MANAGEMENT OF CHOLERA

KALUPA VINCENT
 DEFINITION
Def: Cholera is an acute highly infectious
diarrheal disease of the small intestine caused
by vibrio cholerae characterized by copious
rice watery diarrhoea, vomiting, muscle
cramps, severe dehydration and vascular
collapse.
 CHOLERA
Incubation Period
 From few hours to 5 days.
 CHOLERA
Transmission
Faecal-Oral route through ingestion of
contaminated food and water.
 CHOLERA
Causative Organism
Cholera is caused by vibrio cholerae.
There are two (2) bio-types namely:

Classical cholerae vibrio

Haemolytic el-tar vibrio
 CHOLERA
Characteristics of vibrio cholerae

Comma shaped

Aerobic

Gram negative

Non spore forming
 CHOLERA

Motile organism (possess both flagella and somatic
antigens)

Killed by heat at 55oC for 15 minutes and by phenolic
and hypochlorite disinfectants

Can survive aquatic environments for extended
periods in a ‘dormant state’
 CHOLERA
Epidemiology

Cholera is a disease of low socioeconomic groups
living in unsanitary conditions with poor health
services, unsafe water supply, inadequate or absent
sewage disposal.

It is common in Asia and Africa.
 CHOLERA

Infection spread from contaminated faeces and
water.

Other portable foods include milk, cold cooked
foods and unwashed fruits and vegetables.

Low economic status families are more at risk
 PATHOPHYSIOLOGY OF
CHOLERA
Cholera is transmitted through faecal-oral route
Cholera germ is ingested with contaminated
food or drink
The vibrio cholerae remain in the gut and does
not penetrate into the blood stream
 PATHOPHYSIOLOGY OF
CHOLERA
It adheres to the mucosa of the small intestines
by both outer membrane protein and flagella
adhesions.
Vibrio cholerae produces enterotoxin that causes
excessive fluid and electrolyte loss.
 PATHOPHYSIOLOGY OF
CHOLERA
Sodium Chloride absorption is inhibited and
therefore excreted resulting in water, sodium
chloride, and potassium and bicarbonate loss.
Immunity to both cholera toxin and bacterial
surface antigens follows natural infection.
 PATHOPHYSIOLOGY OF
CHOLERA
Signs of dehydration are common due to excessive
diarrhea and projectile vomiting
Excessive loss of electrolytes; potassium through
diarrhea and vomiting will lead to muscle crumps
If not well managed early, the condition leads to
severe dehydration and excessive loss of fluids and
electrolytes
 PATHOPHYSIOLOGY OF
CHOLERA
Mortality usually results from severe dehydration
and electrolyte loss
Severe dehydration due to severe diarrhea and
projective vomiting brings about circulatory
collapse
Dehydration leads to severe acidosis, kidney
failure which eventually leads to multi organ
 CLINICAL PRESENTATION
Evacuation phase
Mild to acute onset of diarrhoea which initially
contains faecal matter but later becomes watery,
with flecks of white described as rice water
stool.
 CLINICAL PRESENTATION
Projectile vomiting may be present secondary to
endotoxins
Severe dehydration due to diarrhoea and
vomiting 
 CLINICAL PRESENTATION
Collapse phase
Muscle cramps due to loss of electrolytes
Patient develops cold crummy skin with fast weak
pulse due to hypovolemia
Metabolic acidosis indicated by signs of air hunger
with deep sometimes rapid breathing.
 CLINICAL PRESENTATION
Hypovolaemic shock due to vascular depletion
leading to vascular collapse detected by
hypotension, tachycardia, and pulse may be
impalpable at the wrist, cold clammy skin, olyguria.
If no intervention shock can complicate into acute
renal failure and death
 DIAGNOSIS OF CHOLERA
Thorough history taking of onset of
complaints, living in endemic area, living in
community with poor water supply and waste
disposal
Haematological examination for isolation of
vibrio cholarae
 DIAGNOSIS OF CHOLERA
In epidemics, presumptive diagnosis is made on
clinical presentation or epidemiological grounds.
Example, a patient 5 years or older, who
develops acute watery diarrhoea with or without
vomiting residing in an area where cholera is
likely to occur.
 DIAGNOSIS OF CHOLERA
Dark field microscopy of stool may show the
characteristic darting movement of vibrio.
Stool or vomitus or rectal swab for microscopy,
culture and sensitivity confirms the diagnosis
Immunoflorecent allows for rapid diagnosis
MANAGEMENT OF CHOLERA
Aims of management
1. To correct fluid and electrolyte imbalance
2. To eliminate the causative organism
3. To prevent the spread of infection
4. To prevent complications due to loss of fluid
and electrolytes
Management of Dehydration
 REHYDRATION PLAN
Rehydration plan is based on the assessment
and the degree of dehydration as;
Treatment Plan A for Mild dehydration
Treatment Plan B for Moderate dehydration
Treatment Plan C for Severe dehydration
Treatment Plan A
(Mild Dehydration)
 TREATMENT PLAN A
The plan is used to treat mild dehydration
Give more fluids than usual to prevent
dehydration.
You can give plain water, fresh fruit juice,
fresh mashed fruits like bananas.
 TREATMENT PLAN A
Give Oral Rehydration Salt (ORS), soups,
home brewed drinks, breast milk (in children),
yogurt or sour milk.
 TREATMENT PLAN A
ORS amounts to be given in plan A
Patients, who are older than 10 years, give as
much as the patient can take after each loose
stool
Patient should drink about 2000mls of ORS
per day.
 Treatment Plan B
(Moderate Dehydration)
 TREATMENT PLAN B
The plan is used to treat moderate
dehydration
Establish and keep an intravenous line open
Give ORS in the first 24hours, orally or
through intravenous a nasogastric tube, as
follows;
 TREATMENT PLAN B
 Patients who are weighing 30kg and above
should drink about 3800mls of ORS per hour
 If the weight of the patient is not known, then
the age of the patient can be used
 TREATMENT PLAN B
Calculation: weight of the patient ×75mls of
ORS
 If Vomiting occurs wait for 2-5 minutes, then
continue giving slowly
Monitor the patient frequently for
improvement
After 4 hours reassess the patient using
assessment chart.
 TREATMENT PLAN B
 If during assessment there are some signs of
dehydration continue with Plan B and if signs
are severe shift to Plan C
 When there is improvement, the patient will
pass urine and other signs of dehydration will
disappear, then shift to plan A
 Treatment Plan C
(Severe Dehydration)
 TREATMENT PLAN C

