Varicella, commonly known as chickenpox, is a highly contagious viral infection caused by the varicella-zoster virus (VZV). It primarily affects children but can also occur in adults.
As a nurse, understanding the nursing diagnosis, care plans, and interventions for varicella is crucial for providing effective patient care and preventing complications.
Causes (Related to)
The varicella-zoster virus causes varicella and can result from:
- Direct contact with an infected person’s rash or respiratory secretions
- Airborne transmission of respiratory droplets containing the virus
- Contact with contaminated objects or surfaces
- Exposure to an individual with shingles (herpes zoster)
- Weakened immune system
- Lack of vaccination against varicella
Signs and Symptoms (As evidenced by)
Patients with varicella may present with the following signs and symptoms:
Subjective: (Patient reports)
- Fever
- Fatigue
- Loss of appetite
- Headache
- General malaise
Objective: (Nurse assesses)
- Characteristic rash progressing from red bumps to fluid-filled blisters
- Itching
- Scabs forming as blisters heal
- Possible secondary bacterial skin infections
- Elevated body temperature
- Swollen lymph nodes
- Possible respiratory symptoms (cough, runny nose)
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for varicella:
- The patient will maintain intact skin without signs of infection
- The patient will experience relief from itching and discomfort
- The patient will maintain adequate hydration and nutrition
- The patient will demonstrate an understanding of infection control measures
- The patient’s fever will resolve within the normal range
- The patient will show no signs of complications (e.g., pneumonia, encephalitis)
- The patient will verbalize understanding of the disease process and home care instructions
Nursing Assessment
- Perform a thorough skin assessment
Examine the patient’s skin for the characteristic rash, noting its stage of progression and distribution. This helps confirm the diagnosis and monitor the disease’s progression. - Monitor vital signs
Monitoring temperature, heart rate, and respiratory rate helps detect fever and potential complications. - Assess for signs of dehydration.
Check for dry mucous membranes, decreased urine output, and skin turgor. Varicella can lead to decreased fluid intake and increased fluid loss through fever. - Evaluate respiratory status
Listen for abnormal breath sounds and monitor respiratory rate and effort. Varicella can rarely lead to pneumonia, especially in adults. - Assess nutritional status
Monitor food and fluid intake and the presence of oral lesions that may impair eating and drinking. - Evaluate the patient’s level of discomfort
Assess the severity of itching and pain associated with the rash. - Check vaccination history
Determine if the patient has received the varicella vaccine, as this can affect the course and severity of the disease. - Assess for potential complications.
Be vigilant for signs of secondary bacterial infections, neurological symptoms, or severe systemic involvement. - Evaluate the patient’s and family’s understanding of the disease
Assess their knowledge about varicella, its transmission, and necessary precautions to prevent spread.
Nursing Interventions
- Implement isolation precautions
Place the patient in airborne and contact isolation to prevent transmission to others, especially immunocompromised individuals. - Provide symptomatic relief
Administer antipyretics and antihistamines as prescribed to manage fever and itching. Apply calamine lotion or other soothing topical treatments to the skin lesions. - Promote skin integrity
Encourage the patient to avoid scratching and keep nails short to prevent secondary infections. Assist with gentle skin cleansing and the application of prescribed treatments. - Maintain adequate hydration and nutrition.
Encourage fluid intake and offer soft, cool foods that are easy to swallow, especially if oral lesions are present. - Administer antiviral medications if prescribed.
Give antiviral drugs such as acyclovir as ordered, particularly for high-risk patients or those with severe disease. - Monitor for complications
Regularly assess for signs of secondary bacterial infections, pneumonia, or neurological involvement. - Provide education
Teach the patient and family about the disease process, home care, and measures to prevent transmission to others. - Encourage proper hand hygiene.
Emphasize the importance of frequent handwashing for the patient and caregivers to prevent the spread of infection.
Nursing Care Plans
Care Plan 1: Impaired Skin Integrity
Nursing Diagnosis Statement:
Impaired Skin Integrity related to varicella rash as evidenced by vesicular lesions on face, trunk, and extremities.
Related factors/causes:
- Viral infection causing skin eruptions
- Pruritus leading to scratching
- Compromised immune system
Nursing Interventions and Rationales:
- Assess skin lesions daily for signs of healing or complications.
Rationale: Regular assessment allows early detection of potential secondary infections or delayed healing. - Assist with gentle skin cleansing using mild soap and lukewarm water.
Rationale: Proper cleansing helps prevent secondary bacterial infections without irritating the skin further. - Apply calamine lotion or other prescribed topical treatments.
Rationale: These treatments can help soothe itching and promote the healing of lesions. - Encourage the patient to wear loose, soft clothing.
Rationale: Loose clothing minimizes friction and irritation to the affected skin. - Teach the importance of not scratching and keeping nails short.
Rationale: Scratching can lead to secondary infections and scarring.
Desired Outcomes:
- The patient will demonstrate signs of healing skin lesions within 7-10 days.
- The patient will maintain intact skin without signs of infection throughout the illness.
- The patient will verbalize understanding of measures to promote skin healing and prevent complications.
Care Plan 2: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to skin lesions and systemic viral infection as evidenced by the patient’s verbal reports of discomfort and irritability.
Related factors/causes:
- Inflammatory response to viral infection
- Presence of skin lesions
- Headache and general malaise associated with varicella
Nursing Interventions and Rationales:
- Assess pain level using an age-appropriate pain scale regularly.
Rationale: Consistent pain assessment guides appropriate pain management interventions. - Administer prescribed analgesics and antipyretics as ordered.
