Nursing Care of most Common Communicable Diseases of Children in Egypt

General Objective:
The student will gains knowledge and skills about the most common communicable diseases and is able to provide nursing care to children contracting these diseases.

Specific Objectives:
The student will be able to; 1. Identify the most common communicable diseases in Egypt, which are caused by viruses or bacteria. 2. Define the incubational period, communicability period and the mode of transmission of each disease. 3. Assess the nursing problems and the childs needs when he has diphtheria, pertussis, tetanus, scarlet fever, poliomyelitis, measles, German measles, chicken pox, and mumps. 4. Plan for the nursing care of such cases. 5. Know the Prevention of such diseases through immunization.

Introduction:
Communicable disease is defined as an illness caused by an infectious agent or its toxins, which can be transmitted directly or indirectly to a well person. Communicable diseases are caused either by bacteria or virus. Sources of infection consist of man, animal, contaminated food or water, insects and environmental factors, such as, dust and dirt.

Incidence:
More common in pre-school and school-age children due to their exposure to environmental condition unlike those at home.

Definitions of Terms:
Incubational Period:
Time that elapses between the invasion of microorganism and the appearance of signs and symptoms of disease.

Communicability Period:
Time during which the person stricken with the disease and can transmit it to another person directly or indirectly.

Mode of transmission:
Method of spread of disease to man.

Common Communicable Diseases Caused by Bacteria:

1. Diphtheria Etiology:
Corynebacterium diphtheria (Diphtheria bacillus).

Incubational Period:
2-5 days or longer.

Communicability Period:
Several hours before onset of the disease until organism disappear from the respiratory tract.

Mode of Transmission:
Droplet from respiratory tract of an infected person or a carrier directly or indirectly.

Nursing Assessment:
A child with diphtheria usually seeks medical help for one of the following complains (sometimes they are called types).

1. Sore throat:
Fever. Difficulty to swallow. Swelling of the neck. Exudates or a yellow-gray membrane on tonsils and may be the pharynx. (Membrane varies from thin to thick one). Hoarse or croupy cough and stridor. Noisy respiration, the child may have severe respiratory distress. The membrane may cover the vocal cord (When examined with laryngoscope). Purulent, bloody nasal discharge. The membrane can be seen on the nasal septum. This skin ulcer can be confused with impetigo (skin disease). The membrane is not always present in diphtheria.

2. Croup:

3. Nasal discharge:

4. Infected skin ulcer: 5. Other sings and symptoms:

That could be present (especially in severe cases): Purulent conjunctivitis. Otitis media. Ulcerative vulvo-vaginitis. Toxins from organisms produces fever and malaise.

Nursing Consideration:
1. Isolate the child (place him in isolating room, use medical aseptic techniques). Keep the child in isolation until 2 consecutive nose and throat culture are negative (24 hours apart between the two cultures). 2. Bed rest for about 6 weeks for all types except in nasal diphtheria. 3. For respiratory distress (if present): suction to trachea and larynx to remove secretions and pieces of membrane, oxygen humidifier. 4. For fever: check vital signs, use 2-3-4 hours schedule; depending on the degree of fever, degree of respiratory embarrassment and change in pulse rate. Check blood pressure frequently. 5. For the membrane: Oral hygiene (warm mouth wash, never use tooth brush or swabs because of danger of distracting the membrane leading to bleeding and rapid spread of toxins into blood system. 6. Observe: vital signs, secretion and the need for suction, observe signs and symptoms of paralysis. 7. Tracheostomy and /or intubation trays must be ready at bedside table of the child. If tracheostomy or intubation is done, apply the proper care of tracheostomy or intubation. In intubation, the child can expel the tube when he coughs, so watch constantly as he cant call for help. Frequent suctioning of the tube use proper restraints so that he will not remove the tube. 8. If myocarditis appears as a complication, guard the child for exhaustion, beside the other nursing care.

Treatment:
Bed rest. Antibiotics. Anti-toxins.

Prevention:
1. Active immunization: DPT vaccine. 2. Passive immunization: injection with anti-toxins.

Complications;
Bronchopneumonia. Kidney dysfunction. Paralysis. Myocarditis. Cardiac failure.

2. Pertussis (Whooping Cough) Etiology:

Gram-negative bacillus.

Incubation Period:
5-14 days.

Communicability Period:
4-6 weeks from the onset of the disease.

Mode of Transmission:
Droplet (direct and indirect).

