MEASLES

INTRODUCTION

Measles also known as “Tigdas” is now current In every

regions in the Philippines according to the department to
the department of health ( DOH ) Last year there are
21,000 case of measles recorded in the Philippines. The
DOH declared that there is a measle outbreak and
confirmed as of February 6 2019 Wednesday in the
National Capital Region ( NCR ). Data from DOH
epidemiology Bureau showed that from January 1 to 19,
the number of measles cases in NCR has reached 196
much higher than the 20 cases recorded during the
same period in 2018.
Measles is a childhood infection caused by a virus. Once
quite common, measles can now almost always be
prevented with a vaccine. Also called rubeola, measles
can be serious and even fatal for small children. While
death rates have been falling worldwide as more
children receive the measles vaccine, the disease still
kills more than 100,000 people a year, most under age
of 5. Measle is highly contagious illness caused by a
virus that replicates in the nose and throat of an infected
child or adult. Then when someone with measle coughs,
sneezes or talks, infected droplets spray into the air,
where other people can inhale them.
 The infected droplets may also land on a surface, where they
remain active and contagious for several hours. You can acquire
the virus by putting your fingers in your mouth or nose or rubbing
your eyes after touching the infected surface. About ninety
percent of acceptable people who are exposed to someone with
the virus will be infected. Symptoms usually appear within upper
around 10 to 14 days after exposure to the virus.
Signs and symptoms of measles typically include: fever, dry cough,
runny nose, sore throat, inflamed eyes (conjunctivitis). Tiny wheel
spots with bluish-while centers on a red background found inside
the mouth on the inner lining of the cheek also called kolpik’s spots
and skin rash made up of large, flat blotches that often flow into
one another.
 The reason why I decided to take and pursue this case is to
promote health awareness of this viral infection that is very
contagious through direct and indirect contact. Though the measles
itself is not the cause of death of many people specially children 5
years and below who has weak immune system compared to adults
but actually the complications that leas to diarrhea lost of body
fluid that cause of dehydration, pneumonia, and encephalitis. They
may need to be treated or hospitalized to restore their health with
the use of nursing management and the medical team and prevent
severe complications that may lead to death.
Our patient’s admitting diagnosis is measles. As part of our RLE
exposure we were given the opportunity to visit the ward in St.
Christiana. In this particular case study. I present the case of
patient Arianne Macam Beting of Kaunlaran Pasig City. She was
admitted at St. Christiana hospital for the reason of high fever
associated with rashes from chest to lower extremities with
admitting diagnosis of febrile illness with skin rashes t/c measle.
 OBJECTIVE
A. General
 The presentor chose measle a systemic viral infection
as a case study to practice the knowledge and skills as
a competent student nurse.

B. Specific
 - To identify the signs and symptoms of the impetigo.
 - To evaluate
 - To assess
 - To formally give a knowledge on how a person can
prevent of having this bacteria.
NURSING STUDENT HEALTH
HISTORY
Biological Data:
 
 Name: Patient AMB
 Birthday: May, 20, 2018
 Age: 2 years old
 Sex: Female
 Birthplace: Pasig City
 Address: Kaunlaran st. Pasig city
 Civil Status: Child
 Religion: Catholic
 Nationality: Filipino
 Educational Attainment: N/A
 Room Number: Room 403
 Chief Complaint: High fever with rash
 Admitting Diagnosis: Febrile illness associated with
rashes
 Attending Physician:
 Date of Admission: February,16,2020
 Time of Admission: 5:34pm
B. Chief Complaint & Clinical Diagnosis
The patient was brought to St. cristianna due to having a
high fever and rashes in the chest to lower extremities.
 
C. History of Present Illness
3 days prior to admission the patient had fever
according to the mother and the other day she noticed
that her daughter had a rashes in her chest and it
spreads at his back to lower extremities. As of the
mother’s statement when she noticed that her rashes
became darker.
D. Past Medical History
 The patient was born via NSD in a lying-in clinic in
Pasig city.

