Chicken Pox (Varicella) Nursing Care Planning and Management

What is Chicken Pox?

Chickenpox, also called varicella, is a very contagious disease caused by VZV, a DNA virus in the herpesvirus group. Primary infection with VZV causes varicella. After the primary infection, the virus stays latent in the sensory nerve ganglia.

Pathophysiology

Chickenpox is usually acquired by inhaling airborne respiratory droplets from an infected host, and its high contagiousness drives the epidemics that sweep through schools. After inhalation, the virus infects the conjunctivae or the upper respiratory tract mucosa. Viral proliferation occurs in regional lymph nodes of the upper respiratory tract 2-4 days after infection, followed by primary viremia on postinfection days 4-6. A second round of replication occurs in internal organs, most notably the liver and spleen, followed by a secondary viremia 14-16 days post-infection. That secondary viremia brings diffuse viral invasion of capillary endothelial cells and the epidermis. VZV infection of the malpighian layer produces intercellular and intracellular edema, forming the characteristic vesicle. Exposure in a healthy child triggers IgG, IgM, and IgA antibodies; IgG persists for life and confers immunity. After primary infection, VZV spreads from mucosal and epidermal lesions to local sensory nerves and remains latent in the dorsal ganglion cells. Reactivation produces herpes zoster (shingles).

Statistics and Incidences

Most cases occur in children. Since widespread pediatric immunization began in the United States in 1995, varicella has declined dramatically. Before the vaccine, the United States recorded roughly 4 million cases, 10,500 to 13,000 hospitalizations, and 100 to 150 deaths each year. The two-dose program has since cut cases by about 97%, and among people 50 and younger, hospitalizations and deaths have fallen by roughly 94% and 97% (CDC). Countries with tropical and semitropical climates see more adult chickenpox than temperate-climate countries such as the United States and those in Europe.

Causes

Chickenpox is caused by varicella-zoster virus (VZV). It is contagious 1 to 2 days before the blisters appear and stays contagious until all blisters have crusted over.

Clinical Manifestations

Chickenpox appears 10 to 21 days after exposure and usually lasts about 5 to 10 days. The rash moves through three phases: raised pink or red bumps (papules) that break out over several days; small fluid-filled blisters (vesicles) that form over about a day before breaking and leaking; and crusts and scabs that cover the broken blisters and take several more days to heal. Fever accompanies the rash, headache may appear 1 to 2 days before it, and the child feels generalized malaise.

Assessment and Diagnostic Findings

Varicella is usually diagnosed clinically, with testing to confirm when needed.

• PCR testing. The most sensitive method, using PCR to detect VZV in skin lesions (vesicles, scabs, maculopapular lesions).
• IgM testing. Considerably less sensitive than PCR of skin lesions. Commercial IgM assays may be unreliable, false-negative IgM is common, and a positive IgM ELISA, though suggestive of primary infection, does not exclude reinfection or reactivation of latent VZV.
• Paired acute and convalescent sera. A four-fold rise in IgG antibodies has excellent specificity for varicella but is less sensitive than PCR of skin lesions.
• Blood testing. Most children have leukopenia in the first 3 days, followed by leukocytosis; marked leukocytosis may indicate secondary bacterial infection but is not dependable. Significant elevations of alanine aminotransferase (ALT) occur in 20-50% of children and adolescents with varicella complicated by hepatitis, returning to normal within one month in almost all cases.
• Tzanck smear. Scraping and staining the base of a lesion demonstrates multinucleated giant cells, which suggest a herpes virus infection but are not specific for VZV.
• Immunohistochemical staining. Staining of skin lesion scrapings can confirm varicella.

Medical Management

Primary varicella in a healthy child is fairly benign and needs only symptomatic therapy.

Pharmacologic Therapy

• Antiviral therapy. The AAP recommends routine acyclovir or valacyclovir in healthy children when it can be given within 24 hours of the rash for children older than 12 years, those with chronic cutaneous or pulmonary disorders, those on long-term salicylate therapy, and those receiving corticosteroids.
• Varicella zoster immune globulin. VariZIG (Cangene) was approved by the FDA in December 2012 for high-risk individuals within 10 days (ideally within 4 days) of exposure. It reduces complications and the mortality rate, not the incidence.
• Antibiotic therapy. Suspected secondary bacterial infection prompts early empirical antibiotics until culture results return.

