Iloilo Doctors’ College

College of Nursing
West Avenue, Molo, Iloilo City

NCM 112 RLE(GERIATRICS)

TYPHOID FEVER

I. INTRODUCTION

Typhoid fever is a serious disease caused by the bacterium Salmonella  Typhi and can be
life-threatening unless treated promptly with antibiotics (WHO, 2018).
It usually spread through food or water contaminated with an infected person’s feces or
urine. Once Salmonella  Typhi bacteria are eaten or drunk, they multiply and spread into the
bloodstream. The majority of patients with typhoid fever present with fever, fatigue,
headache, nausea, constipation or diarrhea, malaise, abdominal pain or discomfort, and
hepatosplenomegaly. It may also cause liver injury with elevated aminotransferases and
jaundice. Hepatomegaly and jaundice were reportedly observed in 44% and in 33% of
patients with typhoid fever, respectively (Minemura, M., Tajiri, K., & Shimizu, Y., 2014).
Urbanization and climate change have the potential to increase the global burden of
typhoid. In addition, increasing resistance to antibiotic treatment is making it easier for
typhoid to spread through overcrowded populations in cities and inadequate and/or
flooded water and sanitation systems. An estimated 11–21 million people get sick from
typhoid and between 128 000 and 161 000 people die from it every year. Communities
lacking access to safe drinking water and adequate sanitation, and vulnerable groups
including children are at highest risk.

OBJECTIVES

• General Objectives

At the end of this case study, the students will acquire knowledge about the nursing
management for patients with typhoid fever, and gain necessary knowledge, skills, and
attitude for caring patients with the disease.

• Specific Objectives
 Knowledge:
1. Define typhoid fever, its risk factors, causes, signs and symptoms, treatment, and
prevention.
2. Identify and explain the etiology, pathophysiology, and disease process of typhoid
fever.
3. Determine appropriate diagnostic and therapeutic strategies to manage and treat
typhoid fever.

Skills:
1. Appropriately perform assessments and use relevant data to develop nursing
interventions in accordance with the patient’s needs.
2. Carry out competent and appropriate nursing care for the patient with typhoid fever
using the nursing process procedure through interventions and management.
3. Document client’s condition, nursing interventions, and evaluation correctly.
4. Discuss health teachings regarding the patient’s condition.

Attitude:
1. Established rapport with the patient as well as the other members of the family.
2. Recognize the patient’s needs using holistic approach.
3. Display utmost confidence in providing nursing care to the patient whilst maintaining
the confidentiality of the patient’s data.

II. PATIENT’S DATA

Biographical Data

Patient’s Name: N/A

Age: 29 years old

Sex: Male

Weight: N/A

Marital Status: Married

Occupation: N/A
Religion: N/A

Source of Information: Patient

Attending Physician: N/A

Impression/Diagnosis: Typhoid fever

• Bacterial cultures of a liver’s tissue and roseola spots biopsy were positive for Salmonella typhi

Chief Complaint:
 Fatigue, anorexia, malaise, headache, fever and difficulty of concentrating.

Vital Signs revealed as follows:

• Temperature -  40 ºC

• Pulse Rate - N/A

• Respiratory rate - N/A

• Blood pressure - N/A

• Oxygen saturation – N/A

Physical Assessment

• Appeared tired and thin

• Had fever

• Had roseola spots distributed on the trunk

• Upon palpation,the liver edge was tender and is palpated 3cm below the right costal margin, with diffuse
abdominal tenderness

PAST AND PRESENT MEDICAL HISTORY

History of Present Illness

 A 29-yr-old man was admitted to the hospital because of fatigue, anorexia, malaise, headache, fever,
and difficulty concentrating. He appeared tired and thin upon physical examination. His temperature
was 40˚C. His diagnostic test revealed him to be positive for Salmonella typhi. The fecal culture of the
 patient’s wife was also positive for S. typhi, and the molecular typing of the bacterial DNA showed the
wife was a silent carrier and the main source of the typhoidal infection.

