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Nursing Care Plan | NCP Botulism

Botulism is a serious neurotoxic disorder that is caused by the gram-positive, spore-formingbacterium Clostridium botulinum, which is found in soil and in the gastrointestinal (GI) tract of birds, fish, and mammals. Although it is usually harmless in the spore state, the organism flourishes in warm anaerobic environments, causing germination with bacterial multiplication and toxin production. Botulism occurs when the bacterium is ingested into the GI tract or enters through an open wound. Once ingested or embedded, the bacterium enters the vascular system. Toxins act at the neuromuscular junction by impairing the release of the neurotransmitter acetylcholine from the presynaptic membrane. Loss of acetylcholine causes paralysis of voluntary and involuntary muscles.

Approximately 100 cases of botulism are reported each year in the United States, of which 25% are food borne, 72% are infant botulism, and the remainder are from wounds. Botulism has a mortality rate as high as 25%, with death occurring as a result of respiratory failure during the first week. If onset is rapid ( 24 hours) after ingestion of the bacterium, the course of the disease is more severe and potentially fatal. Paralytic ileus is another complication of botulism.

In persons older than 12 months, the spores are unable to germinate in the gut because of the presence of gastric acid, and therefore the food-borne disease is caused by ingesting a preformed toxin. The spores, however, can germinate in the GI tract of infants younger than 1 year because infants have lower levels of gastric acid, decreased levels of normal flora, and an immature immune system. The GI environment in infants is conducive to toxin production, making infants particularly susceptible to the spores present in unprepared foods.

Food-borne botulism occurs when food contaminated with the toxin from the bacteria is ingested. It is caused by the consumption of improperly canned or stored food that is contaminated with spores. Infant botulism occurs when an infant ingests spores in honey or other foods that produce the toxin in the infant’s GI tract. Wound botulism occurs from toxin produced in a wound contaminated with Clostridium botulinum. Indeterminate botulismoccurs in individuals over the age of 1 who have no recognizable source of the disease.

Nursing care plan assessment and examination
Elicit a history from the patient or parents regarding food consumption for the last 12 to 96 hours. Note that the incubation period ranges between 12 and 36 hours but depends on the amount of toxin the person ingested. Encourage the patient not only to identify the type of food but also to explain the food preparation with particular attention to the level of heat to which the food was exposed during preparation. Ask the patient if she or he has experienced any puncture wounds recently, particularly while gardening or working with soil.

Patients may describe symptoms of botulism within 12 hours of exposure. Initially, patients may describe nausea and vomiting, although often they remain alert and oriented without sensory or neurological deficits. Some patients report diarrhea or constipation, whereas others describe a very dry, sore throat and difficulty swallowing; some may experience GI symptoms prior to neurological symptoms, or the symptoms may occur simultaneously. Patients also describe neuromuscular abnormalities. Symptoms usually occur in a descending order from the head to the toes. Ask the patient if he or she has experienced blurred vision, double vision, difficulty swallowing, difficulty speaking, or weakness of the arms and legs.
On inspection, the patient is often awake and alert but may be drowsy, agitated, and anxious. Usually, fever is absent. Cranial nerve involvement occurs early in the disease course and leads to drooping eyelids, double vision, and extraocular muscle paralysis. Most patients lose their gag reflex, and fixed or dilated pupils occur in approximately 50% of patients as the disease progresses. Note if the patient has difficulty speaking. Inspect the symmetry of the facial expression. Evaluate the strength and motion of the extremities because weakness progresses to the neck, arms, thorax, and legs. Ask the patient to shrug her or his shoulders while you press gently on them to test for strength and symmetry. Check for respiratory depression and apnea. As the disorder progresses, respiratory muscle paralysis occurs from phrenic nerve involvement and the patient stops breathing. Infants with botulism are lethargic, suck or nurse poorly, and are constipated. They are listless and have a weak cry, poor head control, and poor muscle tone due to muscle paralysis caused by the bacterial toxin, which can ultimately lead to paralysis of the arms, legs, trunk and respiratory muscles if the infection is untreated.

Because of the potential for lifestyle changes and the lengthy hospitalization, children with botulism are at risk for alterations in growth and development. Assess the growth and development level in all age groups.

Nursing care plan primary nursing diagnosis: Ineffective airway clearance related to respiratory muscle paralysis.

Nursing care plan intervention and treatment
Report cases of botulism toxicity so that others can be protected from the illness. When botulism poisoning from ingestion is suspected, the patient’s stomach is lavaged to remove any unabsorbed toxin; a high colonic enema may also be administered for the same purpose. If impaired swallowing and chewing last longer than 72 hours, enteral feeding via a nasogastric (NG) or nasointestinal tube or total parenteral nutrition is instituted.

Infected wounds are explored and débrided. Usually the physician prescribes antibiotics such as penicillin to kill bacteria in the wound, although the treatment with antibiotics is controversial.

If respiratory paralysis occurs, intubation or tracheotomy and mechanical ventilation are essential to maintain airway and breathing. At least every hour, monitor the patient’s breath sounds, placement, and position of the endotracheal tube; the respiratory rate and lung expansion; and the type and characteristics of secretions. A Foley catheter is inserted to
monitor urinary output and prevent bladder distension.

Other family members who have been exposed to contaminated food should obtain healthcare immediately. Exposed family members should receive an immediate gastric lavage and a high colonic enema to purge their system of the toxin in the bowel if they were exposed. Patients are not given food, fluids, or medications orally until their swallowing status is normal and they have an active gag reflex. Provide mouth care every 2 hours to improve comfort and to destroy oral flora. Because the patient has difficulty speaking, establish other routes for communication. Explain that the ability to speak returns as the condition resolves. During periods of impaired mobility, turn patients every 2 hours, and monitor their skin for breakdown. Egg-crate mattresses or an air bed may be useful. At a minimum of every shift, perform active and/or passive range-of-motion exercises for immobile or bedridden patients. Position unconscious patients on their sides to prevent aspiration of stomach contents; tracheal suction and chest physiotherapy may be indicated to maintain pulmonary hygiene. Offer clarification and support of the information regarding the diagnosis and prognosis to patients and families. Monitor the patient’s and family’s coping mechanisms to determine if effective coping mechanisms are in place.

Nursing care plan discharge and home health care guidelines
Teach the family that botulismis a preventable disorder. Explain that patients should discard any canned food that has a broken seal or an expired date or is swollen. Home-canned foods should be boiled, not warmed, before eating. Boiling for 20 minutes destroys botulismbacteria and spores. Instruct patients living in high altitudes to us a pressure cooker to boil foods adequately. Teach patients to use new cap seals with each canning session if they can at home. Teach the family to recognize the complications of botulism. If the patient survives the poisoning, teach patients and families that residual effects might be present for a year or more. Intensive, multidisciplinary rehabilitation and follow-up may be required to restore full function.

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