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RABIES


DEFINITION: 
An acute infectious disease of warm-blooded animals characterized by involvement of the nervous system resulting in death.

ETIOLOGY
It is caused by the RABIES VIRUS, a rhabdovirus of the genus lyssavirus. RHABDOVIRUS: any group of rod-shaped RNA viruses with 1 important member, rabies virus, pathogenic to man. The virus has a predilection for tissue of mucus-secreting glands and the Central Nervous System. All warm-blooded animals are susceptible to infection with these viruses. LYSSAVIRUS: Greek – frenzy. A genus of the family Rhabdoviridae. There are 2 kinds of rabies. URBAN or CANINE RABIES are transmitted by dogs. SYLVATIC RABIES are transmitted from wild animals and bats which sometimes spread to dogs, cats and livestock.


MODE OF TRANSMISSION: It is commonly communicated to man through the saliva of an infected mammal by an exposure to an open break in the skin such as bites or scratch and inhalation of infectious aerosols such as from bats. In some cases, it is transmitted through organ transplants (corneal transplant), from an infected person.

MEDIA OF TRANSMISSION: Through saliva, tears, urine, serum, liquor and other body fluids.

INCUBATION PERIOD:
The period between the exposure to the virus to the occurrence of the first symptom, is usually 2-8 weeks. It may be as short as 4 days or as long as 2 years depending on depth of laceration and site of wound. The virus moves along nerve axons passively about 3 millimeters per hour. It is not known how the virus remains viable or where it is located during prolonged incubation period.

SUSCEPTIBILITY AND RESISTANCE: All warm-blooded mammals are susceptible. Natural immunity in man is unknown.

DIAGNOSIS:
There is yet no way of immediately segregating those who had acquired rabies infection from those who had been bitten by non-rabid sources. No tests are available to diagnose rabies in humans before the onset of clinical disease. The most reliable test for rabies in patients who have clinical signs of the disease is DIRECT IMMUNOFLUORESCENT STUDY of a full thickness biopsy of the skin taken from the back of the neck above the hair line. The RAPID FLUORESCENT FOCUS INHIBITION TEST is used to measure rabies-neutralizing antibodies in serum. This test has the advantage of providing results within 24 hours. Other tests of antibodies may take as long as 14 days. 
True rabies must be distinguished from RABIES HYSTERIA, a psychological condition in persons who think they have been bitten by a rabid animal. In such cases, a patient ordinarily attempts to emulate convulsive seizures. Patient receiving rabies vaccine treatment may develop paralysis attributable to a sensitization caused by the rabbit brain material in the vaccine. This paralysis may simulate paralytic rabies and may produce symptoms referable to cranial nerves, such as difficulty swallowing, paralysis of the masseter muscles and unilateral or bilateral facial paralysis. Encephalitis without paralysis may be caused by the vaccine treatment and in such cases the disease begins with high fever and headache with may be followed by convulsions and coma.


SIGNS & SYMPTOMS (most common)
a. Sensory change on or near Delirium 
b.the site of entry Insomnia 
c. Fever Convulsions 
d. Laryngeal spasme 
e. Salivation or foaming of the mouth 
f. Sense of apprehension, anxiety, irritabilty 
g. Acute attack: fever, muscle  twitching, hyperventilation and excess salivation 
h. Headache
The usual duration is 2-6 days without medical intervention. Death is often due to convulsion or respiratory paralysis.


