Communicable Disease Nursing

Written Report

“CHOLER
A”
Submitted to:

Ms. Rowena Luce, RN

Clinical Instructor
San Lazaro Hospital

Submitted by:

Nicolas, Jean Therese P.

BSN 104 B/ Grp. B3
 Norzagaray College

Date Submitted:

September 8, 2010

CHOLERA (EL TOR)

Introduction

• Cholera is an acute, bacterial, diarrheal disease

with profuse watery stools, occasional vomiting,
and rapid dehydration.
• If untreated, circulatory collapse, renal failure
and death may occur.
• More than 50% of untreated people with severe
cholera die.
• It occurs worldwide, with periodic epidemics
and pandemics.
• The Philippines were infected in 1858.
• The 1902-1904 cholera epidemic claimed 200,000 lives in the Philippines.
• In the Philippines, there is an incidence rate of approximately one person in 86,241,697.

Etiologic agent
• Certain biotypes of Vibrio cholerae
serogroup 01 which are curved, Gram-
negative bacilli that secrete an enterotoxin
(a toxin that adversely affects cells in the
intestinal tract) called choleragen. Other
Vibrio spp. (Vibrio parahaemolyticus, Vibrio
 vulnificus) also cause diarrheal diseases. Vibrios are halophilic and are thus found in marine
environments.

Reservoirs and Mode of Transmission

• Infected humans and aquatic reservoirs.

• Transmission is via the fecal-oral route, contact with feces or vomitus of infected people,
ingestion of fecally contaminated water and foods especially raw or undercooked shellfish and
other seafood and flies.

Incubation Period

From few hours to 5 days; usually 1-3 days

CLINICAL MANIFESTATIONS

Stage 1: Diarrheal Stage

• Abrupt onset of painless, severe, watery diarrhea that is often voluminous, flecked with
mucus and dead cells, and has a pale, milky appearance that resembles water in which
rice has been rinsed (rice-watery stool)
• Vomiting without nausea that may persist for hours at a time
• Muscle cramps
Stage 2: Dehydration Stage

• Dehydration
• Irritability
• Lethargy
• Sunken eyes
• Dry mouth
• Extreme thirst
• Dry, shriveled skin that's slow to bounce back when pinched into a fold (Washer Woman’s
Hands)
• Little or no urine output
• Low blood pressure
• Irregular heartbeat (arrhythmia)
• Shock

Pathognomonic Sign
 RICE WATERY STOOL

Diagnosis

Rectal swabs or stool specimens should be inoculated onto thio-sulfate-citrate-bile-sucrose

(TCBS) agar; different Vibrio spp. produce different reactions on this medium. Biochemical tests
are used to identify the various species. Biotyping is accomplished using commercially available
antisera.

Laboratory Test:

 darkfield/phase-contrast microscopy, which may yield a large quantity of curved bacilli on

examination of saline suspensions from fresh stool samples. V cholerae are usually variable
in size from 1 to 3 micrometres in length to 0.5 to 0.8 micrometres in diameter, with single
polar flagellum and typical shooting star motility.
 Gram-stain examination of stool culture is cheap and widely available but not a particularly
helpful subsequent laboratory test. Smears can demonstrate small, curved gram-negative
rods.
 Full blood count may show elevated haematocrit in non-anaemic patients as a result of
volume depletion, and a high neutrophil count may be present in severe infection.
 Blood chemistry tests are important in assessing the degree of volume depletion; urea and
creatinine levels are frequently elevated due to volume depletion.

RISK FACTORS

Precipitating factors:

• Contaminated food and water (contact with flies, feces )

• Raw or undercooked seafood (e.g.,
shellfish)
• Poor hygiene and sanitation
• Overcrowding(e.g., refugee camps,
impoverished countries, and areas
devastated by famine, war or natural
disasters)
• Poverty
• Malnutrition
• Compromised Immunity
 • Reduced or nonexistent stomach acid (hypochlorhydria or achlorhydria)

Predisposing factors:

• Age: children and older adults

•  People who have had gastric surgery, who have untreated Helicobacter pylori infection, or
who are taking antacids, H-2 blockers or proton pump inhibitors for ulcers
• Type O blood
• Household exposure
• International travel (Latin America, Africa, Asia, Gulf of Mexico, Middle East)

NURSING CARE MANAGEMENT

• Assess severity, quality, region and time of muscle cramps.