Past Medical History

 Not Stated

Family Health History

 Not Stated

III. PATHOPYSIOLOGY

Anatomy and Physiology

Introduction

The breaking down of large food molecules into smaller molecules is called digestion. The passage of these smaller
molecules into blood and lymph is termed absorption.

The organs that collectively perform digestion and absorption constitute the digestive system and are usually
composed of two main groups: the gastrointestinal (GI) tract and accessory digestive organs. The GI tract is a
continuous tube extending the mouth to the anus. The accessory structures include the teeth, tongue, salivary
glands, liver, gallbladder, and pancreas.

Overview of Digestive System:

Digestion includes six basic processes: ingestion, secretion, mixing and

propulsion, mechanical and chemical digestion, absorption, and defecation.
Mechanical digestion consists of mastication and movements of
gastrointestinal tract that aid chemical digestion. Chemical digestion is a series
of hydrolysis reactions that break down large carbohydrates, lipids, proteins,
and nucleic acids in foods into smaller molecules that are usable by body cells.
Mouth - an oval-shaped opening in the skull. It starts at the lips and ends at the throat. It’s important to several
bodily functions, including breathing, speaking, and digesting food.

Esophagus - The esophagus is a muscular tube that connects the pharynx (throat) to the
stomach. The esophagus contracts as it moves food into the stomach.

Stomach - The cardia, fundus, body, and pyloric portion of the stomach are its

four major divisions. The cardiac orifice the aperture between the esophagus

and the stomach is surrounded by the cardia, as its name suggests.

The first passageway via which food is swallowed, or the inflow component, is this area.

Liver -regulates most chemical levels in the blood and excretes a product called bile. This helps carry away waste
products from the liver. All the blood leaving the stomach and intestines passes through the liver.

Small Intestine - The duodenum, jejunum, and ileum are the three
sections of the small intestine. When combined, they can reach a
maximum length of six meters. The anterior greater omentum covers
all three areas. While the jejunum and ileum are exclusively
intraperitoneal organs, the duodenum has both intraperitoneal and
retroperitoneal portions.

Large Intestine - The colon, rectum, and anus are all parts of the
large intestine. As food approaches the end of its journey through
your digestive system, it continues in one continuous, lengthy tube from the small intestine. When you defecate, the
large intestine removes food waste from the body by converting it into stool.
ETIOLOGY
Typhoid fever is a bacterial infection that can spread throughout the body, affecting many organs. Without
prompt treatment, it can cause serious complications and can be fatal.

• It's caused by a bacterium called Salmonella typhi and Salmonella paratyphi which is related to the
bacteria that cause salmonella food poisoning.

• The Salmonella typhi bacteria will be in the poo of an infected person after they have been to the
toilet.

• If they don't wash their hands properly afterwards, they can contaminate any food they touch.
Anyone else who eats this food may also become infected.

• Less commonly, the Salmonella typhi bacteria can be passed out in an infected person's pee. They
can spread the infection to someone else who eats the contaminated food.

• In parts of the world with poor sanitation, infected human waste can contaminate the water
supply.

• People who drink contaminated water or eat food washed in contaminated water can develop
typhoid fever.
DISEASE PROCESS
SYMPTOMATOLOGY
Early symptoms include:

● Fever or High fever (103°F, or 39.5°C)

● general ill-feeling
 ● abdominal pain

● or higher and severe diarrhea occur as the disease gets worse.

● rash called "rose spots," which are small red spots on the abdomen and chest.

Other symptoms that occur include:

● Bloody stools

● Chills

● Agitation, confusion, delirium, seeing or hearing things that are not there (hallucinations)

● Difficulty paying attention (attention deficit)

● Nosebleeds

● Severe fatigue

● Slow, sluggish, weak feeling

IV. DIAGNOSTIC AND LABORATORY RESULTS

Laboratory Results Normal Significance

Value

WBC ct. 4,600/ 5,000- Decreased The white blood cell (WBC) count in enteric
mm³ 10,000 or typhoid fever is often low. Leukocytosis is
m6m³ common in the first 10 days in children and
may also result from bacteremia, localized
infection, bowel perforation, or other
extraintestinal complications. Reversible
thrombocytopenia may occur.

