Chickenpox, medically known as varicella, is a highly contagious infection caused by the varicella-zoster virus (VZV). This common illness is characterized by an itchy rash with small, fluid-filled blisters. While typically a childhood disease, chickenpox can affect anyone who hasn’t been vaccinated or previously infected. Recognizing and understanding chickenpox is crucial for effective management and preventing its spread, especially among vulnerable populations.
Understanding Chickenpox (Varicella)
Chickenpox, or varicella, is a highly contagious disease caused by the varicella-zoster virus (VZV). It’s an acute infectious disease stemming from the VZV, a DNA virus belonging to the herpesvirus family. After the initial infection, VZV remains dormant in the body within the sensory nerve ganglia. The primary infection of VZV is what manifests as chickenpox.
Pathophysiology of Chickenpox
Chickenpox transmission typically occurs through the inhalation of airborne respiratory droplets from an infected person.
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The highly contagious nature of the varicella-zoster virus (VZV) contributes to rapid outbreaks, especially in school settings. VZV is the direct cause of chickenpox (varicella). Initial infection begins when contaminated respiratory droplets are inhaled, infecting the conjunctiva or the mucous membranes of the upper respiratory tract.
Viral replication starts in the regional lymph nodes of the upper respiratory tract within 2 to 4 days post-infection, followed by primary viremia around days 4 to 6. A second phase of viral replication occurs in internal organs, particularly the liver and spleen, leading to secondary viremia around days 14 to 16 post-infection.
This secondary viremia involves widespread viral invasion of capillary endothelial cells and the epidermis. VZV infection in the Malpighian layer of the skin results in both intercellular and intracellular edema, causing the characteristic vesicle formation.
Infection with VZV triggers the production of immunoglobulin G (IgG), immunoglobulin M (IgM), and immunoglobulin A (IgA) antibodies in healthy children. IgG antibodies provide lifelong immunity. Following the primary infection, VZV is believed to spread from mucosal and epidermal lesions to local sensory nerves and then resides latently in the dorsal ganglion cells of these sensory nerves. Reactivation of VZV leads to herpes zoster, also known as shingles, a clinically distinct syndrome.
Epidemiology and Prevalence
Chickenpox is a widespread disease, predominantly affecting children. However, since the introduction of routine childhood immunization in the United States in 1995, the incidence of varicella has significantly decreased, with reductions of up to 90%. Mortality rates from varicella have also declined by approximately 66% since the vaccination program began in the US. Interestingly, countries with tropical and semitropical climates experience a higher incidence of chickenpox in adults compared to countries with temperate climates like the United States and Europe.
Etiology of Chickenpox
Chickenpox, a common childhood ailment, is caused by the varicella-zoster virus (VZV). The varicella-zoster virus (VZV) is responsible for chickenpox infection and is contagious one to two days before the rash appears and remains contagious until all blisters have crusted over.
Clinical Presentation of Chickenpox
Chickenpox symptoms typically manifest 10 to 21 days after exposure to the virus and last for about five to ten days.
Characteristic Rash
The hallmark of chickenpox is its distinctive rash, progressing through three stages:
- Papules: Initially, raised pink or red bumps (papules) appear over several days.
- Vesicles: These papules develop into small fluid-filled blisters (vesicles) within about a day, before rupturing and leaking.
- Crusts and Scabs: Finally, crusts and scabs form over the broken blisters and require several days to heal completely.
Associated Symptoms
In addition to the rash, chickenpox may present with:
- Fever: Elevated body temperature is a common symptom.
- Headache: Headaches can occur, sometimes preceding the rash by one to two days.
- Malaise: A general feeling of tiredness and discomfort throughout the body.
Diagnostic Assessment for Chickenpox
Healthcare providers can usually diagnose varicella clinically through physical assessment. However, laboratory tests can confirm the diagnosis, especially in atypical cases.
Laboratory Findings
- Polymerase Chain Reaction (PCR) Testing: PCR is the most sensitive method to confirm varicella by detecting VZV DNA in skin lesions (vesicles, scabs, or maculopapular lesions).
- IgM Antibody Testing: IgM testing is less sensitive than PCR. Commercial IgM assays can be unreliable, with false negative results being common. A positive IgM ELISA result may suggest a primary infection but doesn’t rule out reinfection or reactivation of latent VZV.
- Paired Acute and Convalescent Sera: Demonstrating a four-fold increase in IgG antibodies between acute and convalescent sera is highly specific for varicella but less sensitive than PCR of skin lesions for diagnosis.
- Blood Tests: Most children with varicella exhibit leukopenia in the first three days, followed by leukocytosis. Marked leukocytosis might indicate a secondary bacterial infection but is not a reliable sign. Elevated alanine aminotransferase (ALT) levels occur in 20-50% of children and adolescents with varicella complicated by hepatitis, but these levels usually return to normal within a month.
- Tzanck Smear: This test involves scraping the base of lesions and staining the scrapings to identify multinucleated giant cells. The presence of these cells suggests a herpes virus infection but is not specific to varicella-zoster virus.
