCM 103 (RLE)

Typhoid Fever

Submitted by:

BSN II-A

July 2010