E. Family History
 The maternal side of the patient has a history of
diabetes while the paternal side has a history of
hypertension.
  

F. Socio-Economic History

The patient lives with her grandmother. Her mother and father
were OFW their family belong to middle-class.

G. Environmental History

The grandmother own the house were they live.

Gordon’s Eleven Functional
Patterns
 FUNCTION BEFORE DURING INTERPRETATTION
HOSPITALIZATION HOSPITALIZATION
1. Nutrition - She drink milk - she only drink 2 - Decrease of
more than 5 feeding feeding bottles of appetite
bottles of 9oz a day. 9oz a day.

-She loves to eat  

crackers and rice
- She seldom drinks
with soup.
water.
- drinks more than 3
 
glass of water a day.
2. Elimination - She was able to - She was able to No changes in
defecate 1-2 times defecate once. elimination and
normally. voiding pattern
- She can still
- She was able to urinate 3 times.
urinate 3 times
normally.
3. Sleeping - She wasn’t able - She sleeps more - medications
to have a than the last few helps for her to
continuous sleep days because the have a
due to her rashes pain that her comfortable
at the back and rashes caused sleep
difficulty in was lessen.
breathing caused
by her clogged
nose
4.Cognitive - She wasn’t like - She talks to her - her
Perceptual the same before mother and to the communication
Pattern she had the illness, doctors and nurses improves during his
her communication and likes to watch stay
was less and likes to her phone. She
just to lay down was very
cooperative but a
little shy when
5. Activity - She plays with - Still plays with - She can still
Exercise her phone and her phone as perform daily
Pattern mostly just her past-time activities even
watch tv with iv
contraption
6. Values Belief - Her and her - Still believes - cooperates well
Pattern family belongs to that prayers with the doctors
the catholic helps and doctors and nurses
community and can treat.
believes that the
through prayers
and with the help
of the doctor, his
illness will be
treated.
 Review of System

A. General
B. Skin
  YES NO
Rashes or moles /  
Skin itch /  
Breast lumps   /
Breast pain   /
Nipple discharge   /
Hair loss   /
 Head, Eyes, Ears, Nose, Throat
(HEENT)
  YES NO

Visual change   /
Hearing Changes   /
Ear pain   /
Nasal congestion /
Sinus pain   /
Hoarseness   /
Sore throat /

Swallowing difficulty   /
 Neck

  YES NO

Swelling   /

Stiffness   /

Adenopathy   /

Goiter   /
 Breast
  YES NO
Pruritus   /
Rashes /  
Stria   /
Lesions   /
Wounds   /
Incisions   /
Excessive dryness and discoloration   /
Breast pain   /
Soreness   /
Lumps   /
 Respiratory
  YES NO

Cough   /

Wheezing   /

Snoring   /

Shortness of breath   /
 Cardiovascular

  YES NO

Chest pain   /

Palpitations   /

Shortness of breath   /
 Gastrointestinal

  YES NO
Nausea or Vomiting   /
Diarrhea   /
Constipation   /
Abdominal pain   /
Bright red stools   /
Black tarry stools /
Stool incontinence   /
 Genito-Urinary

  YES NO
Pelvic pain   /
Burning with urination (Dysuria) /
Frequent urination (Urinary frequency)   /
Urgent urination (Urinary urgency)   /
Blood in urine (Hematuria)   /
Sexually transmitted disease exposure   /
 Musculoskeletal

  YES NO

Bone pain   /

Joint pain or joint swelling   /

Muscle pain /
 Physical Assessment

 DATE: 2-17-2020
A. General Survey
Received patient lying on bed and awake with IVF of
D5LR 500cc at his right hand to run 55 cc/hr. The patient
weighs 14Kl. During assessment, patient is conscious
and irritated when approach.
B. Vital Signs
Temperature – 38.8
RR - 22
CR - 113 bpm
O2 Saturation - 99%
C.Skin
The patient has a medium white skin, dry skin in
the lower legs. Rashes are visible in the chest down
to lower extremities.
 
