case - steven johnson's

8/3/2019 Case - Steven Johnson's

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Introduction

In 1922, Stevens and Johnson first described 2 patients, boys aged 7 and 8 years, with “an extraordinary,

generalized eruption with continued fever, inflamed buccal mucosa, and severe purulent conjunctivitis.” Both cases

were misdiagnosed by primary care physicians as hemorrhagic measles. Erythema multiforme (EM), originally

described by von Hebra in 1866, was part of the differential diagnosis in both cases, but it was excluded because of

the “character of skin lesions, the lack of subjective symptoms, the prolonged high fever, and the terminal heavy

crusting.” In spite of leukopenia in both cases, Stevens and Johnson in their initial report suspected an infectious

disease of unknown etiology as the cause.

In 1950, Thomas divided EM into 2 categories, as follows: erythema multiforme minor (von Hebra) and

erythema multiforme major (EMM; also known as Stevens-Johnson syndrome, or SJS). Since 1983, the eponym of

Stevens-Johnson syndrome had been used as a synonym for EMM.

Stevens-Johnson Syndrome is a rare disorder characterized by inflammation of the mucous membranes of

the mouth, throat, anogenital region, intestinal tract and membrane lining the eyelids (conjunctiva). Affected

individuals may have abnormalities (lesions) of the skin and mucous membranes that are purplish or red in color.

The abnormalities may be flat (macules) or small and raised (papules). In some cases, the lesions may develop

raised fluid-filled centers (bullae or blisters). Affected individuals may also have blisters and/or bleeding in the

mucous membranes of the lips, eyes, mouth, nasal passage, and genitals. In addition, abnormalities of the eyes

may develop as a result of the lesions caused by Stevens-Johnson Syndrome (ocular sequelae). Such abnormalities

may include infection of the delicate membrane of the eye and eyelids (conjunctiva) and inflammation associated

with an abnormal discharge from the conjunctiva (purulent conjunctivitis).



Some researchers believe that Stevens-Johnson Syndrome is a severe form of Erythema Multiforme, an

inflammatory disorder of the skin and mucous membranes (mucocutaneous) that is triggered by an allergic

reaction. Other researchers believe that Stevens-Johnson Syndrome is an independent syndrome. It is uncertain

exactly what causes the allergic reaction, but researchers think it may be triggered by an allergic reaction tocertain drugs such as antibiotics, including sulfonamides, tetracyclines, amoxicillin, and ampicillin. In some cases,

nonsteroidal anti-inflammatory medications and anticonvulsants, such as Tegretol and phenobarbitals, have also

been implicated. In some cases, it is also possible that the disorder may be triggered by an infection. 50% of the

cases are idiopathic..

Causes: Various etiologic factors (eg, infection, vaccination, drugs, systemic diseases, physical agents,

food) have been implicated as causes of SJS. Drugs most commonly are blamed. Recent reports linked SJS to the

use of drugs, rather than to other etiologic factors. Antibiotics are the most common cause of SJS, followed byanalgesics, cough and cold medication, nonsteroidal anti-inflammatory drug (NSAID), psycho-epileptics, and

antigout drugs. Other drugs also can be involved in the pathogenesis of SJS. Individuals with antigens human

leukocyte antigen Bw44 (HLA-Bw44), a part of human leukocyte antigen B12 (HLA-B12), and human leukocyte

antigen DQB1*0601 (HLA-DQB1*0601) appear to be more susceptible to developing SJS.



ObjectivesPatient Centered Objectives

To realize the significance of health in their lives

To obtain enlightenment on how to maintain health and prevent complications through health

edification

To put the knowledge that he has acquired into practice

To enthusiastically partake in medical care procedures and nursing interventions that would hasten

the healing process and expedite their recuperation

To manifest indications of positive changes in their current health situation

Nurse Centered Objectives

To establish rapport and rehabilitative affinity with the patient

To discern various health issues and problems of the patient who is the center of this study

To accustom ourselves with the definition, etiology, occurrence, diagnostics and management of

stevens-johnson’s disease

To master all the appropriate nursing interventions befitting stevens-johnson’s disease

To utilize the theoretical learning that we have acquired into actual setting particularly in this disease



Anatomy and Physiology of the IntegumentarySystem

The skin is the largest organ in the body: 12-15% of body weight, with a surface area of 1-2 meters.Skin is continuous with, but structurally distinct from mucous membranes that line the mouth, anus,urethra, and vagina. Two distinct layers occur in the skin: the dermis and epidermis. The basic cell type of the epidermis is the keratinocyte, which contain keratin, a fibrous protein. Basal cells are the innermostlayer of the epidermis. Melanocytes produce the pigment melanin, and are also in the inner layer of theepidermis. The dermis is a connective tissue layer under the epidermis, and contains nerve endings,sensory receptors, capillaries, and elastic fibers.

The integumentary system has multiple roles in homeostasis, including protection, temperatureregulation, sensory reception, biochemical synthesis, and absorption. All body systems work in aninterconnected manner to maintain the internal conditions essential to the function of the body.

Follicles and GlandsHair follicles are lined with cells that synthesize the proteins that form hair. A sebaceous gland (thatsecretes the oily coating of the hair shaft), capillary bed, nerve ending, and small muscle are associatedwith each hair follicle. If the sebaceous glands becomes plugged and infected, it becomes a skin blemish(or pimple). The sweat glands open to the surface through the skin pores. Eccrine glands are a type of sweat gland linked to the sympathetic nervous system; they occur all over the body. Apocrine glands are

the other type of sweat gland, and are larger and occur in the armpits and groin areas; these produce asolution that bacteria act upon to produce "body odor".

Hair and NailsHair, scales, feathers, claws, horns, and nails are animal structures derived from skin. The hair shaftextends above the skin surface, the hair root extends from the surface to the base or hair bulb. Geneticscontrols several features of hair: baldness, color, texture.Nails consist of highly keratinized, modified epidermal cells. The nail arises from the nail bed, which isthickened to form a lunula (or little moon). Cells forming the nail bed are linked together to form the nail.

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Skin and HomeostasisSkin functions in homeostasis include protection, regulation of body temperature, sensory reception,water balance, synthesis of vitamins and hormones, and absorption of materials. The skin's primaryfunctions are to serve as a barrier to the entry of microbes and viruses, and to prevent water and

extracellular fluid loss. Acidic secretions from skin glands also retard the growth of fungi. Melanocytesform a second barrier: protection from the damaging effects of ultraviolet radiation. When a microbepenetrates the skin (or when the skin is breached by a cut) the inflammatory response occurs.Heat and cold receptors are located in the skin. When the body temperature rises, the hypothalamus sends a nerve signal to the sweat-producing skin glands, causing them to release about 1-2 liters of waterper hour, cooling the body. The hypothalamus also causes dilation of the blood vessels of the skin,allowing more blood to flow into those areas, causing heat to be convected away from the skin surface.When body temperature falls, the sweat glands constrict and sweat production decreases. If the bodytemperature continues to fall, the body will engage in thermiogenesis, or heat generation, by raising thebody's metabolic rate and by shivering.

Water loss occurs in the skin by two routes.

1. evaporation2. sweating

In hot weather up to 4 liters per hour can be lost by these mechanisms. Skin damaged by burns is lesseffective at preventing fluid loss, often resulting in a possibly life threatening problem if not treated.

