Measles, also known as rubeola, is one of the most contagious infectious diseases, with at least a 90% secondary infection rate in susceptible domestic contacts. Show
What is Measles?Measles is an acute viral respiratory illness.
PathophysiologyIn temperate areas, the peak incidence of infection occurs during late winter and spring. https://www.youtube.com/watch?v=YBceTQ97FnM
Statistics and IncidencesThe practice of administering 2 doses of live-attenuated measles vaccine to children to prevent school outbreaks of measles was implemented when the vaccine was first licensed in 1963.
CausesThe cause of measles is the measles virus, a single-stranded, negative-sense enveloped RNA virus of the genus Morbillivirus within the family Paramyxoviridae.
Clinical ManifestationsThe incubation period from exposure to onset of measles symptoms ranges from 7 to 14 days (average, 10-12 days).
Assessment and Diagnostic FindingsAlthough the diagnosis of measles is usually determined from the classic clinical picture, laboratory identification and confirmation of the diagnosis are necessary for the purposes of public health and outbreak control.
Medical ManagementTreatment of measles is essentially supportive care.
Pharmacologic TherapyMedications used in the treatment or prevention of measles include vitamin A, antivirals (eg, ribavirin), measles virus vaccine, and human immunoglobulin (Ig).
Nursing ManagementThe nurse caring for the child should be aware of the proper procedure to be done and how to handle the patient. Nursing AssessmentAssessment of the patient with measles include:
Nursing DiagnosisBased on the assessment data, the major nursing diagnoses are:
Nursing Care Planning and GoalsThe major goals for a child with measles are:
Nursing InterventionsInterventions for a child with measles are:
EvaluationEvaluation of a child with measles should include:
Documentation GuidelinesDocumentation for a patient with measles include:
Practice Quiz: MeaslesHere’s a 5-item quiz about the study guide. Please visit our nursing test bank page for more NCLEX practice questions. 1. You are the charge nurse on the pediatric unit when a pediatrician calls wanting to admit a child with rubeola (measles). Which of these factors is of most concern in determining whether to admit the child to your unit? A. There are several children receiving chemotherapy on the unit. 1. Answer: D. No negative-airflow rooms are available on the unit. Clients with rubeola require implementation of airborne precautions, which include placement in a negative airflow room, this child cannot be admitted to the pediatric unit.
2. A child age 7 was unable to receive the measles, mumps, and rubella (MMR) vaccine at the recommended scheduled time. When would the nurse expect to administer MMR vaccine? A. In a month from now. 2. Answer: C. At age 10. Based on the recommendations of the American Academy of Family Physicians and the American Academy of Pediatrics, the MMR vaccine should be given at the age of 10 if the child did not receive it between the ages of 4 to 6 years as recommended. Immunization for diphtheria and tetanus is required at age 13. 3. A 6-year-old child is scheduled to have measles, mumps, and rubella (MMR) vaccine. Which of the following route will you expect the nurse to administer the vaccine? A. Intramuscularly in the vastus lateralis muscle. 3. Answer: D. Subcutaneously in the outer aspect of the upper arm. (MMR) the vaccine is administered subcutaneously in the outer aspect of the upper arm.
4. A nurse is preparing to administer a Rubella vaccine to a client prior discharge home. Which of the following is not true regarding this vaccine? A. Pain, redness, swelling, or a lump is some of the adverse reaction. 4. Answer B. Given intramuscularly in the lateral aspect of the middle third of the vastus lateralis muscle. Rubella Vaccine is administered subcutaneously prior hospital discharge to a nonimmune postpartum client.
5. A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)? A. Small blue-white spots are visible on the oral mucosa. 5. Answer: A. Small blue-white spots are visible on the oral mucosa. Koplik’s spots are small blue-white spots visible on the oral mucosa and are characteristic of measles infection.
What is the most important action the nurse can take to help further the profession of nursing?Key Message #1: Nurses should practice to the fullextent of their education and training. Patients, in all settings, deserve care that is centered on their unique needs and not what is most convenient for the health professionals involved in their care.
What is true about self care practices by the professional nurse?Self-care reduces stress, replenishes a nurse's capacity to provide compassion and empathy, and improves the quality of care. It's also recommended by the American Nurses Association in its Code of Ethics. Proper self-care practices for nurses are especially important during COVID-19.
Who defines the standards of care for the practice of nursing select all that apply?Standards of nursing practice developed by the American Nurses' Association (ANA) provide guidelines for nursing performance. They are the rules or definition of what it means to provide competent care.
What is the hallmark of nursing practice?The hallmark of professionalism is accountability, and this is necessary to consolidate the professional status of nursing.
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