CASE PRESENTATION(TYPHOID FEVER)

GROUP A:Eden Pamittan

Leonides Ramonette IsraelElynor reboredo

Blesilda Elaine ObligadoDianne Aglado

Adelna Faye TamayoRhea Lugo

General Objectives:

To have a case study related to our concepts in lecture regarding communicable

diseases. To be able to apply our learning’s from our lectures to our case study. To learn

further regarding on our concepts in lecture.

Specific Objectives:

1. To gather enough and credible data for our case study and be able

to prevent it.

2. To be able to establish rapport to our patient and his family in

order to gain their cooperation for the interview and therapeutic

processes.

3. To be able to know our patients Family background and Health

history in order to trace past and present health condition.

4. To be able to assess our patients developmental stages in life into

three theories namely: Havighurts, Freud, Erikson, or Piaget.

5. To be able to define Typhoid fever along with the patients

complete diagnosis in at least three sources from any medical

surgical textbooks.

6. To be able to assess our patient physically and cephalocaudally.

7. To be able to discuss and explain about the Anatomy and

Physiology of the specific body systems involved in our clients

diagnosis.

8. To be able to present the etiology of Typhoid fever with scientific

basis.

9. To be able to trace the Pathophysiology of Typhoid fever.

10. To be able to show and explain the Doctors Order for our client.

11. To be able to illustrate and explain each Diagnostic Exam

undergone by our patient along with its important information’s.

12. To be able to present and explain the different drugs of our

patient.

13. To be able to present at least 3 nursing theories related and

applicable to the case of the patient.

14. To be able to formulate and present at least 5 nursing care plans

in relation to our clients existing health conditions.

15. To be able to cite our recommendations for this case study and

health teachings for our patients Health condition.

16. To be able to formulate the discharge plan applicable and needed

by our patient in M.E.T.H.O.D pattern.

17. To be able to justify the prognosis of our client concerning his

present condition.

18. To be able to present the list of all the references we used in

coming up with our Case Study.

INTRODUCTION:

Typhoid fever is an acute illness associated with fever caused by the Salmonella typhi bacteria. It can also be caused by Salmonella paratyphi, a related bacterium that usually causes a less severe illness. The bacteria are deposited in water or food by a human carrier and are then spread to other people in the area.

After the ingestion of contaminated food or water, the Salmonella bacteria invade the small intestine and enter the bloodstream temporarily. The bacteria are carried by white blood cells in the liver, spleen, and bone marrow. The bacteria then multiply in the cells of these organs and reenter the bloodstream. Patients develop symptoms, including fever, when the organism reenters the bloodstream. Bacteria invade the gallbladder, biliary system, and the lymphatic tissue of the bowel. Here, they multiply in high numbers. The bacteria pass into the intestinal tract and can be identified for diagnosis in cultures from the stool tested in the laboratory. Stool cultures are sensitive in the early and late stages of the disease but often need to be supplemented with blood cultures to make the definite diagnosis.

First stage

Once signs and symptoms do appear, you're likely to experience:

Fever, often as high as 103 or 104 F (39 or 40 C) Headache Weakness and fatigue A sore throat Abdominal pain Diarrhea or constipation Rash

Children are more likely to have diarrhea, whereas adults may become severely constipated. During the second week, you may develop a rash of small, flat, rose-colored spots on your lower chest or upper abdomen. The rash is temporary, usually disappearing in two to five days.

Second stageIf you don't receive treatment for typhoid fever, you may enter a second stage during which you become very ill and experience:

Continuing high fever Either diarrhea that has the color and consistency of pea soup or severe constipation Considerable weight loss Extremely distended abdomen

The typhoid state By the third week, you may:

Become delirious Lie motionless and exhausted with your eyes half-closed in what's known as the

typhoid state

Life-threatening complications often develop at this time

Cause:

Typhoid fever is another of the infectious diseases which is to be ascribed to a specific virus or poison. Yet the present state of our knowledge would indicate that the disease is not directly communicated by contact of the sick with the well individual. The disease seems capable of manifesting itself with out previous exposure to this disease ;yet it is unquestionable that the excretions — the stools — of a typhoid fever patient may be the means of disseminating the disease among healthy people. The contagion is conveyed in the water of wells and cisterns, as has been amply demonstrated by observations upon the German and Austrian soldiery, as well as by cases in civil life. City physicians

are well aware that typhoid fever is specially apt to occur in those dwellings in which, however elegant the general appointments, the sewerage is defective, as indicated by the odor from the traps. Typhoid fever, while occurring during all seasons of the year, is especially frequent in the fall, at which time it may amount almost to an epidemic. The average mortality varies extremely, being of course greater during epidemics; at these times there may be one fatal result in three or four. At other times, however, the average mortality is rarely more than one in six or seven.

DIAGNOSTIC AND LABARATORY EXAMS:

1. Medical and travel history .Your doctor is likely to suspect typhoid fever based on your symptoms and your medical and travel history. But the diagnosis is usually confirmed by identifying S. typhi in a culture of your blood or other body fluid or tissue.

2. Blood or body fluid or tissue culture .For the culture, a small sample of your blood, stool, urine or bone marrow is placed on a special medium that encourages the growth of bacteria. In 48 to 72 hours, the culture is checked under a microscope for the presence of typhoid bacteria. A bone marrow culture often is the most sensitive test for S. typhi.

3. Antibody and antigen testing .Your doctor may recommend other tests to help diagnose typhoid fever, such as:

Enzyme-linked immunosorbent assay (ELISA). This blood test looks for an antigen that's specific to typhoid bacteria. An antigen is any substance, such as a virus, bacterium, toxin or foreign protein that triggers an immune system response in your body. An ELISA test can identify if you carry the disease, but not whether you have an active infection.

Fluorescent antibody test. This test checks for antibodies to S. typhi. Antibodies are proteins produced by your immune system in response to harmful substances (antigens). Each antibody is unique and defends your body against a single antigen.

New diagnostic tests include those for immunoglobulin M (IgM) and immunoglobulin G (IgG) antibodies, with rapid results (2 minutes to 3 hours). The Typhidot-M test has a specificity of 75% and a sensitivity of 95%. The Tubex test is rapid and detects the O9 antigen.

The classic Widal test is rarely used because of its low sensitivity and specificity. Blood, urine, and stool cultures are still frequently used to isolate S typhi, but the

yield is only about 70%. The duodenal string test may be used to culture bile. CBC may reveal anemia and thrombocytopenia. Liver function test results are commonly elevated. Renal dysfunction may occur, but chronic renal failure has not been reported.

COMPLICATIONS:

Intestinal bleeding or perforation. The most serious complication of typhoid fever — intestinal bleeding or perforation — may develop in the third week of illness. About 5 percent of people with typhoid fever experience this complication. Intestinal bleeding is often marked by a sudden drop in blood pressure and shock, followed by the appearance of blood in your stool.A perforated intestine occurs when your small intestine or large bowel develops a hole, causing intestinal contents to leak into your abdominal cavity and triggering signs and symptoms such as severe abdominal pain, nausea, vomiting and bloodstream infection (sepsis). This life-threatening emergency requires immediate medical care. Other, less common complications Other possible complications include:

Inflammation of the heart muscle (myocarditis) Pneumonia Inflammation of the pancreas (pancreatitis) Kidney or bladder infections Infections of the spine (osteomyelitis) Infection and inflammation of the membranes and fluid surrounding your brain

and spinal cord (meningitis) Psychiatric problems such as delirium, hallucinations and paranoid psychosis

With prompt treatment, nearly all people in industrialized nations recover from typhoid. Without treatment, some people may not survive complications of the disease.

NURSING MEDICAL MANAGEMENT:

Typhoid fever is treated with antibiotics which kill the Salmonella bacteria. Prior to the use of antibiotics, the fatality rate was 20%. Death occurred from overwhelming infection, pneumonia, intestinal bleeding, or intestinal perforation. With antibiotics and supportive care, mortality has been reduced to 1%-2%. With appropriate antibiotic therapy, there is usually improvement within one to two days and recovery within seven to 10 days.Several antibiotics are effective for the treatment of typhoid fever. Chloramphenicol was the original drug of choice for many years. Because of rare serious side effects, chloramphenicol has been replaced by other effective antibiotics. The choice of antibiotics needs to be guided by identifying the geographic region where the organism was acquired and the results of cultures once available. (Certain strains from South America show a significant resistance to some antibiotics.) If relapses occur, patients are retreated with antibiotics.The carrier state, which occurs in 3%-5% of those infected, can be treated with prolonged antibiotics. Often, removal of the gallbladder, the site of chronic infection, will cure the carrier state.

STATISTICS:

PATIENT’S PROFILE:

NAME: F. PRINCIPE AGE: 45 Y/O GENDER: MALE CIVIL STATUS: M,ARRIED ADDRESS: STO. TOMAS, ISABELA BIRTH DATE: BIRTH PLACE: CENTRO STO. TOMAS, ISABELA OCCUPATION: FARMER AND COOK RELIGION: ROMAN CATHOLIC C/C: FEVER, CHILLS, BODY PAIN DATE OF ADMISSION: NOVEMBER 19, 2009 TIME OF ADMISSION:4 PM DATE OF DISCHARGE: FINAL DIAGNOSIS: ATTENDING PHYSICIAN: DR. ALBERT B. DE LEON CONSULTANT: CLINICAL DIAGNOSIS: SOURCE OF INFORMATION:

NURSING HISTORY:Chief Complaint: Fever, chills and abdominal painHistory of present illness:

According to the patient, they were flooded before experiencing fever, chills, and abdominal pain blank days PTA and after drinking water.

History of past illness:The patient had an asthma attack and a motor accident.

Social history:The patient is a smoker and he can consume 2 packs of cigarettes in a day. He is also a drinker and can consume 2 bottles of red horse and 1 bottle of matador.

Family history:her’s side,On the patient’s mother side,has a history of diabetes and on father’s side, a history of colon cancer and heart disease.

GORDON’S 11 FUNCTIONAL PATTERN:

Before Hospitalization During Hospitalization1) Health Perception-

Health Management Pattern

>For him, health is vital to every individual. He considers health as the ability to perform activities of daily living. He believes that being healthy can create/build improvement in every individual’s life.

>He learned to entrust his health with someone else that have a broader knowledge concerning his health (like physicians, nurses and other health practitioners). He became more aware of his health condition.

2) nutrition >He usually takes his meal three times a day and prefers to eat grilled foods. He drinks 7-9 glasses of water every day.