Skin and Sensory ReceptionSensory receptors in the skin include those for pain, pressure (touch), and temperature. Deeper within

the skin are Meissner's corpuscles, which are especially common in the tips of the fingers and lips, andare very sensitive to touch. Pacinian corpuscles respond to pressure. Temperature receptors: more coldones than hot ones.

Skin and SynthesisSkin cells synthesize melanin and carotenes, which give the skin its color. The skin also assists in thesynthesis of vitamin D. Children lacking sufficient vitamin D develop bone abnormalities known as rickets.

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Skin Is Selectively Permeable The skin is selectively soluble to fat-soluble substances such as vitamins A, D, E, and K, as well as steroid hormones such as estrogen. These substances enter the bloodstream through the capillary networks in

the skin. Patches have been used to deliver a number of therapeutic drugs in this manner. These includeestrogen, scopolamine (motion sickness), nitroglycerin (heart problems), and nicotine (for those trying toquit smoking).

Thick Skin The epidermis of thick skin follows the contours of the dermal ridges, producing the epidermal ridgesof the fingerprint. The dermal ridges penetrate into the epidermis as true papillae, and are separated byepithelial downgrowths called interpapillary pegs Five layers of cells or cell products are found in theepidermis: (1) stratum germinativum, columnar basal stem cells; (2) stratum spinosum, polyhedralcells with "spiny" projections: (3) stratum granulosum, diamond shaped cells containing keratohyalin

granules; (4) stratum lucidum, a clear, homogenous line composed of eleidin, a keratohyalintransformation product (not always seen); and (5) stratum corneum, the keratin filled squames

Dermis The dermis is composed of two layers: (1) the papillary dermis closest to the epithelium, is composedof less dense connective tissue and is vascularized with capillary networks penetrating the papillae and(2) the underlying reticular dermis composed of avascular, dense irregular connective tissue

Subcutaneous LayerBeneath the dermis, a layer composed of adipose and loose/dense connective tissues make of the

subcutaneous layer. Numerous structures are found in this layer. The secretory portion of the eccrinesweat glands are found here, with their ducts penetrating the dermis to enter the epidermis through theinterpapillary pegs Also, sensory structures (pacinian corpuscles), nerve bundles, blood vessels, and thebases of hair follicles are found in the subcutaneous layer.

Thin Skin The epidermis differs from that of thick skin in having thinner stratum spinosum, granulosum, andcorneum, and lacks the stratum lucidum . The dermis is not arranged in ridges, but does project into the

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epidermis as true papillae. However, no epidermal ridges are produced The pigment of the skin isproduced by melanocytes, which take up residence in the basal layer (stratum germinativum) andproduce melanin or pigment granules .



Nursing Health HistoryDEMOGRAPHIC DATA



Name: Bienvinido de LeonAge: 65 years oldBirthday: July 14, 1938Address: Blk. 1, San Jose, TarlacStatus: Married

Religion: Roman CatholicDOA: November 27, 2004 @ 8:49 amAttending Physician: Dr. Martinez

ADMITTING DIAGNOSIS: Psoriasis

REASON FOR SEEKING HEALTH CARE: Drowsiness, Chest Pain

HISTORY OF SEEKING HEALTH CARE

• On November 4, 2004, patient noted appearance of macules and lesions first on the extremities

then after a few days, it spread all over the body.• The rashes became very itchy.

• After few more days, patient’s skin became very scaly and the rashes turned brownish.• At about 7:30 in the morning of November 27, 2004, the patient complained of chest pain. Later on,

patient’s relatives noted difficulty of breathing with drowsiness. The condition persisted for 30 minutes. Hesought consultation at CLDH OPD, hence, was admitted.

PERCEPTION OF HEALTH STATUSRates himself as ( 2 )- Able to cope up with ADL’s

On a scale of 1 ( illness ) to ( 5 ) healthy• " Pakiramdam ko, para akong kandilang nauupos.”

• “Habang tumatagal kasi, pahina ako ng pahina.”

PREVIOUS ILLNESS, HOSPITALIZATION AND SURGERY • The patient has hypertension.

• He was not admitted to a hospital before. This was his first time.

• He had not undergone any major or minor surgery.



CLIENT-FAMILY MEDICAL HISTORY • The patient claimed that both his maternal and paternal side has hypertensive and cardiac disorders.

• He does not know any relative suffering from the disease same as his.

IMMUNIZATIONS and COMMUNICABLE DISEASES• The patient had his basic immunizations but not remember when and what kind.

• He had chickenpox, measles, mumps and pneumonia during his childhood and teenage years.

ALLERGIES• The client has no drug, food, or environmental allergies.

CURRENT MEDICATIONS

• Ulcepraz 40 mg. IVP OD

• Nootropil 1 gm. IVP every 8 hours

• Iselpin 1 gram 1 tab every 6 hours

• Laxoberal 1 tbsp. HS

• Imdur 60 mg. 1 tab OD

• Flagyl 500 mg. IV Infusion every 8 hours

• Moriamin Forte 1 tab TID

DEVELOPMENTAL LEVEL

Erik EriksonIntegrity vs. Despair

• He had viewed his life as meaningful and fulfilling.

• He had gone through a lot of hardships but through it all, he is happy that she was able tosurpass all of them.



•

Sigmund FreudAccording to Freud’s early theory, all behaviors are motivated by a desire to satisfy biological

needs and release of tension. Freud believed that gratification behavior is expressed primarily throughdifferent body zone (oral, anal, genital) at certain ages during the course of personality development. “ The goal of development is maximizing need gratification minimizing punishment and guilt usingdefenses to control anxiety. Freud’s theory stated unresolved gratification at a certain stage leads to afixation of development at that stage.

Genital Stage (15 years to adulthood)

• He has reached sexual maturity.

• He has developed an intimate relationship to his partner, who is also his sexual partner.

• He has a successful marriage and a happy family.

Jean PiagetFormal Operations (11+ years )

• The client is able to see relationships of objects, events and situations.

• He can reason in the abstract.

• He logically solves problems.

• Thinks scientifically and solves complex problems.

Lawrence KohlbergKohlberg’s model states that the person’s ability to make moral judgments in a behave and a

morally correct manner develops over a period of time. Kohlberg identified three levels of morality: apreconventional level, based on obedience or punishment; a conventional level when reasoning beginsto focus or more abstract principles of right or wrong rather than established moral truths

Level III: Postconventional

• He understands that it is wrong to violate others' rights.

• He follows laws and orders of the society.

• He respects the dignity of human beings as individuals.



• He has developed morality and ethics.

• His judgements are based on principles of justice.

• He lives by the saying that "Do to others as you would have them do to you."

Harry Stack Sullivan

Theorized that relationships with others influence how one’s personality develops. Approval anddisapproval from significant others influence the formation of one’s personality. To form satisfyingrelationships with others, an individual must complete six stages of development.

Late Adoloscence Has established an intimate and long lasting relationship with someone of the opposite sex.

Havighurst Theorized that there are 6 developmental stages of life, each with essential task to be achieved.

Mastery of task in one developmental stage is essential for mastery of tasks in subsequent stages.When a task in one stage is mastered, it is learned for life.

Stage of Late Maturity

• Adapted with his physiological changes and alterations in health status

• The client had adjusted to retirement.

