Topic: ENTERIC FEVER / TYPHOID FEVER

Subject: Comprehensive Nursing 

Post-Basic B.Sc in Nursing 

Definition:

  1. It is a specific disease due to infection by Salmonella typhi and paratyphi, characterized by prolonged fever, headache, and distention of abdomen, rashes over the trunk, leucopenia, bradycardia and splenomegaly.
  2. It is an acute; life threatening febrile illness caused by salmonella typhi and paratyphi, characterized by a typical continuous fever, relative bradycardia and coloured spots on the trunk.

Source and Spread of infection:

Infection usually spreads by food, flies, fingers, faeces, filth and fomite. Most important is contaminated food and drink. However, in some developing countries it remains in the endemic form.

Incubation period: The incubation period of typhoid fever is about 10 -14 days; that of paratyphoid is somewhat shorter.

Pathophysiology: 

The organisms gain entry ingestion. They are not destroyed by gastric juice so they reach the intestine and invade the mucosa to gain entrance into intestinal lymphatic through payer’s patches. They proliferate in mesenteric lymph nodes and possibly in spleen before they reach the blood. Bacteraemia may occur before the onset of symptoms but usually it coincides with the onset of clinical features. As antibodies appear in the second week, the infection is localized in liver, gall bladder and payer’s patches. The bacilli come to intestine along with bile from the liver.

Payer’s patches and lymphoid follicles become hyperemic, proliferative and later on nacrosed and ulcerated. The floor of an ulcer is formed by muscular coat or very rarely by peritoneum.

Spleen, Liver, Lymph nodes, Heart, Kidney, Lungs, CNS, Gall bladder and Muscles etc may show signs of congestion and inflammation.

Clinical features:

First week;

  • Onset is insidious with headache, malaise, drowsiness and aching in the limbs.
  • Fever is remittent and gradually an increase in severity in a step ladder fashion is usually present throughout the week.
  • Anorexia nausea, vomiting, sore throat, cough are also present and even epistaxis may occur in children.
  • Constipation, lassitude and malaise are present.
  • Pulse shows relative bradycardia.
  • Tongue is always coated with red margins and tip.
  • Abdomen is tumid, Caecal gurgling may be present.

Second week:

  • Rose spots. (At the end of the first week) found in upper abdomen, thorax and on the back of the trunk.
  • Temperature is continuous and is continued in type but it is high with little variation;
  • Headache disappears and patient becomes mentally dull , week and stuporous;
  • Cough may persist, pulse shows tachycardia and tongue is dry and red.
  • Diarrhoea with abdominal distention.
  • Enlarge palpable spleen in 75% cases ( 7-10 days). Liver may be just palpable.
  • Cervical lymphadenopathy, hepatomegaly, tenderness in the right iliac fossa.

Third and fourth week:

  • Delirium, coma vigil, carpology at the end of the second week.
  • The disease if no treatment is given, toxaemia is increases, temperature gradually comes down but the patient becomes very much dull.
  • Various complications gradually develop. Patient may pass into coma and death. ( unless treated with appropriate antibiotic)

Complications:

These are seen 30 % of untreated cases.

  • Alimentary: Parotitis, Harmorrhage, Perforation (0.5%), Peritonitis and Cholycistits.
  • Pulmonary: Bronchitis, Bronchopneumonia, Hypostatic congestion, Lung abscess, Ulcer of larynx.
  • Cardiovascular: Myocarditis, Acute peripheral circulatory failure, and Thrombophlebitis.
  • Nervous:  Meningitis, Convulsion, Coma, Muttering delirium, Coma vigil, Post typhoid intensity, Typhoid state and neuritis.
  • Miscellaneous: Conjunctivitis, Deafness, Nephritis, Cystitis, Osteomyelitis, Spondylitis, Arthritis and Haemolytic anaemia etc.

Special Investigations:

  • Blood count: Leucopoenia with relative lymphocytosis;
  • Blood Culture: Diagnostic , positive in 1st week;
  • Widal test ( agglutination test) : Positive in 2nd week;
  • Stool culture: Positive in 3rd week
  • Urine culture;

Note: widal test- It is agglutination test which defects antibodies to the causative organism.

Management:

  • Patient should be kept in rest with comfortable position and room should be well ventilated. Isolation is very important;
  • Check vital signs every 4 hourly and recorded it. If the temperature is high ( 102 to 103 or above) whole body taped water sponge and head wash to reduce temperature;
  • General nursing care including care of mouth, eyes and skin care is valuable;
  • Diet should be high caloric and in the form of liquids. Milk, horlicks, fruit juice are usually given;
  • Fluid and electrolyte balance is to be maintained. Purgatives should never prescribed.
  • Several antibiotics are effective in enteric fever such as ciprofloxacin in a dose of 500-750 mg 12 hourly orally for 14 days is the drug of choice;
  • Alternatives including co-trimoxazole 2 tab 12 hourly.
  • The dose of Ampicillin 750 mg 6 hourly and chlorramphenical 500 mg 6 hourly for 14 days. Pyrexia may persists for upto 5 days after the start of specific therapy.
  • The chronic carrier should be treated for 4 weeks with ciprofloxacin;

Prevention:

 Improved sanitation and living conditions reduce the incidence of typhoid. Provision of safe drinking water, sanitary disposal of human excreta, sanitary food handling in all eating places, hand washing facilities and control of flies are some of the important preventive measures. Travelers to countries where enteric infections are endemic should be inoculated with one of the three available typhoid vaccines.

Nursing Diagnosis:

  • Altered body temperature related to the presence of infection;
  • Fluid volume deficit related to fluid lost through diarrhea.
  • Knowledge deficit about the infection, and the risk of transmission to others.

Nursing Intervention:

Patient comfort and return of temperature to normal.

  • Assess underlying cause of high temperature;
  • Monitor temperature, pulse and repiration at regular interval;
  • Keep the patient in well ventilated room to allow fresh air;
  • Provide whole body taped water sponge and head wash to reduce temperature
  • Change the linen when patient is diaphoretic;
  • Encourage the patient to take liquid and soft diet;
  • Encourage the patient to take high protein diet and plenty of fluid;
  • Administer antibiotics  as prescribed to prevent infection;
  • Maintain personal hygiene especially care of mouth, eyes and skin;

Maintaining fluid balance:

  • Assess the patient’s physical condition;
  • Monitor risk for fluid volume deficit;
  • Maintain fluid and electrolytic balance;
  • Encourage the patient to take more plenty of fluid;
  • Monitor and maintain intake and output chart;
  • Assess vital signs every 4 hourly and recorded it;

Expected outcomes:

  • Body temperature within normal limits;
  • Maintenance of fluid and electrolyte balance;
  • Patients feel comfortable.

Evaluation:

  • Reduced fever, temperature level normal;
  • Correct dehydration and fluids volume level normal;

Md. Lutfor Rahman

RN, BSN, MPH

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