Chikungunya Virus Nursing Care Management & Care Plan

Chikungunya is a self-limiting febrile viral illness, but the arthralgia is what brings patients in and what lingers. There is no antiviral and no vaccine, so care is symptom control: bring down the fever, manage the joint pain, keep them hydrated, and protect the skin. Watch diabetics closely, because their glucose control slips during infection.

What is Chikungunya Virus?

Chikungunya virus is an insect-borne illness causing sudden-onset fever, arthralgia, and rash. It is transmitted to humans by day-biting mosquitoes of the Aedes genus.

• "Chikungunya" refers to both the virus (CHIKV) and the fever (CHIKF) it causes.
• The term comes from the Swahili or Makonde dialect and means "to be bent over." In Congo it is called "buka-buka" ("broken-broken"). Both describe the stooped posture from severe, chronic, incapacitating arthralgia.
• Humans are the primary host during epidemic periods.

Pathophysiology

The exact pathophysiology is still under investigation; most research comes from the Indian subcontinent and other Asian countries.

• In a murine model, Lum et al showed anti-Chikungunya antibodies were elicited early and directed against the C-terminus of the viral E2 glycoprotein. Both natural and infection-induced antibodies were essential for controlling infection.
• Bernard et al found the virus enters mammalian epithelial cells via a clathrin-independent, Esp-15-dependent, dynamin 2-dependent route, requiring an endocytic pathway with other unknown pathways.
• Aedes aegypti was the primary vector in India and other countries during the 2006-2010 epidemics.
• Analysis of a 2016 Brazil outbreak revealed two novel mutations (K211T in E1 and V156A in E2) that enhanced viral fitness, letting the virus infect host cells independent of cholesterol and turning the outbreak into an epidemic.

Statistics and Incidences

Numerous Chikungunya epidemics have been reported across Southern and Southeast Asia.

• The first Asian epidemic was reported in Bangkok, Thailand, in 1958, continued until 1964, reappeared in the mid-1970s, and declined again in 1976.
• The most severe outbreak was in 2006 on Reunion Island, where one-third of the population was infected, resulting in 237 deaths.
• A historical outbreak on the Indian subcontinent involved 1.42 million people with high morbidity.
• Per 2013-2014 figures from the CDC, ECDC, and PAHO, imported travel-related cases were reported in the United States, Caribbean islands, Britain, France, Germany, Sweden, Portugal, the Canary Islands, and the archipelagos off Western Africa.
• The virus emerged in America in late 2013 and continued spreading to neighboring countries.
• As of 2017, about 1.8 million cases had been reported from 44 countries.
• A total of 124 cases (116 from US states, 8 from US territories) were reported to ArboNET in 2018.
• As of August 1, 2019, 42 cases had been reported in the United States and its territories that year.

Cause

Chikungunya virus is an alphavirus of the Togaviridae family.

• It is a single-stranded RNA virus, approximately 11.8 kb long, with a capsid and a phospholipid envelope.
• It is transmitted by day-biting Aedes mosquitoes. As an arbovirus, it is maintained between humans or other animals and mosquitoes, with humans serving as major reservoirs during epidemics.
• During inter-epidemic quiescence in Africa, the virus is maintained in a sylvatic/epizootic cycle among wild primates, monkeys, rodents, birds, and wild Aedes mosquitoes (Aedes furcifer, Aedes taylori, Aedes luteocephalus, Aedes africanus, Aedes neoafricanus).
• In Asia, it is maintained in an urban cycle involving A aegypti mosquitoes and humans.

Clinical Manifestation

Symptoms usually begin 3-7 days after an infected mosquito bite.