• Has established satisfactory living arrangements

• ·

PSYCHOSOCIAL HISTORY The client’s usual source of stress includes several factors such as his job/ occupation and his

illness. However, he stated that he could easily cope up with these stresses as long as there are those



people who are close to him who are always there to support him. Specifically, these people compriseof his family especially his , wife, and his children. Best of all, he said that his family is a God fearingfamily.

VALUES and BELIEFS The client claimed that he believes in hilots , albularyos , tawas and pag-aatang ( offering of food sacrifices) mainly because of his social status and their background as a typical Filipino. He also saidthat he also resort to traditional/ herbal medicines (eg. Guava leaves) as their primary treatment.

As a Roman Catholic, he does not eat meat during Holy Week. He gives credence to God.

NUTRITION The client claimed that he has a good eating habit not until he became ill. He eats typical Filipino

food comprising mainly of vegetables, meat and rice. He eats more meat than fish and vegetables. Hesays he puts MSG in almost all their viands.

He drinks plenty of water, at least 7 glasses per day.

SLEEP PATTERN The client usually sleeps at around 8-9:00 in the evening and wakes up at around 5 in the

morning. When he became ill, he almost sleeps the entire day because of severe weakness.

RECREATION and HOBBIES The client usually spends his leisure time (free day) breeding chickens and training them for

“sabong”.

LIFE STYLE The client reported that he used to smoke around 10-15 sticks a day. He likewise stated that heis an occasional drinker.

ECONOMIC and SOCIO-CULTURAL DATAOur client is an elementary undergraduate of San JoseElementary School.He is a Kapampangan in ethnic affiliation.He belongs to the economic status letter B.



InspectionandPalpation

exposed to the sun; areas of lighter pigmentation (palms,lips, nail beds) in darkskinned people

SKIN LESIONS: Freckles,some birthmarks, some flatand raised nevi (moles); noabrasions or other lesions

SKIN MOISTURE: Moisturein skinfolds and in axillae(varies with environmentaltemperature and humidity,

body temperature andactivity)

SKIN TURGOR: Whenpinched, skin springs backto previous state

because some areas areeither sloughing, swollenor necrotic.

Presence of papules,erythema, crusting,scaling, necrosis.

There is severe dryness of skin.

When pinch skin slowlysprings back to previousstate.

NOTNORMAL

NOTNORMAL

NOT

NORMAL

NORMAL



HAIR Inspection EVENNESS OF GROWTH:Evenly distributed hair

THICKNESS/THINNESS,

COLOR, LENGTH: Thickhair

INFESTATIONS: Noinfections or infestations

Patches of hair loss due tolesions and erythema inthe scalp

Thin

No infestations

NOTNORMAL

NORMAL

NORMAL

NAILS

Upper

extremities

Inspection

Palpation

SHAPE: Convex curvature;angle between nail bedabout 160 degrees

TEXTURE: Smooth texture

NAIL BED COLOR: Highlyvascular and pink in lightskinned clients; dark-skinned clients may havebrown or black pigmentationin longitudinal steaks

TISSUE SURROUNDING:

Intact epidermis

Uneven curvature.

Rough, brittle texture.

Pale in color

Tissue surrounding theepidermis is scaly and

erythematous

NOTNORMAL

NORMAL

NORMAL

NOT

NORMAL

SKULLANDFACE

Inspection SKULL SIZE, SHAPE, ANDSYMMETRY: Rounded(normocephalic and sym-metric, with frontal, parietal,

Rounded, normocephalicand symmetric.

NORMAL



Palpation

Inspection

and occipital prominences);smooth skull

NODULES/MASSES/LESIO

NS: Smooth, uniformconsistency; absence of nodules or masses

FACIAL FEATURES:Symmetric or slightlyasymmetric facial features;palpebral fissures equal insize; symmetric nasolabial

folds

FACIAL MOVEMENTS:Symmetric facialmovements

Smooth and there is no

presence of nodules;presence of erythema,scaling and papules

Symmetric facial features.

Symmetric facial

movements.

NOT

NORMAL

NORMAL

NORMAL

EYESTRUCTURES

ANDVISUALAQUITY

Inspection EXTERNAL STRUCTURES

EYEBROWS: Hair evenly

distributed; skin intactEyebrows symmetricallyaligned;equal movement

EYELASHES: Equallydistributed; curled slightlyoutward

Uneven distribution of hair

because of scaling in theface

Absence of eyelashes.

Swollen, boggy,

NOTNORMAL

NOTNORMAL



Inspection

andPalpation

Inspection

EYELIDS: Skin intact; nodischarge; no discoloration.Lids close symmetrically

PUPIL: Black in color; equal

in size; normally 3 to 7 mm

in diameter; round, smooth

border, iris flat and round

REACTION TO LIGHT:Illuminated pupil constricts(direct

response)Nonilluminated pupilconstricts(consensual response)

ACCOMMODATION:

Pupils constrict when

looking at near object;

pupils dilate when looking at

far object; pupils converge

when near object is moved

toward nose

VISUAL FIELD

PERIPHERAL VISUALFIELD: When looking

edematous

Presence of conjunctivitis

Black in color; equal insize;round, smooth border, iris

flat and round

Illuminated pupil constricts(directresponse)

Nonilluminated pupilconstricts(consensual response)

Pupils constrict whenlooking at near object;pupils dilate when looking

at far object; pupilsconverge when near objectis moved toward nose

When looking straightahead, client can see

NOTNORMAL

NOTNORMAL

NORMAL

NORMAL

NORMAL

NORMAL



straight ahead, client cansee objects in the periphery

SIX OCULAR

MOVEMENTS: Both eyescoordinated, move inunison, with parallelalignment

objects in the periphery

Both eyes coordinated,move in unison, with

parallel alignment

NORMAL

NORMAL

EARSANDHEARING

Inspection

Palpation

AURICLES

Color same as facial skin

Symmetric position. Linedrawn from lateral angle of

eye to point where top part

of auricle joins head is

horizontal; imaginary line

drawn from the top to the

bottom of the ear varies no

more than 10 degrees from

the vertical.

Mobile, firm, and not tender;

pinna recoils after it is

folded

EXTERNAL EAR CANALAND TYMPHANIC

Color same as facial skin

Symmetric position. Linedrawn from lateral angle of

eye to point where top

part of auricle joins head is

horizontal; imaginary line

drawn from the top to the

bottom of the ear varies

no more than 10 degrees

from the vertical.

Mobile, firm, and tender;pinna recoils after it isfolded, swollen

Distal third contains hair

NORMAL

NORMAL

NOTNORMAL

NORMAL



Inspection MEMBRANE

Distal third contains hair

follicles and glands

Dry cerumen, grayish-tan

color; or sticky, wet

cerumen in various shades

of brown

Pearly gray color,

semitransparent

Normal voice tones audible

GROSS HEARING ACUITY TESTAble to repeatnonconsecutive numbers

follicles and glands

Dry cerumen, grayish-tan

color; or sticky, wet

cerumen in various shades

of brown

Pearly gray color,

semitransparent

Normal voice tones audible

Able to repeatnonconsecutive numbers

NORMAL

NORMAL

NORMAL

NORMAL



NOSEANDSINUSES

Inspection NOSE

Symmetric and straight

No discharge or flaring

Uniform color

Not tender; no lesions

Air moves freely as theclient breathes through thenares

LINING OF NARES:

Mucosa pink

Clear, watery discharge

No lesions

NASAL SEPTUM:

Nasal septum intact and in

midline

Symmetric and straight

No discharge or flaring

Uniform color

Tender, with lesions

Air moves freely as theclient breathes throughthe nares

Mucosa pink

Clear, watery discharge

No lesions

Nasal septum intact and inmidline.

