CHOLERA

DEFINITION Cholera is an acute bacterial enteric disease of GIT characterized by profuse diarrhea, vomiting, massive loss of fluid and electrolytes, which could result in hypovolemic shock, acidosis, and death. ETIOLOGIC AGENT Vibrio cholera/ vibrio coma 1. The organism is a slightly curved rod (comma-shaped), Gram-negative and motile with a polar flagellum. 2. The organism survives well at ordinary temperatures and multiplies well in temperatures ranging from 22-40 degrees centigrade. 3. They survive longer in refrigerated foods. 4. An enterotoxin, choleragen, is elaborated by the organism as it grows in the intestinal tract. PATHOGNOMONIC SIGN Rice-water stools INCUBATION PERIOD The incubation period ranges from a few hours to five days, usually one to three days. PERIOD OF COMMUNICABILITY The organisms are communicable during the stool-positive stage, usually a few days after recovery; however, occasionally the carrier may have the organism for several months. MODE OF TRANSMISSION 1. Fecal transmission passes via the oral route from contaminated water, milk and other foods. 2. The organisms are transmitted through the ingestion of food or water contaminated with the stools or vomitus of a patient. 3. Flies, soiled hands, and utensils also serve to transmit the infection.

PATHOGENESIS AND PATHOLOGY 1. Fluid loss is attributed to the enterotoxin elaborated by the organism as it lies in opposition with the lining cells of the intestines. 2. The toxin stimulates adenylate cyclase, which results in the conversion of adenosine triphosphate (ATP) to cyclic adesine monophosphate (cAMP) 3. The mucosal cells are stimulated to increase the secretion of chloride. The increased secretion is associated with water and bicarbonate loss. 4. The toxin acts upon the intact epithelium on the vasculature of the bowel, thus resulting in the outpouring of intestinal fluids. 5. Fluid loss of 5 to 10% of the body weight results in dehydration and metabolic acidosis. 6. If treatment is delayed or inadequate, acute renal failure and hypokalemia become secondary problems. PRINCIPAL PATHOGENIC EVENTS IN CHOLERA 1. 2. 3. 4. The passage of Vibrio cholerae into the small intestines The multiplication of the bacteria in the small intestines The production of enterotoxin by the bacteria Secretion of isotonic fluid by the intestinal epithelium in response to the production of enterotoxin

CLINICAL MANIFESTATIONS 1. There is an acute, profuse, watery diarrhea with no tenesmus or intestinal cramping 2. Initially, the stool is brown and contains fecal material, but soon becomes pale gray and rice water-like 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 into the orbits. 6. The skin is cold; the fingers and toes are wrinkled, assuming the characteristic washerwomans hand. 7. Radial pulses become imperceptible and blood pressure unobtainable. 8. Cyanosis is present. 9. The voice becomes hoarse and then is lost, such that the patient speaks in whispers (aphonia) 10. Breathing is rapid and deep.

11. Despite marked diminished peripheral circulation, consciousness is present. 12. The patient develops oliguria and sometimes even anuria. 13. Temperature could be normal at the onset of the disease but becomes subnormal in later stages, especially if the patient is in shock. 14. When the patient is in deep shock, the passage of diarrhea stops. 15. Death may come as rapidly as four hours after onset, but usually on the first or the second day if not properly treated. PRINCIPAL DEFICITS 1. Extracellular volume in the loss of intestinal fluid that can lead to: a. Severe dehydration with the appearance of washerwomans hand, restlessness, and excessive thirst, and b. Circulatory collapse or shock. 2. Metabolic acidosis is due to the loss of a large volume of bicarbonate-rich stools, which results in rapid respiration with intervals of apnea (kussmaul respiration). 3. Hypokalemia is due to a massive loss of potassium through the stools. Patient may manifest abdominal distention that could be attributed to paralytic ileus. 4. Renal failure occurs as a consequence of prolonged, untreated shock or unrelieved hypokalemia. 5. Convulsions and tetany are probably caused by loss of magnesium. 6. Hypoglycemia may occur in untreated children who have been in stupor for several days. 7. Corneal scarring can occur in a stuporous patient who has lost the wink reflex. 8. Acute pulmonary edema may follow hydration in cases of uncorrected metabolic acidosis (Wehrle & top, 1991).

DIAGNOSTIC EXAMS 1. Rectal swab 2. Darkfield or phase microscopy 3. Stool exam

MODALITIES OF TREATMENT Treatment of cholera consists of correcting the basic abnormalities without delayrestoring the circulating blood volume and blood electrolytes to normal levels. 1. Intravenous treatment is achieved by rapid intravenous infusion of an alkaline saline solution containing sodium, potassium, chloride, and bicarbonate ions in proportions comparable to that in water-stools. 2. Oral therapy rehydration can be completed by the oral route (ORESOL, HYDRITES) unless contraindicated or if the patient is not vomiting. 3. Maintenance of the volume of fluid and electrolytes lost after rehydration. This is done by careful intake and output measurement. 4. Antibiotics a) Tetracycline 500 mg every 6 hours might be administered to adults; 125 mg/ kg body weight for children every 6 hours for 72 hours. b) Furazolidone 100mg for adults and 125 mg/kg for children might be given every 6 hours for 72 hours. c) Chloramphenicol may also be given 500 mg for adults and 18 mg/kg for children every 6 hours for 72 hours. d) Contrimoxazole may also be administered 8mg/kg for 72 hours. NURSING MANAGEMENT 1. Medical aseptic protective care must be provided. Hand washing is imperative before any food item is handled. 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 of. 7. Concurrent disinfection must be applied. 8. Food must be properly prepared. 9. Environmental sanitation must be observed. 10. Weighing the patient provides additional data that there is no deficit in fluid input. 11. Appropriate diet is given according to the stage of recovery.

COMMON NURSING DIAGNOSIS 1. 2. 3. 4. 5. 6. 7. Altered nutrition: less than body requirement Altered tissue perfusion Activity intolerance Knowledge deficit High risk for fluid volume deficit Diarrhea Impaired skin integrity

PREVENTION 1. 2. 3. 4. 5. Food and water supply must be protected from fecal contamination Water should be boiled or chlorinated. Milk should be pasteurized. Sanitary disposal of human excreta is a must. Sanitary supervision is important.