Hand, Foot, and Mouth Disease (HFMD)

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Hand Foot and Mouth Disease
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In this study guide, learn more about Hand, foot, and mouth disease or HFMD, and discover more about its pathophysiology, causes, signs and symptoms, nursing care management, and interventions.

Hand, foot, and mouth disease or HFMD is a common viral infection that is common in young children under age 10. Teens and adults can seldom acquire an infection. HFMD is caused by Coxsackievirus A16 and Enterovirus 71. It usually occurs in the summer and early fall. HFMD is usually not serious. Regular hand-washing and withdrawing close contact with people who are infected with hand-foot-and-mouth disease may help reduce the risk of infection.

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

Hand-foot-and-mouth disease (HFMD) is an acute viral illness that presents as a vesicular eruption in the mouth, but it can also involve the hands, feet, buttocks, and/or genitalia.

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

Pathophysiology

The pathophysiology of HFMD involves the following:

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

Causes

Hand, foot, and mouth disease is caused by viruses that belong to the Enterovirus family.

  • Coxsackievirus A16. Coxsackievirus A16 is typically the most common cause of hand, foot, and mouth disease in the United States. Other coxsackieviruses can also cause the illness.
  • Coxsackievirus A6. Coxsackievirus A6 can also cause HFMD and the symptoms may be more severe.
  • Enterovirus 71 (EV-A71). Enterovirus 71 (EV-A71) has been associated with cases and outbreaks in East and Southeast Asia. Although very rare, EV-A71 has been associated with more severe diseases, such as encephalitis.

Transmission

A person could get HFMD through the following:

  • Breathing air after a sick person coughs or sneezes.
  • Touching a sick person or making other close contact, like kissing, hugging, or sharing cups or eating utensils.
  • Touching a sick person’s feces, such as changing diapers, then touching your eyes, nose, or mouth.
  • Touching objects and surfaces that have the virus on them, like doorknobs or toys, then touching your eyes, nose, or mouth.

Statistics and Incidences

Epidemics of HFMD generally occur in the summer to early fall months, although cases can occur sporadically all year.

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

Clinical Manifestations

Most children have mild symptoms for 7 to 10 days.

  • Fever and flu-like symptoms. Children often get a fever and other flu-like symptoms three to six days after they catch the virus; symptoms may include fever, eating or drinking less, sore throat and feeling unwell.
  • Mouth sores. One or two days after the fever starts, the patient may get painful mouth sores (herpangina); these sores usually start as small red spots, often in the back of that mouth, that blister and can become painful.
  • Skin rash. The patient may get a skin rash on the palms of the hands and soles of the feet; it may also show up on the knees, elbows, buttocks, or genital area; the rash usually looks like flat, red spots, sometimes with blisters; fluid in the blister and the scab that forms as the blister heals may contain the virus that causes hand, foot, and mouth disease.

Assessment and Diagnostic Findings

The diagnosis of hand-foot-and-mouth disease (HFMD) is typically based on clinical grounds; laboratory studies are usually unnecessary.

  • Culture. The virus can be isolated and identified via culture and immunoassay from cutaneous lesions, mucosal lesions, or stool samples; in patients with vesicles, vesicle swabs are also a good source for viral collection.
  • Serologic testing. Serologic testing (eg, acute and convalescent antibody levels) may be obtained.

Medical Management

There is no specific medical treatment for hand, foot, and mouth disease.

  • Relieve fever and pain. Take over-the-counter medications to relieve fever and pain caused by mouth sores; never give aspirin to children.
  • Prevent dehydration. Drink enough liquids; mouth sores can make it painful to swallow, so the patient might not want to drink much; make sure they drink enough to stay hydrated.

Pharmacologic Management

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

  • Antipyretics/analgesics. These agents are used to control fever and pain.
  • Topical anesthetics. These agents can be applied to ulcerations to control pain.
  • Antihistamines. These agents act by competitive inhibition of histamine at the H1 receptor.

Nursing Management

Nursing care of a patient with hand, foot, and mouth disease include the following:

Nursing Assessment

Nursing assessment of a patient with HFMD may include:

  • History. The incubation period of hand-foot-and-mouth disease (HFMD) lasts approximately 1 week; patients then report a sore mouth or throat; malaise may develop; rarely, vomiting occurs in HFMD cases caused by EV-71.
  • Physical exam. Initially, macular lesions appear on the buccal mucosa, tongue, and/or hard palate; these mucosal lesions rapidly progress to vesicles that erode and become surrounded by an erythematous halo.

Nursing Diagnosis

Based on the assessment data, the major nursing diagnosis for a patient with HFMD are:

Nursing Care Planning and Goals

The nursing care plan goals for a patient with HFMD includes:

  • Improve the integrity of the skin and mucous membranes.
  • Improve nutritional intake. 
  • Prevent infection.
  • Relieve pain.

