Measles Nursing Care Plans Diagnosis and Interventions
Measles NCLEX Review and Nursing Care Plans
Measles, also known as Rubeola , is a viral infection that is common in children. It is a highly preventable disease due to the effectiveness of the vaccine that was developed and licensed for use in the 1960s.
Unfortunately, vaccination against measles is not as efficient in developing countries compared to Western nations. The World Health Organization (WHO) estimates that that measles kills about 100,000 people every year, which are mostly children younger than 5 years old.
Signs and Symptoms of Measles
The signs and symptoms of rubeola or measles come in stages that last a total of 2 to 3 weeks and include:
Stage 1: Incubation
The incubation period of measles is 10 to 14 days after being infected by the virus. There can be no signs and symptoms of measles at this stage.
Stage 2: Non-specific or Flu-like Signs and Symptoms
Measles can be evidenced by the following flu-like symptoms which may last for 2 to 3 days:
- Fever – can be low or mid-grade
- Rhinorrhea – runny nose
- Persistent cough
- Sore throat
- Conjunctivitis– inflamed eyes
Stage 3: Acute Illness
- Rash – small red spots that are slightly raised; the skin shows a red, splotchy appearance; usually start in the face and continue down the chest, arms, and lower extremities; rash fades from the face first and last in the lower extremities
- Koplik’s spot – small, bluish-white spot with a bright red background; usually found in the buccal mucosa (the inside lining of the cheeks)
- Fever – a rapid increase of body temperature occurs
Stage 4: Communicable Period
The infected person is contagious starting from 4 days before the rash shows up, until 4 days after the rash resolves, which is a total of about 8 days.
Causes and Risk Factors of Measles
Measles is spread through the air droplet method, which may happen when the infected person talks, sneezes, or coughs into the air which is then inhaled by others.
The droplets may also land in surface and remain contagious for a few hours, which can then infect a person who touches the surface and puts their fingers in their nose, mouth, or rubs their eyes with them.
The rubeola virus can replicate in the nose and throat of the infected person.
The risk factors for measles are as follows:
- Age – infants younger than 12 months are not eligible to receive the vaccine yet
- Unvaccinated young children and vulnerable adults
- Contact with an infected individual
- Impaired immune response to vaccination
- Household crowding or suboptimal living
- Epidemic exposure – traveling to developing countries where measles is common or vaccination is not as efficient as in developed nations
- Vitamin A deficiency
Complications of Measles
The following are the common complications of measles:
- Respiratory infections. Untreated measles may result to lower immunity against pathogens. This may result to various respiratory infections, such as laryngitis, croup, bronchitis, and pneumonia.
- Pregnancy complications. Pregnant women should avoid measles as it can contribute to problems in pregnancy, such as low birth weight of the fetus, preterm labor, or even maternal death.
- Bacterial ear infection
Diagnosis of Measles
- History taking – to check for details of exposure, medical history, and any allergy to antibiotics
- Physical examination – to assess for Koplik’s spot, rash, and other clinical manifestations
- Sputum culture – a cotton swab is inserted into the throat to obtain a sample for culture
- Urine culture – measles virus RNA can be detected in the urine
- Chest X-ray – to check for any inflammation or collapse in the lungs
Prevention of Measles
Two doses of the MMR vaccine have about 97% effectiveness in the prevention of measles according to the Center for Disease Control and Prevention (CDC).
- First dose – given at age 12 to 15 months
- Second dose – given at age 4 to 6 years
Infants under 12 months who are travelling outside the U.S. is recommended to get an early first dose at age 6 to 11 months. A second dose is given at 12 to 15 months, and a third dose is given at 4 to 6 years.
Teenagers and adults who have not received MMR vaccine are strongly recommended to get vaccinated as soon as possible, with the two doses being at least four weeks apart.
Treatment for Measles
There is no specific antiviral therapy for rubeola or measles. The treatment is mainly supportive management and prevention of complications. The condition usually improves within 7 to 10 days.
Medications. The following medications are given in patients with measles:
- Vaccination – non-immunized people may receive post-exposure vaccination within 72 hours of exposure to the virus so that the symptoms would be milder and last shorter if measles does develop.
- Antipyretics – over-the counter fever reducers may be given to manage the body temperature; aspirin should not be given to children or adolescents with measles symptoms due to the risk of Reye’s syndrome in these age groups
- Oral or intravenous fluid therapy – excessive loss of water and salt due to fever require immediate replacement through encouraging increased oral fluid intake or the administration of parenteral fluids
- Vitamin A – large doses of vitamin A at 200,000 IU are recommended for infected children age over 1 year to prevent the development of severe symptoms of measles
- Immune serum globulin – these proteins act as antibodies and can be given to vulnerable patient groups such as infants, immunocompromised people, and pregnant women who have been exposed to rubeola virus; the injection should be administered within 6 days of exposure to prevent measles or lessen the symptoms if it occurs
Isolation. A patient with measles should be isolated 4 days before the rash breaks out and 4 days after it resolves. Infected infants may be irritated with bright lights. They need to be placed in a dark and quiet room with little disturbance.
