I.GENERAL OBJECTIVES:

The general objective of this study is to broaden our knowledge and understanding about rabies, its management and the attitude that we must obtain to be an effective and efficient nurse to patients having this kind of disease.

SPECIFIC OJECTIVES:We aim to:

Define rabies Review the anatomy and physiology of the affected system Trace the pathophysiology of rabies Discuss common diagnostic and laboratory examinations related to the

disease Formulate a possible nursing care plan with patients who have rabies Discuss possible medications to be administer to a patient with rabies

II. 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. Category of exposure to suspect rabid animal Post-exposure measures

Category I – touching or feeding animals, licks on intact skin (i.e. no exposure) None

Category II – nibbling of uncovered skin, minor scratches or abrasions without bleeding

Immediate vaccination and local treatment of the wound

Category III – single or multiple transdermal bites or scratches, licks on broken skin; contamination of mucous membrane with saliva from licks, exposures to bats.

Immediate vaccination and administration of rabies immunoglobulin; local treatment of the wound

DiagnosisNo tests are available to diagnose rabies infection in humans before the onset of clinical

disease, and unless the rabies-specific signs of hydrophobia or aerophobia are present, the clinical diagnosis may be difficult. Post mortem, the standard diagnostic technique is to detect rabies virus antigen in brain tissue by fluorescent antibody test.Transmission

People are infected through the skin following a bite or scratch by an infected animal. Dogs are the main host and transmitter of rabies. They are the source of infection in all of the estimated 55 000 human rabies deaths annually in Asia and Africa.

Bats are the source of most human rabies deaths in the United States of America and Canada. Bat rabies has also recently emerged as a public health threat in Australia, Latin America and western Europe. Human deaths following exposure to foxes, raccoons, skunks, jackals, mongooses and other wild carnivore host species are very rare.

Transmission can also occur when infectious material – usually saliva – comes into direct contact with human mucosa or fresh skin wounds. Human-to-human transmission by bite is theoretically possible but has never been confirmed.

Rarely, rabies may be contracted by inhalation of virus-containing aerosol or via transplantation of an infected organ. Ingestion of raw meat or other tissues from animals infected with rabies is not a source of human infection.Prevention

Eliminating rabies in dogsRabies is a vaccine-preventable disease. The most cost-effective strategy for preventing

rabies in people is by eliminating rabies in dogs through vaccination. Vaccination of animals (mostly dogs) has reduced the number of human (and animal) rabies cases in several countries, particularly in Latin America. However, recent increases in human rabies deaths in parts of Africa, Asia and Latin America suggest that rabies is re-emerging as a serious public health issue.

Preventing human rabies through control of domestic dog rabies is a realistic goal for large parts of Africa and Asia, and is justified financially by the future savings of discontinuing post-exposure prophylaxis for people. Preventive immunization in people

Safe, effective vaccines also exist for human use. Pre-exposure immunization in people is recommended for travellers to high-risk areas in rabies-affected countries, and for people in certain high-risk occupations such as laboratory workers dealing with live rabies virus and other lyssaviruses, and veterinarians and animal handlers in rabies-affected areas. As children are at particular risk, their immunization could be considered if living in or visiting high risk areas.

III. EXAMS AND TESTS

← Testing: No specific testing is needed because there is no way to detect if the rabies virus has been passed to you. It is not necessary to bring the animal itself to the emergency department because the doctors do not have the ability to test animals for rabies. The local health department will coordinate testing of the animal in question.

← Examination: Your vital signs will be taken (temperature, heart rate, breathing rate, and blood pressure). You will be asked a series of questions about the animal and the exposure. The doctor will also ask questions about immunization you may have been given before against rabies and tetanus.

Certain medications used for the treatment of rheumatoid arthritis and the prevention and treatment of malaria (for example, chloroquine and mefloquine) can interact with the rabies vaccine should it be given. Bring a medication list or the pill bottles of all current medications you are taking to the emergency department.

If there is a concern that you may actually have rabies, it is important to tell the doctor about any history of jobs, hobbies, recent international travel, and exposure to animals.

IV. ANATOMY AND PHYSIOLOGY

 Brain Structure  Function Associated Signs and Symptoms

Basal Ganglia  Subcortical gray matter nuclei. Processing link between thalamus and motor cortex. Initiation and direction of voluntary movement. Balance (inhibitory), Postural reflexes.

Part of extrapyramidal system: regulation of automatic movement. 

Movement disorders: chorea, tremors at rest and with initiation of movement, abnormal increase in muscle tone, difficulty initiating movement.

