# A 4-year-old child with varicella (chickenpox) is being cared for at home. Which nursing intervention should the nurse prioritize when educating the parents?

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> subject: Infectious Diseases

## 문제

A 4-year-old child with varicella (chickenpox) is being cared for at home. Which nursing intervention should the nurse prioritize when educating the parents?

## 보기

1. Instruct parents to keep the child's fingernails short and clean to prevent secondary bacterial infection **✔ 정답**
2. Advise parents to give ibuprofen for fever reduction and comfort
3. Recommend applying calamine lotion to all vesicles
4. Suggest using cool compresses to soothe the itching

**정답: 1**

## 해설

Keeping nails short and clean prevents secondary bacterial infection from scratching, which is the priority in home care. Other options are contraindicated (aspirin risks Reye's syndrome) or not priority (topical antibiotics, hot baths).

## 심화 해설

Understanding Varicella and Home Care Priorities

When caring for a child with varicella at home, the primary nursing goal is to prevent complications while the disease runs its natural course. The characteristic pruritic vesicular rash creates a significant risk for secondary bacterial infections, most commonly caused by Staphylococcus aureus or Group A Streptococcus. Scratching disrupts the skin barrier, introducing these pathogens from the child's own skin or nails into the vesicles, which can lead to impetigo, cellulitis, or, in severe cases, invasive bacterial infections. The SHEA practice update emphasizes that in residential and home settings, a standardized approach to infection prevention is critical, and this begins with basic hygiene measures that interrupt the chain of infection at the portal of entry [1].

Instructing parents to keep the child's fingernails short and clean is the most direct mechanical intervention to reduce excoriation and bacterial inoculation. This aligns with the foundational IPC principle of minimizing host susceptibility by maintaining intact skin integrity, a concept highlighted in the SHEA guidance for pediatric care outside the acute hospital environment [1]. While the guideline focuses on broader transmission prevention, the same principle applies to autoinoculation within a single patient. Clean, short nails harbor fewer bacteria and cause less trauma if the child does scratch, making this the highest priority for preventing a common and serious complication.

Analysis of Incorrect Options

**Option 2: Advise parents to give ibuprofen for fever reduction and comfort.** This is contraindicated. The use of nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen in children with varicella has been associated with an increased risk of severe necrotizing soft tissue infections. Acetaminophen is the recommended antipyretic for fever and discomfort in varicella. The SHEA practice update stresses the importance of safe, evidence-based supportive care to avoid iatrogenic complications in pediatric residential settings [1].

**Option 3: Recommend applying calamine lotion to all vesicles.** While calamine lotion can provide symptomatic relief from itching, it is not applied to "all vesicles" indiscriminately, especially those that are open, crusted, or located near the eyes and mucous membranes. Furthermore, its role is purely symptomatic and does not address the primary safety risk of secondary bacterial infection. The SHEA guideline would prioritize an intervention that directly prevents infection transmission over a comfort measure [1].

**Option 4: Suggest using cool compresses to soothe the itching.** Cool compresses are a safe, non-pharmacological comfort measure for pruritus. However, like calamine lotion, this is a symptomatic intervention. In the hierarchy of nursing priorities, preventing a major complication like bacterial superinfection takes precedence over managing the symptom of itching, especially when the preventive measure (nail hygiene) is simple and highly effective. The SHEA framework directs us to first implement measures that block the most significant infection pathways [1].

References (research sources)

- [1]SHEA practice update: infection prevention and control (IPC) in residential facilities for pediatric patients and their families.Research articleGuzman-Cottrill JA, Blatt DB, Bryant KA, McGrath CL, Zerr DM, Rosenthal A, Kociolek LK, Murphy C, Ravin KA. (2025) · DOI: 10.1017/ice.2024.124

## 임상 시나리오

Clinical Practice Guide: Home Care for Pediatric Varicella

Priority Nursing Intervention

Prevention of secondary bacterial skin infection is the highest priority. The primary mechanical intervention is **keeping the child’s fingernails trimmed short and meticulously clean**. This reduces bacterial load under the nails and minimizes skin excoriation if the child scratches, thereby interrupting the portal of entry for pathogens like *Staphylococcus aureus* and Group A Streptococcus.

Key Home Care Instructions

- **Nail Care:** Inspect and clean under the nails frequently with soap and water. Keep nails filed smooth to prevent sharp edges.

- **Hygiene:** Bathe the child daily with lukewarm water and mild soap to cleanse the skin and reduce bacterial colonization. Pat skin dry gently; do not rub.

- **Pruritus Management:** Apply calamine lotion sparingly to intact vesicles for symptomatic relief. Use oral antihistamines like diphenhydramine or hydroxyzine as prescribed for severe itching. Cool compresses may also be used.

- **Fever Management:** Use **acetaminophen** only. **Avoid ibuprofen and other NSAIDs** due to the established risk of severe necrotizing soft tissue infections in varicella.

- **Infection Control:** Isolate the child at home until all vesicles have crusted over (typically 5-7 days) to prevent airborne and contact transmission.

Monitoring and When to Seek Medical Attention

Educate parents to monitor for signs of secondary bacterial infection and other complications. Instruct them to contact the healthcare provider immediately if they observe:

- Increased redness, warmth, swelling, or purulent drainage from any vesicle.

- Fever persisting beyond the fourth day of illness or returning after defervescence.

- Lethargy, irritability, neck stiffness, or difficulty waking.

- Vomiting or refusal to drink, indicating risk of dehydration.

## 핵심 개념

- **Varicella (Chickenpox)** — A highly contagious viral infection caused by the varicella-zoster virus, characterized by a pruritic vesicular rash.
- **Secondary Bacterial Infection** — A bacterial infection occurring in skin already damaged by a viral infection, commonly caused by Staphylococcus aureus or Group A Streptococcus in varicella lesions.
- **Excoriation** — Mechanical skin damage or abrasion, typically caused by scratching, that disrupts the epidermal barrier.
- **NSAID (Nonsteroidal Anti-inflammatory Drug)** — A class of drugs including ibuprofen that is generally contraindicated in varicella due to an association with an increased risk of invasive bacterial complications.

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