Andres Bonifacio College

School of Nursing
College Park, Dipolog City

Case Presentation on Cholera

Submitted by: Palma, Brent Aljoer Submitted to: Mr. Art Bryan Arcinas, R.N.
Rendon, Joan E.
Suan, Monica C.

Date of Submission: September 26, 2022

 Andres Bonifacio College

Institutional Vision: The center of excellence in instruction, research, technology, extension, athletics, and arts.

Institutional Mission: We commit to provide affordable quality education with values in industry, intelligence, integrity, and undertake relevant research and socially-responsive
community service using innovative technologies.

School of Nursing

Mission:

The School of Nursing shall generate, competent, safe, and compassionate professional nurses committed to:

a. Practice high standards of nursing care utilizing research and evidence-based practices that are culturally appropriate.
b. Active involvement in local, national, and global issues affecting nursing, people’s health, and the environment.
c. Ongoing holistic growth and development of the self and other.
 Andres Bonifacio College
School of Nursing

General Objectives:
At the end of the case presentation the learners must be able to acquire sufficient knowledge, refine their independent and collaborative skills, improve their understanding,
provide comprehensive care, and use effective communication in dealing with a patient with Cholera.

Specific Objectives:
1. Provide clear introduction regarding Cholera.
2. Comprehensively present the pathophysiology of Cholera.
3. Discuss the different Nursing Care Plans.
4. Demonstrate teamwork all throughout the presentation.
5. Accept corrections and give room for improvement on knowledge, skills, and attitude.
6. Demonstrate competence and critical-thinking skills in presenting the case.
 Table of contents
I. Introduction
i. Description of Cholera
ii. Signs and Symptoms
iii. Causes
II. Anatomy and Physiology
III. Pathophysiology
IV. Related Studies
V. Nursing Care Plans
i. Deficient Fluid Volume related to Diarrhea and Vomiting
ii. Imbalanced nutrition: less than body requirements related to loss of fluids as evidenced by diarrhea and inadequate intake
iii. Risk for infection related to microorganisms that penetrate the gastrointestinal tract
VI. References
I. Introduction

Cholera
Cholera is an acute diarrheal infection caused by ingestion of food or water contaminated with the bacterium Vibrio cholerae. Cholera remains a global threat to public health
and an indicator of inequity and lack of social development. It is an acute serious illness characterized by sudden onset of acute and profuse colorless diarrhea, vomiting, severe
dehydration, muscular cramps, cyanosis and in severe cases collapse.

Etiologic Agent: Vibrio El Tor

Signs and Symptoms

About 1 in 10 people with cholera will experience severe symptoms, which, in the early stages, include:

• Profuse watery diarrhea, sometimes described as “rice-water stools”

• Vomiting
• Dehydration
• Leg cramps or muscle cramps
• Restlessness or irritability

People with severe cholera can develop severe dehydration, which can lead to kidney failure. If left untreated, severe dehydration can lead to shock, coma, and death within hours.

Causes

✓ Cholera transmission is closely linked to inadequate access to clean water and sanitation facilities. Typical at-risk areas include peri-urban slums, and camps for internally
displaced persons or refugees, where minimum requirements of clean water and sanitation are not been met.
✓ Disruption of water and sanitation systems, or the displacement of populations to inadequate and overcrowded camps – can increase the risk of cholera transmission, should
the bacteria be present or introduced.
✓ Malnutrition increases susceptibility to cholera. Because gastric acid can quickly render an inoculum of V cholerae noninfectious before it reaches the site of colonization in
the small bowel, hydrochlorhydria or achlorhydria of any cause increases susceptibility.
✓ The profuse diarrhea produced by cholera patients contains large amounts of the infectious Vibrio cholerae germ that can infect others if swallowed. This can happen when
the bacteria get on food or into water. To prevent the bacteria from spreading, all feces (human waste) from sick persons should be thrown away carefully to ensure it does
not contaminate anything nearby.
II. Anatomy and Physiology

Digestive System

This system is one of the most affected systems in the body if there is cholera. To cause the diarrheal disease cholera, Vibrio cholerae must effectively colonize the small
intestine. In order to do so, the bacterium needs to successfully travel through the stomach and withstand the presence of agents such as bile and antimicrobial peptides in the intestinal
lumen and mucus. The bacterial cells penetrate the viscous mucus layer covering the epithelium and attach and proliferate on its surface.

