Table of Contents
1. Introduction to Measles
Measles is a highly contagious acute viral illness characterized by fever, cough, coryza, conjunctivitis, and a distinctive maculopapular rash. It remains one of the leading causes of death among young children globally, despite the availability of a safe and effective vaccine.
Key Facts About Measles
- Measles affects approximately 20 million people worldwide each year
- Before widespread vaccination, measles caused an estimated 2.6 million deaths annually
- The virus can remain active and contagious in the air or on infected surfaces for up to 2 hours
- Approximately 90% of susceptible individuals who are exposed to someone with measles will develop the disease
- Measles can lead to serious complications, particularly in young children, pregnant women, and immunocompromised individuals
As nursing professionals, understanding the complete clinical picture of measles is essential for early identification, appropriate management, and effective prevention strategies to reduce the burden of this preventable disease.
2. Etiology and Epidemiology
Causative Agent
Measles is caused by the measles virus (MeV), a member of the genus Morbillivirus in the family Paramyxoviridae. It is an enveloped, single-stranded, negative-sense RNA virus that primarily infects the respiratory tract and then spreads throughout the body.
Transmission
Measles spreads primarily through:
- Direct contact with infectious droplets
- Airborne spread via coughing and sneezing
- Respiratory secretions (the virus can live up to 2 hours on surfaces)
Epidemiological Factors
| Factor | Details |
|---|---|
| Incubation Period | 7-14 days (average 10 days) from exposure to onset of fever; 14 days until rash appears |
| Period of Communicability | From 4 days before to 4 days after rash appearance; most contagious during the prodromal phase |
| Susceptibility | Universal among those who have not been vaccinated or had previous infection |
| Risk Factors |
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| Age Distribution | Most common in children under 5 years, but can affect any age |
| Seasonality | In temperate climates, peaks in late winter and spring; in tropical regions, outbreaks occur year-round |
Global Burden of Measles
Despite significant progress in global vaccination coverage, measles continues to be a public health challenge. Outbreaks frequently occur in areas with low vaccination rates, emphasizing the importance of maintaining high community immunity levels. The disease remains endemic in many countries in Africa and Asia, with periodic outbreaks occurring even in countries where measles elimination had previously been achieved.
3. Pathophysiology of Measles
Understanding the pathophysiology of measles is crucial for nursing assessment and intervention. The disease progression follows a predictable pattern that affects multiple body systems.
Measles Infection Progression
Entry
Respiratory tract infection via droplets
Replication
Local lymphoid tissue
Viremia
Virus enters bloodstream
Systemic Spread
Multiple organ involvement
Immune Response
Rash development
Figure 1: Progression of measles virus infection in the body
Detailed Pathophysiological Process
- Initial Infection: The measles virus enters the respiratory tract and infects epithelial cells. The virus uses the CD150 (SLAM) receptor on immune cells to gain entry.
- Local Replication: The virus initially replicates in the respiratory epithelium and local lymphoid tissue, including tonsillar tissue and cervical lymph nodes.
- Primary Viremia: From the respiratory tract and local lymph nodes, the virus enters the bloodstream, causing primary viremia around 2-3 days after infection.
- Reticuloendothelial System Spread: The virus infects and replicates in reticuloendothelial cells throughout the body, including the liver, spleen, and lymph nodes.
- Secondary Viremia: Around 5-7 days after infection, a more significant secondary viremia occurs, spreading the virus to multiple organs including the skin, respiratory tract, conjunctivae, and central nervous system.
- Immune Response and Rash Development: The characteristic measles rash is actually a manifestation of the cell-mediated immune response to infected capillary endothelial cells in the skin. This immune response helps clear the virus but also contributes to pathology.
- Temporary Immunosuppression: Measles virus causes a marked but temporary suppression of cell-mediated immunity, leaving patients vulnerable to secondary bacterial infections for several weeks to months.