Aspartate- 790 U/l 8-46 U/l Increased An increased AST level is often a sign of liver
aminotransferase disease.

Lactate 1,562 140 -280 Increased Higher than normal LDH levels usually means
Dehydrogenase U/l  U/l you have some type of tissue damage or
disease.
 Thickness of the terminal
ileum and clumped enlarged
mesenteric lymph nodes in
RLQ

Roseola spots on the tunk

Salmonella Typhi

V. NURSING CARE PLAN

DEFINING NURSING NURSING OUTCOME RATIONALE EVALUATION

CHARACTERISTIC DIAGNOSIS INTERVENTION IDENTIFICATION
 After nursing
SUBJECTIVE: Imbalanced intervention, the INDEPENDENT: Goals were met
Nutrition: Less patient will be as evidenced by
“Gaka-dulaan ako than body able to: Review Identifies progressive
gana mag kaon mas requirements nutritional deficiencies, weight gain
gusto ko na lang i- related to history including suggests
decreased food resulting from
pahuway.” as Short term: possible
intake occurring preferences. interventions. patient’s
verbalized by the
with fatigue and Improve intake improved
patient anorexia appetite and
of nutritional
requirements Monitor caloric consumed
OBJECTIVE: Observe and
RATIONALE: and consume intake and adequate
adequate record patient’s insufficient
 Anorexia nutritional
Imbalanced nourishment food intake. quality of food
 Malaise demands.
Nutrition: Less and prevent consumption.
 Fatigue
Than Body further weight
 Thin
Requirements loss.
appearance
and identify any May reduce
circumstances Long term: fatigue and thus
affecting Recommend enhance intake
nutrition that Demonstrate small, frequent while preventing
may transpire progressive meals or gastric
during nursing weight gain between-meal distention. Use
care. toward goal with nourishment. of Ensure or
absence of signs similar products
REFRENCE: of malnutrition. Suggest a bland provides
diet, low in additional
Swearingen, P. roughage, proteins and
L., & Wright, J. avoiding hot, calories.
D. (2019). All-in- spicy or very
one nursing care acidic food as
planning indicated.
resource When oral
medical-surgical, lesions are
pediatric, Encourage/Assist present, pain
maternity, and with good oral may restrict
Psychiatric- hygiene; before type of foods
Mental Health. and after meals, patient can
Elsevier. tolerate.
use of soft-
bristled
toothbrush for
gentle brushing.
Provide dilute,
alcohol-free
mouthwash if
oral mucosa is
ulcerated.
Enhances
appetite and
oral intake.
DEPENDENT: Diminish
bacterial growth
Encourage use of and minimizing
nutritional the possibility of
infection.
 supplements.

Adequate
protein and
calories are
COLLABORATIVE: important for
healing, fighting
Consult with
and providing
dietitian. energy.

Aids in
establishing
dietary plan to
meet individual
needs.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE Hyperthermia SHORT TERM: INDEPENDENT 
related to
“I feel my body After 30 mins of Monitor patient Fever pattern
increased
temperature is nursing temperature may aids in
metabolic rate, After 7 days of
high and feel a intervention the and degree and diagnosing
illness (Belleza, patterns underlying nursing
loss of appetite” M., 2021) patient body
disease intervention,
as verbalized by temperature
goal was met as
the patient will decrease Observe for Chills often evidence that
shaking skills precede during
and profuse the patient was
high
diaphoresis temperature able to
and in presence demonstrate
of generalized temperature
infection within normal
LONG TERM: range and free
Wash hands Reduce cross
from chills
OBJECTIVE After 7 days of with anti- contamination
nursing bacterial soap and prevents the
-pale before and after spread of
intervention the
each care of infection
-Weight loss patient will be activity and
able to encourage
-Weak demonstrate proper hygiene May help reduce
temperature fever. Use of ice
-Body malaise
within normal water and
range and free Provide tepid
- high body alcohol may
sponge baths
temperature from chills cause chills and
and avoid the
use of ice water can elevate
-Roseola spots and alcohol temperature
Vital signs May reflect
inappropriate
antibiotic
Temp: 40◦c Monitor signs of therapy
deterioration of
Condition or
failure to
improve with
therapy

