Signs and Symptoms of Measles (Stages):

Measles, a highly contagious acute illness caused by the morbillivirus, progresses through a predictable sequence of symptoms, divided into three distinct stages: prodromal, eruptive (or exanthem), and convalescent. Clinical suspicion for measles arises particularly when patients present with the classic triad of the three “Cs”: cough, conjunctivitis (inflammation of the conjunctiva, the clear membrane covering the white part of the eye), and coryza (runny nose).

Stage 1: Prodromal Phase (3 days):

The incubation period, the time between infection and the start of symptoms, typically lasts approximately 10-14 days, during which patients usually do not show any noticeable signs or symptoms. The prodromal phase marks the abrupt onset of mild to moderate symptoms, characterized by:

• Fever

• Headache

• A general feeling of being unwell or tired (malaise)

• Loss of appetite (anorexia)

• Swollen lymph nodes in the neck

• Abdominal pain

• Diarrhea

• Vomiting

Stage 2: Eruptive Stage (Exanthem/Rash):

This stage is marked by the abrupt onset of more severe symptoms, including:

• Very high fever

• Cough

• Sensitivity to light (photophobia)

• Red, watery eyes (conjunctivitis)

• Hoarseness of the voice

• Distinctive white spots with a bluish-white center on a red background (Koplik spots) on the mucous membrane inside the mouth, typically found next to the molar teeth. These spots are diagnostic of measles and may disappear shortly before or as the rash appears.

• The body temperature often rises on the first day of this stage (reaching approximately 37.8-39.4 degrees Celsius), may slightly decrease around the third day, and then rise again on the fourth day with the appearance of the rash.

• The characteristic measles rash typically appears around the fourth day of this stage. It usually starts on the forehead, behind the ears, and on the neck, before spreading downwards over the face and then to the rest of the body. The rash is a red, slightly raised (maculo-papular) eruption, which can give the face a somewhat puffy or swollen appearance.

Stage 3: Convalescent Stage:

This stage signifies the beginning of recovery, with the gradual improvement and eventual disappearance of signs and symptoms. Key features include:

• Desquamation of the skin, meaning the rash begins to fade and the skin may peel or flake.

• A gradual decline in body temperature back to normal.

• Resolution of hoarseness.

• Weight gain as the patient’s appetite returns and their overall condition improves.

Predisposing Factors:

Several factors increase the risk of measles infection within a community:

• Unprotected communities with low immunization coverage: The most significant risk factor is a lack of vaccination against measles.

• Malnourished children: Poor nutrition weakens the immune system, making children more susceptible.

• Overcrowding and poor ventilation: Close proximity and enclosed spaces facilitate the airborne transmission of the virus.

• Children with previous severe infections: Having recovered from other severe infections, such as tuberculosis, can sometimes leave the immune system temporarily weakened.

Nursing Care/Management for a Patient within 72 Hours of Measles:

Aims of Care/Management:

1. To reduce elevated body temperature.

2. To correct dehydration caused by fever, vomiting, or diarrhea.

3. To prevent the development of further complications.

Admission:

1. Admit the child to a well-ventilated room and ideally place them in an isolation unit within the children’s ward to prevent the spread of infection.

2. Accurately record the patient’s personal details, including their full name, age, contact information for the next of kin, and their complete address on the necessary admission forms.

3. Provide reassurance and support to the mother or caregiver, explaining the child’s condition and the plan of care.

Observations:

1. Regularly monitor and record the patient’s vital signs, including their temperature, pulse rate, respiratory rate, blood pressure, and weight, in a dedicated observation chart to establish a baseline and track changes.

2. Perform a thorough head-to-toe physical assessment to identify any additional signs or symptoms, such as jaundice (yellowing of the skin or eyes), edema (swelling), signs of dehydration, cyanosis (bluish discoloration of the skin), pallor indicative of anemia, and swollen lymph nodes (lymphadenopathy). Document all findings clearly in the patient’s medical file.

3. Inform the attending doctor about the patient’s condition and be prepared to assist with any required investigations and medical treatments.

4. Implement prescribed nursing procedures based on the assessment findings, such as initiating tepid sponging to reduce a high fever.

Investigations:

1. Conduct necessary laboratory investigations as ordered by the physician to help rule out other potential diagnoses and assess the patient’s condition, such as:

   • A blood slide for malaria parasites, especially in malaria-endemic areas.

   • A full blood count (FBC) to assess overall blood cell counts and rule out other infections.

   • Urinalysis to check for any abnormalities in the urine.

   • Salivary measles-specific IgA testing, though this is less commonly performed in routine practice.

Medical Treatments:

1. It is important to note that there is no specific antiviral treatment for measles; management focuses on alleviating symptoms and preventing complications.

