METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY

Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

I. INTRODUCTION

Rabies is an acute viral disease of the central nervous system that affects

humans and other mammals. It is almost exclusively transmitted through saliva

from the bite of an infected animal. Another name for the disease is hydrophobia,

which literally means "fear of water," a symptom shared by half of all people

infected with rabies. Other symptoms include fever, depression, confusion,

painful muscle spasms, sensitivity to touch, loud noise, and light, extreme thirst,

painful swallowing, excessive salivation, and loss of muscle tone. If rabies is not

prevented by immunization, it is essentially always fatal.

Worldwide, approximately 15,000 cases of human rabies continue

to occur annually. Remarkably, although more than one million persons in the

United States are bitten each year by animals, on average, only one or two

persons die from the disease each year. Nevertheless, with the continued

encroachment of humans on animal habitats, both for housing and recreational

purposes, rabies remains a public health concern. Both domestic and wild

animals may transmit rabies. With the widespread vaccination of domesticated

animals in the United States, dogs in particular, the number of cases of rabies

has significantly declined. In 1955 domesticated animals, especially dogs,

constituted 47% of the reported rabies cases. By 1994, fewer than 2% of positive
 METROPOLITAN MEDICAL CENTER
COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

tests occurred in dogs. In fact, in the 1990s, cats outnumbered dogs as

transmitters of the disease. As of 1997, most cases of rabies are in wild animals,

particularly bats, raccoons, skunks, foxes, wolves, and coyotes. Anyone who has

been bitten by an animal, regardless of age or sex, can contract rabies. However,

people whose occupations involve routine exposure to a domestic animal that

has not been immunized or to wildlife are at a greater risk for getting the disease.

As a result, cave explorers, farm and ranch workers, animal trainers and

caretakers, forest rangers, animal exterminators, some laboratory workers, and

veterinarians are at a higher risk.

 METROPOLITAN MEDICAL CENTER
COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

II. ANATOMY AND PHYSIOLOGY

Brain Structure Function Associated Signs and

Symptoms
Basal Ganglia Subcortical gray matter • Movement
nuclei. Processing link disorders: chorea,
between thalamus and tremors at rest and
motor cortex. Initiation with initiation of
and direction of movement,
voluntary movement. abnormal increase
Balance (inhibitory), in muscle tone,
Postural reflexes. difficulty initiating
movement.
Part of extrapyramidal • Parkinson's.
system: regulation of
automatic movement.

Thalamus Processing center of the • Altered level of

cerebral cortex. consciousness.
Coordinates and • Loss of perception.
regulates all functional • Thalamic
activity of the cortex via syndrome -
the integration of the spontaneous pain
afferent input to the opposite side of
cortex (except olfaction). body.

Contributes to affectual
expression.
 METROPOLITAN MEDICAL CENTER
COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

Hypothalamus Integration center of • Hormonal

Autonomic Nervous imbalances.
System (ANS): • Malignant
Regulation of body hypothermia.
temperature and • Inability to control
endocrine function. temperature.
• Diabetes Insipidus
Anterior Hypothalamus: (DI).
parasympathetic activity • Inappropriate ADH
(maintenance function). (SIADH).
• Diencephalic
Posterior Hypothalamus: dysfunction:
sympathetic activity "neurogenic
("Fight" or "Flight", storms".
stress response.

Behavioral patterns:
Physical expression of
behavior.

Appestat: Feeding
center.

Pleasure center.
 METROPOLITAN MEDICAL CENTER
COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

Cerebellum Coordination and control • Tremors.

of voluntary movement. • Nystagmus
(Involuntary
movement of the
eye).
• Ataxia, lack of
coordination.
 METROPOLITAN MEDICAL CENTER
COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

• Pons Respiratory Center. • Pupils:

Cranial Nerves: Size: Pinpoint

 CN V - • LOC:
Trigeminal (Skin
of face, tongue, Semi-coma
teeth; muscle of "Akinetic Mute".
mastication), "Locked In"
[motor and Syndrome.
sensory].
 CN VI - • Movement:
Abducens
(Lateral rectus Abnormal extensor.
muscle of eye Withdrawal.
which rotates
eye outward), • Respiratory:
[motor].
 CN VII - Apneustic
Facial (Muscles (Abnormal
of expression), respiration marked
[motor and by sustained
sensory]. inhalation).
 CN VIII - Hyperventilation.
Acoustic
(Internal auditory • CN Deficits: CN VI,
passage), CN VII.
[sensory].
• Medulla Crossing of motor tracts. • Movement:
Oblongata Ipsilateral
Cardiac Center. (same side)
plegia
Respiratory Center. (paralysis).
• Pupils:
Vasomotor (nerves having
muscular control of the blood Size: Dilated.
vessel walls) Center Reactivity:
Fixed.
Centers for cough, gag,
swallow, and vomit. • LOC:
Comatose.
Cranial Nerves: • Respiratory:

 CN IX - Abnormal
Glossopharyneal breathing
(Muscles and mucous patterns.
membranes of pharynx, Ataxic.
the constricted openings Clustered.
from the mouth and the Hiccups.
oral pharynx and the
posterior third of • CN Palsies
tongue.), [mixed]. (Inability to
 CN X - Vagus control
(Pharynx, larynx, heart, movement):
lungs, stomach),
[mixed]. Absent Cough.
 CN XI - Accessory Gag.
(Rotation of the head
and shoulder), [motor].
 CN XII - Hypoglossal
(Intrinsic muscles of the
tongue), [motor].

METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003
III. PATHOPHYSIOLOGY

Precipitating: Precipitating

-Contact with animal -Age

-Wounds contact with rhabdovirus -Sex

Point of entry

The virus quickly travel along the neural pathway

Pathway into the the CNS to other organs

Rhabdovirus causes widespread changes throughout

the CNS

Negribodies

This consist of neural necrosis and mononuclear

Cellular infiltration

Thalamus Hypothalamus Cranial nerve Pons Medulla

Basal
Extremely damaged
ganglia

irritability perspiration painful spasm at Copius impaired

fever mouth salivation swallowing
regulates
 depression (pathognomonic
voluntary
photophobia anorexia sign for
moements
rabies

METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

IV. MEDICAL MANAGEMENT

Post-exposure prophylaxis

Treatment after exposure, known as post-exposure prophylaxis (PEP), is highly

successful in preventing the disease if administered promptly, generally within

ten days of [Link] washing the wound as soon as possible with

soap and water for approximately five minutes is very effective at reducing the

number of viral particles. “If available, a virucidal antiseptic such as povidone-

iodine, iodine tincture, aqueous iodine solution or alcohol (ethanol) should be

applied after washing...Exposed mucous membranes such as eyes, nose or

mouth should be flushed well with water.”

In the United States, the Centers for Disease Control and Prevention (CDC)

recommend patients receive one dose of human rabies immunoglobulin (HRIG)

and four doses of rabies vaccine over a fourteen day period. The immunoglobulin

dose should not exceed 20 units per kilogram body weight. HRIG is very

expensive and constitutes the vast majority of the cost of post-exposure

treatment, ranging as high as several thousand dollars. As much as possible of

this dose should be infiltrated around the bites, with the remainder being given by
deep intramuscular injection at a site distant from the vaccination site. The first

dose of rabies vaccine is given as soon as possible after exposure, with

METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

additional doses on days three, seven and fourteen after the first. Patients who

have previously received pre-exposure vaccination do not receive the

immunoglobulin, only the post-exposure vaccinations on day 0 and 2. Modern

cell-based vaccines are similar to flu shots in terms of pain and side effects. The

old nerve-tissue-based vaccinations require multiple painful injections into the

abdomen with a large needle, are cheap, but are being phased out and replaced

by affordable WHO ID (intradermal) vaccination regimens.

Intramuscular vaccination should be given into the deltoid, not gluteal area which

has been associated with vaccination failure due to injection into fat rather than

muscle. In infants the lateral thigh is used as for routine childhood vaccinations.

Finding a bat in the room of a sleeping infant is regarded as an indication for

post-exposure prophylaxis. The recommendation for the precautionary use of

post-exposure prophylaxis in occult bat encounters where there is no recognized

contact has been questioned in the medical literature based on a cost-benefit

analysis. However, recent studies have further confirmed the wisdom of

maintaining the current protocol of precautionary administering of PEP. in cases

where a child or mentally compromised individual has been left alone with a bat,

METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND
TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

especially in sleep areas (where a bite/or exposure may occur while the victim is

asleep and unaware or awake and unaware that a bite occurred). This is

illustrated by the September though there was no apparent report of a bite; as

shown in the following conclusion made by the doctors involved in the case:

Despite recent criticism (45), the dramatic circumstances surrounding our

patient's history, as well as increasingly frequent reports of human rabies

contracted in North America, support the current Canadian guidelines which state

that RPEP [PEP] is appropriate in cases where a significant contact with a bat

cannot be excluded (45). The notion that a bite or an overt break in the skin

needs to be seen or felt for rabies to be transmitted by a bat is a myth in many

cases. It is highly recommended that PEP be administered as soon as possible.

Begun with little or no delay, PEP is 100% effective against rabies. In the case in

which there has been a significant delay in administering PEP, the treatment

should be administered regardless of that delay, as it may still be effective. If

there has been a delay between exposure and attempts at treatment, such that

the possibility exists that the virus has already penetrated the nervous system,

the possibility exists that amputation of the affected limb might thwart rabies, if

the bite or exposure was on an arm or leg. This treatment should be combined

with an intensive PEP regimen.

METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND
TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

Blood-brain barrier

Some recent works have shown that during lethal rabies infection, the blood-

brain barrier (BBB) does not allow anti-viral immune cells to enter the brain, the

primary site of rabies virus replication. This aspect contributes to the

pathogenicity of the virus and artificially increasing BBB permeability promotes

viral clearance. Opening the BBB during rabies infection has been suggested as

a possible novel approach to treat the disease, even though no attempts have

yet been made to determine whether or not this treatment could be successful.

Induced coma

In 2005, American teenager Jeanna Giese survived an infection of rabies

unvaccinated. She was placed into an induced coma upon onset of

symptoms and given ketamine, midazolam, ribavirin, and amantadine.

Her doctors administered treatment based on the hypothesis that

 detrimental effects of rabies were caused by temporary dysfunctions in the

brain and could be avoided by inducing a temporary partial halt in brain

function that would protect the brain from damage while giving the immune

system time to defeat the virus. After thirty-one days of isolation and

seventy-six days of hospitalization, Giese was released from the

[Link] survived with almost no permanent sequelae and as of 2009

was starting her third year of university studies.

METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND
TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

Giese's treatment regimen became known as the "Milwaukee protocol", which

has since undergone revision (the second version omits the use of ribavirin).

There were 2 survivors out of 25 patients treated under the first protocol. A

further 10 patients have been treated under the revised protocol and there have

been a further 2 [Link] anesthetic drug ketamine has shown the potential

for rabies virus inhibition in rats, and is used as part of the Milwaukee protocol.

On April 10, 2008 in Cali, Colombia, an eleven year-old boy was reported to

survive rabies and the induced coma without noticeable brain damage.
 METROPOLITAN MEDICAL CENTER
COLLEGE OF ARTS, SCIENCE AND
TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

V. DRUG STUDY

BRAND NAME Imovax Rabies, RabAvert

GENERIC NAME Rabies vaccine, human diploid cell
CLASSIFICATION Active Immunizing Agent
INDICATIONS AND > Postexposure antirabies immunization: adults and children: five 1-ml
DOSAGE doses of HDCV I.M. give first dose as soon as possible after exposure;
give additional doses on days 3,7,14, and 28 after first dose. If no
antibody response occurs after this primary series, booster dose is
recommended.
> Preexposure preventive immunization or persons in high-risk groups:
adults and children: three 1-ml injections I.M. give first dose on day 0
( first day of therapy), second dose on day 7, and third dose on day 21
or 28. Or, 0.1 ml I.D. on same dosage schedule.
ACTION Promotes active immunity to rabies

Route Onset Peak Duration

I.M, I.D. 1 wk 1-2 mo >2yr
ADVERSE EFFECT CNS: fatigue, fever, headache, dizziness
 GI: nausea, abdominal pain, diarrhea
MUSCULOSKELETAL: muscle aches
SKIN: erythema, injection site pain, itching, swelling
OTHER: serum sickness, anaphylaxis
NURSING > Keep epinephrine 1:1000 available to treat anaphylaxis
CONSIDERATIONS > Use vaccine immediately after reconstitution
> Alert!!! Don’t use ID for postexposure rabies vaccines
> Stop corticosteroids therapy during immunizing period unless therapy
is essential for treatment of other conditions
> Report all serious reactions

METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND
TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
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BRAND NAME Rabies Immune Globulin, Human

GENERIC NAME Hyperab, Imogam Rabies-HT
CLASSIFICATION Immunomodulator
INDICATIONS AND > Rabies exposure: adults and children: 20 international units/kg I.M. at
DOSAGE time of first dose of rabies vaccine. Half of dose is used infiltrate wound
area; remainder is given IM in diff. site.
ACTION Provides passive immunity to rabies.

Route Onset Peak Duration

I.M, 24 hr Unknown unknown
ADVERSE EFFECT CNS: slight fever
GU: nephrotic syndrome
SKIN: reash, pain, redness, and induration at injection site.
Other: anaphylaxis, angioedema
NURSING > Obtain hx of animal bites, allergies, and reactions to immunization. Have epi
CONSIDERATIONS 1:1000 ready to treat anaphylaxis
 > Ask pt. when last tetanus immunization was rcvd

> Don’t give live-virus vaccines within 3 months of rabies immune globulin

> Don’t give more than 5ml I.M. at one injction site; divide IM doses over 5ml give at
diff site

> Clean wound thoroughly with soap and water, this is the best prophylaxis against
rabies

METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND
TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

