16.21 Varicella

Varicella, commonly known as chickenpox, is a highly contagious disease that is a result of primary infection with the varicella-zoster virus, a member of the herpes virus family. It commonly occurs in clients aged four to ten years old, but with the advent of vaccination, cases have drastically reduced. Infection in children tends to be milder than in adult clients.^[1]

A potential complication of varicella is a secondary bacterial infection due to scratching the lesions. In immunosuppressed clients, the infection may spread to the central nervous system with a high mortality rate. Pregnant women who become infected with varicella can spread the virus to the fetus, which can have devastating effects. If infected in the first 28 weeks, congenital varicella syndrome can occur. With this syndrome, the fetus can have multiple birth defects and neurological deficits. When infection occurs closer to delivery, neonatal varicella can occur. These infants are at high risk for pneumonia and other complications.^[2]

Pathophysiology

The varicella-zoster virus is spread via the air by coughing and sneezing or by direct contact with skin lesions. When the virus is inhaled, it initially infects the upper airways but eventually spreads to the circulation and causes the characteristic skin lesions. After the initial infection, the virus travels to sensory nerves where it remains dormant. Exposure to the virus also triggers the production of antibodies that confer life-long immunity. However, in states of immunosuppression later in life, this same virus can be reactivated and lead to a condition called shingles.^[3]

Assessment (Recognizing Cues)

Physical Exam

In younger children, varicella presents with a skin rash or oral sores. In the adolescent population, varicella may initially present with muscle aches, poor appetite, nausea, or headache that progresses to sores in the mouth, fever, and a rash. The rash of varicella starts as small red dots on the face, back, and chest that eventually spreads to the rest of the body, including the genitals, palms of hands, and soles of the feet. After 12 hours of initial rash formation, the rash progresses to blisters that are extremely itchy. Eventually, the blisters will scab over.^[4] See Figure 16.29^[5] for an image of the blisters associated with varicella.

Common Laboratory and Diagnostic Tests

Varicella is diagnosed clinically based on the rash and associated signs and symptoms. The diagnosis can be confirmed with vesicle fluid or lesion scrapings examined under a microscope. Blood can be tested for the presence of the virus. In pregnant women, fetal varicella can be diagnosed via ultrasound or PCR testing of amniotic fluid.^[6]

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with varicella include symptom management and the prevention of complications. Nursing diagnoses for clients with varicella are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment. Possible nursing diagnoses for clients with varicella are as follows^[7]:

• Hyperthermia r/t disease process
• Impaired skin integrity r/t skin lesions
• Disturbed body image r/t skin lesions
• Risk for infection r/t bacterial infection of skin lesions

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, achievable, relevant, and timebound (SMART) within a set time frame based on the application of appropriate nursing interventions. Sample expected outcomes for clients with varicella include the following^[8]:

• The client will exhibit minimal scarring by the end of the disease course.
• The client will not develop signs of secondary infection such as redness, edema, or purulent discharge.

Interventions (Generate Solutions & Take Action)

Medical Interventions

Medical treatment for varicella consists of supportive care and symptom relief. Proper skin care can help relieve itching and prevent secondary infections. Skin should be cleaned daily with warm water, and calamine lotion can be used for itching relief. Secondary infections from scratching can be prevented by trimming nails and wearing gloves. Acetaminophen can be administered to manage fever or pain. For clients who are immunocompromised or at increased risk for complication development, varicella-zoster immunoglobulin or antiviral medications may be prescribed. Pregnant women who become infected should also receive antiviral medication.^[9]

Nursing Interventions

Registered nurses develop interventions based on the expected outcomes of the client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client. When caring for a client with varicella, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching, as described in the following subsections.^{[10],[11],[12]}

Nursing Assessments

• Assess the skin to determine the severity of chickenpox and evaluate lesions for secondary bacterial infection.
• Assess the client’s perception of their body image due to varicella lesions and provide interventions as indicated.
• Assess for a history of immunodeficiency, as this is a risk factor for developing complications.

Nursing Actions

• Encourage a referral to an infectious disease specialist for a pediatric client with immunodeficiency.
• Administer antiviral medications or varicella-zoster immunoglobulin, as prescribed by the health care provider.
• Ensure adequate fluid intake, as some pediatric clients with varicella may have a reduced appetite.

Client Teaching

• Educate clients and their caregivers that aspirin should not be used in pediatric clients with varicella due to the increased risk of developing Reye’s syndrome.
• Teach the client and their caregivers that cold compresses and lotion can help prevent dry skin and itching.
• Teach the client and their caregivers that the child should stay home while infectious until the blisters are scabbed and dried.
• Educate the client and their family about the importance of receiving the varicella-zoster vaccine to prevent varicella. The vaccine can also be administered to clients not previously vaccinated within three days of virus exposure. It will not prevent the development of varicella, but it may improve the client outcomes

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.