Cellular Impact
At the cellular level, measles causes several characteristic effects:
- Multinucleated giant cells (Warthin-Finkeldey cells) – pathognomonic feature seen in respiratory epithelium and lymphoid tissues
- Cytopathic effects – include cell fusion and formation of syncytia (giant cells)
- Immune complex formation – contribute to symptoms like rash and arthralgia
- T-cell dysfunction – leads to increased susceptibility to secondary infections
This understanding of measles pathophysiology guides nursing assessment by highlighting the importance of monitoring respiratory function, fever patterns, rash progression, and vigilance for complications due to immunosuppression.
4. Clinical Manifestations
Measles progresses through distinct clinical phases. Recognition of these stages is essential for nursing assessment and early intervention.
Classic Stages of Measles
Incubation Period
Duration: 7-14 days
Symptoms: Asymptomatic, virus replicating
Prodromal Phase
Duration: 2-4 days
Symptoms: Fever, the “3 C’s” (cough, coryza, conjunctivitis), malaise, anorexia
Exanthematous Phase
Duration: 5-7 days
Symptoms: Characteristic rash, high fever, worsening respiratory symptoms
Recovery Phase
Duration: 7-10 days after rash onset
Symptoms: Gradual symptom resolution, fine desquamation, brownish discoloration of skin
Remember the “3 C’s” of Measles Prodrome
This classic triad appears during the prodromal phase, before the characteristic rash develops.
Pathognomonic Features
Koplik’s Spots
Small, bluish-white spots on a red background appearing on the buccal mucosa opposite the molars. These are considered pathognomonic for measles.
Figure 2: Representation of Koplik spots on buccal mucosa
- Appear 1-2 days before the rash
- Often missed because they are transient
- Usually disappear within 48 hours after rash onset
Maculopapular Rash
The characteristic measles rash follows a predictable pattern of spread and appearance.
Day 1
Begins behind ears, spreads to face
Day 2
Spreads to trunk and upper extremities
Day 3
Reaches lower extremities
Day 4
Begins to fade in order of appearance
- Red, blotchy, maculopapular rash
- Initially discrete lesions that become confluent
- Accompanied by highest fever
- May leave brownish discoloration as it fades
- Can be followed by fine desquamation
Other Clinical Manifestations
| System | Manifestations |
|---|---|
| General | High fever (often >104°F/40°C), malaise, fatigue, anorexia |
| Respiratory | Cough (typically dry, becoming productive), rhinorrhea, nasal congestion, sore throat, hoarseness |
| Ocular | Conjunctivitis, photophobia, periorbital edema, excessive tearing |
| Gastrointestinal | Nausea, vomiting, diarrhea, abdominal pain (more common in children) |
| Lymphatic | Generalized lymphadenopathy, particularly occipital and cervical nodes |
| Neurological | Headache, irritability, altered mental status (if complications develop) |
Warning Signs of Severe Disease
Be vigilant for the following signs that may indicate severe measles or developing complications:
- Persistent high fever after 3 days of rash
- Severe respiratory distress (stridor, wheezing, cyanosis)
- Severe dehydration
- Neurological symptoms (seizures, altered consciousness)
- Poor feeding in infants
- Severe vomiting or diarrhea
- Signs of bacterial superinfection (purulent discharge, severe ear pain)
These signs require immediate medical attention and may necessitate hospitalization.
5. Diagnosis and Assessment
Accurate diagnosis of measles is critical for appropriate nursing management and infection control. While clinical presentation is often suggestive, laboratory confirmation is important, especially in regions where measles is not common.
Nursing Assessment
Comprehensive Assessment Components
Laboratory Diagnosis
| Test | Details | Nursing Considerations |
|---|---|---|
| Serology (IgM antibodies) |
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| RT-PCR |
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| Viral Culture |
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Differential Diagnosis
Nurses should be aware of other conditions that may present similarly to measles:
Other Viral Exanthems
- Rubella (German measles)
- Roseola (HHV-6)
- Erythema infectiosum (Fifth disease)
- Varicella (chickenpox)
- Enterovirus infections
Non-Infectious Conditions
- Drug eruptions
- Kawasaki disease
- Stevens-Johnson syndrome
- Toxic shock syndrome
- Allergic reactions
MEASLES Diagnostic Approach
M Manifestations – classic symptoms (3 C’s)
E Exposure – history of contact with infected person
A Appearance – of rash and its progression
S Spots – look for Koplik spots
L Laboratory – confirmation when possible
E Exclude – differential diagnoses
S Severity – assess for complications
Reporting Requirements
Measles is a notifiable disease in most countries. Nurses should be aware of local reporting requirements:
- Report suspected cases immediately to local public health authorities
- Do not wait for laboratory confirmation to report
- Provide information on vaccination status, exposure history, and contacts
- Facilitate contact tracing by collecting appropriate information
6. Nursing Management in Hospital
Hospital-based nursing management of measles requires a comprehensive approach focusing on infection control, symptom management, complication prevention, and supportive care. Nurses play a crucial role in the multidisciplinary management of hospitalized children with measles.
