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Measles Nursing Diagnosis and Interventions

Measles is a highly contagious viral infection, which is characterized by fever, cough, conjunctivitis (inflammation of the lining of connective eye / conjunctiva) and skin rash. The disease is caused by infection of measles virus, Paramixovirus class. Transmission of the infection occurs because of inhaling spray saliva from patients with measles. Patients can transmit the infection within 2-4 days before the onset of skin rash and 4 days after the rash there. Before the widespread use of measles vaccination, measles outbreaks occur every 2-3 years, especially in children aged pre-school and elementary school children. If someone has had measles, then the rest of his life he normally would be immune to this disease.

Symptoms begin to appear within 7-14 days after infection, which are: body heat, sore throat, runny nose, cough, muscle pain, red eyes (conjuctivitis). And 2-4 days later, small white spots appear on the inside of the mouth. Rash (redness of skin) that feels a bit itchy appear 3-5 days after the onset of the above symptoms. This could take the form of macular rash (rash reddish flat) and papules (red rash that stands out). At first the rash appears on the face, which is in front of and below the ears and on the neck next to the side. Within 1-2 days, the rash spreads to the trunk, arms and legs, while a rash on the face began to fade. At the peak of the disease, the patient was very ill, and the rash extends his body temperature reached 40 ° Celsius. At 3-5 days later his temperature dropped, the patient begins to feel well and left immediately rash disappeared. Fever, lethargy, runny nose, cough and red eyes and inflammation for several days followed by a red blotchy rash that started on the face and spread to the body and there for 4 days to 7 days.

1. Impaired social interaction related to isolation from friends.

Expected results:
  • Children demonstrate an understanding of the restrictions.
  • Appropriate child activities and interact.

1. Explain the reason for the isolation and use of special vigilance.
Rational: to increase children's understanding of the discussion.

2. Let the children play the gloves and masks.
Rational: to facilitate positive coping.

3. Provide diversion activities.
Rational: the right to perform activities and interact.

4. Encourage parents to stay with their children during hospitalization.
Rational: to reduce separation and provide proximity.

5. Prepare children for changes perampilan friends physically.
Rationale: to encourage the acceptance of friends.

2. Risk for impaired skin integrity related to raking pruritus.

Expected results: the skin remains intact

1. Keep nails short and clean.
Rational: to minimize the trauma and secondary infection.

2. Wear gloves or elbow restrein.
Rational: to prevent scratching.

3. Give clothes are thin, loose, and not to irritate.
Rationale: because excessive heat can increase itching.

4. Close area of ​​pain (long sleeves, long pants, underwear layer).
Rational: to prevent scratching.

5. Give lotion that softens (very little on the open lesions).
Rationale: because the open lesions to reduce drug absorption increased pruritus.

6. Avoid exposure to sunlight or heat.
Rationale: cause rashes.