Typhoid Fever Nursing Care Management Study Guide

Typhoid fever still kills when it's missed. It's common wherever sanitation is poor and people are packed together, and it's curable with antibiotics if you catch it early. Untreated, it can be fatal. Here's what to recognize, what to monitor, and how to manage the patient.

What is Typhoid Fever?

Typhoid fever, also called enteric fever, is a potentially fatal multisystemic illness caused mainly by Salmonella enterica serotype typhi, and to a lesser extent serotypes paratyphi A, B, and C. Presentation ranges from overwhelming systemic illness to little more than diarrhea with a low-grade fever. Untreated, it can progress to delirium, obtundation, intestinal hemorrhage, bowel perforation, and death within 1 month of onset.

Pathophysiology

Salmonella in the gut gets engulfed by phagocytic cells, carried through the mucosa, and presented to macrophages in the lamina propria.

• Typhi and paratyphi enter primarily through the distal ileum.
• Specialized fimbriae let them adhere to lymphoid tissue over the ileum (Peyer patches), the relay point for macrophages moving from gut to lymphatic system.
• The bacteria hijack the macrophages' machinery to reproduce as they travel through the mesenteric lymph nodes to the thoracic duct and into the reticuloendothelial tissues of the liver, spleen, bone marrow, and lymph nodes.
• They multiply until a critical density is reached, then trigger macrophage apoptosis and break into the bloodstream to invade the rest of the body.
• They infect the gallbladder via bacteremia or infected bile, re-enter the GI tract in the bile, and reinfect Peyer patches.
• Bacteria that don't reinfect the host are shed in stool, ready to infect the next person.

Causes

Typhoid spreads through food or water contaminated by the urine or feces of infected carriers. Typhoidal salmonella have no nonhuman vectors.

• Contaminated food. Paratyphi is more often transmitted in food from street vendors.
• Migration. Paratyphi is more common among newcomers to urban areas, who tend to be immunologically naive to it. Current typhoid vaccines target typhi and give little or no protection against paratyphi.
• Decreased stomach pH. Typhoidal salmonella survive a stomach pH as low as 1.5. Antacids, histamine-2 receptor antagonists (H2 blockers), proton pump inhibitors, gastrectomy, and achlorhydria all decrease stomach acidity and make infection easier.
• Poor hygiene. Cases cluster where hygiene is poor, including well-off university students living in crowded group households.

Statistics and Incidences

• Typhoid occurs worldwide, mostly in developing nations with poor sanitation.
• It's endemic in Asia, Africa, Latin America, the Caribbean, and Oceania, but 80% of cases come from Bangladesh, China, India, Indonesia, Laos, Nepal, Pakistan, or Vietnam.
• It infects roughly 21.6 million people and kills an estimated 200,000 every year.
• Treated, mortality risk is 0.2% with few long-term sequelae.
• Untreated, it runs several weeks with long-term morbidity that often involves the central nervous system.
• 54% of US cases reported between 1999 and 2006 were male.
• Most cases involve school-aged children and young adults.

Clinical Manifestations

Typhi and paratyphi are clinically indistinguishable. Watch for:

• Fever. Stepwise pattern: temperature climbs through the day, drops by the next morning, and the peaks and troughs rise over time.
• GI symptoms. Over the first week, diffuse abdominal pain and tenderness develop, sometimes with fierce colicky right upper quadrant pain.
• Rose spots. Salmon-colored, blanching, truncal maculopapules, usually 1-4 cm wide and fewer than 5 in number, resolving within 2-5 days.
• Abdominal distention. The abdomen distends and soft splenomegaly is common; by the third week distention is severe.
• Pea soup diarrhea. Foul, green-yellow, liquid stool.

Assessment and Diagnostic Findings

Diagnosis is primarily clinical.

• Culture. The long-standing criterion standard is culture isolation, considered 100% specific.
• Polymerase chain reaction. PCR has been used for diagnosis with varying success.
• Radiography. Radiography of the kidneys, ureters, and bladder is useful if bowel perforation is suspected.
• CT and MRI. Used to investigate abscesses in the liver, bones, or other sites.
• Bone marrow aspiration. BMA culture is the most sensitive method of isolating S typhi.
• Histology. The hallmark finding is tissue infiltration by macrophages containing bacteria, erythrocytes, and degenerated lymphocytes.

Medical Management

Don't delay treatment for confirmatory tests. Prompt antibiotics sharply reduce complications and deaths.

• Medical care. If a patient presents with unexplained typhoid symptoms within 60 days of returning from an endemic area, or after eating food prepared by a known carrier, start broad-spectrum empiric antibiotics immediately.
• Surgical care. Surgery is indicated for intestinal perforation. If antibiotics fail to clear hepatobiliary carriage, resect the gallbladder.
• Diet. Monitor and replace fluids and electrolytes diligently. A soft, digestible oral diet is preferable when there's no abdominal distention or ileus.
• Activity. No specific activity limits. Rest helps, but keep the patient mobile if tolerated.

Pharmacological Management

Definitive treatment is based on susceptibility.

• Antibiotics. Empiric until susceptibilities return; recommendations vary.
• Corticosteroids. Dexamethasone may lower mortality in severe cases complicated by delirium, obtundation, stupor, coma, or shock, but only once bacterial meningitis is ruled out by cerebrospinal fluid studies.

Nursing Management

Nursing Assessment

• History. Ask about travel. A severe, nonspecific febrile illness in a patient exposed to typhoidal salmonella should always raise typhoid as a possibility.
• Physical exam. Presentation ranges from mild (low-grade fever, headache, fatigue, malaise, anorexia, cough, constipation, rash or rose spots) to fatal complications like intestinal perforation, GI hemorrhage, encephalitis, and cranial neuritis.

Nursing Diagnosis

• Risk for fluid volume deficit related to poor intake, nausea, vomiting, and diarrhea.
• Imbalanced nutrition, less than body requirements, related to poor intake and excessive output.
• Acute pain related to inflammation of the small intestine.
• Activity intolerance related to mandatory bed rest.
• Hyperthermia related to increased metabolic rate.

Nursing Care Planning and Goals

• Maintain normal fluid volume.
• Improve nutritional intake.
• Reduce pain.
• Resume ADLs.
• Maintain normal body temperature.

Nursing Interventions

• Support ADLs. Help meet daily needs, involve the family, and explain why bed rest prevents complications and speeds healing.
• Push fluids. Monitor hydration and daily intake, encourage more fluids, and coordinate IV fluids with the team.
• Improve nutrition. Track caloric intake and weight loss, make mealtimes comfortable, and push protein and vitamin C.
• Manage pain. Assess location, duration, intensity, and character; apply warm compresses to painful areas; give analgesics as prescribed.
• Control temperature. Monitor temperature and pattern, watch for chills and profuse diaphoresis, give tepid sponge baths (no ice water or alcohol), and give antipyretics as prescribed.

Evaluation

Goals are met when the patient maintains normal fluid volume, improves nutritional intake, reports reduced pain, resumes ADLs, and maintains a normal body temperature.

Documentation Guidelines

• Individual findings, including contributing factors, interactions, and specifics of behavior.
• Cultural and religious beliefs and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward desired outcomes.