Infection Control Measures
Isolation Precautions
Supportive Care
Respiratory Support
- Position patient to optimize respiratory function (semi-Fowler’s position)
- Administer humidified oxygen as needed to maintain saturation >95%
- Monitor respiratory rate, effort, and oxygen saturation
- Perform chest physiotherapy as indicated
- Suction secretions as needed, particularly in young children
- Prepare for intubation and mechanical ventilation if severe respiratory distress develops
Fever and Discomfort Management
- Administer antipyretics as prescribed (acetaminophen/paracetamol preferred)
- Provide tepid sponging for high fever (>39°C)
- Ensure appropriate clothing and light bedding
- Monitor temperature trends and response to interventions
- Assess pain using age-appropriate scales
- Provide comfort measures and distraction techniques
Fluid and Nutritional Support
- Maintain accurate intake and output records
- Assess hydration status regularly (mucous membranes, skin turgor, fontanelle in infants)
- Administer IV fluids as prescribed for dehydrated patients
- Encourage oral fluids when tolerated
- Offer small, frequent, easily digestible meals
- Consider nasogastric or enteral feeding for prolonged poor intake
- Monitor weight daily in young children
Skin and Mucous Membrane Care
- Provide gentle skin care, avoiding harsh soaps
- Apply moisturizers to prevent dryness during desquamation phase
- Change position frequently to prevent pressure ulcers
- Promote good oral hygiene with soft toothbrush or mouth swabs
- Apply lubricating eye drops for conjunctivitis
- Dim lights if photophobia is present
Pharmacological Management
| Medication | Indication | Nursing Considerations |
|---|---|---|
| Vitamin A |
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| Antibiotics |
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| Antipyretics |
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Monitoring and Complication Management
Key Monitoring Parameters
Respiratory System
- Respiratory rate, pattern, effort
- Oxygen saturation
- Breath sounds
- Cough character and frequency
Neurological Status
- Level of consciousness
- Irritability
- Headache severity
- Seizure activity
- Nuchal rigidity
General Status
- Vital signs q4h or more frequently if unstable
- Hydration indicators
- Rash progression
- Oral intake
- Urine output
Complication Management
Be prepared to quickly identify and respond to these common complications:
| Complication | Nursing Interventions |
|---|---|
| Pneumonia | Increase respiratory monitoring, administer oxygen, position for optimal breathing, assist with sputum specimen collection, prepare for chest X-ray, administer antibiotics |
| Encephalitis | Neurological assessments q2-4h, seizure precautions, elevate head of bed 30°, minimize stimulation, prepare for lumbar puncture, administer anticonvulsants if prescribed |
| Dehydration | Intensify fluid monitoring, strict I&O, daily weights, administration of IV fluids, monitoring of electrolytes |
| Otitis Media | Assess for ear pain, monitor temperature, position with affected ear up, administer analgesics and antibiotics |
Psychosocial Support
7. Home Care Management
Many children with uncomplicated measles can be managed at home with appropriate nursing guidance and support. Effective home care management requires comprehensive parent education and regular follow-up.