D. Head
Head’s configuration is normal with no lesions.
Scalp has a no visible dandruff.
E. Eyes

The client’s eyelids and eyebrows are symmetrical in

alignment and movement. Pupils are black.

F. Ears

Ears is a little dark than the face color. No redness or rashes

in the area.

G. Nose

The nares of the client is normal. Nose is not clogged.

H. Oral Cavity

Patient’s lips are not dry.

I. Neck

The patient’s neck is in its normal size.

J. Breast and Axilla

Breast and Axilla are in normal condition . No lesions or lymph

nodes in these areas.
K. Thorax and Lungs

Chest is not bulging. Patient’s breathing is normal. Breathing

sound upon auscultation is normal.

L. Heart
The heartbeat is normal. No murmur sounds. No skip beats
noted.
M. Abdomen

The abdomen is in its normal shape and has a normal growling

sounds. Rashes in the abdominal area is noted.

N. Lower Extremities

Rashes are present in the genital area along with the legs and
feet. Nail beds are in good color.
 Laboratory Examination
EXAMINE NAME Analysis
RESULT REFERENCE
RANGES
Hemoglobin 132 120 – 170
Hematocrit 0.42 0.38 - 0.48
White Blood Cell 5.5 5.0 – 10.0
     
Differential Count:    
Segmenters 0.44 0.45 – 0.65
Lymphocytes 0.50 0.20 – 0.35
Eosinophils 0.03 0.02 – 0.04
Monocytes 0.03 0.02 – 0.05
Anatomy and Physiology
INTEGUMENTARY SYSTEM
Skin has three layers:
 The epidermis, the outermost layer of skin, provides a waterproof
barrier and creates our skin tone.
Layers of epidermis:
 Stratum basale. The deepest layer of the epidermis, the stratum
basale, lies closest to the dermis and is connected to it along a
wavy a borderline that resembles corrugated cardboard; this
basal layer contains epidermal cells that receive the most
adequate nourishment via diffusion of nutrients from the dermis.
 Stratum spinosum. As the epidermal layers move away from the
dermis and become part of the more superficial layers, the stratum
spinosum.
 Stratum granulosum. Upon reaching the stratum granulosum, the
layers become flatter and increasingly full of keratin.
 Stratum lucidum. Finally, they die, forming the clear stratum
lucidum; this latter epidermal layer is not present in all skin
regions, it occurs only where the skin is hairless and extra thick,
that is, on the palms of the hands and soles of the feet.
 Stratum corneum. The outermost layer, the stratum corneum, is 20
to 30 cells layers thick but it accounts for about three-quarters of
epidermal thickness; it rubs and flakes off slowly and steadily as the
dandruff familiar to everyone; then, this layer is replaced by cells
produced by the division of the deeper stratum basale cells.
 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.
 Functions:
1. Protection. The skin protects deeper tissues from mechanical
damage (bumps), chemical damage (acids and bases), ultraviolet
radiation (damaging effects of sunlight), bacterial damage, thermal
damage (heat or cold), and desiccation (drying out).
2. Temperature regulation. The skin aids in body heat loss or heat
retention as controlled by the nervous system.
3. Elimination. The skin aids in the secretion of urea and uric acid
through perspiration produced by the sweat glands.
PATHOPHYSIOLOGY
Precipitating
•Environment
•Contract to people Predisposing
•2 years old
with german
•Unvaccinated
measles

Rubella Virus
(German Measles)

Transmitted via
Respiratory
droplets

Infected cells in
the upper
respiratory tract
 Virus multiplies

Pyrogen release Lympocyte .50 Cough

Extends in the Cefuroxime

Increase body
regional lymph through 250 mg
Temp. 38.8 C
nodes IV Q8

Paracetamol
Virus spread
( Tempra ) 140
through blood
mg Q4
Reduced Temp to
Rashes develops
37 C