>His illness has a great impact in his appetite that is why he only eats 1 cup of rice.

3)elimination >He defecates once everyday with dark browned stool. He urinates 4-5 times a day with yellow amber in color.

>He defecates once every day with dark browned stool. He has a hyperactive bowel sound.(>35/min)

4)exercise >His exercise is walking 3 kilometers every day and he also considers his activity of daily living.

>Because of his condition, he can not perform all the activities he always executes when he is not yet ill but he does isotonic exercise.

5)sleep >he sleeps 5-6hours a day. He said that he easily asleep when

he drinks alcohol. He sleeps at 10 or 11 pm and wakes up at 4- 5

am. He doesn’t have a nap time.

>He hardly sleeps at night because of the new

environment he’s staying. He sleeps at 12 pm and

wakes up at 4 am but with a naptime of 4 hours.

6)cognitive >He speaks clearly, loudly and passionate. Therefore, everyone could definitely understand him.

>He speaks clearly but he hardly focuses nor answers other questions.

7)self perception >He said that he loves himself and considers himself a good citizen and a strong and responsible husband and father.

>During his hospitalization, he considers himself as a burden to the family because he thought that he loses his father role.

8)social >he has a good relationship w/ his family. He stands as the bread winner of the family. He has a good relationship w/ his neighbors as well.

>He becomes closer with his family when he is hospitalized. They help him to achieve his wellness.

9)spiritual >He is a Roman Catholic follower. They go to mass once a month but he has a strong faith in God.

>He considers that his condition is just the plan of God to test his faith with him.

10)sexual pattern >He and his wife are still active. They perform it 3x a week. They are blessed w/ 3 children;2 girls and 1 boy.

They need privacy to do it but because of the place where he was, they cannot do it but they still love

each other.11 coping-stress pattern > He use to drink alcohol to

relieve the stress he feels. He also enjoys playing w/ her grandchildren.

He is getting all his strength and hope to his family. He don’t forget to ask for God’s guidance and mercy so that he’ll able to be relieve from the discomforts he has.

Many skin conditions can be treated with phototherapy, including:

Pruritus (itchiness). Phototherapy may be beneficial in many different forms of pruritus, particularly those associated with diabetes, liver disorders, uremic pruritus (itchiness due to kidney problems), and itchiness without an identifiable cause.

Atopic dermatitis. Dermatitis (inflammation of the skin) with intense itching, often due to an allergic reaction. Phototherapy has been used in the treatment of atopic dermatitis for decades. It is most helpful in chronic, moderate cases of the disease and may reduce the need for potent corticosteroids. However, many treatment exposures may be required to control the condition and recurrence rates are high and rapid, requiring frequent maintenance sessions.

Seborrheic dermatitis. Dermatitis marked by oily scales, crusty yellow patches and itching. Phototherapy may be very effective in severe cases of seborrheic dermatitis, but flares may occur, requiring further treatment.

Psoriasis. A skin disease characterized by raised, red patches of skin often covered with silvery scales. Phototherapy is frequently used to help manage many types of psoriasis, although the erythrodermic and pustular varieties may be more difficult to treat. It may be combined with other therapies (e.g., anthralin, vitamin D analogs, retinoids).

Vitiligo. Patches of skin lacking pigmentation (color). Phototherapy may cause repigmentation of the skin by stimulating the production of melanocytes. Doses of ultraviolet light must be tended to more carefully than in other disorders because of increased photosensitivity associated with the condition.

Generalized lichen planus. A skin condition marked by flat, shiny, violet papules. Phototherapy may provide an effective alternative to corticosteroids in the treatment of generalized lichen planus. Complete remissions may occur, although it may require many sessions and not all patients respond.

Alopecia areata. Patches of hair loss. Certain forms of phototherapy (topical or systemic psoralens plus ultraviolet A [PUVA] light) may help to regrow hair. However, the response varies from patient to patient.

Urticaria pigmentosa. A skin disease with brownish papules that sting when touched. Phototherapy may relieve the itching and stinging and may flatten and reduce lesions. In many cases, even long-term symptoms (e.g., migraines, flushing) decrease gradually as treatment is continued. Recurrences are common but respond as well to additional treatment as the original lesions.

Generalized granuloma annulare. A chronic rash marked by flat, ring-like spots with lighter centers. Phototherapy has been reported to clear the lesions completely, although long-term maintenance may be required to prevent recurrences.

Cutaneous graft-versus-host disease (GvHD). A condition in which cells from transplanted tissue of a donor cause an immune system attack on the tissue of the recipient. Phototherapy can improve some types of GvHD. There is some debate as to whether phototherapy may be useful in the prevention of GvHD shortly after transplantation.

Conditions treated with phototheraPhototherapy is prescribed primarily to treat seasonal affective disorder (SAD), a mood disorder characterized by depression in the winter months, and is occasionally employed to treat insomnia and jet lag. The exact mechanisms by which the treatment works are not known, but the bright light employed in phototherapy may act to readjust the body's circadian (daily) rhythms, or internal clock. Other popular theories are that light triggers the production of serotonin, a neurotransmitter believed to be related to depressive disorders, or that it influences the body's production of melatonin, a hormone derived from serotonin that may be related to circadian rhythms.py

Functions of the Urinary System

One of the major functions of the Urinary system is the process of excretion. Excretion is the process of eliminating, from an organism, waste products of metabolism and other materials that are of no use. The urinary system maintains an appropriate fluid volume by regulating the amount of water that is excreted in the urine. Other aspects of its function include regulating the concentrations of various electrolytes in the body fluids and maintaining normal pH of the blood. Several body organs carry out excretion, but the kidneys are the most important excretory organ. The primary function of the kidneys are to maintain a stable internal environment (homeostasis) for optimal cell and tissue metabolism. They do this by separating urea, mineral salts, toxins, and other waste products from the blood. They also do the job of conserving water, salts, and electrolytes. At least one kidney must function properly for life to be maintained.

Six important roles of the kidneys are:

Regulation of plasma ionic composition. Ions such as sodium, potassium, calcium, magnesium, chloride, bicarbonate, and phosphates are regulated by the amount that the kidney excretes.

Regulation of plasma osmolarity. The kidneys regulate osmolarity because they have direct control over how many ions and how much water a person excretes.

Regulation of plasma volume. Your kidneys are so important they even have an effect on your blood pressure. The kidneys control plasma volume by controlling how much water a person excretes. The plasma volume has a direct effect on the total blood volume, which has a direct effect on your blood pressure. Salt(NaCl)will cause osmosis to happen; the diffusion of water into the blood.

Regulation of plasma hydrogen ion concentration (pH). The kidneys partner up with the lungs and they together control the pH. The kidneys have a major role because they control the amount of bicarbonate excreted or held onto. The kidneys help maintain the blood Ph mainly by excreting hydrogen ions and reabsorbing bicarbonate ions as needed.

Removal of metabolic waste products and foreign substances from the plasma. One of the most important things the kidneys excrete is nitrogenous waste. As the liver breaks down amino acids it also releases ammonia. The liver then quickly combines that ammonia with carbon dioxide, creating urea which is the primary nitrogenous end product of metabolism in humans.

The liver turns the ammonia into urea because it is much less toxic. We can also excrete some ammonia, creatinine and uric acid. The creatinine comes from the metabolic breakdown of creatine phospate (a high-energy phosphate in muscles). Uric acid comes from the break down of nucleotides. Uric acid is insoluble and too much uric acid in the blood will build up and form crystals that can collect in the joints and cause gout.

Secretion of Hormones The endocrine system has assistance from the kidney's when releasing hormones. Renin is released by the kidneys. Renin leads to the secretion of aldosterone which is released from the adrenal cortex. Aldosterone promotes the kidneys to reabsorb the sodium (Na+) ions. The kidneys also secrete erythropoietin when the blood doesn't have the capacity to carry oxygen. Erythropoietin stimulates red blood cell production. The Vitamin D from the skin is also activated with help from the kidneys. Calcium (Ca+) absorption from the digestive tract is promoted by vitamin D.

CC: Chapter Check: Name the role of the kidneys and how they work?

[edit] Organs in the Urinary System

[edit] Kidneys And Their Structure

The kidneys are a pair of bean shaped, reddish brown organs about the size of your fist.It measures 10-12 cm long. They are covered by the renal capsule, which is a tough capsule of fibrous connective tissue. Adhering to the surface of each kidney is two layers of fat to help cushion them. There is a concaved side of the kidney that has a depression where a renal artery enters, and a renal vein and a ureter exit the kidney. The kidneys are located at the rear wall of the abdominal cavity just above the waistline, and are protected by the ribcage. They are considered retroperitoneal, which means they lie behind the peritoneum. There are three major regions of the kidney, renal cortex, renal medulla and the renal pelvis. The outer, granulated layer is the renal cortex. The cortex stretches down in between a radially striated inner layer. The inner radially striated layer is the renal medulla. This contains pyramid shaped tissue called the renal pyramids, separated by renal columns.

[edit] Renal Vein

The renal veins are veins that drain the kidney. They connect the kidney to the inferior vena cava. Because the inferior vena cava is on the right half of the body, the left renal vein is generally the longer of the two. Unlike the right renal vein, the left renal vein often receives the left gonadal vein (left testicular vein in males, left ovarian vein in females). It frequently receives the left suprarenal vein as well.

Renal Artery

The renal arteries normally arise off the abdominal aorta and supply the kidneys with blood. The arterial supply of the kidneys are variable and there may be one or more renal arteries supplying each kidney. Due to the position of the aorta, the inferior vena cava and the kidneys in the body, the right renal artery is normally longer than the left renal artery. The right renal artery

normally crosses posteriorly to the inferior vena cava. The renal arteries carry a large portion of the total blood flow to the kidneys. Up to a third of the total cardiac output can pass through the renal arteries to be filtered by the kidneys.

Ureters

The ureters are two tubes that drain urine from the kidneys to the bladder. Each ureter is a muscular tube about 10 inches (25 cm) long. Muscles in the walls of the ureters send the urine in small spurts into the bladder, (a collapsible sac found on the forward part of the cavity of the bony pelvis that allows temporary storage of urine). After the urine enters the bladder from the ureters, small folds in the bladder mucosa act like valves preventing backward flow of the urine. The outlet of the bladder is controlled by a sphincter muscle. A full bladder stimulates sensory nerves in the bladder wall that relax the sphincter and allow release of the urine. However, relaxation of the sphincter is also in part a learned response under voluntary control. The released urine enters the urethra.