Parent Education
Infection Control at Home
- Keep child isolated from non-immune household members
- Practice good hand hygiene before and after caring for the child
- Avoid sharing personal items
- Cover coughs and sneezes with tissues
- Disinfect frequently touched surfaces
- Restrict visitors until 4 days after rash onset
- Notify school, daycare, and close contacts of exposure
Symptom Management
- Administer antipyretics as prescribed for fever management
- Use humidifier to ease respiratory symptoms
- Dim lights for photophobia
- Provide cool, soft foods for sore throat
- Use warm saline gargles for older children
- Apply petroleum jelly to crusty lesions if needed
- Provide quiet activities during recovery
Hydration and Nutrition
- Offer small, frequent sips of fluids
- Encourage popsicles, ice chips, and favorite beverages
- Monitor urine output (at least 4-6 wet diapers per day in infants)
- Provide small, frequent meals of favorite foods
- Avoid spicy, acidic, or rough-textured foods
- Continue breastfeeding for infants
- Track fluid intake with a simple chart
When to Seek Medical Care
- Difficulty breathing or rapid breathing
- Persistent high fever for more than 2 days
- Severe headache, stiff neck, or altered consciousness
- Persistent vomiting or inability to keep fluids down
- Severe ear pain
- Significant decrease in urine output
- Seizures or convulsions
- Severe cough or chest pain
Home Monitoring Guidelines
Daily Monitoring Checklist for Parents
| Parameter | What to Check | Concerning Signs |
|---|---|---|
| Temperature | Check temperature 2-4 times daily | Fever above 39.5°C (103°F) that doesn’t respond to medication or persists more than 3 days after rash appears |
| Hydration | Track fluid intake and urine output; check for moist mucous membranes | Decreased urination, dark urine, dry mouth, absence of tears, sunken eyes or fontanelle |
| Breathing | Count breaths for 1 minute while child is at rest | Fast breathing (>40 breaths/min in children >1 year; >50 in infants), difficulty breathing, chest indrawing |
| Activity Level | Observe for playfulness, interest in surroundings | Lethargy, excessive sleepiness, difficulty waking, irritability |
| Feeding | Record number of feeds and amount consumed | Refusal to eat or drink for more than 8 hours, inability to keep anything down |
| Rash | Monitor progression and appearance | Rash that becomes purple, bruise-like, or does not fade with pressure |
Parents should record observations daily and share this information during follow-up appointments or phone consultations.
Follow-up Care
Follow-up Schedule and Nursing Interventions
HOME CARE for Measles – Parent Education Mnemonic
H Hydration – maintain adequate fluid intake
O Observe – for warning signs requiring medical attention
M Medications – give antipyretics and prescribed medications as directed
E Environment – keep room quiet, dim, and comfortable
C Containment – prevent spread to others
A Activity – allow for adequate rest
R Respiratory care – use humidifier, monitor breathing
E Eating – encourage small, frequent nutritious meals
8. Prevention and Control
Prevention and control of measles is primarily achieved through vaccination, but also includes various public health measures. Nurses play a vital role in both individual and community-level prevention efforts.
Vaccination
MMR Vaccine Schedule
The measles, mumps, and rubella (MMR) vaccine is highly effective at preventing measles:
- First dose: 12-15 months of age
- Second dose: 4-6 years of age
- Two doses provide approximately 97% protection against measles
- Can be given as MMR or MMRV (includes varicella)
Special Vaccination Considerations
- Catch-up vaccination: For unvaccinated children and adults without evidence of immunity
- International travel: Infants 6-11 months should receive one dose before travel to endemic areas
- Outbreak response: Age of first dose may be lowered to 6 months in outbreak settings
- Healthcare workers: Should have documented immunity through vaccination or serology
Contraindications
- Severe allergic reaction to previous dose or vaccine component
- Pregnancy
- Severe immunodeficiency
- Recent administration of blood products or immunoglobulins
- Moderate or severe acute illness
Nursing Role in Vaccination
- Screen for contraindications and precautions
- Educate parents about benefits and potential side effects
- Address vaccine hesitancy with evidence-based information
- Ensure proper storage, handling, and administration
- Document vaccination in appropriate records
- Schedule follow-up for second dose
Post-Exposure Prophylaxis
| Intervention | Indication | Timing | Nursing Considerations |