Nursing Assessment:
Three stages: a- Catarrhal stage: (coryza or prodormal stage) It lasts 7-14 days. Mild fever, headache, anorexia. Sneezing. Persistent cough with tearing. b- Paroxysmal stage (Spasmodic or whooping stage): Lasts 14-28 days (2-4 weeks). Paroxysmal cough develops. It is characterized by several sharp coughs in one expiration, followed by one deep inspiration, which may be accompanied by a whoop. Cough is worse at night, interferes with sleep and frequently causes vomiting. With cough, face becomes flushed and in some instances cyanosis and dyspnea might occur. Anorexia. Lymphocytosis occurs.

c- Convalescent stage:
It lasts 21 days. Cough and vomiting become less.

Nursing Consideration:
1. Isolation: Disinfection all utensils. 2. Bed rest: keep the child in bed in a well ventilated room. 3. For paroxysmal stage: Provide; Calm atmosphere to avoid emotional swings as laugh and cry causing coughing attacks. Avoid dust in the room. Oxygen with humidity to relief cyanosis (may use oxygen tent). 4. For vomiting:

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6. 7. 8. 9.

Raise head and shoulders of older children to avoid aspiration of vomitus. For young children, place them on abdomen if no one is attending in the room. Mouth care. Small frequent feeding. Refeed the child immediately after vomiting. Accurate intake and output must be kept. For anorexia: High caloric soft diet. Encourage the child to eat. Weight the child daily. If anoxia occurs during paroxysms a tracheo-pharyngeal suction may be needed. So keep the suction machine available. Protect the child from secondary infection, keep him warm. Observe: respiratory distress and convulsions. Observe signs and symptoms of airway obstruction e.g. restlessness, cyanosis, retraction.

Treatment:
Symptomatic: sedatives and antispasmodics are important. Antibiotics are effective if given early (Ampicillin and Erythromycin).

Prevention:
a- Active immunization: DPT vaccine. b- Passive immunization: Gamma Globulin. c- In exposed immunized children, give an immediate booster dose of pertussis vaccine.

Complication:
Otitis media. Bronchiectasis. Hemorrhage may occur. Marasmus. Encephalitis. Pneumonia.

3. Tetanus (Lock Jaw) Etiology:

Clostridium tetanti (tetanus bacillus).

Incubational Period:
3-21 days.

Communicability Period:
Not communicable from man to man, as the organism usually live in animals intestinal tract.

Mode of Transmission:
Through a wound as organism is present in soil.

Nursing Assessment:
Onset of the disease is either gradual or acute. 1. Convulsions are the first warning symptoms in children. 2. Excessive irritability and restlessness. 3. Difficulty in swallowing. 4. Stiff neck. 5. Within 24-48 hours, the muscular stiffness progress: Trismus i.e. tight jaw, inability to open the mouth. Stiff arm and legs, then entire stiffness of the body. Swallowing usually becomes impossible. Resus sardonicus due to spasm of facial muscles. Opisthotonos, i.e., backward arching of the back as a result of the dominance of the extensor muscles of the spine, head draws back. These ongoing tetanic spasms lasts about 10 seconds and occurs following a slightest stimuli, such as, claming the door or bumping the bed. 6. Dyspnea and cyanosis can develop. 7. Fever 38.5 -40C. 8. Constipation may develop. 9. Lumbar puncture reveals increase reveals increase spinal fluid pressure.

Nursing Consideration:
1. Isolation. 2. Protect the child from any stimuli (auditory or tactile stimuli), so place the child in dark, quite room and minimum handling. 3. If dyspnea and cyanosis are present, give oxygen. 4. For tetanic spasm: Protect the child from falling.

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6. 7. 8. 9.

The nurse must be alert for number, duration and frequency of convulsion (in relation to sedation administered). Record any change in trismus or inability to swallow. For inability to swallow: I.V. therapy for nutrition and fluid balance. Gavage feeding may be ordered. So, the nurse must report if insertion of the tube causes convulsions. Accurate intake and output chart is necessary. Mouth care if he can open his mouth. For constipation, give enema. Check vital signs carefully. If tracheostomy is performed; care of tracheostomy. Naso-pharyngeal suction is done frequently.

Treatment:
Antibiotics (Penicillin). Antitoxin. Tranquilizers.

Prevention:
1. Active immunization: DPT vaccine. 2. Passive immunization: Injection of tetanus immuno-globulin or antitoxin (a few hours after a wound occur).

