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Varicella Zoster Infection
An infectious case study
Christelle Brookshiel Joy D. Marba, RNMaria Rachel Ann M. Dagupan, RN
Donita Rose R. Candido, RNMistletoe R. Sanchez, RN
Sheila O. Mabalot, RN
Varicella Zoster Infection Also known as “Chickenpox” Acute disease cause by a DNA virus. Highly contagious Most common in children. Easily transmissible through airborne,
droplets, direct contact with blisters
Statistics reveals…… Worldwide distribution Common on crowded places. 10th most common childhood disease in
the Philippines.
MORBIDITY: 10 Leading Causes, Number and Rate
5-Year Average (2003-2007) & 2008
Diseases
5-Year Average (2003-2007)
2008*
Number Rate Number Rate
1. Acute Respiratory Infection ** - - 1,647,178 1840.6
2. Acute Lower Respiratory Tract Infection and Pneumonia 683,443 837.90 780,199 871.8
3. Bronchitis/Bronchiolitis 593,284 732.50 519,821 580.8
4. Hypertension 371,467 457.60 499,184 557.8
5. Acute Watery Diarrhea 581,611 712.70 434,445 485.4
6. Influenza 381,371 470.40 362,304 404.8
7. TB Respiratory 111,418 137.30 96,497 107.8
8. Acute Febrille Illness *** 22,225 27.60 35,381 39.5
9. Diseases of the Heart 36,240 44.60 32,541 36.4
10. Chickenpox 29,197 40.40 25,677 28.7
CNGH 3 cases – April 1 case on the first week of
April 2 cases by the end of April
General Objective
Acquisition of the knowledge, skills and the right attitude in the management of patients diagnosed with Varicella Zoster Infection.
Address the primordial needs and problems associated with this diagnosis with the best medical and nursing intervention available.
Specific Objectives To reveal the general assessment
including the nursing history obtained objectively from our chosen patient.
To discuss the etiology, risk factors and clinical manifestations of Varicella Zoster Infection as it relates to the actual experiences of the subject and the management involved.
To develop an effective nursing intervention
To deliver effective nursing care to patient.
To develop appropriate discharge plan of the patient.
Significance of the Study This study will provide a brief discussion
regarding Varicella Zoster infection its prognosis and management.
Significance of the Study
To patient: to promote understanding of the disease process; its prognosis and nursing and medical management.
To the professionals: as a reference in planning an effective management of patients diagnosed with Varicella Zoster Infection.
To the society: as a reference in the investigation of suspected Varicella Zoster infection as well as the preventive measures and precautions to be considered in case of living in a susceptible community.
Scope and Limitation
Conducted at Ward 3 of Camp Navarro General Hospital.
The information was gathered from the patient through an interview, from the on-duty Health care providers who rendered medical and nursing management.
CLIENT PROFILE
NAME: PATIENT ISO AGE: 23 YEARS OLD ADDRESS: TUMAGA, ZAMBOANGA CITY GENDER: MALE MARITAL STATUS: MARRIED OCCUPATION: SOLDIER BRANCH OF SERVICE: PHILIPPINE NAVY RANK: S1YN UNIT ASSIGNMENT: NISF, PN, BAGONG
CALARIAN, Z.C. LENGTH OF SERVICE: 6 YEARS
CLIENT PROFILE BIRTH DAY: 09 MARCH 1991 BIRTH PLACE: BARANGAY TUMAGA, Z.C. NATIONALITY: FILIPINO RELIGION: BORN AGAIN DIALECT SPOKEN: TAGALOG, CHAVACANO EDUCATIONAL ATTAINMENT: COLLEGE
LEVEL HEIGHT: 5’4 WEIGHT: 69 kg
CLIENT PROFILE CHIEF COMPLAINTS: ON and OFF FEVER X 4 DAYS; RASHES AT FACE AND LEGS X 4 DAYS SORE THROAT and ITCHINESS BODY PAIN PS: 7/10 MEDICAL IMPRESSION: VARICELLA ZOSTER
INFECTION DATE and TIME of ADMISSION: 01 1300H
MARCH 2015 DATE AND TIME OF DISCHARGE: 16 MARCH
2015 FINAL DIAGNOSIS: VARICELLA
CONCEPT OF HEALTH, ILLNESS AND HOSPITALIZATION
health is very important aspect of human being because without good health, one cannot fully perform his duties and responsibilities.
