A CASE PRESENTATION ON MEASLES

Presented to the Faculty of the school of Nursing

Adventist Medical Center College
Brgy. San Miguel, Iligan City

In Partial Fulfillment
Of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

PADURA, CHERYL C.

MARCH 11, 2019

OBJECTIVES

On the completion of this case presentation, the listeners will be able to:

 Understand the pathophysiology and etiology of measles

 Understand the different assessment parameters involving the function of each system involved.

 Determine the contrast between the anatomical and physiological structure involved in the damage and pathophysiological
explanation of measles.

 Describe the diagnostic tests used, its results and how it is performed.

 Recognize the contributing risk factors associated in the development of the skin rashes.

 Identify the different signs and symptoms that may be manifested by the patient with measles.

 Learn the basic and appropriate nursing interventions, treatment plan.

 Learn the importance of vaccination.

INTRODUCTION

Measles is a highly contagious, serious disease caused by a virus. Before the introduction of measles
vaccine in 1963 and widespread vaccination, major epidemics occurred approximately every 2–3 years and
measles caused an estimated 2.6 million deaths each year.

Approximately 110 000 people died from measles in 2017 – mostly children under the age of 5 years, despite the
availability of a safe and effective vaccine.

Measles is caused by a virus in the paramyxovirus family and it is normally passed through direct contact and
through the air. The virus infects the respiratory tract, then spreads throughout the body. Measles is a human
disease and is not known to occur in animals.

Accelerated immunization activities have had a major impact on reducing measles deaths. During 2000– 2017,
measles vaccination prevented an estimated 21.1 million deaths. Global measles deaths have decreased by 80%
from an estimated 545 000 in 2000* to 110 000 in 2017.

In 2010, the World Health Assembly established 3 milestones towards the future eradication of measles to
be achieved by 2015:

increase routine coverage with the first dose of measles-containing vaccine (MCV1) by more than 90% nationally
and more than 80% in every district;

reduce and maintain annual measles incidence to less than 5 cases per million;

reduce estimated measles mortality by more than 95% from the 2000 estimate; and

In 2012, the Health Assembly endorsed the Global Vaccine Action Plan, with the objective of eliminating measles in
four WHO regions by 2015 and in five regions by 2020.

By 2017, the global push to improve vaccine coverage resulted in an 80% reduction in deaths. During 2000– 2017,
with support from the Measles & Rubella Initiative and Gavi, the Vaccine Alliance, measles vaccination prevented
an estimated 21.1 million deaths; most of the deaths averted were in the African region and in countries supported
by the Gavi Alliance.

But without sustained attention, hard fought gains can easily be lost. Where children are unvaccinated, outbreaks
occur. Because of low coverage nationally or in pockets, multiple regions were hit with large measles outbreaks in
2017, causing many deaths. Based on current trends of measles vaccination coverage and incidence, the WHO
Strategic Advisory Group of Experts on Immunization (SAGE) concluded that measles elimination is greatly under
threat, and the disease has resurged in a number of countries that had achieved, or were close to achieving,
elimination.

WHO continues to strengthen the global laboratory network to ensure timely diagnosis of measles and track
international spread of the measles viruses to allow more coordinated country approach in targeting vaccination
activities and reduce measles deaths from this vaccine-preventable disease.

The first sign of measles is usually a high fever, which begins about 10 to 12 days after exposure to the
virus, and lasts 4 to 7 days. A runny nose, a cough, red and watery eyes, and small white spots inside the cheeks
can develop in the initial stage. After several days, a rash erupts, usually on the face and upper neck. Over about 3
days, the rash spreads, eventually reaching the hands and feet. The rash lasts for 5 to 6 days, and then fades. On
average, the rash occurs 14 days after exposure to the virus (within a range of 7 to 18 days).

Most measles-related deaths are caused by complications associated with the disease. Serious complications are
more common in children under the age of 5, or adults over the age of 30. The most serious complications include
blindness, encephalitis (an infection that causes brain swelling), severe diarrhoea and related dehydration, ear
infections, or severe respiratory infections such as pneumonia. Severe measles is more likely among poorly
nourished young children, especially those with insufficient vitamin A, or whose immune systems have been
weakened by HIV/AIDS or other diseases.

Unvaccinated young children are at highest risk of measles and its complications, including death.
Unvaccinated pregnant women are also at risk. Any non-immune person (who has not been vaccinated or was
vaccinated but did not develop immunity) can become infected.

Measles is still common in many developing countries – particularly in parts of Africa and Asia. The overwhelming
majority (more than 95%) of measles deaths occur in countries with low per capita incomes and weak health
infrastructures.

