Post-registration Certificate Course in

Infection Control Nursing

2022-2023

Patient Care Study on patient with

Varicella Zoster (Chickenpox)

Student Name : Wan Yuen Ki (APN)

Parent Hospital : Ruttonjee & Tang Siu Kin Hospital

Mentor : Penoy Wong (APN)

Word Count : 2500 words

Submission Date : 20 Jul 2023

 Contents

1. Introduction P.

2. Learning Objectives P.

3. Pathophysiology of Chickenpox P.

4. Patient Care Plan P.

Patient Profile P.
Nursing Assessment P.
Nursing Diagnosis P.
Intervention and Rationale P.
Evaluation P.

5. Conclusion P.

6. References P.

7. Appendix P.
Introduction

Chickenpox, caused by varicella zoster virus (VZV), is a highly contagious disease that is
transmitted from person to person with direct contact or airborne spread.1 It is the same virus that
causes herpes zoster. Chickenpox is usually self-limited, but may cause severe complications such as
lower respiratory tract infection, skin and soft tissue infection, or even death.1
Although VZV infection is generally a self-limited illness in immunocompetent children, serious
and life-threatening complications occur more commonly in certain groups of patients, particularly
neonates, pregnant women, adults, and immunocompromised persons. 5-12 For these reasons,
infection control of VZV is important in hospital settings where patients are at higher risk of severe
morbidity and mortality. In addition to patients, healthcare workers (HCWs) have the potential of
exposure to VZV from infected patients. Furthermore, VZV can be transmitted to and from HCWs and
other susceptible patients in the hospitals. To prevent the transmission of VZV infection in the
hospital settings, the development and implementation of hospital policies for appropriate infection
control is warranted.

Learning Objective

In this patient care study, I would like to illustrate the importance of early diagnosis of
chickenpox. Hence, strategies of outbreak control and investigation for preventing further
spread of disease, together with the specific nursing care and treatment can be carried out.

Pathophysiology

After a case of chickenpox run its course, the virus lies dormant in the ganglia of the spinal nerve
tracts. Then the virus reactivates and travels along the peripheral nerves to the skin, where the
viruses multiply and produce painful vesicular eruptions. It is most common in older adults and
people who are immunocompromised.

Although VZV typically affects the trunk of the body, the virus may also be noted on the buttocks
or face. If an ophthalmic nerve is involved, the client may potentially experience keratitis, ulceration,
and possibly blindness. Secondary infection resulting from scratching the lesions is common.

An individual with an outbreak of VZV is infectious for the first 2 to 3 days after the eruption. The
incubation period ranges from 7 to 21 days. The total course of the disease is 10 days to 5 weeks from
onset to full recovery. Some individuals may develop painful post herpetic neuralgia long after the
lesions heal.
Chickenpox is characterized initially by a burning, tingling, numbness, or itchiness of the skin in
the affected area. VZV infection can lead to central nervous system (CNS)
involvement; pneumonia develops in about 15% of cases. Approximately 20% of people who have had
chickenpox will develop herpes zoster.

Nursing Care Plan

Patient’s Profile

Miss Leung is a 23-year-old clerk, she has no medical history with good past health. She lived
with her mother and grandfather. She had no travel history and animal contact.
Miss Leung presented to the emergency department with 2-day history of fever up to 39°C, with
malaise and headache. She had appeared a new onset rash over right peri-orbital area and chin area
1 day earlier. The rash was non-itchy. Initially, she admitted to general ward for management.
2-day after admission, the rash spread up to abdomen and trunk. Some of the vesicular rash
with fluid filled and become itchy. A second opinion was also requested from the dermatology
department who confirmed the likely clinical diagnosis of viral exanthema. Miss Leung was sent to
isolation ward for care with suspected varicella infection.
On examination, she was feverish at 38.6°C with a heart rate of 73 beats/min and blood
pressure of 122/88. She had a widespread maculopapular rash with small pustules, which were
coalescing in parts, covering her trunk, back of ears and both lower limbs. There were a few scattered
excoriation marks over the torso and limbs. Cardiovascular, respiratory and abdominal examinations
showed no significant findings. Her vesicle fluid and blood were sent out for viral culture and serology
(IgG) for VZV, and monkey pox. Unfortunately, the laboratory was not able to process VZV IgM.
Nursing Assessment