Parkinson's. 

Thalamus Processing center of the cerebral cortex. Coordinates and regulates all functional activity of the cortex via the integration of the afferent input to the cortex (except olfaction).

Contributes to affectual expression. 

Altered level of consciousness.

Loss of perception.

Thalamic syndrome - spontaneous pain opposite side of body. 

Hypothalamus Integration center of Autonomic Nervous System (ANS): Regulation of body temperature and endocrine function.

Anterior Hypothalamus: parasympathetic activity (maintenance function).

Posterior Hypothalamus: sympathetic activity ("Fight" or "Flight", stress response.

Behavioral patterns: Physical expression of behavior.

Appestat: Feeding center.

Pleasure center.  

Hormonal imbalances.

Malignant hypothermia.

Inability to control temperature.

Diabetes Insipidus (DI).

Inappropriate ADH (SIADH).

Diencephalic dysfunction: "neurogenic storms". 

Cerebellum 

 

Coordination and control of voluntary movement. 

Tremors.

Nystagmus (Involuntary movement of the eye).

Ataxia, lack of coordination. 

Pons 

 

Respiratory Center.

Cranial Nerves:

CN V - Trigeminal (Skin of face, tongue, teeth; muscle of mastication), [motor and sensory]. CN VI - Abducens (Lateral rectus muscle of eye which rotates eye outward), [motor]. CN VII - Facial (Muscles of expression), [motor and sensory]. CN VIII - Acoustic (Internal auditory passage), [sensory]. 

Pupils:

Size: Pinpoint LOC:

Semi-coma "Akinetic Mute". "Locked In" Syndrome.

 Movement:

Abnormal extensor. Withdrawal.

Respiratory:

Apneustic (Abnormal respiration marked by sustained inhalation). Hyperventilation.

CN Deficits: CN VI, CN VII.

Medulla  Oblongata

 

Crossing of motor tracts.

Cardiac Center.

Respiratory Center.

Vasomotor (nerves having muscular control of the blood vessel walls) Center 

Centers for cough, gag, swallow, and vomit.

Cranial Nerves:

CN IX - Glossopharyneal (Muscles and mucous membranes of pharynx, the constricted openings from the mouth and the oral pharynx and the posterior third of tongue.), [mixed]. CN X - Vagus (Pharynx, larynx, heart, lungs, stomach), [mixed]. CN XI - Accessory (Rotation of the head and shoulder), [motor]. CN XII - Hypoglossal (Intrinsic muscles of the tongue), [motor].

Movement: Ipsilateral (same side) plegia (paralysis).

Pupils:

Size: Dilated. Reactivity: Fixed.

LOC: Comatose.

Respiratory:

Abnormal breathing patterns. Ataxic. Clustered. Hiccups.

CN Palsies (Inability to control movement):

Absent Cough. Gag. 

V. DRUG STUDY

BRAND NAME Imovax Rabies, RabAvert

GENERIC NAME Rabies vaccine, human diploid cell

CLASSIFICATION Active Immunizing Agent

INDICATIONS AND DOSAGE

> Postexposure antirabies immunization: adults and children: five 1-ml 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, dizzinessGI: nausea, abdominal pain, diarrheaMUSCULOSKELETAL: muscle achesSKIN: erythema, injection site pain, itching, swellingOTHER: serum sickness, anaphylaxis

NURSING CONSIDERATIONS

> Keep epinephrine 1:1000 available to treat anaphylaxis> 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

BRAND NAME Rabies Immune Globulin, Human

GENERIC NAME Hyperab, Imogam Rabies-HT

CLASSIFICATION Immunomodulator

INDICATIONS AND DOSAGE

> Rabies exposure: adults and children: 20 international units/kg I.M. at 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 feverGU: nephrotic syndromeSKIN: reash, pain, redness, and induration at injection site.Other: anaphylaxis, angioedema

NURSING CONSIDERATIONS

> Obtain hx of animal bites, allergies, and reactions to immunization. Have

epi 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

BRAND NAME Tetanus toxoid

CLASSIFICATION Immunomodulator

INDICATIONS AND DOSAG

> Primary immunization to prevent tetanus : adults and children age 7 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, encelophatyCV: tachycardia, hypotension, flushingMUSCULOSKELWTAL: aches, painsSKIN: erythema, pruritusOTHER: anaphylaxis, chills

NURSING CONSIDERATIONS

> Obtain hx. Of allergies and rxn to immunization> 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