|---|---|---|---|
| MMR Vaccine |
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Within 72 hours of exposure |
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| Immune Globulin (IG) |
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Within 6 days of exposure |
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Outbreak Control Measures
Public Health Interventions
The Role of Herd Immunity
Herd immunity is crucial for protecting those who cannot be vaccinated against measles:
- Requires 93-95% vaccination coverage in a population to prevent sustained transmission
- Protects vulnerable groups including:
- Infants too young to be vaccinated
- Pregnant women
- Immunocompromised individuals
- Those with medical contraindications to vaccination
- Declining vaccination rates have led to resurgence of measles in previously controlled regions
- Nurse-led education about the importance of community protection is vital
Prevention in Healthcare Settings
Healthcare Facility Measures
Staff Protection
- Verify immunity status of all healthcare personnel
- Vaccinate non-immune staff without contraindications
- Maintain documentation of immunity status
- Develop protocols for post-exposure management
- Exclude susceptible exposed staff from work
Facility Protocols
- Screen patients for measles symptoms at entry points
- Implement respiratory hygiene/cough etiquette
- Establish rapid triage protocols for suspected cases
- Designate isolation rooms with appropriate ventilation
- Develop notification systems for potential exposures
Patient Management
- Schedule suspected measles cases at end of day when possible
- Have patients use separate entrances when available
- Provide masks to patients with respiratory symptoms
- Minimize time in waiting areas
- Maintain airborne precautions during visits
- Ensure rooms used by measles patients remain vacant for at least 2 hours after use
PREVENT Measles Mnemonic
P Promote vaccination according to schedule
R Recognize early symptoms for prompt isolation
E Educate families and communities about measles
V Verify immunity status of contacts
E Enforce infection control measures
N Notify public health authorities of cases
T Trace contacts for post-exposure prophylaxis
9. Complications of Measles
Despite being considered a childhood illness, measles can lead to serious complications, particularly in young children, malnourished individuals, and those with compromised immune systems. Recognizing and promptly addressing these complications is a critical nursing responsibility.
Risk Factors for Complications
- Age <5 years or adults >20 years
- Malnutrition, particularly vitamin A deficiency
- Immunocompromised states (HIV/AIDS, chemotherapy, transplant recipients)
- Pregnancy
- Underlying chronic conditions
- Unvaccinated status
- Overcrowded living conditions
Children with these risk factors require closer monitoring and more aggressive management.
Major Complications by System
| System | Complications | Assessment Findings | Nursing Interventions |
|---|---|---|---|
| Respiratory |
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| Neurological |
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| Gastrointestinal |
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| Ocular |
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| Hematological |
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Special Focus: SSPE
Subacute Sclerosing Panencephalitis (SSPE)
SSPE is a rare but devastating late complication of measles infection:
- Pathophysiology: Progressive, fatal neurological disease caused by persistent measles virus infection in the brain
- Incidence: Approximately 4-11 per 100,000 measles cases; higher risk when infection occurs before age 2
- Latency period: Usually appears 7-10 years after acute measles infection
- Clinical progression:
- Stage 1: Behavioral changes, poor school performance, mood changes
- Stage 2: Myoclonic jerks, seizures, motor dysfunction
- Stage 3: Rigidity, progressive unresponsiveness, autonomic instability
- Stage 4: Coma, vegetative state, minimal brain functioning
- Diagnostic findings: Elevated measles antibodies in CSF, characteristic EEG patterns
- Treatment: No curative treatment; supportive care and seizure management
- Prognosis: Usually fatal within 1-3 years of diagnosis
- Prevention: Measles vaccination is the only effective prevention
Nursing implications: SSPE highlights the critical importance of measles prevention through vaccination, even in countries where acute measles is now rare. When discussing vaccination with parents, nurses should include information about this devastating late complication.