He was a little bit sad because of his condition. However, he doesn’t lose hope because he knew that with proper treatment his condition will be alleviated. He was a little bit disappointed too because he believes that this condition is just for children but then he still contracted the disease.
IMMEDIATE FACTOR THAT BROUGHT ABOUT ILLNESS
he contracted the disease from one of his colleagues who also had a previous Varicella Zoster Infection four days prior the signs and symptoms became evident.
COMPREHENSIVE HISTORY
4 days prior to Admission:
on and off fever, sore throat, rashes that started from the face and later invaded his lower extremities, itchiness and body malaise- No meds taken at home.
PAST MEDICAL HISTORY
fully immunized as a child. Last hospitalization 2010 at Manila Naval Hospitalchief complaints: Fever and body MalaiseTreatment received: Paracetamol and antibiotics.Patient can’t remember exact diagnosis.No known Allergy
FAMILY AND SOCIAL HISTORY
Hypertension from his father Diabetes and kidney disease-
mother Heart disease - grandmother
Physical Assessment SCALP/ HAIR all areas and is free from masses,
lumps, and dandruff with no areas of tenderness upon palpation.
Hair - evenly distributed. Some parts show Varicella lesions
on the ventral part of the head.
Physical Assessment FACE Oval in shape, symmetrical and no
involuntary muscle movement.
There are varicella lesions evident on the left and right cheek of the patient.
HEALTH PERCEPTION- HEALTH MAINTENANCE PATTERN
Patient perceives health as important. He verbalized that he is healthy and was fully immunized as a child. If he is not feeling well, he takes medications like over-the-counter drugs.
He verbalized that before he was admitted he feels at ease and sleep for about 7-8 hours yet it still depends on his assigned duties. He seeks medical assistance on a clinic or hospital
NUTRITIONAL PATTERN normal meal pattern eats fruits and vegetables. He has a
good appetite with no difficulty in chewing and swallowing food.
drinks approximately 7-9 glasses of water everyday
Hypoallergenic diet upon admission.
ELIMINATION PATTERN
defecate everyday usually in the morning.
He sometimes experiences some difficulty in defecating yet he just eat fruits high in fiber like papaya and ripe mangoes to facilitate his elimination pattern.
He urinates 3-5 times a daily during hospitalization.
ACTIVITY- EXERCISE PATTERN independent in performing activities of
daily living such as feeding, general mobility, toileting, bathing, grooming and home maintenance.
He also has a routine 20-30 exercise composed of jogging and walking once or twice a week.
Spends his leisure time by playing games on his phone during confinement
COGNITIVE- PERCEPTUAL PATTERN
Patient is well oriented with his name, time, place, date, family members.
Patient is conscious and coherent.
During hospitalization, patient doesn’t have any changes in his senses.
SLEEP- REST PATTERN
has an average of 7-8 hours of sleep most of the time.
His sleeping schedule depends on his work schedule.
SELF-PERCEPTION – SELF- CONCEPT PATTERN
the patient describes himself active and a healthy individual. He is the breadwinner of the family.
During the hospitalization, the patient verbalized that he wanted to go home and go back to his work in his usual routine.
ROLE-RELATIONSHIP PATTERN
nuclear family structure
married for more than one year and is a father of a six month old child.
SEXUAL- REPRODUCTIVE PATTERN
patient verbalized that he is not experiencing any problems involving reproductive system and their sexual relationship
COPING- STRESS PATTERN
The patient verbalized that if they encounter problems, they solve it as a family and stated that every time he feel stressful, he usually open up and talk to his wife.
VALUE- BELIEF PATTERN
Born Again Christian.
He stated that faith is very important and religion guides him to strengthen his faith to God. According to him, he draws his strength from God which gives him the willpower to continue and enjoy living.
Anatomy and Physiology
The immune System
Infection occurs when a pathogen invades body cells and reproduces.
