Nursing Care Plan For Typhoid Fever

Typhoid fever is a serious and potentially life-threatening bacterial infection caused by the Salmonella typhi bacteria. 

This infection primarily affects the intestinal tract and the bloodstream, causing symptoms such as fever, headache, fatigue, abdominal pain, and loss of appetite.

Every year, between 11 and 20 million individuals are still affected by typhoid disease, which also causes 128,000 to 16,000 fatalities. 

One of the main causes of death and morbidity in densely populated and unsanitary places is typhoid fever. 

According to reports, the “4Fs” transmitted salmonella (flies, fingers, feces, and fomites)

The bacteria are usually spread through contaminated food and water, and can also be transmitted through close contact with an infected person. 

Without proper treatment, typhoid fever can lead to severe complications such as sepsis, organ failure, and even death

Prevalent of Typhoid Fever

Typhoid fever morbidity and mortality drastically decreased in industrialized nations as a result of better housing conditions and the advent of drugs.

However, the disease continues to be a public health issue in developing countries in Africa, America, South-East Asia, and the Western Pacific (WHO,2018).

According to the World Health Organization, there are 11–20 million cases of typhoid fever worldwide each year, resulting in 128,000–161,000 fatalities. 

Populations without access to clean water and proper sanitization are more likely to contract typhoid.

Children, disadvantaged groups, and poor communities are more at risk.

Incidence of Typhoid Fever

Typhoid and paratyphoid fever cases decreased by 44.6% from 25.9 million in 1990 to 14.3 million globally in 2017. 

From 439.6 per 100,000 person-years in 2017, age-standardized incidence rates decreased by 54.9%. 

At present, it is fewer than 1% with quick treatment. However, a chronic bladder infection will only occur in 1-6% of infected people.

Typhoid fever is more common in some regions of the world than others. Children between the ages of 5 and 19 have the highest incidence of typhoid fever.

Epidemiology

Salmonella typhi causes the potentially fatal virus typhoid fever, which continues to be a major public health concern worldwide, particularly among the underprivileged population of emerging nations like Nigeria. 

Typhoid affects between 11 and 20 million people annually, and between 128,000 and 161,000 people die from it.

Incubation Period

The incubation period differs for typhoid fever and paratyphoid fever.

Typhoid fever: It is usually 8-14 days but this depends on the infective dose and can vary from 3 days to one month.

Paratyphoid fever:  It is usually 1-10 days.

Causative Organism: 

Typhoid fever is caused by salmonella typhi and salmonella paratyphi.

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Mode of Transmission

Typhoid fever is transmitted through the fecal-oral route. It can be transmitted through direct and indirect contacts.

Direct contact: This occurs when a person is directly in contact with infected faeces, urine, handling patients their infected towel and/or bed linens.

Indirect Contact:These involved  Pathogens being carried by flies, contaminated equipment to the susceptible host or  drinking of contaminated water. 

Portal of Entry: 

The portal entry for salmonella typhi infection is the mouth usually through ingestion of contaminated water or food.

Reservoir of Typhoid

Human beings are the only reservoir for salmonella typhi while salmonella paratyphi has both human and animal reservoirs. 

Classification of Typhoid Fever

There is no established classification system for typhoid fever. However, typhoid fever may be classified informally as follows;

• Duration of illness 
• Severity of illness
• Virulence factors

Classification of typhoid fever according to duration of illness 

1 . Acute disease 

• Sudden – onset 
• Severe in nature 
• Last less than 12 months
• Mostly symptomatic

2 . Chronic disease 

• Lasts more than 12 months 
• Less severe
• Asymptomatic
• Spread infection to others

 Severity of illness

1 . Mild disease

• Early diagnosis and treatment
• Antibiotic susceptibility
• Absence of complications

2 . Moderate to severe disease

• Late presentation
• Presence of complications
• Antibiotic resistance

Classification of typhoid fever according to Virulence factors

• High virulence factors e.g. Vi antigen-positive strains
• Low virulence factor

Causes of typhoid fever 

Typhoid fever is brought on by the bacterium salmonella typhi. Contaminated food, beverages, or water can transmit the germs. 

People who have salmonella typhi infection carry the bacteria in their blood and gastrointestinal tract.

Salmonella typhi is expelled from the body through the feces. 

If a person consumes food or drinks prepared by an infected person, they run the risk of contracting typhoid fever.

People who have had typhoid fever in the past are still thought to be carriers of the illness even when they show no signs of it (as in the instance of “typhoid Mary” in the United States).

Predisposing Factors of Typhoid Fever

Other predisposing factors of typhoid fever are

• People who travel to endemic areas
• Poor hygiene habit 
• Poor sanitation conditions 
• Contact with someone who recently suffered from typhoid fever
• Crowded housing
• Immunosuppressive illness such as AIDS
• Consumption of raw fruits and vegetables contaminated with sewage.
• Childhood
• Health workers
• Laboratory workers

Pathophysiological of Typhoid Fever

Typhoid fever is an infectious disease caused by the bacillus salmonella typhi ingested in contaminated food and characterized by a bacteraemia.