The plan is used to treat severe dehydration

The aim is to treat shock (hypovolaemic shock) or to prevent
shock

This treatment should be given immediately

Start intravenous infusion with isotonic solutions ringers
lactate or 0.9% sodium chloride (normal saline) immediately
 TREATMENT PLAN C
Give ORS while infusion of isotonic solutions
is running, if unable to swallow Give ORS via
through a nasogastric tube.
 TREATMENT PLAN C

Calculation of fluids to be given in severe
dehydration

Give 100ml/kg in 3 hours as follows;

30ml/kg within 30 minutes then 70mls/kg in the next 2
and half hours (2 hours: 30minutes)
Reassess the patient very frequently
 TREATMENT PLAN C

If the patient can drink, give about 5ml/kg/ per
hour of ORS in addition to the intravenous fluid.

Assess the dehydration level after 3 hour and re-
classify the level of dehydration and manage
accordingly
 TREATMENT PLAN C

If the patient shows no signs of dehydration after
treatment with intravenous fluids or ORS, continue
with ORS give as much as the patient can drink (at
least 300mls)

Only shift to treatment plan B or A when the patient
has improved or stable
MANAGEMENT OF CHOLERA
Antimicrobial Agents
Tetracycline 500mg 8 hourly for 7 days
Doxycycline 100mg 12 hourly for 7 days
Co-trimoxazole 960mg 12 hourly for 7 days
Ciprofloxacin 500mg 8 hourly for 7 days
Erythromycin 500mg 8 hourly for 7 days
MANAGEMENT OF CHOLERA
Aims of management
1. To correct fluid and electrolyte imbalance
2. To allay anxiety
3. To prevent the spread of infection
4. To promote healing
5. To prevent complications due to loss of fluid
and electrolytes
 NURSING CARE

The unit should be clean and well
ventilated to prevent further nosocomial
infections

Equipment such as drip stands, intravenous
set and observations tray should be within
patient’s environment.
 NURSING CARE
OBSERVATION

Observe general condition of patient to come up with
interventions.

Monitor vital signs such as temperature, pulse, respirations
and blood pressure frequently to monitor prognosis.

The frequency of vital sign observations depends on
patient’s condition.
 NURSING CARE

Observe the quality and amount of stool passed by
patient; colour, smell and staining to monitor extent of
condition.

Monitor the intake and output and record on the fluid
balance charts to promote fluid overload and promotion
of adequate nutrition and rehydration.

Monitor stool for amount, consistency and colour and
report any deviation from normal.
 NURSING CARE

Observe for any signs of dehydration such as
loss of skin elasticity, sunken eyes, and
thirsty and dry mucus membranes of the
mouth and rehydrate if need be.

Observe for psychological state of the
patient and intervene appropriately
 NURSING CARE
Infection prevention
Isolate patient away from other patients to
prevent spread of infection.
Place a label, ‘ISOLATION’ on the door to
notify the visitors not to enter the unity
unnecessarily for prevention of infection
 NURSING CARE

People who come in contact with this patient
should observe isolation techniques such, putting
on gowns and masks whenever they enter the
room, washing hands before and after attending to
the patient.