Used to reduce
fever by its
central action on
the
Collaborative: hypothalamus
Administer anti-
pyretics as To control the
prescribed spread of
infection
Administer
antibiotics as
prescribed

VI. DRUG STUDY

Drug Name Classification Indications and Side Effects and Special Nursing
and Contraindications Adverse Effects Precautions Responsibilities
Mechanism of
Action
Generic Classifications: Indications: Side Effects: Before taking ▫ Check the
Name: Antibiotic A prescription ▫ Headache tetracycline Doctor’s
Tetracycline medicine used to ▫ Stomach upset ▫ Tell your order.
Mechanism of treat the symptoms ▫ Loss of appetite doctor if you
Trade/Brand Action: of bacterial infection ▫ Trouble have an ▫ Read the
Name: Tetracycline of the skin, swallowing allergy to label of the
Sumycin, passively diffuses intestines, ▫ Dizziness tetracycline. drug
Actisite, through porin respiratory tract, ▫ Swollen tongue carefully.
Achromycin V channels in the urinary tract, ▫ Sore throat ▫ Tell your
bacterial genitals, lymph ▫ Nausea doctor if you ▫ Check for
membrane and nodes, and other ▫ Vomiting have or
Dosage: any
reversibly binds body systems. ▫ Diarrhea have ever
250 - 500 mg documented
to the 30S had lupus. drug
ribosomal Contraindications: Adverse Effects: allergies to
Route:
subunit, ▫ Hypersensitivity Gastrointestinal: ▫ Avoid tetracycline.
PO (per
preventing to tetracycline ▫ Anorexia prolonged
orem/by
binding the tRNA ▫ Severe hepatic ▫ Epigastric distress exposure to
mouth) ▫ Ensure
to mRNA- dysfunction ▫ Black hairy tongue sunlight. medicine is
ribosome ▫ Dysphagia
Frequency administered
complex, and ▫ Enterocolitis
and Timing: ▫ Should be correctly.
thus interfering
500 mg PO avoided on
with protein Teeth:
q12h patients ▫ Give with
synthesis. ▫ Permanent
- 8:00 - 8:00 with adequate
250 mg PO discoloration diuretics. fluid.
q6h ▫ Enamel hypoplasia
- 12:00 - 6:00 ▫ Avoid
12:00 - 6:00 Skin: antacids,
▫ Maculopapular and dairy
erythmatous products
rashes within 3 hrs
▫ Exfoliative of
dermatitis tetracycline.
▫ Onycholysis and
discoloration of
nails ▫ Encourage
the patient
to take the
Liver: antibiotic for
▫ Hepatotoxicity the whole
▫ Live failure course of
their
Hypersensitiviy treatment.
reactions:
▫ Urticaria
▫ Angioneurotic
edema
▫ Anaphylaxis
▫ Pericarditis
▫ Serum sickness
like reactions, as
fever, rash, and
arthralgia