Measles outbreaks can be particularly deadly in countries experiencing or recovering from a natural disaster or
conflict. Damage to health infrastructure and health services interrupts routine immunization, and overcrowding in
residential camps greatly increases the risk of infection.

Measles is one of the world’s most contagious diseases. It is spread by coughing and sneezing, close
personal contact or direct contact with infected nasal or throat secretions.

The virus remains active and contagious in the air or on infected surfaces for up to 2 hours. It can be transmitted by
an infected person from 4 days prior to the onset of the rash to 4 days after the rash erupts.

Measles outbreaks can result in epidemics that cause many deaths, especially among young, malnourished
children. In countries where measles has been largely eliminated, cases imported from other countries remain an
important source of infection.

No specific antiviral treatment exists for measles virus.

Severe complications from measles can be avoided through supportive care that ensures good nutrition, adequate
fluid intake and treatment of dehydration with WHO-recommended oral rehydration solution. This solution replaces
fluids and other essential elements that are lost through diarrhoea or vomiting. Antibiotics should be prescribed to
treat eye and ear infections, and pneumonia.

All children diagnosed with measles should receive two doses of vitamin A supplements, given 24 hours apart. This
treatment restores low vitamin A levels during measles that occur even in well-nourished children and can help
prevent eye damage and blindness. Vitamin A supplements have been shown to reduce the number of deaths from
measles by 50%.

Routine measles vaccination for children, combined with mass immunization campaigns in countries with
high case and death rates, are key public health strategies to reduce global measles deaths. The measles vaccine
has been in use for over 50 years. It is safe, effective and inexpensive. It costs approximately one US dollar to
immunize a child against measles.

The measles vaccine is often incorporated with rubella and/or mumps vaccines. It is equally safe and effective in
the single or combined form. Adding rubella to measles vaccine increases the cost only slightly, and allows for
shared delivery and administration costs.

In 2017, about 85% of the world's children received 1 dose of measles vaccine by their first birthday through routine
health services – up from 72% in 2000. Two doses of the vaccine are recommended to ensure immunity and
prevent outbreaks, as about 15% of vaccinated children fail to develop immunity from the first dose. In 2017, 67% of
children received the second dose of the measles vaccine.

Of the estimated 20.8 million infants not vaccinated with at least one dose of measles vaccine through routine
immunization in 2017, about 8.1 million were in 3 countries: India, Nigeria and Pakistan.
DEFINITION OF TERMS

Antibiotics – if a bacterial infection, such as pneumonia and ear infection, develops while you and your
child has measles, your doctor may prescribe an antibiotics.

Enanthem- 20% with petechial lesions on soft palate and uvula.

Exanthem- pruritic, pink to red macules and papules which begin on face and spread to neck, trunk, and
extremities over 24 hrs.

Isolation – because measles is highly contagious from about four days before to four days after the rash
breaks out, people with measles shouldn’t return to activities in which they interact with other people
during this period.

Koplik’s Spot – tiny white spots with bluish-white centers on a red background found inside the mouth
on the inner lining of the cheek.

Measles - is a childhood infection caused by a virus. It is also called rubeola.

Pneumonia - is an infection that inflames the air sacs in one or both lungs. The air sacs may fill with
fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty
breathing. A variety of organisms, including bacteria, viruses and fungi.

Prodrome- low-grade fever , headache, sore throat, conjunctivitis,rhinorrhea, cough and

lymphadenopathy. Symptoms often resolve with appearance of rash

Vaccine - a substance used to stimulate the production of antibodies and provide immunity against one
or several diseases, prepared from the causative agent of a disease, its products, or a synthetic substitute,
treated to act as an antigen without inducing the disease.

Vitamin A - is a nutrient important to vision, growth, cell division, reproduction and immunity. Vitamin
A also has antioxidant properties. Antioxidants are substances that might protect your cells against the
effects of free radicals — molecules produced when your body breaks down food or is exposed to
tobacco smoke and radiation.
PERSONAL PROFILE

Patient’s Name: Baby Nikka

Room Number: 415
Age: 10 months Old
DOB: March 04, 2018
Gender: Female
Address: P-5 Robocon, Linamon, Lanao del Norte
Religion: Roman Catholic
Usual Health Care Provider: Physician, Community Health Workere
Reason for Health Contact: Cough, Runny Nose and 5 days fever
Date of Confinement: February 18, 2019
Source of History: 90 % Mother, 10% chart
Attending Physician: Dr. Riza Canoy
Admitting Diagnosis: Pediatric Community Acquired Pneumonia Category C
Fever for 5 Days
Oral Thrush
Discharge Date: February 28, 2019; 6:30 PM
Final Diagnosis: PCAP C-moderate
Diaper Dermatitis
Measles, Oral Thrush