Stomach

Primarily houses food for mixing with hydrochloric acid and other secretions. It is and enlarged segment of the digestive tract in the left superior part of the abdomen. As the
food enters the stomach, the food is mixed with stomach secretions to become a semifluid mixture called chyme. Although some digestion occurs in the stomach, that is not its
principal function. Stomach secretions from the gastric glands include hydrochloric acid (kills microorganisms and activate pepsin), pepsin (breaks covalent bonds of proteins to
form smaller peptide chains), mucus (lubricates the epithelial walls of the stomach an protect them from damaging effects of acidic chyme and pepsin), and intrinsic factor (binds
with b12 and makes it more readily absorbed in the small intestines).

Small Intestine

A long tube-like organ that connects the stomach and the large intestine. It is about 20 feet long and folds many times to fit inside the abdomen. It helps to further digest food
coming from the stomach. It absorbs nutrients (vitamins, minerals, carbohydrates, fats, proteins) and water from food so they can be used by the body. The small intestine is part of
the digestive system. The length is greater in males than in females. It receives bile juice and pancreatic juice through the pancreatic duct, controlled by the sphincter of Oddi.

The Small Intestine is divided in 3 divisions:

• Duodenum-The first part of the small intestine. It connects to the stomach. The duodenum helps to further digest food coming from the stomach. It absorbs nutrients
(vitamins, minerals, carbohydrates, fats, proteins) and water from food so they can be used by the body.
 • Jejunum-The jejunum helps to further digest food coming from the stomach. It absorbs nutrients (vitamins, minerals, carbohydrates, fats, proteins) and water from
food so they can be used by the body.

• Ileum -The ileum helps to further digest food coming from the stomach and other parts of the small intestine. It absorbs nutrients (vitamins, minerals, carbohydrates,
fats, proteins) and water from food so they can be used by the body. The small intestine connects the stomach and the colon.

Large Intestines

The large intestine has 3 primary functions: absorbing water and electrolytes, producing and absorbing vitamins, and forming and propelling feces toward the rectum for
elimination. By the time indigestible materials have reached the colon, most nutrients and up to 90% of the water has been absorbed by the small intestine. The role of the ascending
colon is to absorb the remaining water and other key nutrients from the indigestible material, solidifying it to form stool. The descending colon stores feces that will eventually be
emptied into the rectum. The sigmoid colon contracts to increase the pressure inside the colon, causing the stool to move into the rectum. The rectum holds the feces awaiting
elimination by defecation.
 Renal System

The renal function is also affected if there is cholera. Aside from the digestive system, it also targets the kidneys. Cholera might lead to dehydration if it is left
untreated. Severe dehydration will also follow which affects the blood circulation. When the kidneys lose their filtering ability, excess amounts of fluids, some electrolytes and
wastes build up in the body — a potentially life-threatening condition. In people with cholera, kidney failure often accompanies shock.

Kidneys
A pair of bean-shaped organs found along the posterior wall of the abdominal cavity. The kidneys' job is to filter the blood. They remove wastes, control the body's fluid
balance, and keep the right levels of electrolytes. All the blood in your body passes through them about 40 times a day.
Ureters
Are a pair of tubes that carry urine from the kidneys to the urinary bladder. The ureters are bilateral thin (3 to 4 mm) tubular structures that connect the kidneys to the urinary
bladder, transporting urine from the renal pelvis into the bladder. The muscular layers are responsible for the peristaltic activity that the ureter uses to move the urine from the kidneys
to the bladder.
Urinary bladder
A sac-like hollow organ used for the storage of urine. The urinary bladder is located along the body’s midline at the inferior end of the pelvis. The size and shape of the
urinary bladder varies with the amount of urine it contains and with the pressure it receives from surrounding organs.
III. Pathophysiology

Legend: Factors Management Action Signs and Symptoms Definition/ Lab Test Complication

Precipitating Factors:
• Malnutrition
Predisposing Factors: • Improper sanitation
• Socioeconomic status Ingestion of food contaminated with Vibrio
• Improper food handling
• Environment Cholera
• Food contaminated with Vibrio Cholera

Vibrio cholerae is a species of Gram-negative, facultative

Incubation period: 2 hours to 5 days Bacteria travel to the small intestine
anaerobe and comma-shaped bacteria. Found in water/food
contaminated with feces infected of cholera.

