In the partial fulfillment of the requirement for the Summer Affiliation on Communicable

Diseases

BACHELOR OF SCIENCE IN NURSING

LEVEL 3

“Smallpox Virus”

Presented by:

Tolentino, Cyrill Alexandria G.

BSN Level 3 Section A

Presented to:

Bernadette Sofia C. Ligot

Clinical instructor
 July 2022

A. DEFINITION

The variola virus, an orthopoxvirus, is the cause of smallpox, an acute infectious

disease. Before it was eradicated, it was one of the most terrible diseases known to mankind,
responsible for millions of fatalities. It is thought to have been around for at least three
thousand years. Edward Jenner developed the smallpox vaccine in 1796, which was the first
effective vaccine ever. He noticed that milkmaids who had previously contracted cowpox did
not contract smallpox and demonstrated how other individuals may be protected against
smallpox using a similar vaccination.

B. RISK FACTORS

NON-MODIFIABLE RISK FACTORS

 Age (0-19 years) - Their immunity had not been boosted by subclinical infection or
revaccination, many vaccinated individuals were protected against clinical smallpox
for a much longer period than 5 years.
 Pregnant women- Premature births, stillbirths, and abortions are more common in
pregnant women with smallpox infection than among healthy women. Hemorrhagic
and flat smallpox, which are linked to exceptionally high fatality rates, are more
common in pregnant women.
 Immunity- The immune systems of babies are still developing and immature, making
them more prone to sickness. Thus, weak immune system renders them less able of
fighting off infections.

MODIFIABLE RISK FACTORS

 Direct contact with infected bodily fluids - Viruses that can spread to other people
can be found in blood and bodily fluids like saliva, sperm, and vaginal fluid. You may
contact the smallpox virus if you come into touch with someone else's blood or bodily
fluids. When blood is present in the fluid, body fluids like sweat, tears, vomit, or urine
may contain and spread these viruses, but the likelihood is low.
 Physical contact with someone with smallpox – Once mouth and throat sores first
formed in smallpox patients, they became infectious (early rash stage). When they
 sneezed or coughed, the virus was transferred to other persons by droplets that
traveled from their mouth or nose.
C. PATHOPHYSIOLOGY

NON-MODIFIABLE RISK
MODIFIABLE RISK FACTORS
FACTORS
 Direct contact with infected bodily fluids
 Age
 Physical contact with someone with
 Pregnant women
smallpox
 Immunity

Variola virus

Inhalation of air
droplet

Spreads to bone marrow Fever

Endothelial cell vessel walls

Skin lesions
expanding and dermal
capillaries dilating.
Vesicular lesions Toxemia

Encephalitis Immunological complexes Death

Blindness
Arthritis Virulence mechanisms

Immune response

DNA transcription

Complement-regulatory
protein (CRP)

Complement system

C3b and C4b

Fusion proteins

Extracellular substances and

encouraging destruction
Legends: Risk factors Pathophysiology Complications Signs and symptoms

The variola virus infects the host, which then spreads smallpox. Though the virus can
enter through the skin, the point of entry for the injection often lies in the respiratory
mucosa. The virus quickly spreads to the adjacent lymph nodes after infection. The virus
enters the blood after the third or fourth day of infection and spreads to the bone marrow,
sleep, and more lymph nodes. Fever and toxemia appear between days 8 and 12 after the
virus has been detected in the blood. The virus is now concentrated in the dermis' blood
vessels and mouth mucosa, causing the initial enanthem and exanthem. By day 14, the
host is contagious and the kidneys, liver, spleen, lymph nodes, and bone marrow are well
populated with virus. Skin lesions initially form as a result of endothelial cell vessel walls
expanding and dermal capillaries dilating. These lesions spread to the epidermis, where
swollen cells eventually grow until they breach their membranes.

Pus builds up after vesicular lesions as a result of polymorphonuclear cells

accumulating inside the vesicle. The legions ultimately scab over when the pus eventually
disappears. Overwhelming toxemia typically causes death, most likely because of
circulating immunological complexes. The long-term effects of secondary infections can
also include encephalitis, blindness, and arthritis.

