POLIOMYELITIS

SUBMITTED TO- Ms. MANJU M.S

LECTURER
COMMUNITY HEALTH NURSING
JCN

SUBMITTED BY – Mr. JAYRAJ SINGH

1ST YEAR MSc NURSING
JCN
 Subject: Community Health Nursing

Unit: Unit VI

Topic: poliomyelitis

Group: Second B.sc Nursing

Date and time: 10/11/16, 3 to 4 pm

Duration: 1 hour

Previous knowledge: The students have some knowledge about poliomyelitis.

Method of teaching: Panel discussion.

Teaching Aids: Black board, chart, OHP and LCD

Student teacher name mr. R .Singh

Teacher supervisor: Ms. pooja

General Objective: At the end of the class students will develop adequate knowledge about poliomyelitis in children and
develop positive attitude about poliomyelitis in children that will help them to practice skill in the clinical settings while
dealing with nursing care of poliomyelitis in children.

Specific Objective: At the end of class students are able to

- define poliomyelitis
- describe the incidence of poliomyelitis
- explain the epidemiology of poliomyelitis
- discuss the pathogenesis of poliomyelitis
- enlist the clinical manifestations of poliomyelitis
- listout the complications of poliomyelitis
- mention the diagnosis of poliomyelitis
- describe the prophylaxis against poliomyelitis
- enumerate the various treatment modalities of poliomyelitis
- explain the prognosis of poliomyelitis
- discuss the nursing management of poliomyelitis.
TIME SPESIFIC CONTENT TEACHERS ACTIVITY A.V EVALUATION
OBJECTIVES ACTIVITY LEARNERS AIDS

2min Introduction

Infections agents from the external and internal environment

may involve the human organism and set up inflammatory
reactions thought the body, the inflammation of the central
nervous system is diverse , and most devasting type of disease
affecting the children age group is poliomyelitis. It is an acute
viral infection caused by papliovirus, which replicates mainly
in the gastrointestinal tract and later may affect the central
nervous system causing paralysis

Definition
2min The students Define Listen PPT Define
are able to Poliomyelitis is an infectious disease caused by enterovirus, poliomyelitis carefully poliomyelitis
define the poliovirus is an RNA virus with three distinct serotypes viz 1, and take
poliomyelitis. 2 and 3. Type 1 is the most frequent and type 2 the least down the
common cause of paralytic poliomyelitis. notes
Incidence Listen
Describe the What is the
2min The students PPT
In 1980 nearly 42,000 cases were notified to WHO, the data incidence of carefully incidence of
are able to
describe the from 136 countries representing 82 percent of total population. poliomyelitis poliomyelitis?
incidence of Now immunization has brought marked reduction.
poliomyelitis Lameness surveys in several Northern India states revealed
annual incidence rates of 2 to 5 per 1000 rural pre-school
children and 1 to 3 per 1000 urban pre-school children.
 Surveys in south India suggest that the prevalence of
poliomyelitis lameness among school children is about 3 to 5
per 1000 implying an annual incidence in the whole
population of about 15 per 100,000. Polio has been completely
eradicated from the Americans and many other parts of
country.
2min The students Epidemiology Explain the Listen PPT How
are able to epidemiology carefully poliomyelitis
explain the Man is the only reservoir and natural host of the virus. of and clarifies will spread?
epidemiology Poliovirus is excreted in the stool of patients for two weeks poliomyelitis the doubts
of before and 6 to 8 weeks after the onset of the illness. Fecal
poliomyelitis
contamination of the edible substances may occur, either due
to human association or through the filth and flies. The virus
may also be water- borne because of contamination with
sewage. Poliovirus enters the human body, through the mouth
and alimentary tract.
Discuss the Listen PPT
The students What is the
Pathogenesis pathogenesis carefully
4min are able to pathophysiolo-
of and clarifies
discuss the The virus of poliomyelitis multiples in the intestines, if there poliomyelitis the doubts -gy of
pathogenesis is no local tissue immunity against the infection. It then travels
of poliomyelitis?
to the regional lymph nodes and reticuloendothelial structures.
poliomyelitis
Viremia may occur for a short period. As a result of this, the
specific types of anti bodies are produced in the blood and the
gut. If the immune response is adequate and fast the virus is
neutralized and the illness is aborted. Antibodies act mainly at
the site of external proliferation of the virus. If conditions for
the spread of virus are present, the virus involves the nervous
system, reaching there either along nerve pathways or through
the blood stream. In the nervous system anterior horn cells,
 bulbar nuclei and cerebellar cortex are primarily affected.