Restrict visitors because they can also get the
infection.
 NURSING CARE

The linen which is used by the patient should be
disinfected with JIK 1:6 and should be labelled
“infectious” before sending it to the laundry.

It should not be mixed with other linen from the
wards for prevention of spread.

Administer prescribed medication to treat the
causative organism and prevent further spread.
 NURSING CARE
All utensils used by patient should be
disinfected and should be restricted to the
patient only to cut on the spread of infection.
 NURSING CARE
Nutrition

Give some copious drinks and a light diet free from
irritants to prevent further GIT irritation.

If patient is unable to take food and fluids orally
commence him/her on intravenous fluids for rehydration.

Insert a nasogastric tube for feeding, if the patient can not
tolerate orally to promote adequate nutrition
 NURSING CARE
Maintain strict intake and output for
monitoring nutrition and prevent overload.
 NURSING CARE
Hygiene

Thorough assessment of hygiene to be done
for baseline

Assisted /bed bath can be given depending
on the condition of the patient to promote
comfort, self esteem and to remove dirty.
 NURSING CARE

Assist the patient with oral care to prevent
complications of a dirty mouth such as mouth
infections and also promote salivation as the patient’s
mouth can be dry due to excessive loss of fluids.

Change linen whenever soiled for comfort of the
patient.

Ensure perineal area is cleaned for comfort.
 NURSING CARE
Psychological care

Assess the psychological state of the patient for
baseline

Patients with dysentery may feel as if they have been
neglected due to isolation and restriction of visitors.

Give proper psychological care to allay anxiety.
 NURSING CARE

Educate the disease process to patient which should
include the cause, mode of transmission, signs and
symptoms, treatment and complications for cooperation.

Need to explain all the medical procedures to the patient
to gain cooperation

Explain to the patient the reason for isolation which is
prevention of spread of infection to allay anxiety.
 NURSING CARE

Explain also to the significant others on why they are
not allowed to visit the patient to gain cooperation.

Allow patients to ask questions and answer them
truthfully to allay anxiety.

Depending on the situation, involve the patient in
care and encourage patient to be involved in small
assignment tasks to instil feeling of self esteem.
 NURSING CARE
Elimination

Observe intake and output and record for baseline.

Observe stool for amount, contents and odour to
monitor client’s condition.

Provide bed pan in the initial stage but as condition
improves, encourage patient to go to the toilet, this is
to promote hygiene.
 PREVENTION OF CHOLERA

Proper waste disposal and treatment of the germ
infected faecal waste (and all clothing and bedding that
come in contact with it) produced by cholera victim is of
primary importance

Sewage treatment of general sewage before it enters the
waterways or underground water supplies prevent
possible undetected patients from spreading the disease
 PREVENTION OF CHOLERA

Sterilization and disinfection: boiling, filtering, and
chlorination of water kill the bacteria produced by cholera
patients and prevent infections, when they do occur, from
spreading.

All materials like clothing and beddings that come in
contact with cholera patients should be sterilized in hot
water using chlorine bleach.
 PREVENTION OF CHOLERA

Hands that touch cholera patients or their clothing
should be thoroughly cleaned and sterilized.

All water used for drinking, washing or cooking
should be sterilized by boiling or chlorination in a
Cholera endemic area.
 PREVENTION OF CHOLERA

Improve water supply and sanitation thorough
chlorination, boiling and proper covering

Contact tracing: follow up all the cases at home once
one member of the family is diagnosed with Cholera

Personal hygiene like hand washing with soap after
use of toilet, food covering, etc.
 PREVENTION OF CHOLERA

Postpone festivals and gatherings especially in
Cholera endemic areas

Change of attitudes/behaviours e.g. wash hands, boil
water, heat food before eating, use toilet or latrine

Adequate treatment of cases to cut the transmission
cycle
 PREVENTION OF CHOLERA
Active reporting of suspected cases in areas
previously uninfected (notification).
Complications of Cholera
COMPLICATIONS OF CHOLERA

Paralytic ileus due to fluid and electrolyte imbalance
leading to paralysis of smooth muscles of the large
intestine due to loss of electrolytes, like potassium.

Dehydration resulting from excess loss of fluids and
electrolytes from the cellular compartment
COMPLICATIONS OF CHOLERA

Circulatory collapse secondary to fluid depletion in
the cardiovascular

Hypovolaemic shock due to reduced plasma volume
secondary to diarrhoea

Muscle weakness due to excessive loss of electrolytes
like potassium
COMPLICATIONS OF CHOLERA

Cardiac failure due to excessive loss of fluids and
electrolytes

Renal failure due to reduced renal perfusion
secondary to dehydration

Metabolic acidosis secondary to loss of electrolytes
COMPLICATIONS OF CHOLERA
Hypokalaemia secondary to loss of potassium
due to diarrhoea
Cardiac arrhythmias resulting from fluid and
electrolyte depletion
ANY QUESTIONS!!!