Urinary Bladder

The urinary bladder is a hollow, muscular and distendible or elastic organ that sits on the pelvic floor (superior to the prostate in males). On its anterior border lies the pubic symphysis and, on its posterior border, the vagina (in females) and rectum (in males). The urinary bladder can hold approximately 17 to 18 ounces (500 to 530 ml) of urine, however the desire to micturate is usually experienced when it contains about 150 to 200 ml. When the bladder fills with urine (about half full), stretch receptors send nerve impulses to the spinal cord, which then sends a reflex nerve impulse back to the sphincter (muscular valve) at the neck of the bladder, causing it to relax and allow the flow of urine into the urethra. The Internal urethral sphincter is involuntary. The ureters enter the bladder diagonally from its dorsolateral floor in an area called the trigone. The trigone is a triangular shaped area on the postero-inferior wall of the bladder. The urethra exits at the lowest point of the triangle of the trigone. The urine in the bladder also helps regulate body temperature. If the bladder becomes completely void of fluid, it causes the patient to chill.

Urethra

Female urethra (labeled at bottom right.)

Male Sphincter urethrae muscle - The male urethra laid open on its anterior (upper) surface. (Region visible, but muscle not labeled.)

The urethra is a muscular tube that connects the bladder with the outside of the body. The function of the urethra is to remove urine from the body. It measures about 1.5 inches (3.8 cm) in a woman but up to 8 inches (20 cm) in a man. Because the urethra is so much shorter in a woman it makes it much easier for a woman to get harmful bacteria in her bladder this is commonly called a bladder infection or a UTI. The most common bacteria of a UTI is E-coli from the large intestines that have been excreted in fecal matter. Female urethra

In the human female, the urethra is about 1-2 inches long and opens in the vulva between the clitoris and the vaginal opening.

Men have a longer urethra than women. This means that women tend to be more susceptible to infections of the bladder (cystitis) and the urinary tract.

Male urethra

In the human male, the urethra is about 8 inches long and opens at the end of the head of the penis.

The length of a male's urethra, and the fact it contains a number of bends, makes catheterisation more difficult.

The urethral sphincter is a collective name for the muscles used to control the flow of urine from the urinary bladder. These muscles surround the urethra, so that when they contract, the urethra is closed.

There are two distinct areas of muscle: the internal sphincter, at the bladder neck and the external, or distal, sphincter.

Human males have much stronger sphincter muscles than females, meaning that they can retain a large amount of urine for twice as long, as much as 800mL, i.e. "hold it".

Nephrons

A nephron is the basic structural and functional unit of the kidney. The name nephron comes from the Greek word (nephros) meaning kidney. Its chief function is to regulate water and soluble substances by filtering the blood, reabsorbing what is needed and excreting the rest as urine. Nephrons eliminate wastes from the body, regulate blood volume and pressure, control levels of electrolytes and metabolites, and regulate blood pH. Its functions are vital to life and are regulated by the endocrine system by hormones such as antidiuretic hormone, aldosterone, and parathyroid hormone.

Each nephron has its own supply of blood from two capillary regions from the renal artery. Each nephron is composed of an initial filtering component (the renal corpuscle) and a tubule specialized for reabsorption and secretion (the renal tubule). The renal corpuscle filters out large solutes from the blood, delivering water and small solutes to the renal tubule for modification.

Glomerulus

The glomerulus is a capillary tuft that receives its blood supply from an afferent arteriole of the renal circulation. The glomerular blood pressure provides the driving force for fluid and solutes to be filtered out of the blood and into the space made by Bowman's capsule. The remainder of the blood not filtered into the glomerulus passes into the narrower efferent arteriole. It then moves into the vasa recta, which are collecting capillaries intertwined with the convoluted tubules through the interstitial space, where the reabsorbed substances will also enter. This then combines with efferent venules from other nephrons into the renal vein, and rejoins with the main bloodstream.

Afferent/Efferent Arterioles

The afferent arteriole supplies blood to the glomerulus. A group of specialized cells known as juxtaglomerular cells are located around the afferent arteriole where it enters the renal corpuscle. The efferent arteriole drains the glomerulus. Between the two arterioles lies specialized cells called the macula densa. The juxtaglomerular cells and the macula densa collectively form the juxtaglomerular apparatus. It is in the juxtaglomerular apparatus cells that the enzyme renin is formed and stored. Renin is released in response to decreased blood

pressure in the afferent arterioles, decreased sodium chloride in the distal convoluted tubule and sympathetic nerve stimulation of receptors (beta-adrenic) on the juxtaglomerular cells. Renin is needed to form Angiotensin I and Angiotensin II which stimulate the secretion of aldosterone by the adrenal cortex.

Glomerular Capsule or Bowman's Capsule

Bowman's capsule (also called the glomerular capsule) surrounds the glomerulus and is composed of visceral (simple squamous epithelial cells) (inner) and parietal (simple squamous epithelial cells) (outer) layers. The visceral layer lies just beneath the thickened glomerular basement membrane and is made of podocytes which send foot processes over the length of the glomerulus. Foot processes interdigitate with one another forming filtration slits that, in contrast to those in the glomeruluar endothelium, are spanned by diaphragms. The size of the filtration slits restricts the passage of large molecules (eg, albumin) and cells (eg, red blood cells and platelets). In addition, foot processes have a negatively-charged coat (glycocalyx) that limits the filtration of negatively-charged molecules, such as albumin. This action is called electrostatic repulsion.

The parietal layer of Bowman's capsule is lined by a single layer of squamous epithelium. Between the visceral and parietal layers is Bowman's space, into which the filtrate enters after passing through the podocytes' filtration slits. It is here that smooth muscle cells and macrophages lie between the capillaries and provide support for them. Unlike the visceral layer, the parietal layer does not function in filtration. Rather, the filtration barrier is formed by three components: the diaphragms of the filtration slits, the thick glomerular basement membrane, and the glycocalyx secreted by podocytes. 99% of glomerular filtrate will ultimately be reabsorbed.

The process of filtration of the blood in the Bowman's capsule is ultrafiltration (or glomerular filtration), and the normal rate of filtration is 125 ml/min, equivalent to ten times the blood volume daily. Measuring the glomerular filtration rate (GFR) is a diagnostic test of kidney function. A decreased GFR may be a sign of renal failure. Conditions that can effect GFR include: arterial pressure, afferent arteriole constriction, efferent arteriole constriction, plasma protein concentration and colloid osmotic pressure.

Any proteins that are roughly 30 kilodaltons or under can pass freely through the membrane. Although, there is some extra hindrance for negatively charged molecules due to the negative charge of the basement membrane and the podocytes. Any small molecules such as water, glucose, salt (NaCl), amino acids, and urea pass freely into Bowman's space, but cells, platelets and large proteins do not. As a result, the filtrate leaving the Bowman's capsule is very similar to blood plasma in composition as it passes into the proximal convoluted tubule. Together, the glomerulus and Bowman's capsule are called the renal corpuscle.

Proximal Convoluted Tubule (PCT)

The proximal tubule can be anatomically divided into two segments: the proximal convoluted tubule and the proximal straight tubule. The proximal convoluted tubule can be divided further into S1 and S2 segments based on the histological appearance of it's cells. Following this naming

convention, the proximal straight tubule is commonly called the S3 segment. The proximal convoluted tubule has one layer of cuboidal cells in the lumen. This is the only place in the nephron that contains cuboidal cells. These cells are covered with millions of microvilli. The microvilli serve to increase surface area for reabsorption.

Fluid in the filtrate entering the proximal convoluted tubule is reabsorbed into the peritubular capillaries, including approximately two-thirds of the filtered salt and water and all filtered organic solutes (primarily glucose and amino acids). This is driven by sodium transport from the lumen into the blood by the Na+/K+ ATPase in the basolateral membrane of the epithelial cells. Much of the mass movement of water and solutes occurs in between the cells through the tight junctions, which in this case are not selective.

The solutes are absorbed isotonically, in that the osmotic potential of the fluid leaving the proximal tubule is the same as that of the initial glomerular filtrate. However, glucose, amino acids, inorganic phosphate, and some other solutes are reabsorbed via secondary active transport through cotransport channels driven by the sodium gradient out of the nephron.

] Loop of the Nephron or Loop of Henle

The Nephron Loop or Loop of Henle.

The loop of Henle (sometimes known as the nephron loop) is a U-shaped tube that consists of a descending limb and ascending limb. It begins in the cortex, receiving filtrate from the proximal convoluted tubule, extends into the medulla, and then returns to the cortex to empty into the distal convoluted tubule. Its primary role is to concentrate the salt in the interstitium, the tissue surrounding the loop.

Descending limbIts descending limb is permeable to water but completely impermeable to salt, and thus only indirectly contributes to the concentration of the interstitium. As the filtrate descends deeper into the hypertonic interstitium of the renal medulla, water flows freely out of the descending limb by osmosis until the tonicity of the filtrate and interstitium equilibrate. Longer descending limbs allow more time for water to flow out of the filtrate, so longer limbs make the filtrate more hypertonic than shorter limbs.

Ascending limbUnlike the descending limb, the ascending limb of Henle's loop is impermeable to water, a critical feature of the countercurrent exchange mechanism employed by the loop. The ascending limb actively pumps sodium out of the filtrate, generating the hypertonic interstitium that drives countercurrent exchange. In passing through the ascending limb, the filtrate grows hypotonic since it has lost much of its sodium content. This hypotonic filtrate is passed to the distal convoluted tubule in the renal cortex.

Distal Convoluted Tubule (DCT)

The distal convoluted tubule is similar to the proximal convoluted tubule in structure and function. Cells lining the tubule have numerous mitochondria, enabling active transport to take place by the energy supplied by ATP. Much of the ion transport taking place in the distal convoluted tubule is regulated by the endocrine system. In the presence of parathyroid hormone, the distal convoluted tubule reabsorbs more calcium and excretes more phosphate. When aldosterone is present, more sodium is reabsorbed and more potassium excreted. Atrial natriuretic peptide causes the distal convoluted tubule to excrete more sodium. In addition, the tubule also secretes hydrogen and ammonium to regulate pH. After traveling the length of the distal convoluted tubule, only 3% of water remains, and the remaining salt content is negligible. 97.9% of the water in the glomerular filtrate enters the convoluted tubules and collecting ducts by osmosis.

Maintaining Water-Salt Balance

It is the job of the kidneys to maintain the water-salt balance of the blood. They also maintain blood volume as well as blood pressure. Simple examples of ways that this balance can be changed include ingestion of water, dehydration, blood loss and salt ingestion.