Blood:
▫ Hemolytic anemia
▫ Thrombocytopenia
▫ Neutropenia
▫ Eosinophilia

Drug Name Classification Indications and Side Effects and Special Nursing
and Mechanism Contraindications Adverse Effects Precautions Responsibilities
of Action
SIDE EFFECTS: -Culture Check the
Generic Name: Classifications: Indications: ● Headache infection before doctor’s order.
Chloramphenicol Antibiotic - Serious ● Nausea beginning
infections for ● Vomiting therapy. Apply the 10
which no other ● Fever -Do not give this rights of
antibiotic is ● Diarrhea drug IM medication.
Trade/ Brand effective. ● Stomatitis (intramuscular)
Name: -Acute infections ● Glossitis because it is Reduce dosage
Chloromycetin Mechanism of caused by ● Mental ineffective. in patients with
Actions: Salmonella typhi. confusion - renal or hepatic
Bacteriostatic -Serious infections ● Delirium Chloramphenicol disease.
Dosage: 25 effect against caused by ● Skin rash may cause blood
mg/kg susceptible Salmonella, problems. Monitor serum
bacteria. Haemophilus levels
Prevents cell influenzae, ADVERSE periodically as
Route: IV replication. rickettsiae, EFFECTS: indicated in the
(Intravenous) lymphogranuloma. ● Blood dosage section.
dyscrasias
Contraindications: ● Bone marrow Monitor
-Contraindicated hypoplasia hematologic
Frequency and with allergy to ● Aplastic data carefully,
Timing: q6h chloramphenicol. anemia especially with
(12:000 NN – -Use cautiously ● Angioneurotic long term
6:00 PM – 12:00 with renal failure, edema therapy by any
MN – 6:00 AM) hepatic failure, Superinfections route of
G6PD deficiency, administration.
intermittent
porphyria, and
pregnancy
lactation.

VII. DISCHARGE PLAN

 Practice good personal hygiene such as regular washing of your hands with water to reduce
the risk of spreading infectious diseases.
 Make sure to take plenty of fluids, eat healthy foods, and enough rest.
 Vaccination against typhoid fever is recommended.
 Monitor patient temperature degrees and patterns.
 Avoid eating uncooked or raw foods and buying from street vendors to avoid
contamination.
 Take prescribed antibiotics.

VIII. RRL

Typhoid Fever: Tracking the Trend in Nigeria

 Typhoid fever continues to pose a serious health challenge in developing countries. A
reliable database on positive blood cultures is essential for prompt interventions. To
generate reliable data on Salmonella enterica serovar Typhi (S. Typhi)-positive blood culture
trends in typhoidal Salmonella in Nigeria alongside changing contextual factors and
antimicrobial resistance patterns, a retrospective cohort study was conducted in two
hospitals in Lagos between 1993 and 2015. Medical records of typhoid patients were
reviewed for positive culture and antibiogram, using standard procedures and analyzed.
Additional data were retrieved from a previous study in seven facilities in Abuja and three
hospitals in Kano from 2008 to 2017 and 2013 to 2017, respectively. A declining trend in
percent positivity of S. Typhi was observed in Abuja with more erratic trends in Lagos and
Kano. In Lagos, more than 80% of the isolates from the entire study period exhibited
multiple drug resistance with a generally increasing trend. Of the chosen contextual factors,
improvements were recorded in female literacy, access to improved water supply, diarrheal
mortality in children younger than 5 years, gross domestic product, and poverty while
access to improved sanitation facilities decreased over time nationally. Typhoid fever still
poses a serious health challenge in Nigeria and in antibiotic resistance, and is a major health
security issue. A combined approach that includes the use of typhoid vaccines,
improvements in sanitation, and safe water supply is essential .

. https://doi.org/10.4269/ajtmh.18-0045

Typhoid fever control in the 21st century: where are we now?

Momentum for achieving widespread control of typhoid fever has been growing over the past decade. Typhoid conjugate
vaccines represent a potentially effective tool to reduce the burden of disease in the foreseeable future and new data have
recently emerged to better frame their use-case.
Recent findings: They describe how antibiotic resistance continues to pose a major challenge in the treatment of typhoid
fever, as exemplified by the emergence of azithromycin resistance and the spread of Salmonella Typhi strains resistant to
third-generation cephalosporins. We review efficacy and effectiveness data for TCVs, which have been shown to have high-
level efficacy (≥80%) against typhoid fever in diverse field settings. Data from randomized controlled trials and
observational studies of TCVs are reviewed herein. Finally, we review data from multicountry blood culture surveillance
studies that have provided granular insights into typhoid fever epidemiology. These data are becoming increasingly
important as countries decide how best to introduce TCVs into routine immunization schedules and determine the optimal
delivery strategy.
Summary: Continued advocacy is needed to address the ongoing challenge of typhoid fever to improve child health and
tackle the rising challenge of antimicrobial resistance.
https://doi.org/10.1097/QCO.0000000000000879