2. Administer the following medications as prescribed by the doctor, based on the patient’s specific symptoms:

   • Antibiotics, such as Cephalexin or Amoxyl syrup, may be prescribed to treat any underlying or secondary bacterial infections. Intravenous Ceftriaxone may be used for more severe bacterial infections.

   • Analgesics, such as Syrup Cetamol (paracetamol), to help reduce pain and fever.

   • Antihistamines, such as Calamine lotion applied topically, to help relieve itching associated with the rash.

   • Vitamin A capsules are typically given to children below 1 year of age to help prevent eye complications associated with measles.

   • Grovit drops or a multivitamin syrup may be prescribed to help improve appetite and nutritional intake.

Fluids and Diet:

1. Ensure the patient receives plenty of oral fluids to replace fluids lost due to fever, vomiting, or diarrhea.

2. Offer easily digestible foods that are rich in vitamins and proteins to support recovery.

3. Encourage the child to eat frequent small meals if their appetite is reduced.

4. If the child is unable to eat or drink adequately, a nasogastric tube may be necessary for feeding.

5. In cases of severe dehydration, intravenous fluids will be administered as prescribed.

Skin Care:

1. Encourage measures to prevent excessive scratching of the skin, such as padding the child’s fingers if necessary.

2. Apply prescribed calamine lotion to help soothe itching.

Mouth and Eye Care:

1. Emphasize the importance of maintaining good oral hygiene by providing frequent mouth care using warm saline rinses.

2. Keep the nostrils clear and ensure cleanliness around any nasogastric tube.

3. For mouth ulcers, apply gentian violet 1% as prescribed.

4. Use glycerin borax to lubricate the lips and prevent cracking.

5. Gently clean the eyes with warm saline solution, being careful to avoid rubbing them.

6. If necessary, apply prescribed TEO (Tetracycline Eye Ointment) as directed.

7. If only one eye is affected, encourage the child to lie on the affected side to help prevent the infection from spreading to the other eye.

8. Protect the eyes by minimizing exposure to direct sunlight due to photophobia.

Hygiene and Bed Rest:

1. Ensure the patient receives a daily bath and that bedding is changed frequently to maintain hygiene.

2. Take appropriate precautions when dealing with ear discharge and administer antibiotics as prescribed.

3. Disinfect used soiled linen and utensils thoroughly.

4. Dispose of used swabs, discharges, or secretions in a safe and appropriate manner.

Visitor and Ward Management:

1. Restrict the number of visitors and adhere to established visiting hours to minimize the risk of further infection.

2. Keep the volume of radios and televisions low to promote a restful environment for the patient.

3. Encourage dim lighting in the room due to the patient’s photophobia.

4. Promote adequate sleep by dimming or switching off lights and minimizing noise levels.

Observations:

1. Continue to monitor the patient’s overall condition and vital signs on a regular basis.

2. Be vigilant for any deviations from the patient’s normal condition and take appropriate action.

3. Implement measures to manage fever, such as performing tepid sponging, offering cold drinks, and applying a cold compress to the forehead if the temperature remains very high.

Bowel and Bladder Care:

1. Monitor the patient’s bowel movements and treat diarrhea or constipation as needed.

2. Observe and address any issues related to the child’s urine output.

Exercises and Health Education:

1. Encourage the patient to engage in active and passive exercises, including deep breathing exercises, as their condition allows.

2. Provide age-appropriate stimulation for the child’s mind with play objects like toys.

3. Provide education to the mother or caregiver about the mode of transmission of measles, its signs and symptoms, and preventive measures.

Complications of Measles:

Measles can lead to a range of complications, some of which can be severe and even life-threatening, particularly in young children and individuals with weakened immune systems.

Respiratory System:

• Laryngitis: Inflammation of the larynx (voice box), leading to hoarseness and difficulty breathing.

• Croup: A viral infection affecting the upper airway, characterized by a distinctive barking cough and stridor (a high-pitched whistling sound during breathing).

• Bronchitis: Inflammation of the bronchi (the main air passages of the lungs), causing coughing, wheezing, and difficulty breathing.

• Pneumonia: Infection of the lungs, which is a leading cause of death associated with measles. Pneumonia can be caused by the measles virus itself (primary viral pneumonia) or by secondary bacterial infections.

• Bronchiectasis: Long-term damage to the bronchi, causing them to widen permanently, leading to chronic coughing and mucus production.

Central Nervous System (CNS):

• Encephalitis: Inflammation of the brain, a rare but very serious complication that can cause long-term neurological damage.

• Mental Retardation: Long-term cognitive impairment, which can be a consequence of measles encephalitis.