Clinical picture depends on the number and location of

involved neurons. The whole of CNS may be involved, except

I. entire cerebral cortex, minus motor area

II. cerebellum except vermis and deep midline nuclei
III. White matter of spinal cord.
The damage may however, revert in 3 to 4 weeks after
onset.
7min The students Enlist the Listen Chart
are able to Clinical Manifestations clinical carefully
enlist the manifestations and take
clinical The incubation period is 7 to 14 days. The following clinical of down the
manifestations types are known poliomyelitis notes
of
I. Asymptomatic (silent)
poliomyelitis
II. Abortive
III. Nonparalytic
IV. Paralytic this may be spinal, bulbar, bulbospinal
or encephalitic depending on the location of the
lesions.

Asymptomatic (silent)

In 90-95 % of the susceptible persons infected with the virus,

the infection is asymptomatic.

Abortive polio Define

Abortive polio
Here the virus has invaded the blood stream, thus causing a
sort of Viremia, the nervous system however affected. Such
subjects have influenza like manifestations with bodily pains,
fever, sore throat, anorexia etc.

Nonparalytic polio

The poliovirus has entered the nervous system without

destroying the cells. The febrile illness (secondary to Viremia)
is therefore, followed by meningeal irritation manifested in the
form of neck stiffness, head ache, pain in neck and back
muscles, vomiting etc. no paralysis occurs in this variety.
Lumbar puncture can assist in arriving at the diagnosis but is
best avoided. The neck and back stiffness can be demonstrated
by “ kiss-the-knee” and “ Tripod sign”

“kiss-the-knee” – consists in directing the child to sit up and

kiss his knee. The test is positive, if child fails to do so
without bending the knee, this is owing to the nuchal rigidity.

“Tripod sign”- it is elicited by asking the child to sit up. The

test is positive if he assumes a tripod position while doing so

Here lumber puncture for diagnosis may cause the

developmental paralysis

Paralytic polio

a) Spinal form involving the extremities, neck abdomen,

diaphragm and intercostals, is the commonest in clinical
practice. Its major manifestations are

 Fever and other constitutional symptoms

 Muscle pain and tenderness in large proportions of
 cases (not all)
 Flaccid paralysis which is patchy and of lower motor
neuron type (Involvement of anterior horn cells) lower
limbs, secondly, large muscles are more often involved
than small muscles. The frequency of muscle
involvement as follows

FREQUENCY OF MUSCLE INVOLVEMENT IN

POLIOMYELITIS
LOWER LIMBS
Quadriceps > Tibialis anterior > peroneal muscles
UPPER LIMBS
Deltoid > Biceps > Triceps
TRUNK
Abdominal muscles > Back Muscles > Intercostals >
Diaphargm

There is absolutely no sensory loss. The bulge produced as a

result of weakness of the abdominal wall muscles when the
child cries is termed ‘phantom hernia’ which is valuable
sign.

b) Bulbar form is relatively less severe because of

involvement of vital meduallary centers. It is characterized by
paralysis of muscles supplied by cranial nerves (dysphagia,
nasal speech and dysphonia due to involvement of soft palate
and pharynx and facial paralysis) and vital respiratory and
circulatory centers. Mild hypertension may also accompany.

c) Bulbospinal form is the combination of both spinal and

 bulbar forms and is encountered in about 25% cases of
paralytic polio.

d) Encephalatic form is relatively uncommon. Besides other

manifestations, some changes in sensorium (irritability,
drowsiness or even unconsciousness) is invariably present. It
may well occur as an isolated entity or on top of bulbar or
spinal forms.

As a rule, poliomyelitis continues to progress in the acute

phase (roughly when the child is febrile) until it reaches its
peak. Then it begins to show signs of recovery which occurs
maximally in the first few weeks. Thereafter, recovery slows
down during the next 6 months. Recovery may still continue
at a much slower pace upto 2 years.

Most of the deaths in poliomyelitis occur from respiratory

failure due to involvement of the vital center in bulbar form or
from severe paralysis of diaphragm and intercostals muscles.

Complication
2min The students Listout the Take down PPT What are the
are able to • Gastrointestinal system: bleeding, perforation and complications the points complications
listout the dilation. of of
complications • Cardiovascular system: hypertension, tachycardia, poliomyelitis poliomyelitis?
of congestive cardiac failure, myocarditis, cardiac arrest.
poliomyelitis
• Pulmonary system: respiratory distress, pneumonia,
pulmonary edema.
• Urinary system: transient paralysis of bladder, calculi,
infection.
3min The students Diagnosis Mention the Listen PPT How will you
are able to diagnosis of carefully diagnose the
In large majority of the cases, diagnosis of paralytic polio is
mention the poliomyelitis and take poliomyelitis?
clear from the clinical profile. An acute onset of asymmetrical
diagnosis of down the
flaccid paralysis must arouse a suspicion of poliomyelitis.
poliomyelitis notes
Lumbar puncture should be done only to exclude the
possibility of bacterial meningitis. It should, however be
avoided as far as possible in view of the risk involved.
Cerebrospinal fluid shows a moderate increase in cells and an
inconsistent elevation of protein. Sugar and chloride levels are
usually normal. Poliovirus may be isolated from the
cerebrospinal fluid and oropharynx in the early part of illness.
Demonstration of poliovirus in feces does not establish the
diagnosis. The serum of the patient shows a rise in titer of
polio antibodies during convalescence.

