CHOLERA
This is an acute intestinal disease caused by vibrio cholerae characterized by profuse diarrhoea
and vomiting.
CAUSATIVE ORGANISM
It is caused by vibrio cholerae.
This is a Gram negative facultative anaerobe organism
It is a comma shape bacteria that grows rapidly at a very high pH (8.5 – 9.5) and killed in
an acidic medium.
Example of Gram positive organism are bacillus anthracis, clostridia tetani,
lactobacillus acidofillus, mycobacterium species, staphylococcus and streptococci,
Gram negative – campylobacter spp, e. coli, helicobacter pylori, pseudomonas, proteus
spp, salmonella, vibrio cholera, Treponema pallidum, Neisseria gonorrhoea
MODE OF TRANSMISSION
It is transmitted through the oro-faecal route and hence transmitted
Eating of contaminated food and water including vegetables and fruits.
Rarely, hand-to-mouth transmission after using a contaminated toilet and
neglecting hand hygiene OR after handling excreta and infected linen of patients.
because a large inoculum of organism is needed to transmit the infection.
NB: Epidemics often occur from faecal contamination of water supplies or street vended foods.
PREDISPOSING FACTORS
Leaving in an endemic area
Eating food from outside the home i.e. food vendors not sure of the food source and
how it was cook
Eating cold uncovered foods
Eating fresh uncooked vegetables e.g. lettuce, carrot or unpeeled fruits e.g. mango,
apple
Not washing hands properly before ingestion of food. (i.e. shaking of hands with an
individual with vibrio cholera)
Lack of proper waste disposal technique – this leads to the spread of the disease. NB :
Transmission by flies
Poor environmental hygiene (dirty environment gives room for the micro-organism to
harbour.
In addition, conditions that causes Hypochlorhydria and Achlorhydria (reduced or absence of
HCl in gastric juice) increases an individual’s risk of acquiring cholera
these includes:
A. Children (immature gastric glands)
B. Elderly (atrophy of the gastric glands)
C. Certain drugs e.g. Antacids, H2 receptor antagonist, proton pump inhibitor
D. Gastrectomy
E. Vagotomy it is a surgical procedure that involves the resection of the vagus nerves.
INCUBATION PERIOD
It is variable, but usually from 24 to 72hrs.
PATHOPHYSIOLOGY
Following the ingestion of food or water containing the organism in an individual with
normal gastric acidity, the organism is killed in the acidic medium in the stomach, unless
very large numbers of the organisms are ingested especially drinking of contaminated
water.
In those with decrease stomach acidity, the organism survives the stomach acidity and
enters into the small intestines (duodenum and upper jejunum).
In the duodenum, the organism (vibrio cholerae) then attaches itself to the walls of the
small intestines where they multiply (because of its alkaline medium) and release a toxin
called cholera toxin (CTX) or entero-toxin.
These toxins release act only locally i.e. It does not invade the systemic circulation or
cause physical damage to the intestinal wall.
CTX binds to the intestinal walls, where it blocks the absorption of sodium and chloride
by the microvilli. It also promotes the secretion of sodium and water by the crypt cells
(nearby cells or the intestinal wall).
NB : (the toxin causes human cells to extract water and electrolytes from the intestinal
wall).
This creates a salt-water environment in the small intestines, which through osmosis
pull fluids through the intestinal cells into the lumen, as this fluid moves through the
large intestines it attracts more fluids creating the massive amounts of diarrhea.
Unless the lost fluid and electrolytes are replaced adequately, the infected person may
develop shock from profound dehydration and acidosis from loss of bicarbonate
leading to death.
SIGNS AND SYMPTOMS
Sudden, profuse, watery stool.
This stool is initially brown and contains fecal matter, later becomes pale gray or milky
resembling water in which rice has been rinsed or water from boiled rice hence the
name “rice-water stool” (characteristic sign in cholera)
The stool contains flecks of mucus and has a fishy odour smell.
The level of the diarrhoea is so enormous that you can lose about 10 – 18 litres of fluid
over 24hours (ECF = 14L, ICF – 28L)
NB : Stool volume during cholera is more than that of any other infectious diarrhea
The diarrhoea is associated with severe abdominal cramps as a result of loss of sodium,
chloride and potassium.
Severe vomiting :
NOT PART : vomiting is caused by decreased gastric and intestinal motility;
Fever is typically absent i.e. Temperature could be normal at the onset of disease but
becomes subnormal in the later stage especially if patient is in shock.
Dehydration - Signs of dehydration which includes
Dry or sticky mouth, thirst, decreased skin turgor, Oliguria,
a weak, rapid heart rate; Decreased blood pressure, skin becomes cool and clammy skin
Weakness
Sunken eyes
Acute weight loss
Confusion, altered level of consciousness
related to peripheral vasoconstriction or decreased peripheral perfusion and in the absence of
infection.