Once consumed, typhoid bacteria cross the epithelial layer of the intestinal wall.

They are then quickly consumed by macrophages and transported to the aggregates of lymphoid tissue in the small intestine (Peyer’s patches) where the immune function of the gut is most concentrated. 

The typhoid bacteria alter host cell signalling and function in such a way that host cells ultimately promote the survival and replication of S. typhi and S. paratyphi.

The incubation stage of a typhoid infection is characterized by the replication and transfer of S. typhi and S. paratyphi from the Peyer’s patches in the gastrointestinal system, through the lymphatic, to the organs of the reticulo-endothelial system including the lymph nodes, spleen, bone marrow, and liver.

Once in the gallbladder, S. typhi and S. paratyphi are secreted back into the gastrointestinal tract. 

Having been previously exposed to the organism, the Peyer’s patches respond with an intense inflammatory reaction leading to congestion and clogging of the microcirculation and capillaries with release of lytic lysosomal enzymes and other inflammatory mediators.

This results in varying degrees of necrosis and ulceration of Peyer’s patches of which the clinical manifestation is bleeding and perforation. 

The terminal ileum is the most common site of perforation, but perforation has also been reported to occur anywhere from the duodenum to the colon including the gallbladder and appendix. 

Depending on the strength of the host’s immune system and the size of the inoculum, the incubation phase may last 3 days to 3 weeks.

During this interval, a patient may have no symptoms or vague complaints of fever and abdominal pain. 

Once the bacterial load reaches a critical mass, an individual is said to have an active typhoid infection

Signs and symptoms of typhoid fever

Salmonella typhi lives in humans. Person with typhoid fever carries the bacteria in their bloodstream and intestinal tracts.

The clinical manifestation of typhoid fever can be described in weeks as stated below

Typhoid: 1st week

• Persistent headache 
• Weakness and fatigue 
• Dry cough 
• Loss of appetite
• Abdominal pain 
• Diarrhoea and constipation 
• Rash 
• Shivering attacks and temperature rise gradually, peak in the afternoon and falls in the morning 
• The face becomes drawn and pallid, throat is dry and inflamed.

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Typhoid: 2nd week

• Painful and distended abdomen in the right lower quadrant
• Severe diarrhoea with characteristic pea soup stool
• Constipation 
• Hepatosplenomegaly (enlargement of the liver and spleen)
• The widal  test is strongly positive 
• Weight loss 

Typhoid: 3rd week

• The patients remains weak and ill
•  The fever is high and oscillates very little over 24 hours 
• Intestinal haemorrhage due to bleeding in the congested Peyer’s.
• Intestinal perforation in the distal ileum.
• Encephalitis 
• Neuropsychiatric (mental disorders attributed to disease of the nervous system).
• Metastatic abscesses
• Endocarditis
• Otitis
• Cholecystitis

Typhoid: 4th week

• Gradual reduction in temperature 
• Abdominal distension slowly improves over a few days
• Intestinal and neurologic complications may still occur in surviving untreated individuals.
• Weight loss and cell debilitating weakness
• Some survivors become asymptomatic salmonella 

Nursing Diagnosis For typhoid fever .

1. Hyperthermia related to inflammatory response evidenced by raised body temperature of 39.5oC.
2. Acute abdominal pains related to inflammation of the Peyer’s Patches, evidenced by patient’s verbalization.
3. Imbalanced nutrition less than body requirement related to loss of appetite, evidenced by loss of weight.
4. Disturbed sleep pattern related to sever headache evidenced by restlessness.

Outcome Identification

• Patient’s body temperature will be reduced by 1oC within 15 to 20 minutes of nursing intervention.
• Patient will verbalize relieve of abdominal pain within 10 to 15 minutes to one hour of nursing intervention.
• Patient’s nutritional status will improve within 24 hours of nursing intervention, and patient regained at least 0.5kg weight.
• Patient will maintain a stable sleep pattern within 2 to 3 hours of nursing intervention.

Plan

• To reduce body temperature.
• To relieve abdominal pain.
• To maintain balanced nutrition.
• To promote rest and appropriate sleep pattern.

Implementation of Care

To Reduce Temperature

• Expose patient by removing tight clothing and opening windows, thus reducing body temperature by collection.
• Tepid sponge and leave sponge on the fore head, to reduce body temperature by radiation.
• Leave drops of water on the body surface to reduce temperature by radiation and evaporation.
• Turn on fan at a low setting; let it circulate the air around the patient to keep the patient from becoming too cold.
• Give plenty of fluids and reduce body temperature by conduction.
• Monitor body temperature every 30 minutes and record it to detect patient’s response to treatment.
• Administer and chart prescribed antibiotics, antipyretic and antimalarial as prescribed e.g. IV paracetamol 600mg IV ceftriaxone 1g and 1m Emal 150mg.