Complication:
Anoxia. Atelectasis. Pneumonia.

4. Scarlet Fever Etiology:

Streptococcus pyogeneous. (Beta hemolytic streptococcus group A).

Incubational Period:
2-5 days.

Communicability Period:
From onset to recover.

Mode of Transmission:
Droplet infection, direct and indirect.

Nursing Assessment:
In acute sudden onset: (toxin from the site of infection is absorbed into blood stream). Prodromal signs: Vomiting. High fever then it drops when rash appears. Headache. Rapid pulse. Tongue: white tongue coating desquamates and red strawberry tongue results. Tonsils are red, enlarged, swallow, and may have a patchy whitish exudates on their surface. Then, rash appears within the first 5 days of the disease. The rash will be all over the body but not on the face. The chest and back are affected first, and then the rash moves down-wards involving the legs last. The rash fades upon pressure. Distinct odor of the skin. Desquamation i.e., peeling of the skin, is the typical of scarlet fever. Desquamation could occur early at 4-5-6 day or later to 4th week of the disease. It starts at the top of the body and proceeds downwards.

Nursing Considerations:
1. 2. 3. 4. Isolation. Bed rest for 12 days and good ventilated room. Keep patient warm, dry and comfortable as possible. For the distinct odor which associates with scarlet fever: daily bath and change linen frequently. 5. For skin: - Lubricate skin well with oil (daily) as Dr. order. - Protect skin under and around the nose and lips with ointment. (When nasal discharge is constant). 6. Nasal aspiration by gentle suction or soft rubber ear syringe is essential. 7. If the child is less than 2 years, elevate head and shoulders to prevent danger of otitis media. 8. Accurate intake and output chart is important. 9. Diet in the first week: High caloric liquids then soft diet. Avoid irritant liquid juice citrus. 10. For constipation, which accompanies scarlet fever enema or mild cathartics is needed. 11. If there is pain in cervical lymph nodes, treat with heat in the form of hot packs or cold in the form of ice collar according to doctors order. 12. Observe for complications.

Treatment:
Penicillin. Diet. Sedatives for pain.

Prevention:
No immunization.

Complication:
Rheumatic fever. Glomerulo-Nephritis. Pneumonia.

Communicable Diseases Caused by Virus:

1. Chicken Pox (Varicella)
This is a highly communicable disease in children.

Etiology:
Virus [Varicella- Zoster- Virus (VZV)].

Incubational Period:
10-21 days (2-3 weeks).

Communicability Period:
One day before and six days after the appearance of the first vesicle.

Mode of Transmission:

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Droplet (direct or indirect). Dry scabs are not infectious.

Nursing Assessment:
Onset is sudden with: Prodromal Stage: Mild or light fever. Anorexia. Headache. Acute Phase: Rash: Successive crops of macules, papules, vesicles, crusts (vesicles heals by forming the crusts by the end of the two weeks). (Acute Phase). Rash appears in successive crops and lesions in all stages of development at the same time. Rash is itchy.

Nursing Consideration:
1. Isolation: Use medical aseptic technique. Nasal and oral discharge, cloths and linens are currently disinfected. Keep the child in isolation until all crusts disappear. 2. For rash (lesion): Cleaning the skin according to doctors order once or twice daily. Cool sponge bath without soap. Change childs clothes and bed linens daily to prevent skin infection. For itchy lesions, nails must be cut and cleaned. Mittens and gloves to prevent skin scratching. Restraints may be needed to control scratching. Observe the skin lesions, change in appearance and it must be recorded. If lesions in mouth, mouth wash. If lesions in genital organ, apply cold compresses. 3. For fever: Check vital signs and record it, especially temperature. Keep records for the first 7 days of the disease. 4. If secondary infection to skin occurs: intake and out put chart must be kept accurate. 5. Observe for complications and report immediately to the doctor.

Treatment:
No specific treatment. To relieve itching, calamine lotion, antihistamine and local aneaethetaic ointment are prescribed. Antibiotics for secondary infection. Dont give aspirin due to high risk of Reye syndrome.

Prevention:
None

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Complication:
Abscess. Encephalitis. Glomerulonephritis may occur.

2. Measles (Rubeola)
Most cases occur before adolescent and it occurs more in spring months.

Etiology:
Virus RNA.

Incubational Period:
7-14 days (usually 10-20 days).

Communicability Period:
4 days before the appearance of rash to 5days after rash appearance.