• Fever. High-grade fevers (up to 105°F) are among the most common symptoms.
• Arthralgia. Usually polyarticular and migratory, frequently involving the small joints of the hands, wrist, and ankle, with less involvement of large joints (knee, shoulder) and associated arthritis. Joint pain is worse in the morning, improves with slow movement, and worsens with strenuous exercise.
• Cutaneous. A flushed face and trunk, followed by a diffuse erythematous maculopapular rash of the trunk and extremities, sometimes the palms and soles. The rash fades gradually and may evolve into petechiae, urticaria, xerosis, or hypermelanosis, or resolve with desquamation.
• Neurological. During the 2005-2006 Indian Ocean outbreak, 23 patients presented with neurological symptoms, abnormal CSF, and positive CSF IgM or RT-PCR for Chikungunya virus.
• Others. Rare presentations include severe rheumatoid arthritis, neuroretinitis, uveitis, hearing loss, myocarditis, and cardiomyopathy.

Assessment and Diagnostic Findings

Diagnostic testing is available through some commercial labs, many state health departments, and the CDC.

• Serological testing. Chikungunya-specific IgM antibodies appear upon cessation of viremia, usually by day 5-7, and stay positive for 3-6 months. IgG-neutralizing antibodies appear after 7-10 days and may persist several months. Both are detected by ELISA through the CDC and several state health departments.
• Viral culture. The virus may be isolated within the first 3 days of illness during active viremia by inoculation of blood into mice or mosquitoes; culture-based detection is available through the CDC.
• Molecular diagnostics. RT-PCR uses structural and nonstructural domains of the genome and is available through the CDC.

Medical Management

There is no specific antiviral therapy or vaccine. Treatment relieves symptoms.

• Relieve joint pain and fever. Rest, fluids, and NSAIDs for acute pain and fever.
• Monitor glucose. Poor glycemic control has been reported in diabetics with Chikungunya; monitor blood glucose closely in these patients.
• Conservative treatment. Manage electrolyte imbalance and prerenal azotemia, with hemodynamic monitoring based on severity.

Nursing Management

Nursing Assessment

• History. An acute febrile illness with a 3-7 day incubation period. It affects all ages and both sexes equally, with an attack rate of 40%-85%.
• Physical examination. High-grade fevers (up to 105°F), pharyngitis, conjunctival suffusion, conjunctivitis, and photophobia. Cervical or generalized lymphadenopathy is reported rarely.

Nursing Diagnosis

• Hyperthermia related to increased metabolic demand.
• Deficient fluid volume related to dehydration.
• Pain related to joint inflammation.
• Impaired skin integrity related to cutaneous manifestations.

Nursing Care Planning and Goals

• Improve body temperature.
• Restore adequate fluid volume.
• Relieve pain.
• Improve skin integrity.

Nursing Interventions

• Improve body temperature. Remove excess clothing and covers, give antipyretics as prescribed, perform tepid sponge baths, and adjust cooling measures to the patient's response.
• Restore fluid volume. Assess skin turgor and oral mucous membranes for dehydration; assess urine color and amount and report urine output less than 30 ml/hr for 2 consecutive hours; encourage the prescribed fluid intake and give parenteral fluids as prescribed.
• Relieve pain. Acknowledge pain immediately, provide rest periods for relief and sleep, and give analgesics as ordered while monitoring effectiveness and adverse effects.
• Improve skin integrity. Check impaired sites at least once daily for color change, redness, swelling, warmth, pain, or infection; provide tissue care; tell the patient to avoid rubbing and scratching; provide gloves or clip nails if needed; give antibiotics as ordered.

Evaluation

Goals are met when the patient shows improved body temperature, restored fluid volume, pain relief, and improved skin integrity.

Documentation Guidelines

• Individual findings, including factors affecting, interactions, nature of social exchanges, and specifics of individual behavior.
• Cultural and religious beliefs and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward the desired outcome.

Key Points

• Chikungunya is a self-limiting febrile viral illness transmitted by day-biting Aedes mosquitoes.
• It is an alphavirus of the Togaviridae family. Symptoms begin 3-7 days after the bite and include fever, arthralgia, rash, and neurological signs.
• There is no specific antiviral therapy. Care is symptom control: fever, joint pain, hydration, and skin protection.