Nursing Care Plan for Typhoid Fever

Nursing Care Plan - NCP for Typhoid Fever

Typhoid Fever

Typhoid fever, also known as enteric fever, is a potentially fatal multisystemic illness caused primarily by Salmonella typhi. The protean manifestations of typhoid fever make this disease a true diagnostic challenge. The classic presentation includes fever, malaise, diffuse abdominal pain, and constipation. Untreated, typhoid fever is a grueling illness that may progress to delirium, obtundation, intestinal hemorrhage, bowel perforation, and death within one month of onset. Survivors may be left with long-term or permanent neuropsychiatric complications.


Pathophysiology

All pathogenic Salmonella species are engulfed by phagocytic cells, which then pass them through the mucosa and present them to the macrophages in the lamina propria. Nontyphoidal salmonellae are phagocytized throughout the distal ilium and colon. With toll-like receptor (TLR)–5 and TLR-4/MD2/CD-14 complex, macrophages recognize pathogen-associated molecular patterns (PAMPs) such as flagella and lipopolysaccharides. Macrophages and intestinal epithelial cells then attract T cells and neutrophils with interleukin 8 (IL-8), causing inflammation and suppressing the infection.

In contrast to the nontyphoidal salmonellae, S typhi enters the host's system primarily through the distal ilium. S typhi has specialized fimbriae that adhere to the epithelium over clusters of lymphoid tissue in the ilium (Peyer patches), the main relay point for macrophages traveling from the gut into the lymphatic system. S typhi has a Vi capsular antigen that masks PAMPs, avoiding neutrophil-based inflammation. The bacteria then induce their host macrophages to attract more macrophages.

It co-opts the macrophages' cellular machinery for their own reproduction as it is carried through the mesenteric lymph nodes to the thoracic duct and the lymphatics and then through to the reticuloendothelial tissues of the liver, spleen, bone marrow, and lymph nodes. Once there, the S typhi bacteria pause and continue to multiply until some critical density is reached. Afterward, the bacteria induce macrophage apoptosis, breaking out into the bloodstream to invade the rest of the body.

The gallbladder is then infected via either bacteremia or direct extension of S typhi –infected bile. The result is that the organism re-enters the gastrointestinal tract in the bile and reinfects Peyer patches. Bacteria that do not reinfect the host are typically shed in the stool and are then available to infect other hosts.

Life cycle of Salmonella typhi.

Signs and Symptoms

Typhoid fever is characterized by a slowly progressive fever as high as 40 °C (104 °F), profuse sweating, gastroenteritis, and nonbloody diarrhea. Less commonly, a rash of flat, rose-colored spots may appear.

Classically, the course of untreated typhoid fever is divided into four individual stages, each lasting approximately one week. In the first week, there is a slowly rising temperature with relative bradycardia, malaise, headache and cough. A bloody nose (epistaxis) is seen in a quarter of cases and abdominal pain is also possible. There is leukopenia, a decrease in the number of circulating white blood cells, with eosinopenia and relative lymphocytosis, a positive diazo reaction and blood cultures are positive for Salmonella typhi or paratyphi. The classic Widal test is negative in the first week.

In the second week of the infection, the patient lies prostrate with high fever in plateau around 40 °C (104 °F) and bradycardia (sphygmothermic dissociation), classically with a dicrotic pulse wave. Delirium is frequent, frequently calm, but sometimes agitated. This delirium gives to typhoid the nickname of "nervous fever". Rose spots appear on the lower chest and abdomen in around a third of patients. There are rhonchi in lung bases. The abdomen is distended and painful in the right lower quadrant where borborygmi can be heard. Diarrhea can occur in this stage: six to eight stools in a day, green with a characteristic smell, comparable to pea soup. However, constipation is also frequent. The spleen and liver are enlarged (hepatosplenomegaly) and tender, and there is elevation of liver transaminases. The Widal reaction is strongly positive with antiO and antiH antibodies. Blood cultures are sometimes still positive at this stage. (The major symptom of this fever is the fever usually rises in the afternoon up to the first and second week.)

In the third week of typhoid fever, a number of complications can occur :

• Intestinal hemorrhage due to bleeding in congested Peyer's patches; this can be very serious but is usually not fatal.
• Intestinal perforation in the distal ileum: this is a very serious complication and is frequently fatal. It may occur without alarming symptoms until septicaemia or diffuse peritonitis sets in.
• Encephalitis
• Metastatic abscesses, cholecystitis, endocarditis and osteitis

The fever is still very high and oscillates very little over 24 hours. Dehydration ensues and the patient is delirious (typhoid state). By the end of third week the fever has started reducing this (defervescence). This carries on into the fourth and final week.

NCP - Nursing Care Plan for Typhoid Fever

Assessment

1. Health History Now
   Why patients enter the hospital and what the major complaints of patients, so it can be enforced priority nursing issues that may arise.
2. Previous Health History
   Does the patient had been ill and treated with the same disease.
3. Family Health History
   Does anyone in the family of patients, the sick like a patient.
4. Psychosocial History
   Intrapersonal: the feeling felt client (anxious / sad)
   Interpersonal: relationship with other people.
5. Patterns of health function
   • The pattern of nutrition and metabolism.
     Usually the client is reduced appetite due to a disruption in the small intestine.
   • Rest and sleep patterns
     During the pain patients feel unable to rest because the patient felt pain in her stomach, nausea, vomiting, sometimes diarrhea.
6. Physical examination
   • Awareness and patient's general condition
     Patient awareness of the need to study the unconscious - not conscious (composmentis - coma) to assess the severity of the patient's disease prognosis.
   • Vital Signs and physical examination Head to foot
     Blood pressure, pulse, respiration, temperature which is a measure of the general condition of patient / patient's condition and includes examination from head to toe by using the principles of inspection, auscultation, palpation, percussion), in addition to body weight were also aware of any decline weight because of the increased nutritional deficiencies that occur, so it can be calculated nutritional needs required.

Nursing Diagnosis

The increase in body temperature associated with the infection process of salmonella thypii

Intervention

Objectives : Normal body temperature
Intervention :

• Observation of the client's body temperature
Rational: to know the changes in body temperature.
• Encourage the family to put on clothing that can absorb sweat like cotton
  Rational: to maintain body hygiene
• Collaboration with physicians in the provision of anti piretik
  Rational: to reduce the heat to the drug