Reabsorption of water

Direct control of water excretion in the kidneys is exercised by the anti-diuretic hormone (ADH), released by the posterior lobe of the pituitary gland. ADH causes the insertion of water channels into the membranes of cells lining the collecting ducts, allowing water reabsorption to occur. Without ADH, little water is reabsorbed in the collecting ducts and dilute urine is excreted.

There are several factors that influence the secretion of ADH. The first of these happen when the blood plasma gets too concentrated. When this occurs, special receptors in the hypothalamus release ADH. When blood pressure falls, stretch receptors in the aorta and carotid arteries stimulate ADH secretion to increase volume of the blood.

Reabsorption of Salt

The Kidneys also regulate the salt balance in the blood by controlling the excretion and the reabsorption of various ions. As noted above, ADH plays a role in increasing water reabsorption in the kidneys, thus helping to dilute bodily fluids. The kidneys also have a regulated mechanism for reabsorbing sodium in the distal nephron. This mechanism is controlled by aldosterone, a steroid hormone produced by the adrenal cortex. Aldosterone promotes the excretion of potassium ions and the reabsorption of sodium ions. The release of Aldosterone is initiated by the kidneys. The juxtaglomerular apparatus is a renal structure consisting of the macula densa, mesangial cells, and juxtaglomerular cells. Juxtaglomerular cells (JG cells, also known as granular cells) are the site of renin secretion. Renin is an enzyme that converts angiotensinogen (a large plasma protein produced by the liver) into Angiotensin I and eventually into Angiotensin II which stimulates the adrenal cortex to produce aldosterone. The reabsorption of sodium ions is followed by the reapsorption of water. This causes blood pressure as well as blood volume to increase.

Atrial natriuretic hormone (ANH) is released by the atria of the heart when cardiac cells are streatched due to increased blood volume. ANH inhibits the secretion of renin by the juxtaglomerular apparatus and the secretion of the aldosterone by the adrenal cortex. This promotes the excretion of sodium. When sodium is excreted so is water. This causes blood pressure and volume to decrease.

Hypernatremia

An increase in plasma sodium levels above normal is hypernatremia. Sodium is the primary solute in the extracellular fluid. Sodium levels have a major role in osmolarity regulation. For excitable cells the electrochemical gradient for sodium across the plasma membrane is critical for life. Water retention and an increased blood pressure usually are signs of hypernatremia. If the plasma sodium levels are below normal it is called hyponatremia. Signs of this are low plasma volume and hypotension.

Diuretics

A diuretic (colloquially called a water pill) is any drug that elevates the rate of bodily urine excretion (diuresis). Diuretics also decrease the extracellular fluid (ECF) volume, and are primarily used to produce a negative extracellular fluid balance. Caffeine, cranberry juice and alcohol are all weak diuretics. In medicine, diuretics are used to treat heart failure, liver cirrhosis, hypertension and certain kidney diseases. Diuretics alleviate the symptoms of these diseases by causing sodium and water loss through the urine. As urine is produced by the kidney, sodium and water – which cause edema related to the disease – move into the blood to replace the volume lost as urine, thereby reducing the pathological edema. Some diuretics, such as acetazolamide,

help to make the urine more alkaline and are helpful in increasing excretion of substances such as aspirin in cases of overdose or poisoning. The antihypertensive actions of some diuretics (thiazides and loop diuretics in particular) are independent of their diuretic effect. That is, the reduction in blood pressure is not due to decreased blood volume resulting from increased urine production, but occurs through other mechanisms and at lower doses than that required to produce diuresis. Indapamide was specifically designed with this is mind, and has a larger therapeutic window for hypertension (without pronounced diuresis) than most other diuretics. Chemically, diuretics are a diverse group of compounds that either stimulate or inhibit various hormones that naturally occur in the body to regulate urine production by the kidneys. Alcohol produces diuresis through modulation of the vasopressin system.

Diseases of the Kidney

Diabetic nephropathy (nephropatia diabetica), also known as Kimmelstiel-Wilson syndrome and intercapillary glomerulonephritis, is a progressive kidney disease caused by angiopathy of capillaries in the kidney glomeruli. It is characterized by nodular glomerulosclerosis. It is due to longstanding diabetes mellitus, and is a prime cause for dialysis in many Western countries.

An image of a kidney stone.

In medicine, hematuria (or "haematuria") is the presence of blood in the urine. It is a sign of a large number of diseases of the kidneys and the urinary tract, ranging from trivial to lethal.

Kidney stones, also known as nephrolithiases, urolithiases or renal calculi, are solid accretions (crystals) of dissolved minerals in urine found inside the kidneys or ureters. They vary in size from as small as a grain of sand to as large as a golf ball. Kidney stones typically leave the body in the urine stream; if they grow relatively large before passing (on the order of millimeters), obstruction of a ureter and distention with urine can cause severe pain most commonly felt in the flank, lower abdomen and groin. Kidney stones are unrelated to gallstones.

Case Study I was 34 weeks pregnant when I noticed blood in my urine. I immediately went to my OBGYN where I was told that I had a bladder infection and given an antibiotic. The next morning I experienced the most intense pain. I was rushed to the ER where I was told that I had kidney stones. The doctors explained that there was nothing they could do as long as I was pregnant. The next 3 weeks of my life were filled with intense pain and multiple painkillers. After I delivered my baby, CAT scans were done and I was informed that I had 6 kidney stones. It took three more weeks for me to pass all of the stones the largest measuring 5 mm. The stones were tested and I was informed that my body had been building up calcium due to my pregnancy and this was the cause of the kidney stones. I continued to have kidney pain for 6 months after passing the stones. I now live my life on a low calcium diet and the hope that my body will not develop more kidney stones.

Pyelonephritis When an infection of the renal pelvis and calices, called pyelitis, spreads to involve the rest of the kidney as well, the result is pyelonephritis. It usually results from the spread of fecal bacterium Escherichia coli from the anal region superiorly through the urinary tract. In severe cases, the kidney swells and scars, abscesses form, and the renal pelvis fills with pus. Left untreated, the infected kidney may be severely damaged, but administration of antibiotics usually achieve a total cure.

glomerulonephritis Inflammation of the glomerular can be caused by immunologic abnormalities, drugs or toxins, vascular disorders, and systemic diseases. Glomerulonephritis can be acute, chronic or progressive. Two major changes in the urine are distinctive of glomerulonephritis: hematuria and proteinuria with albumin as the major protein. There is also a decrease in urine as there is a decrease in GFR (glomerular filtration rate). Renal failure is associated with oliguria (less than 400 ml of urine output per day).

Renal Failure Uremia is a syndrome of renal failure and includes elevated blood urea and creatinine levels. Acute renal failure can be reversed if diagnosed early. Acute renal failure can be caused by severe hypotension or severe glomerular disease. Diagnostic tests include BUN and plasma creatinine level tests. It is considered to be chronic renal failure if the decline of renal function to less than 25%.

Diabetes Insipidus

This is caused by the deficiency of or decrease of ADH. The person with (DI) has the inability to concentrate their urine in water restriction, in turn they will void up 3 to 20 liters/day. There are two forms of (DI), neurogenic, and nephrogenic. In nephrogenic (DI) the kidneys do not respond to ADH. Usually the nephrogenic (DI) is characterized by the impairment of the urine concentrating capability of the kidney along with concentration of water. The cause may be a genetic trait, electrolyte disorder, or side effect of drugs such as lithium. In the neurogenic (DI), it is usually caused by head injury near the hypophysisal tract.

Urinary tract infections (UTI's)

The second most common type of bacterial infections seen by health care providers is UTI's. Out of all the bacterias that colonize and cause urinary tract infections the big gun is Escherichia coli.

In the hospital indwelling catheters and straight catheterizing predispose the opportunity for urinary tract infections. In females there are three stages in life that predispose urinary tract infections, that is menarche, manipulation between intercourse, and menopause. However, a small percentage of men and children will get urinary tract infections. In men it is usually due to the prostate gland growth which usually occurs in older age men. In children it can occur 3% to 5% in girls and 1% in boys, uncircumcised boys it is more common than circumcised ones to have a urinary tract infection, in girls it may be the result of onset of toilet training, some predispositions for getting urinary tract infection include family history and urinary tract anomalies. In neonates urinary tract infections is most common when bacteremia is present.

Dialysis and Kidney Transplant

Plugged into dialysis

Generally, humans can live normally with just one kidney. Only when the amount of functioning kidney tissue is greatly diminished will renal failure develop. If renal function is impaired, various forms of medications are used, while others are contraindicated. Provided that treatment is begun early, it may be possible to reverse chronic kidney failure due to diabetes or high blood pressure. If creatinine clearance (a measure of renal function) has fallen very low ("end-stage renal failure"), or if the renal dysfunction leads to severe symptoms, dialysis is commenced. Dialysis is a medical procedure, performed in various different forms, where the blood is filtered outside of the body.

Kidney transplantation is the only cure for end stage renal failure; dialysis, is a supportive treatment; a form of "buying time" to bridge the inevitable wait for a suitable organ.

The first successful kidney transplant was announced on March 4, 1954 at Peter Bent Brigham Hospital in Boston. The surgery was performed by Dr. Joseph E. Murray, who was awarded the Nobel Prize in Medicine in 1990 for this feat.

There are two types of kidney transplants: living donor transplant and a cadaveric (dead donor) transplant. When a kidney from a living donor, usually a blood relative, is transplanted into the patient's body, the donor's blood group and tissue type must be judged compatible with the patient's, and extensive medical tests are done to determine the health of the donor. Before a cadaveric donor's organs can be transplanted, a series of medical tests have to be done to determine if the organs are healthy. Also, in some countries, the family of the donor must give its consent for the organ donation. In both cases, the recipient of the new organ needs to take drugs to suppress their immune system to help prevent their body from rejecting the new kidney.

Review QuestionsAnswers for these questions can be found here

1.While reading a blood test I notice a high level of creatinine, I could assume from this that

A) There is a possibility of a UTIB) There is a possibility of diabetesC) There is a possibility of kidney failureD) There is nothing wrong, this is normal

2.Direct control of water excretion in the kidneys is controlled by

A) Anti-diuretic hormoneB) The medulla oblongataC) Blood plasmaD) Sodium amounts in the blood

3. Nephrons

A) Eliminate wastes from the bodyB) Regulate blood volume and pressureC) Control levels of electrolytes and metabolitesD) Regulate blood pHE) All of the above

4. If I am dehydrated, my body will increase

A) ATPB) ADPC) Diluted urineD) ADH

5.Which part of the nephron removes water, ions and nutrients from the blood?