NORMAL

NORMAL

NOTNORMAL

NORMAL

NORMAL

NORMAL

MOUTHAND

InspectionLIPS AND BUCCAL

MUCOSA Lips are edematous and



OROPHARYNX

InspectionandPalpation

Uniform pink color (darker,

eg, bluish hue, in

Mediterranean groups and

dark-skinned clients)

Soft, moist, smooth textureSymmetry of contour. Ability

to purse lips

INNER LIPS AND BUCCAL

MUCOSA

Uniform pink color (freckled

brown pigmentation in dark-

skinned clients)

TEETH AND GUMS

32 adult teeth

Smooth, white, shiny toothenamel

Pink gums (bluish or darkpatches in dark-skinnedclients) Moist, firm textureto gums

TONGUE/FLOOR OFMOUTH

swollen; unable to purse

lips

Reddish, swollen

Teeth appear to becomplete.

Smooth , and presence of tarry black regionsspecifically at the molarand pre molar region.

Gums have blackishdiscoloration specially atthe upper region of theoral cavity.

Not normal

Not NORMAL

NORMAL

NOTNORMAL

NOTNORMAL



Inspection

TONGUE

Central Position

Pink in color (some brownpigmentation on tongueborders in dark skinnedclients); moist; slightlyrough; thin whitish coathing

Moves freely; no tenderness

Smooth tongue base withprominent veins

Central Position

Darkish red in color, hasabundant whitishpigmentation

Moves freely; no

tenderness

Smooth tongue base hasprominent veins

NORMAL

Not Normal

NORMAL

NORMAL

NECK

Inspection

Palpation

NECK MUSCLES

Muscle equal in size; headcentered

Coordinated, smoothmovements with nodiscomfort

Equal muscle strength

LYMPH NODES

Muscle equal in size; headcentered

Uncoordinated,movements withdiscomfort

Muscle weakness

NORMAL

NOTNORMAL

NOTNORMAL



Palpation

Inspection

Palpation

Not palpable

TRACHEA

Central alignment in midlineof neck; spaces are equal onboth sides

THYROID GLAND

Not Visible

Lobes may not be palpated

If palpated, lobes are small,smooth, centrally located,painless, and rise freely withswallowing

Not Palpable

Central alignment inmidline of neck; spacesare equal on both sides

Not Visible

Lobes may not be palpated

, lobes are small, smooth,centrally located, painless,and rise freely withswallowing

NORMAL

NORMAL

NORMAL

NORMAL



THORAXANDLUNGS

Inspection

Palpation

Palpation

Percussion

POSTERIOR THORAX

Chest symmetric

Skin intact; uniformtemperature

Chest wall intact; notenderness masses

Full and symmetric chestexpansion (ie, when theclient takes a deep breath,your thumbs should move

apart an equal distance andat the same time; normallythe thums separate 3 to 5cm [1 ½ to 2 in] during deepinspiration)

VOCAL (TACTILE)FREMITUS:

Bilateral symmetry of vocalfremitus

Low-pitched voices of malesare more readily palpatedthan higher-pitched voicesof females

THORAX: Percussion notesresonate

Lowest point of resonance isat the diaphragm (ie, at the

Chest symmetric

Skin is scaly anderythematous

Chest wall intact; withtenderness

Full and symmetric chestexpansion when the clienttakes a deep breath, thethumbs separate 3 to 5 cm

[1 ½ to 2 in] during deepinspiration)

Bilateral symmetry of vocal fremitus

Low-pitched voices of males are more readilypalpated than higher-pitched voices of females

Percussion notes resonate

Resonance is felt at thediaphragm at the level of

NORMAL

NOTNORMAL

NOTNORMAL

NORMAL

NORMAL

NORMAL

NORMAL

NORMAL



ABDOMEN

Inspection There should be no lesions,nodules. It should be clear.

Skin is scaly and someparts are swollen andreddish

NOTNORMAL



Auscultation

Palpation

Percussion

Hollow sound heard.Hypoactive bowel sound.

Smooth, flat surface

Dull sound heard.

No abnormal findingsnoted.



NORMAL

NORMAL

NORMAL

• UPPEREXTRE

MITIES

Inspection,palpation

All peripheral pulses shouldbe present, symmetrical

joint movement,

discoloration, moist, fingersare complete no lesion,infection or any skin break.

Weak, thready pulse; skinis scaly, with crusting andpapules; skin is dry and

has poor skin turgor;limited range of motionbecause of severe bodyweakness

NOTNORMAL

• LOWEREXTREMITIES

Inspection,palpation

All peripheral pulses shouldbe present, symmetrical

joint movement,discoloration, moist, fingersare complete, no lesion,

infection or any skin break.

skin is scaly, with crustingand papules; skin is dryand has poor skin turgor;limited range of motionbecause of severe body

weakness

NOTNORMAL



Review of Systems

PERIPHERAL PERFUSION

Patient is pale looking and appears weak.

The nails of upper and lower extremities are also pale in color; exhibits poor capillary refill

His blood study shows a low number of RBC, Hemoglobin and hematocrit

RESPIRATORY SYSTEM

Crackles auscultated.

Patient’s RR is 20 cpm.

Non-productive cough noted Difficulty of breathing noted

CARDIOVASCULAR SYSTEM

Patient’s BP is 140/80 mmHg & CR is 80 bpm.

His maternal and paternal side had a history of Hypertensive diseases and as well as havingheart diseases

GASTROINTESTINAL

The patient has no episodes of diarrhea.

Hypoactive bowel sounds

Constipation

Presence of erythema, rashes, scaling in the abdomen



MUSCULOSKELETAL

Has difficulty of moving because of weakness

The patient is unable to sustain ADLs and needs assistance and support

He also claimed that he has no muscle spasm or loss of sensation from his bony to muscularprominence

NEUROLOGIC

The patient in general felt weakness and felt a sense of uselessness

Exhibits no difficulty of hearing

Has slurred speech because of the inability of the lips to close

Reflexes are poor

GENITOURINARY

Exhibits normal micturation/voiding pattern.

Bowel movement was noted at the descending colon with characteristics of normal activity

No dysuria nor hematuria noted.

There is no pain reported during micturation and defacation

PERSONP• 65 year old male, married

• smoker (10-15 sticks a day)



• alcohol drinker

• lives with his familyPast History:- No surgeries- No hospitalizations

-History of chickenpox, mumps and measles (childhood years)

• Practicing, Devout Roman Catholic

• Expressed some concern over the prognosis of his disease whether he could still recover or not

E• Voiding with no difficulty

• Clear and yellow urine

• Voids in the bed using a bedpan

• Defecates with difficulty because he still has to exert effort

• No laxatives used at home

• Normoactive bowel sounds

• No distention or tenderness on palpation

R• No sleep aids used at home

• ROM limited on both upper and lower extremities

• Performs ADL's with difficulty due to severe weakness

S• RBC, Hgb and Hct lower than the normal range• Albumin lower than normal range

• Stool exam positive for occult blood

• With lesions, skin breaks and scaling on the entire body

• Normal liver, gallbladder, pancreas, spleen, kidneys as shown in the ultrasound

• Chest X-ray done: Impression: PTB Moderately advanced

O



• Crackles auscultated

• RR: 18 Breaths per minute

• With non productive cough

N• Soft diet because of swollen buccal mucosa

• States hospital food is "not bad at all"

• States that he is not "picky" with regards to foods

• Prefers to eat vegetables, meat and lots of rice

• Height: 5 feet 7 in.