PRESENT HISTORY
Five days before admission, the patient showed symptoms of fever. The mother went to the community
health center and asked for medication for fever, she was given Paracetamol (Calpol) 1.2 ml every 6 hrs. Baby
Nikka felt relieved. As days went by, another episode of fever (38.8 C), Paracetamol was given again, and felt
relieved. On the 3rd day of on and off fever, baby Nikka showed symptoms of cough. The mother still continued to
feed and gave Paracetamol. On the 5th day the mother wonder why baby Nikka stopped eating cerelac and stopped
taking breast milk. That prompted them to seek help and took baby Nikka to the Emergency Department of
Adventist Medical Center Hospital-Iligan.
During the assessment of baby Nikka they found oral thrush at the back of her cheeks, skin rashes started
to erupt and persistent cough was noted. Blood work was done and chest x-ray was performed. They film of the
chest x-ray showed that baby nikka had Pneumonia. That prompted the admission.

PAST HISTORY

Baby nikka’s mother started her prenatal check up at 8 weeks age of gestation, it was regular at the health
center in Robocon, Linamon Lanao del Norte. She had a total of 9 check ups. No known maternal illness, no
medications taken during pregnancy.

Baby nikka was born on March 04, 2018 via natural vaginal spontaneous delivery. The mother cannot recall
the exact birth weight of baby Nikka. Patient had a ggod cry, no resuscitation done, no complications after delivery.
Normal result of the newborn screening.

Baby Nikka is exclusively breastfeed until 6 months. Cerelac was introduced. Baby Nikka has a good
appetite.

Baby Nikka, received BCG vaccine during after delivery, 3 doses of Hep B, 3 doses of DPT, 3 shots of PCV
but the measles vaccine.
ANATOMY AND PHYSIOLOGY

Measles is a childhood infection caused by the highly infectious measles virus. The illness begins with
fever, runny nose, and a cough. A few days later, a characteristic rash begins to form all along the body, and the
fever may reach a high of 104° Fahrenheit. Ear infections are a common problem for measles patients, and left
untreated, can lead to hearing loss. While most cases of measles are mild, resulting in itching and discomfort, it
can cause serious problems, such as pneumonia and encephalitis (swelling of the brain).
Thanks to an effective vaccine, measles is no longer as prevalent as it once was. However, due to a lack of
vaccination in the past few years, there have been some recent worldwide measles outbreaks. In 2013, nearly
150,000 children died from the easily-preventable infection. Because measles only infects humans, it is a great
candidate for elimination -- if vaccine compliance is high enough.

Measles Virus Structure

The measles virus belongs to the paramyxoviridae family. It is round, like a ball, and has an envelope on the
outside. When it leaves the host cell, the measles virus steals part of the cell's membrane to make the envelope,
which can then help hide the virus from the host's immune system. Underneath the envelope is the matrix, made
from a protein called M. The matrix acts as glue to connect the envelope to the inside of the virus.
The viral genome is covered by a nucleocapsid protein called N. Two other proteins in the virus are the large
protein called L, and the phosphoprotein called P. Both of these are involved with making new copies of the
measles virus. They help copy the genome and make new viral proteins.

Electron micrograph of measles virus.

Measles Virus Replication

Measles virus has two proteins, called H and F, sticking out from its envelope that help it enter a host cell. These
proteins help the virus attach to the outside of the cell. The virus then fuses its envelope with the host cell
membrane to get inside. To imagine this, picture two bubbles fusing together to become one larger bubble (just
remember that the virus will be much smaller than the host cell
SKIN

The skin is the largest organ of the body, with a total area of about 20 square feet. The skin protects us from
microbes and the elements, helps regulate body temperature, and permits the sensations of touch, heat, and
cold.

Skin has three layers:

 The epidermis, the outermost layer of skin, provides a waterproof barrier and creates our skin tone.
 The dermis, beneath the epidermis, contains tough connective tissue, hair follicles, and sweat glands.
 The deeper subcutaneous tissue (hypodermis) is made of fat and connective tissue.

The skin’s color is created by special cells called melanocytes, which produce the pigment melanin.
Melanocytes are located in the epidermis.