Nursing Interventions

The nursing interventions for a patient with HFMD are:

  • Improve the condition of the oral mucous membranes. Plan and implement a meticulous mouth care regimen after each meal regularly and every 4 hours while awake; provide systemic or topical analgesics as prescribed; serve foods and fluids lukewarm or cold; serve frequent small meals or snacks spaced throughout the day; encourage soft foods (e.g., mashed potatoes, puddings, custards, creamy cereals); and encourage the use of straw.
  • Improve skin integrity. Monitor status of skin around wound; monitor patient’s skin care practices, noting the type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing; tell patients and folks to avoid rubbing and scratching; and provide gloves or clip the nails if necessary.
  • Improve nutritional intake. Ascertain healthy body weight for age and height; refer to a dietitian for complete nutrition assessment and methods for nutritional support; provide a pleasant environment; provide good oral hygiene and dentition; and consider six small nutrient-dense meals instead of three larger meals daily to lessen the feeling of fullness.
  • Prevent infection. Wash hands and teach patient and SO to wash hands before contact with patients and between procedures with the patient; encourage intake of protein-rich and calorie-rich foods; encourage fluid intake of 2,000 to 3,000 mL of water per day, unless contraindicated; recommend the use of soft-bristled toothbrushes to protect mucous membranes; and teach the patient, family, and caregivers, the purpose and proper technique for maintaining isolation.
  • Relieve pain. Provide rest periods to promote relief, sleep, and relaxation; get rid of additional stressors or sources of discomfort whenever possible; and determine the appropriate pain relief method.

Evaluation

Goals are met as evidenced by:

  • Improved integrity of the skin and mucous membranes.
  • Improved nutritional intake. 
  • Prevention of infection.
  • Relief from pain.

Documentation Guidelines

Documentation in a patient with HFMD include:

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

Practice Quiz: Hand, Foot, and Mouth Disease (HFMD)

Quiz time about Hand, Foot, and Mouth Disease (HFMD)! For more practice questions, visit our NCLEX practice questions page.

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1. The nurse is assigned to a client who has been diagnosed with hand, foot, and mouth disease. Which PPE will the nurse plan to use when preparing to assess the client? (Select all that apply.)

1. Gloves
2. Goggles
3. Gown
4. N95 respirator
5. Surgical face mask
6. Shoe covers

A. 1, 2, and 3
B. 1, 2, and 4
C. 1, 3, and 4
D. 1, 4, 5, and 6
E. 1, 2, 3, 4, 5, and 6

1. Answer: C. 1, 3, and 4.

  • Option C: Prioritization. The nurse should don an N95 respirator or high-efficiency particulate air filter respirator, a gown, and gloves because HFMD is spread through airborne means and by direct contact with lesions.
  • Options A, B, D, and E: Surgical face masks filter particularly large particles and will not render protection from HFMD. Goggles and shoe covers are not required for airborne or contact precautions.

2. The school nurse is asked which action will take to have the most impact on the incidence of infectious diseases in school. The correct response is:

A. Grant written information about infection control to all parents
B. Ensure that students are immunized according to national guidelines
C. Make soap and water easily accessible in the classrooms
D. Educate students on how to cover their mouths when coughing

2. Answer: B. Ensure that students are immunized according to national guidelines.

  • Option B: Prioritization. The incidence of once-common infectious diseases like measles, chickenpox, and mumps has been most effectively reduced by immunization of all school-aged children.
  • Option A, C, and D: The other options are also important but will not have much impact as immunization.

3. You are the charge nurse on the pediatric unit when a pediatrician calls wanting to admit a child with hand, foot, and mouth disease. Which of these factors is of most concern in determining whether to admit the child to your unit?

A. There are several children receiving chemotherapy on the unit.
B. The infection control nurse liaison is not on the unit today.
C. The unit is not staffed with the usual number of RNs.
D. No negative-airflow rooms are available on the unit.

3. Answer: D. No negative-airflow rooms are available on the unit.

  • Option D: Because clients with HFMD require implementation of airborne precautions, which include placement in a negative airflow room, this child cannot be admitted to the pediatric unit.
  • Option A, B, and C: The other circumstances may require actions such as staff reassignments but would not prevent the admission of a client with HFMD.

4. A client has hand, foot, and mouth disease. Contact precautions are initiated. Which rule must be observed to follow contact precautions?

A. A clean gown and gloves must be worn when in contact with the client.
B. Everyone who enters the room must wear an N-95 respirator mask.
C. All linen and trash must be marked as contaminated and send to biohazard waste.
D. Place the client in a room with a client with an upper respiratory infection.

4. Answer: A. A clean gown and gloves must be worn when in contact with the client.

  • Option A: A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated items in the room.
  • Option B: A respirator mask is required only with airborne precautions, not contact precautions.
  • Option C: All linen must be double-bagged and clearly marked as contaminated.
  • Option D: The client should be placed in a private room or in a room with a client with an active infection caused by the same organism and no other infections.

5. Which element in the circular chain of infection can be eliminated by preserving skin integrity?

A. Host
B. Reservoir
C. Mode of transmission
D. Portal of entry

5. Answer: D. Portal of entry

  • Option D: In the circular chain of infection, pathogens must be able to leave their reservoir and be transmitted to a susceptible host through a portal of entry, such as broken skin.

References

Sources and references for this study guide for HFMD:

  • Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders,. [Link]
  • Kimberlin, D. W. (2018). Red Book: 2018-2021 report of the committee on infectious diseases (No. Ed. 31). American academy of pediatrics.
  • Oshinsky, D. M. (2005). Polio: an American story. Oxford University Press. [Link]
  • Willis, L. (2019). Professional guide to diseases. Lippincott Williams & Wilkins. [Link]
Marianne is a staff nurse during the day and a Nurseslabs writer at night. She is a registered nurse since 2015 and is currently working in a regional tertiary hospital and is finishing her Master's in Nursing this June. As an outpatient department nurse, she is a seasoned nurse in providing health teachings to her patients making her also an excellent study guide writer for student nurses. Marianne is also a mom of a toddler going through the terrible twos and her free time is spent on reading books!

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