• Weight: approx. 80 kg.

• Swollen lips and buccal mucosa

• Without dentures

• Redness in the gums

IDEAL Diagnostic and Laboratory Examinations Lab Studies:

• No laboratory studies (other than biopsy) exist that can aid the physician in establishing thediagnosis.

•

A complete blood count (CBC) may reveal a normal white blood cell (WBC) count or a nonspecificleukocytosis. A severely elevated WBC count indicates the possibility of a superimposed bacterialinfection.

• Determine renal function and evaluate urine for blood.

• Electrolytes and other chemistries may be needed to help manage related problems.

• Cultures of blood, urine, and wounds are indicated when an infection is clinically suspected.



Imaging Studies:

• Chest radiography may indicate the existence of a pneumonitis when clinically suspected. Otherwise,routine plain films are not indicated.

Other Tests:

• Skin biopsy is the definitive diagnostic study but is not an emergency department (ED) procedure.

o Skin biopsy demonstrates that the bullae are subepidermal.

o Epidermal cell necrosis may be noted.

o Perivascular areas are infiltrated with lymphocytes



December 1, 2004

CreatinineAF

67 umol/LRV

71-133umol/L

Potassium 3.6 mmol/L 3.6-5.0 mmol/L

PROTHROMBIN TIME

December 2, 2004

Patient’s Time 11.8 secNormal Value

10-14 sec

Control Time 13.5 sec 9.5-14.3 sec

% Activity 101% 70-130%

EHR 0.99 0.90-1.27



December 5, 2004

PotassiumAF

4.54 mmol/LRV

3.5-5.3 mmol/L

Albumin 19 g/L 39-50 g/L

Routine Blood CountDecember 5, 2004

WBC

AF

5.9

RV

4-10RBC 3.62 4.5-5.5

HGB 10.7 13-17

HCT 31.6 40-50

PLT 238 150-400

Lymphocytes 12 20-40

Monocytes 17 2-10

Neutrophils 71 40-80



Routine Blood CountDecember 1, 2004

WBCAF6.3

RV4-10

RBC 3.41 4.5-5.5

HGB 10.0 13-17

HCT 29.7 40-50

PLT 169 150-400

Lymphocytes 13.9 20-40

Monocytes 8.3 2-10

Neutrophils 77.8 40-80

Patient’s Diagnostic and Laboratory Exams



Routine Stool ExamDecember 4, 2004

Occult Blood: Positive

Abdominal UltrasoundDecember 6, 2004

The liver is normal in size. The intrahepatic and common ducts are not

dilated. No parenchymal mass noted. The gallbladder shows no calculus.

Pancreas and spleen are normal in size.Both kidneys are normal in size and echopattern. No calculus or

hydronephrosis is noted. The urinary bladder is unremarkable. The prostategland is not enlarged.

No peritoneal fluid or mass is noted.

Medical Management• Emergency Department Care: Most patients present early and prior to obvious signs of

hemodynamic compromise. The single most important role for the ED physician is to detect SJS early andinitiate the appropriate ED and inpatient management.



• Care in the ED must be directed to fluid replacement and electrolyte correction.

• Skin lesions are treated as burns.

• Patients with SJS should then be treated with special attention to airway and hemodynamic stability, fluid

status, wound/burn care, and pain control.

• Treatment of SJS is primarily supportive and symptomatic. Some have advocated cyclophosphamide,plasmapheresis, hemodialysis and immunoglobulin, but none of those should be considered standard atthis time.

o Manage oral lesions with mouthwashes.

o Topical anesthetics are useful in reducing pain and allowing the patient to take in fluids.

o

Areas of denuded skin must be covered with compresses of saline or Burow solution.

• Underlying diseases and secondary infections must be identified and treated. Offending drugs must bestopped.

• The use of systemic steroids is controversial. Some authors believe that they are contraindicated. Treatment with systemic steroids has been associated with an increased prevalence of complications.

• Address tetanus prophylaxis.

• Supportive systemic therapy: Management of patients with SJS usually is provided in ICUs or

burn centers. No specific treatment for SJS exists; therefore, most patients are treated symptomatically. Inprincipal, the symptomatic treatment of patients with SJS does not differ from the treatment for patientswith extensive burns.

o Fluid management is provided by macromolecules and saline solutions during the first 24 hours.



o After the second day of hospitalization, oral intake of fluids provided by nasogastric tube often isbegun, so that intravenous fluids can be tapered progressively and discontinued, usually in 2weeks.

o Massive parenteral nutrition is necessary as soon as possible to replace the protein loss and to

promote healing of cutaneous lesions.

o Intravenous insulin therapy may be required because of impaired glycoregulation.o Patients with SJS are at a high risk of infection. Sterile handling and/or reverse-isolation nursing

techniques are essential to decrease the risk of nosocomial infection.o Cultures of blood, catheters, gastric tubes, and urinary tubes must be performed regularly.o Because of the association between SJS and sulfonamides, avoid the use of silver sulfadiazine,

commonly used in burn units; instead, use another antiseptic, such as 0.5% silver nitrate or 0.05%chlorhexidine, to paint and bathe the affected skin areas.

o Prophylactic systemic antibiotics are not recommended.o The diagnosis of sepsis is difficult. Carefully consider the decision to administer systemic

antibiotics. The first signs of infection are an increase in the number of bacteria cultured from theskin, a sudden drop in fever, and deterioration of the patient's condition, indicating the need forantibiotic therapy. The choice of antibiotic usually is based on the bacteria present on the skin.Because of impaired pharmacokinetics, similar to that present in burn patients, the administrationof high doses may be required to reach therapeutic levels. Monitoring the serum levels is necessaryto adjust the dosage.

o Environmental temperature raised to 30-32°C reduces caloric loss through the skin. Fluidized airbeds are recommended if a large portion of the skin on the patient's backside is involved. Heatshields and infrared lamps are used to help reduce heat loss.

o Anticoagulation with heparin for the duration of hospitalization is recommended. Antacids reduce

the incidence of gastric bleeding.o Pulmonary care includes aerosols, bronchial aspiration, and physical therapy. Tranquilizers are usedto the extent limited by respiratory status.

o Several skin care approaches have been described. Extensive debridement of nonviable epidermis,followed by immediate cover with biologic dressings, such as porcine cutaneous xenografts,cryopreserved cutaneous allografts, and amnion- or collagen-based skin substitutes, are among therecommended treatments. Leaving the involved epidermis that has not yet peeled off in place andusing biologic dressings only on raw dermis also has been recommended. Skin allotransplantationreduces pain, minimizes fluid loss, improves heat control, and prevents bacterial infection.Hyperbaric oxygen also can improve healing.



