St. Paul College of Ilocos Sur
COLLEGE DEPARTMENT
Bayubay, San Vicente, Ilocos Sur
In partial fulfillment of the requirements for
NCM 101 (Care of Individuals and Family with Maternal and Child
Health)
(Related Learning Experiences)
A Case Study
Respectfully Submitted to:
Mrs. July Tricia Pili
Clinical Instructor
Respectfully Submitted by:
Leizel R. Dait
Mary Grace Incillo
(BSN-II)
Introduction:
In constructing this case study, we decided to explore our self in dealing
with different kind of diseases in which will help in developing our skills and
knowledge particularly in formulating and rendering patient’s care and services.
The primary purpose of this case study is to exhibit information regarding
Typhoid fever which will help in easy recognition of the disease. Hence,
preventing the complication or other consequences that might occur to patients
with the disease. This is also to develop and enhance our nursing skills
particularly in formulating appropriate nursing management to patients with such
illness.
As we encountered in the clinical setting, typhoid fever-its mechanisms
and process was too vague for us. Through this case study, we were able to
achieve information regarding the disease condition that will help In further
formulating and providing appropriate care to the patient.
Typhoid fever is a bacterial disease, caused by Salmonella typhi. It is
transmitted through the ingestion of food or drink contaminated by the feces or
urine of infected people. Symptoms usually develop 1–3 weeks after exposure,
and may be mild or severe. They include high fever, malaise, headache,
constipation or diarrhea, rose-colored spots on the chest, and enlarged spleen
and liver. Healthy carrier state may follow acute illness. Typhoid fever can be
treated
with
antibiotics.
However,
resistance
to
common
antimicrobials
is
widespread. Healthy carriers should be excluded from handling food.
It is important for the physician to understand that the typical causes and
presentations of typhoid fever in infants and children are variable, depending
upon the child’s age and underlying medical condition.
Expansive comprehension regarding the disease condition will provide
good perception and information that will benefit both the patient and the nurse
in dealing, exploring and managing such kind of disease. The objectives that
follow will contribute in attaining the benefits in knowledge and skills in
recognizing the condition- Typhoid Fever.
Definition
Typhoid fever is a life-threatening bacterial infection caused by the
bacterium Salmonella Typhi (S. Typhi). According to the CDC, typhoid fever is
common in developing countries, where it affects about 22 million persons each
year.
Transmission:
Humans serve as the natural host as well as reservoir. Faeco-oral
contamination is the most common route of infection. Consuming raw fruit and
vegetables contaminated with sewage water, shellfish, and ice creams are the
significant risk factors for contracting S. typhi infection. Epidemiological studies
have suggested that small inocula are sufficient for water borne transmission but
large inocula is required for food borne organism transmission.
Clinical features
Symptomatology of typhoid fever is highly variable ranging from mild illness
with low-grade fever, dry cough, and malaise to severe illness associated with
complications. Depending on age of the patient clinical manifestations vary.

School going children and adolescents: Onset is usually insidious.
Fever, myalgia, anorexia, headache and abdominal pain are the initial
features. In early phase diarrhea is common but later constipation
ensues. Patient may develop cough, epistaxis and lethargy. Within a
week of onset, fever increases in stepwise fashion and becomes
unremitting and high grade. During second week of illness all the
symptoms increase in severity and patient may appear toxic, lethargic,
and disoriented. Delirium and Stupor may occur. On examination relative
bradycardia (disproportionate to the degree of fever) is characteristic.
Hepatosplenomegaly with abdominal distention and generalized
tenderness are common findings. Few patients with typhoid fever may
develop macular or maculopapular, discrete erythematous rash, raised
from skin, blanching on pressure on about 7-10th day of illness (rose
spots) usually seen on chest and abdomen in crops. On healing they
leave small hyperpigmented areas. S. Typhi can be cultured from these
lesions (60% yield). Chest examination may reveal scattered rhonchi and
crepitations. Without complications all signs and symptoms subsides
within 2-4 weeks except malaise and lethargy, which may persist for 1-2
months.

Infants and young children: Typhoid fever usually presents as mild fever,
malaise and diarrhea and is commonly labeled as acute gastroenteritis in
this age group, however sepsis may occur.

Neonatal typhoid fever: S. typhi can be transmitted vertically.
Antenatally it can cause (may lead) to chorio-amnionitis, miscarriage, fetal
death (58) and premature delivery. Neonatal typhoid usually presents
within 72 hours of delivery with hypo or hyperthermia, vomiting, diarrhea,
abdominal distention, convulsions, hepatomegaly and jaundice. Poor
feeding and weight loss may be significant.
Risk Factors
S typhi are able to survive a stomach pH as low as 1.5. Antacids, histamine-2
receptor antagonists (H2 blockers), proton pump inhibitors, gastrectomy, and
achlorhydria decrease stomach acidity and facilitate S typhi infection.
HIV/AIDS is clearly associated with an increased risk of nontyphoidal Salmonella
infection; however, the data and opinions in the literature as to whether this is
true for S typhi infection are conflicting. If an association exists, it is probably
minor.
Other risk factors for clinical S typhi infection include various genetic
polymorphisms. These risk factors often also predispose to other intracellular
pathogens. For instance, PARK2 and PACGR code for a protein aggregate that
is essential for breaking down the bacterial signaling molecules that dampen the
macrophage response. Polymorphisms in their shared regulatory region are
found disproportionately in persons infected with Mycobacterium leprae and S
typhi.
On the other hand, protective host mutations also exist. The fimbriae of S typhi
bind in vitro to cystic fibrosis transmembrane conductance receptor (CFTR),
which is expressed on the gut membrane. Two to 5% of white persons are
heterozygous for the CFTR mutation F508del, which is associated with a
decreased susceptibility to typhoid fever, as well as to cholera and tuberculosis.
The homozygous F508del mutation in CFTR is associated with cystic fibrosis.
Environmental and behavioral risk factors that are independently associated with
typhoid fever include eating food from street vendors, living in the same
household with someone who has new case of typhoid fever, washing the
hands inadequately, sharing food from the same plate, drinking un purified
water, and living in a household that does not have a toilet. As the middle class
in south Asia grows, some hospitals there are seeing a large number of typhoid
fever cases among relatively well-off university students who live in group
households with poor hygiene.
Complications: 10-20% of patients have occult blood in stools, 3% having
malena and 0.5-3% of patients may develop intestinal perforation, followed by
peritonitis presenting as sudden tachycardia, hypotension, abdominal distention
with guarding, rigidity and rebound tenderness. Hypothermia usually occurs after
the first week of disease. Perforation size may range from pinpoint to several
centimeters. Gram-negative sepsis may ensue. X-ray abdomen may suggest free
air in abdomen. Altered sensorium has high case fatality rate. Study from
Malaysia
showed
that
children
with
splenomegaly,
thrombocytopenia
and
leucopenia are more likely to develop complications (20). Short duration of
symptoms, inadequate antimicrobial treatment, male sex and leucopenia were
the independent risk factors for enteric perforation from a study done in Turkey
(23). Intestinal bleeding usually occurs from multiple, variable sized punched out
ulcers in the distal ileum and proximal colon.
Other complications include – Pneumonia by superinfection with organisms other
than
Salmonella
typhi,
bronchitis
(10%),
toxic
myocarditis,
neurological
complications including raised intracranial pressure, cerebral thrombosis, acute
cerebellar ataxia, chorea, aphasia, deafness, psychosis, transverse myelitis,
peripheral neuritis, optic neuritis, meningitis, encephalomyelitis, Guillian-Barre
syndrome,
cranial
nerve
palsies.
Other
reported
complications
are
–
Disseminated
intravascular
coagulation
(DIC),
thrombocytopenia,
Hemolytic
Uremic syndrome (HUS), Hepatitis, Splenic and bone marrow granulomas,
glomerulonephritis,
leukocytoclastic
pancreatitis,
vasculitis,
splenic
Suppurative
/
liver
abscess,
cutaneous
lymphadenitis,
cutaneous
ulcerations,
thrombosis, phlebitis, fatal bone marrow necrosis, pyelonephritis, nephrotic
syndrome, endocarditis, orchitis, osteomyelitis and suppurative arthritis especially
in children with hemoglobinopathies.
GENERAL OBJECTIVES:
This case study aims to identify and determine the general health
problems and needs of the patient with an admitting diagnosis of typhoid Fever.
This presentation also intends to help patient promote health and medical
understanding of such condition through the application of the nursing skills.
Specific Objectives:

To raise the level of awareness of patient on health problems that he
may encounter.

To facilitate patient in taking necessary actions to solve and prevent the
identified problems on his own.

To help patient in motivating him to continue the health care provided by
the health workers.

To render nursing care and information to patient through the application
of the nursing skills.

To be able to develop knowledge, skills and attitude in rendering nursing
care and understand the course of the disease condition

To be able to acquire medical information regarding Typhoid Fever and
gain understanding on the pathophysiology and etiology of the disease

To be able to formulate appropriate nursing management and intervention
for the patient.

To help the patient prevent complications that will situate life in danger
through acquiring appropriate knowledge and awareness regarding the
disease condition.

To provide the patient and his family important information about the
disease concerning the health status of the patient.

To provide the patient and her family an awareness regarding the proper
management of the patient including the do’s and the dont’s in his
condition.

To help the patient and the family recognize significance of having good
health and it’s maintenance.
Part I. Assessment
A. General Information
Name:
mE. A. Campos
Age:
9 y/o
Gender:
male
Civil Status:
single
Nationality:
Filipino
Educational Attainment:
grade school
Occupation:
none (still as student)
Religion:
Pentecost
Address:
Maratudo, Magsingal, Ilocos Sur
Arrived on unit by:
tricycle
Accompanied by:
Mrs. Campos (mother)
Chief complaint:
Abdominal pain and fever
Date Admitted:
September 21, 2009
Time:
1:05pm
Admitted by:
Dr. Rapisura/
Rondal
Admitting Institution:
Metro Vigan Cooperative Hospital
Room/Ward:
Ward C
Admitting Diagnosis:
t/c Dengue Fever vs.
Typhoid fever
Admitting Vital Signs:
BP:
80/60mmHg
Temp: 36.7 oC
Pulse: 86 bpm
RR:
Medications:
21 bpm
Ampicillin 500mg, IV ANST qo6
Chlonampenecol 500mg, IV ANST qo6
Paracetamol 250mg /ml PO qo4
B. Nursing History
I.
Health Perception – Health management Pattern
Client’s description of his health:
Before Admission:
> “nasakit tiyan ko, makasar-sarwaen nak ken
agtakki nak
pay.” As verbalized by the patient
>he is healthy before he had stomachache, diarrhea and vomiting
At Present:
>“nasakit pay lang tiyan ko, haan nak met agtakkin
ken maulawen” as verbalized by the patient.
>he is getting well and discovered the sign and
symptoms of his illness.
>he is suspected to typhoid fever and he also has
UTI.
He sees himself as a totally ill person because he cannot do anymore
the things he usually does like playing with his siblings. He rely his present
condition with the help of the therapeutic personnel and by following the
prescribed medications. The patient perceived that he is not healthy because of
his condition
Health Management:
Self:
Mr. Campos can manage to look to his well-being with minimal
assistance. He can walk but has unsteady gait, he asks someone to carry the
IV stand in going to the toilet.
Family:
If the nurse is not around, his mother looks up to his condition and
needs. He consider his loved ones as his pillar of support.
History of Present Illness:
>he ate a meat of dog on Sunday evening and that’s the time he
started to have a stomached ache, diarrhea and vomiting according to the
mother of the patient.
History of Past Illness:
According to the SO of the patient the patient did not yet experienced
having serious health problems other than fever, colds and cough. He had no
previous hospitalization.
History of Hospitalization:
>This is his first hospitalization (September 21, 2009)
according to the mother.
History of Illness in the Family:
According to the SO of the patient, their family has the history of
Hypertension, UTI and Heart Disease.
Expectations of Hospitalization:
> “namnamaek nga mapalaing da toy anak ko ken ipan da amin
nga kabaelan da tapnu malaing sigud toy anakko”
as verbalized by the mother.
Anticipation of problem with caring for self upon discharge:
>after he will be discharge in the hospital the mother does not
expect any problem regarding to the health of his son.
Knowledge of treatment or practices prescribed:
>the patient have some knowledge about the medication he
received.
Reactions to above prescriptions:
>The patient feels that he is getting well because of the
Medication that he received.
II. Nutrition and Metabolic Pattern
2.1 Usual food intake:
Breakfast: he usually eats rice, meat & bread for breakfast.
Lunch: he eats rice, fish, chicken, meat & vegetable.
Supper: he eats rice, fish, chicken, meat & vegetable.
Snacks: he eats crackers & biscuit, junk foods.
2.2 Usual fluid intake:
Preferences: he likes to drink water &soft drinks
: he said that for a day, he can drink the following
with their corresponding amounts as follows:
>5-6 glasses of water
>1-2 bottles of 8ounce softdrinks
2.3 Any problems with ability to eat
>He doesn’t have any problem with his ability to eat.
2.4 Any food restrictions
> The patient has loss his appetite and hasn’t eaten a lot. He is
on a DAT (Diet as Tolerated) EDCF (Except Dark Colored Foods).
III. Elimination Pattern
3.1 Bladder:
Usual Frequency/Day:
>he urinated 2-3x a day
Color:
>Yellow
Complaints on the usual pattern urination:
>He has complaints to his urination pattern.
The patient has problem on his elimination pattern. He usually
urinates 2-3 times a day with difficulty. He feels pain in his urination.
3.2 Bowel:
Usual Pattern/Day:
>he usually defecates 0-1x a day
Complaints on the usual pattern of bowel movement:
No pain defecating.
Consistency:>Modulate or in a small amount.
The patient defecates once a day usually early in the morning
before going to school with yellow to brown color. He verbalized that
sometimes however, it is hard in consistency with dark color, which
generally depends on what he eats.
3.3 Any assertive device:
>He doesn’t use any assertive device.
IV. Activity Exercise Pattern
4.1 Usual daily week activities:
Before
Exercise: Walking before and after going to school.
Leisure: Before admission: he usually watch t.v and
4.2 Any limitation of physical activity:
play with his friends.
Before hospitalization:
He could perform activities of his daily living. According to him, he
often plays with his siblings and this serves as a form of exercise for
him.
During hospitalization:
His activity was limited lying on bed but the patient is given his
bathroom privileges.
V. Sleep – rest pattern
Before hospitalization:
He has the normal 6-8 hours sleep. He also has his nap time for
1-2 hours a day. Sleeping and watching the television are his form of
rest.
During hospitalization:
He doesn’t have the adequate time of sleep since he is disturbed
with the nurses that enter the room every now and then, and because of
the environmental changes of his surroundings. He also has inadequate
time to rest since he doesn’t have enough time to sleep.
