Question

Allergy: No allergy to food and medication
Accommodation: Ward with Philhealth
Initial Diagnosis:
Measles, Pregnancy Uterine 33 5/7 weeks AOG G1P0 with Intestinal Complications (AGE)
Chief complaint:
Fever and productive cough
History of Present Illness:
The client was admitted to the San Lazaro Hospital last August 4, 2020. 2 weeks prior to
consultation: (+) undocumented fever, intermittent, no other associated symptoms no
consultation done, no medications taken. 1 week PTC: (+) onset of productive cough (yellow
mucus), colds, no fever or rashes, no consult done, no meds taken. Interval history revealed
persistence of cough and colds until 1 day (+) rashes, non-pruritic on abdomen which spread
to the trunk and face. Sought consult and was prescribed vitamins and sent home.
Past Medical/ Personal and Social History:
No previous hospitalizations and surgeries.
Past Medical History:
(-) PTB
(-) Diabetes Mellitus
(-) Asthma
(-) Hypertension
(-) Cancer
(-) allergy
Family History:
(-) Hypertension
(-) Diabetes
(-) Cancer
(-) PTB
(-) Asthma
Admission Order
The patient was admitted on August 19, 2020 at 7:00 am with a chief complaint of fever and
productive cough. Client was admitted to Emergency Room. Consent was secured for
admission. Client was the transferred to Adult Female Ward. Patient received with IVF D5LR
1L regulated at 150cc/hr. Client’s vital signs are (BP - 100/70 RR - 25 T - 38.3 HR - 116 O2
saturation - 95%) There is a presence of fever with macula-papular rash on the patient with
productive cough (whitish to yellowish mucus secretion). The patient also showed sign of body
weakness, poor appetite, abdominal pain and defecates a mushy consistency stool. Physician
ordered for CBC, BT, Measles IgG, IgM, CXR-PA view, Serum Creatinine, Na, K, SGPT, SGOT, and Stool exam. Paracetamol 1 tab PRN for fever >37.8, Hexetidine 10 ml for oral
gargle was given. Performed tepid sponge bath. Encouraged to increase fluid intake.
Maintained high back rest. Advised the watcher not to leave the client unattended. Kept
monitored the safety of the client by maintaining side rails up. Vital signs monitored q4 and
recorded. Intake and Output monitored. Watched out for (WOF) any signs of respiratory
distress such as dyspnea or increased respiratory rate. The following day, client was seen
awake and lying in bed. Client’s vital sign are (BP- 90/60 RR-23 T- 36.7 HR-97 O2 sat- 97%).
Client still manifested maculopapular rash with body malaise. Cough still productive with
crackles heard on both upper lung area. IVF D5LR 1L regulated at 150cc/hr was started.
Noted and referred Physician’s order for Isoxsuprine 10mg/tab, 2tabs PO TID and
Dexamethasone 6mg/amp TIV q6 x4 doses. . IVF PNSS 1L at 110cc/hr to follow. Advised not
to scratch the skin to prevent skin integrity impairment. Maintained HOB elevation at 30-40
degrees. Provided a quiet and calm environment. Instructed the watcher not to leave the
patient alone. Kept monitored the safety of the client by maintaining side rails up. Instructed
dietary intake as tolerated. Vital signs monitored q4 and recorded. Intake and Output
monitored. WOF vaginal bleeding and refer to the staff nurse immediately. Client was seen
awake and lying in bed. Client’s vital sign are (BP 100/60 RR-22 T-36 HR-85 O2 sat95%).
Client manifested conjunctivitis and still showed presence of rash in the skin. Cough still
productive. Acetylcysteine 600mg 1-tab dissolve in 50cc water ODHS were given. Patient was
ordered for discharge. Noted and instructed the patient regarding the following home
medications ordered by the Physician, Co-amoxiclav 625 mg 1tab TID for 7 days, Hexetidine
gargle 10ml TID, Multivitamins 1tab OD and B-Complex 1tab OD. Encouraged client to
increase oral fluid intake. Advised to follow-up to OPD after 1 week. Vital signs monitored and
recorded.

