Just like any infectious disease, nurses are on the front lines of monkeypox (mpox). We need to know how to care for these patients and how to minimize the risk of spread to other patients and our families.
This guide covers what monkeypox is, how it's transmitted, how to protect yourself and others, the staged rash, key nursing interventions, diagnosis, treatment, and the complications to monitor for.
Monkeypox is a virus similar to smallpox — both belong to the orthopoxvirus genus. It's a zoonotic disease with natural hosts in animals (primates and rodents) that causes fevers, body aches, malaise, and a pustular rash resembling smallpox, though less deadly and less contagious.
This is not a new virus; it normally occurs in the tropical forests of West and Central Africa and occasionally causes small outbreaks elsewhere. A brief 2003 US outbreak had only 71 confirmed cases, with no spread to healthcare staff or other patients and no deaths. A more recent and widespread outbreak (since May 2022) reached over 21,000 US cases and 50,000+ globally — check the CDC for updated statistics.
Transmission of Monkeypox
Monkeypox spreads by several routes, some more common than others.
Skin-to-Skin Contact
The most common route. Most contagious when lesions are present — which is why it commonly spreads via sex, even though it is not an STI.
Respiratory Droplets
Coughing, sneezing, or speaking can transmit infection — but prolonged face-to-face contact is usually required.
Fomites
The virus can live on bed linens, clothing, and surfaces — reportedly up to 15 days — and infect whoever touches them.
Is Monkeypox an STI?
Despite what some news outlets implied, monkeypox is NOT a sexually transmitted infection, and it is not something you "only get through gay sex." Many current cases were in the community of men who have sex with men — but this is just how viruses behave: they spread within one community before reaching others.
When is a patient no longer contagious? A person is infectious from the onset of clinical symptoms until all lesions have scabbed over and re-epithelialization has occurred.
What to do if exposed
Monitor for symptoms for up to 21 days after exposure.
If symptoms develop, isolate for at least 5 days to watch for a rash.
If a rash develops, isolate until evaluated by a healthcare professional (likely until lesions resolve).
How Dangerous Is Monkeypox?
It's hard to predict, since most data comes from Africa, where access to quality healthcare is more limited and the predominant clade is more deadly — up to 3–6% of cases die there. In the US current outbreak there has been one confirmed death (in LA).
Most current infections circulate among younger, generally healthy people. We have not yet seen large numbers of older patients with significant comorbidities or immunocompromised patients — groups expected to have higher complication and death rates. Even without death, monkeypox can last for weeks and leave painful, sometimes scarring lesions.
Prevention
Prevention is the most important aspect of infection control. Monkeypox prevention includes:
Universal Precautions
Always — proper hand hygiene and clean gloves when contact with body fluids is anticipated. One of the most important things we do in healthcare.
Isolation Precautions
Suspected or confirmed cases get contact and droplet precautions per facility protocol — gown, gloves, N95, and eye protection.
N95 Mask
The CDC currently recommends an N95 when entering the room of a monkeypox patient.
Vaccination
Because monkeypox and smallpox are related, the smallpox vaccine is effective against monkeypox — but it's in short supply and reserved for high-risk patients.
Who qualifies for vaccination? Patients with close, prolonged contact with monkeypox; those whose recent (last 2 weeks) sex partner was diagnosed; and men or transgender/non-binary people who have sex with men and in the last 2 weeks had multiple/group sex partners, sex at a commercial venue, or sex in an area with ongoing transmission.
Symptoms & Assessment
Patients usually have a prodrome lasting up to 5 days before the characteristic rash appears.
Prodromal symptoms
Fever
A temperature above 100.4°F.
Headache
Patients often report a severe headache.
Back & Body Aches
Myalgias are common, as with many viruses.
Fatigue
Patients are often very tired and run down.
Lymphadenopathy
Swollen lymph nodes, localized or generalized — a feature that helps distinguish monkeypox from smallpox.
Relevant history
Recent Travel
Travel to an endemic area such as West Africa or the Congo Basin.
Recent Exposures
Any recent contact with someone who may have had monkeypox.
Sexual History
Recent sexual contact or history that would raise their risk.
Physical exam
The exam centers on inspecting the skin and noting lesion quality, number, and location.
Cardiac/Resp: tachycardia (especially with fever); mild tachypnea, occasional cough.
Skin & Extremities: characteristic lesions; lymphadenopathy in axillae or groin.
The Monkeypox Rash
The characteristic rash begins about 1–4 days after the other symptoms (some patients get the rash first). It progresses from macule → vesicle → pustule → scab, typically lasting 2–3 weeks. Patients are infectious until the scabs fall off and a new skin layer forms.
The vesiculopustular monkeypox rash.
1
Enanthem Stage
In some cases, lesions first form in the mouth and/or on the tongue.