• Assess for signs of dehydration. Observe for excessively dry skin and mucous membranes,
decreased skin turgor, slowed papillary refill.
• Note number, color, amount, consistency and characteristic of stool and vomitus.
• Note generalized muscle weakness or cardiac dysrhythmias.
• Observe for overt bleeding and test stool daily for occult blood.
• Monitor input and output strictly.
• Monitor vital signs. Blood pressure, pulse, respiration and temperature.
• Weigh daily.
• Increase fluid intake.
• Estimate fluid volume losses like diaphoresis.
• Measure urine specific gravity and observe for oliguria.
• Maintain oral restrictions, bed rest and avoid exertion.
• Provide bed pan or bedside commode.
• Provide a bland diet.
• Assist patient in ambulating to the bathroom.
• Medical septic protective care must be provided.
• Contact precautions must be observed.
• A thorough and careful personal hygiene must be provided.
• Stool, urine and other infected secretions must be properly disposed of.
• Concurrent disinfection must be applied.
• Food must be properly prepared.
• Environmental sanitation must be observed.
TREATMENT
Cholera requires immediate treatment because the disease can cause death within hours.

• Rehydration. The goal is to replace fluids and electrolytes lost through diarrhea using a
simple rehydration solution, Oral Rehydration Salts (ORS), that contains specific proportions of
water, salts and sugar. The ORS solution is available as a powder that can be reconstituted in
boiled or bottled water. Without rehydration, approximately half the people with cholera die.
With treatment, the number of fatalities drops to less than 1 percent.

• Intravenous fluids. During a cholera epidemic, most people can be helped by oral

rehydration alone, but severely dehydrated people may also need intravenous fluids.
• Antibiotics. Recent studies show that a single dose of azithromycin (Zithromax, Zmax) in
adults or children with severe cholera helps shorten diarrhea duration and decreases vomiting.
• Zinc supplements. Research has shown that zinc may decrease and shorten the duration of
diarrhea in children with cholera.

PREVENTION

• Wash your hands. Frequent hand washing is the best way to control cholera infection. Wash
your hands thoroughly with hot, soapy water, especially before eating or preparing food, after
using the toilet, and when you return from public places. Carry an alcohol-based hand sanitizer
for times when water isn't available.
• Avoid untreated water. Contaminated drinking water is the most common source of cholera
infection. For that reason, drink only bottled water or water you've boiled or disinfected
yourself. Coffee, tea and other hot beverages, as well as bottled or canned soft drinks, wine
and beer, are generally safe. Carefully wipe the outside of all bottles and cans before you
open them and ask for drinks without ice..
• Eat food that's completely cooked and hot. Cholera bacteria can survive on room
temperature food for up to five days and aren't destroyed by freezing. It's best to avoid street
vendor food, but if you do buy it, make sure your meal is cooked in your presence and served
hot.
• Avoid sushi. Don't eat raw or improperly cooked fish and seafood of any kind.
• Be careful with fruits and vegetables. When you're traveling, make sure that all fruits and
vegetables that you eat are cooked or have thick skins that you peel yourself. Avoid lettuce in
particular because it may have been rinsed in contaminated water.
• Be wary of dairy foods. Avoid ice cream, which is often contaminated, and unpasteurized
milk.
• Cholera vaccine. Because travelers have a low risk of contracting cholera and because the
traditional injected vaccine offers minimal protection, no cholera vaccine is currently available
in the United States. A few countries offer two oral vaccines that may provide longer and better
immunity than the older versions did. If you'd like more information about these vaccines,
contact your doctor or local office of public health. Keep in mind that no country requires
immunization against cholera as a condition for entry.