Through a variety of virulence mechanisms, the variola virus is extremely adept in

thwarting the host immune response. The virus has an inner and outer envelope and is a
double-stranded DNA virus. Lipids and proteins make up the core membrane, which
covers the virus's central portion. Large amounts of 186 kbp DNA and about 10 gene-
expression enzymes can be found in the core itself. Additionally, there are nucleoproteins
essential for DNA transcription. It has been established that the variola virus contains a
complement-regulatory protein (CRP). By serving as a co-factor for serine protease factor
I, the CRP deactivates the host complement system. This is accomplished by cleaving
C3b and C4b, which will shield the host cell from the complement cascade's attack. The
infection also has the capacity to fuse out of the host cell through fusion proteins,
exposing them to extracellular substances and encouraging destruction.
D. MANAGEMENT

i. Medical

Treatment of smallpox patients generally involves supportive care and a

healthcare setting requires isolation and adherence to proper infection and
environmental controls.

Antivirals

There are three primary antiviral therapies that have shown effectiveness
against orthopoxviruses including variola (the virus that causes smallpox) in animals
and in vitro studies. However, there is no treatment for smallpox disease that has been
tested in people who are sick with the disease and been proven effective in this
population.

Vaccination

Vaccination with replication-competent smallpox vaccines can prevent or

lessen the severity of disease if given within 2 to 3 days of the initial exposure. They
may decrease symptoms if given within the first week of exposure. People who are
vaccinated must take precautions when caring for the place on their arm where they
were vaccinated, so they can prevent the vaccinia virus from spreading.
 ii. Pharmacological

Nursing Responsibilities
Generic Name: Tecovirimat
Action Rationale
Verify the doctor’s order then follow and To ensure safety, to give quality care and to avoid
Brand Name: Tpoxx
administer the drug noting the 14 R’s. medication errors.
Dose/ Route/Frequency:
Assess for the contraindications To prevent any untoward complications.
600 mg PO BID
To evaluate for occurrence of any adverse effects
Classification: Antivirals Perform a thorough physical assessment
associated with drug therapy.
Mechanism of Action:
Distract the patient by changing her focus on Minimize fear and alleviate pain during
It inhibits the function of a major
different view and administer the drug slowly. administration.
envelope protein required for the
production of extracellular virus. The drug Observe for expected therapeutic effect and for The patient needs to be evaluated and monitored,
prevents the virus from leaving an adverse effects, evaluate and monitor the patient. especially for high-alert medications.

infected cell, hindering the spread of the

virus within the body.

Desired Effect:
The desired effect of this drug is to
prevent the spread of virus 10 and reduce
viremia.
 Nursing Responsibilities
Generic Name: Paracetamol
Action Rationale
Verify the doctor’s order then follow and To ensure safety, to give quality care and to avoid
Brand Name: Calpol
administer the drug noting the 14 R’s. medication errors.
Dose/ Route/Frequency:
Administer the drug with food. To prevent GI upset.
5 ml PO q 4 hrs prn
Administer the drug whenever necessary
Classification: Antipyretic specifically when body temperature is greater or To prevent overdosing of the drug.
equal to 37. 8 C.
Mechanism of Action:
Promote comfort, instructs the SO to change the
Promote dispersal of body heat when the body
Decreases fever by inhibiting the effects clothes whenever he sweat and teach him to do temperature is higher than normal.
of pyrogens on the hypothalamic heat tepid sponge bath.
regulating centers and by a hypothalamic
action leading to sweating and
vasodilatation.

Desired Effect: Observe for expected therapeutic effect and for The patient needs to be evaluated and monitored,
The desired effect of this drug is to reduce adverse effects, evaluate and monitor the patient. especially for high-alert medications.
fever as evidence by sweating and body
temperature at normal range.
 E. PREVENTION OF COMPLICATIONS

Potential complications that may occur include:

 Blindness
 Severe Dehydration
 Encephalitis

Monitoring and Managing Potential Complications:

 Blindness- Topical steroid therapy may be combined with antiviral therapy for
treatment of disciform keratitis if the cornea is intact and the active infection has
cleared.
- Vitamin A supplementation, especially to malnourished children
- Good eye care that includes eye lubrication and saline-soaked protective
eye pads
 Severe Dehydration- Resuscitation with intravenous or intraosseous (IV/IO) fluid
 Encephalitis- Consider lumbar puncture for cerebrospinal fluid (CSF) evaluation to
evaluate for other treatable conditions
- Monitor and assess airway, breathing, circulation, disability (ABCD)
and give emergency treatments
F. NURSING CARE PLAN

Hyperthermia 

Assessment

Subjective: verbalization of, “nagbara met toy bagbagi kon ma’am, ken nagbudo
agitoy bagbagik”
Objective: red spots on tongue, pustules, irritability, BT of 38.9

Nursing diagnosis:
Hyperthermia related to viral infection secondary to smallpox as evidenced by
red spots on tongue, pustules, irritability and verbalization of, “nagbara met toy
bagbagi kon ma’am, ken nagbudo agitoy bagbagik”
Nursing Inference:

If the immune system is unable to completely eliminate the virus from the body, it
may retreat to skin sensory nerve cell bodies, where it is protected from the patient's immune
system.