To relieve pain

• Place patient in a comfortable position to provide comfort and alleviate pains.

• Provide diversional therapy to the patient e.g. watching television to direct patient’s attention from the present condition.

• Apply warm compress to the abdomen to relieve abdominal pain.

• Give anti-spasmodic agents e.g. Hyosine butylobromide 10mg tds x 3/7 to reduce gastric motility thereby causing a delay in emptying of the stomach contents.

 

To stimulate appetite

• Give easily digestible diets e.g. pap to stimulate appetite.
• Encourage patient on oral hygiene twice a day to stimulate the flow of saliva thereby promoting appetite.
• Serve small, attractive meals that the patient can tolerate to stimulate the appetite.
• Give assorted fruits e.g. oranges, avocado pears to prevent constipation.

To Promote Sleep

• Nurse patient in a well-dressed bed and comfortable position to promote sleep.
• Give warmth bath before bedtime to refresh the body and promote sleep.
• Open nearby doors and windows for cross ventilation to promote comfort.
• Provide dimmed light in the ward at night to induce sleep.
• Avoid unnecessary noise to promote sleep.
• Advice patient to wear light night gown to promote freedom.

Evaluation

• Patient’s body temperature was reduced after 45 minutes of nursing intervention.
• Patient’s abdominal pain was relieved after 30 minutes of nursing intervention.
• Patient’s nutritional status was maintained after 24 hours of nursing intervention.
• Patient’s sleeping pattern was improved after 3 hours of nursing intervention.

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TYPHOID FEVER NURSING CARE PLAN

S/N	Nursing Diagnosis	Nursing Objective	Nursing Intervention	Scientific Rationale	Evaluation
1.	Hyperthermia related to inflammatory response, evidenced by raised body temperature of 39.5oC.	Patient’s body temperature will reduce by 1oC within 10 to 15 minutes of nursing intervention.	Admit patient in a well-ventilated room. Check and record vital signs. Expose and tepid sponge the patient. Open nearby windows and provide fan. Observe temperature every hour and record. Give prescribed antipyretic e.g. I.V. Paracetamol 600mg stat.	It will allow patient to get enough air, thereby reducing body temperature. For baseline data. To reduce body temperature by radiation. Helps to reduce temperature by convection. Helps the nurse to know the severity of the condition and patient’s response to treatment. Antipyretics have a depressing effect on the heat regulating centre in the hypothalamus, thereby reducing the body temperature.	Patient’s body temperature was reduced by 1oC after 15 minutes of nursing intervention.

S/N	Nursing Diagnosis	Nursing Objective	Nursing Intervention	Scientific Rationale	Evaluation
2.	Acute abdominal pains related to inflammation of the Peyer’s patches, evidenced by patient’s verbalization.	Patient will verbalize relief of abdominal pains within 30 minutes to one hour of nursing intervention.	Place patient in a comfortable position. Apply warm compress to the abdomen. Provide diversional therapy to the patient e.g. storytelling, watching of television. Give antispasmodic drugs e.g. Hyosine Butylobromade (Buscopan) 10mg tds x 3/7.	To provide comfort and alleviate pains. To relief abdominal pains. To divert patient’s attention from the pain. To reduce intestinal spasms, thereby reducing pain.	Patient’s abdominal pain was relieved after one hour of nursing intervention.
3.	Imbalanced nutrition less than body requirement related to anorexia, evidenced by loss of weight.	Patient’s nutritional status will improve within 2 – 3 hours of nursing intervention and patient will gain at least 0.5kg weight.	Give oral toileting. Give easily digestible food e.g. pap and serve in an attractive manner. Encourage fluid intake and fruits. Monitor amount of nutrients and calories consumed by patient. Encourage fluid intake.	To stimulate appetite. This will stimulate and increase appetite. To prevent constipation. To know the cause of less intake so as to determine appropriate interventions. To prevent dehydration.	Patient’s nutritional status was maintained after 3 hours of nursing intervention.

S/N	Nursing Diagnosis	Nursing Objective	Nursing Intervention	Scientific Rationale	Evaluation
4.	Disturbed sleep pattern related to severe headache, evidenced by restlessness.	Patient will maintain a stable sleep pattern within 2 to 3 hours of nursing intervention.	Nurse patient in a well-made bed and comfortably. Give warm bath before bedtime. Provide dimmed light at night. Nurse patient in a noise-free environment. Administer and chart prescribed medication e.g. Diazepam 10mg.	To promote sleep. Helps to refresh the body and promote comfort. Dimmed light helps to induce sleep. Noise-free environment helps to promote sleep, thereby reducing pains. It helps to calm the patient’s brain, thereby inducing sleep.	Patient’s sleeping pattern was improved after 3 hours of nursing intervention.