Mode of Transmission:
Droplet (direct or indirect).

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Nursing Assessment:
a- Coryza: Primary symptoms which resembles common cold and occur before rash appearance: Sneezing. Fever (range from 38.5 to 40C, tending to be highest just before the appearance of rash). Brassy or barking cough. On the 4th day, conjunctivitis and photophobia. Acute catarrhal inflammation of the mucous membrane of the nose. Enlarged posterior cervical lymph nodes. b- Kopliks Spots: Are pathogenic appear on day before rash. Whitish spots resting on a reddish base appear on the inside of the mouth. They can appear and disappear suddenly. c- Rash: Rash appears on 2nd to 5th day and remain about a week. Appears first on face, behind the ears, on the neck, forehead or cheeks. Then, spread downwards over the rest of the body (trunk, arms, and legs). The rash is pinkish in color, begins with macular lesions which progress to the popular type. Then, rash becomes dark in color (brownish color on 5th day). Desquamation, which is find usually, follow the rash appearance and then fads (disappear). Rash is itchy.

Nursing Consideration:
1. Isolation. 2. Bed rest: Occupy the child in bed after acute phase with activities. Explain the reason for being in bed if the child is old enough to understand. 3. For photophobia and conjunctivitis: Subduced light make the child more comfortable. Dark room. Eye care with warm saline solution to remove secretions or crust. Keep childs hands away from eyes, examine coma for signs and symptoms of ulceration. 4. For fever: Measure the temperature carefully. Antipyretic as doctors order. Encourage fluids. Tipped compresses. 5. For itchy rash: Observe degree of itching and apply lotion or ointment as doctors order. 6. For Kopliks spots: Mouth care. Use gargle solution. 7. Carry out the plan of care of complicated cases, such as, encephalitis (convulsions), dyspnea. etc.

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Treatment:
Symptomatic. Antibacterial therapy.

Prevention:
abActive immunization: live attenuated vaccine. Passive immunization: Newborn through the mothers while they were in uterus. Gamma-globulin.

Complication:
Otitis media. Tracheobronchitis. Imptiago,purpura. Lymphoadenitis. Pneumonia. Encephalitis.

3. German Measles (Rubella)

It is not as communicable as measles. Fetus may contact the disease in uterus if the mother develops the disease during the pregnancy (1st trimester).

Etiology:
Virus.

Incubation Period:
14 to 21 days.

Communicable Period:
During Prodromal period and for 5 days after the rash.

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Mode of Transmission:
1. Direct contact with nose and throat secretions of infected persons. 2. Indirect via articles freshly contaminated with nasopharyngeal secretion. 3. Trans-placenta congenital infection form infected mother to the fetus.

Nursing Assessment:
Prodromal Stage: Mild fever (Disappear when rash appear). Slight malaise, headache, and anorexia. Running nose, sore throat. Rash is faint macular rash. It is small pinpoint pink or pale red macules which are closely grouped to look like scarlet blush (botchy), which fades on pressure. It begins on face and hairline move to trunk then extremities. - Rash disappears in 3 days. Swelling of posterior cervical and occipital lymph nodes. No Kopliks spots or photophobia.

Nursing Consideration:
1. Isolation especially form pregnant women. 2. Bed rest until fever subsided.

Treatment:
Symptomatic.

Prevention:
abActive immunization; live attenuated rubella virus vaccine. Passive immunization: Gamma- globulin.

Complication:
Fetus damage if mother contacts the disease during pregnancy. Newborn may have congenital anomalies, such as deafness, mirocephaly, mental retardation. Encephalitis.

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4. Mumps (infectious Parotitis)

Mumps is common in children 5-10 years. It is acute virus infectious disease, which may involve, many organs but commonly affects the salivary glands (mainly parotids glands).

Etiology:
Virus.

Incubational Period:
14-21 days.

Communicability Period:

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One to six days before the first symptoms appears until the swelling disappears.

Mode of Transmission:
Direct or indirect contact with salivary secretion of infected person.

Nursing Assessment:
1. Prodromal stage Corayza:
Low-grade fever. Vomiting. Headache. Malaise and anorexia.

Acute Phase:
2. Pain in or behind ears and pain on swallowing or chewing. 3. Swelling and pain in glands (unilateral or bilateral), which return to normal in 10 days. 4. Orchitis in males and mastitis in female adolescent may occur.