Nursing Goal
  After 1-2 hours of nursing intervention the patient’s body temperature falls from 38.9
to 37.2 ℃ 

Nursing Responsibilities Rationale

1. Monitor body temperature. For baseline data.
2. Provide isolation  To prevent infecting others
3. Instruct patient and SO to cover mouth To prevent the spread of infection via
and nose during coughs or sneezes airborne droplet
4. Maintaining fluid and electrolyte balance Electrolyte and protein loss may also occur
in these patients
5. Monitor environmental temperature Room temperature should be altered to
maintain near-normal body temp.
6.   Administer medications, as indicated, Antipyretic drugs lower body temperature
such as:  by blocking the synthesis of prostaglandin
 Antipyretic drug that act in the hypothalamus

Evaluation

After 2 hours of nursing intervention the patient’s body temperature falls from
38.9 to 37.2℃. 
G. RESEARCH BASED ON THE MANAGEMENT

If an outbreak of smallpox were to occur today, it's likely that most doctors
wouldn't realize what it was in its early stages, which would allow the disease to spread.
Even one confirmed case of smallpox would be considered an international health
emergency. The Centers for Disease Control and Prevention can do definitive testing
using a tissue sample taken from one of the lesions on the skin of the infected person.

Isolated

The patient should be isolated until all scabs have fallen off (about 3-4 wk after
rash onset) to prevent transmission of the variola virus to non-immune persons. Think
about various aspects that contribute to the patient's overall wellbeing in addition to
providing medical care. Patients who are isolated may experience anxiety, depression, or
stigma. Due to the decreased frequency of interactions with clinical staff due to the
requirement for PPE, they could also feel ignored. Include visitor-friendly strategies in
your facility's strategy, especially for pediatric patients. Every visitor will have to be
immunized and wear the proper PPE.

Vaccine

Only the smallpox vaccine can prevent smallpox. The vaccine is created using the
vaccinia virus, a different pox-like virus linked to smallpox. The vaccine aids in the body
building smallpox immunity. A hypodermic needle is not used to administer the smallpox
vaccine. It does not involve an injection like many vaccines. A bifurcated (two-pronged)
needle that has been dipped into the vaccination solution is used to administer the
vaccine. The needle retains a droplet of the vaccination when it is removed. The skin is
then punctured 15 times in quick succession with the needle. Although the prick is not
deep, it will nevertheless result in a hurting place and one or two drops of blood.
Typically, the upper arm is used for the vaccination.

The best defense against contracting the smallpox virus is the smallpox vaccine. A
sore arm, fever, and body aches are among the typical, minor symptoms that the majority
of patients experienceThe vaccine does carry certain riskier side effects, though. In the
 past, one million vaccinations resulted in reactions in roughly 1,000 persons that were
serious but not life-threatening.

References:

Centers for Disease Control and Prevention (October 18, 2021). Smallpox. Retrieved from
https://www.cdc.gov/smallpox/about/index.html

E.Medicine Medscapes (July 28, 2022). Smallpox Treatment & Management. Retrieved from
https://emedicine.medscape.com/article/237229-treatment

Mayoclinic (September 22, 202). Diagnosis Treatment. Retrieved from

https://www.mayoclinic.org/diseases-conditions/smallpox/diagnosis-treatment/drc-20353032

Health New York (April 2003). Smallpox Questions and Answers: The Disease and Vaccine.
Retrieved from https://www.health.ny.gov/publications/7004/

Centers for Disease Control and Prevention (July 24, 2017). Protect and Care for Smallpox
Patients. Retrieved from
https://www.cdc.gov/smallpox/bioterrorism-response-planning/healthcare-facility/protect-
care-patients.html#:~:text=If%20consultation%20with%20CDC%20and,%2C%20contact
%2C%20and%20airborne%20precautions.