Nursing Diagnosis for Measles
Nursing Care Plan for Measles 1
Nursing Diagnosis: Ineffective Breathing Pattern related to nasal congestion secondary to rubeola as evidenced by persistent cough, shortness of breath, and SpO2 level of 89%
Desired Outcome: The patient will achieve effective breathing pattern as evidenced by normal respiratory rate, oxygen saturation within the target range, and verbalize ease of breathing.
|Measles Nursing Interventions||Rationales|
|Assess the patient’s vital signs and characteristics of respirations at least every 4 hours.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. Normal respiratory rates depend on the age of the patient: 0 to 6 months: 30 to 60 cycles per minute 6 to 12 months: 24 to 30 cpm1 to 5 years: 20 to 30 cpm6 and above: 12 to 20 cpm|
|Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is within the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within the target range.|
|Administer the prescribed medications.||To resolve hyperthermia and manage the viral infection.|
|Elevate the head of the bed. Assist the patient to assume semi-Fowler’s position. Encourage plenty of rest and adequate hydration.||Head elevation and semi-Fowler’s position help improve the expansion of the lungs, enabling the patient to breathe more effectively.|
|Check the vaccination history of the patient. If he/she has not been vaccinated with MMR vaccine, post-exposure vaccine may be given.||Non-immunized people may receive post-exposure vaccination within 72 hours of exposure to the virus so that the symptoms would be milder and last shorter if measles does develop.|
|Consider giving immune serum globulin to vulnerable patient groups such as infants, immunocompromised people, and pregnant women who have been exposed to rubeola virus.||To prevent measles or at least lessen its symptoms if it occurs.|
|Consider giving vitamin A for children over the age of 1 year.||Large doses of vitamin A at 200,000 IU are recommended for infected children age over 1 year to prevent the development of severe symptoms of measles|
Nursing Care Plan for Measles 2
Nursing Diagnosis: Hyperthermia related to infective process of rubeola as evidenced by temperature of 38.5 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse
Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.
|Measles Nursing Interventions||Rationales|
|Assess the patient’s vital signs at least every 4 hours.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antivirals and antipyretics administered.|
|Remove excessive clothing, blankets, and linens. Adjust the room temperature.||To regulate the temperature of the environment and make it more comfortable for the patient.|
|Administer the prescribed anti-pyretic medications.||Use the antipyretic medication to stimulate the hypothalamus and normalize the body temperature.|
|Provide a tepid sponge bath.||To facilitate the body in cooling down and to provide comfort.|
|Encourage the patient to increase oral fluid intake as tolerated, and/or provide intravenous fluid replacement as prescribed.||Excessive loss of water and salt due to fever require immediate replacement through encouraging increased oral fluid intake or the administration of parenteral fluids.|
|Elevate the head of the bed.||Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.|
Nursing Care Plan for Measles 3
Nursing Diagnosis: Risk for Infection (Cross-contamination)
Desired Outcome: The patient will be able to avoid the cross-contamination of the viral infection.
|Measles Nursing Interventions||Rationales|
|Assess vital signs and observe for any signs of infection as well as for any signs of respiratory distress.||To establish patient’s baseline and monitor for any changes in vital signs and flu symptoms.|
|Place the patient in isolation and provide adequate ventilation in the room.||Isolation: To reduce the risk of infecting other patients, staff, and visitors in the hospital ward or care facility. A patient with measles should be isolated 4 days before the rash breaks out and 4 days after it resolves. Infected infants may be irritated with bright lights. They need to be placed in a dark and quiet room with little disturbance. Ventilation: To allow enough oxygenation in the room.|
|Obtain a sputum sample for culture if the patient develops any phlegm.||To confirm the presence of any bacterial respiratory complication and its causative agent.|
|Teach the patient how to perform proper hand hygiene, covering the mouth when coughing, and oral care.||To maintain patient’s safety. To prevent spreading airborne pathogens and reduce the risk of cross-contamination.|
|Educate the patient and caregiver about proper skin care through washing the rash with soap and water. Advise the patient and caregiver to prevent scratching the affected areas.||It is important to maintain the cleanliness of the affected areas by washing with mild soap and water.|
More Measles Nursing Diagnosis
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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