Skin Conditions

 Rash: Nearly any change in the skin’s appearance can be called a rash. Most rashes are from simple
skin irritation; others result from medical conditions.
 Dermatitis: A general term for inflammation of the skin. Atopic dermatitis (a type of eczema) is the
most common form.
 Eczema: Skin inflammation (dermatitis) causing an itchy rash. Most often, it’s due to an overactive
immune system.
 Psoriasis: An autoimmune condition that can cause a variety of skin rashes. Silver, scaly plaques on
the skin are the most common form.
 Dandruff: A scaly condition of the scalp may be caused by seborrheic dermatitis, psoriasis, or
eczema.
 Acne: The most common skin condition, acne affects over 85% of people at some time in life.
 Cellulitis: Inflammation of the dermis and subcutaneous tissues, usually due to an infection. A red,
warm, often painful skin rash generally results.
  Skin abscess (boil or furuncle): A localized skin infection creates a collection of pus under the skin.
Some abscesses must be opened and drained by a doctor in order to be cured.
 Rosacea: A chronic skin condition causing a red rash on the face. Rosacea may look like acne, and is
poorly understood.
 Warts: A virus infects the skin and causes the skin to grow excessively, creating a wart. Warts may
be treated at home with chemicals, duct tape, or freezing, or removed by a physician.
 Melanoma: The most dangerous type of skin cancer, melanoma results from sun damage and other
causes. A skin biopsy can identify melanoma.
 Basal cell carcinoma: The most common type of skin cancer. Basal cell carcinoma is less dangerous
than melanoma because it grows and spreads more slowly.
 Seborrheic keratosis: A benign, often itchy growth that appears like a “stuck-on” wart. Seborrheic
keratoses may be removed by a physician, if bothersome.
 Actinic keratosis: A crusty or scaly bump that forms on sun-exposed skin. Actinic keratoses can
sometimes progress to cancer.
 Squamous cell carcinoma: A common form of skin cancer, squamous cell carcinoma may begin as
an ulcer that won’t heal, or an abnormal growth. It usually develops in sun-exposed areas.
 Herpes: The herpes viruses HSV-1 and HSV-2 can cause periodic blisters or skin irritation around
the lips or the genitals.
 Hives: Raised, red, itchy patches on the skin that arise suddenly. Hives usually result from an allergic
reaction.
 Tinea versicolor: A benign fungal skin infection creates pale areas of low pigmentation on the skin.
 Viral exantham: Many viral infections can cause a red rash affecting large areas of the skin. This is
especially common in children.
 Shingles (herpes zoster): Caused by the chickenpox virus, shingles is a painful rash on one side of the
body. A new adult vaccine can prevent shingles in most people.
 Scabies: Tiny mites that burrow into the skin cause scabies. An intensely itchy rash in the webs of
fingers, wrists, elbows, and buttocks is typical of scabies.
 Ringworm: A fungal skin infection (also called tinea). The characteristic rings it creates are not due
to worms.

NOSE

The nose is the body's primary organ of smell and also functions as part of the body's respiratory system.
Air comes into the body through the nose. As it passes over the specialized cells of the olfactory system,
the brain recognizes and identifies smells. Hairs in the nose clean the air of foreign particles. As air
moves through the nasal passages, it is warmed and humidified before it goes into the lungs.

The most common medical condition related to the nose is nasal congestion. This can be caused by
colds or flu, allergies, or environmental factors, resulting in inflammation of the nasal passages. The
body's response to congestion is to convulsively expel air through the nose by a sneeze.

Nosebleeds, known medically as epistaxis, are a second common medical issue of the nose. As many as
60 percent of people report nosebleed experiences, with the highest rates found in children under 10 and
adults over 50.
LUNGS

The lungs are a pair of spongy, air-filled organs located on either side of the chest (thorax).
The trachea (windpipe) conducts inhaled air into the lungs through its tubular branches, called bronchi.
The bronchi then divide into smaller and smaller branches (bronchioles), finally becoming microscopic.
The bronchioles eventually end in clusters of microscopic air sacs called alveoli. In the alveoli, oxygen
from the air is absorbed into the blood. Carbon dioxide, a waste product of metabolism, travels from the
blood to the alveoli, where it can be exhaled. Between the alveoli is a thin layer of cells called the
interstitium, which contains blood vessels and cells that help support the alveoli.
The lungs are covered by a thin tissue layer called the pleura. The same kind of thin tissue lines the
inside of the chest cavity -- also called pleura. A thin layer of fluid acts as a lubricant allowing the lungs
to slip smoothly as they expand and contract with each breath.