If the response is quick and effective, the infection will be eliminated or contained so quickly that the disease will not occur.
Disease can occur when immunity is low or impaired, when virulence of the pathogen (its ability to damage host cells) is high, and when the number of pathogens in the body is great.
How Infection happens
Varicella Zoster Virus
SneezingCoughingContact with blisters
HOST
StressNo known history of VZV
Lack of sleep
Non-immunized
Exposed to crowdInfected person
On and off feverRashes on face and legsSore throat and itchinessMyalgiaPain scale= 7/10
4 days prior to admission
Same S&S with increasing severity
Upon Admission
Signs and Symptoms
Hematology Result
Parameter Result Normal Values SIGNIFICANCE
RBC 5.68 x 10 /L (within normal)
4.0-5.5 x 10 /L Indicative of decreased plasma volume.
HGB 161 g/L (slightly high normal)
120-160 g/L Increases with hemoconcentration.
Platelet 98 x 10 /L (decreased)
100-300 x 10 /L Viral infection.
Granulocytes 47.7% (decreased)
50-70% Decreases when in stressful states.
Lymphocytes 44.4% (Increased)
20-40% Viral infection.
COURSE IN THE WARD
Admission (01 1300HMarch 2015
- A 23 year old male from Barangay Tumaga, Zamboanga City
- chief complaints of maculopapular lesions from head to toe, intermittent fever, body pain and itchiness of lesions for 3 days.
COURSE IN THE WARD
Admission (01 1300HMarch 2015
- following orders were given: admit to isolation ward, diet as tolerated, increase fluid intake, respiratory/droplet precaution, patient to wear mask at all times. Diagnostic procedure order was complete blood count.
COURSE IN THE WARD
Admission (01 1300HMarch 2015
following therapeutics such as Acyclovir 500 mg/tablet, 4 tablets once a day per orem for 5 days and Paracetamol 500mg/tablet, 1 tablet PRN for Temperature of 38.3 degrees Celsius. Cpt C MC also ordered for D5NSS 1 liter regulated at 40-41 gtts/min for 3 cycles
COURSE IN THE WARD 1400H Received by the
afternoon shift 3pm-11pm NOD with elevated body temperature of 38 degrees Celsius and skin warm to touch. Nursing interventions were rendered such us: cold compress applied to forehead, encouraged to increase fluid intake, regulated IVF fluid to its desired rate and Paracetamol 500 mg tablet was given.
COURSE IN THE WARD
1600H
1800H
Hematology report was relayed to MOD with significant values of RBC 5.68x10/L, HGB 161 g/L, PLT 98x10/L, Lymphocytes 44.4%, Granulocytes 47.7%
Latest temperature recorded: 36.1 degrees Celsius.
COURSE IN THE WARD 1 (02 0840HMarch 2015
1500H
MOD ordered IVF of D5NSS 1 Liter to follow at 40-41gtts/min for 3 cycles and was noted by NOD. Encouraged patient to verbalize feelings and concerns, placed on a comfortable position, advised not to prick blisters. Encouraged to practice personal hygiene and observe proper handwashing.
COURSE IN THE WARD DAY 2 (03 0720HMarch 2015 0830H 1100H
Patient complained of body malaise. The following intervention was rendered by NOD: Assessed health status, encouraged verbalization of feelings and concerns, provided well ventilated and comfortable environment and monitored patient at intervals. MOD ordered IVF to follow of D5NSS 1 Liter regulated at 40-41gtts/min and was noted by NOD. MOD ordered further more IVF to follow of D5LR 1 liter for 12hours for 2 cycles and was noted by NOD.
COURSE IN THE WARD DAY 3 (04 0720HMarch 2015) 0800H
Patient complained of itchiness all over body. The following intervention was rendered by NOD: Assessed health status, encouraged verbalization of feelings and concerns, instructed to increase fluid intake, instructed to avoid scratching of vesicles and removal of crusts, advised to practice personal hygiene and handwashing, monitored at intervals for unusualities.MOD ordered for IVF to be consumed then discontinue after last ordered cycle of D5LR and was noted by NOD.