Nursing Management

Care combines supportive measures, antiviral therapy, varicella-zoster immune globulin (VZIG), and management of secondary bacterial infection.

Nursing Assessment

• History taking. Elicit any recent community outbreak and any exposure at school, daycare, or among family.
• Immunizations. Note whether the child received the varicella vaccine and whether the child is immunocompromised, including recent systemic steroid use, to guide management.
• Immunocompromised child. These children often have severe, complicated varicella and a higher mortality rate than immunocompetent children.

Nursing Diagnosis

• Hyperthermia related to viral infection.
• Impaired skin integrity related to mechanical factors (stress, tear, friction).
• Disturbed body image related to skin lesions.
• Deficient knowledge about the condition and treatment.
• Risk for infection related to damaged skin tissue.

Nursing Care Planning and Goals

• The client rests comfortably.
• The client or caregiver verbalizes needed information about the disease, signs and symptoms, treatment, and complications of varicella zoster.
• The client stays free of secondary infection, with intact skin free of redness or new lesions.
• The client has minimal risk of transmission through universal precautions.
• The client verbalizes feelings about the lesions and continues daily activities.
• The client shows a positive body image, able to look at, talk about, and care for the lesions.

Nursing Interventions

• Patient education. Teach parents the importance and safety of the varicella-zoster vaccine.
• Manage pruritus. Use cool compresses and regular bathing; warm soaks and oatmeal or cornstarch baths reduce itching and add comfort.
• Trim fingernails. Trim the nails and have the child wear mittens while sleeping to limit scratching.
• Dietary measures. Provide a full, unrestricted diet; encourage fluids in children with reduced appetite to maintain hydration.

Evaluation

Goals are met when the client rests comfortably, the client or caregiver verbalizes the needed information, the client stays free of secondary infection with intact skin, transmission risk stays minimal through universal precautions, and the client verbalizes feelings about the lesions while showing a positive body image and continuing daily activities.

Documentation Guidelines

• Temperature and other findings, including vital signs and mentation.
• Characteristics of lesions or condition.
• Causative and contributing factors.
• Impact of the condition on personal image and lifestyle.
• Current or recent antibiotic therapy.
• Plan of care and teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment of or progress toward desired outcomes.
• Modifications to the plan of care.

Frequently Asked Questions

What causes chickenpox? Chickenpox (varicella) is caused by the varicella-zoster virus (VZV), a DNA herpesvirus. Primary infection produces the itchy, blistering rash of chickenpox; after recovery the virus stays latent in the sensory nerve ganglia and can reactivate years later as herpes zoster (shingles) (CDC).

How contagious is chickenpox and when does it spread? It is highly contagious and spreads through airborne respiratory droplets and contact with the fluid in the blisters. A person is contagious 1 to 2 days before the rash appears and remains contagious until every lesion has crusted over, which is the basis for isolation precautions.

How much has the vaccine reduced chickenpox in the United States? A great deal. Before the vaccine became available in 1995, the country saw about 4 million cases and 100 to 150 deaths each year. The two-dose program has cut cases by roughly 97 percent, and hospitalizations and deaths among people 50 and younger have fallen about 94 percent and 97 percent (CDC).

How is chickenpox diagnosed? It is usually a clinical diagnosis based on the characteristic rash. When confirmation is needed, PCR of a skin lesion is the most sensitive test. IgM serology is far less reliable, and a four-fold rise in IgG on paired acute and convalescent sera is specific but less sensitive than PCR.

Why should a child with chickenpox never be given aspirin? Aspirin and other salicylates during a viral illness such as varicella are linked to Reye syndrome, a rare but serious condition causing liver and brain injury. Use acetaminophen for fever instead, and teach families to read labels for hidden salicylates.

What are the priority nursing concerns? Control fever and itching, protect the skin from secondary bacterial infection through good hygiene and trimmed nails, isolate the child to prevent spread, maintain hydration, and identify the immunocompromised child early, since that child faces a much higher risk of severe, complicated disease.