A ) vasa rectaB ) loop of henleC ) proximal convuluted tubuleD ) peritubular capillariesE ) glomerulus

6.Kidneys have a direct effect on which of the following

A ) Blood pressureB ) How much water a person excretesC ) Total blood volumeD ) pH

E ) all of the above

7. Why do substances in the glomerulus enter the Bowman's capsule?

A ) the magnetic charge of the Bowman's capsule attracts the substancesB ) the substances are actively transported into the Bowman's capsuleC ) blood pressure of the glomerulus is so great that most substances in blood move into capsuleD ) little green men force it in with their ray guns

8. What happens in tubular excretion?

A ) urine bonds are formed between the wastesB ) wastes are diffused from the tubuleC ) wastes move into the distal convoluted tubule from the bloodD ) blood pressure forces wastes away from the kidney

9. The countercurrent exchange system includes_________and_________.

A ) glomerulus and macula densaB ) proximal convoluted tubule and distal convoluted tubuleC ) loop of Henle and collecting tubuleD ) afferent arteriole and efferent arterioleE ) ureters and bladder

10. The function of the loop of the nephron in the process of urine formation is:

A ) reabsorption of waterB ) production of filtrateC ) reabsorption of solutesD ) secretion of solutes

11. Name the six important roles of the kidneys.

Glossary

Antidiuretic: lessening or decreasing of urine production or an agent that decreases the release of urine.

Catheterisation: a catheter is a tube that can be inserted into a body cavity, duct or vessel. Catheters thereby allow drainage or injection of fluids or access by surgical instruments. The process of inserting a catheter is catheterisation. In most uses a catheter is a thin, flexible tube: a "soft" catheter; in some uses, it is a larger, solid tube: a "hard" catheter.

Dehydration: condition resulting from excessive loss of body fluid.

Diabetes: a general term for a disease characterized by the begining stages and onset of renal failure. It is derived from the Greek word diabaínein, that literally means "passing through," or "siphon", a reference to one of diabetes' major symptoms—excessive urine production.

Diuresis: secretion and passage of large amounts of urine.

Diuretic: increasing of urine production, or an agent that increases the production of urine.

Erythropoietin: hormone that stimulates stem cells in the bone marrow to produce red blood cells

Fibrous Capsule: the kidney's loose connective tissue

Glomerulus: capillary tuft that receives its blood supply from an afferent arteriole of the renal circulation.

Gluconeogenesis: the cycle of producing a glucose form fat or protein; preformed by the kidney in times of long fasting, initially gluconeogenesis is preformed by the liver

Juxtaglomerular (JG) cells: Renin-secreting cells that are in contact with the macula densa and the afferent arterioles of the renal nephron.

Juxtaglomerular apparatus (JGA): A site of juxtaglomerular cells connecting with the macula densa where renin is secreted and sensor for control of secretion of golmerular filtration rate.

Loop of Henle/ Nephron Loop: u-shaped tube that consists of a descending limb and ascending limb; primary role is to concentrate the salt in the interstitium, the tissue surrounding the loop

Medullary Pyramids or Renal Pyramids: the cone shaped masses in the kidney

Micturition: another name for excretions

Nephron: basic structural and functional unit of the kidney; chief function is to regulate water and soluble substances by filtering the blood, reabsorbing what is needed and excreting the rest as urine

Podocytes: filtration membrane, in the visceral layer of the bowman's capsule

Renal Calculi: kidney stones, solid crystals of dissolved minerals in urine found inside the kidneys

Renal Cortex: outer portion of the kidney

Renal Lobe: each pyramid together with the associated overlying cortex

Renal Pelvis: a central space, or cavity that transmits urine to the urinary bladder via the ureter

Renin: hormone released by the Juxtaglomerular (JG) cells of the kidneys when blood pressure falls

TURP: transurethral resection of the prostate. During TURP, an instrument is inserted up the urethra to remove the section of the prostate that is blocking urine flow. This is most commonly caused by benign prostatic hyperplasia (BPH). A TURP usually requires hospitalization and is done using a general or spinal anesthetic. It is now the most common surgery used to remove part of an enlarged prostate.

Urethra: a muscular tube that connects the bladder with the outside of the body

Ureters: two tubes that drain urine from the kidneys to the bladder

Urine: liquid produced by the kidneys, collected in the bladder and excreted through the urethra

Urinary Bladder: a hollow, muscular and distensible or elastic organ that sits on the pelvic floor

Urinary System: a group of organs in the body concerned with filtering out excess fluid and other substances from the bloodstream

LABARATORY EXAM:DATE

TEST NORMAL RESULT INTERPRETATION

11-19-09

HEMATOLOGY: WBC RBC HEMATOCRIT PLATELET COUNT

MALE:5-10X 10g/L 4-6X 10g/LMALE: 40-50FEMALE: 38-48150,000-300,000/cu mm

11.15.640

275,000/cu mm

>due to infection>normal>normal

>normal

11-19-09

URINALYSIS: COLOR APPEARANCE REACTION SPECIFIC GRAVITY PROTEIN GLUCOSE RBC’S/HPF WBC’S/HPF EPITHELIAL CELLS BACTERIA CRYSTAL/LPF

a. AMORPHOUS URATES

YELLOW AMBERCLEARACIDIC1.0010NEGATIVENEGATIVE

YELLOWSLIGHTY TURBIDACIDIC1.015NEGATIVEPOSITIVE5-8/HPF4-6/HPFRAREFEWPOSITIVE

Normal

Normal

Normal Glucosuria

11-19-09

FECALYSIS: BACTERIA Negative ++++ (+ )salmonella

COLOR CONSISTENCY BACTERIA RBC PUST CELLS PARACITES OR OVA

Brown

Negative

Brownwatery +++None 0-1/hpsNo ova or parasites

typhiNormal

11-19-09

LABORATORY RESULTS: BLOOD CHEM. RESULT GLUCOSE FBS

70-105mg/dl 150.8mg/dl >positive diabetes mellitus

11-19-09

MISCELLANEOUS TEST: TYPHOID IgG/IgM RAPID TEST RBS

Negative

70-160mg/dl

POSITIVE(anti S. typhi IgG)

271mg/dl

11-19-09

DIFFERENTIAL COUNT: SEGMENTERS LYMPHOCYTES EOSINOPHILS BSMP

.40-.60

.20-.49

.01-.05

0.670.310.02NEGATIVE

COURSE IN THE WARD:

Doctor’s order Rationale Nursing responsibility11-19-09

Please admit to room 301 under Dr. AdL

secure consent

start IVF with D5NM X 12hours plus vitamin B-complex ANST

For proper medical management

For legal purposes and in order for the patient to know all management to be done

Admitted to pay ward

Explanations given and secured consent

I

DAT and no dark color food

lab CBC, UA,F/A,

Monitor BP, CR,RR and Temp. q 4And record

Monitor I and O every 8 hours

Refer result as soon as possible

Refer for any problem

FBS for AM advice NPO

meds: ◦ start ceftriaxone(triavex) 1g

slow IV push now then q 12 hrs ANST

Ibuprofen+ paracetamol(muskelax) 1 tab PC PRN for fever, headache, and body pain

Continue glimepiride(getryl) 2 mg 1 tab OD 30 mins. AC

11-20-09

It may alter fecalysis result

CBC-to evaluate blood components for maintenance of body fluids and electrolytesU/A- to determine glucose in the urineF/A- to determine presence of bacteria

Use as a baseline data

To know if the patient has a balance intake and output

To check for any problems and complications

to determine the proper management

no alteration for the result

to avoid infection

for pain reliever

to lower blood glucose

Advice the patient not to eat dark color food

secured for lab request, follow up result and referred to ROD

monitor and record

measure and check q shift

refer to C.I or NOD

refer to C.I or NOD

Instructed patient not to eat and drink anything

administer medication through IV push

Administered effectively and efficiently and watched for the s/s of drug

Administered drug effectively and efficiently

Checked the patency of the IV line

Referred to NOD

8 am IVF TF PNSS 1L x 12 hrs

Problem- 38.8 degree celcius

Give paracetamol 1 ampule IM

Continue TSB c/o NAOD and student nurse incharge

Continue meds

11-21-09 IVF to consume

MGH

Home meds:Ciprofloxaxin 50 mg/ tab BID, 6 am-4 pm on a full stomachGlimepiride(getryl) 2 mg/ tab OD 30 mins ACIbuprofen + paracetamol(muskelax) 1 tab TID PRN for fever, headache and body pain

Increase fluid intake

Advice proper disposal of human excretion and secretion

Advice segregation of dirty utensils

Diabetic diet; 1800 calories

Avoid table sugar of all beverages

for recovery

body mechanism to the disease

to lower temperature

aids decrease in temperature

for recovery

for recovery

recovered

for recovery

To replace loss fluid o the body and balance electrolytes

To avoid contamination to other people

To avoid contamination

For management of diabetes mellitus

For management of DM

Administered medication IM w/ monitoringTSB done by the student nurse in charge

Administered effectively and efficiently and watched for the s/s of drug

check for the consumption of the IVF and monitored drop factor as doctor’s order

monitored for fast recovery

Advice to take clean and safe water

Segregate waste to its proper disposal

Instruct patient and S.O to wash utensils properly

Advice patient to decrease sugar intake

Advice patient to decrease sugar intake

ANATOMY AND PHYSIOLOGY:

The human digestive system is a complex series of organs and glands that processes food.

In order to use the food we eat, our body has to break the food down into smaller molecules

that it can process; it also has to excrete waste.

Most of the digestive organs (like the stomach and intestines) are tube-like and contain the

food as it makes its way through the body. The digestive system is essentially a long,

twisting tube that runs from the mouth to the anus, plus a few other organs (like the liver

and pancreas) that produce or store digestive chemicals.

TheDigestiveProcess:

The start of the process - the mouth: The digestive process begins in the mouth. Food is

partly broken down by the process of chewing and by the chemical action of salivary

enzymes (these enzymes are produced by the salivary glands and break down starches into

smaller molecules).

On the way to the stomach: the esophagus - After being chewed and swallowed, the food

enters the esophagus. The esophagus is a long tube that runs from the mouth to the

stomach. It uses rhythmic, wave-like muscle movements (called peristalsis) to force food

from the throat into the stomach. This muscle movement gives us the ability to eat or drink

even when we're upside-down.

Human Digestive System

In the stomach - The stomach is a large, sack-like organ that churns the food and bathes it

in a very strong acid (gastric acid). Food in the stomach that is partly digested and mixed

with stomach acids is called chyme.