+ V. Cholera from the stool culture Production of enterovirus

Antibiotic treatment
Subunits V. cholera binds to GM1 ganglioside
receptor. A subunit is released to the cell.

Irritation of the mucosal lining of the small Stimulates adenylate cyclase

intestine

Increase cAMP
Altered reabsorption and vomiting

Inhibits Na+ absorption

 Water goes out of cell Rice-watery diarrhea

Fluid imbalance • Oral hydration solution

• Parenteral supplementation
• IV fluids

Hypovolemic shock Dehydration

Poor circulation of blood Loss of potassium

Organ failure

Decrease GRF Decrease renal perfusion Cardiac arrythmias

Decrease urine
output

Acute tubular necrosis Sudden cardiac arrest

Renal failure

Death
IV. Related Studies
John Snow, Cholera, the Broad Street Pump; Waterborne Diseases Then and Now
Cholera was a major global scourge in the 19th century, with frequent large-scale epidemics in European cities primarily originating in the Indian subcontinent. John Snow
conducted pioneering investigations on cholera epidemics in England and particularly in London in 1854 in which he demonstrated that contaminated water was the key source of
the epidemics. His thorough investigation of an epidemic in the Soho district of London led to his conclusion that contaminated water from the Broad Street pump was the source of
the disease and, consequently, the removal of the handle led to cessation of the epidemic. He further studied cholera in London homes that were receiving water from two water
supply systems; one from the sewage contaminated portion of the Thames River and the other that drew its water upstream from an uncontaminated part of the river. Rates of
infection among clients of the distribution system drawing contaminated water far exceeded the, rates among those served by the company whose water intake was from above the
contaminated section of the river. This demonstration reinforced the goals of the sanitation movement, which developed sewage drainage systems and water purification systems in
cities and towns in the following decades, therewith vastly reducing the threats of cholera, typhoid and many other waterborne diseases. Despite progress being made globally, the
public health problems of waterborne disease, including cholera, are by no means gone today, even in high-income countries. The tragic introduction of cholera after the earthquake
devastation in Haiti in 2010 resulted in many thousands of cases and deaths from cholera indicating the still-present dangers of diseases spread into disaster situations. Cholera and
other waterborne diseases remain some of the heaviest burdens of disease and death in low-income countries, especially after natural disasters or warfare as in Yemen in 2017 and
are continuing challenges for global health.

Dr. John Snow investigated fatalities that had been documented in residences that were mostly close to the water pump and drank from it. His documented evidence revealed
that the outbreak was caused by tainted water from this pump; he forced the removal of the handle, and the pandemic, which was already falling owing to people leaving the region,
completely stopped. Snow rejected the prevailing Miasma Theory and proposed that contaminated water was the primary means of transmission of cholera. A cholera pandemic
struck in 1854, impacting local tailor and shop clerk families that lived nearby in Regent Street. Around 600 people died in one week in September 1854 as a result of the epidemic,
which brought intense diarrhea and an extremely high mortality rate. Except for those who had a habit of drinking water from the Broad Street pump, cholera was not an issue in
Soho. In addition, he examined water samples taken from the pump and discovered white particles floating in them, which he assumed were the contaminant's source.
 Epidemiology of Cholera in the Philippines

