Hand, Foot, and Mouth Disease (HFMD)

HFMD is usually mild and self-limiting, but it is highly contagious and the mouth sores are what derail the patient. Painful ulcers cut intake, so the real nursing work is pain control, keeping the child hydrated, and stopping spread. It is caused by Coxsackievirus A16 and Enterovirus 71, mostly in children under age 10, and peaks in summer and early fall.

What is Hand, Foot, and Mouth Disease (HFMD)?

HFMD is an acute viral illness that presents as a vesicular eruption in the mouth and can also involve the hands, feet, buttocks, and genitalia.

• Coxsackievirus A type 16 (CV A16) causes most cases, but the illness is also associated with coxsackievirus A5, A7, A9, A10, B2, and B5 strains.
• Enterovirus 71 (EV-71) has caused HFMD outbreaks with neurologic involvement in the western Pacific region.
• HFMD is often confused with foot-and-mouth (hoof-and-mouth) disease, which affects cows, sheep, and pigs.
• It is usually not serious but very contagious, spreading quickly at schools and day care centers.

Pathophysiology

• Infection occurs via the fecal-oral route or contact with skin lesions and oral secretions.
• Viremia develops, followed by invasion of the skin and mucous membranes.
• Widespread apoptosis likely produces the characteristic lesions.

Causes

HFMD is caused by viruses in the Enterovirus family.

• Coxsackievirus A16. The most common cause in the United States. Other coxsackieviruses can also cause it.
• Coxsackievirus A6. Can cause HFMD with more severe symptoms.
• Enterovirus 71 (EV-A71). Linked to cases and outbreaks in East and Southeast Asia. Rarely, it causes more severe disease such as encephalitis.

Transmission

A person can get HFMD through:

• Breathing air after a sick person coughs or sneezes.
• Touching a sick person or close contact like kissing, hugging, or sharing cups or utensils.
• Touching a sick person's feces, such as during diaper changes, then touching the eyes, nose, or mouth.
• Touching contaminated objects and surfaces like doorknobs or toys, then touching the eyes, nose, or mouth.

Statistics and Incidences

Epidemics generally hit in summer to early fall, though sporadic cases occur year-round.

• EV-71 epidemics have been more frequent in Southeast Asia in recent years, including Taiwan (1998) and Singapore (2000).
• Risk factors include child care attendance, contact with HFMD, large family size, and rural residence.
• Most reports show no sexual predilection; some epidemic data show a slight male-to-female ratio of 1.2-1.3:1.
• Children younger than 10 years are most commonly affected, with subsequent outbreaks among family members and close contacts.

Clinical Manifestations

Most children have mild symptoms for 7 to 10 days.

• Fever and flu-like symptoms. Often 3 to 6 days after catching the virus: fever, reduced eating or drinking, sore throat, and feeling unwell.
• Mouth sores. One or two days after fever onset, painful mouth sores (herpangina) appear, often starting as small red spots at the back of the mouth that blister.
• Skin rash. Flat red spots, sometimes with blisters, on the palms and soles, and possibly the knees, elbows, buttocks, or genital area. Blister fluid and the scab that forms as it heals can contain the virus.

Assessment and Diagnostic Findings

Diagnosis is clinical; labs are usually unnecessary.

• Culture. The virus can be isolated from cutaneous lesions, mucosal lesions, or stool. In patients with vesicles, vesicle swabs are a good source.
• Serologic testing. Acute and convalescent antibody levels may be obtained.

Medical Management

There is no specific treatment for HFMD.

• Relieve fever and pain. Over-the-counter agents for fever and mouth-sore pain. Never give aspirin to children.
• Prevent dehydration. Mouth sores make swallowing painful, so push enough fluids to keep the child hydrated.

Pharmacologic Management

The goals are to reduce morbidity and prevent complications.

• Antipyretics/analgesics. Control fever and pain.
• Topical anesthetics. Applied to ulcerations to control pain.
• Antihistamines. Act by competitive inhibition of histamine at the H1 receptor.

Nursing Management

Nursing Assessment

• History. Incubation lasts about 1 week, then the patient reports a sore mouth or throat; malaise may develop. Rarely, vomiting occurs in EV-71 cases.
• Physical exam. Macular lesions appear first on the buccal mucosa, tongue, and hard palate, then rapidly progress to vesicles that erode and become surrounded by an erythematous halo.

Nursing Diagnosis

• Impaired oral mucous membrane related to dehydration and mouth sores.
• Imbalanced nutrition: less than body requirements related to decreased appetite from painful mouth sores.
• Impaired skin integrity related to lesions on the hands and feet.
• Risk for infection related to decreased immunity.
• Acute pain related to painful mouth sores.

Nursing Care Planning and Goals

• Improve skin and mucous membrane integrity.
• Improve nutritional intake.
• Prevent infection.
• Relieve pain.

Nursing Interventions

• Protect the oral mucosa. Give meticulous mouth care after each meal and every 4 hours while awake; provide systemic or topical analgesics as prescribed; serve foods and fluids lukewarm or cold; offer frequent small meals; encourage soft foods (mashed potatoes, puddings, custards, creamy cereals); encourage use of a straw.
• Improve skin integrity. Monitor the skin around lesions and the patient's skin care practices (soap, water temperature, frequency); tell patients and family to avoid rubbing and scratching; use gloves or clip nails if needed.
• Improve nutritional intake. Establish a healthy body weight for age and height; refer to a dietitian; provide a pleasant environment and good oral hygiene; consider six small nutrient-dense meals instead of three larger ones to lessen fullness.
• Prevent infection. Wash hands and teach the patient and family to wash hands before contact and between procedures; encourage protein-rich and calorie-rich foods; encourage fluid intake of 2,000 to 3,000 mL per day unless contraindicated; use soft-bristled toothbrushes; teach isolation technique.
• Relieve pain. Provide rest periods for relief, sleep, and relaxation; remove added stressors and sources of discomfort; choose an appropriate pain relief method.

Evaluation

Goals are met when skin and mucous membrane integrity improve, nutritional intake improves, infection is prevented, and pain is relieved.

Documentation

• Individual findings: factors affecting the patient, interactions, social exchanges, specifics of behavior.
• Cultural and religious beliefs and expectations.
• Plan of care.
• Teaching plan.
• Responses to interventions, teaching, and actions performed.
• Attainment or progress toward desired outcomes.