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
None
intact skin (i.e. no exposure)
Category II – nibbling of uncovered skin, minor Immediate vaccination and local
scratches or abrasions without bleeding treatment of the wound
Category III – single or multiple transdermal bites Immediate vaccination and
or scratches, licks on broken skin; contamination of administration of rabies
mucous membrane with saliva from licks, immunoglobulin; local treatment of
exposures to bats. the wound
Diagnosis
No 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 dogs
Rabies 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 • 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.
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.
Cerebellum Coordination and control • Tremors.
of voluntary movement. • Nystagmus
(Involuntary
movement of the
eye).
• Ataxia, lack of
coordination.
• 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
muscle of eye extensor.
which rotates eye Withdrawal.
outward), [motor].
CN VII - Facial • Respiratory:
(Muscles of
expression), Apneustic
[motor and (Abnormal
sensory]. respiration marked
CN VIII - by sustained
Acoustic (Internal inhalation).
auditory Hyperventilation.
passage),
[sensory]. • CN Deficits: CN VI,
CN VII.
• 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].
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
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
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