Central nerve system Glasgow Coma Scale(GCS): E4V54M6, Pupils Equal 3mm and reactive to
light
Respiratory system Oxygen saturation(SpO2) 100%, Respiratory rate(RR) 15/min, on room
air. Air entry equal in bilateral lung field and vesicular lung sound was
auscultated, no abnormal lung sound noted.
Cardiovascular system NIBP 122/86 mmHg, HR 73 bpm (sinus rhythm)
Haemoglobin 11.8 g/dL, platelet count 141 x109/L, International
normalised ratio (INR)1.01

Gastrointestinal system Allow diet as tolerance, good appetite. Hstix 4.9mmol/L,

Abdomen soft and no distention; bowel sound normal
Liver function test: Alkaline phosphatase 36 IU/L, alanine transaminase
33 IU/L

Renal system Self-voiding with clear urine

Renal function test: Na 137 mmol/l, K 3.6 mmol/l, urea 4.6 mmol/l,
creatinine 56 μmol/l

Skin integrity Maculopapular rash with small pustules, which were coalescing in
parts, covering her face, trunk, back of ears and both lower limbs.
Mobility 4 Limbs power 5/5, self-care independently

Pain/ Discomfort Complain of pain, as a tingling sensation and pruritus over the truck,
back and face. Numerical Rating Scale: 7/10
Laboratory result WBC 2.53 x109/L, Lymphocyte 1.36 x109/L, Neutrophil 1.88 x109/L
C-reactive Protein 22 mg/L. Atypical Lymphocytes 0.36 x10 9/L
Microbiology Temperature 38.6 °C
Vesicular fluid Monkey pox virus DNA, PCR : Not detected
Varicella zoster virus DNA, PCR : Detected
Blood Malaria Parasite : Not detected
Malaria parasite : Not detected
Measles virus Ag IgM : Not detected
Dengue fever : Not detected
Using of: Oral Acyclovir, Doxycycline, Panadol, Ibuprofen, Piriton
For the contact tracing, due to the direct contact with the others (Staffs, relatives, patients who are
stay in the same cubicle the day before)

1 IgG positive
1 IgG Negative
Grandfather: Old age with risk of infection

Major nursing goals for a client with Chickenpox may include increased understanding of the

disease condition and treatment regimen, relief of discomfort from the lesions, emphasis on strict

contact isolation, development of self-acceptance, and absence of complications.

The following are the nursing priorities for patients with zoster:

Manage acute pain and discomfort

Minimize complications and infections

Promote healing and prevent scarring

Educate patient on self-care measures

Support emotional well-being

Nursing assessment

Nursing Diagnosis Interventions Rationale

Knowledge Deficiencies
regarding disease,
prognosis, treatment,
self-care, and discharge
needs
Independent
Assess emotional ability to
assimilate information and
understand instructions. Respect
client’s need to use denial and
coping techniques initially.
Plan frequent short sessions for
teaching. Include written
information—a few pieces at each
visit.
Initial shock and anxiety can
block intake of information.
Self-esteem, lifestyle, and
denial of own responsibility in
acquiring or transmitting
disease become issues that
must be dealt with.
Client will likely feel
overwhelmed and need time
and repeated contacts to
absorb information, the scope
 of, and the requirements
for treating the infection.
Written materials allow for
later review and reinforcement
of information presented.
Include significant other (SO) and Provides opportunity to learn
family in discussions and information first hand, ask
conferences, as appropriate. questions, and provide support
for client.

Expected outcomes
Knowledge: Disease Process
Verbalize understanding of condition, disease process, and potential complications.

Identify relationship of signs and symptoms to the disease process and correlate symptoms with causative factors.

Knowledge: Treatment Regimen

Verbalize understanding of goals of treatment.

Initiate necessary lifestyle changes.

Participate in treatment regimen.

Nursing Diagnosis Interventions Rationale

Risk for Social Isolation

Expected outcomes
Social Support
Identify stable support system and supportive individual(s).