COURSE IN THE WARD DAY 4-14 (05 0700H March 2015 to 15 March 2015)
NOD focus of care was towards promotion of health and wellness and the following interventions were rendered to the patient: Assessed health status, encouraged verbalization of feelings and concerns, advised to adhere health care management for early recovery, imparted health teachings on personal hygiene and handwashing, provided a well ventilated and comfortable environment, due meds given as ordered.
COURSE IN THE WARD
Day 15 (16 March 2015) Patient was discharged per MOD’s order in fair condition and upon accomplishment of clearance. Discharged health teachings were imparted and acknowledged by the patient.
Name of the Drug
Classification Mechanism of Action Indication Nursing Considerations
Generic Name:AcyclovirBrand Name:Herpex Dosage:200mg Frequency:4 tabs once a day Route:Oral
Antiviral drug The acyclovir is converted to an active form by the virus itself, and the virus then uses the active form of acyclovir rather than the nucleoside it normally uses to manufacture DNA, a critical component of viral replication.
Side effectsnausea,Vomiting, diarrhea and headache. agitation, confusion, rash
Recurrent genital Herpes infection.
Herpes Zoster infection ( Shingles) Chickenpox( Varicella) PO
Contraindication:hypersensitivity
Assessment History: Allergy to acyclovir,
Teaching points Oral acyclovir is not a cure.
Avoid sexual intercourse while visible lesions are present.
You may experience these side effects: Nausea, vomiting, loss of appetite, diarrhea; headache, dizziness. Report difficulty urinating, rash, increased severity or frequency of recurrences.
Name of the Drug
Classification
Mechanism of Action
Indication Nursing Considerations
Generic Name:ParacetamolBrand Names:FeverganClassification:Dosage: 500 mgFrequency: PRNRoute: Oral
AnalgesicsAntipyretic
Decreases fever by inhibiting the effect of pyrogens on the hypothalamus by Vasodilation.
Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not have anti-inflammatory action because of its minimal effect on peripheral prostaglandin synthesis.
Relief of mild to moderate pain; treatment of fever
ContraindicationHypersensitivity to the drug. Intolerance to tartrazine (Yellow dye #5), alcohol, sugar, saccharin.Allergy to acetaminophen
Assess patient’s fever or pain; type of pain, location, intensity, duration, temperature and diaphoresis.
History: Allergy to acetaminophen, impaired hepatic function, chronic alcoholism, pregnancy, lactation
Give drug with food if GI upset occurs.Discontinue drug if hypersensitivity reactions occur.
Problem list
Increased body temperature Impaired skin integrity Knowledge deficit regarding Varicella
Zoster infection
Long term objective
the patient will no longer be afflicted by the varicella virus and will not trigger the reactivation of the virus inside the body which can lead to a major complication known as Herpes Zoster infection that is more serious than the previous case. Also, for the professionals- to be equipped with the knowledge, skills and right attitude needed to address the similar case in the future.
C. Nursing Care Plans
Assessment Nursing Diagnosis Objective of care Interventions Evaluation
Subjective cues: “Ma’am ta sinti man iyo caliente pati duele el di mio cabesa” as verbalized by the patient.
Objective cues:Skin warm to touchTemperature of 38°C.
Elevated body temperature
At the end of 8 hours nursing intervention the Patient will be able to maintain body temperature within normal range of 36°C to 37.5 °C
*Assess health condition of the patient*Provide a well-ventilated environment*Encourage significant others to perform tepid sponge bath or cold compress. *Encourage to increase fluid intake.
At the end of 8 hours nursing intervention, the patient's latest body temperature is 36.1°C.
Assessmen
t
Nursing
Diagnosis
Objective
of care
Interventio
ns
Evaluation
*Administered anti pyretic medication as ordered.
*Monitored patient’s core temperature at frequent intervals.
Assessment Nursing
Diagnosis
Objective of
Care
Interventio
ns
Evaluation
Subjective cues: “Manada ya ta crisi butuy na dimiyo cara hasta na dimiyo pi es” as verbalized Objective cues:Presence of vesicular Lesions all over the body. Some of the lesions are vesicles filledWith serous fluid; others are darker in color.