- Immunohistochemical Staining: Immunohistochemical staining of skin lesion scrapings can specifically confirm varicella.
Medical Management of Chickenpox
Uncomplicated chickenpox in healthy children is generally a mild disease requiring only symptomatic treatment.
Pharmacological Interventions
Symptom management in children primarily involves topical and oral medications.
- Antiviral Therapy: Routine use of antiviral medications like acyclovir or valacyclovir is recommended by the AAP for children older than 12 years, those with chronic skin or lung conditions, those on long-term salicylate therapy, and children receiving corticosteroids, if treatment can be initiated within 24 hours of rash onset.
- Varicella Zoster Immune Globulin (VariZIG): VariZIG, approved by the FDA in December 2012, is indicated for high-risk individuals within 10 days (ideally within 4 days) of chickenpox exposure. It reduces the severity and mortality rate of varicella, though it does not prevent infection.
- Antibiotic Therapy: If secondary bacterial infection is suspected, empirical antibiotic therapy should be started promptly while awaiting culture results.
Nursing Management of Chickenpox
Nursing care focuses on supportive measures, antiviral therapy, administering varicella-zoster immune globulin (VZIG), and managing secondary bacterial infections.
Nursing Assessment
Nursing assessment for a child with chickenpox includes:
- History Taking: Assess for recent chickenpox outbreaks in the community and any known exposure at school, daycare, or within the family.
- Immunization History: Determine if the child has received the varicella vaccine or if they are immunocompromised, including recent steroid use, to guide management.
- Assessment of Immunocompromised Children: Recognize that immunocompromised children are at higher risk for severe and complicated varicella with increased mortality rates.
Nursing Diagnoses for Chickenpox
Based on the assessment data, relevant nursing diagnoses for chickenpox may include:
- Risk for Infection related to compromised skin integrity secondary to chickenpox lesions and weakened immune response.
- Impaired Skin Integrity related to vesicular rash and itching.
- Acute Pain related to skin lesions and itching.
- Hyperthermia related to the infectious process.
- Deficient Knowledge related to the disease process, home care, and prevention of transmission.
- Risk for Social Isolation related to the contagious nature of chickenpox and the need for isolation.
- Disturbed Body Image related to the presence of visible rash and lesions.
Nursing Care Planning and Goals
Desired outcomes for a child with chickenpox include:
- The patient will achieve comfort, as evidenced by rest and reduced itching.
- The patient or caregiver will demonstrate understanding of the disease, its signs and symptoms, treatment, and potential complications.
- The patient will remain free from secondary infection, evidenced by intact skin without signs of secondary infection.
- The patient will have minimal risk of disease transmission through adherence to appropriate precautions.
- The patient will express feelings about the lesions and maintain engagement in daily activities as tolerated.
- The patient will demonstrate a positive body image, shown by the ability to look at, discuss, and care for lesions.
Nursing Interventions
Nursing interventions for a child with chickenpox include:
- Symptom Management:
- Administer or recommend antipruritics to relieve itching.
- Advise cool baths or compresses to soothe skin irritation.
- Encourage loose, cotton clothing to minimize skin irritation.
- Administer antipyretics as needed to manage fever.
- Preventing Secondary Infection:
- Educate the patient and family on the importance of hand hygiene.
- Advise against scratching lesions to prevent secondary bacterial infections.
- Monitor lesions for signs of infection (increased redness, warmth, purulent drainage).
- Education and Support:
- Provide comprehensive education about chickenpox, its contagious period, and home care measures.
- Explain the importance of isolation during the contagious period to prevent spread.
- Address concerns about body image and provide emotional support.
- Educate about the varicella vaccine for prevention in susceptible individuals.
- Medication Administration:
- Administer antiviral medications as prescribed, ensuring timely administration within 24 hours of rash onset when indicated.
- Administer varicella zoster immune globulin (VariZIG) as prescribed for high-risk individuals post-exposure.
- Administer antibiotics if secondary bacterial infection is diagnosed.
Evaluation of Nursing Care
Goals are met when:
- The patient is comfortable and able to rest adequately.
- The patient or caregiver verbalizes understanding of chickenpox, its management, and potential complications.
- The patient remains free from secondary infection, with healthy skin and healing lesions.
- Disease transmission risk is minimized through implemented precautions.
- The patient expresses feelings about lesions and continues daily activities within limitations.
- The patient demonstrates positive self-perception and ability to manage their condition.
Nursing Documentation
Documentation for a child with chickenpox should include:
- Temperature and other assessment findings, including vital signs and mental status.
- Detailed description of lesions and skin condition.
- Identifying causative and contributing factors.
- Impact of the condition on body image and lifestyle.
- Current or recent antibiotic or antiviral therapy.
- Nursing care plan.
- Patient and family teaching plan.
- Responses to nursing interventions and teaching.
- Progress towards desired patient outcomes.
- Any modifications to the care plan.