Dipenhydramine
30 mg through IV
 Medical Surgical Nursing
Management
 Closely monitor intake and output and administer oral
I.V fluids as ordered.
 Monitor hydration status by checking skin turgor,
urinary output.
 Observe mouth and skin frequently.
 Perform comfort measure related to the eyes.
-Apply cool compress
-Discourage rubbing the eyes
 Monitor temperature every 4 hours. Provide sponge bath if
temperature above normal.
 Perform passive range of motion exercise every 4 hours while
the child is awake because movement may be restricted.
 Provide quiet and peaceful environment with diversion activities.
 Provide care measurement for oral mucous membrane
o Use soft toothbrush only
o Apply prescribed ointment to dried, cracked lips.
DRUG STUDY
DRUG CLASSIFICSA INDICATIO SIDE EFFECT NURSING
TION N RESPONSIBILITY
Generic - Therapeutic: - Relief of - CNS: Drowsiness -
name: allergy, allergic headaches  
Diphenhy cough, cough symptoms
dramine remedies, caused by
antihistamines histamine
Brand , antitussives release
name: including:
Allerdryl Anaphylaxi
s, seasonal
and
perennial
allergic
rhinitis,
allergic
dermatose
s.
DRUG CLASSIFICSATI INDICATIO SIDE EFFECT NURSING
ON N RESPONSIBILITY
Generic - used to reduce - Used to - cause -
name: fever in bacteria reduce fever gastrointestinal  
Paracetam or viral in bacteria problems or allergic
ol infections. or viral skin reactions. Blood
infection dyscrasia ( e.g
Brand
thrombocytopenia ),
name:
methaemoglobinemia,
Tempra
and hemolytic anemia
are very rare. A
minority of the
subjects with aspirin
intolerance responds
to paracetamol with
bronchospasms. It is
not safety established
if paracetamol can
cause a nephropathy,
like drug
NURSING CARE PLAN
ASSESSMEN Nursing Planning Intervention Evaluation
T Diagnosis
Subjective: Impaired skin After 8 hours -demonstrated After 8 hours of
“Na Integrity of nursing good skin hygiene nursing
ngangati po intervention, like washing intervention, the
yung mga the client thoroughly and pat client was able to
rashes will be dry carefully. display
niya” able to improvement as
display evidenced by
Verbalize by absence of
the the improvemen
t as itchiness
grandmothe
r evidenced
by:
Objective:
-absence of
-disruption itchiness
of skin
integrity
surface at
ASSESSMENT Nursing Diagnosis Planning Intervention Evaluation
Subjective: Hyperthermia After 8 hours of nursing IDEPENDENT: After 8 hours of
“ meron siyang intervention the the comprehensive nursing
 Provide tepid
rashes ” patient temperature will intervention the patient
Sponge bath.
will:
verbalized by the lower down from  Promote bed rest
grandmother.  Provide cool Maintain normal
circulating air using temperature of 37.5 *C
Objective: a fan
Maintain Vital Sign at
Temperature 38.8  Provide oral
normal levels
hygiene.
RR - 22 Bpm  Monitor Vital sign Be alert and responsive
be comfortable in bed.
CR - 113 bpm  

DEPENDENT:
O2 Saturation - 99%
 Maintain IV Fluid as
  ordered by
physician
   Administer anti-
pyretic as ordered
 
Administer antibiotic as
  ordered

 
DISCHARGE PLAN
 Medication
-discuss all the take home medication to the patient
-emphasize hand washing
-encourage the parents to prepare nutritious food
-provide health teaching for the family
 Treatment
-Emphasized hand washing
-Encourage relative to prepare foods that are nutritious such as
vegetable and fruits.
 Outpatient order
-Remind the family on their follow-up check up with the
physician.
-maintain a good and clean environment
 Diet
-provide balanced diet
 Hygiene
-personal hygiene daily
-Keep the patient’s skin intact and free of lesion.