Rationale: Medication can help alleviate pain and reduce fever, improving patient comfort. - Provide non-pharmacological pain relief measures such as distraction or guided imagery.
Rationale: These techniques can complement medication in managing pain and discomfort. - Apply cool compresses to affected areas if tolerated.
Rationale: Cool compresses can provide localized relief from itching and pain. - Position the patient comfortably, avoiding pressure on affected skin areas.
Rationale: Proper positioning can minimize discomfort and prevent irritation of lesions.
Desired Outcomes:
- The patient will report decreased pain levels within 2 hours of interventions.
- The patient will demonstrate improved comfort and ability to rest or engage in activities.
- The patient will verbalize the effective use of pain management strategies.
Care Plan #3: Risk for Infection
Nursing Diagnosis Statement:
Risk for Infection related to compromised skin integrity and potential exposure to secondary pathogens.
Related factors/causes:
- Open skin lesions provide potential entry points for bacteria
- Scratching of lesions
- Weakened immune system due to viral infection
Nursing Interventions and Rationales:
- Implement proper hand hygiene and teach its importance to patients and families.
Rationale: Hand hygiene is crucial in preventing the spread of infection and the introduction of secondary pathogens. - Monitor temperature and other vital signs regularly.
Rationale: Elevated temperature or changes in vital signs may indicate the development of a secondary infection. - Assess skin lesions for signs of infection (increased redness, swelling, purulent discharge).
Rationale: Early detection of infection allows for prompt treatment. - Maintain a clean environment and change bed linens regularly.
Rationale: A clean environment reduces the risk of introducing pathogens to open lesions. - Administer antibiotics if prescribed for secondary bacterial infections.
Rationale: Prompt treatment of secondary infections prevents further complications.
Desired Outcomes:
- The patient will remain free from signs and symptoms of secondary infection throughout the course of the illness.
- The patient and family will demonstrate proper hand hygiene and infection control measures.
- The patient’s skin lesions will heal without complications.
Care Plan 4: Deficient Knowledge
Nursing Diagnosis Statement:
Deficient Knowledge related to varicella disease process, transmission, and home care management as evidenced by patient and family’s questions and misconceptions.
Related factors/causes:
- Lack of previous experience with varicella
- Misunderstandings about the viral nature of the disease
- Unfamiliarity with home care measures and infection control
Nursing Interventions and Rationales:
- Provide clear, age-appropriate information about varicella, its cause, and its typical course.
Rationale: Understanding the disease process helps alleviate anxiety and promotes cooperation with treatment. - Teach proper home care measures, including skin care and comfort measures.
Rationale: Proper home care can prevent complications and promote healing. - Explain the importance of isolation precautions and how long they should be maintained.
Rationale: Understanding transmission prevention helps protect others from infection. - Discuss potential complications and when to seek medical attention.
Rationale: Awareness of warning signs ensures prompt medical intervention if needed. - Provide written materials or reliable online resources for reference.
Rationale: Written information reinforces verbal teaching and serves as a future reference.
Desired Outcomes:
- Patient and family will verbalize understanding of varicella, its transmission, and home care measures.
- The patient and family will demonstrate proper infection control techniques.
- The patient and family will identify signs and symptoms that require medical attention.
Care Plan 5: Imbalanced Nutrition: Less than Body Requirements
Nursing Diagnosis Statement:
Imbalanced Nutrition: Less than Body Requirements related to decreased oral intake secondary to fever, malaise, and oral lesions as evidenced by poor appetite and weight loss.
Related factors/causes:
- Presence of oral lesions causing discomfort while eating
- Fever and general malaise reduce appetite
- Altered taste sensation due to illness
Nursing Interventions and Rationales:
- Assess nutritional status, including weight, intake, and output.
Rationale: Regular assessment helps identify nutritional deficits and guide interventions. - Offer small, frequent meals of soft, cool foods.
Rationale: Smaller portions may be more appealing, and soft foods are easier to eat with oral lesions. - Encourage adequate fluid intake, offering a variety of beverages.
Rationale: Maintaining hydration is crucial, especially with fever present. - Apply oral analgesic solutions before meals if oral lesions are present.
Rationale: Reducing oral pain can make eating more comfortable. - Consider nutritional supplements as prescribed by the healthcare provider.
Rationale: Supplements can help meet nutritional needs when oral intake is insufficient.
Desired Outcomes:
- The patient will demonstrate improved oral intake within 3 days.
- The patient will maintain a stable weight throughout the course of the illness.
- The patient will verbalize satisfaction with comfort measures for eating and drinking.
References
- American Academy of Pediatrics. (2021). Red Book: 2021-2024 Report of the Committee on Infectious Diseases (32nd ed.). Itasca, IL: American Academy of Pediatrics.
- Centers for Disease Control and Prevention. (2021). Chickenpox (Varicella). Retrieved from https://www.cdc.gov/chickenpox/index.html
- Gershon, A. A., Breuer, J., Cohen, J. I., Cohrs, R. J., Gershon, M. D., Gilden, D., … & Yamanishi, K. (2015). Varicella zoster virus infection. Nature Reviews Disease Primers, 1(1), 1-20.
- Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). NANDA International Nursing Diagnoses: Definitions & Classification 2018-2020. Thieme.
- Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing (8th ed.). Elsevier.
- Lissauer, T., & Carroll, W. (2017). Illustrated Textbook of Paediatrics (5th ed.). Elsevier.
- World Health Organization. (2014). Varicella and herpes zoster vaccines: WHO position paper, June 2014. Weekly Epidemiological Record, 89(25), 265-287.
