LYCEUM-NORTHWESTERN UNIVERSITY

COLLEGE OF NURSING

NCM 116: RELATED LEARNING EXPERIENCE

CASE PRESENTATION: ANIMAL BITE

PRESENTED BY:
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COLLEGE OF NURSING

I. Introduction
Rabies is a preventable viral disease most often transmitted through the bite of a rabid animal. The rabies virus infects the central nervous
system of mammals, ultimately causing disease in the brain and death. The vast majority of rabies cases reported to the Centers for Disease Control
and Prevention (CDC) each year occur in wild animals like bats, raccoons, skunks, and foxes, although any mammal can get rabies.
II. Objectives
At the end of the case presentation, you should be able to:
 Summarize the burden of rabies
 Describe the epidemiological features of rabies
 Describe the steps in the management of dog bite

III. Overview of Anatomy & Physiology

The skin is the largest organ of the body, accounting for about 15% of the total adult body weight. It performs many vital functions, including
protection against external physical, chemical, and biologic assailants, as well as prevention of excess water loss from the body and a role in
thermoregulation. The skin is continuous, with the mucous membranes lining the body’s surface. The integumentary system is formed by the skin and
its derivative structures. The skin is composed of three layers: the epidermis, the dermis, and subcutaneous tissue. The outermost level, the epidermis,
consists of a specific constellation of cells known as keratinocytes, which function to synthesize keratin, a long, threadlike protein with a protective role.
The middle layer, the dermis, is fundamentally made up of the fibrillar structural protein known as collagen. The dermis lies on the subcutaneous tissue,
or panniculus, which contains small lobes of fat cells known as lipocytes.
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COLLEGE OF NURSING

IV.Description of the Disease

a. Pathophysiology (Paradigm)
Rabies virus infection is remarkable for the lack of evident pathology despite dramatic neurologic symptoms. Minimal inflammation and
neuronal cytopathy may be observed even postmortem. Similarly, viremia does not occur or play a role in spread to the CNS.
Pathophysiology has been best characterized in canine rabies variants. Canine rabies in humans requires deep-muscle inoculation.
Endogenous muscle micro-RNA bind to viral transcripts and limit both replication and viral protein production, such that the virus is able to evade
detection by antigen-presenting cells. Once enough virus replicates (or with a high-level inoculum or direct nerve injury), it binds motor neuron
junctions at postsynaptic nicotinic acetylcholine receptors, which initiates uptake into the motor endplate. From here, the virus rapidly propagates
across motor axons and chemical synapses in retrograde fashion toward the ganglia and nerve roots, at which point the prodromal symptoms of
neuralgia and hypoesthesia may begin, in addition to fever and flulike illness.
Once reaching the CNS, it spreads throughout via the more ubiquitous nicotinic acetylcholine receptors of the brain. Of note, anterograde
spread of rabies virus may then occur via sensory and autonomic pathways from the CNS to viscera, explaining many of the symptoms of
progressive disease. Throughout propagation of the virus along motor pathways, the virus elicits little inflammation, and the motor neurons continue
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COLLEGE OF NURSING

their otherwise normal functions of neurotransmission. Increasing signs of inflammation develop as CNS and visceral spread occurs, although a
significant paucity of findings remains, other than mild nonspecific MRI T2 enhancements. Spinal fluid remains largely acellular, even in the presence
of detectable rabies virus.

b. Etiology (risk factors)

Rabies is a highly neurotropic virus that evades immune surveillance by its sequestration in the nervous system. Upon inoculation, it enters
the peripheral nerves. A prolonged incubation follows, the length of which depends on the size of the inoculum and its proximity to the CNS.
Amplification occurs until bare nucleocapsids spill into the myoneural junction and enter motor and sensory axons. At this point, prophylactic therapy
becomes futile, and rabies can be expected to follow its fatal course, with a mortality rate of 100%.
The rabies virus travels along these axons at a rate of 12-24 mm/d to enter the spinal ganglion. Its multiplication in the ganglion is heralded
by the onset of pain or paresthesia at the site of the inoculum, which is the first clinical symptom and a hallmark finding. From here, the rabies virus
spreads quickly, at a rate of 200-400 mm (7-15 inches) per day, into the CNS, and spread is marked by rapidly progressive encephalitis. Thereafter,
the virus spreads to the periphery and salivary glands, where it may be transmitted to others.
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COLLEGE OF NURSING