In children, the signs may include :
Fever
Convulsion
Coma
DIAGNOSTIC INVESTIGATION
Routine Stool Examination
Stool specimen appears as Rice water and On Microscopy contain Mucus.
Stool Culture
Rectal swab
NB: Specimens should not be collected from bed pans
FBC – shows elevated haematocrit due to haemoconcentration
WBC – will also be elevated
BUE + Cr
Serum sodium is low reflecting the substantial loss of sodium in the stool.
Serum urea and Cr may be high indicating a pre-renal azotemia.
The extent of elevation depends on the degree and duration of dehydration
ABGs
Blood pH < 7.35
Blood bicarbonate will decreased
Blood C02 decreased (< 35mmHg) for compensation.
MANAGEMENT
The main aim of management is to correct fluid and electrolyte imbalance and prevent further
complications
NURSING MANAGEMENT
Admit the patient to a special cholera unit or in an isolation ward.
Patient should be placed or put onto a special bed called cholera cot if available, this is a
bed with a hole through which a calibrated bucket is placed underneath to allow for
collection of stool.
This helps the health worker to calculate fluid losses and replacement needs
Assess for degree of dehydration
Rehydrate the patient by setting up intravenous line and initiate IV therapy using ringers
lactate at a rate of about 50-100mls/kg/hr.
Continue rehydration of patient until diarrhoea stops
Regular assessment of the patient every 1-2hrs is done and hydration continued
Give ORS when vomiting stops as much as client can take during the rehydration phase
Use barrier nursing in taken care of the patient
This includes:
Use of gloves before handling articles
Appropriate Handwashing
Wearing of appropriate gowns
concurrent disinfection of articles and stools of infected persons e.g.
stools and vomitus should be disinfected before their disposal.
clothes, linen, and utensils should be disinfected or boiled
Contaminated floors, furniture, etc., should be scrubbed with chlorinated lime solution or
(bleach)
OBSERVATION
Monitor Vital signs especially pulse and blood pressure and report any abnormality
Accurate measurement of fluid Intake and output including liquid stool noting its
frequency
Observe the stool for its consistency, amount and colour
Observe the vomiting for its consistency, amount and colour monitor and frequently
assess hydration status
Observe for signs of complication
Do regular skin assessment
Regular (daily) weighing of client
NUTRITION
Give nourishing diet when vomiting stops.
This food will be warm and will be serve at frequent intervals
This food should be high in calories
Food should be attractive
If possible patient should be served his favourite meal.
Continue breastfeeding infants and young children.
PERSONAL HYGIENE
Observe good personal cleanliness.
Bed bath at least twice daily
Regular oral hygiene and care of lips
DRUGS
Antibiotics are also used
These include :
Doxycycline
Azithromycin
Tetracycline
Ciprofloxacin
COMPLICATION
Hypovolemic shock
Acute renal failure
Metabolic acidosis - Acidemia results when respiratory compensation is unable to
sustain a normal blood pH.
Hypokalemia – From potassium loss in stools which will interfere with normal heart
function.
Hypoglycemia – from becoming too weak to eat depleting your energy stores,very
common in children.
Death
PREVENTION AND CONTROL
Environmental hygiene should be established in endemic areas.
Protection and purification of water supplies
Proper disposal of both dry and wet refuse
vegetables and fruits should be properly washed in salt solution before eating OR
Avoidance of eating fresh uncooked vegetables or unpeeled fruits
Any source of water apart from pipe borne should be boiled
Investigate contacts and give treatment if positive
Health education on the mode of spread and measures to prevent it
Education on good hygienic practises e.g. washing of hands before eating, before
touching food and after visiting the toilet with soap and water
Ensure regular periodic medical check up for food vendors
Discourage communal eating and sharing of cups, cutlery
Provision of portable water
Drinking portable water
Provide toilet in communities to prevent indiscriminate defaecation
Food should be protected from flies
Immunization against typhoid at least once a year
Stool, vomiting and urine of infected persons should be disinfected before discarding
Left-over food should be discarded of infected person should be discarded
Advise against buying and eating food outside the home
Ensure that food vendors cover their food and keep the selling environment
Eat foods that have been thoroughly cooked and that are still hot and steaming.
Refer to typhoid notes
Cholera vaccine
cut fruits sold by vendors should not be allowed.
Protect foods from fly contamination
Notification of cases
Corpse of infected person should be disinfected with lysol and lime
NURSING DIAGNOSIS
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
A homemade equivalent is 6 teaspoons of sugar and one half teaspoon of salt in a liter of
water; a half cup of orange juice or some mashed banana can provide potassium.