Nursing Consideration:
1. Isolation. 2. Bed rest until swelling disappears. 3. For fever: Encourage fluids and soft food, avoid food required chewing, and tipped compresses, antipyretics. 4. For glands: Mouth care and gargle frequently. Apply hot or cold compresses for the swelling. Use ice bag (watch weight of the bag in order not to increase the pain). 5. For Orchitis: Support scrotum, use cold compresses for 20 minutes, then, remove it for 30 minutes, then, reapply it for 20 minutesetc. 6. For Mastitis: Breast support, use cold compresses.

Treatment:
Symptomatic. Sedatives. abActive immunization: Live attenuated vaccine. Passive immunization: Gamma- globulin.

Prevention: Complication:
Rare, sterility, Ovaritis, inflammation of testicles, Deafness.

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5. Poliomyelitis (infantile Paralysis)

It attacks the brain stem and spinal cord.

Etiology:
Virus. The disease is caused by any one of 3 polioviruses: a- Type 1 (Brunhilde). b- Type 2 (Lansing). c- Type 3 (Leon).

Incubational Period:
5-14 days.

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Communicability Period:
Latter period of incubational period till the first week of acute illness.

Mode of Transmission:
Oral contamination by intestinal and pharyngeal secretions of infected person.

Predisposing Factors:
1. 2. 3. 4. 5. Fatigue and muscle exertions. Cortisone administration. Tonsillectomy and adenoectomy. Tooth extraction. I.M injection of D.P.T. vaccine.

Nursing Assessment:
Severity of nerve involvement can vary from an absence of all clinical signs of paralysis to complete paralysis. There are different possible consequences of infection: 1Inapparent Poliomyelitis: (Silent) No signs or symptoms appears. 2Abortive Poliomyelitis: Initial symptoms of upper respiratory tract infection: fever, headache, vomitingetc. 3Non-Paralytic Poliomyelitis: Problems as those of Aseptic Meningitis Syndrome: Stiffness of neck, back and limbs. Nausea and vomiting become more severe than stage II. Fever. Increase protein in C.S.F. 4Paralytic Poliomyelitis: This may begin with manifestations of the abortive or non-paralytic type. Spinal: paralysis appear within a day or two after the above manifestations and 2-5 days from onset of the disease: Muscles of the chest, abdominal wall, diaphragm, urinary bladder and bowel can be affected constipation or stool incontinent and urinary incontinent may occur. Bulbar: More life threatening. It causes damage to cranial nerve nuclei, vital centers of respiration, circulation and temperature control. It may leads to swallowing problem and regurgitation of fluids from nose and inability to swallow saliva, which puddles in the pharynx. If not aspirated chocking may occur. Encephalitis: Manifesting as encephalitis, only diagnosed as polioencephalitis if spinal or bulbar affections or both are present:

Paralysis of limbs is the most common affected muscles.

Convulsion. Personality disturbances.

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Nursing Considerations:
1. Isolation and bed rest. 2. In acute stage: Put the child under close observation. Notify the doctor about the degree and progress of the paralysis (7or8 days of the disease). Rate and type of respiration and signs of respiratory distress must be observed and reported. Oxygen therapy or place the child on respirator when cyanosis occurs. If tracheostomy is done in case of diaphragmatic paralysis, care of tracheostomy. 3. For paralysis: Change position frequently. Careful positioning for affected limbs each time he is turned or moved. To minimize the degree of deformity, correct body alignment and optimum position must be maintained. Place the child on firm mattress. Use footboard to prevent foot drop when child is on back. If the child is on abdomen, pull the mattress away from foot of bed and letting feet protrude over the edge to prevent pressure on toes. Application of heat to affected muscles to relax them. 4. Suction of the pharynx and postural drainage to prevent aspiration of secretions. 5. For swallowing difficulties: Soft diet if they can swallow with difficulty. If swallowing is difficult, use gavage feeding. 6. For incontinent: Skin care and perineal region is padded to provide absorption for excretions. Catheter may be done. 7. For constipation: Use enemas. 8. Treat fever and headache.

Treatment:
aSymptomatic. Physiotherapy.

Prevention:
Active immunization: Trivalent poliovirus vaccine. (TOPV). Sabine: Attenuated virus, which is administered orally. Salk: Killed virus, which is administered by injection. Note: If a child is affected by poliomyelitis, he must receive the vaccine to prevent further infection from the other poliovirus types. b- Passive immunization: Gamma- globulin.