In the small intestine - After being in the stomach, food enters the duodenum, the first part

of the small intestine. It then enters the jejunum and then the ileum (the final part of the

small intestine). In the small intestine, bile (produced in the liver and stored in the gall

bladder), pancreatic enzymes, and other digestive enzymes produced by the inner wall of

the small intestine help in the breakdown of food.

In the large intestine - After passing through the small intestine, food passes into the large

intestine. In the large intestine, some of the water and electrolytes (chemicals like sodium)

are removed from the food. Many microbes (bacteria like Bacteroides, Lactobacillus

acidophilus, Escherichia coli, and Klebsiella) in the large intestine help in the digestion

process. The first part of the large intestine is called the cecum (the appendix is connected

to the cecum). Food then travels upward in the ascending colon. The food travels across the

abdomen in the transverse colon, goes back down the other side of the body in the

descending colon, and then through the sigmoid colon.

The end of the process - Solid waste is then stored in the rectum until it is excreted via the

anus.

Digestive System Glossary:

anus - the opening at the end of the digestive system from which feces (waste) exits the

body.

Appendix - a small sac located on the cecum.

Ascending colon - the part of the large intestine that run upwards; it is located after the

cecum.

Bile - a digestive chemical that is produced in the liver, stored in the gall bladder, and

secreted into the small intestine.

cecum - the first part of the large intestine; the appendix is connected to the cecum.

chyme - food in the stomach that is partly digested and mixed with stomach acids. Chyme

goes on to the small intestine for further digestion.

Descending colon - the part of the large intestine that run downwards after the transverse

colon and before the sigmoid colon.

Duodenum - the first part of the small intestine; it is C-shaped and runs from the stomach

to the jejunum.

Epiglottis - the flap at the back of the tongue that keeps chewed food from going down the

windpipe to the lungs. When you swallow, the epiglottis automatically closes. When you

breathe, the epiglottis opens so that air can go in and out of the windpipe.

Esophagus - the long tube between the mouth and the stomach. It uses rhythmic muscle

movements (called peristalsis) to force food from the throat into the stomach.

Gall bladder - a small, sac-like organ located by the duodenum. It stores and releases bile

(a digestive chemical which is produced in the liver) into the small intestine.

Ileum - the last part of the small intestine before the large intestine begins.

Jejunum - the long, coiled mid-section of the small intestine; it is between the duodenum

and the ileum.

Liver - a large organ located above and in front of the stomach. It filters toxins from the

blood, and makes bile (which breaks down fats) and some blood proteins.

Mouth - the first part of the digestive system, where food enters the body. Chewing and

salivary enzymes in the mouth are the beginning of the digestive process (breaking down

the food).

Pancreas - an enzyme-producing gland located below the stomach and above the intestines.

Enzymes from the pancreas help in the digestion of carbohydrates, fats and proteins in the

small intestine.

Peristalsis - rhythmic muscle movements that force food in the esophagus from the throat

into the stomach. Peristalsis is involuntary - you cannot control it. It is also what allows you

to eat and drink while upside-down.

Rectum - the lower part of the large intestine, where feces are stored before they are

excreted.

Salivary glands - glands located in the mouth that produce saliva. Saliva contains enzymes

that break down carbohydrates (starch) into smaller molecules.

Sigmoid colon - the part of the large intestine between the descending colon and the

rectum.

Stomach - a sack-like, muscular organ that is attached to the esophagus. Both chemical and

mechanical digestion takes place in the stomach. When food enters the stomach, it is

churned in a bath of acids and enzymes.

Transverse colon - the part of the large intestine that runs horizontally across the

abdomen.

Functions of the Digestive System

The digestive system includes the digestive tract and its

accessory organs, which process food into molecules that can be

absorbed and utilized by the cells of the body. Food is broken

down, bit by bit, until the molecules are small enough to be

absorbed and the waste products are eliminated. The digestive

tract, also called the alimentary canal or gastrointestinal (GI) tract, consists of a long

continuous tube that extends from the mouth to the anus. It includes the mouth, pharynx,

esophagus, stomach, small intestine, and large intestine. The tongue and teeth are accessory

structures located in the mouth. The salivary glands, liver, gallbladder, and pancreas are

major accessory organs that have a role in digestion. These organs secrete fluids into the

digestive tract.

Food undergoes three types of processes in the body:

Digestion

Absorption

Elimination

Digestion and absorption occur in the digestive tract. After the nutrients are absorbed, they

are available to all cells in the body and are utilized by the body cells in metabolism.

The digestive system prepares nutrients for utilization by body cells through six activities,

or functions.

Ingestion. The first activity of the digestive system is to take in food through the mouth.

This process, called ingestion, has to take place before anything else can happen.

Mechanical Digestion. The large pieces of food that are ingested have to be broken into

smaller particles that can be acted upon by various enzymes. This is mechanical digestion,

which begins in the mouth with chewing or mastication and continues with churning and

mixing actions in the stomach.

Chemical Digestion The complex

molecules of carbohydrates, proteins,

and fats are transformed by chemical

digestion into smaller molecules that can

be absorbed and utilized by the cells.

Chemical digestion, through a process

called hydrolysis, uses water and

digestive enzymes to break down the

complex molecules. Digestive enzymes

speed up the hydrolysis process, which is

otherwise very slow.

Movements. After ingestion and mastication, the food particles move from the mouth into

the pharynx, then into the esophagus. This movement is deglutition, or swallowing. Mixing

movements occur in the stomach as a result of smooth muscle contraction. These repetitive

contractions usually occur in small segments of the digestive tract and mix the food

particles with enzymes and other fluids. The movements that propel the food particles

through the digestive tract are called peristalsis. These are rhythmic waves of contractions

that move the food particles through the various regions in which mechanical and chemical

digestion takes place.

Absorption. The simple molecules that result from chemical digestion pass through cell

membranes of the lining in the small intestine into the blood or lymph capillaries. This

process is called absorption.

Elimination. The food molecules that cannot be digested or absorbed need to be eliminated

from the body. The removal of indigestible wastes through the anus, in the form of feces, is

defecation or elimination.

General Structure of the Digestive System

The long continuous tube that is the digestive tract is about 9 meters in length. It opens to

the outside at both ends, through the mouth at one end and through the anus at the other.

Although there are variations in each region, the basic structure of the wall is the same

throughout the entire length of the tube.

The wall of the digestive tract has four layers or tunics:

Mucosa

Submucosa

Muscular layer

Serous layer or serosa

The mucosa, or mucous membrane layer, is the innermost tunic of the wall. It lines the

lumen of the digestive tract. The mucosa consists of epithelium, an underlying loose

connective tissue layer called lamina propria, and a thin layer of smooth muscle called the

muscularis mucosa. In certain regions, the mucosa develops folds that increase the surface

area. Certain cells in the mucosa secrete mucus, digestive enzymes, and hormones. Ducts

from other glands pass through the mucosa to the lumen. In the mouth and anus, where

thickness for protection against abrasion is needed, the epithelium is stratified squamous

tissue. The stomach and intestines have a thin simple columnar epithelial layer for

secretion and absorption.

The submucosa is a thick layer of loose connective tissue that surrounds the mucosa. This

layer also contains blood vessels, lymphatic vessels, and nerves. Glands may be embedded

in this layer.

The smooth muscle responsible for movements of the digestive tract is arranged in two

layers, an inner circular layer and an outer longitudinal layer. The myenteric plexus is

between the two muscle layers.

Above the diaphragm, the outermost layer of the digestive tract is a connective tissue called

adventitia. Below the diaphragm, it is called serosa.

Organs of the Digestive System

At its simplest, the digestive system is a tube running from mouth to anus. Its chief goal is

to break down huge macromolecules (proteins, fats and starch), which cannot be absorbed

intact, into smaller molecules (amino acids, fatty acids and glucose) that can be absorbed

across the wall of the tube, and into the circulatory system for dissemination throughout

the body.

Regions of the digestive system can be divided into two main parts: the alimentary tract

and accessory organs. The alimentary tract of the digestive system is composed of the

mouth, pharynx, esophagus, stomach, small and large intestines, rectum and anus.

Associated with the alimentary tract are the following accessory organs: salivary glands,

liver, gallbladder, and pancreas.

Mouth

The mouth, or oral cavity, is the first part of the digestive

tract. It is adapted to receive food by ingestion, break it into

small particles by mastication, and mix it with saliva. The lips,

cheeks, and palate form the boundaries. The oral cavity

contains the teeth and tongue and receives the secretions from

the salivary glands.

Lips and Cheeks

The lips and cheeks help hold food in the mouth and keep it in place for chewing. They are

also used in the formation of words for speech. The lips contain numerous sensory

receptors that are useful for judging the temperature and texture of foods.

Palate

The palate is the roof of the oral cavity. It separates the oral cavity from the nasal cavity.

The anterior portion, the hard palate, is supported by bone. The posterior portion, the soft

palate, is skeletal muscle and connective tissue. Posteriorly, the soft palate ends in a

projection called the uvula. During swallowing, the soft palate and uvula move upward to

direct food away from the nasal cavity and into the oropharynx.

Tongue

The tongue manipulates food in the mouth and is used in speech. The surface is covered

with papillae that provide friction and contain the taste buds.

Teeth

A complete set of deciduous (primary) teeth contains 20 teeth. There are 32 teeth in a

complete permanent (secondary) set. The shape of each tooth type corresponds to the way

it handles food.

Pharynx and Esophagus

Pharynx

The pharynx is a fibromuscular passageway that connects the nasal and oral cavities to the

larynx and esophagus. It serves both the respiratory and digestive systems as a channel for

air and food. The upper region, the nasopharynx, is posterior to the nasal cavity. It

contains the pharyngeal tonsils, or adenoids, functions as a passageway for air, and has no

function in the digestive system. The middle region posterior to the oral cavity is the

oropharynx. This is the first region food enters when it is swallowed. The opening from the

oral cavity into the oropharynx is called the fauces. Masses of lymphoid tissue, the palatine

tonsils, are near the fauces. The lower region, posterior to the larynx, is the

laryngopharynx, or hypopharynx. The laryngopharynx opens into both the esophagus and

the larynx.

Food is forced into the pharynx by the tongue.

When food reaches the opening, sensory

receptors around the fauces respond and

initiate an involuntary swallowing reflex. This

reflex action has several parts. The uvula is

elevated to prevent food from entering the

nasopharynx. The epiglottis drops downward

to prevent food from entering the larynx and

trachea in order to direct the food into the

esophagus. Peristaltic movements propel the

food from the pharynx into the esophagus.