Lung Conditions

 Pneumonia: Infection in one or both lungs. Bacteria, especially Streptococcus pneumoniae, are
the most common cause.
 Acute bronchitis: An infection of the lungs' large airways (bronchi), usually caused by a virus.
Cough is the main symptom of acute bronchitis.
 Bronchiectasis: The airways (bronchi) become inflamed and expand abnormally, usually after
repeated infections. Coughing, with large amounts of mucus, is the main symptom of
bronchiectasis.
 Lymphangioleiomyomatosis (LAM): A rare condition in which cysts form throughout the lungs,
causing breathing problems similar to emphysema. LAM occurs almost exclusively in women of
childbearing age.
 Cystic fibrosis: A genetic condition in which mucus does not clear easily from the airways. The
excess mucus causes repeated episodes of bronchitis and pneumonia throughout life.
  Interstitial lung disease: A collection of conditions in which the interstitium (lining between the
air sacs) becomes diseased. Fibrosis (scarring) of the interstitium eventually results, if the
process can't be stopped.
 Lung cancer: Cancer may affect almost any part of the lung. Most lung cancer is caused by
smoking.
 Tuberculosis: A slowly progressive pneumonia caused by the bacteria Mycobacterium
tuberculosis. Chronic cough, fever, weight loss, and night sweats are common symptoms of
tuberculosis.
 Acute respiratory distress syndrome (ARDS): Severe, sudden injury to the lungs caused by a
serious illness. Life support with mechanical ventilation is usually needed to survive until the
lungs recover.
 Coccidioidomycosis: A pneumonia caused by Coccidioides, a fungus found in the soil in the
southwestern U.S. Most people experience no symptoms, or a flu-like illness with complete
recovery.
 Histoplasmosis: An infection caused by inhaling Histoplasma capsulatum, a fungus found in the
soil in the eastern and central U.S. Most Histoplasma pneumonias are mild, causing only a short-
lived cough and flu-like symptoms.
 Hypersensitivity pneumonitis (allergic alveolitis): Inhaled dust causes an allergic reaction in the
lungs. Usually this occurs in farmers or others who work with dried, dusty plant material.
 Influenza (flu): An infection by one or more flu viruses causes fever, body aches, and coughing
lasting a week or more. Influenza can progress to life-threatening pneumonia, especially in older
people with medical problems.
 Mesothelioma: A rare form of cancer that forms from the cells lining various organs of the body
with the lungs being the most common. Mesothelioma tends to emerge several decades
after asbestos exposure.
 Pertussis (whooping cough): A highly contagious infection of the airways (bronchi) by
Bordetella pertussis, causing persistent cough. A booster vaccine (Tdap) is recommended for
adolescents and adults to prevent pertussis.
 Pulmonary hypertension: Many conditions can lead to high blood pressurein the arteries leading
from the heart to the lungs. If no cause can be identified, the condition is called
idiopathic pulmonary arterial hypertension.
 Pulmonary embolism: A blood clot (usually from a vein in the leg) may break off and travel to
the heart, which pumps the clot (embolus) into the lungs. Sudden shortness of breath is the most
common symptom of a pulmonary embolism.
 Severe acute respiratory syndrome (SARS): A severe pneumonia caused by a specific virus first
discovered in Asia in 2002. Worldwide prevention measures seem to have controlled SARS,
which has caused no deaths in the U.S.
 Pneumothorax: Air in the chest; it occurs when air enters the area around the lung (the pleural
space) abnormally. Pneumothorax can be caused by an injury or may happen spontaneously.

EYE

Our eyes might be small, but they provide us with what many people consider to be the most important
of our senses – vision.

How vision works

Vision occurs when light enters the eye through the pupil. With help from other important structures in
the eye, like the iris and cornea, the appropriate amount of light is directed towards the lens.