VI. Cognitive – Perceptual Pattern
Before hospitalization:
He is normal in terms of his cognitive abilities. He has good
memory and reasoning skills. He can easily comprehend on things. In
terms of his perceptual pattern, he has no problems with his senses.
During hospitalization:
He was not as normal as before in his cognitive and perceptual pattern.
He
responds
not
so
clearly
and
not
well
understood.
He
responds
inappropriately to verbal and physical stimuli but sometimes still can obey
simple commands. He was
not that cooperative throughout the interview that is
why his mothers is the one answering some of the questions asked..
VII. Self – Perception Pattern
He sees himself as a person with a good personality. He has been a
good friend, brother and a son. He said he has to be a good person in order
not to hurt others. He also describes himself as a typical type of student and
person.
VIII. Role – Relationship Pattern
8.1 Language spoken:
The patient can speak Filipino, and Iloco. He conversed mostly in Iloco
and was able to express himself well.
8.2 Manage of Speaking:
Client speaks more on Iloco. Client is not very fluent in speaking Filipino,
but can understand the language a little.
8.3 Significant other to client:
Client’s significant other is her mother.
8.4 Complaints Regarding the Family:
The client has no complaints about her family.
Before hospitalization:
He has a close relationship with his family. They were five siblings
in their family. He was at the middle. I was also able to ask his mother
about his being a son and she confessed that he is a good son but at
times he doesn’t obey her. He is also a responsible student and knows
all his duties as a friend.
During hospitalization:
He learned to appreciate the beauty of having a family that gives
you strength and support no matter what. But, he is very much irritable
because he is sick.
IX. Sexuality – Sexual Pattern
He didn’t respond to this matter.
X. Coping – Stress management Pattern
Before hospitalization:
He does not fully identify his situations having stress but he
always tell his parents when something is wrong.
During hospitalization:
He shares his problems to his family. He verbalizes his feelings
especially to his mother.
XI. Value Belief System
11.1 Source of strength and meaning
> For the client the primary source of strength in giving meaning
to his life is God and next to God is his family. For his God is his
greatest strength and savior especially in his difficult situation in his life….
11.2 Importance of God to client
> For the client God is very important to her and to his family for
she consider God as their savior, protector and Lord in his life.
11.3 Religious Practices
> The client seldom hears mass and seldom prays.
11.4 Request for religious person/practice
> The patient doesn’t have any request for religious person.
Paradigm of the Pathophysiology of the Disease
Ingestion of Bacteria
(Direct/indirect contact with a carrier of disease
& ingestion of contaminated food or water)
Bloodstream
Reticuloendothelial system
(Lympnodes, Peyer’s patches, spleen, liver)
Lymph nodes are swollen
Elevation of
temperature
Formation of sloughs
which are often bile colored
There is chilly
Development of
sensation & aching all
rose spots, abdominal
over the body
pain and splenomegaly
Intense intestinal
inflammatory response particularly
in the Peyer’s patches with
associated necrosis
The fever is
accelerated &, nausea,
vomiting, and diarrhea
Hemorrhage &
perforation occur
Typhoid
Fever
Explanation:
The pathophysiology of typhoid fever is a complex process which
proceeds through several stages.
The disease begins through ingestion of the bacteria Salmonella typhosa
through contaminated food or water or having a direct or indirect contact with a
carrier
of
the
disease
which
later
gains
access
to
the
blood
stream
(bacteremia). During which bacteria invade macrophages and spread throughout
the reticuloendothelial system (Lympnodes, Peyer’s patches, spleen, liver) which
result the lymph nodes swollen which is manifested by elevation of temperature.
Then there is a Formation of sloughs which are often bile colored which is
develod rose spots, abdominal pain and splenomegaly as manifested by chilling
sensation & aching all over the body. From here a marked of a more intense
intestinal
inflammatory
response
particularly
in
the
Peyer’s
patches
with
associated necrosis is develops due to result of perforation and hemorrhage due
to the extension of the lesion and continous erosion of the epithelial lining of
the small intestines which is manifested by fever acceleration, nausea, vomiting,
and diarrhea which results Typhoid Fever.
Clinical Manifestation
1. Onset
a. Headache, chilly sensation, aching all over the body
b. Nausea, vomiting, and diarrhea
c. By the 4th and 5th day, all symptoms are worst
d. Fever is higher in the morning than it was in the afternoon
e. Breathing is accelerated, the tongue is furred, the skin is dry and
hot, abdomen is distended and tender
f.
Rose spots appear on the abdominal wall on the 7th to the 9th day
g. On the second week symptoms become more aggravated.
Temperature remains in uniform level. Rose spots become more
prominent.
2. Typhoid State
a. Intense symptoms decline in severity
b. The tongue protrudes, becomes dry and brown
c. Teeth and lips accumulate a dirty-brown collection of dried mucus
and bacteria known as sordes (preventable by good nursing care)
d. Patient seems to be starring blankly (Coma vigil)
e. Twitching of the tendon sets in especially the wrist (subsultus
tendinum)
f.
Patient mutters deliriously and picks up aimlessly at bedclothes
with his fingers in continous fashion (Carphologia)
g. There is constant tendency of the patient to slip down to the foot
part of the bed
h. In severe cases rambling delirium sets in, often ending in death
What is typhoid fever?
Typhoid fever is a life-threatening bacterial infection caused by the bacterium
Salmonella Typhi (S. Typhi). According to the CDC, typhoid fever is common in
developing countries, where it affects about 22 million persons each year. The
incidence of typhoid fever in US citizens and residents who travel abroad is
very low.
How is typhoid fever spread?
S. Typhi live only in humans, and are carried in the bloodstream and intestinal
tracts of people who have typhoid fever. A small number of persons recover
from typhoid fever but continue to carry the bacteria.
Both the carriers and the people who have active typhoid fever shed S. Typhi
in their stools. Typhoid fever is spread by consuming food or beverages that
have been handled by a person who is shedding S. Typhi, or if sewage
contaminated with S. Typhi bacteria gets into water used for drinking or
washing food.
What are the symptoms of typhoid fever?
When S. Typhi bacteria are consumed, they multiply and spread into the
bloodstream. The body reacts with signs and symptoms such as:

a sustained fever as high as 103°F to 104° F (39 to 40 C)

weakness

stomach pains

headache

loss of appetite

sometimes a rash of flat, rose-colored spots
The symptoms of typhoid fever may resemble other medical conditions or
problems. Always consult your physician for a diagnosis.
How is typhoid fever diagnosed?
Typhoid fever can be diagnosed using a blood test or stool sample to
determine the presence of S. Typhi bacteria.
How can typhoid fever be prevented?
A vaccination for typhoid fever is available. However, it can lose effectiveness
after several years, so a booster vaccination may be necessary.
Other preventives for typhoid fever are:

only use water that has been boiled or chemically disinfected for:
o
drinking, or preparing beverages such as tea or coffee
o
brushing teeth
o
washing face and hands
o
washing fruits and vegetables
o
washing eating utensils and food preparation equipment
o
washing the surfaces of tins, cans, and bottles that contain food or
beverages

do not eat food or drink beverages from unknown sources

any raw food could be contaminated, including:
o
fruits, vegetables, salad greens
o
unpasteurized milk and milk products
o
raw meat
o
shellfish
o
any fish caught in tropical reefs rather than the open ocean
Taking antibiotics is not a preventive for typhoid fever.
Treatment for typhoid fever:
See your physician immediately if you think you have been exposed to typhoid
fever. People who do not get treatment may continue to have fever for weeks
or months, and may eventually die from complications. Treatment will probably
include an antibiotic to treat the disease. Specific treatment for typhoid fever will
be determined by your physician based on:

your age, overall health, and medical history

extent of the disease

your tolerance for specific medications, procedures, or therapies

expectations for the course of the disease

your opinion or preference
It is important to remember that the danger of typhoid fever does not end when
symptoms disappear. You could still be carrying S. Typhi and the illness could
return, or you could pass the disease to other people. People who have typhoid
fever should:

take any prescribed antibiotics.

wash your hands after using the bathroom.

have a series of stool cultures - to ensure that the S. Typhi bacteria are
no longer present.
C.
PHYSICAL ASSESSMENT
Date assessed: September 23, 2009
General assessment: conscious and coherent
Initial vital signs: BP:
80/60mmHg
Temp: 36.7 oC
Pulse: 86 bpm
RR:
21 bpm
A. Head
1. Skull
Methods of Assessment: Palpation and Inspection
> Proportional to size, oval with prominence in frontal, symmetrical in all planes,
no lumps, smooth skull contour.
2. Scalp/ hair
Methods of Assessment: Inspection
> White scalp, no lies, nits and dandruff, no lesions, hair evenly distributed.
Slightly thin, shiny, free from split ends.
3. Face
Methods of Assessment: Inspection
> Oval, symmetrical facial movements, facial expressions depend on mood, no
involuntary movements.
4. Eyes/ Vision

External eye structures
Method of Assessment: Inspection
Eyes are symmetrical in line with outer canthus and with pink conjunctiva, skin
intact, lids closed symmetrically, sclera is white

Eyeball
 No protrusion, scant amount of secretion

Lid Margins
 No scaling, lid closed symmetrically, no discoloration, no
discharges 18 involuntary-blinks/min

Eyebrows/ lashes
 symmetrically, thin, raises and lower symmetrically, hair evenly
distributed, parallel with each other.

Visual Acuity
Method of assessment: Inspection
White sclera and Salmon pink, shinny moist conjunctiva

Extraocular muscle function (cranial nerve III, IV and VI)
Method of assessment: Inspection
Eyes are able to move superiorly, laterally without experiencing pain.
Pupillary Reflex
Method of assessment: Inspection
Both pupils react to light

Internal Eye Structure with opthalmascope
-----not done----5. Ears/ Hearing

External Ear
Method of Assessment: Inspection
Pinna
 Parallel, symmetrical proportional to size of hand, bean shaped,
skin is same as surrounding area in line with outer cantus of the
eyes.
Palpation
 Firm cartilage, non tender, recoils after it is folded
External Canal
 Pinkish clean with scant amount of serum

Hearing
Method of Assessment: Inspection
The patient has no hearing defect, he is able to hear sounds clearly and he
can hear ticking sounds on both ears.

