Nursing Care Plan for Measles

Measles

Measles is a highly contagious viral disease, which affects mostly children. It is transmitted via droplets from the nose, mouth or throat of infected persons. Initial symptoms, which usually appear 8–12 days after infection, include high fever, runny nose, bloodshot eyes, and tiny white spots on the inside of the mouth. Several days later, a rash develops, starting on the face and upper neck and gradually spreading downwards.

There is no specific treatment for measles and most people recover within 2–3 weeks. However, particularly in malnourished children and people with reduced immunity, measles can cause serious complications, including blindness, encephalitis, severe diarrhoea, ear infection and pneumonia. Measles can be prevented by immunization.
Source : who.int


Nursing Care Plan for Measles

Physical Examination

Physical examination is to measure vital signs and other measurements and examination of all parts of the body using the techniques of inspection, palpation, percussion, and auscultation. (Potter, 2005: 159)

Physical Assessment of Measles :

1. Typically in 3 days with malaise and high fever.
2. Cough, runny nose, and conjunctivitis occurs in 24 hours. These symptoms gradually increased, reaching a peak with the appearance of rash on day four.
3. About two days before the rash, spots appear on the mucous membranes in the mouth. Spots increased in number at 3 days and spread to all mucous membranes. It emerged at the end of the second day after the rash.
4. Rash appears first on the hair area and then spread from head to foot about 3 days. During this phase, high fever, lymphadenopathy, and pharyngitis, occurred in a typical. Left rash began to decrease more than 5 to 6 days. Fever persists for 3 days in the time of rash that is usually because of complications.

Nursing Diagnosis for Measles and Nursing Interventions for Measles

1. High risk of infection related to the host and infectious agents.
   
   Expected results :
   • Children who are vulnerable do not have the disease.
   • Infection does not spread
   • Children do not show evidence of complications such as infection and dehydration.
   
   Nursing Intervention :
   • Identify high-risk children
     Rational: to ensure children avoid exposure
   • Make a referral to a community health nurse if necessary.
     Rational: to ensure proper procedures at home.
   • Monitor temperature
     Rational: increased body temperature is not expected to indicate an infection.
   • Maintain good body hygiene.
     Rational: to reduce the risk of secondary infection from the lesions.
   • Give a little water absorption, but often a child or a favorite drink and fine food.



2. Pain related to skin lesions, malaise
   
   Expected results :
   • The skin and mucous membranes clean and free from irritation.
   • Children show evidence of a minimum of discomfort.
   
   Nursing Intervention :
   • Use a cool mist vaporiser, mouthwash, and tablets suck.
     Rational: to keep mucous membranes moist.
   • Clean the eye with physiological saline solution
     Rational: to remove secretions or leprosy
   • Keep your child cool.
     Rational: because the air is too hot can increase itching.
   • Give a cold water bath and give a lotion such as calamine
     Rational: to reduce itching.
   • Give analgesic, antipyretic, and antipruritus according to the needs and requirements.
     Rational: to reduce pain, lower body temperature, and reduce the itching.