Impaired skin integrity Related to Varicella Zoster Infection
At the end of the patient’s hospital stay and series of interventions carried out, the patient’s skin lesions will heal without evidence of a secondary infection.
*Assess patient’s condition *Educate patient on the following: Wash the hands each time the area is touched.Wash any soiled clothes or linens in warm water and soap.
At the end of the patient’s hospital stay and series of interventions carried out,The Patient’s skin lesions are dry and crusty, with no new blisterFormation. Skin lesions healed without evidence of a secondary infection.
Assessment Nursing Diagnosis Objective of
Care
Interventions Evaluation
*Use masks, special clothing, and gloves for all those who come into the room and the patient himself.
*Always wash hands after touching the patient or objects that may be contaminated, and before giving the action to other clients.
*All contaminated items disposed of or put into a special place and labeled prior to decontamination or reprocessed back *Educate patient to always trimmed fingernails and avoid scratching the affected areas. *Take medications as prescribed.
Assessment
Nursing Diagnosis
Objective of Care
Interventions Evaluation
Subjective cues: Ara pa gayot ya krisi chickenpox comigo,cosa gaha yo debe hace para puede ayuda di mio cuerpo”
Deficient knowledge of the cause of the skin disorder and recommendedTreatment.
At the end of 8 hours nursing intervention the Patient will be able toVerbalize understanding of the disease process and participate in the treatment plan.
Provide verbal and written instructions for self-care.
*Encourage proper hygiene.
*Teach how to take care of skin lesions.
*Wear a clean cotton undershirt each day.
*Do not allow other family members to use your towels.
At the end of 8 hours nursing intervention the Patient acknowledged the health teachings being imparted to him. “ Si,mas ya puede yay o intende el cosa ta pasa na di mio cuerpo. O hala keda ya iyo bueno”
Assessment
Nursing Diagnosis Objective of Care Interventions Evaluation
*Encourage clients to avoid all forms of friction (touched, scratched by hand)
*Take medications as prescribed *Educate patient on how to create a cleansing solution. Instructed patient to mix one liter of water with one teaspoon of salt and use this as cleanser.
Discharge PlanningMEDICATION -Promotes adherence
measures by thoroughly explaining the importance of taking multivitamins to improve immunity.
EXERCISES -Organize patient care and activities to maximize periods of uninterrupted rest.
-Advise to take adequate rest periods at appropriate intervals to avoid fatigue.
TREATMENT - Emphasize the importance of follow-up visits to the requesting physician.
- Emphasize the importance and benefits of proper hand hygiene.
HEALTH TEACHING
- Provide the benefits of a healthy lifestyle.- Encouraged family members to seek
medical attention when suspected reinfection occurs.
- Educated patient for possible signs of Herpes Zoster infection and to seek medical attention if noticed.
- Explain proceedings of proper disposal of nose and throat discharges.
- Educated the importance of covering mouth when coughing or sneezing and avoiding crowded places.
- General health measures (adequate sleep, proper diet and maintaining clean surroundings)
OUT-PATIENT - Patient must report at a specified time for his follow-up checkup in order to monitor the disease prognosis.
DIET - Encouraged patient to include consumptions of fruits and vegetables regularly and how it improve the immune system.
SPIRITUAL NURSING
- Supporting religious practices.
ConclusionVaricella Zoster Infection or commonly known as “Chickenpox” is highly contagious disease caused by herpes virus varicella, characterized by vesicular eruptions on the skin and mucous membranes usually with mild constitutional manifestations. Because it is widely distributed, anyone can be susceptible for contracting the disease even adults has no excuse. Seeking consultation and taking the proper management is essentially important as it provides mutual benefit; to the patient, it will halt the spread of the virus in the body which can lead to serious complications and to the community for minimizing the risk of contracting the disease from the infected individual which can pose a larger threat of a possible epidemiological outbreak. Isolating the patient is considered and meticulous handling of the case by following the infection control protocol is a must. With proper management of the disease, the patient can recover and restore to its optimal function as an individual.
-END-
Muchisimas Gracias!
