Measles is a highly contagious viral infection that primarily affects the respiratory system and can cause severe complications. The Measles nursing diagnosis focuses on identifying and treating measles symptoms, preventing complications, and preventing transmission to others.
Causes (Related to)
Measles can affect patients in various ways, with several factors contributing to its severity and progression:
- Viral infection caused by the measles virus (paramyxovirus)
- Unvaccinated or incomplete vaccination status
- Compromised immune system
- Age-related vulnerability (especially young children)
- Chronic health conditions such as:
- Malnutrition
- Vitamin A deficiency
- HIV/AIDS
- Cancer
- Immunosuppressive therapy
- Environmental factors including:
- Exposure to infected individuals
- Travel to endemic areas
- Poor living conditions
- Inadequate healthcare access
Signs and Symptoms (As evidenced by)
Measles presents with distinctive signs and symptoms that nurses must recognize for proper diagnosis and treatment.
Subjective: (Patient reports)
- High fever
- Severe cough
- Runny nose
- Red, watery eyes
- Body aches
- Fatigue
- Loss of appetite
- Koplik’s spots (before the rash appears)
Objective: (Nurse assesses)
- Elevated temperature (typically >101°F/38.3°C)
- Characteristic maculopapular rash
- Conjunctivitis
- Coryza
- Lymphadenopathy
- Photophobia
- Respiratory distress signs
- Dehydration signs
Expected Outcomes
The following outcomes indicate the successful management of measles:
- The patient will maintain a normal temperature within 7-10 days
- The patient will demonstrate adequate hydration status
- The patient will maintain a clear airway and a regular breathing pattern
- The patient will show improvement in rash symptoms
- The patient will avoid complications
- The patient will prevent transmission to others
- The patient will return to normal activities within 2-3 weeks
Nursing Assessment
Monitor Vital Signs
- Check temperature, pulse, respiratory rate, and blood pressure every 4 hours
- Document fever pattern and response to antipyretics
- Monitor for signs of complications
Assess Respiratory Status
- Monitor breathing patterns
- Assess for respiratory distress
- Auscultate lung sounds
- Document cough characteristics
- Monitor oxygen saturation
Evaluate Skin Condition
- Assess rash progression
- Document characteristics and distribution
- Monitor for secondary infections
- Check mucous membranes
- Document Koplik’s spots if present
Check for Complications
- Monitor for signs of pneumonia
- Assess for encephalitis symptoms
- Watch for ear infections
- Check for dehydration
- Monitor nutritional status
Review Risk Factors
- Verify vaccination status
- Document exposure history
- Assess immune status
- Review travel history
- Check vitamin A levels
Nursing Care Plans
Nursing Care Plan 1: Hyperthermia
Nursing Diagnosis Statement:
Hyperthermia related to inflammatory response to measles virus infection as evidenced by temperature 103°F, flushed skin, and increased respiratory rate.
Related Factors:
- Viral infection
- Inflammatory response
- Increased metabolic rate
- Dehydration
Nursing Interventions and Rationales:
- Monitor temperature q4h
Rationale: Tracks fever progression and response to interventions - Administer antipyretics as ordered
Rationale: Reduces fever and associated discomfort - Provide cooling measures
Rationale: Helps reduce body temperature through conduction
Desired Outcomes:
- Temperature will return to normal range within 7 days
- The patient will report improved comfort
- The patient will maintain adequate hydration
Nursing Care Plan 2: Risk for Impaired Skin Integrity
Nursing Diagnosis Statement:
Risk for Impaired Skin Integrity related to the presence of maculopapular rash and pruritus as evidenced by widespread skin eruptions.
Related Factors:
- Viral rash
- Scratching
- Inflammation
- Altered skin chemistry
Nursing Interventions and Rationales:
- Assess skin condition q8h
Rationale: Monitors rash progression and complications - Apply skin care measures
Rationale: Promotes comfort and prevents secondary infection - Maintain cool environment
Rationale: Reduces itching and discomfort
Desired Outcomes:
- The patient will demonstrate healing of the rash without complications
- The patient will maintain skin integrity
- The patient will demonstrate proper skin care techniques
Nursing Care Plan 3: Risk for Respiratory Complications
Nursing Diagnosis Statement:
Risk for Respiratory Complications related to viral infection and inflammatory response as evidenced by cough and increased respiratory secretions.
Related Factors:
- Upper respiratory tract inflammation
- Increased mucus production
- Coughing
- Immune response
Nursing Interventions and Rationales:
- Monitor respiratory status q4h
Rationale: Enables early detection of complications - Promote proper positioning
Rationale: Enhances airway clearance and breathing efficiency - Provide humidity
Rationale: Helps liquefy secretions and reduce cough
Desired Outcomes:
- The patient will maintain a clear airway
- The patient will demonstrate an effective breathing pattern
- The patient will avoid respiratory complications
Nursing Care Plan 4: Risk for Social Isolation
Nursing Diagnosis Statement:
Risk for Social Isolation related to required isolation precautions as evidenced by limited visitor contact and restricted activities.
Related Factors:
- Communicable disease status
- Required isolation
- Physical discomfort
- Activity restrictions
Nursing Interventions and Rationales:
- Explain isolation procedures
Rationale: Promotes understanding and compliance - Facilitate alternative communication methods
Rationale: Maintains social connections during isolation - Provide age-appropriate activities
Rationale: Reduces the impact of isolation
Desired Outcomes:
- The patient will maintain social connections within isolation constraints
- The patient will demonstrate positive coping mechanisms
- The patient will comply with isolation requirements
Nursing Care Plan 5: Deficient Knowledge
Nursing Diagnosis Statement:
Deficient Knowledge related to unfamiliarity with measles management and prevention as evidenced by questions about transmission and vaccination.
Related Factors:
- Lack of exposure to information
- Misinterpretation of information
- Cultural beliefs
- Language barriers
Nursing Interventions and Rationales:
- Provide disease education
Rationale: Increases understanding of condition and management - Teach prevention strategies
Rationale: Reduces risk of transmission - Discuss vaccination importance
Rationale: Promotes future prevention
Desired Outcomes:
- The patient will demonstrate an understanding of measles management
- The patient will verbalize the importance of vaccination
- The patient will implement prevention strategies
References
- Berger M, Schärer M, Kolyvanos Naumann U, Käser L, Vetter W. Masern (Rubeola) [Rubeola]. Praxis (Bern 1994). 2006 Jul 19;95(29-30):1111-9. German. https://pubmed.ncbi.nlm.nih.gov/16916173/
- Drutz J. Measles. Pediatr Rev. 2016 May;37(5):220-1. doi: 10.1542/pir.2015-0117. PMID: 27139333.
- Kiefer L. Dealing with measles. CMAJ. 2001 Oct 16;165(8):1005-6. PMID: 11699693; PMCID: PMC81531.
- Lüthy IA, Kantor IN. Sarampión [Measles]. Medicina (B Aires). 2020;80(2):162-168. Spanish. PMID: 32282323.
- Moss WJ. Measles. Lancet. 2017 Dec 2;390(10111):2490-2502. doi: 10.1016/S0140-6736(17)31463-0. Epub 2017 Jun 30. PMID: 28673424.
