Case - Steven Johnson's

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 to certain 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 by analgesics, 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.

Objectives Patient 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 Integumentary System 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 innermost layer of the epidermis. Melanocytes produce the pigment melanin, and are also in the inner layer of the epidermis. 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, temperature regulation, sensory reception, biochemical synthesis, and absorption. All body systems work in an interconnected manner to maintain the internal conditions essential to the function of the body. Follicles and Glands Hair follicles are lined with cells that synthesize the proteins that form hair. A sebaceous gland (that secretes the oily coating of the hair shaft), capillary bed, nerve ending, and small muscle are associated with 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 a solution that bacteria act upon to produce "body odor". Hair and Nails Hair, scales, feathers, claws, horns, and nails are animal structures derived from skin. The hair shaft extends above the skin surface, the hair root extends from the surface to the base or hair bulb. Genetics controls several features of hair: baldness, color, texture. Nails consist of highly keratinized, modified epidermal cells. The nail arises from the nail bed, which is thickened to form a lunula (or little moon). Cells forming the nail bed are linked together to form the nail.

Skin and Homeostasis Skin 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 primary functions 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. Melanocytes form a second barrier: protection from the damaging effects of ultraviolet radiation. When a microbe penetrates 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 water per 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 body temperature continues to fall, the body will engage in thermiogenesis, or heat generation, by raising the body's metabolic rate and by shivering. Water loss occurs in the skin by two routes. 1. evaporation 2. sweating In hot weather up to 4 liters per hour can be lost by these mechanisms. Skin damaged by burns is less effective at preventing fluid loss, often resulting in a possibly life threatening problem if not treated. Skin and Sensory Reception Sensory 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, and are very sensitive to touch. Pacinian corpuscles respond to pressure. Temperature receptors: more cold ones than hot ones. Skin and Synthesis Skin cells synthesize melanin and carotenes, which give the skin its color. The skin also assists in the synthesis of vitamin D. Children lacking sufficient vitamin D develop bone abnormalities known as rickets.

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 include estrogen, scopolamine (motion sickness), nitroglycerin (heart problems), and nicotine (for those trying to quit smoking). Thick Skin The epidermis of thick skin follows the contours of the dermal ridges, producing the epidermal ridges of the fingerprint. The dermal ridges penetrate into the epidermis as true papillae, and are separated by epithelial downgrowths called interpapillary pegs Five layers of cells or cell products are found in the epidermis: (1) stratum germinativum, columnar basal stem cells; (2) stratum spinosum, polyhedral cells with "spiny" projections: (3) stratum granulosum, diamond shaped cells containing keratohyalin granules; (4) stratum lucidum, a clear, homogenous line composed of eleidin, a keratohyalin transformation 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 composed of 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 Layer Beneath 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 eccrine sweat glands are found here, with their ducts penetrating the dermis to enter the epidermis through the interpapillary pegs Also, sensory structures (pacinian corpuscles), nerve bundles, blood vessels, and the bases 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, and corneum, and lacks the stratum lucidum . The dermis is not arranged in ridges, but does project into the

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

Nursing Health History DEMOGRAPHIC DATA

Name: Bienvinido de Leon Age: 65 years old Birthday: July 14, 1938 Address: Blk. 1, San Jose, Tarlac Status: Married Religion: Roman Catholic DOA: November 27, 2004 @ 8:49 am Attending 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. He sought consultation at CLDH OPD, hence, was admitted.

PERCEPTION OF HEALTH STATUS Rates 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 Erikson Integrity 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 to surpass all of them.

• Sigmund Freud According 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 through different 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 using defenses to control anxiety. Freud’s theory stated unresolved gratification at a certain stage leads to a fixation 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 Piaget Formal 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 Kohlberg Kohlberg’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: a preconventional level, based on obedience or punishment; a conventional level when reasoning begins to 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 and disapproval from significant others influence the formation of one’s personality. To form satisfying relationships 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 comprise of his family especially his , wife, and his children. Best of all, he said that his family is a God fearing family. 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 said that 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. He says 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 he is an occasional drinker. ECONOMIC and SOCIO-CULTURAL DATA Our client is an elementary undergraduate of San JoseElementary School. He is a Kapampangan in ethnic affiliation. He belongs to the economic status letter B.

SANITATION, WATER SOURCE, HOUSING, TOILET, GARBAGE With regards to their sanitation, they usually clean their house everyday and also their surroundings. Their house is concrete walled. According to him, the house is well-ventilated and welllighted. Their toilet is with flush. They get their water from an artesian pump. They also dispose off their garbage by means of boring a hole at the ground and through burning.