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Complication:
Emotional disturbance. Gastric dilatation. Hypertension.

Nursing Care Plan for a Child with Communicable Disease:

Nursing Diagnosis:
Potential for infection related to (communicable disease). Risk factors: Susceptible host. Infectious agent.

Nursing Goal: (1)

Assist in identifying etiologic agent.

Nursing Intervention:
Recognize exanthema (rash) associated with communicable disease.

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Operate under a high index of suspicious for children who are susceptible to infectious diseases. Identify high-risk children to whom communicable disease may be fatal. In case of cut-break, advice parents to confine child to home. Assist in performing tests used to identify the organism, such as collection of specimens for culture. Be aware of significance of test results in terms of the etiologic agent and childs level of immunity.

Expected Outcome:
Disease is recognized early. Appropriate interventions are implemented. Prevent occurrence of the disease.

Nursing Goal: (2) Nursing Intervention:

Participate in public education regarding prophylactic immunization and method of spread of communicable disease. Participate in immunization programs or screening programs to identify streptococcal infections.

Expected Outcome:
Disease is prevented.

Nursing Goal: (3)

Prevent spread of the disease.

Nursing Intervention:
Institute appropriate isolation procedures. Make referral to public health nurse when necessary to ensure appropriate isolation procedures at home. Work with families to ensure compliance with therapeutic regiments. Identify close contacts who may require prophylactic treatment (specific immune globulin or antibiotics). Report disease to local health department.

Expected Outcome:
Infection remains confined to original source.

Nursing Goal: (4)

Prevent complications.

Nursing Intervention:
Ensure compliance with therapeutic regimen (bed rest, antibiotics, adequate hydration). Institute seizure precautions if febrile convulsion is a possibly. Monitor temperature as unexpected elevations may signal infection. Attention to good body hygiene. Ensure adequate hydration: With small frequent sips of water or favorite drinks and soft bland food (gelatin, pudding, ice or soups).

Feed again after vomiting.

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Observe for signs of hydration

Expected Outcome:
Child exhibits no evidence of complications, such as infection or hydration.

Nursing Diagnosis:
Potential for impaired skin integrity related to (disease). Risk factors: Child with propensity to scratch.

Nursing Goal:
Prevent child from scratching the skin.

Nursing Intervention:
Keep nails short and clean. Apply mittens or elbow restraints. Dress in light weight, loose and non-irritating clothes. Cover affected area (e.g., long sleeves, pants). Bath in cool water with no soap or apply cold compresses. Apply soothing lotions. Avoid exposure to heat or sun. Skin remains intact.

Expected Outcome:

Nursing Diagnosis:
Impaired social interaction related to isolation.

Nursing Goal: (1)

Prepare the child for isolation if hospitalized.

Nursing Intervention:
Explain reason for confinement and use of any special precautions. Child demonstrates understanding of isolation.

Expected Outcome: Nursing Goal: (2)

Promote social interaction.

Nursing Intervention:
Allow the child to play with gloves and gown. Always introduce your self (as a nurse) to child and allow him to see your face before wearing the protective clothes. Provide diversionary activities. Encourage parents to remain with the child during hospitalization. Help child views isolation as challenging rather than solely negative experience. Encourage contact with friend via telephone (in hospital he can use intercom between childs room and nurse station).

Expected Outcome:

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Child engages in suitable activities and interactions.

Nursing Diagnosis:
Pain related to skin lesions.

Nursing Goal:
Relive discomfort.

Nursing Intervention:
Keep mucous membranes moist, so, use cool- moist vaporizer and gargles. Apply petroleum to chapped lips or nares. Cleanse eyes with saline solution. Keep skin clean (change bed clothes and linens at least daily). Administer oral hygiene. Assess need for pain and antipyretic medication. Employ non-pharmacological pain reduction techniques, such as distraction through quite play. Skin and mucous membrane are clean and free of irritants. Child exhibits minimum evidence of discomfort.

Expected Outcome:

Nursing Diagnosis:
Altered family processes related to child with an acute illness.

Nursing Goal:
Provide emotional support.

Nursing Intervention:
Reinforce familys effort to carry out the plan of care. Provide assistance when necessary, such as, visiting the nurse to help with home care. Keep family aware of childs progress, stress rapidly of recovery in most cases. Prepare childs peers for altered physical appearance, such as, with chicken pox, poliomyelitisetc.

Expected Outcome:
Family continues to comply with expectations. Peers accept the child.

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