Ear canal and tympanic membrane with otoscope
----not done---6. Nose
 Nasal system intact in midline, symmetrical, no discharge, no
flaring
7. Mouth/ lips
 Pinkish, smooth, moist, well- defined, symmetrical

Gums
 Pinkish, moist, no swelling, no discharge, no reaction

Teeth
 well-aligned, free from caries, no halitosis

Tongue
 Central position, medium,pink, slightly rough on top, moist, shiny
and freely movable

Palate
 Hart palate
lighter pink, more irregular texture
 Soft palate
light pink, smooth uvula in midline

Oropharynx/ tonsils
 pink,smooth,no discharge behind tonsillar pillars, gag reflex
8. Cheeks
 smooth
9. Neck
 proportional to the size of the body and head, symmetrical and slightly
able to move
 no lump, masses or tenderness
10. Chest
 Symmetrical, fair complexion, no deformities, with 18 breaths/ minute
 no lumps, masses and tenderness and area of deformities.
11. Heart
 No heaves or abnormal pulsation.
 apical pulse is 89 beats/min
 >jugular veins are not visible
12. Breast
 no heaves or abnormal pulsation.
 >jugular veins are not visible.
 >symmetrical, slightly brownish nipple, no dimpling, cracks and
discharge.
 >uniform skin color, smooth intact, no lumps, masses and tenderness.
13. Abdomen
 >symmetrical, same color as the color of the body, no scars
 audible bowel sounds, no friction rub.
 >no masses, lumps, tenderness and distention. Tympany in all quadrants
14. Upper extremities
Musculoskeletal structures, skin, nails
Method of Assessment: Inspection and Palpation
Muscles are equal in size with coordinated body movements without discomfort
and pain; no noted swelling or masses.
Lymph Nodes
Method of Assessment: Palpation
Non-palpable
Thyroid gland
Method of Assessment: Palpation
Non-palpable
15. Lower Extremities
Musculoskeletal structures, skin and toenails
Method of Assessment: Inspection
With fair skin color, with untrimmed toenails, symmetrical right and left lower
extremities, no edema noted