Cephalo-Caudal Assessment BODY PART

METHOD

NORMAL FINDINGS

 SKIN

 Inspection

COLOR: Varies from light to COLOR: The color varies NOT deep brown; from ruddy from reddish, black and NORMAL pink to light pink; from brownish. yellow overtones to olive UNIFORMITY: uniform except

ACTUAL FINDINGS

Generally in areas Uniformity:

INTERPRETA TION

Varies

exposed to the sun; areas of because some areas are NOT lighter pigmentation (palms, either sloughing, swollen NORMAL lips, nail beds) in dark or necrotic. skinned people SKIN LESIONS: Freckles, some birthmarks, some flat Presence of papules, and raised nevi (moles); no erythema, crusting, NOT NORMAL abrasions or other lesions scaling, necrosis.  Inspection and Palpation

SKIN MOISTURE: Moisture in skinfolds and in axillae (varies with environmental There is severe dryness of temperature and humidity, skin. NOT body temperature and NORMAL activity)

SKIN TURGOR: When pinched, skin springs back to previous state When pinch skin slowly springs back to previous NORMAL state.

 HAIR

 Inspection

EVENNESS OF GROWTH: Patches of hair loss due to NOT Evenly distributed hair lesions and erythema in NORMAL the scalp THICKNESS/THINNESS, COLOR, LENGTH: Thick hair Thin NORMAL INFESTATIONS: No No infestations NORMAL infections or infestations

 NAILS

 Inspection

SHAPE: Convex curvature; Uneven curvature. angle between nail bed about 160 degrees

Upper extremities

 Palpation

TEXTURE: Smooth texture

Rough, brittle texture.

NAIL BED COLOR: Highly Pale in color vascular and pink in light skinned clients; darkskinned clients may have brown or black pigmentation in longitudinal steaks Tissue surrounding TISSUE SURROUNDING: epidermis is scaly Intact epidermis erythematous

 SKULL AND FACE

 Inspection

NOT NORMAL

NORMAL NORMAL

the and

NOT NORMAL

SKULL SIZE, SHAPE, AND Rounded, normocephalic NORMAL SYMMETRY: Rounded and symmetric. (normocephalic and symmetric, with frontal, parietal,

and occipital prominences); smooth skull NODULES/MASSES/LESIO NS: Smooth, uniform consistency; absence of nodules or masses  Palpation

 Inspection

Smooth and there is no NOT presence of nodules; NORMAL presence of erythema, scaling and papules Symmetric facial features.

FACIAL FEATURES: Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial Symmetric folds movements.

facial

NORMAL

NORMAL

FACIAL MOVEMENTS: Symmetric facial movements

 EYE STRUCT URES AND VISUAL AQUITY

 Inspection

EXTERNAL STRUCTURES EYEBROWS: Hair evenly Uneven distribution of hair NOT distributed; skin intact because of scaling in the NORMAL Eyebrows symmetrically face aligned; equal movement EYELASHES: Equally Absence of eyelashes. NOT distributed; curled slightly NORMAL outward Swollen, boggy,

EYELIDS: Skin intact; no edematous discharge; no discoloration. Lids close symmetrically

NOT NORMAL

Presence of conjunctivitis NOT PUPIL: Black in color; equal Black in color; equal in NORMAL in size; normally 3 to 7 mm size; in diameter; round, smooth round, smooth border, iris flat and round NORMAL border, iris flat and round

 Inspection and Palpation  Inspection

REACTION TO LIGHT: Illuminated pupil constricts (direct response) Nonilluminated pupil constricts (consensual response)

Illuminated pupil constricts (direct response) Nonilluminated pupil NORMAL constricts (consensual response) NORMAL

ACCOMMODATION: Pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object is moved toward nose

Pupils constrict when looking at near object; pupils dilate when looking at far object; pupils converge when near object NORMAL is moved toward nose

VISUAL FIELD PERIPHERAL FIELD: When

VISUAL When looking ahead,

looking straight client can see

straight ahead, client can objects in the periphery NORMAL see objects in the periphery Both eyes coordinated, SIX OCULAR move in unison, with MOVEMENTS: Both eyes parallel alignment NORMAL coordinated, move in unison, with parallel alignment  Inspection  EARS AND HEARING

 Palpation

AURICLES NORMAL

Color same as facial skin

Color same as facial skin

Symmetric position. Line drawn 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.

