I

 Isolation. Patients will need to be on isolation precautions to decrease

transmission within the community; emphasize the need for immediate
isolation when early catarrhal symptoms appear.
 Skin care. Measles causes extreme pruritus; nursing interventions include
keeping the patient’s nails short, encourage long pants and sleeves to
prevent scratching, keeping skin moist with health care provider
recommended lotions, and avoiding sunlight and heat.
 Eye care. Treat conjunctivitis with warm saline when removing eye
secretions and encourage patient not to rub eyes; protect the eyes from
the glare of strong light.
 Hydration. Encourage oral hydration; medical literature encourages the
use of oral rehydration solution.
 Temperature control. Antipyretics should be administered to the patient
as ordered for a temperature greater than 100.4 Fahrenheit unless
directed elsewise by a healthcare provider; be sure to remind parents not
to administer aspirin due to the risk of Reye’s syndrome.
Assess the overall condition of the skin.

Assess the skin for:

 Pruritus (itching) or mechanical trauma

Reassess the skin regularly and whenever the patient’s condition or treatment plan results
in an increased number of risk factors.

Assessment of the patient with measles include:

 Physical exam. Assess the child for symptoms that may indicate the
presence of measles.
 Knowledge of the disease. Assess the patient’s or significant other’s
knowledge regarding the disease.
 Hygienic practices. Assess the family’s hygienic practices to prevent the
spread of the disease.
Intervention:
1. Keep nails short and clean.
Rational: to minimize the trauma and secondary infection.
2. Wear gloves or elbow restrain from scratching
Rational: to prevent scratching.

3. Give clothes that are thin, loose, and not irritating

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.
Cold bath, good hygiene, anti-itch cream

1. Emphasize the need for immediate isolation when early catarrhal

symptoms appear .
2. If immune serum of globulin is available (gamma Globulin), explain this
to the family and refer to physician or clinic giving this service.
3. Observe closely the patient for complications during and after the acute
stage.
4. Teach, demonstrate, guide and supervise adequate nursing care
indicated.
5. Explain proceedings in proper disposal of nose and throat discharges.
6. Teach concurrent and terminal disinfection.
Nursing Care
1. Protect eyes of patients from glare of strong light as they are apt to be
inflamed.
2. Keep the patient in an adequately ventilated room but free from drafts
and chilling to avoid complications of pneumonia.
3. Teach, guide and supervise correct technique of giving sponge bath for
comfort of patient.
4. Check for corrections of medication and treatment prescribed by
physician.
5. Keep infected person in isolation until the 5th day of rash.
6. Keep the patient in bed until fever and cough subside.
7. Provide eye care (i.e., clean eyelid, irrigate eye with saline).
8. Protect eyes of patients from glare of strong light as they are apt to be inflamed.
9. Keep the patient in an adequately ventilated room but free from drafts and chilling to
avoid complications of pneumonia.
 10. Increase fluid intake during fever.
11. Increase humidity in the patient’s room to relieve cough.
12. Administer tepid baths and apply soothing lotion (such as calamine) to relieve itching of
skin.
13. Immune serum or gamma-globulin may be given to modify illness and reduce
complication.
14. Antibacterial therapy may be given as ordered for treatment of complication (i.e.,
respiratory infection or gastroenteritis).
15. Maintain good body hygiene of patient to reduce the risk of secondary infection from the
lesions.
16. Use a cool mist vaporizer, mouthwash, and tablets to suck on to keep mucous membranes
moist.
17. Give analgesic, antipyretic, and anti-pruritus as ordered to reduce pain, lower body
temperature, and reduce the itching.

 Skin became clean, dry and intact.

 Mucous membranes stayed moist, discomfort will stay within defined
tolerable range by the patient.
 Patient understood the purpose of isolation, cooperate and be free of
distress.

If goals were not met with the health of the patient, we need to reassess and begin the
process over, noting why the goals weren’t met, and make changes to the new plan of care
for the patient to make sure new goals will be completed, in order to accomplish the health
goals of patient care.
After the
nursingimplementation
the
patient’s mother
was able to
performinstructions
and thepatient was
able tomaintain intact
skin