Just like a lens in a camera sends a message to produce a film, the lens in the eye 'refracts' (bends)
incoming light onto the retina. The retina is made up by millions of specialised cells known as rods and
cones, which work together to transform the image into electrical energy, which is sent to the optic disk
on the retina and transferred via electrical impulses along the optic nerve to be processed by the brain.
 Anatomy of the eye
What makes up an eye
 Iris: regulates the amount of light that enters your eye. It forms the coloured, visible part of your eye in front of the lens. Light
enters through a central opening called the pupil.
 Pupil: the circular opening in the centre of the iris through which light passes into the lens of the eye. The iris controls
widening and narrowing (dilation and constriction) of the pupil.
 Cornea: the transparent circular part of the front of the eyeball. It refracts the light entering the eye onto the lens, which then
focuses it onto the retina. The cornea contains no blood vessels and is extremely sensitive to pain.
 Lens: a transparent structure situated behind your pupil. It is enclosed in a thin transparent capsule and helps to refract
incoming light and focus it onto the retina. A cataract is when the lens becomes cloudy, and a cataract operation involves the
replacement of the cloudy lens with an artificial plastic lens.
 Choroid: the middle layer of the eye between the retina and the sclera. It also contains a pigment that absorbs excess light so
preventing blurring of vision.
 Ciliary body: the part of the eye that connects the choroid to the iris.
 Retina: a light sensitive layer that lines the interior of the eye. It is composed of light sensitive cells known as rods and cones.
The human eye contains about 125 million rods, which are necessary for seeing in dim light. Cones, on the other hand,
function best in bright light. There are between 6 and 7 million cones in the eye and they are essential for receiving a sharp
accurate image and for distinguishing colours. The retina works much in the same way as film in a camera.
 Macula: a yellow spot on the retina at the back of the eye which surrounds the fovea.
 Fovea: forms a small indentation at the centre of the macula and is the area with the greatest concentration of cone cells.
When the eye is directed at an object, the part of the image that is focused on the fovea is the image most accurately
registered by the brain.
 Optic disc: the visible (when the eye is examined) portion of the optic nerve, also found on the retina. The optic disc identifies
the start of the optic nerve where messages from cone and rod cells leave the eye via nerve fibres to the optic centre of the
brain. This area is also known as the 'blind spot’.
 Optic nerve: leaves the eye at the optic disc and transfers all the visual information to the brain.
 Sclera: the white part of the eye, a tough covering with which the cornea forms the external protective coat of the eye.
 Rod cells are one of the two types of light-sensitive cells in the retina of the eye. There are about 125 million rods, which are
necessary for seeing in dim light.
 Cone cells are the second type of light sensitive cells in the retina of the eye. The human retina contains between six and
seven million cones; they function best in bright light and are essential for acute vision (receiving a sharp accurate image). It is
thought that there are three types of cones, each sensitive to the wavelength of a different primary colour – red, green or blue.
Other colours are seen as combinations of these primary colours.
HEALTH EDUCATION PLAN

Measles is a disease associated with varied local customs and beliefs, which have a major influence on
the management. Management of the CUSTOMS AND BELIEFS is at times more important than the
drugs in measles. Harmless practices like a black thread around neck or a visit to temple can be allowed.
We should discourage harmful practices like “fomenting with hot bricks, instilling cow’s milk drops in
nostrils and eyes, giving him a purge; all in an attempt to bring out the rash completely.” Few customs
could be encouraged for the benefit of the child e.g. applying oil all over the body or feeding rose jam,
groundnuts, curds, black dried grapes. Every mother and grand mother will have different sets of beliefs.
A doctor must know local customs and beliefs in that area for successful management of a child with
measles.

We will discuss the management under 4 headings

A. Management in OPD
B. Indications for hospitalization
C. Management in hospital
D. Follow up examination after measles

A. Management in OPD:

There is no drug available that can act on the measles viruses. Outcome of the disease depends largely
on adequate nutrition, fluid intake, symptomatic therapy, early diagnosis and treatment of complications.
1. Fluid Intake: In a sick child fluid intake may be low. There is more evaporative loss due to
fever and rapid respiratory rate. Fluid may be lost due to diarrhoea. All these factors in a child,
who has only a loti-full of water in his body, make him prone for dehydration. Ensuring adequate
fluid intake may be lifesaving.

2. Nutrition: Measles is severe in malnourished children. It is one of the most common infectious
diseases precipitating malnutrition. Malnutrition is an important cause of death in measles.
Nearly every child, who had measles, loses weight. Appetite is lost during any febrile illness. On
the other hand more calories are needed. There is a tendency amongst families to restrict diet
during measles. Breast milk is incorrectly stopped during diarrhoea after measles. Unless there is
profuse diarrhoea; milk and routine diet is advocated. Adequate nutrition ensures smooth sailing.

3. Diarrhoea: As diarrhoea in measles is directly due to viral infection of the G.I. tract, antibiotics
are not going to be useful. Oral rehydration is the mainstay of treatment. Diarrhoea for more than
15 days may be due to lactose intolerance, where withdrawl of milk is necessary or due to
secondary bacterial infection, when antibiotics will be curative. Continuing rice-dal-vegetable
kanji and breast milk in any diarrhoea is an essential part of treatment.

4. Antibiotics: In disease as severe as measles, it is difficult not to give antibiotics for a sick
looking child. It is proved beyond doubts that antibiotics do not prevent bacterial infection. Still
everybody of us is always tempted to give an antibiotic.

