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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.
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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
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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.
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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%.
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BIBLIOGRAPHY

Health Assessment in Nursing 4rth Edition.; Lippincot, William and Wilkins

Comprehensive Handbook of Laboratory Diagnostic Tests with Nursing Implication 5th Edition.
Anne M. Van Leeuwen; Debra J. Poelhuis-Leth; Mickey Lynn Bladh

Nursing 2013 Drug Handbook. Lippincott, Williams and Wilkins

Nursing Care Plan 9th Edition. Marilyn E. Doenges, Alice C. Murr, Mary Frances Moorhouse