CholeraCholera

EltorEltorPrepared by:

Leancris A. CondeBSN III-B

Bicol University College of Nursing

Cholera is a worldwide disease with an estimated incidence of more than five million cases per year, most of which occur in Asia and Africa, with 8% of cases requiring hospitalization. Cholera is a devastating disease, the epidemics of which, until 1992, were caused by Vibrio cholerae serogroup O1 biotype classical or El Tor. The classical biotype is believed to have caused the first six pandemics, which occurred in the Indian subcontinent and subsequently in other areas of the world between 1817 and 1923.

Definition

An acute bacterial enteric disease of the GIT characterized by:

profuse diarrhea,

vomiting

massive loss of fluid and electrolytes

that could result to hypovolemic shock, acidosis and death

Etiologic Agent

Vibrio Cholera/ Vibrio Coma1.the organism are slightly

curved rods (coma shaped), gram negative(-) motile with a single polar flagellum

2.Organism survive well at ordinary temperature and can grow well in temperature from

22-40 degrees centigrade

3.They can survive well at ordinary temperature and can survive longer in refrigerated food

4.An enterotoxin, choleragen, is elaborated by organisms as they grow in intestinal tract

Electron Micrograph of Vibrio cholerae

Description: Vibrio cholerae is a gram-negative, facultatively anaerobic, curved (vibrio-shaped), rod prokaryote that causes the disease cholera

The Vibrio cholerae bacterium

Description: The Vibrio cholerae bacterium under an electron microscope. Color has been added to show the nucleic acid (orange) and the flagellum (tail), which is used by the bacterium to move.

Pathognomonic Sign

RICE-WATER STOOL

Incubation Period

The incubation period ranges from

Few hours to five(5) days

Usually

One to three(3) days

Period of Communicability

The organism are communicable

during stool positive stage

few days after recovery

occasionally carrier may have the organism for several months

Mode of Transmission

1.Fecal transmission passes via oral route from contaminated water, milk, and other foods

2.The organisms are transmitted through ingestion of food or water contaminated with stool or vomitus of patient

3.Flies, soiled hands, and utensils also serve to transmit the infection.

Patho-physiolog

y

1. There is an acute, profuse, watery diarrhea with no tenesmus or intestinal cramping

2. Initially, the stool is brown and contains fecal materials, but soon becomes pale gray, “rice-water” in appearance with an inoffensive, slightly fishy odor.

3. Vomiting often occurs after diarrhea has been established

4. Diarrhea causes fluid loss amounting to 1 to 30 liters per day owing to subsequent dehydration and electrolyte loss.

5. Tissue turgor is poor and eyes are sunken in the orbit

6. The skin is cold, fingers and toes are wrinkled, assuming the characteristic “washer-woman’s hand.”

7.Radial pulses become imperceptible and blood pressure unobtainable.

8.Cyanosis is present.

9. The voice becomes hoarse and then, is lost, so that the patient speaks in whisper(aphonia).

10. Breathing is rapid and deep.11. Despite marked diminished

peripheral circulation, unconciousness is present.

12. Patient develops oliguria and may even develop anuria.

13. Temperature could be normal at the onset of disease but becomes subnormal in the later stage especially if patient is in shock.

14. When patient is in deep shock, the passage of diarrhea stops.

15. Death may occur as for hours after onset, but usually occurs on the first or second day if not properly treated.

Principal deficits:1. Extra cellular volume in the loss of

intestinal fluid that can lead to:a. severe dehydration with the

appearance f washer-woman’s hand”b. circulatory collapse or shock

2. Metabolic acidosis is due to loss of large volume of bicarbonate-rich stool that results in rapid respiration with intervals of apnea.

3. Hypokalemia is due to massive loss of potassium in stool. Patient may manifest abdominal distention that could be attributed to paralytic ileus.

A case of severe dehydration from cholera

Description: A child, lying on a cholera cot, showing typical signs of severe dehydration from cholera. The patient has sunken eyes, lethargic appearance, and poor skin turgor, but within 2h was sitting up, alert, and eating normally

1.Rectal Swab- is a laboratory test to isolate and identify organisms in the rectum that can cause gastrointestinal symptoms and disease. Normally, many organisms are present in the lower gastrointestinal (GI) tract, but some can act as pathogens (disease-causing organisms) in the bowel.

2. Stool Exam-It refers to a series of laboratory tests done on fecal samples to analyze the condition of a person's digestive tract in general. Among other things, a fecalysis is performed to check for the presence of any reducing substances such as white blood cells (WBCs), sugars, or bile and signs of poor absorption as well as screen for colon cancer.

3. Dark field or phase microscopy Exam. of cholera stools by dark-field or

phase-contrast microscopy often shows the highly motile vibrios darting through the field, particularly when the concentrations of vibrios are > 10(5) per ml of stool

Dark field and phase contrast microscopy have been used to screen liquid or rice-water fecal specimens for V. cholerae. Liquid stool or enrichment broth is examined for the presence of organisms with a darting or "shooting star" motility.