Esophagus

The esophagus is a collapsible muscular tube that serves as a passageway between the

pharynx and stomach. As it descends, it is posterior to the trachea and anterior to the

vertebral column. It passes through an opening in the diaphragm, called the esophageal

hiatus, and then empties into the stomach. The mucosa has glands that secrete mucus to

keep the lining moist and well lubricated to ease the passage of food. Upper and lower

esophageal sphincters control the movement of food into and out of the esophagus. The

lower esophageal sphincter is sometimes called the cardiac sphincter and resides at the

esophagogastric junction.

Stomach

The stomach, which receives food from the esophagus, is located in the upper left quadrant

of the abdomen. The stomach is divided into the fundic, cardiac, body, and pyloric regions.

The lesser and greater curvatures are on the right and left sides, respectively, of the

stomach.

Gastric Secretions

The mucosal lining of the stomach is simple columnar epithelium with numerous tubular

gastric glands. The gastric glands open to the surface of the mucosa through tiny holes

called gastric pits. Four different types of cells make up the gastric glands:

Mucous cells

Parietal cells

Chief cells

Endocrine cells

The secretions of the exocrine gastric glands - composed of the mucous, parietal, and chief

cells - make up the gastric juice. The products of the endocrine cells are secreted directly

into the bloodstream and are not a part of the gastric juice. The endocrine cells secrete the

hormone gastrin, which functions in the regulation of gastric activity.

Regulation of Gastric Secretions

The regulation of gastric secretion is accomplished through neural and hormonal

mechanisms. Gastric juice is produced all the time but the amount varies subject to the

regulatory factors. Regulation of gastric secretions may be divided into cephalic, gastric,

and intestinal phases. Thoughts and smells of food start the cephalic phase of gastric

secretion; the presence of food in the stomach initiates the gastric phase; and the presence

of acid chyme in the small intestine begins the intestinal phase.

Stomach Emptying

Relaxation of the pyloric sphincter allows chyme to pass from the stomach into the small

intestine. The rate of which this occurs depends on the nature of the chyme and the

receptivity of the small intestine.

Small and Large Intestine

Small Intestine

The small intestine extends from the pyloric sphincter to the ileocecal valve, where it

empties into the large intestine. The small intestine finishes the process of digestion,

absorbs the nutrients, and passes the residue on to the large intestine. The liver,

gallbladder, and pancreas are accessory organs of the digestive system that are closely

associated with the small intestine.

The small intestine is divided into the duodenum, jejunum, and ileum. The small intestine

follows the general structure of the digestive tract in that the wall has a mucosa with simple

columnar epithelium, submucosa, smooth muscle with inner circular and outer

longitudinal layers, and serosa. The absorptive surface area of the small intestine is

increased by plicae circulares, villi, and microvilli.

Exocrine cells in the mucosa of the small intestine secrete mucus, peptidase, sucrase,

maltase, lactase, lipase, and enterokinase. Endocrine cells secrete cholecystokinin and

secretin.

The most important factor for regulating secretions in the small intestine is the presence of

chyme. This is largely a local reflex action in response to chemical and mechanical

irritation from the chyme and in response to distention of the intestinal wall. This is a

direct reflex action, thus the greater the amount of chyme, the greater the secretion.

Large Intestine

The large intestine is larger in diameter than the small intestine. It begins at the ileocecal

junction, where the ileum enters the large intestine, and ends at the anus. The large

intestine consists of the colon, rectum, and anal canal.

The wall of the large intestine has the same types of tissue that are found in other parts of

the digestive tract but there are some distinguishing characteristics. The mucosa has a

large number of goblet cells but does not have any villi. The longitudinal muscle layer,

although present, is incomplete. The longitudinal muscle is limited to three distinct bands,

called teniae coli, that run the entire length of the colon. Contraction of the teniae coli

exerts pressure on the wall and creates a series of pouches, called haustra, along the colon.

Epiploic appendages, pieces of fat-filled connective tissue, are attached to the outer surface

of the colon.

Unlike the small intestine, the large intestine produces no digestive enzymes. Chemical

digestion is completed in the small intestine before the chyme reaches the large intestine.

Functions of the large intestine include the absorption of water and electrolytes and the

elimination of feces.

Rectum and Anus

The rectum continues from the signoid colon to the anal canal and has a thick muscular

layer. It follows the curvature of the sacrum and is firmly attached to it by connective

tissue. The rectum and ends about 5 cm below the tip of the coccyx, at the beginning of the

anal canal.

The last 2 to 3 cm of the digestive tract is the anal canal, which continues from the rectum

and opens to the outside at the anus. The mucosa of the rectum is folded to form

longitudinal anal columns. The smooth muscle layer is thick and forms the internal anal

sphincter at the superior end of the anal canal. This sphincter is under involuntary control.

There is an external anal sphincter at the inferior end of the anal canal. This sphincter is

composed of skeletal muscle and is under voluntary control.

Accessory Organs

The salivary glands, liver, gallbladder, and pancreas are not part of the digestive tract, but

they have a role in digestive activities and are considered accessory organs.

Salivary Glands

Three pairs of major salivary glands (parotid, submandibular, and sublingual glands) and

numerous smaller ones secrete saliva into the oral cavity, where it is mixed with food

during mastication. Saliva contains water, mucus, and enzyme amylase. Functions of saliva

include the following:

o It has a cleansing action on the teeth.

o It moistens and lubricates food during mastication and swallowing.

o It dissolves certain molecules so that food can be tasted.

o It begins the chemical digestion of starches through the action of amylase,

which breaks down polysaccharides into disaccharides.

Liver

The liver is located primarily in the right hypochondriac and epigastric regions of the

abdomen, just beneath the diaphragm. It is the largest gland in the body. On the surface,

the liver is divided into two major lobes and two smaller lobes. The functional units of the

liver are lobules with sinusoids that carry blood from the periphery to the central vein of

the lobule.

The liver receives blood from two sources. Freshly oxygenated blood is brought to the liver

by the common hepatic artery, a branch of the celiac trunk from the abdominal aorta.

Blood that is rich in nutrients from the digestive tract is carried to the liver by the hepatic

portal vein.

The liver has a wide variety of functions and many of these are vital to life. Hepatocytes

perform most of the functions attributed to the liver, but the phagocytic Kupffer cells that

line the sinusoids are responsible for cleansing the blood.

Liver functions include the following:

secretion

synthesis of bile salts

synthesis of plasma protein

storage

detoxification

excretion

carbohyrate metabolism

lipid metabolism

protein metabolism

filtering

Gallbladder

The gallbladder is a pear-shaped sac that is attached to the visceral surface of the liver by

the cystic duct. The principal function of the gallbladder is to serve as a storage reservoir

for bile. Bile is a yellowish-green fluid produced by liver cells. The main components of bile

are water, bile salts, bile pigments, and cholesterol.

Bile salts act as emulsifying agents in the digestion and absorption of fats. Cholesterol and

bile pigments from the breakdown of hemoglobin are excreted from the body in the bile.

Pancreas

The pancreas has both endocrine and exocrine functions. The endocrine portion consists of the scattered islets of Langerhans, which secrete the hormones insulin and glucagon into the blood. The exocrine portion is the major part of the gland. It consists of pancreatic acinar cells that secrete digestive enzymes into tiny ducts interwoven between the cells. Pancreatic enzymes include anylase, trypsin, peptidase, and lipase. Pancreatic secretions are controlled by the hormones secretin and cholecystokinin.

PATHOPHYSIOLOGY:

--------------------------------------------------------

----------------------------- ↓

↓

Predisposing Factors:

o Status Geneso Ageo Sexo Socio-economic

Precipitating Factors:

o Environmento Unsanitary

Food Handlingo Ingestion of

Contaminated Food

S.typhi is shed in human feces

Contamination of food and water

Ingestion of contaminated food or water by humans

S.typhi tries to survive in acidic environment of the stomach

Remaining bacteria invade epithelial cells in the intestine

Macrophages from Peyer’s

Macrophages from Peyer’s

IF NOT TREATED:

IF TREATED:

Overwhelming sepsis

Antibiotic Therapy

NURSING CARE PLAN 1:

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective:“masakit ang tiyan ko”as verbalized by the patient

Diarrhea r/t infectious processes; parasites

After 8 hours, the patient shall reestablish

>observe stools for volume, frequency, characteristics and

>for laboratory examination

Goal-met;The patient was able to understand his disease

-Fever-Headache-Abdominal Pain

Secondary Bacteremia

Bacteria is shed into the blood stream

Infection spreads to other systems

-Endocarditis-Renal Failure-Brain Infxn

Circulatory Failure

DEATH!

-Elimination/ decrease in number of S.typhi -Alleviation of signs and symptoms-Recovery from condition

Changes brought about by sepsis accumulate in the heart, brain, and kidneys

Objective: Hyperactive bowel sounds, more than 35 times per min. 7-8x watery stools per day

and maintain normal pattern of bowel functioning from >35x/min to 5-35x/min. bowel sounds

precipitating factors.>note reports of abdominal or rectal pain associated with episodes>auscultate abdomen.>observe for presence of associated factors such as fever/chills and abdominal pain. >evaluate diet history and note nutritional/fluid and electrolyte status.>determine recent exposure to different/foreign environments and change in drinking water/fluid intake>restrict solid food intake as indicated>limit caffeine and high fiber foods; avoid milk and citrus fruits as appropriate.>administer anti diarrheal medications, as indicated.>provide privacy during defecation.>review

process as evidenced by doing the prevention and control of the disease.

causative factors and appropriate interventions> review food preparation, emphasizing, adequate cooking time and proper refrigeration/ storage > emphasize importance of handwashing

NURSING CARE PLAN 2:ASSESSMENT

DIAGNOSIS PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective:“Nilalagnat po ako” as the patient stated.

Objective:BT: 38˚ CSkin warm to touch

Hyperthermia related to illness.

After 1 hour, the patient will maintain a normal range of body temperature as manifested by decrease BT: from

>Instruct patient to increase fluid intake.>Perform tepid sponge bath as needed.>Encourage patient to use light –colored clothes.>promote cool environment by

>To prevent dehydration.>Heat loss by evaporation and conduction.>Dark-colored clothes absorb heat therefore they increase

Goal-met:The patient was able to maintain a normal temperature as evidenced by a body temp. of 37.5°C.

