Nursing Care

As mentioned in the last post, nursing care of people infected with the measles virus is centered on mitigating symptoms. The goal here is to support the patient, to put in them in the best condition to let their immune system fight the measles infection.

Basic care includes:

Nursing Care/Intervention	Rationale
Monitor temperature, blood pressure, heart rate, respiratory and oxygen saturation	Vital signs indicate what is happening in the body, in this case it reflects infection course (especially temperature)
Medication administration- Tylenol, anti-itch	Keep temperature down so it does not cause damage to brain
Thorough physical assessment	Keep track of symptoms, notice subtle changes, keep track of and control pain
Hygiene- keep skin clean and dry	Maintain skin integrity to reduce risk of secondary infection
Keep patient isolated from unvaccinated individuals	Prevent spread of infection

This summarizes basic nursing care that one would give a patient with measles. The best nursing care that could be given, however, is the MMR vaccine to prevent infection in the first place. Last plug for vaccines…

 Gesagt, K. (2015). Measles Explained-Vaccinate or Not? Youtube. Retrieved from

https://www.youtube.com/watch?v=y0opgc1WoS4

Nursing Care Plans (2014). Measles Nursing Diagnosis and Interventions. Retrieved from http://nanda-nursing-care-plan.blogspot.com/2014/01/measles-nursing-diagnosis-and.html

Nursing Diagnoses

Because there is no "cure" for measles, nursing care is centered around addressing the symptoms of the virus. The goal is to reduce the discomfort and harm done by the disease process. It is supportive. 

Here is a summary of what some of the nursing diagnoses for someone would be. In this case, assume the patient is a child, as most of those afflicted with the measles virus are. 

NURSING DIAGNOSIS	INTERVENTION	EXPECTED OUTCOME
Fever related to viral infection	Give acetaminophen Monitor temperature and other vital signs	Fever will decrease to be in normal range within 4 hours
Risk for Impaired skin Integrity related to rash	Cold bath, good hygiene, anti-itch cream	Skin will stay clean, dry and intact
Acute pain related to rash, irritated mucous membranes	Anti-itch cream, cool mist vaporizer	Mucous membranes will stay moist, discomfort will stay within defined tolerable range by patient
Risk for imbalanced nutrition	Ensure proper hydration and prepare easy to digest, appealing foods specific to patient. Encourage small meals, frequently	Pt will stay hydrated and properly nourished will well balanced meals. No signs or symptoms of hypoglycemia
Risk for impaired social interaction related to isolation secondary to infection	Facilitate interaction without physical touch (internet), distraction techniques, play for kids, provide rationale for isolation	Pt will understand purpose of isolation, cooperate and be free of distress

References:

Nursing Care Plans (2014). Measles Nursing Diagnosis and Interventions. Retrieved from

http://nanda-nursing-care-plan.blogspot.com/2014/01/measles-nursing-diagnosis-and.html

Treatment of Measles

There is no treatment for measles, no wonder drug. There is only supportive therapy and PREVENTION. Measles is a preventable disease. So let’s first investigate the treatment options if you have already contracted the virus and then look into prevention.

Supportive treatment and possible side effects

Treatment	Purpose	Side Effects
Tylenol/Acetaminophen	Reduce fevers	Liver damage if taken in excess of 4g/day
Post-Exposure Vaccine	Within 72 hrs of exposure, reduce risk of developing measles/mitigate course of virus	May not be effective/hard to pinpoint exposure because takes a while for symptoms to appear
Post-Exposure Immunoglobulin	Within 6 days of exposure (and after 72 when vaccine is possible), reduce risk of developing measles/mitigate course of virus	May not be effective/hard to pinpoint exposure because takes a while for symptoms to appear
Antibiotics	Prevent superinfection from bacteria while immune system is compromised	GI side effects, allergic reaction, etc (depends on specific antibiotic)

Other supportive treatment includes bed rest, fluids, etc. In developing countries, Vitamin A supplementation is recommended but the science behind why is unclear.

Prevention- MMR VACCINE

The MMR vaccine (measles, mumps and rubella) is a series of two injections. It is recommended that one dose is given at 12 to 15 months and the second dose be given any time after the initial injection plus 28 days (recommended to have second injection by school age). There is NO EVIDENCE behind the claim that the MMR vaccine is linked to autism.

You do not have to be a young child to get the vaccine, anyone can get it! There are some people who should not because it is a live vaccine. People who should not get the vaccine:

1.     Pregnant Women- no vaccine during pregnancy but recommended to get it after delivery. If vaccinated, advised not to get pregnant within 30 days of vaccine.

2.     Immunosuppressed- people with illnesses or treatment (ex: Chemotherapy or Prednisone- a steroid) that suppress immune system should got get the live vaccine.