• Treatment of chronic ocular manifestations

o In the case of mild chronic superficial keratopathy, long-term lubrication may be sufficient. Inaddition to lubrication, some patients may require a cosmetically acceptable long-term lateraltarsorrhaphy. The visual rehabilitation in patients with severe ocular involvement resulting in

profound dry eye syndrome with posterior lid margin keratinization, limbal stem cell deficiency,persistent epithelial defects with subsequent corneal neovascularization, and frank corneal opacitywith surface conjunctivalization and keratinization, is difficult and often frustrating for both thepatient and the physician. A close, usually long-term, relationship between the patient and thephysician needs to be established to achieve the best possible result.

o Removal of keratinized plaques from posterior lid margins, along with mucous membrane grafting,is usually the first step and one of the most important determining factors for future success of corneal surgeries. Preferably, a skilled oculoplastic surgeon with specific experience on patientswith SJS should perform this procedure.

• Subsequently, limbal stem cell transplantation with superficial keratectomy removing conjunctivalized orkeratinized ocular surface can follow. Patients with persistent corneal opacity require lamellar orpenetrating keratoplasty in the next step. To preserve corneal clarity after the visual reconstruction, along-term use of gas permeable scleral contact lenses may be necessary to protect the ocular surface.Long-term management frequently involves treatment of trichitic lashes and/or eyelid margin repair fordistichiasis or entropion. If the ocular surface repeatedly fails to heal upon multiple surgical interventions,keratoprosthesis may be considered as the procedure of last resort.

Clinical Manifestations• Ocular symptoms

o Red eye

o Tearing

o Dry eye

o Pain

o Blepharospasm

o Itching

o Grittiness

o Heavy eyelid



o Foreign bodysensation

o Decreased vision

o Burn sensation

o Photophobia

o Diplopia

Physical:

• External examination

o Conjunctival hyperemia (ie, red eye)

o Entropion

o Skin lesions

o Nasal lesions

o Mouth lesions

o Discharge (ie, catarrhal, mucous, membranous

• Typically, the disease process begins with a nonspecific upper respiratory tract infection.

o This usually is part of a 1- to 14-day prodrome during which fever, sore throat, chills, headache, andmalaise may be present.

o Vomiting and diarrhea are occasionally noted as part of the prodrome.

• Mucocutaneous lesions develop abruptly. Clusters of outbreaks last from 2-4 weeks. The lesions aretypically nonpruritic.

• A history of fever or localized worsening should suggest a superimposed infection; however, fever hasbeen reported to occur in up to 85% of cases.



• Involvement of oral and/or mucous membranes may be severe enough that patients may not be able toeat or drink.

• Patients with genitourinary involvement may complain of dysuria or an inability to void.

• A history of a previous outbreak of SJS or of erythema multiforme may be elicited. Recurrences may occurif the responsible agent is not eliminated or if the patient is reexposed.

• Typical symptoms are as follows:

o Cough productive of a thick purulent sputum

o Headache

o Malaise

o Arthralgia

• The rash can begin as macules that develop into papules, vesicles, bullae, urticarial plaques, or confluenterythema.

o The center of these lesions may be vesicular, purpuric, or necrotic.

o The typical lesion has the appearance of a target. The target is considered pathognomonic.

o Lesions may become bullous and later rupture, leaving denuded skin. The skin becomes susceptibleto secondary infection.

o Urticarial lesions typically are not pruritic.

o Infection may be responsible for the scarring associated with morbidity.



o Although lesions may occur anywhere, the palms, soles, dorsum of hands, and extensor surfacesare most commonly affected.

o The rash may be confined to any one area of the body, most often the trunk.

o Mucosal involvement may include erythema, edema, sloughing, blistering, ulceration, and necrosis.

• The following signs may be noted on examination:

o Fever

o Orthostasis

o Tachycardia

o

Hypotension

o Altered level of consciousness

o Epistaxis

o Conjunctivitis

o Corneal ulcerations

o

Erosive vulvovaginitis or balanitis

o Seizures, coma

Drug StudyGENERICNAME BRAND

NAME

DRUGCLASSES

ACTION DOSAGE INDICATION CONTRAINDICATION SIDEEFFECT DRUG TODRUGINTERACTIO

N



Metronidazole Flagyl Antiprotozoals

A directactingtrichomonacide andamebicide

that worksat bothintestinalandextraintestinal sites. It isthought toenter thecells of microorganism that

containsnitroreductase. Itinhibitssynthesiscausing celldeath.

500mg. IVinfusion q 8

Bacterialinfectionscaused byanaerobicmicroorganis

ms

Contraindicated inpatientshypersensitive to drug

Vertigo,headache,dizziness,syncope,flushing,

rhinitis,abdominalpain,nausea,vomiting,diarrhea,pruritus,rashes,fever

Cimetidine:Increased riskof metronidazoletoxicity

NURSINGCONSIDERATI

ON

Use cautiously in patients with history of blood dyscrasia or CNS disorder.

Monitor liver function tests carefully.



GENERICNAME

BRAND

NAME

DRUGCLASS

ES

ACTION DOSAGE

INDICATION CONTRAINDICATION

SIDEEFFECT

DRUG TODRUG

INTERACTION

Isosorbide

dinitrate

Imdur Anti-

anginals

Thought to

reducecardiacoxygendemand bydecreasingpreload andafterload.Drug alsomayincreaseblood flow

through thecollateralcoronaryvessels.

60 mg.

i tabOD

Acute

anginalattacks.

Contraindicat

ed inpatientshypersensitivity tonitrates

CNS:

lethargy,seizures,anxiety,dizziness,hallucination,depressionGI: nausea,vomiting,diarrea,epigastric

distress,

Antihypertens

ives: Mayincreasehypotensiveeffects

NURSINGCONSIDERATI

ON

Use cautiously in patients with blood volume depletion and hypotension.

Monitor blood pressure frequently.



GENERICNAME

BRAND

NAME

DRUGCLASS

ES

ACTION DOSAGE


SIDEEFFECT

DRUG TODRUG

INTERACTION

Sodium

picosulfate

Laxobe

ral

Laxativ

es

Stimulant

laxative thatincreasesperistalsis.

1 tbsp

@ HS

Acute

constipation

Contraindicat

ed in pts withulcerativebowellesions, fecalimpaction,intestinalobstruction.

nausea,

vomitinganddiarrhea,loss of normalbowelfunction,electrolyteimbalance

NURSING

CONSIDERATION

Determine whether patient has adequate fluid intake, exercise, diet.

Avoid exposing product to heat or light.

Drug is for short-term use.



GENERICNAME

BRANDNAME

DRUGCLASS

ES

ACTION DOSAGE


SIDEEFFECT

DRUG TODRUG

INTERACTIONSucralfate Iselpin Antiulc

erdrugs

Protectssurface of ulcer byforming abarrier.

1 tabq6

Short termtreatment forduodenalulcers

No knowncontraindications

dizziness,sleepiness,headache,vertigo,nausea,vomiting,dry mouth,flatulence

Antacids: Maydecreasebinding of drug togastroduodenal mucosa,impairingeffectiveness.

NURSINGCONSIDERA

TION

Use cautiously in pts with chronic renal failure.

Monitor for severe constipation.