Use resources for assistance, as appropriate.

Express increased sense of self-esteem.

Nursing Diagnosis Interventions Rationale

Acute Pain Assess for presence of pain. Help Pain is a frequent problem in
related to client identify and quantify the majority of the SCI
Physical injury; damage or pain, including, location, type of population and can occur not
dysfunction of nervous pain, and intensity on a only above the level of injury
system scale of 0 to 10. but also at or below the level
Traction apparatus of injury and in both complete
As evidenced by and incomplete injuries. An
Verbal reports of pain individual with SCI is likely to
experience many types of
painful sensations at or below

Evaluate increased irritability,
muscle tension, restlessness,
and unexplained vital sign changes.
Assist client in identifying
precipitating factors.
Provide comfort measures, such as
position changes, massage,
ROM exercises, and warm or cold
packs, as indicated.
Encourage use of relaxation
techniques, such as guided
imagery, visualization, and deep-
breathing exercises.
Provide diversional activities—
television, radio, telephone,
and unlimited visitors, as
appropriate.
Administer medications, as
indicated, for example: muscle
relaxants, such as dantrolene
(Dantrium) and baclofen
(Lioresal); analgesics; anti-anxiety
agents, such as, alprazolam (Xanax),
and diazepam (Valium).
Expected outcomes
Client Will
Pain Control
Identify ways to manage pain.
the level of injury that can be
troublesome to categorize,
making effective treatment
difficult.
Nonverbal cues indicative of
pain or discomfort require
timely intervention. Burning
pain and muscle spasms can
be precipitated or aggravated
by multiple factors, such as
anxiety, tension, external
temperature extremes, sitting
for long periods, and bladder
distention.
Alternative measures for pain
control reduce need for
pharmacological
agents and provide emotional
support.
Relaxation and diversional
activities refocus attention,
promote sense of control, and
possibly enhance coping
abilities.
These medications relieve
muscle spasm and pain
associated with spasticity.
They also alleviate anxiety and
promote rest.
Demonstrate use of relaxation skills and diversional activities as individually indicated.

Report relief or control of pain and discomfort.

Nursing Diagnosis Interventions Rationale

Expected outcomes
Conclusion
The control and investigation of outbreaks of varicella are important for preventing further

spread of varicella disease. Strategies for controlling varicella outbreaks include confirming the

outbreak, identifying cases, implementing varicella control measures, conducting case investigations,

and establishing surveillance for additional cases. Achieving and maintaining high varicella

vaccination coverage rates in preschool children with one dose and in school and college populations

and healthcare workers with two doses will be important to prevent varicella outbreaks. Varicella

case-based surveillance, including detection of varicella outbreaks, is important for documenting the

impact of the two-dose varicella vaccination policy and changes to varicella epidemiology.

Appendix

Pharmacology

Drug Acyclovir
Type Anti-viral
Usage HSV infections, genital herpes of the skin and mucous membranes (primary and
frequently recurring genital herpes).
Herpes zoster infection
Effects Aciclovir is converted to aciclovir monophosphate by virus-specific thymidine
kinase then further converted to aciclovir triphosphate by other cellular
enzymes. Aciclovir triphosphate competes with deoxyguanosine triphosphate
for viral DNA polymerase and incorporates into viral DNA to block DNA synthesis
and viral replication.
Side effects Significant: Contact sensitisation (topical). Gastrointestinal disorders: Nausea,
vomiting, diarrhoea, abdominal pain. General disorders and administration site
conditions: Fatigue, fever. Investigations: Increased liver enzymes (reversible),
BUN and creatinine. Nervous system disorders: Headache, dizziness. Skin and
subcutaneous tissue disorders: Pruritus, rash, photosensitivity, urticaria,
accelerated diffuse hair loss. Vascular disorders: Phlebitis (IV).
Potentially Fatal: Thrombotic thrombocytopenic purpura/haemolytic uraemic
syndrome (immunocompromised patients). Renal failure.