It is important for those of us who can get the vaccine to do so because of the phenomenon called herd immunity. If there are individuals in the community who are not vaccinated (pregnant women and immunosuppressed), they are susceptible to infection. HOWEVER, if the majority of the population is immune, the disease will not spread.

Check out this video for more information:

References:

Barinaga, J.L., Skolnik, P.R. (2015). Prevention and treatment of Measles. UptoDate. Retrieved from http://www.uptodate.com/contents/prevention-and-treatment-of-measles?source=machineLearning&search=measles+treatmnet&selectedTitle=3~150&sectionRank=2&anchor=H44#H930379

Measles – Treatments and drugs (2015). Mayo Clinic. Retrieved from http://www.mayoclinic.org/diseases-conditions/measles/basics/treatment/con-20019675

Signs and Symptoms

As I discussed in the last post, the measles virus follows a fairly specific trajectory of symptom presentation. For a refresher, here is a summary of the three phases:

1. Incubation Period (6-19 days): the infected individual is likely asymptomatic (no symptoms) during this time period. Some people may experience very temporary respiratory symptoms or fever. A person is usually the most contagious five days before the appearance of rash (prodrome period) to four days afterward.

2.  Prodrome Period (2-8 days): infected individuals will have a fever (up to 40 degrees Celsius), just feel icky (technical term “malaise”), have a loss of appetite, red eyes and a cough. Koplik’s spots may appear on mucosa (mainly in the mouth) and they looks like tiny grains of salt.

à You can imagine that these symptoms are incredibly uncomfortable and would cause someone to seek care, especially the high fever.

3. Exanthem Period (6-7 days): the characteristic rash appears in this phase. It typically starts on the face and spreads from the core of the body outwards and from the head downwards.

The standard set of symptoms is common when an individual contracts the measles virus. However, there can be very serious complications worth noting. These are most common in children under 5 years of age, immunocompromised patient, pregnant women, individuals with vitamin A deficiency or inadequate nutrition. 

The most severe complication is Encephalitis (brain swelling due to infection). It occurs in 1 out of 1000 cases, of those cases 25% will develop lasting neurodevelopmental deficits such as blindness and 15% will die.

Other complications include blindness, pneumonia, severe diarrhea and dehydration and ear infections. Another complication that is very rare is called Subacute sclerosing panencephalitis (SSPE). This is a progressive, neurodegenerative disease caused by the measles virus 7-10 years after initially diagnosed with the initial infection.

References:

Barinaga, J., Skolnik, P. (2015). Clinical manifestations and diagnosis of measles. Retrieved from http://www-uptodate-com.offcampus.lib.washington.edu/contents/clinical-manifestations-and-diagnosis-of-measles?source=search_result&search=measles&selectedTitle=1~150#H21

Complications of Measles (2015). CDC. http://www.cdc.gov/measles/about/complications.html

Diagnosis of the Measles Virus

Measles is diagnosed by the presence of certain characteristic symptoms and confirmed by specific lab tests. A blood sample is tested for the presence of special measles-specific antibodies (IgM) and RNA strands exclusive to the measles virus. A throat swab and urine test can also be done to detect the presence of a measles infection. The first step in diagnosis, however, is the analysis of symptoms. Measles follows a characteristic pattern:

1. Incubation Period (6-19 days): the infected individual is likely asymptomatic (no symptoms) during this time period. Some people may experience very temporary respiratory symptoms or fever. Inside the body the virus is multiplying and moving from the respiratory tract (where it enters the body, locally) to the lymphatic system (how it spreads all over the body, systemically). Because the infected individual may have no symptoms, it can be very dangerous in terms of spreading to other people. A person is usually the most contagious five days before the appearance of rash (prodrome period) to four days afterward.

2.  Prodrome Period (2-8 days): infected individuals will have a fever (up to 40 degrees Celsius), just feel icky (technical term “malaise”), have a loss of appetite, red eyes and a cough. Koplik’s spots may appear on mucosa (mainly in the mouth) and they looks like tiny grains of salt.

3. Exanthem Period (6-7 days): the characteristic rash appears in this phase. It typically starts on the face and spreads from the core of the body outwards and from the head downwards. See pictures for what this rash looks like!

The important take away here is that measles is very contagious, especially during the incubation period when you might not even know if you have it. If there is any chance you’ve been exposed, contact your doctor/nurse to get further testing to diagnose the virus and stay away from anyone who has not been vaccinated! Also, to prevent all this trouble in the first place, GET VACCINATED!!!! Just a subtle plug for immunizations…

 Reference/More resources: 

Barinaga, J.L., Skolnik, P. (2015). Clinical Manifestations and Diagnosis of Measles. Retrieved from http://www-uptodate-com.offcampus.lib.washington.edu/contents/clinical-manifestations-and-diagnosis-of-measles?source=machineLearning&search=measles+diagnosis&selectedTitle=1~150&sectionRank=1&anchor=H25#H25

Measles (Rubeola) (2015). CDC. Retrieved from http://www.cdc.gov/measles/hcp/index.html

Pathophysiology of Measles

I’ve been stressing the importance of vaccines and I will continue to do so throughout this blog. BUT just for the sake of education, let’s say someone was not vaccinated and exposed to the measles virus... what next? For this post I’ll go into some detail about the pathophysiology of measles- basically, what happens in the body after someone contracts virus.