• Epilepsy: A neurological disorder characterized by recurrent seizures, which can develop following measles infection, particularly after encephalitis.

Gastrointestinal (GIT):

• Gastroenteritis: Inflammation of the stomach and intestines, resulting in symptoms like diarrhea, vomiting, and abdominal pain.

• Hepatitis: Inflammation of the liver, which can lead to jaundice (yellowing of the skin and eyes) and liver dysfunction.

• Mesenteric Adenitis: Inflammation of the lymph nodes in the mesentery, a fold of tissue that supports the intestines, causing abdominal pain.

• Appendicitis: Inflammation of the appendix, which may require surgical removal.

• Ileocolitis: Inflammation of the ileum (the lower part of the small intestine) and the colon (the large intestine).

Ear, Nose, and Throat (ENT):

• Otitis Media: Infection of the middle ear, a common complication of measles, causing ear pain, fever, and sometimes hearing loss.

• Corneal Ulceration: The formation of ulcers on the cornea of the eye, which can potentially cause vision impairment or even blindness.

Others/Rare:

• Myocarditis: Inflammation of the heart muscle, which can affect the heart’s ability to pump blood effectively.

• Glomerulonephritis: Inflammation of the glomeruli, the filtering units of the kidneys, potentially leading to kidney failure.

• Exacerbation of Tuberculosis (TB): Measles infection can weaken the immune system, potentially reactivating a latent tuberculosis infection.

Test Questions

MCQ: Which virus causes measles?
a) Influenza virus
b) Morbillivirus
c) Respiratory syncytial virus
d) Rotavirus
Answer: b) Morbillivirus
Explanation: Measles is caused by the morbillivirus, a member of the Paramyxoviridae family.

MCQ: During which stage of measles does the characteristic red maculo-papular rash appear?
a) Incubation stage
b) Prodromal phase
c) Eruptive phase
d) Convalescent phase
Answer: c) Eruptive phase
Explanation: The characteristic red maculo-papular rash appears during the eruptive phase of measles.

MCQ: What is the primary aim of nursing care in managing measles?
a) To reduce the risk of bacterial infection
b) To relieve itching and rash discomfort
c) To prevent complications and dehydration
d) To administer specific antiviral medication
Answer: c) To prevent complications and dehydration
Explanation: The primary aim of nursing care in managing measles is to prevent complications and dehydration, as there is no specific antiviral medication for measles.

MCQ: Which symptom is part of the classic triad used for suspecting measles?
a) Fever
b) Cough
c) Diarrhea
d) Jaundice
Answer: b) Cough
Explanation: The classic triad for suspecting measles includes cough, conjunctivitis, and coryza (runny nose).

MCQ: What is the incubation period for measles?
a) 2-5 days
b) 7-10 days
c) 10-14 days
d) 21-28 days
Answer: c) 10-14 days
Explanation: The incubation period for measles typically lasts from 10 to 14 days.

MCQ: Which vitamin is administered to prevent eye complications related to measles in children below one year?
a) Vitamin B
b) Vitamin C
c) Vitamin D
d) Vitamin A
Answer: d) Vitamin A
Explanation: Vitamin A capsules are administered to children below one year to prevent eye complications associated with measles.

MCQ: Which stage of measles is characterized by an abrupt onset of severe symptoms, including very high fever and photophobia?
a) Incubation phase
b) Prodromal phase
c) Eruptive phase
d) Convalescent phase
Answer: c) Eruptive phase
Explanation: The eruptive phase of measles is characterized by an abrupt onset of severe symptoms, including very high fever and photophobia.

MCQ: What is the primary mode of measles transmission?
a) Contact with contaminated food
b) Direct skin-to-skin contact with an infected person
c) Airborne droplets from an infected person’s respiratory secretions
d) Ingestion of contaminated water
Answer: c) Airborne droplets from an infected person’s respiratory secretions
Explanation: Measles is primarily transmitted through airborne droplets when an infected person coughs or sneezes.

MCQ: Which of the following is NOT a risk factor for measles?
a) Immunodeficiency in children
b) Travel to areas where measles is endemic
c) Malnutrition
d) Taking vitamin supplements
Answer: d) Taking vitamin supplements
Explanation: Immunodeficiency, travel to endemic areas, and malnutrition are risk factors for measles, but taking vitamin supplements is not directly associated with measles risk.

MCQ: Which stage of measles marks the beginning of improvement, characterized by skin desquamation and a decline in body temperature?
a) Incubation phase
b) Prodromal phase
c) Eruptive phase
d) Convalescent phase
Answer: d) Convalescent phase
Explanation: The convalescent phase of measles marks the beginning of improvement, characterized by skin desquamation, a decline in body temperature, and the resolution of symptoms.