GENERICNAME

BRAND

DRUGCLASS

ACTION DOSAGE

INDICATION

CONTRAINDICATION

SIDEEFFECT

DRUG TODRUG



NAME INTERACTION

Pantoprazolesodium

Ulcepraz

Anti-UlcerDrugs

Suppresses

gastric

acidsecretion

40 mg.IVP OD

Treatmentof erosiveesphagitis

Contraindicatedin patients

hypersensitive

to the drug

headache,dizziness,

mental

confusion,anorexia,nausea,

vomiting,flatulence,abdominalpain, GIdisorder,

rectaldisorderba

ck pain,

neck pain

Ampicillin,Ketoconazole

: MAy

decreaseabsorption of these drugs

NURSINGCONSIDERATI

ON

Drug can be given without regard to meals.

Drug should not be used within 16 weeks.

GENERICNAME

BRANDNAME

DRUGCLASS

ACTION DOSAGE

INDICATION

CONTRAINDICATION

SIDEEFFECT

DRUG TODRUG

INTERACTION



Levocarnitine

(L-Carnitine)

Carnicor MiscellaneousDrugs

Facilitatestransportof long

chain fattyacids into

cellularmitochondria. The

fatty acidsare thenused toproduceenergy.

330 mg.1 tab TID

Carnitinedeficiency

No knowncontraindications

nausea,vomiting,cramps,diarrhea,body odor

Valproic Acid:Increased

requirementsfor carnitine.

Adjust

dosage.

NURSINGCONSIDER

ATION

Don’t use oral formulations in patients with end stage renal disease, those on dialysis.

Monitor blood chemistry results as well as vital signs.

PathophysiologyPredisposing Factors:

Autoimmune Disorders, Heredity, Use of Sulfonamides, Antibiotics, NSAIDs, Allopurinol,AntiConvulsants



Patient’s immune system responds by mounting an Cellular Suicide

exaggerated attack on all keratinocytes of the skin and mucous

membranes that have drug particles bound to them Extensive Epidermal

Sloughing

Rapid, progressing exfoliative changes

Multisystem organ involvement

Death



Evaluation

SJS is definitely a nightmare, but there is hope. With adverse drug reactions being

the 4th leading cause of death in North America, it behooves each person to think

carefully before taking something. If a blood relative has had an allergic reaction to a

drug in the past, even a mild one, consider yourself at risk and avoid the drug.

"I was shocked to find out after my reaction that my father and brother both had

developed skin rashes when they took sulfa drugs for short periods in their lives," Callejo

said. "If only I'd known." It makes more sense, however, to seek drug-free alternatives

for one's ailments if and when they arise.

Nevertheless, knowledge is power and the group felt that more education about

drug reactions and SJS are all that we need. Farrell said forcefully, "It is so tragic. You're

warned not to give aspirin to children. How can you not tell people about a life-

threatening reaction to a drug . . . any drug?"



CUES NURSING

DIAGNOSIS

SCI.EXPLANATIO

N

GOAL INTERVENTION RATIONALE EVALUATION



S;" Masakitangbuongkatawan

ko dahilsa mgasugat ko."PasinScale: 4/5O:- gener

alizedweakness

-withscaling,erythema,lesionsandnecrosis intheentire

body- with

lesionsinmouth,buccalmucosa

Acutepain R/Tinflammation,swelling,

lesions of the entirebody

The ptexperiencesunpleasantsensation dueto stimulation

of painreceptors. This happenswhen painsubstancewere releaseand transmitit in the brainvia the spinalcord and onceit has been

sent canperceived asPAIN.

After 1hour of nursingintervention,

patient's painwill belessened.

Encourage reportsof pain, notinglocation, duration,and quality of pain.

-Maintainimmobilization of affected part.

-Explainprocedures beforebeginning them.

-Provide alternatecomfort measuressuch as massage,backrub, andposition changes.

-Encourage use of stressmanagementtechniques such as

progressiverelaxation, deepbreathingexercises.

-Identifydivertionalactivitiesappropriate for

Influences choice of/monitorseffectiveness of interventions.

-Relieves pain andprevent bonedisplacement/extension of tissue injury.

-Allows patient toprepare mentally foractivity as well as toparticipate incontrolling level of

discomfort.

-Improves generalcirculation; reducesareas of localpressure and musclefatigue.

-Refocuses attention,promotes sense of control, and may

enhance copingabilities in themanagement of pain.

-Prevents boredom,reduces tension, andcan increase musclestrength; mayenhance self-esteem

GOAL:MET The patient'spaindecreasedfrom 4/5 to

2/5.



- withswollenconjunctiva

-

withreddish,swollengums

- V/S:BP-140/80 CR-85 RR-

18 T-37.2

patient age,physical abilities,and personalpreferences.

Administeranalgesics asprescribed.

and coping abilities.

-This provides relief of pain.



CUES NURSINGDIAGNOSI

S

SCI.EXPLANATIO

N

GOAL INTERVENTION RATIONALE EVALUATION

S:

" Hindi akomakagalaw ngmabuti dahil samga sugat ko"O;" Masakit angbuong katawanko dahil sa mgasugat ko. "Pasin Scale: 4/5O

-generalizedweakness

- with scaling,erythema,lesions andnecrosis inthe entirebody

- Inability topurposefullymove within

the physicalenvironment, includingbed mobility,transfer andambulation

- Limited ROM- Decreased

muscle

Impaired

physicalMobility R/Tpain

The pt

experiences alimitationof abilityforindependentphysicalmovement due topain.

At the

end of 4hoursof nursinginterventionthepatient will

beabletoincreasestrength/function of affected

andcompensatorybodyparts.

-Assess degree of

immobility producedby injury / treatmentand note patient'sperception of immobility.

-Encourageparticipation indivertional/recreational

activities. Maintainstimulatingenvironment.

Instruct patient/assist withactive/passive ROMexercises of affectedand unaffectedextremities.

-Assistwith/encourage self activities.

-Provide/assist withmobility by meansof wheelchair

-Patient maybe

restricted by self-view/self perceptionout of proportionwith actual physicallimitation.

Provides opportunityfor release of energyand refocusesattention.

-Increases bloodflow to muscles andbone to improvemuscle tone,maintain jointmobility.

-Improves musclestrengthened

circulation andpromotes self-directed wellness.

-Early mobilityReducescomplications of bedrest.

GOAL:MET

At the endof 4hoursof nursingintervention thepatientwas abletoincreasestrength/f unction of

affectedandcompensatory bodyparts.



strength- Imposed

restrictionsof movement

crutches.



CUES NURSINGDIAGNOS

IS

SCI.EXPLANATIO

N

GOAL NURSINGINTERVENTION

RATIONALE EVALUATION

S:O:-

generalizedweakness

- withscaling,erythema, lesionsandnecrosisin theentire

body- with

lesions inmouth,buccalmucosa

- withswollenconjunctiva

- with

reddish,swollengums

V/S: BP-140/80CR- 85RR-18 T-37.2

Risk forfurther

infection.related toinadequate primarydefenses(brokenskin andtraumatized tissue)

The pt is atrisk for being

invaded bypathogenicorganismsdue todamagetissue whichmay be aportal of entryto othermicroorganism.

At theend of 8

hours of nursinginterventions,thepatientwillmaintainstablevitalsigns.

Maintain aseptictechnique when

caring for wound.

Inspect d wound;note characteristicsof drainage.

Monitor vital signs.

Instruct the patientnot to touch thewound site.

Administerantibiotics asindicated.

Minimizesopportunity for

introduction of bacteria.

Early detection of developing infectionprovides opportunityfor timelyintervention andprevention forfurther infections.