As we already know, measles is transmitted by respiratory droplets. That is, it’s spread by contact with secretions from the respiratory system: nose, throat and mouth. This may mean airborne contact (a sneeze) or from contact with surfaces that have shared contact with these infected secretions. Airborne transmission is the most frequent mode.

After a person contracts the virus but before they show symptoms they are in the “incubation” period. A person is still infectious to other people during this time... Pretty dangerous since they might not even know they have the virus. The incubation period lasts around 1-2 weeks before symptoms appear. During this period the virus is infecting the cells of the immune system (more specifically, endothelial, epithelial, monocyte and macrophage cells). It first attacks cells of the respiratory tract and then moves on to the lymph nodes. It destroys lymph tissue and enters the bloodstream (called viremia). One in the bloodstream the virus can spread all over the body including the skin and organs such as the kidney, bladder and even the central nervous system (CNS). Once it enters the CNS it can cause swelling and brain damage because of the inflammatory reaction it causes in the brain. It is this condition (encephalitis) that causes most of the devastating and fatal complications of the measles virus. 

1 in 1000 measles cases will experience encephalitis and of those individuals, 25% will have neurodevelopmental problems for the rest of their life and 15% will die from the disease.

Because of the way the virus attacks immune cells in the body, there is a specific course of symptoms that occur. Think: red rash, blotchy spots, runny nose, etc. More on the symptoms next week.

References:

Barinaga, J., Skolnik, P. (2015). Clinical manifestations and diagnosis of measles. Retrieved from http://www-uptodate-com.offcampus.lib.washington.edu/contents/clinical-manifestations-and-diagnosis-of-measles?source=search_result&search=measles&selectedTitle=1~150#H21

Caserta, M. T. (2014). Measles. The Merck Manual. Retrieved from http://www.merckmanuals.com/professional/pediatrics/miscellaneous_viral_infections_in_infants_and_children/measles.html

Epidemiology of Measles

Measles was first described by a Persian doctor in the 9^th century, but cases of the disease were not reported nationally until 1912. Thousands and thousands of people died from measles or suffered lifelong effects of the disease until in 1963 when a vaccine was made available to the public. Before the vaccine was created, 90% of children became infected by the disease before the age of 15. It was considered the 5^th most common cause of death for children under 5. The vaccine was so successful that the US decided to attempt elimination of the disease completely. Elimination of the disease essentially means that for at least one year there was absolutely no continuous transmission of the disease. In 2000 that goal was officially realized in the US.

Sadly, measles elimination has not kept us immune from the disease. As I mentioned in my last post, recently there have been a series of outbreaks. The US is currently experiencing what is called a “multi-state outbreak.” Measles is a worldwide problem. Because we now have the ability to travel all over the world, the disease can easily be transmitted among people who are not vaccinated. If someone is not vaccinated and travels to a country where they are exposed to the disease, when they return to the US they can infect others who are not vaccinated. Because the disease is so contagious it can spread very quickly. People who are not vaccinated are very susceptible to acquiring the infection.

The most recent outbreak is linked to Disneyland. In December a group of individuals were exposed and since that exposure, 178 cases of measles in 17 states have been reported. Hence the term "multi-state" outbreak. In 2014, 644 cases in 27 states were reported, representing the largest cluster of cases since the disease was eliminated.

Check out this video on how measles make a comeback:

If you are less into videos and more into articles, here are a couple great ones to get you started:

http://www.nytimes.com/interactive/2015/02/02/us/measles-facts.html

http://www.npr.org/blogs/health/2015/03/16/393336901/vaccination-gaps-helped-fuel-disneyland-measles-spread

References:

Barinaga, J., Skolnik, P. (2015). Epidemiolofy and transmission of measles. UptoDate. Retrieved from http://www-uptodate-com.offcampus.lib.washington.edu/contents/epidemiology-and-transmission-of-measles?source=search_result&search=epidemiology+of+measles&selectedTitle=1~150

Hensley, S. (2015). Vaccination gaps helped fuel disneyland measles spread. NPR. Retrieved from http://www.npr.org/blogs/health/2015/03/16/393336901/vaccination-gaps-helped-fuel-disneyland-measles-spread

Measles cases and outbreaks. (2015). CDC. Retrieved from  

http://www.cdc.gov/measles/cases-outbreaks.html

Measles history (2015). CDC. Retrieved from http://www.cdc.gov/measles/about/history.html