1 Conceptualize the pathophysiological alterations distinct to the case. (FLOW CHART)

* Establish the pathophysiological triad of Host – Agent – Environment specific to the
case.
* Trace the pathophysiological changes and highlight problems that are
experienced by the client.
* Connect the pertinent nursing care and medical – surgical management to the
various signs and symptoms presented by the client

Answer 1

Pathophysiology of Measles

Its a highly contagious disease, mainly transmitting via respiratory tract. The disease can cause severe immuno supression in an individual.The incubation period is 7-10 days.

Establish the pathophysiological triad of Host – Agent – Environment specific to the case.

The epidemiological triad consist of Host, Agent and Environment. This is a model, that helps to explain about the disease causing organism,the disease and the environmental factors that aids in the progression and spread of the disease.

• Agent: The agent is the microorganism that causes the disease in a healthy individual. An agent may be bacteria,virus, fungus, or parasite. Here the disease causing agent is measles virus (Paramyxo virus) belongs to Paramyxoviridae family
• Host: The host is the living animal that carries the disease. A host doesn’t need to get sick everytime. Sometimes hosts may remain as carriers without showing any symptoms of the disease. It also depends up on the genetic status, immunity power and health status of the individual.Here The patient is pregnant and she is low immune.
• Environment: The factors that can affect the spread of the disease is called as the environment. Here environment includes, the area where the patient works,the climate, sanitation,social environment, polluted environment etc.

Trace the pathophysiological changes and highlight problems that are experienced by the client.
Fever and productive cough developed due to the presence of inflammation and intial attack of the virus to the respiratory tract, especially the epithelium of trachea and bronchi. Development of skin rash is a common symptom associated with measles. When the virus spread in to the body through the small blood vessels, they start to infect the bloo vessels also, This may results in production of certain chemicals which can cause rash over the skin. Most of the time the rash ia associated with severe itching.The rash usually begins in the face, then spread to whole body.The rashes may be associated with high fever also. There may be manifestations of weakness, poor appetite, abdominal pain and defecates a mushy consistency stool. The severe attack of the virus in respiratory tract can cause altered respiratory rate, breathing difficulty etc. the virus can also attack and affect the eyes, cornea, conjunctiva etc, among which conjunctivitis is very common.the severe involvement of lung parenchyma may cause the development of productive cough and alter the oxygen saturation of the patient.

Connect the pertinent nursing care and medical – surgical management to the various signs and symptoms presented by the client

Nursing management

• Assess the respiratory status of the patient.
• Monitor the vitals
• Provide an upright position to improve oxygenation.
• In case of elevated body temperature provide sponge bath.
• Maintain the nutritional status of the patient.
• Ensure that the patients intake is adequate/
• Monitor the intake and output.
• Monitor for symptoms of any bleeding
• Maintain the skin integrity
• Apply skin soothening solutions as per prescription
• Monitor the remperature
• Prevent falls by elevating the side rails up
• Maintain the fluid status of the patient

Medical management

There is no as such medical managemnt for measles. Symptomatic managemnt can be given to the patient based on reported symptoms. They incude antipyretics to reduce the temperture. Usually paracetamol is given. Analgesics can be given to reduce sever pain.Airway patency to be maintained, for that bronchodilators can be administred.Nutrition suppliments can be given as Iv fluids.Oral gargling can be given with Hexetidine 10 ml in case of reported sore throat.Supplimental oxygen therapy can be intiated if any breathing difficulty develops.Anti inflammatory drugs like dexamethasone can be given.Acetylcysteine 600mg 1-tab dissolve in 50cc water can be given in case of productive cough.B-complex tablets and multi vitamins can work as nutritional suppliments. there is no effective Surgical Management.