Differential diagnosis is usually from pseudoparalysis (survy,

acute osteomyelitis, trauma etc) Meningitis, encephalitis,
meningismus and post diaphtheretic paralysis and guilian-
Burre syndrome will be done by careful neurological
assessment and involvement.
PPT
Treatment Enumerate the What are the
The students Listen
12min are able to various treatment
carefully
There is no specific treatment for poliomyelitis; Management treatment of modalities of
enumerate the and clarifies
is primarily symptomatic and supportive and supportive. poliomyelitis poliomyelitis?
various Hospitalization of all cases of paralytic polio necessary the doubts
treatment of
poliomyelitis Adequate bed rest
Physical activity and trauma increases the risk of paralysis in
the fatigued muscles. Only mild sedation may be given to a
spinal paralysis to ally anxiety, sedative should be withheld
from patients with bulbar or encephalitis features.
Relief of pain
Relief from pain and spasm of muscles during acute stage of
illness is very important. Dry heat with infrared lamp, hot
packs or hot tub baths are helpful in relieving pain. Analgesics
may be administered.
Neutral positing of the limbs
Overstretching of paralyzed muscles is prevented by placing
the limbs in optimum comfort position and function with aid
of sand bags. Rigid splinting in the plaster casts is not
necessary.
Physiotherapy exercises
As soon as the pain, spasm relived physiotherapy exercises
started to prevent deformity and promote development of
muscle power in the non-paralyzed muscle.
Adequate nutrition
The diet should be nutritious, balanced and wholesome. In
case of difficulty in swallowing the patient is nursed in prone
position with head on one side and foot end of the bed raised
to allow gravity drainage of the food if aspirated.
Respiratory management
A close watch of respiratory distress is needed. In case of
diaphragm and intercostals, the child is best treated with in a
respirator. Positioning to avoid aspiration is important.
Tracheostomy is need when there is constriction of
hypopharynx (rope sign) or paralysis of vocal cards.
Ventilator support may and antihypertensive therapy be
 needed in some cases.
Rehabilitation
Rehabilitation is needed after the acute stage has passed. For
physical rehabilitation help of occupational therapist and
physiotherapist be sought to rehabilitate the child in the
society. Emotional and psychological support helps to prepare
child for better adjustment in life despite handicap.

6min The students Prophylaxis Describe the Listen OHP What are the
are able to prophylaxis carefully prophylactic
It is important to have all children immunised as it is the sole
describe the effective means of preventing poliomyelitis. against and clarifies measures for
prophylaxis poliomyelitis the doubts poliomyelitis?
against Active Immunization
poliomyelitis In active immunization 2 types of polio vaccine are used
I. Salk inactivated polio vaccine (IPV) administered by
injection
II. Sabin oral live attenuated polio vaccine (OPV). It is
recommended vaccine in most countries.

I. Inactivated polio vaccine (IPV) Salk vaccine

This vaccine contains all 3 types of poliovirus, inactivated by
formation the primary or initial immunisation consists of 4
inoculations, the first 4 to 6 weeks intervals and fourth 6 to 12
months later. The first dose of vaccine is given when the
infant 3 to 4 months old. But it is better to give the inactivated
vaccine after the infant is aged 6 months because maternal
antibodies depress the immunity to killed vaccine.
II. oral polio vaccine (OPV) (Sabin vaccine)
It is live vaccine prepared from attenuated strains of the 3
types of poliovirus. It is given as trivalent vaccine. The
National immunization programme in India recommends 3
doses of OPV starting from 11/2 month. The interval between
doses should not be less than one month. OPV is concurrently
given with DPT, BCG vaccine. One booster dose of OPV is
recommended 18 to 24 month. Even at birth 1 dose of OPV
will be given.
Passive immunization
With 5 to 15 ml, according to age gammaglobulin, some
measures of protection are afforded for 6 weeks
During pulse immunization, the following should be kept in
mind:
 Avoid all provoking factors eg: over excretion and
chilling, injections (including DPT) and tonsillectomy
operations.
 Children should remain away from crowded places and
swimming pools.
 Proper disposal of urine and faeces of the patient.
 When there is an outbreak of epidemic all sources of
water must be protected.
 Milk must be pastured and fruits should be washed
with permanganate solution before using.
 Active immunization with OPV during an outbreak is
of great possible.
 Children must avoid excessive physical strain during an
epidemic.