2
Macular Stage
Flat, rounded red spots appear. Lasts 1–2 days.
3
Papular Stage
Macules become raised red bumps (papules). Lasts 1–2 days.
4
Vesicular Stage
Papules become raised bumps filled with clear fluid. Lasts 1–2 days.
5
Pustular Stage
Vesicles fill with pus, initially firm/deep-seated, then developing a central umbilication. Lasts 5–7 days.
6
Scab Stage
Pustules crust into scabs that fall off after about a week. Lasts 7–14 days.
Nursing Interventions
For a patient suspected of having monkeypox, several interventions can begin right away:
Isolate
Contact and droplet precautions. Monkeypox is not airborne, so a negative-pressure room is not required (though prudent if chickenpox is also possible). Always follow facility protocol.
Place the IV
At least one IV, preferably 20 gauge or larger, for normal saline. These patients are often tachycardic and febrile.
Prime Your Fluids
Spike at least 1 L of NSS ready to infuse, with a verbal or electronic order before administering.
Bedside Monitor
For significantly ill, tachycardic patients, place on a cardiac monitor and obtain a full set of vitals.
Administer Meds
Verify and give what's needed — antipyretics (Tylenol), analgesics (morphine, Toradol), antiemetics (Zofran).
Diagnosis of Monkeypox
Diagnosis is largely clinical, based on history and the rash, but lab confirmation is recommended during an outbreak.
PCR Swab
Swab lesions with a dry synthetic swab — obtain 2 swabs from at least 2 different lesions. Vigorous swabbing is fine; no need to unroof the lesion.
Antibody Testing
IgM is detectable ~5 days after rash onset; IgG ~8 days after.
Electron Microscopy
Reveals brick-shaped poxvirus virions — indistinguishable from smallpox.
Other (nonspecific) lab abnormalities: leukocytosis, transaminitis (elevated liver enzymes), thrombocytopenia, and hypoalbuminemia. None are specific to monkeypox.
Prognosis & Treatment
In the current US outbreak, most patients recover fully at home without hospitalization. More severe presentations are admitted for extended treatment. For most people, treatment is symptomatic, like most viral illnesses.
Supportive care
Antipyretics
Tylenol or ibuprofen to control fever and pain.
Fluids
Encourage oral hydration (IV if admitted) to speed recovery and prevent complications like AKI.
Rest
Rest helps the body heal as quickly as possible.
Antivirals
Tecovirimat (TPOXX)antiviral — severe disease
Reserved for admitted patients with severe disease. It inhibits the orthopoxvirus protein required for virus particle formation and has reduced mortality in animal models when started early. Dosing:600 mg IV/PO Q12H × 14 days (for 40–120 kg). Side effects: headache, nausea, abdominal pain.
Cidofovir / Brincidofovirantiviral alternatives
Cidofovir is effective against monkeypox in animal studies. Brincidofovir, a prodrug of cidofovir, is also approved for monkeypox, though it showed elevated liver enzymes in animal studies.
Complications & Monitoring
Most patients recover well at home, but watch for complications, especially in higher-risk groups.
Higher-Risk Patients
Immunocompromised patients (HIV/AIDS, leukemia, chronic steroids/immunosuppressants), children under 8, pregnant or breastfeeding women, and those with active skin disease (severe eczema, impetigo, burns) are at increased risk of severe complications.
Secondary bacterial infections can strike while the immune system is busy. Common ones include:
Sepsis
Bacterial infection at any site (UTI, lung, skin) can drive sepsis. See sepsis management.
Bronchopneumonia
Suspect with productive cough, SOB, adventitious sounds, and respiratory distress — evaluate with a CXR.
Encephalitis
Confusion, migraines, seizures, altered mental status. Worked up with brain imaging, EEG, and lumbar puncture.
Clinical Pearls
1
Lymphadenopathy distinguishes monkeypox from smallpox. Swollen nodes plus a staged vesiculopustular rash is the classic picture.
2
Contagious until scabs fall off. Infectivity runs from symptom onset through complete re-epithelialization — not airborne, so no negative-pressure room required.
3
It is NOT an STI. Skin-to-skin contact spreads it, sex included, but framing it as a sexually transmitted infection is wrong and stigmatizing.
4
TPOXX is for severe, admitted disease. Most patients just need supportive care — fluids, antipyretics, and rest.
This info look great! As a FNP in the Emergency department I have seen today more than 10- patients with Monkey Pox . It has been challenging to decide the the proper treatment of each case because the patient present at different stages of the virus. I am appreciate this info.
This info look great! As a FNP in the Emergency department I have seen today more than 10- patients with Monkey Pox . It has been challenging to decide the the proper treatment of each case because the patient present at different stages of the virus. I am appreciate this info.
Audrey, I love that you find it useful! Thank you so much for being on the front lines!!