5. Symptomatic Therapy: Paracetamol for fever, chloral hydrate for sedation, cough suppressive,
skin lotion like caladryl to reduce itching, steam inhalation to soothen respiratory mucosa and
prevention of exposure to bright light if child has photophobia are the symptomatic measures to
be taken routinely. Some children develop constipation which may need a soap stick or liquid
paraffin. Vitamin C may be given as it is supposed to prevent corneal complications. All children
with measles have low vitamin A levels and one oral vitamin A dose ( Govt / inj aquasol given
oraly) should be given.

B. Indications for hospitalization:

The most difficult and vital decision in management of measles is “which child needs hospitalization.”
The guideline given is useful to select “ at risk children.” Optimum care is needed to save these lives.
1. Rash : if there is darkening, desquammation in large plaques or haemorrhages in the rash.
 2. Hoarseness of voice particularly if laryngeal obstruction is suspected.
3. Dehydration grade II or more
4. Blood and mucus in stools.
5. More than 10 stools in a day.
6. Convulsion or altered consciousness.
7. Respiratory distress with flaring of alae nasi.
8. Malnourished, underweight children.
9. Infant unable to suck due to soreness of mouth and tongue.
10. Severe anemia.

C. Management in hospital:

Investigation:
Laboratory and radiology can help the better Management. Investigations should be done for a specific
purpose. A “ routine list of investigations”.

For every child with measles is unnecessary. Following are the indications and significance of each
Diagnostic tool in management of measles.
1. Haemoglobin is done for (a) Pre-existing anemia (b) anemia during measles (bone marrow
suppression) (c) anemia after measles (iron and vitamin deficiencies.)

2. Total and differential W.B.C. counts to suspect and diagnose the cause of complications as
bacterial. Increased total count with neutrophils suggests bacterial complications.

3. ESR if done 1 month after measles can suggest the possibility of flare up of tuberculosis. A
westergren reading of more than 50mm at the end of 1st hour should alert the doctor to search for
further evidence of tuberculosis.

4. Tuberculin test is often negative during and for 6 weeks after measles. A routine T.T. is done 6
weeks after in every case of measles at some centers. We should do T.T. if child has fever for
more than 15 days duration after measles.

5. C.S.F. examination is indicated if child has altered consciousness or convulsions.

6. X-Ray chest during the attack of measles, X-Ray chest can show (a) bronchopnemonia or
pneumonia following secondary bacterial infection. (b) Bronchilolitis diagnosed by the findings
of emphysema, rhonchii and breathlessness. (c) Pre-existing tuberculosis, X-Ray chest 1 month
after measles can suggest the flare up of tuberculosis.
Treatment:
As described above SYMPTOMATIC CARE is essential. In a child with respiratory distress, OXYGEN
and suction of the oropharynx is the first step in bringing the disturbed physiology to normalcy.
GENTION VIOLET application for soreness of mouth and tongue prevents fungal overgrowth. Codein
is given to suppress the distressing hacking cough.

INTRAVENOUS FLUIDS are required for correction of dehydration and for maintenance. Electrolyte
imbalance can complicate the picture. Generally a second drip of polyelectrolyte solution like Isolyte or
DLR-P serves the purpose. Sodium bicarbonate is diluted and pushed I.V. if signs of acidosis like deep
rapid respiration are noted.

ANTIBIOTICS are given if child has bronchopneumonia, otitis media, pyoderma or diarrhoea after
subsidance of the rash. Antibiotic therapy is tailored to suit the economic status of the parents. Omnatax,
mikacin are good in hospitalised children. In poor patients “ penicillin injection or septran “ is the
cheapest and best treatment.

STEROIDS Is a double edged weapon in the management of measles. In an uncomplicated disease in

initial stages steroids are harmful while in some complications they are life saving. In active phase of
viremia steroids will suppress the immunological responses and the disease will be more severe. So
steroids are contraindicated when rash is in active phase. If a child with measles has tuberculosis
already, and is not on antitubercular drugs, steroids will surely flare up the tuberculosis.

Steroids are indicated in encephalitis and toxemia with bronchopneumonia. Dexamethasone is preferred
over other steroids. So steroids should be used more as “a life saving measure” than a routine measure in
the management of measles.

GAMMAGLOBULINS attenuate the severity of measles and are supposed to prevent complication. In
a serious child it should be given. Even though the efficacy is not proved, it surely will not harm. Dose
is 0.2 to 0.3 ml 10% gammaglobulin subcutaneous or IM injection. The maximum efficacy is observed
if given within 5 days of exposure to measles.