Symmetric position. Line NORMAL drawn 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; NOT Mobile, firm, and not tender; pinna recoils after it is NORMAL folded, swollen pinna recoils after it is folded EXTERNAL AND

EAR CANAL TYMPHANIC Distal third contains hair NORMAL

 Inspection

MEMBRANE Distal third contains follicles and glands

follicles and glands hair

Dry cerumen, grayish-tan NORMAL color; or sticky, wet Dry cerumen, grayish-tan cerumen in various shades color; or sticky, wet of brown cerumen in various shades NORMAL of brown Pearly gray color, semitransparent NORMAL Pearly gray color, semitransparent Normal voice tones audible NORMAL Normal voice tones audible GROSS HEARING ACUITY TEST Able to repeat nonconsecutive numbers

Able to repeat nonconsecutive numbers

 NOSE AND SINUSES

Inspection

NOSE Symmetric and straight No

discharge

or

Symmetric and straight

flaring No

discharge

or

Uniform color

Uniform color

Not tender; no lesions

Tender, with lesions

flaring

NORMAL NORMAL

NOT NORMAL

Air moves freely as the Air moves freely as the client breathes through the client breathes through NORMAL nares the nares LINING OF NARES: Mucosa pink Clear, watery discharge No lesions

Mucosa pink Clear, watery discharge No lesions

NORMAL

NASAL SEPTUM: Nasal septum intact and in NORMAL Nasal septum intact and in midline. midline

 MOUTH AND

 Inspection

LIPS AND MUCOSA

BUCCAL Lips are edematous and

Uniform pink color (darker, swollen; unable to purse Not normal eg, bluish hue, in lips Mediterranean groups and dark-skinned clients) Soft, moist, smooth texture Symmetry of contour. Ability to purse lips

OROPHA RYNX

 Inspection and Palpation

INNER LIPS AND BUCCAL MUCOSA Reddish, swollen

Not NORMAL

Uniform pink color (freckled brown pigmentation in darkskinned clients) TEETH AND GUMS

Teeth appear complete.

32 adult teeth Smooth, white, shiny tooth enamel Pink gums (bluish or dark patches in dark-skinned clients) Moist, firm texture to gums TONGUE/FLOOR MOUTH

OF

to

be NORMAL

NOT Smooth , and presence of NORMAL tarry black regions specifically at the molar and pre molar region. NOT NORMAL Gums have blackish discoloration specially at the upper region of the oral cavity.

TONGUE  Inspection

Central Position

Central Position

NORMAL

Pink in color (some brown Darkish red in color, has pigmentation on tongue abundant whitish Not Normal borders in dark skinned pigmentation clients); moist; slightly rough; thin whitish coathing Moves freely; no tenderness

NORMAL Moves freely; no NORMAL Smooth tongue base with tenderness prominent veins Smooth tongue base has prominent veins NECK MUSCLES

 NECK  Inspection

Muscle equal in size; head Muscle equal in size; head NORMAL centered centered Coordinated, movements discomfort

smooth Uncoordinated, with no movements discomfort

Equal muscle strength

 Palpation

LYMPH NODES

Muscle weakness

NOT with NORMAL NOT NORMAL

Not palpable

Not Palpable NORMAL

 Palpation

TRACHEA Central alignment in midline Central alignment in of neck; spaces are equal on midline of neck; spaces NORMAL both sides are equal on both sides

 Inspection

THYROID GLAND Not Visible

 Palpation

Not Visible NORMAL

Lobes may not be palpated If palpated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing

Lobes may not be palpated , lobes are small, smooth, NORMAL centrally located, painless, and rise freely with swallowing

 THORAX AND LUNGS

POSTERIOR THORAX  Inspection

Chest symmetric

Chest symmetric

NORMAL

  Palpation

Skin intact; temperature

uniform Skin is scaly erythematous

Chest wall intact; tenderness masses

no Chest wall tenderness

Full and symmetric chest expansion (ie, when the client takes a deep breath, your thumbs should move apart an equal distance and at the same time; normally the thums separate 3 to 5 cm [1 ½ to 2 in] during deep inspiration)  Palpation

 Percussion

VOCAL FREMITUS:

and NOT NORMAL

intact;

with NOT NORMAL Full and symmetric chest expansion when the client takes a deep breath, the NORMAL thumbs separate 3 to 5 cm [1 ½ to 2 in] during deep inspiration)

(TACTILE)

Bilateral symmetry of Bilateral symmetry of vocal vocal fremitus fremitus Low-pitched voices of Low-pitched voices of males males are more readily are more readily palpated palpated than higherthan higher-pitched voices pitched voices of females of females Percussion notes resonate THORAX: Percussion notes resonate Resonance is felt at the Lowest point of resonance is diaphragm at the level of at the diaphragm (ie, at the