Musculoskeletal functions
Method of Assessment: Inspection
Able to move right lower extremity, with limitations, with(-) deformity,(-)
tenderness
Deep tendon reflexes and plantar reflex
----not done---16. Genitals and Pelvis
External genitals:
----not done----17. Rectum
-----not done---D.
LABORATORY EXAMINATIONS
Cross Matching
Cross-matching blood, in transfusion medicine, refers to the complex testing
that is performed prior to a blood transfusion, to determine if the donor's blood
is compatible with the blood of an intended recipient, or to identify matches for
organ transplants. Cross-matching is usually performed only after other, less
complex tests have not excluded compatibility. Blood compatibility has many
aspects, and is determined not only by the blood types (O,A,B,AB), but also by
blood factors, (Rh, Kell, etc,)
Blood Type: AB
RH Type: positive
Hematocrit and hemoglobin measurements are blood tests. They are part of a
complete blood count, or CBC. Hematocrit measures the amount of red blood
cells that are in blood.
Hemoglobin is a protein-iron compound in the blood that carries oxygen from
the lungs to all cells. A hemoglobin test determines how much hemoglobin is in
the blood.
Together, the hematocrit and hemoglobin tests help diagnose anemia and
polycythemia. Anemia is a shortage of red blood cells due to reduced
production of red cells, destruction of red cells, or loss of red cells from internal
or external bleeding. Polycythemia is production of too many red blood cells.
Test:
Result
Normal value
Hematocrit
28%
M(40-54%)
Hemoglobin
96g/L
M(135-180g/L)
Nursing Responsibilities:
Before the Test: Explain the test procedure and the purpose of the test. Assess
the clients knowledge of the test
During the Test: Adhere to standard precautions
After the test: Apply pressure to the venipuncture site. Explain that some
bruising, discomfort and swelling may appear at that site that warm, moist
compress can alleviate this. Monitor signs of infection. Notify the doctor of
significant findings and administer blood products as ordered based on the test
results.
Typhoid
IgM- Negative
IgG-Positive
IgM Positive Only
Acute typhoid fever
-Implications for the presence of IgG antibodies include previous infection(in
which case current fever may not be due to typhoid) or relapse or re infection.
IgM and IgG positive
Acute typhoid fever(in the middle of infection)
IgM-IgG negative
probably not typhoid
Dengue Test
Igm-Negative
IgG- Negative
Urinalysis
Urinalysis is the physical, chemical, and microscopic examination of urine. It
involves a number of tests to detect and measure various compounds that pass
through the urine.
Test
Result
Macroscopic Exam
Color
Yellow
Transparency
Slightly
Chemical Exam
Specific Gravity
1.005
pH
7.0
Sugar
-(Neg)
Albumin
-
Nitrites
-
Blood
-
Microscopic exam
Pus cell
1-3 hpf
RBC
3-6 hpf
Epithelial cells
few
Amorphous
Urates
Occassional
Radiology Department
Normal Chest Findings
The lungs are clear
The heart is not enlarged
Mediastinum, diaphragm and sulci are intact
Ultrasound
Ultrasonography is another procedure for viewing areas inside the body. Highfrequency sound waves that cannot be heard by humans enter the body and
bounce back. Their echoes produce a picture called a sonogram. These pictures
are shown on a monitor like a TV screen and can be printed on paper.
Impression:
Unremarkable liver, gallbladder, pancreas, spleen, kidneys and Urinary Bladder
-Negative for Ascites or hydrothorax
EVALUATION
I. Discharge Planning
Medications
 Ampicillin 500mg, IV ANST qo6
 Chlonampenecol 500mg, IV ANST qo6
 Paracetamol 250mg /ml PO qo4
Exercise
 Have physical activities in tolerable one
 Take enough rest and sleep.
Treatment
 Should undergo medical procedure if instructed to prevent the progression
of the disease.
Health Teachings
 Stay away from factors that contribute to the occurrence of further harm
to his condition
and he must not eat raw foods, instead he must eat the
ones that are nutritious
OPD Follow – Up
 Should regularly consult her health care provider or the clinic to note for
any changes in status.
 To have a follow – up check – up in the OPD after 1 week.
Diet
 Eat variety of nutritious foods for energy source and reservation
 Law salt, sodium and cholesterol intake
 Increase intake of Vitamin C and protein rich foods.
 Iron rich foods to prevent anemia.
References:
Reyala, Jean P, et. Al. Community Health Nursing Services in the Philippines.
9th Edition.,2000
http://emedicine.medscape.com/article/231135-overview
http://www.pediatriconcall.com/fordoctor/diseasesandcondition/infectious_diseases/ty
phoid_fever.asp
http://www.rapidlearningcenter.com/biology/anatomy-physiology/19-The-DigestiveSystem.html
http://www.soulhealer.com/anatomy-dig.htm
E.
Data from TEXTBOOK
Description: A systemic infection characterized by continued fever, malaria,
anorexia, slow pulse, involvement of lymphoid tissues, especially ulceration of
Peyer’s Patches, enlargement of spleen, rose spots on trunk and diarrhea. Many
mild typical infections are often unrecognized. A usual fatality of 10% is reduced
to 2 or 3 % by antibiotic therapy.
Etiologic Agent: Salmonella typosa, typhoid bacillus
Source of Infection: Feces and urine of infected persons
Family contacts may be transient carrier. Carrier state is common among
persons over 40 years of age especially females.
Mode of Transmission: Direct or indirect contact with patient or carrier. Principal
vehicles are food and water. Contamination is usually by hands of carrier. Flies
are vectors.
Incubation Period: Variable, average 2 weeks, usual range 1 to 3 weeks.
Period of Communicability: As long as typhoid bacilli appear in excreta; usually
from appearance of prodromel symptoms from first week through out
convalescence.
Susceptibility, Resistance and Occurrence: Susceptibility is general although
many adults appear to acquire immunity through unrecognized infections.
Attack rates decline with age after second or third decades. A high degree of
resistance usually follows recovery.
Methods of prevention and Control: Same preventive and control measures in
Dysentery and in addition, immunization with a vaccine of high antigenecity.
Nursing Responsibilities:
Demonstrate to family how to give bedside care, such as tepid sponge, feeding,
changing of bed linen, use of bedpan and mouth care.
Any bleeding from the rectum, blood in stools, sudden acute abdominal pain,
restlessness, falling of temperature should be reported at once to the physician
or the patient should be brought to the hospital.
CONCLUSIONS
After having series of research about the disease, its management
and after completing the case study, the group had come out with the following
conclusions.
 That although the group had not monitored the patient’s discharge, follow
– up check up must be done.
 That a specimen taken from him during the span of hospitalization and
any other procedure be established for further diagnostic test, exams and
detection for the progression of the disease.
 That there should be a continuous monitoring of the patient’s condition
with regards to changes with his digestive system, skin turgor, respiratory
status and other systemic affectations of his condition.
 That patient will be given nutritious foods rich in carbohydrates, proteins
such as meat and beans, iron rich foods and vitamin C rich foods,
including citrus fruits to regain energy.
 That the patient will closely monitor for administration of medicines to
prevent further systemic complication and any other serious complications.
RECOMMENDATIONS
After dealing with the patient and studying his condition we recommend
him the following:
 Should
comply
to
any
medical
procedure
so
that
more
serious
complications can be prevented.
 Have him visit regularly with the physicians for more intensive monitoring
and treatment of the disease condition.
 Should
undergo
regular
check-ups,
medical
procedure
laboratory examinations to make definitive diagnosis,
and
other
lab results and
assess if it is a risk for the development of other serious complications
 Eat foods that have been thoroughly cooked and that are still hot and
steaming.
 Avoid raw vegetables and fruits that cannot be peeled. Vegetables like
lettuce are easily contaminated and are very hard to wash well.
 He must be very careful with the foods he will take in, and he must
always remember the preventive measures.
 Avoid foods and beverages from street vendors. It is difficult for food to
be kept clean on the street.
REVIEW OF ANATOMY AND PHYSIOLOGY
Each cell of the body requires a constant supply of nutrients to use as
the basic building blocks of the body and for the hundreds of biochemical
process that are continuously going on within the body. The digestive system is
the way in which the body transforms food into the energy it needs to build,
repair and fuel itself.
To be absorbed and used by the body, however, food substances must first be
broken down into pieces small enough to cross the cellular membrane. The first