Despite being a cholera-endemic country, data on cholera in the Philippines remain sparse. Knowing the areas where cholera is known to occur and the factors that lead to its
occurrence will assist in planning preventive measures and disaster mitigation. Cholera has been increasingly reported in the past decade. It is most feared because of its tendency to
spread rapidly resulting in deaths in a short time, if appropriate treatment is not provided. For fear of trade and travel sanctions, countries were disinclined to report cholera, unless
large outbreaks ensued. Although countries in Asia have been reporting cholera, it is believed that more cases are not being identified and instead being reported as acute watery
diarrhea. Cholera is endemic in the Philippines however data on cholera in the country remained sparse, until 2008 when surveillance was strengthened. From 2008 to 2013, 42,071
suspected and confirmed cholera cases were reported in 87% of provinces and metropolitan areas in the country, confirming the endemicity of cholera in the Philippines. Poor access
to improved sanitation was associated with cholera. On the other hand, despite access to improved water sources, cholera remains to be seen. The latter is most probably due to the
breakdown and non-chlorination of water systems. We identified areas where cholera has been known to occur in the Philippines, this will assist in the development and
implementation of policies to minimize the morbidity and mortality due to this disease.
V. Nursing Care Plans
Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
Subjective: Deficient Fluid Volume At the end of my 8- hour Independent: 1. To ensure accurate picture of fluid At the end of my 8- hour
The patient verbalized, related to Excessive fluid shift, the patient will: 1. Monitor I&O balance, status. shift, goals were
Sige na ko ug suka ug loss as evidenced by being aware of altered 2. Hypotension, fever, and
kalibanga, ma’am. Mga profuse diarrhea and Establish a fluid volume intake or output. tachycardia can indicate response Fully met:
tulo na ni sya kaadlaw. vomiting at a functional level as 2. Assess vital signs to and or effect of fluid loss. 1. Stable vital signs
Sakit pud akong tiyan. evidenced by: 3. Urge the patient to 3. Oral fluid replacement is Partially met:
drink the prescribed indicated for mild fluid deficit and 2. Slight changes in
Objective: 1. Stable vital signs amount of fluid. is a cost-effective method for skin turgor
• Pain scale:6/10 2. Good skin turgor 4. Educate patient about replacement treatment. 3. Prompt capillary
• Frequent watery 3. Prompt capillary refill possible causes and 4. Enough knowledge aids the refill time
stool 4. Moist mucous effects of fluid loss or patient in taking part in their plan 4. Moist mucous
• Poor skin turgor membranes decreased fluid intake. of care. membranes
• Vital signs: 5. Adequate input and 5. Weigh the patient 5. Daily weight is an indicator of 5. The patient
▪ T: 37.1- output. daily. overall fluid and nutritional verbalized slight
degree 6. The patient verbalized 6. Emphasize the status. relief.
Celsius relief and comfort. relevance of 6. Increasing the patient’s 6. Positive changes
▪ P: 83 bpm maintaining proper knowledge level will assist in of input and output
▪ RR: 19 bpm nutrition and hydration. preventing and managing the
▪ BP: 110/80 Dependent: problem.
7. Provide supplemental 7. Fluids are necessary to maintain
fluids and electrolytes hydration status. Fluids may be
replacement, as given in this manner if client is
ordered. unable to take oral fluid, is NPO
8. Administer for procedures, or when rapid
medications, as ordered fluid resuscitation is required.
(antibiotics). 8. Antibiotics are recommended in
cholera-infected patients with
serious dehydration, or moderate
dehydration with continuing net
fluid losses despite rehydration.
 Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
Subjective: Imbalanced nutrition: After 8 hours of nursing Independent: 1. Provides information At the end of my 8- hour shift,
“Tulo ka adlaw nako ge less than body interventions, the client 1. Monitor intake and about overall fluid goals were:
diarrhea tas suka pud. requirements related to will be able to: output. balance.
Way lami ikaon” as loss of fluids as 2. Observe for 2. Indicates excessive fluid Partially met:
verbalized by the evidenced by diarrhea 1. Maintain adequate excessively dry skin loss or resultant 1. Client was able to