Complications in Special Populations
Pregnant Women
- Increased risk of pneumonia
- Higher hospitalization rates
- Potential for premature labor
- Spontaneous abortion
- Low birth weight infants
- Maternal death (rare)
Nursing focus: Close monitoring of respiratory status and fetal well-being
Immunocompromised Children
- Prolonged viral shedding
- Atypical presentation without rash
- Giant cell pneumonia
- Progressive measles encephalitis
- Higher mortality rates
Nursing focus: Extended isolation, vigilant monitoring for subtle symptom changes
Malnourished Children
- More severe disease course
- Higher risk of all complications
- Prolonged recovery time
- Increased likelihood of corneal ulceration
- Higher case fatality rate
Nursing focus: Nutritional rehabilitation, vitamin A supplementation
Early Recognition: The Key to Preventing Mortality
The majority of measles-related deaths are due to complications rather than the disease itself. Early recognition and prompt intervention are critical for preventing adverse outcomes:
- Teach parents specific warning signs that require immediate medical attention
- Implement more frequent follow-up for high-risk children
- Ensure vitamin A administration per WHO guidelines for all children with measles
- Maintain high index of suspicion for complications even during recovery phase
- Develop systems for rapid assessment and referral when complications are suspected
10. Case Study and Application
Case Study: 4-year-old with Measles
Clinical Scenario:
Michael, a 4-year-old boy, is brought to the emergency department with a 3-day history of high fever (39.8°C), cough, coryza, red eyes, and irritability. Today, his mother noticed a red rash beginning behind his ears and spreading to his face. He has no documented measles vaccination. On examination, you note Koplik spots on his buccal mucosa, conjunctivitis, and a maculopapular rash on his face and upper neck. His respiratory rate is 32 breaths/minute with occasional coughing episodes. He appears tired and is clinging to his mother.
Assessment
Subjective Data
- 3-day history of high fever
- Cough and runny nose
- Irritability and fatigue
- New onset of rash starting behind ears
- No documented measles vaccination
- Mother reports decreased appetite
Objective Data
- Temperature: 39.8°C
- Respiratory rate: 32 breaths/minute
- Koplik spots present on buccal mucosa
- Bilateral conjunctivitis
- Maculopapular rash on face and upper neck
- Intermittent coughing episodes
- Appears fatigued and clingy
Nursing Diagnosis
- Hyperthermia related to inflammatory process as evidenced by temperature of 39.8°C
- Ineffective breathing pattern related to inflammatory process as evidenced by tachypnea and coughing
- Risk for deficient fluid volume related to fever, decreased oral intake, and increased insensible losses
- Risk for impaired skin integrity related to rash and potential for scratching
- Risk for infection transmission related to highly contagious nature of measles virus
Planning and Implementation
Evaluation and Outcomes
- Temperature decreased to 38.2°C after antipyretic administration
- Respiratory rate remains elevated but no signs of respiratory distress
- Michael is drinking small amounts of fluid and has had appropriate urine output
- Rash has spread to trunk following expected progression
- Laboratory results confirm measles diagnosis
- Parents demonstrate understanding of home care instructions
- Contact investigation initiated by public health department
Discharge Planning
- Continue isolation at home until 4 days after rash onset
- Follow up with primary care provider in 48-72 hours
- Return to emergency department if:
- Difficulty breathing or rapid breathing
- Persistent high fever despite antipyretics
- Severe headache or stiff neck
- Lethargy or decreased responsiveness
- Inability to drink or persistent vomiting
- Complete measles vaccination for siblings without contraindications
- Schedule MMR vaccination for Michael once recovered
Critical Thinking Questions for Nursing Students
Assessment
- What additional assessment data would be helpful for this patient?
- How would your assessment priorities differ if Michael were 10 months old instead of 4 years old?
- What complications should you be monitoring for based on Michael’s presentation?
Planning
- What isolation precautions are necessary, and how would you explain these to the family?
- Develop a plan for monitoring Michael’s hydration status at home.
- What community resources might be helpful for this family during the isolation period?
Intervention
- How would you address vaccine hesitancy if the parents express concerns about future vaccinations?
- What techniques could you use to encourage fluid intake in a reluctant 4-year-old?
- How would you modify your care if Michael developed signs of encephalitis?
Evaluation
- What outcomes would indicate successful home management of measles?
- How would you evaluate the effectiveness of your teaching about complications?
- What follow-up is needed to ensure community protection from this case?
M.E.A.S.L.E.S Clinical Reasoning Framework
M Monitor for complications and disease progression
E Educate patients and families about the disease and home care
A Assess thoroughly, focusing on respiratory and hydration status
S Support comfort through symptom management
L Limit transmission through appropriate isolation
E Ensure adequate nutrition and hydration
S Secure follow-up care and vaccination planning