NORMAL NORMAL NORMAL NORMAL

th th level of the 8th to 10th rib the 8 to 10 rib posteriorly) posteriorly) NOT Percussion on the rib Percussion on the rib NORMAL  Auscultation normally elicits dullness normally elicits dullness

CHEST: Vesicular and Crackles heard bronchovesicular breath sounds

 Palpation

ANTERIOR THORAX Normal breathing pattern

NOT NORMAL ABnormal pattern

breathing

NOT NORMAL

uniform Skin is edematous, with NOT papules NORMAL Chest wall intact; no Chest wall intact; with tenderness tenderness masses Skin intact; temperature

Full symmetric excursion; Full symmetric excursion; thumbs normally separate thumbs normally separate 3 3 to 5 cm to 5 cm

NORMAL

 ABDO MEN

Inspection

There should be no lesions, Skin is scaly and some NOT nodules. It should be clear. parts are swollen and NORMAL reddish

Auscultation

No abnormal findings Hollow sound heard. noted. Hypoactive bowel sound.

NORMAL

Smooth, flat surface

NORMAL

Palpation Percussion Dull sound heard.

No abnormal findings noted.

NORMAL

No abnormal findings noted.

• U Inspection, palpation PPER EXTRE MITIE S

All peripheral pulses should be present, symmetrical joint movement, discoloration, moist, fingers are complete no lesion, infection or any skin break.

Weak, thready pulse; skin NOT is scaly, with crusting and NORMAL papules; skin is dry and has poor skin turgor; limited range of motion because of severe body weakness

• L Inspection, OWER palpation EXTRE MITIE S

All peripheral pulses should be present, symmetrical joint movement, discoloration, moist, fingers are complete, no lesion, infection or any skin break.

skin is scaly, with crusting NOT and papules; skin is dry NORMAL and has poor skin turgor; limited range of motion because of severe body weakness

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 having heart 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 muscular prominence 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

PERSON P • •

65 year old male, married smoker (10-15 sticks a day)

• •

• •

alcohol drinker lives with his family Past 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 • • • • • •

O

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

• • •

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 the diagnosis.

•

A complete blood count (CBC) may reveal a normal white blood cell (WBC) count or a nonspecific leukocytosis. A severely elevated WBC count indicates the possibility of a superimposed bacterial infection.

•

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

Creatinine

AF 67 umol/L

RV 71-133umol/L

Potassium

3.6 mmol/L

3.6-5.0 mmol/L

PROTHROMBIN TIME December 2, 2004 Patient’s Time

11.8 sec

Normal 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 Potassium

AF 4.54 mmol/L

RV 3.5-5.3 mmol/L

Albumin

19 g/L

39-50 g/L

WBC RBC

Routine Blood Count December 5, 2004 AF 5.9 3.62

RV 4-10 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

WBC RBC

Routine Blood Count December 1, 2004 AF 6.3 3.41

RV 4-10 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 Exam December 4, 2004 Occult Blood: Positive Abdominal Ultrasound December 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 prostate gland 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 and initiate 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 at this 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 be stopped.

•

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. In principal, the symptomatic treatment of patients with SJS does not differ from the treatment for patients with 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 is begun, so that intravenous fluids can be tapered progressively and discontinued, usually in 2 weeks.

o

Massive parenteral nutrition is necessary as soon as possible to replace the protein loss and to promote healing of cutaneous lesions.

o o

Intravenous insulin therapy may be required because of impaired glycoregulation. 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. Cultures of blood, catheters, gastric tubes, and urinary tubes must be performed regularly. 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. Prophylactic systemic antibiotics are not recommended. 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 the skin, a sudden drop in fever, and deterioration of the patient's condition, indicating the need for antibiotic 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 administration of high doses may be required to reach therapeutic levels. Monitoring the serum levels is necessary to adjust the dosage. Environmental temperature raised to 30-32°C reduces caloric loss through the skin. Fluidized air beds are recommended if a large portion of the skin on the patient's backside is involved. Heat shields and infrared lamps are used to help reduce heat loss. Anticoagulation with heparin for the duration of hospitalization is recommended. Antacids reduce the incidence of gastric bleeding. Pulmonary care includes aerosols, bronchial aspiration, and physical therapy. Tranquilizers are used to the extent limited by respiratory status. 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 the recommended treatments. Leaving the involved epidermis that has not yet peeled off in place and using biologic dressings only on raw dermis also has been recommended. Skin allotransplantation reduces pain, minimizes fluid loss, improves heat control, and prevents bacterial infection. Hyperbaric oxygen also can improve healing.