Nursing Management

Health History Ask the patient where did he go or if he

recently traveled Know if the patient is treated with antibiotics Ask the patient if he has been in close

contact with anyone who has recently with diarrheal disease

What the patient recently eaten. It is helpful to ask the patient to list every food tasted

Know if they are employed in a food preparation service

LOOK

CONDITION

Well, Alert Restless, Irritable*

Lethargic, Unconscious, Floppy

EYE Sunken Very Sunken and Dry

TEARS Present Absent Absent

MOUTHTONGUE

Moist Dry Very Dry

STOOL Loose Rice Watery Rice Watery

FEEL

SKIN PINCH

Goes Back Quickly

Goes Back Slowly

Goes Back Very Slow

DECIDE

The patient has no sign of dehydration

If the patient has two or more signs, including at least one sign, there is moderate dehydration

If the patient has two or more signs, including at least one sign, there is severe dehydration

Presence of mucus or blood on stool should be inspected and recorded

Measurement of intake and output is vital in determining fluid balance

Liquid stool should be measured and documented along with a record of the frequency of stool

Note the consistency and form of the stool as the key indicator of the type and the severity of the diarrheal disease

Risk for fluid volume deficit r/t severe diarrhea and vomiting

Hypothermia r/t hypovolemia Potential for Impaired skin integrity

r/t dehydration Deficient knowledge about the

infection and the risk of transmission to others

Metabolic Acidosis r/t bicarbonate, sodium, potassium ions and other electrolyte losses

To be able to maintain fluid and electrolyte balance

To prevent further severe complications

To improve the knowledge of patient and relatives about the disease and risk of transmission

1. Medical aseptic protective care must be provided.

2. Enteric isolation must be observed 3. Vital signs must be recorded

accurately 4. Intake and output must be accurately

measured 5. A thorough and careful personal

hygiene must be provided

6. Excreta must be properly disposed off.

7. Concurrent disinfection must be applied

8. Food must be properly prepared.

9. Environmental sanitation must be observed

Treatment of cholera consists in correcting the basic abnormalities without delay– restoring the circulating blood volume and blood electrolytes to normal levels.

1. Intravenous treatment is achieved by rapid intravenous infusion of alkaline saline solution containing sodium, potassium, chloride and bicarbonate ions in proportions comparable to that in water-stool.

2. Oral therapy rehydration can be completed by oral route (ORESOL,HYDRITES) unless contraindicated or, if patient is not vomiting.

3. Maintenance of the volume of fluid and electrolyte lost after rehydration. This is done by careful intake and output measurement.

4. Antibiotics:a. Tetracycline 500 mg every 6 hrs.

might be administered to adults, and 125mg/kg body weight for children every 6hrs. for 3days

b. Furazolidone 100mg for adults and 125mg/kg for children, might be given every 6hrs. For 3 days.

c. Chloramphenicol may also be given 500mg for adults and 18mg/kg for children every 6hrs. For 3days.

d. Cotrimoxazole can also be administered 8mg/kg for 3days.

Patient expected outcomes may consist of:

1. Attains fluid balance 2. Acquires knowledge and

understanding about infectious diarrhea and transmission potential

3. There are no further complications

Prevention and

Control

1. Vaccination 2. Environmental sanitation

a.) Excreta disposalb.) Water Supply Sanitationc.) Food sanitationd.) Fly controle.) Disinfectionf.)Proper disposal of dead

Vaccination

Safe, highly protective oral cholera vaccines

◙ Currently, internationally licensed oral cholera vaccine can be used for preventive vaccination campaigns. ◙ This vaccine has been deployed in a mass vaccination campaign in a cholera-endemic area of Mozambique and proved in principle that mass cholera vaccine campaigns are feasible, safe and protective.

In fact it is the only effective approach known at present to the problem of control of cholera and its eventual eradication.

a.) Excreta disposal

◙ The safe disposal of excreta should be ensured so that possible contamination of water sources is prevented and there is no exposure to flies.

◙ Adequate use of powdered chlorine should be made to sprinkle over excreta and soiled surface in and around the latrines.

Where pipe water supplies are existing, steps should be taken to protect the water sources from possible contamination and to promote operation of water works at maximum efficiency.

“Boil it, cook it, peel it, or forget

it”

◙ Sale of exposed prepared foods and cut fruits sold by vendors should not be allowed. ◙ Strict supervision of sanitation of eating places and hygiene of food handlers is of importance. ◙ People may be encouraged to eat cooked and hot food.

◙ Fly control campaign is desirable in control of cholera. ◙ The measures should aim at elimination of breeding places. ◙ Prompt collection and disposal of garbage and excreta in urban and rural areas are essential for effective fly control

Washing the hands thoroughly and properly before handling foods should be done.

e.) DisinfectionConcurrent and terminal disinfection of infective

materials of each patient would prevent the spread of vibrios.

Patients' stools and vomit should be disinfected before their disposal. Chlorinated lime and Lysol have been found very effective for the purpose. In rural areas, it may be feasible to burn or bury the excretal wastes.

Patients' clothes, linen, and utensils should be boiled or dipped in 2% Lysol or chlorinated lime solution. Contaminated floors, furniture, etc., may be scrubbed with either 2% Lysol or chlorinated lime solution

f.)Disposal of Dead

Sanitary disposal of dead patients with due respect to the religious and social customs should be ensured. The disposal of corpses into the rivers, which is practiced in some places, is dangerous and should be prohibited.

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