38 to 36.5-37.5˚ C.

use of fan or opening windows.>Provide supplemental oxygen as ordered.>Promote surface cooling by undressing as permitted by the patient.>Encourage patient to eat citrus fruits.

>Monitor body temperature.

body temperature.> Heat loss by convection.

>To offset or increase oxygen demands and consumption.>Heat loss by radiation and conduction. >Citrus fruits are rich in vitamin C which boosts the immune system.>To assess any untoward incidence.

NURSING CARE PLAN 3:ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE EVALUATION

Subjective:“Masakit ang tiyan ko” as the patient verbalized

Objective:Guarding behaviorMoaningirritability

Acute pain related to illness.

After 4 hours, the patient will verbalize relieved or lessen pain as manifested by full cooperation toward the health providers.

>Encourage patient to verbalize feelings about the pain.>Assess pain; include characteristics, location, duration, frequency and quality. >Accept patients description of the pain

>Ascertain

>Evaluate patients response about pain.

>To rule out worsening condition or developing complications.>Pain is subjective therefore it cant be felt by other.>Evaluate

Goal-partially met:The patient verbalized a lessen pain but it’s still hurt a little bit as evidenced by partial cooperation with the health providers.

patients knowledge of and expectations about the pain management.>Note when the pain usually occurs such that when he is walking, and other actions that aggravate the pain.>Identify ways of minimizing the pain such as proper positioning, massage, use of cold or warm co press, quiet environment, imaging or musical.>Monitor vital signs of the patient.

>Discuss with the SO’s the ways they can help the patient to minimize the pain and the precipitating factors of the pain.>Encourage patient to have adequate rest.

patients response.

>To medicate prophylactic ally, as appropriate.

>Promote non-pharmacological management and to distract attention.

>Vital signs are usually altered when there is pain.>To assist the patient for his wellness.

Prevents fatigue.

NURSING CARE PLAN 4:

ASSESSMENT

DIAGNOSIS PLANNING INTERVENTION

RATIONALE

EVALUATION

Subjective:Daytime drowsiness and lethargy

Sleep deprivation related to uncomfortabl

At the end of the shift, the patient will report

>Encourage patient to restrict foods rich in caffeine.

>Caffeine keeps individual awake.

Goal-met:The patient reported a good sleep/rest

Objective:Irritability, inability to concentrate, slowed reaction and apathy

e sleep deprivation.

improvement in sleep/rest pattern.

>Recommend patient to have bedtime snacks.>Suggest to abstain from daytime nap.>Provide quiet environment by closing the windows and avoid making noise.>Encourage him to drink milk before bedtime.>Limit the visitors.

>Clustering of nursing activities.> Provide bed comfort by preventing bed sheet from crumpling.>Discuss to him the relaxation techniques and musical therapy.>Turn off the light as permitted by the patient.

>Sense of fullness promotes sleep.

>It impairs the ability to sleep at night time.>Quiet environment facilitates sleep.

>Milk contain tryptophan which triggers to sleep.>Provide rest to the patient.>Prevent patient from disturbing.>A comfortable bed promotes sleeping.

>To lessen tension and prepare him for sleep.

>Light affects the sleeping ability of individual.

pattern as evidenced by good comprehension and cooperation with the health providers.

NURSING CARE PLAN 5:

ASSESSMEN DIAGNOSI PLANNING INTERVENTIO RATIONALE EVALUATIO

T S N N Subjective:“Isang baso o kalahati lang kinakain ko na kanin”

Objective:Loss of appetite in eating the prepared meal.

Imbalanced nutrition: less than the requirement related to illness.

At the end of the shift, the patient will verbalize understanding of body and energy needs as manifested by eating a nutrient dense food such as rice, meet and fruits if not restricted.

>discuss to the patient the importance of balancing calorie intake and energy expenditure.>Determine the diet of the patient.>Identify psychological significance of food to the patient.>Encourage patient to make a decision to lead an active life and control food habits.>Discuss eating habits including food preferences.>Encourage SO to eat with the patient.

>Prevent unpleasant odors or sights.>Limit fluids 1 hour prior to meal

>A balance calorie intake and energy expenditure lead to healthy body.

>To know if he has food restriction.>Psychological factors make a big effect on patient’s appetite.>To appeal to patient’s likes or dislikes.

>To increase appetite of the patient.>To enhance intake.

>They can cause loss of appetite.>Water makes stomach full.

Goal-met:The patient was able to understand the balance body requirement as evidenced by eating of the balanced diet food.

DRUG STUDY1:NAME OF DRUG

CLASSIFICATION

ACTION INDICATION

ADVERSE REACTION

NURSING RESPONSIBILITIES

Generic name: Ceftriax

oneBrand name:

TriavexDosage:

Broad spectrum antibiotic

Inhibits bacterial cell wall synthesis, rendering cell wall

For the treatment of gram negative organisms: H.influenza

CNS:Headache, dizziness, weakness, paresthesia, fever, chills,

>Observe 10 R’s>Do skin testing>Before administration, ask patient if he is allergic to

1 g slow IV push now then q 12˚ ANST

osmotically unstable, leading to cell death

e, E.coli, E.aerogenes, P. mirabilis,Klebsiella, Citrobacter, Enterobacter, Salmonella, Shigella, Acinetobacter, B.fragilis, Neisseria, Serratia;gram positive organism: S.pneumoniae, S.pyogenes, S.aureus;serious lower respiratory tract, urinary tract, skin, gonococcal, intraabdominal infections, septicemia, meningitis, bone joint infection.

seizureG.I.:Nausea, vomiting, diarrhea, anorexia, pain glossitis, bleeding;↑ AST(SGOT), ALT(SGPT), bilirubin, LDH, alk phosphate;abdominal pain, pseudo membranous colitisG.U.:Proteinuria, vaginitis, proritus, ↑ BUN, nephrotoxicity, renal failureHEMA:Leucopenia, thrombocytopenia, agranulocytosis, anemia, neutropenia, eosinophilia, lymphocytosis, pancytopenia, hemolytic

penicillin or cephalosporin.>monitor PT and INR in patients w/ impaired vitamin K synthesis or low vitamin K stores. Vitamin K therapy may be needed.˃Tell patient to report adverse rection promptly>Instruct patient to report d/comfort at IV insertion site>Teach patient & family receiving home care how to prepare and give drugs

Generic Name: Ibuprof

en + Pracetamol

Brand Name: Muskel

ax

Nonsteroidal anti infalamatory drug+ Analgesi

Inhibits prostaglandin synthesis by decreasi

Rheumatoid arthritis, osteo arthritis, primary

CV: Tachycardia, peripheral edema, palpitation

Renal, liver, blood studies: BUN, creatini

Dosage:1 tab, TID PC PRN

c , antipyretic

ng enzyme needed for biosynthesis; analgesic, anti inflammatory, anti pyretic

dysmenorrhea, gout, dental pain, musculo skeletal disorders, fever.

s, dysrhytmias,CNS:Headache, dizziness, drowsiness, fatigue, tremors, confusion, insomnia, anxiety, depressionEENT:Tinnitus , hearing loss, blurred visionGI:Nausea,anorexia, vomiting, diarrhea, jaundice, cholestatic hepatitis, constipation, flatulence, cramps, dry mouth, peptic ulcerGU:

ne, AST (SGOT), ALT (SGPT), Hgb, before treatment, periodically thereafter

Pain: note type, duration, location, intensity with ROM

Audiometric, ophthalmic examination before, during, after treatment; for

Nephrotoxicity: dysuria, hematuria, oliguria, azotemiaHEMA: blood dyscrasias, increase bleeding time

eye, ear

problems: blurred vision, tinnitus, may indicate toxicity

Cardiac status: edema,(peripheral), tachycardia, palpitations; monitor B/P, pulse for character, quality, rhythm

GENERIC NAME:

Glimepiride

Beta- blocker

Unknown. Lowers glucose

CNS:Dizziness, asthenia, headache

Tell patient to take drug w/ first meal of

Brand name:

GetrylDosage :1 or 2 mg PO once daily w/ first main meal of day; usual maintenance dose is 1 to 4 mg PO once daily.

level, possibly by stimulating release of insulin from functioning pancreatic beta cells, and may lead to decreased sensitivity of peripheral tissues to insulin.

EENT:Changes in accommodationG.I.:NauseaHEMATOLOGIC:Leukopenia, hemolytic anemia, agranulocytosis, thrombocytopenia, aplastic anemia, pancytopeniaHEPATIC:Cholestatic jaundiceMETABOLIC:Hypoglycemia, dilutional hyponatremiaSKIN:Pruritus, erythema, urticaria, morbillifor

the day

Make sure patient understands that therapy relieves symptoms but doesn’t cure the disease. He should also understand potential risk and advantaged of taking the drug and of other treatment method

m, maculopapular eruptions, photosensitivity reactions.

. Stress

importance of adhering to diet, weight reduction, exercise and personal hygiene program.

Advise patient to wear or carry medical identification at all times.

Advise patient to consult prescriber before

taking any OTC drugs.

Teach patient to carry candy or other simple sugars to treat mild

episodes of low glucose level. Patient experiencing severe episodes may need hospital treatment.

Advise patient to avoid

alcohol, w/c lowers glucose level.

DISCHARGE PLAN:

Medications:Instructed patient to take his home medication in time with the right dose and right frequency.

CIPROFLOXAN 50 mg/tab BID 6 am-4 pm on a full stomach GLIMEPIRIDE(GETRYL) 2 mg/ tab 30 mins. AC IBUPROFEN + PARACETAMOL(TRIAVEX) 1 tab BID PRN for fever,

headache and body painExercise:Encouraged patient to perform deep breathing exercise to increase the supply of oxygen in the body. Advised to limit physical activities especially those activities that are strenuous or tough to prevent fatigue.Treatment:

Promoted cool environment to facilitate relaxation Instructed to get adequate rest and sleep Advised to increase oral intake Advised SO’s to do tepid sponge bath if his temp is >37.8

degree Celsius

Hygiene: Advise proper disposal of human excretion and secretion Advise segregation of dirty utensils

OPD:Instructed patient to come back on september 04, 2009 at people’s emergency hospital for his OPD check up.

Diet:

instruct patient to eat not more than 1800 cal avoid table sugar or all beverages

Spiritual:Advised to continue asking guidance to God and always pray for his wellness.Advised to go to mass every Sunday

CASE PRESENTATI

ON(TYPHOID FEVER)

GROUP A:Eden Pamittan

Leonides Ramonette IsraelElynor reboredo

Blesilda Elaine ObligadoDianne Aglado

Adelna Faye TamayoRhea Lugo