MANAGEMENT A. PREVENTION
1.Responsible pet ownership
a) pet immunization, esp. cats, usually starting at 3 months of age and every year thereafter
b) don’t allow pets to roam around the streets
c) take care of your pets, keep them in good health – bathe, feed with clean adequate food and provide clean sleeping quarters
2.Thoroughly clean ALL BITES AND SCRATCHES made by any animal with strong medicinal soap or solution.
3.Responsible awareness. Report immediately rabid or suggestive of rabies domestic or wild animals to proper authorities (local government clinic, veterinarians or community officials).
4. Pre-exposure to high risk individuals. Veterinarians, hunters, people in contact with animals (zoo), butchers, lab-staff in contact with rabies, forest rangers/caretakers.
5.DOH Standard Protocol
a) If dog is apparently healthy, observe the dog for 14 days. If it dies or show signs suggestive or rabies, consult a physician.
b) If the dog shows signs suggestive of rabies, kill the dog immediately and bring head for lab examination. Submit for immunization while waiting for results.
c) If the dog is not available for observation (killed, died or stray), submit for immunization. *see DOH- Revised Guidelines on Management of Animal Bite Patients- 2007 for more complete guide B.

MEDICAL INTERVENTIONS
a. Local wound treatment. Immediately wash wound with soap and water. Treat with antiseptic solutions such as iodine, alcohol and other disinfectants.
b. Antibiotics and anti-tetanus as prescribed by physician.
c. Rabies – Specific Treatment. Post-exposure treatment is given to persons who are exposed to the rabies virus. It consists of active immunization (vaccination) and passive immunization (immune globulin administration).


a. ACTIVE IMMUNIZATION – aims to induce the body to develop antibodies and T-cells against rabies up to 3 years. It induces an active immune response in 7-10 days after vaccination, which may persist for one year or more provided primary immunization is completed MEDICAL AGENT: Human Diploid Cell rabies Vaccine (HDCV)

b.PASSIVE IMMUNIZATION – aims to provide IMMEDIATE PROTECTION against rabies which should be administered within the first 7 days of active immunization. The effect of the immune globulin is only short term. Rabies antibodies are introduced before it is physiologically possible for the patient to begin producing his own antibodies after vaccination. Some of the RIG is infiltrated around the site and the rest is given intramuscularly. MEDICAL AGENT: Rabies Immune Globulin (RIG)


C. NURSING INTERVENTIONS
1. HIGH RISK FOR INFECTION TRANSMISSION
* provide patient isolation
* handwashing. Wash hands before and after each patient contact and following procedures that offer contamination risk while caring for an individual patient. Handwashing technique is important in reducing transient flora on outer epidermal layers of skin.
* Wear gloves when handling fluids and other potential contaminated articles. Dispose of every after patient care. Gloves provide effective barrier protection. Contaminated gloves becomes a potential vehicle for the transfer of organisms.
* Practice isolation techniques. To prevent self-contamination and spread of disease.

 2. KNOWLEDGE DEFICIT
(about the disease, cause of infection and preventive measures)
* assess patient’s and family’s level of knowledge on the disease including concepts, beliefs and known treatment.
* Provide pertinent data about the disease: 
a. organism and route of transmission 
b. treatment goals and process 
c. community resources if necessary
* allow opportunities for questions and discussions

3. ALTERED BODY TEMPERATURE: FEVER RELATED TO THE PRESENCE OF INFECTION. Since fever is continuous, provide other modes to reduce discomfort.
 * If patient is still well oriented, Inform the relation of fever to the disease process. The presence of virus in the body
* Monitor temperature at regular intervals
* Provide a well ventilated environment free from drafts and wind. 

4. DEHYDRATION related to refusal to take in fluids secondary to throat spasms and fear of spasmodic attacks.
•  Assess level of dehydration of patient.
* Maintain other routes of fluid introduction as prescribed by
* the physician e.g. parenteral routes Moisten parched mouth with cotton or gauze dipped in water 
* but not dripping.

 References
1. Taber’s Cyclopedic Medical Dictionary 17th Edition. 1994. Singapore: Davis Company. Department of Health.2000.
2. Community Health Nursing Services in the Philippine Department of Health, 9th Edition.Philippines.DOH Smeltzer, Suzanne and Bare, Brenda. 2000.
3. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 9th Edition. Philadelphia: Lippincott Williams and Wilkins

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