Temperatureelevation/tachycardia mayreflect developingsepsis.

Minimize theopportunity forcontamination.

Wide- spectrum

antibiotics may beusedprophylactically, orantibiotic therapymy be gearedtoward specificorganisms.

GOAL:ME T

At theend of 8hours of nursinginterventions, thepatientachievetimelywoundhealing.



CUES NURSINGDIAGNOSIS

SCIENTIFICEXPLANATIO

N


RATIONALE OUTCOME



S:“Nahihirapan ako pagdumudumidahilmadalas,matigas.”O:-Decreasedbowelsounds-Decreasedactivity

level-Withabdominaldistension

ConstipationR/Timmobility

The ptexperiences achange innormal bowelhabitscharacterizedby a decreasein frequencyand passage of hard dry stoolsdue toimmobility thatdecreases hisperistalsis.

After 4hours of nursingintervention, the pt willreestablishnormalpatterns of bowelfunctioning.

Note abdominaldistention andauscultate bowelsounds.

Use bedpan untilallowed out of bed.

Provide privacy.

Beginprogressive dietas tolerated.

Provide rectal

tube,suppositoriesand enemas asneeded.

Administerlaxatives, stool

Distention andabsence of bowelsounds indicatethat bowel is notfunctioning,possibly due tosudden loss of parasympatheticenervation of thebowel.

Promotescomfort, reducesmuscle tension.

Promotes

psychologiccomfort.

Solid foods arenot started untilbowel soundshave returned orflatus passed.

Maybe necessaryto relieve

abdominaldistension,promoteresumption of normal bowelhabit.

Soften stool,promotes normal

After 4 hoursof nursingintervention,GOAL MET,the pt wasable toreestablishednormalpatterns of bowelfunctioning.



softeners, asindicated.

bowel habits anddecreasesstraining.

CUES NURSINGDIAGNOSIS

SCIENTIFICEXPLANATIO

N


RATIONALE OUTCOME



S:O:-Decreased activitylevel

- -Inability topurposefullymovewithinthephysical

environment,includingbedmobility,transf er andambul

ation- Limite

d ROM- Decre

asedmusclestrength

Risk forfurtherimpairedskin integrityin the bonyprominencesof the rightand left heel,sacrum andpelvis R/Tphysicalimmobilization

Because thepatient isunable tomove freely,he uses hisright and leftheels to movehimself in thebed. The pt’sskin isadverselyaltered due toimmobilization,which causesan impairedcirculation to

an immobilizedarea, thus,causing a highrisk of impaired skinintegrity.

After 1hour of nursingintervention, the ptwilldemonstratetechniques topreventskinbreakdown.

Anticipate and usepreventivemeasures in pts whoare at risk for skinbreakdown.

Assess nutritionalstatus and initiatecorrectivemeasures, asindicated. Providebalance diet, e.g.adequate proteins,vitamins andminerals.

Maintain strict skinhygiene.

Perform passiveROM exercises..

Keep sheets andbedclothes clean,dry and free from

wrinkles, crumbsand other irritatingmaterials.

Provide for safetyduring ambulation.

Limit exposure to

Decubitus ulcers aredifficult to heal, andprevention is the besttreatment.

An improvednutritional state canhelp prevent skinbreakdown andpromotes ulcerhealing.

To protect susceptibleskin from breakdown.

Improves circulation,muscle tone and jointmotion and promotespt participation.

Avoidsfriction/abrasions of skin.

Loss of muscle controland debilitation mayresult in impairedcoordination.

Decreased sensitivityto pain/heat/cold

After 1 hourof nursingintervention, GOALMET, the ptwas able todemonstratetechniquesto preventskinbreakdown.



Imposedrestrictions of movement

temperatureextremes/ use of heating pad or icepack.

Examine feet andnails routinely andprovide foot and nailcare as indicated.

Observe fordecubitus ulcerdevelopment andtreat immediatelyaccording toprotocol.

Administernutritionalsupplements andvitamins asindicated.

increases risk of tissuetrauma.

Foot problems arecommon among ptswho are debilitated.

Timely interventionmay preventextensive damage.

Aids in healing/cellular

regeneration.



Discharge PlanMedications

Instructed client to religiously take medications prescribed by the physician.

Exercise

Advised to perform activities according to tolerance for relaxation and endurance. (as prescribed)

Relaxation and deep breathing exercises especially in the morning.

Gentle increasing exercise is helpful, prevents excessive fatigue and conserves energy for healing.

Treatment

Instructed patient to treat wounds properly, as prescribed by the physician.

Advised to do aseptic technique when cleaning the wound.

Health Teachings

Provide patient a thorough explanation of the disease process, treatment regimen and follow-up.

Teach the importance of follow-up care, healthy diet and adequate rest.

Encourage alternating rest period and activity.

Advise SO to provide comfort measures and divers ional activities such as music, television. Thesepromote relaxation and helps refocus attention.

Teach client to avoid stress.

Discuss need for safe environment (removing scattered drugs) at home and use of assistive devices

because of impaired mobility. Maintain nutritional status and promote overall health by encouraging good oral intake.

Instruct the patient to finish all prescribed medications, especially antibiotics.

OPD/ Follow-Up



Advise patient to come back after 1 week of discharge for follow-up check-up at the OPD. This will provideongoing monitoring of progression and resolution of disease process.

Diet

Adequate hydration and nutrition to promote wellness and health.

Maintain a balanced diet to improve body’s ability to heal itself.

Advise patient to increase intake of foods rich in vitamin C like fruits and vegetables for collagenformation that promotes tissue regeneration and healing of wound.

Instructed patient to eat foods rich in protein such as eggs, meat and fish to facilitate tissue formation.

Complications and Prognosis



Complications:

• Ophthalmologic - Corneal ulceration, anterior uveitis, panophthalmitis, blindness

• Gastroenterologic - Esophageal strictures

• Genitourinary - Renal tubular necrosis, renal failure, penile scarring, vaginal stenosis

• Pulmonary - Tracheobronchial shedding with resultant respiratory failure

• Cutaneous - Scarring and cosmetic deformity, recurrences of infection through slow-healing ulcerations

Prognosis:

• Individual lesions typically should heal within 1-2 weeks, unless secondary infectionoccurs. The majority of patients recover without sequelae.

• Development of serious sequelae, such as respiratory failure, renal failure, and blindness,determines prognosis in those affected.

• Up to 15% of all patients with SJS die as a result of the condition.



Nursing Care Plans• Acute pain R/T inflammation, swelling, lesions of the entire body

• Constipation R/T immobility

• Impaired physical Mobility R/T pain

• Risk for further impaired skin integrity in the bony prominences of the right and left

heel, sacrum and pelvis R/T physical immobilization

• Risk for further infection. related to inadequate primary defenses (broken skin and

traumatized tissue)



STEVENS- JOHNSON



SYNDROME

GROUP II BSN 4 -A



Lea Marie Salazar

Rey Raniaga

Loredel Melegrito

Shiela Tomas

Mayleen Mutuc

Kristine Padlan

Melissa Matusalem

Giovanni Tebia

Jennelyn Pascual

Michelle Sidoro

Jennilyn Dampil

Aleda Pineda

Michael Tan

Raymond Lorenzo

Hermel Joseph Paras

A Case Study



Submitted To

Ms. Odette Tanedo, R.N.December 9, 2004

case - steven johnson's

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