Pulse immunization: In order to eradicate wild polio virus

from the community and environments, vaccination of the
entire child population of the area in one single day is required
 to be given. This is termed “Pulse immunization”. Such a
mass immunization given twice a year for 3 consecutive years.
Since 1995 the government of India has initiated pulse polio
immunization to achieve eradication from country.
Four-pronged strategy for total eradication of polio
globally
I. High routine immunization coverage with OPV
II. Supplementary immunization in the form of pulse
immunization program or an alternative strategy
III. Effective surveillance system
IV. Final stage comprising mopping up by door to door
immunization campaign
Prognosis
2min The students Explain the Listen PPT
are able to The mortality is around 5 to 7 %.The course of disease is too prognosis of carefully
explain the variable ranging from complete recovery to complete poliomyelitis
prognosis of paralysis. Most of cases fall somewhere in between.
poliomyelitis Residual deformities in the form of post polio residual
paralysis (PPRP) includes (a) Wasted flail limb, (b) Genu
recurvatum ,(C) Valgus foot Deformities are more frequent in
distal limbs and joints. In foot uniaxial rather than biaxial
deformities are common. PPT What are the
Discuss the
The students Nursing management Listen nursing
8min nursing
are able to carefully management
I. Assisting with the diagnosis management
discuss the and clarifies for child
of
nursing The nurse assists in collecting sample of stools and throat poliomyelitis the doubts suffering from
management of swab and CSF from suspected cases in a sterile technique. poliomyelitis?
poliomyelitis
II. providing care in hospital
In hospitalized children nurse will helps in providing adequate
bed rest in a neutral position. Administration of analgesics and
medication, attention to solving problems like retention of
urine and constipation by simple measures, positioning and
avoiding aspiration. Suctioning tracheostomy secretion (if
done), providing physiotherapy and passive range of exercises
after recovery from acute phase.
III. prevent the spread of the disease
Disease prevention can be done by safe disposal of excreta,
vomitus and other body wastes, appropriate isolation and
separation from others. Frequent hand washing when caring
the affected child.
IV. provide optimum nutrition
Maintaining of adequate fluid and diet intake is important. In
case of difficulty in swallowing the patient is nursed in prone
position with head on one side and foot end of the bed is
raised to allow gravity drainage to prevent aspiration.
V. Educating family members for home care
The nurse is responsible for teaching family members how to
provide the needed care, preventing spread of disease by
preventing contamination of water bodies and avoiding
excessive physical strain to avoid pain.
VI. Employ comfort measures
In order to reduce pain analgesics and mild sedation
administered whenever necessary. Dry heat with infrared
lamp, hot packs or hot-tub baths are also given to reduce pain.
2min Summary
Poliomyelitis is a worldwide disease affecting people
particularly in Africa and Asia. It is an acute viral infection
caused by an RNA virus. It is primarily an infection of the
human alimentary tract spreads through oral fecal
contamination, but the virus may infect the central nervous
system resulting in varying degrees of paralysis and possibly
death. The clinical manifestations ranges from asymptomatic
type to paralytic type based on the involvement of nervous
system paralytic type are classified into Spinal, Bulbar, and
Bulb spinal and Encephalitic form. Diagnosis is mainly done
through throat, stool and CSF samples. Immunization against
polio is sole effective means of preventing poliomyelitis.
Therapeutic management includes adequate bed rest, relieving
pain, neutral positioning of the limbs and rehabilitation,
physiotherapy in post acute stage.
Assignment to the student
Incidence of poliomyelitis in various states of India in past
three years

1min Conclusion
Poliomyelitis is an acute viral infection caused by an RNA
virus. It is primarily an infection of human alimentary tract but
it affects the nervous system causing varying degrees of
paralysis and sometime death. So we have discussed
incidence, epidemiology, pathogenesis, clinical
manifestations, complications, diagnosis treatment, prognosis
and nursing management.
 Evaluation
Students are given test
1. a) define poliomyelitis
b) what are the clinical manifestations and discuss the
pathogenesis of poliomyelitis
c) Discuss the treatment modalities of poliomyelitis

Student Bibliography

1. “The short text book of pediatrics” by Suraj Gupta’s. 4th edition, 2009, Jaypee publishers, New Delhi, page no: 169-172

2. “ Ghai’s Essentials pediatrics” edited by O P Ghai, 5th edition, 2000, Interprint publishers , New delhi , page no: 182-185
Bibliography

1. “park’s textbook of preventive and social Medicine” by K. Park, 18 th edition, 2005, Banarasidas publishers, Jabalpur, India,
Page no: 161-67
2. Marlow R. Drothy, Redding A Barbara’s “Textbook of pediatric Nursing”, 6th edition 2005, Elsevier publication, Philadelphia
Page no: 932 -933
3. Hocken berry J Marilyn’s “wong’s Essentials of pediatric Nursing”, 7 th edition 206, Mosby publishers, Missouri, U.S.A. page no: 442-43.