Drug Piriton (Chlorphenamine)

Type Anti-histamine
Usage
Effects Chlorphenamine, an alkylamine derivative, is a sedating antihistamine that
competitively and reversibly inhibits histamine H 1- receptor in the
gastrointestinal and respiratory tract and blood vessels. This prevents the
release of histamine, prostaglandins and leukotrienes, and also prevents the
migration of inflammatory mediators. Synonym: chlorpheniramine.
Side effects Significant: Sedation; excitation (in young children). Eye disorders: Blurred
vision. Gastrointestinal disorders: Dry mouth, nausea, vomiting, diarrhoea,
epigastric pain. General disorders and administration site conditions: Fatigue,
lassitude. Metabolism and nutrition disorders: Anorexia, increased
appetite. Nervous system disorders: Somnolence, disturbance in attention,
abnormal coordination, dizziness, headache.

Drug Panadol
Type Analgesics (Non-Opioid) & Antipyretics
Usage
Effects Paracetamol is a para-aminophenol derivative that exhibits analgesic and
antipyretic actions and weak anti-inflammatory activity. The mechanism of its
analgesic effect has not been fully determined but may be associated with the
inhibition of prostaglandin synthesis in the CNS and to a lesser extent, through
peripheral blockage of pain-impulse generation. It produces antipyresis by
inhibiting the hypothalamic heat-regulating centre. Synonym: acetaminophen.
Side effects Reduced rate of absorption with colestyramine. Increased absorption with
metoclopramide and domperidone. Prolonged use of paracetamol may enhance
the anticoagulant effect of warfarin and other coumarins, thus increasing the
risk of bleeding. Concomitant use of other potentially hepatotoxic drugs or
drugs that induce liver microsomal enzymes (e.g. barbiturates) may increase the
risk of paracetamol toxicity. Reduced clearance with probenecid and isoniazid.
Elimination half-life may be prolonged with salicylamide. Reduced bioavailability
and efficacy of lamotrigine. May increase the plasma concentration of
chloramphenicol and busulfan. Increased risk of high anion gap metabolic
acidosis with flucloxacillin.

Drug  Ibuprofen
Type Nonsteroidal anti-inflammatory drugs (NSAIDs).
Usage help alleviate mild to moderate pain
Ibuprofen, an NSAID, has analgesic, anti-inflammatory and
antipyretic properties. It inhibits cyclooxygenase-1 and 2 thereby,
reducing the production of prostaglandin precursors.
Effects
Side effects Adverse Reactions
Significant: Hypertension, platelet aggregation, prolong bleeding time, elevated
transaminase levels, hyperkalaemia, drowsiness, dizziness, blurred or
diminished vision, scotomata, changes in colour vision; photosensitivity
(topical); renal papillary necrosis (prolonged use), mask symptoms of infection,
Na and fluid retention, oedema, risk for impairment of female fertility. Rarely,
aseptic meningitis, severe blood dyscrasias (e.g. agranulocytosis,
thrombocytopenia, aplastic anaemia). Ear and labyrinth
disorders: Tinnitus. Gastrointestinal disorders: Nausea, vomiting, abdominal
pain, flatulence, diarrhoea, dyspepsia, constipation, melaena,
haematemesis. General disorders and administration site conditions: Fatigue;
pain and burning sensation in the administration site
(inj). Investigations: Increased lactate dehydrogenase. Metabolism and nutrition
disorders: Hypokalaemia, hypernatraemia, hypoalbuminaemia (inj). Nervous
system disorders: Headache. Psychiatric disorders: Nervousness. Renal and
urinary disorders: Urinary retention (inj). Skin and subcutaneous tissue
disorders: Rash, pruritus. Vascular disorders: Hypotension (inj).
Potentially Fatal: CV thrombotic events (e.g. MI or stroke), gastrointestinal
ulceration, inflammation, perforation or haemorrhage; rarely, severe hepatic
reactions (e.g. fulminant hepatitis, liver necrosis, hepatic failure); very rarely,
Stevens-Johnson syndrome, exfoliative dermatitis, toxic epidermal necrolysis,
acute generalised exanthematous pustulosis (AGEP); drug eosinophilia and
systemic symptoms (DRESS) or multiorgan hypersensitivity reactions.