c. Disease process
There are three clinical phases of the disease:
 Prodromal phase - the onset of clinical rabies in man includes 2-4 days of prodromal.
 Excitation phase - the excitation phase begins gradually and may persist to death.
 Paralytic phase - hydrophobia, if present, disappears and swallowing becomes possible.
d. Manifestations _ signs and symptoms
The first symptoms of rabies may be similar to the flu, including weakness or discomfort, fever, or headache. There also may be discomfort,
prickling, or an itching sensation at the site of the bite. These symptoms may last for days.
Symptoms then progress to cerebral dysfunction, anxiety, confusion, and agitation. As the disease progresses, the person may experience
delirium, abnormal behavior, hallucinations, hydrophobia (fear of water), and insomnia. The acute period of disease typically ends after 2 to 10 days.
Once clinical signs of rabies appear, the disease is nearly always fatal, and treatment is typically supportive. Less than 20 cases of human survival
from clinical rabies have been documented. Only a few survivors had no history of pre- or postexposure prophylaxis.

The signs, symptoms, and outcome of rabies in animals can vary. Symptoms in animals are often similar to those in humans. These include
early nonspecific symptoms, acute neurologic symptoms, and ultimately death.
V. Laboratory and Diagnostic test
Diagnosis in humans
Several tests are necessary to diagnose rabies ante-mortem (before death) in humans; no single test is sufficient. Tests are performed on
samples of saliva, serum, spinal fluid, and skin biopsies of hair follicles at the nape of the neck. Saliva can be tested by virus isolation or reverse
transcription followed by polymerase chain reaction (RT-PCR). Serum and spinal fluid are tested for antibodies to rabies virus. Skin biopsy specimens are
examined for rabies antigen in the cutaneous nerves at the base of hair follicles.
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COLLEGE OF NURSING

Tests for rabies might include:

Saliva test. You’ll spit into a tube. It’ll be sent to a lab to look for signs of rabies.
Skin biopsy. Your provider will take a small sample of skin from the back of your neck. Your skin sample will be sent to a lab to look for signs of
rabies.
Cerebrospinal fluid test (lumbar puncture). Your provider will use a needle to take a cerebrospinal fluid (CSF) from your lower back. Your
CSF sample will be sent to a lab to look for signs of rabies.
Blood tests. Your provider will use a needle to take blood from your arm. Your blood will be sent to a lab to look for signs of rabies.
MRI. You’ll lie in a machine that takes pictures of your brain. Your provider will use the pictures to help determine what’s causing your
symptoms.
VI.Medical Management
There’s no approved treatment for rabies once you have symptoms. If you’ve been exposed to rabies (were bitten by or been in contact with an
infected animal), contact a healthcare provider as soon as possible. Clean the wound gently but thoroughly with soap and water. Ask your provider for
additional instructions on cleaning the wound. Your provider will give you a series of shots (vaccinations) to prevent the virus from causing rabies.
They’ll also give you an antibody treatment directly to the wound if you’ve never been vaccinated before.
Medications prevent an infection from traveling to your brain if you’ve been exposed to rabies (post-exposure prophylaxis/PEP). These medications
are often combined:
Rabies vaccine. Your healthcare provider will give you four shots over 14 days. If you’ve already been vaccinated before exposure, you’ll only need
two shots. The vaccine teaches your body to destroy the rabies virus before it enters your brain.
Human rabies immune globulin (HRIG). Your provider will give you shots around the wound. HRIG gives you antibodies (molecules that fight
infection) that will destroy the virus near the wound until your body takes over. You shouldn’t get HRIG if you’ve been vaccinated before your exposure.