BRAND NAME Tetanus toxoid

CLASSIFICATION Immunomodulator
INDICATIONS AND > Primary immunization to prevent tetanus : adults and children age 7
DOSAG and older: 0.5ml I.M. 4 to 8 weeks apart for two doses, then give third
dose 6 to 12 months after second. children ages 6 weeks to 6 years:
although use isn’t recommended in children younger than age 7 the
following dosage schedule may be used; 0.5 ml IM for two doses, each
4 to 8 weeks apart, followed by third dose 6 to 12 months after the
second dose
> Booster dose to prevent tetanus: adults and children age 7 and older:
0.5ml IM at 10 year intervals.
> Postexposure prevention of tetanus: adults for a clean, minor wound
give emergency booster doseif more than 10 years have elapsed since
last dose. For all other wounds, give booster dose if more than 5 years
have elapsed since last dose.

ACTION Promotes immunity to tetanus by inducting anti toxin production

 Route Onset Peak Duration
I.M,subQ After 2 doses Unknown >10 yr
ADVERSE EFFECT CNS: seizures, slight fever, headache, malaise, encelophaty
CV: tachycardia, hypotension, flushing
MUSCULOSKELWTAL: aches, pains
SKIN: erythema, pruritus
OTHER: anaphylaxis, chills
NURSING > Obtain hx. Of allergies and rxn to immunization
CONSIDERATIONS > Determine date of last tetanus immunization
> Keep epi available 1:1000 to treat anaphylaxis
> Adsorbed form produces longer immunity. fluid form provides quicker
booster effects in pt. Actively immunized previously

METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND
TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

VI. COMMUNITY MANAGEMENT

“Bantay Rabies sa Barangay.”

Description:

This program is made to encourage people in the community to enhance their

knowledge about rabies. This can prevent and control the possible increase in number of

people who have the disease. This will open the minds of the people to conduct rabies

prevention activities to protect the spread of rabies.

Objectives:
 General Objectives:

 The general objective of the health teaching is to help the

learners broaden their understanding on how to manage rabies

that can affect their health and daily living activities.

Specific Objectives:

 Knowledge

 We will enable to expand and explore their

definition and understanding of rabies.

 Skills

 These are to ensure that the patient’s relatives

know the intervention and things to take in action to

prevent for having rabies.

METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
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 Attitude

 These are to make sure that the family has a positive

attitude to know the rabies eagerly.

Methodology:

 We observed one problem that can be given an intervention. Then we

had gathered information in the Public Health Nurse for the health

teaching and through Internet Searching. We had written and explained it

 in English for the patient relatives to easily understand the health

teaching. We used therapeutic communication with the family.

Evaluation:

The people in the community had gained knowledge about rabies. Starting from

simple description of the disease up to, on how it can be prevented and control.

Programs:

• Bantay Rabies sa Barangay (BRB)

BRB are community-based volunteers composed mostly of barangay officials

whose main responsibility is to translate and execute the rabies program at the

frontlines according to established implementing guidelines and the provisions of

the existing national and provincial laws.

METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

• Rabies Film Showing

Forty-one (41) rabies film showings were conducted with 6,977 viewers

composed of barangay officials, school children, parents, housewives, retirees,

Tanods, BHW, probationers, BALA, and MRPEC members in the municipalities

of Balilihan, Maribojoc, Loon, Tubigon, Clarin, Danao, Anda, Loboc, Guindulman,

and Sevilla.
• Distribution of Information Materials

This year, 8,000 pieces of information materials of different types including

leaflets, posters, book marks and copies of the National Rabies Law were

distributed.

References: [Link]

Overview/[Link]

METROPOLITAN MEDICAL CENTER

COLLEGE OF ARTS, SCIENCE AND TECHNOLOGY
Formerly METROPOLITAN HOSPITAL COLLEGE OF NURSING
1357 G. Masangkay Street, Sta. Cruz, Manila 1003

RABIES

A Study
Presented to
The Faculty of
Metropolitan Medical Center
College of Arts, Science, and Technology

In Partial Fulfillment of
The Requirements for
Nursing Care Management 203
Related Learning Experience in the Community

Submitted by:
 Feliciano, Nicole Paolo
Kabigting, Gian Carlo
Largado, Jovit
Morales, Genecio
Ng, Jeddy
Oloris, Shiela
Ponce, Billy Joel
Pornel, Jerome
Ramos, Dianne
Reyes, Dustin Dave
Sanchez, Ma. Rosalina
Sedilla, Batch
Ventigan, Filmore
Villamin, Charmaine
III-D4

Submitted to:

Ma’am David RN, BSN

CHN Instructor

Mr. Robert R. Mendiola, RN, BSN, RMT

CHN Coordinator

RLE CHN Exposure

April 26-30, 2010