ADMISSION OF PATIENT
Ms. Akosua Naa was admitted through the Triage unit of the Accident and Emergency Department in a conscious state with IV Dextrose Saline insitu. She was brought in well dressed, very ill and in a wheelchair, accompanied by her mother. They were warmly welcomed into the nurses’ station. The mother was offered a seat and gave the necessary information about the client including name, age, sex, religion, residential address, and next of kin. The data was recorded into the admission and discharge book as well as the daily ward state form. The client was immediately admitted into a warm and a comfortable bed.
Temperature 38.0 Degrees Celsius
Pulse 106 Beats per minute
Respiration 23 Cycles per minute
Blood pressure 83/60 mm/Hg
Upon these assessments, the client was a sponge with tepid water to reduce the body temperature from 38.0 to 37.5 after an hour.
The health problems identified were abdominal pain and distension, headache, pyrexia, and malaise. A nose-gastric tube was passed to decompress the abdomen. Catheterization was also done and her IV line was very patent. The medical doctor on duty attended to her and prescribed the following medications to her;
IV Pethidine 100mg b.d× 24hrs
IV Ciprofloxacin 400mg b.d× 48 hrs
IV Flagyl 500mg t.d.s ×48 hrs
IV Dextrose saline 2 liters
IV Normal saline 2 liters
Ringers lactate 2 litres
The investigations ordered were Fasting blood sugar, grouping and cross matching, chest x-ray, an abdominal x-ray (supine and erect).
The relatives were informed about the hospital policies which include payment of a deposit if she had no health insurance, time of visits, and the items the patient may need during hospitalization which include a cup, spoon, bucket, towel, bowl, or plate, and others.
The client and the mother were reassured that competent health personnel was willing to help Akosua recover without complication. These words of encouragement helped relieved their anxiety.
The medical treatments prescribed by the doctor were explained to the client and the due ones were administered. Blood samples were taken to the laboratory and she was taken to the x-ray department for an x-ray examination. She was also instructed not to take anything by mouth since she would possibly undergo emergency surgery. My client was reviewed by the leader of the surgical team and the diagnosis was confirmed as typhoid fever with perforation.
PATIENT’S CONCEPT OF ILLNESS
When Miss Akosua Naa and her mother were asked about their knowledge about Typhoid Fever, it was found out that they know little about the condition. The client accepted the diagnosis and expressed her willingness to corporate with health personnel to facilitate early recovery. The mother was disturbed and said all the people in their village were saying that her daughter committed an abortion that was why she had severe abdominal pain. This form of misconception about her daughter by the society worried her and said she prays to God that everything goes on successfully. Besides they did not attribute the occurrence to any evil force or witch crafting but rather it is a natural occurrence.
LITERATURE REVIEW ON PATIENT’S CONDITION
Typhoid fever is an acute infectious disease that produces fever, prostration, stupor, enlarged spleen, and intestinal inflammation in the individual. Typhoid perforation is a disease condition that is said to be a complication of uncontrollable or untreated typhoid fever.
Typhoid Fever has an increasing rate or is endemic in many areas where environmental sanitation is poor.
It is widely spread in Africa and other third-world countries.
It affects all age groups but more common among 10-25 age groups. There are estimated cases of 13-17% worldwide resulting in approximately 600,000 deaths per annum.
It is endemic in most developing countries including Ghana as a result of rapid population growth, inadequate human waste treatment and disposal, limited and inadequate treated water supplies.
The disease incidence rises at the end of the rainy season resulting in its seasonal variation.
Typhoid fever is caused by Salmonella Typhi. This flagellated gram-negative bacteria has no known host except humans. Ingested people and carriers harbor the bacteria and pass them out in their feces and urine to sources of drinking water through indiscriminate refuse disposal. This aggravates especially if these sources are not well purified before consumption. Also, contamination of food through food handlers who may be a carrier and water that has been polluted with sewage is used for irrigation of vegetables like lettuce and cabbage.
The bacteria usually enter the body through the mouth by ingestion of contaminated food or water. The organisms penetrate the interstitial wall and multiply in the lymphoid tissue called the Peyers patches. It first enters the bloodstream within 24-72 hours causing septicemia and systemic infection. The lymph follicles along the interstitial wall in which the typhoid bacilli have multiplied, become inflamed and necrotic, and may slough off, leaving ulcers in bowels tissues which may erode blood vessels causing hemorrhage into the bowel.
This perforates the wall of the bowel allowing the contents of the bowel to enter the peritoneal cavity causing peritonitis.
MODE OF TRANSMISSION
Salmonella Typhi is transmitted through contaminated water and food, occasionally, flies act as vectors. Some cases pass through chronic biliary carriers by fecal contamination.
However, many cases are acquired through travels to endemic areas.
It has an incubation period of 10-14 days.
1ST WEEK (PRODROMAL SIGNS AND SYMPTOMS)
The patient develops a high fever that may persist; temperature rise for the first 4-5 days is in a step ladder fashion with a temperature difference of 0.5 degrees Celsius.
Severe headache, malaise, constipation, vague abdominal pain (cannot classify the pain), drowsiness, dry cough, may also manifest.
In children, however, there is a slow pulse, epistaxis, rhinorrhea, and conjunctivitis, photophobia, bleeding under the skin, weight loss, anorexia, and convulsion.
2ND WEEK (RASH STAGE)
The clinical features above become more severe. Appearance of rashes called rose-red-spot, on the upper abdomen, chest and back which fades with pressure. The spleen becomes palpable. There is diarrhoea with offensive pea soup-like stools containing undigested materials and sometimes peelings from the intestinal walls.
3RD WEEK (BLEEDING AND COMA STAGE)
Bleeding and perforation may occur with a decline in temperature. Patient becomes better and later goes into coma. By the fourth (4th) week, the patient recovers.
Other signs and symptoms may include; tenderness, chills, dyspnoea, anaemia, dysuria, dehydration and hepatomegaly.
- MEDICAL COMPLICATION
- SURGICAL COMPLICATIONS
– Intestinal perforation
– Intestinal haemorrhage
– Gall stone formation
– Cerebral abscess
INTESTINAL PERFORATION: This is the most common complication of typhoid fever. It is a break in the intestinal wall which occurs when erosion, infection, or other factors like trauma create a weak spot in the organ, and intestinal pressure causes a rupture. This occurs in typhoid fever when the disease is not diagnoses and treated earlier.