Hookworms Nursing Care Planning and Management

Hookworms are blood-feeding nematodes that infect the small intestine, and the harm they do is chronic, not dramatic: iron-deficiency anemia, malnutrition, and stunted growth, hardest on children and pregnant women. Infection tracks poverty and poor sanitation, spreads through skin contact with contaminated soil, and the child you see may have nothing more than pallor and a vague history of going barefoot. Your work is recognizing the anemia, treating the worm, and breaking the soil-to-skin cycle.

What are Hookworms

Human hookworm disease is a common helminth infection caused predominantly by the nematodes Necator americanus and Ancylostoma duodenale; lesser players include Ancylostoma ceylonicum, Ancylostoma braziliense, and Ancylostoma caninum. Infection is acquired through skin exposure to larvae in soil contaminated by human feces. Soil becomes infectious about 9 days after contamination and stays infectious for weeks depending on conditions.

Pathophysiology

The life cycle starts when hookworm eggs pass in feces into soil. Each day in the intestine, a mature female A duodenale produces about 10,000 to 30,000 eggs, a mature female N americanus 5000 to 10,000. On soil under the right conditions, each egg develops into an infective larva. These larvae are developmentally arrested and nonfeeding, and if they cannot find a host they die when their metabolic reserves run out, usually in about 6 weeks. Growth is most proliferative in sandy, moist soil at an optimal temperature of 20 to 30°C; there the larvae hatch in 1 or 2 days to become rhabditiform larvae (L1). The rhabditiform larvae feed on feces and undergo 2 molts, becoming infective filariform larvae (L3) after 5 to 10 days. L3 go through developmental arrest and survive in damp soil for as long as 2 years, but desiccate quickly in direct sunlight, drying, or salt water; they live in the top 2.5 cm of soil and move vertically toward moisture and oxygen. The larvae migrate through the dermis, enter the bloodstream, and reach the lungs within 10 days, breaking into alveoli and causing mild, usually asymptomatic alveolitis with eosinophilia. In 3 to 5 weeks the adults reach sexual maturity, and the females begin producing eggs that appear in the host's feces.

Statistics and Incidences

Human infection with A duodenale or N americanus affects an estimated 472 million people worldwide. Infection and disease now turn up most often in immigrants, refugees, and adoptees from tropical countries. Cutaneous larva migrans is endemic in the southeastern states and Puerto Rico, and the canine hookworm A caninum has reportedly caused eosinophilic enteritis in Australia and the United States. Infection is most prevalent in tropical and subtropical zones, roughly between latitudes 45°N and 30°S, and in some communities prevalence runs as high as 90%. In 2010, an estimated 117 million people in sub-Saharan Africa were infected, along with 64 million in East Asia, 140 million in South Asia, 77 million in Southeast Asia, 30 million in Latin America and the Caribbean, 10 million in Oceania, and 4.6 million in the Middle East and North Africa. In endemic areas the highest prevalences are among school-aged children and adolescents, possibly from age-related changes in exposure and immunity. Studies from China and Brazil show a consistently rising prevalence, from 15% at age 10 years to 60% at age 70 years and older, with egg counts in stool climbing in the same pattern. Males and females are equally susceptible.

Causes

N americanus is the globally predominant human hookworm and the only member of its genus known to infect humans; it is a small, cylindrical, off-white worm, with adult males measuring 7 to 9 mm and adult females 9 to 11 mm. Poor hygiene and sanitation feed infestations because the worms thrive in dirty, unkempt surroundings. Ingesting water infested with hookworm eggs also leads to infection.

Clinical Manifestations

Ground or dew itch is an erythematous, pruritic, papulovesicular rash at the site of entry on the palms or soles, lasting 1 to 2 weeks after initial infection; intense scratching commonly seeds a secondary bacterial infection. When the worms break from the venous circulation into the pulmonary air spaces, expect cough, fever, and reactive bronchoconstriction with wheezing on auscultation. As the worms migrate into the GI tract and mature in the jejunum, patients may have diarrhea, vague abdominal pain, colic, flatulence, nausea, or anorexia. Signs of iron-deficiency anemia are often insensitive but may include pallor, chlorosis (greenish-yellow skin discoloration), hypothermia, spooning nails, tachycardia, or high-output cardiac failure. Cutaneous larva migrans shows pathognomonic raised serpiginous tracts (creeping eruptions) with surrounding erythema that can last as long as 1 month untreated, most often on the lower extremities but sometimes on the trunk or upper extremities depending on the entry site.

Assessment and Diagnostic Findings

Confirm anemia with CBC and peripheral blood smear showing iron-deficiency changes; microscopy reveals hypochromic, microcytic RBCs, and eosinophilia is surprisingly persistent, likely from adult worms attached to the intestinal mucosa. Confirm the infection with direct microscopic analysis of fecal samples for hookworm eggs, fixing the specimen in formalin and preparing it as a wet mount.

Medical Management

Most classic hookworm disease is managed outpatient with anthelmintic and iron therapy plus an appropriate diet. Patients with anemia and malnutrition may need both iron supplements and nutritional support, including folate. For cutaneous larva migrans with minimal symptoms, specific anthelmintic treatment may be unnecessary. Blood transfusion is indicated in rare cases of acute severe GI hemorrhage; in chronic anemia, packed RBCs should be given slowly and are usually followed by a diuretic to prevent rapid fluid overload.

Pharmacologic Management

Anthelmintics are the drug of choice. Effective agents include the benzimidazoles (albendazole, mebendazole) and pyrantel pamoate. The CDC continues to recommend a 400-mg single dose of albendazole (per its website, July 26, 2018) but notes albendazole is still not FDA approved for treating hookworm infection.

Nursing Management

Nursing Assessment

Most patients come from known endemic areas and often have a history of wearing open footwear or going barefoot there. On exam, skin and pulmonary findings are minimal, and early larval-migration findings differ from late established GI infection findings.

Nursing Diagnoses

Acute pain related to mucosal irritation. Ineffective tissue perfusion related to blood loss. Impaired skin integrity related to persistent scratching. Deficient knowledge related to the disease process and treatment.

Nursing Care Planning and Goals

The child has diminished pain, perfusion returns to normal, itching and scratching are reduced, and the child and caregivers gain enough knowledge about the disease and its treatment.

Nursing Interventions

To reduce pain, provide rest periods for relief and sleep, acknowledge reports of pain immediately, remove other sources of discomfort, and choose the appropriate pain relief method. To improve perfusion, obtain diagnostic tests as indicated and give blood transfusion as indicated. To protect skin, check the affected site at least once daily for color change, redness, swelling, warmth, pain, or other signs of infection, give skin care as needed, use sterile dressing technique during wound care, clip the nails as needed, and teach proper handwashing, wound cleansing, dressing changes, and topical medication. To build knowledge, set learning priorities within the care plan, provide physical comfort and a calm uninterrupted environment, involve the patient in the teaching plan, help integrate information into daily life, and give clear, thorough explanations and demonstrations.

Evaluation

Goals are met when pain is diminished, perfusion has returned to normal, itching and scratching are reduced, and the child and caregivers have enough knowledge about the disease and its treatment.

Documentation Guidelines

Document individual findings (contributing factors, interactions, nature of social exchanges, specifics of behavior), cultural and religious beliefs and expectations, the plan of care, the teaching plan, responses to interventions and teaching, and attainment or progress toward outcomes.