Classification: Anti-rabies
Generic name: Purified Chick
Embryo Cell
Brand name: RabAvert
Dose/Frequency/Route:
The individual dose for adults,
children is 1mL given
intramuscularly.
In adults, administer vaccine
by IM injection into the deltoid
muscle. In small children,
administer vaccine into the
anterolateral zone of the thigh.
ASSESSMENT
LYCEUM-NORTHWESTERN UNIVERSITY
COLLEGE OF NURSING
Mechanism of Action: Indication:
Intramuscular injection of
RabAvert is indicated for
RABAVERT (Rabies preexposure vaccination,
in both primary series and
Vaccine) induces
booster dose, and for
lymphocytes to produce postexposure prophylaxis
against rabies in all age
virus neutralizing
groups.
antibodies that provide
adequate protection Contraindications:
against rabies virus. In view of the almost
invariably fatal outcome of
rabies, there is no
contraindication to
postexposure prophylaxis,
including pregnancy.
History of anaphylaxis to
the vaccine or any of the
vaccine components
constitutes a
contraindication to
preexposure vaccination
with this vaccine.
PLANNING IMPLEMENTATION
Side effects: Nursing
In a very rare cases, Responsibilities:
neurological and
 The healthcare
neuroparalytical events
provider should also
have been reported in
question the patient,
temporal association with
parent, or guardian
administration of
about the current
RabAvert. This include
health status of the
cases of hypersensitivity.
vaccinee and reactions
to a previous dose of
Adverse effects:
RabAvert or a similar
The most commonly
product
occurring adverse
 Preexposure
reactions are injection -site
vaccination should be
reactions, such as
postponed in the case
injectionsite erythema,
of sick & covalescent
induration and pain; flu-
persons and those
like symptoms, such as
considered to be in the
asthenia, fatigue, fever,
incubation stage.
headache, myalgia and
malaise; arthralgia,
dizziness,
lymphadenopathy, nausea,
and rash.
RATIONALE EVALUATION

Subjective:
“Nakagat ako ng palaboy
laboy na aso habang
nakikipagkwentuhan sa
kaibigan ko” as verbalized
by the patient.
Objective:
 Irritability and facial
grimace
 Disruption of skin
surface
 Vital signs as follows:
 T: 37.1 C
 PR: 83
 RR: 22
 BP: 120/80
Nursing Diagnosis:
Impaired skin integrity
related to disruption of
skin surface with
destruction of skin layers.
LYCEUM-NORTHWESTERN UNIVERSITY
COLLEGE OF NURSING
Within 8 hours of Independent After 8 hours of nursing
 Provide baseline
nursing intervention, the  Assess the skin; note intervention, the client
information about the
client will be able to the color, diameter was able to achieve
wound & possible
achieve timely wound and condition of the timely wound healing
changes
healing wound
 Washing the affected
 Thoroughly wash the
area is very effective
wound as soon as
in reducing the
possible with soap
number of viral
and water
particles
 Apply antiseptic
 To avoid the spread
solution in the wound
of viral disease in
 Keep the skin free
the surrounding area
from infection and
 To promote proper
pressure
blood circulation and
 Implement contact
to reduce the risk of
isolation for
infection
respiratory secretions,
 To reduce the the
especially saliva in
risk for cross-
the duration of illness
contamination
 Invesitgate for
 Deterioration in the
change in thought
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COLLEGE OF NURSING

process level of
 Examine the wound consciousness may
daily indicate worsening of
the patient’s
condition
 Identifies presence of
wound healing
Dependent
 Administer anti-
tetanus and anti-  To provide protection
rabies and prevents the
immunoglobulin as spread of the disease
prescribed

VII. Evaluation and Discharge Planning

Call 911 for any of the following:

 Your mouth and throat are swollen.
 You are wheezing or have trouble breathing.
 You have chest pain or your heart is beating faster than normal for you.
 You feel like you are going to faint.

Seek care immediately if:

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COLLEGE OF NURSING

 Your face is red or swollen.

 You have hives that spread over your body.
 You feel weak or dizzy.