If the child has (1) anemia with HB less than 5 gm% (2) toxemia or septicemia (3) haemorrhagic
complications, BLOOD TRANSFUSION many be needed. The dose is 20 ml/kg/day. Many times in
seriously ill children, blood transfusion alters the picture.

In case of respiratory distress with predominant rhonchiri, BRONCHODILATORS nebuliser,

aminophylline 4 mg./kg/dose every 6-8 hourly helps in clearing the respiratory passage. LANOXIN is
indicated in C.C.F. diagnosed by anxiety, heart rate above 200/minute, liver and spleeen palpable and
mottled skin appearance.

VITAMINS AND MINERALS are given if there is pre-existing deficiency and to meet the increased
demands during illness. Vitamin C is supposed to be useful in corneal lesions. Vitamin A is given if skin
complications arise. B Vitamins are given to ensure adequate marrow function which is suppressed by
measles. Vitamins can be given in injectable form during hospital stay, or orally in the form of
multivitamin C or AD drops.

Adequate nutrition must be established. Concentrated glucose given I.V. does not supply adequate
calories. 10 ml of 50% glucose will give hardly 20 calories. We have to give calories in thousands (1200
to 1500). If required ryles tube feeding is given for first 2-3 days. A doctor should not be much worried
about child's digestive power. Cereals + pulses +fats + milk as semisolid paste (not liquid) is the most
suitable food. This type of kanji meets the social, cultural, economic, nutritional requirements.
A proper RECORD OF PROGRESS is valuable in evaluating therapy. As temperature, respiratory rate,
number of stools settle down, it surely gives an indications to a successful outcome. If weight is
recorded at admission and 15 days later, we can easily diagnose malnutrition at an earlier stage.

D. Follow up Examination at 1 month

After 1 month of illness child should be re-examined for 1) otitis media 2) chronic diarrhoea 3) weight
loss or inadequate gain 4) flare up of tuberculosis 5) neurological signs & symptoms 6) pyoderma 7)
residual respiratory complications 8) nutritional anemias.

Manage your child's symptoms:

 Give your child liquids as directed. Liquids help prevent dehydration. Ask how much liquid to
give your child each day and which liquids are best for him. Give your child water, juice, or
broth instead of sports drinks. He may need an oral rehydration solution (ORS). An ORS has the
right amounts of water, salts, and sugar your child needs to replace body fluids. Ask your child's
healthcare provider where you can get ORS.
 Help your child rest. He should rest as much as possible and get plenty of sleep.
 Use a cool mist humidifier. A humidifier helps increase air moisture in your home. This may
make it easier for your child to breathe and help decrease his cough.
 Give your child a variety of healthy foods. Healthy foods include fruits, vegetables, whole-
grain breads, low-fat dairy products, beans, lean meats, and fish. This will help your child feel
better and have more energy. If he is not hungry or gets tired easily, try feeding him smaller
amounts more often.
 Protect your child's eyes. Keep the lights dim or give your child sunglasses to wear. This will
help decrease pain caused by sensitivity to light.
Prevent measles:

 Ask your child's healthcare provider about the MMR vaccine. This vaccine helps protect
your child and others around him from measles, mumps, and rubella.
 Prevent the spread of germs. Have your child stay away from others, especially anyone who is
pregnant, or who has not had the MMR vaccine. Keep your child home from school or daycare
until his healthcare provider says he can return

DISCHARGE PLAN

Name Of Patient: Baby Nikka Age: 10 months old Gender: Female

Room No. 415 Date: February 18, 2019
Chief Complaints: 5 days of fever
Oral Thrush
Cough
Diagnosis/Impression: 5 days of fever
Oral Thrush
PCAP category C
Attending Physician: Dr. Riza Canoy

Medications Dosage/Frequency Nursing Instruction

Heraclene 1 capsule once a day for 2
months
Muconase Nasal Spray
1-2 sprays/nostril 3x a day
Immuzinc Drops
2 ml once a day for 10 days
Dakracart Cream
Apply to vulvar area

OPD Visits: Follow up check up after 1 week with Dr. Riza Canoy
Diet: Diet For Age- Breastfeeding, cerelac supplement
Push water as tolerated for hydration
Health Teachings: Good hygiene always.
 Bathe Baby Nikka everyday
 Change diaper and apply cream as frequent as possible.
 Always elevate head when feeding cerelac to prevent aspirations.

PROGNOSIS

The probable outcome is excellent in uncomplicated cases. Complications such as pneumonia and
encephalitis can be severe, however. Pneumonia accounts for 60% of deaths due to measles, because it
is more common than encephalitis. Encephalitis has a mortality of 15%.