patient. and inadequate intake hydration. and slowed capillary dehydration. maintain adequate
2. Consume adequate refill. 3. Hypotension, tachycardia, hydration
Objective: nutritional 3. Assess vital signs. fever can indicate 2. Consume adequate
• Frequent watery requirements. 4. Weigh daily. response to and or effect nutritional requirements.
stools. 3. Maintain skin 5. Provide good oral of fluid loss. 3. Maintain skin integrity
• Hyperactive integrity. hygiene. 4. Indicator of overall fluid
bowel sounds; 6. Educate the patient on and nutritional status.
diarrhea. the body’s nutritional 5. Good oral hygiene can
• Capillary refill needs. increase an individual’s
test takes longer Dependent: appetite. The oral mucosa
than 2 seconds 7. Give oral rehydration is also a vital part of
• Loss of weight solution (ORS). salvia production which
with inadequate 8. Observe the results of will further aid in the
food intake the electrolyte. digestion of food.
• Vs Taken: 6. This will allow the patient
▪ T: 37.1- to gain knowledge in the
degree area of how to
Celsius independently care for
▪ P: 83 bpm oneself upon discharge.
▪ RR: 19 bpm 7. Rehydration and
▪ BP: 110/80 replacement of fluid loss
through the stool.
8. Know the level of
hydration and the
effectiveness of
interventions.
 Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
Subjective: Risk for electrolyte After 8 hours of nursing Independent: 1. Shock occurs when low At the end of my 8- hour shift,
“Nag sige kog pamati imbalance related to interventions, the client 1. Monitor Vital signs blood volume causes a goals were:
ug sakit sa tiyan ug diarrhea and vomiting. will be able to: 2. Supply balanced drop in blood pressure
kalibanga” as electrolyte IV solutions this is due to electrolyte Fully met:
verbalized by the Prevent onset of as directed. imbalance caused by 1. Electrolyte levels back to
patient. infection as evidenced 3. Educate the patient cholera. normal
by: about dietary sources 2. Lactated Ringer’s 2. Good skin turgor
Objective: of electrolytes. solution has an electrolyte 3. Stable vital signs
• Loss of appetite 1. Electrolyte levels 4. Educate the patient concentration similar to 4. No reports of any
• Nausea and back to normal about limiting the use that of extracellular fluid vomiting and diarrhea
vomiting 2. Good skin turgor of over-the-counter 3. A balanced diet provides 5. Hydration level back to
• Poor skin turgor 3. Stable vital signs antacids and laxatives. the patient with sources of normal range
• Vital signs: 4. No reports of any 5. Monitor intake and electrolytes to prevent
▪ T: 37.1- vomiting and diarrhea output imbalances
degree 5. Hydration level back 6. Encourage patient to 4. Excessive use of antacids
Celsius to normal maintain hydration that contain magnesium
▪ P: 83 bpm Dependent: has a laxative effect that
▪ RR: 19 bpm 7. Oral Rehydration may cause diarrhea
▪ BP: 110/80 Solution. 5. To observe the hydration
8. Administer oral status of the patient.
medications as 6. To replace the ongoing
prescribed fluid losses until diarrhea
stops.
7. To treat dehydration
caused by diarrhea.
8. Decreases the duration of
diarrhea and volume of
stool.
VI. References
Books:
Vanputte, et al. (2019). Seeley’s Essentials of Anatomy and Physiology. 10th Ed. McGraw-Hill Education.
Reyala, et. al. (2002). Community Health Nursing Services in the Philippines. 9th Ed. Community Health Nursing Section, National League of Philippine Government Nursing, Inc.
Hinkle, et. al. (2022). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. 15th Ed. Wolters Kluwer Health, Inc.
Doenges, M. et. al. (2013). Nurse’s Pocket Guide: Diagnosis, Prioritized Interventions, and Rationales. 13th Ed. F. A. Davis Company.

Websites:
Fanous, M. & King, K. (2022, July 1). Cholera. National Library of Medicine. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK470232/
Centers of Disease Control and Prevention. (2020, October 2). Cholera – Vibrio Cholerae Infection. Retrieved from: https://www.cdc.gov/cholera/illness.html
Lopez, A.L. et. al. (2015, January 8). Epidemiology of Cholera in the Philippines. The Public Library of Science. Retrieved from:
https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003440
Tulchinsky, T. (2018, March 30). John Snow, Cholera, the Broad Street Pump; Waterborne Diseases Then and Now. Elsevier Public Health Emergency Collection. Retrieved
from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7150208/