step in this process is digestion. Digestion begins in the mouth. Food, once
chewed, travels through the throat or pharynx to the esophagus and then on to
the stomach. From the stomach, it passes into the small, then large intestines
where it is further digested with the aid of bile and enzymes from the pancreas
and liver, and finally absorbed. Any waste materials of this process exit the
body through the colon and rectum.
Gastrointestinal tract
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from
the oral cavity, where food enters the mouth, continuing through the pharynx,
oesophagus, stomach and intestines to the rectum and anus, where food is
expelled. There are various accessory organs that assist the tract by secreting
enzymes to help break down food into its component nutrients. Thus the
salivary glands, liver, pancreas and gall bladder have important functions in the
digestive system. Food is propelled along the length of the GIT by peristaltic
movements of the muscular walls.
The primary purpose of the gastrointestinal tract is to break down food into
nutrients, which can be absorbed into the body to provide energy. First food
must be ingested into the mouth to be mechanically processed and moistened.
Secondly, digestion occurs mainly in the stomach and small intestine where
proteins, fats and carbohydrates are chemically broken down into their basic
building blocks. Smaller molecules are then absorbed across the epithelium of
the small intestine and subsequently enter the circulation. The large intestine
plays a key role in reabsorbing excess water. Finally, undigested material and
secreted waste products are excreted from the body via defecation (passing of
feces). In the case of gastrointestinal disease or disorders, these functions of
the gastrointestinal tract are not achieved successfully. Patients may develop
symptoms
of
nausea,
vomiting,
diarrhea,
mal
absorption,
constipation
or
obstruction. Gastrointestinal problems are very common and most people will
have experienced some of the above symptoms several times throughout their
lives.
In the digestive system, ingested food is converted into a form that can be
absorbed into the circulatory system for distribution to and utilization by the
various tissues of the body. This is accomplished both physically, by mastication
in the mouth and churning of the stomach, and chemically, by secretions and
enzymes of the gastrointestinal tract. Beginning at the mouth, all food passes
through the alimentary canal (pharynx, esophagus, stomach, and intestines)
before it reaches the anus, where undigested matter is eliminated as waste.
The outer walls of the digestive tract are composed of layers of muscle and
tissue that undergo waves of contraction (peristalsis), thereby pushing the food
along its digestive path. The inner lining contains glands that secrete the acids
and enzymes necessary to break down food into a form utilizable by the body.
Digestion begins in the mouth, where chewing reduces the food to fine texture,
and saliva moistens it and begins the conversion of starch into simple sugars
by means of an enzyme, salivary amylase. The food is then swallowed, passing
through the pharynx and down the muscular esophagus, or gullet, to the
expanded muscular pouchlike section of the gastrointestinal tract, the stomach.
Specialized cells in the stomach secrete digestive enzymes and gastric juices,
which act on the partially digested food. The stomach also physically churns
and mixes the food. The stomach secretions include the enzyme pepsin, which
acts on proteins; hydrochloric acid, essential for the action of pepsin; and an
enzyme, gastric lipase, which begins the breakdown of fats. The gastric juices
of young children contain, in addition to those just mentioned, the enzyme
rennin, which acts on milk. Some foods, including simple sugars and alcohol,
are absorbed directly through the stomach wall and do not remain in the
stomach. Most food, however, is not absorbed in the stomach and passes into
the duodenum (first section of the small intestine) in the form of a thick liquid
called chyme.
Digestive enzymes from the pancreas and bile from the liver act on the chyme
in the duodenum. These enzymes include pancreatic lipase, which breaks down
fats into glycerol and fatty acids; pancreatic amylase, which continues the
breakdown of starches and most other carbohydrates into disaccharides; and
trypsin and erepsin, which break down whole and partially digested proteins
(proteoses and peptones) into amino acids, the end products of protein
digestion. Bile is essential for emulsifying large fat globules into smaller ones
that are more easily digested by pancreatic lipase. In addition, intestinal juices
are secreted by small glands in the intestinal wall called the crypts of
LieberkUhn. Like the pancreatic juices, intestinal juices contain enzymes that
continue the digestion of proteins and fats and also contain three enzymes that
break down disaccharides into glucose, galactose, and fructose (simple sugars).
The digested food is absorbed into the circulatory and lymphatic systems
through small fingerlike projections of the intestinal wall, called villi. Undigested
material passes into the large intestine, where most of the water is absorbed
and the solid material, or feces, is excreted through the anus.
Basic structure
The gastrointestinal tract is a muscular tube lined by a special layer of cells,
called epithelium. The contents of the tube are considered external to the body
and are in continuity with the outside world at the mouth and the anus.
Although each section of the tract has specialised functions, the entire tract has
a similar basic structure with regional variations. The wall is divided into four
layers as follows:
Mucosa: The innermost layer of the digestive tract has specialised epithelial
cells supported by an underlying connective tissue layer called the lamina
propria. The lamina propria contains blood vessels, nerves, lymphoid tissue and
glands that support the mucosa. Depending on its function, the epithelium may
be simple (a single layer) or stratified (multiple layers).
Areas such as the mouth and oesophagus are covered by a stratified squamous
(flat) epithelium so they can survive the wear and tear of passing food. Simple
columnar (tall) or glandular epithelium lines the stomach and intestines to aid
secretion and absorption. The inner lining is constantly shed and replaced,
making it one of the most rapidly dividing areas of the body! Beneath the
lamina propria is the muscularis mucosa. This comprises layers of smooth
muscle which can contract to change the shape of the lumen.
Submucosa: The submucosa surrounds the muscularis mucosa and consists of
fat, fibrous connective tissue and larger vessels and nerves. At its outer margin
there is a specialized nerve plexus called the submucosal plexus or Meissner
plexus. This supplies the mucosa and submucosa.
Muscularis externa: This smooth muscle layer has inner circular and outer
longitudinal layers of muscle fibres separated by the myenteric plexus or
Auerbach plexus. Neural innervations control the contraction of these muscles
and hence the mechanical breakdown and peristalsis of the food within the
lumen.
Serosa/ Mesentery: The outer layer of the GIT is formed by fat and another
layer of epithelial cells called mesothelium.
The Individual Components of the Gastrointestinal System
Oral cavity
The oral cavity or mouth is responsible for the intake of food. It is lined by a
stratified squamous oral mucosa with keratin covering those areas subject to
significant abrasion, such as the tongue, hard palate and roof of the mouth.
Mastication refers to the mechanical breakdown of food by chewing and
chopping
actions
of
the
teeth.
The
tongue,
a
strong
muscular
organ,
manipulates the food bolus to come in contact with the teeth. It is also the
sensing organ of the mouth for touch, temperature and taste using its
specialised sensors known as papillae.
Insalivation refers to the mixing of the oral cavity contents with salivary gland
secretions. The mucin (a glycoprotein) in saliva acts as a lubricant. The oral
cavity also plays a limited role in the digestion of carbohydrates. The enzyme
serum amylase, a component of saliva, starts the process of digestion of
complex carbohydrates. The final function of the oral cavity is absorption of
small molecules such as glucose and water, across the mucosa. From the
mouth, food passes through the pharynx and oesophagus via the action of
swallowing.
Salivary Glands
Three pairs of salivary glands communicate with the oral cavity. Each is a
complex gland with numerous acini lined by secretory epithelium. The acini
secrete their contents into specialised ducts. Each gland is divided into smaller
segments called lobes. Salivation occurs in response to the taste, smell or even
appearance of food. This occurs due to nerve signals that tell the salivary
glands to secrete saliva to prepare and moisten the mouth. Each pair of
salivary glands secretes saliva with slightly different compositions.
Parotids: The parotid glands are large, irregular shaped glands located under
the skin on the side of the face. They secrete 25% of saliva. They are situated
below the zygomatic arch (cheekbone) and cover part of the mandible (lower
jaw bone). An enlarged parotid gland can be easier felt when one clenches
their teeth. The parotids produce a watery secretion which is also rich in
proteins. Immunoglobins are secreted help to fight microorganisms and aamylase proteins start to break down complex carbohydrates.
Submandibular: The submandibular glands secrete 70% of the saliva in the
mouth. They are found in the floor of the mouth, in a groove along the inner
surface of the mandible. These glands produce a more viscid (thick) secretion,
rich in mucin and with a smaller amount of protein. Mucin is a glycoprotein that
acts as a lubricant.
Sublingual: The sublinguals are the smallest salivary glands, covered by a thin
layer of tissue at the floor of the mouth. They produce approximately 5% of the
saliva and their secretions are very sticky due to the large concentration of
mucin. The main functions are to provide buffers and lubrication.
esophagus
The esophagus is a muscular tube of approximately 25cm in length and 2cm in
diameter. It extends from the pharynx to the stomach after passing through an
opening in the diaphragm. The wall of the oesophagus is made up of inner
circular and outer longitudinal layers of muscle that are supplied by the
oesophageal nerve plexus. This nerve plexus surrounds the lower portion of the
oesophagus.
The
oesophagus
functions
primarily
as
a
transport
medium
between compartments.
Stomach
The stomach is a J shaped expanded bag, located just left of the midline
between the esophagus and small intestine. It is divided into four main regions
and has two borders called the greater and lesser curvatures. The first section
is the cardia which surrounds the cardial orifice where the oesophagus enters
the stomach. The fundus is the superior, dilated portion of the stomach that has
contact with the left dome of the diaphragm. The body is the largest section
between the fundus and the curved portion of the J.
This is where most gastric glands are located and where most mixing of the
food occurs. Finally the pylorus is the curved base of the stomach. Gastric
contents are expelled into the proximal duodenum via the pyloric sphincter. The
inner surface of the stomach is contracted into numerous longitudinal folds
called rugae. These allow the stomach to stretch and expand when food enters.
The stomach can hold up to 1.5 litres of material. The functions of the stomach
include:
1. The short-term storage of ingested food.
2. Mechanical breakdown of food by churning and mixing motions.
3. Chemical digestion of proteins by acids and enzymes.
4. Stomach acid kills bugs and germs.
5. Some absorption of substances such as alcohol.
Most of these functions are achieved by the secretion of stomach juices by
gastric glands in the body and fundus. Some cells are responsible for secreting
acid and others secrete enzymes to break down proteins.
Small Intestine
The small intestine is composed of the duodenum, jejunum, and ileum. It
averages approximately 6m in length, extending from the pyloric sphincter of the
stomach to the ileo-caecal valve separating the ileum from the caecum. The
small intestine is compressed into numerous folds and occupies a large
proportion of the abdominal cavity. The duodenum is the proximal C-shaped
section that curves around the head of the pancreas. The duodenum serves a
mixing function as it combines digestive secretions from the pancreas and liver
with the contents expelled from the stomach. The start of the jejunum is marked
by a sharp bend, the duodenojejunal flexure. It is in the jejunum where the
majority of digestion and absorption occurs.
The final portion, the ileum, is the longest segment and empties into the
caecum at the ileocaecal junction. The small intestine performs the majority of
digestion and absorption of nutrients. Partly digested food from the stomach is
further broken down by enzymes from the pancreas and bile salts from the liver
and gallbladder. These secretions enter the duodenum at the Ampulla of Vater.
After
further
digestion,
food
constituents
such
as
proteins,
fats,
and
carbohydrates are broken down to small building blocks and absorbed into the
body's blood stream. The lining of the small intestine is made up of numerous
permanent folds called plicae circulares. Each plica has numerous villi (folds of
mucosa) and each villus is covered by epithelium with projecting microvilli
(brush border). This increases the surface area for absorption by a factor of
several hundred. The mucosa of the small intestine contains several specialised
cells. Some are responsible for absorption, whilst others secrete digestive
enzymes and mucous to protect the intestinal lining from digestive actions.
Large Intestine
The large intestine is horse-shoe shaped and extends around the small intestine
like a frame. It consists of the appendix, caecum, ascending, transverse,
descending and sigmoid colon, and the rectum. It has a length of approximately
1.5m and a width of 7.5cm. The caecum is the expanded pouch that receives
material from the ileum and starts to compress food products into faecal
material. Food then travels along the colon. The wall of the colon is made up
of several pouches (haustra) that are held under tension by three thick bands of
muscle (taenia coli).
The rectum is the final 15cm of the large intestine. It expands to hold faecal
matter before it passes through the anorectal canal to the anus. Thick bands of
muscle, known as sphincters, control the passage of faeces. The mucosa of the
large intestine lacks villi seen in the small intestine. The mucosal surface is flat
with several deep intestinal glands. Numerous goblet cells line the glands that
secrete mucous to lubricate faecal matter as it solidifies. The functions of the
large intestine can be summarised as:
1. The accumulation of unabsorbed material to form faeces.
2. Some
digestion
by
bacteria.
The
bacteria
are
formation of intestinal gas.
3. Reabsorption of water, salts, sugar and vitamins.
Liver
responsible for
the
The liver is a large, reddish-brown organ situated in the right upper quadrant of
the abdomen. It is surrounded by a strong capsule and divided into four lobes
namely the right, left, caudate and quadrate lobes. The liver has several
important functions. It acts as a mechanical filter by filtering blood that travels
from the intestinal system. It detoxifies several metabolites including the
breakdown of bilirubin and oestrogen. In addition, the liver has synthetic
functions, producing albumin and blood clotting factors. However, its main roles
in digestion are in the production of bile and metabolism of nutrients. All
nutrients absorbed by the intestines pass through the liver and are processed
before traveling to the rest of the body. The bile produced by cells of the liver,
enters the intestines at the duodenum. Here, bile salts break down lipids into
smaller particles so there is a greater surface area for digestive enzymes to act.
Gall Bladder
The gallbladder is a hollow, pear shaped organ that sits in a depression on the
posterior surface of the liver's right lobe. It consists of a fundus, body and neck.
It empties via the cystic duct into the biliary duct system. The main functions of
the gall bladder are storage and concentration of bile. Bile is a thick fluid that
contains enzymes to help dissolve fat in the intestines. Bile is produced by the
liver but stored in the gallbladder until it is needed. Bile is released from the
gall bladder by contraction of its muscular walls in response to hormone signals
from the duodenum in the presence of food.
Pancreas
Finally, the pancreas is a lobular, pinkish-grey organ that lies behind the
stomach. Its head communicates with the duodenum and its tail extends to the
spleen. The organ is approximately 15cm in length with a long, slender body
connecting the head and tail segments. The pancreas has both exocrine and
endocrine functions. Endocrine refers to production of hormones which occurs in
the Islets of Langerhans. The Islets produce insulin, glucagon and other
substances and these are the areas damaged in diabetes mellitus. The exocrine
(secretrory) portion makes up 80-85% of the pancreas and is the area relevant
to the gastrointestinal tract.
It is made up of numerous acini (small glands) that secrete contents into ducts
which eventually lead to the duodenum. The pancreas secretes fluid rich in
carbohydrates and inactive enzymes. Secretion is triggered by the hormones
released by the duodenum in the presence of food. Pancreatic enzymes include
carbohydrases, lipases, nucleases and proteolytic enzymes that can break down
different components of food. These are secreted in an inactive form to prevent
digestion of the pancreas itself. The enzymes become active once they reach
the duodenum.