o o

o o

o

o o o

•

Immunomodulatory therapy: Several specific therapeutic approaches (eg, plasmapheresis, intravenous immunoglobulin, thalidomide, immunosuppressive therapy) have been used in the acute phase of SJS, but none of the studies has been conclusive. Symptomatic treatment remains the mainstay in the management of SJS. o The use of systemic corticosteroids is most controversial. The only rationale for the use of corticosteroids was based on the concept that SJS is a delayed-type hypersensitivity reaction. One report suggests that prompt, short-term corticosteroid therapy appears to be a strategic key to minimize damage from SJS. Studies suggest that treatment with glucocorticosteroids is associated with an increased morbidity and mortality. In one study, a mortality rate of 91% in the steroidtreated group of patients with acute SJS caused by infection is suggestive of an iatrogenic source of mortality. o Steroids may enhance the risk of sepsis, increase protein catabolism, and delay epithelization. Long-term steroid therapy may delay the onset of SJS, but it does not halt its progression. Conversely, SJS can occur in patients who undergo long-term glucocorticosteroid therapy. o It has been argued that the use of systemic corticosteroids should be a standard therapy in the acute phase of SJS and that a prospective randomized trial is not adequate because of ethical reasons. However, this argument has not been accepted widely. o After an acute phase of SJS with persistent or recurrent ocular inflammation, patients may benefit from short-term systemic corticosteroids and/or long-term immunosuppressive therapy, particularly with cyclosporin, azathioprine, or cyclophosphamide. This treatment may reduce the severity of conjunctivitis and improve the prognosis quod visum by reducing the damage to the ocular surface.

Surgical Care: •

Treatment of acute ocular manifestations o o o o o

Treatment of acute ocular manifestations usually begins with aggressive lubrication of the ocular surface. As inflammation and cicatricial changes ensue, most ophthalmologists use topical steroids, antibiotics, and symblepharon lysis. In case of exposure keratopathy, tarsorrhaphy may be required. Maintenance of ocular integrity can be achieved through the use of adhesive glues, lamellar grafts, and penetrating keratoplasty, either in the acute phase or in subsequent, follow-up care. Visual rehabilitation in patients with visual impairment can be considered once the eye has been quiet for at least 3 months.

•

•

Treatment of chronic ocular manifestations o

In the case of mild chronic superficial keratopathy, long-term lubrication may be sufficient. In addition to lubrication, some patients may require a cosmetically acceptable long-term lateral tarsorrhaphy. 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 opacity with surface conjunctivalization and keratinization, is difficult and often frustrating for both the patient and the physician. A close, usually long-term, relationship between the patient and the physician 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 patients with SJS should perform this procedure.

Subsequently, limbal stem cell transplantation with superficial keratectomy removing conjunctivalized or keratinized ocular surface can follow. Patients with persistent corneal opacity require lamellar or penetrating keratoplasty in the next step. To preserve corneal clarity after the visual reconstruction, a long-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 for distichiasis 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

Dry eye

o

Itching

o

Red eye

o

Pain

o

Grittiness

o

Tearing

o

Blepharospasm

o

Heavy eyelid

o

Foreign body sensation

o

Decreased vision

o

Photophobia

o

Burn sensation

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, and malaise 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 are typically nonpruritic.

•

A history of fever or localized worsening should suggest a superimposed infection; however, fever has been 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 to eat 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 occur if 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 confluent erythema. 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 susceptible to 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 surfaces are 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

Epistaxis

o

Orthostasis

o

Conjunctivitis

o

Tachycardia

o

Corneal ulcerations

o

Hypotension

o

Erosive vulvovaginitis or balanitis

o

Altered level of consciousness

o

Seizures, coma

Drug Study GENERIC NAME

BRAN D NAME

DRUG CLASS ES

ACTION

DOSA GE

INDICATION

CONTRA INDICATION

SIDE EFFECT

DRUG TO DRUG INTERACTIO N

Metronidazole

NURSING CONSIDERATI ON

Flagyl

Antipro tozoals

A direct 500 acting mg. IV trichomonac infusio ide and nq8 amebicide that works at both intestinal and extraintestin al sites. It is thought to enter the cells of microorgani sm that contains nitroreducta se. It inhibits synthesis causing cell death.  Use cautiously in patients with history  Monitor liver function tests carefully.

Bacterial infections caused by anaerobic microorganis ms

Contraindicat ed in patients hypersensitiv e to drug

Vertigo, headache, dizziness, syncope, flushing, rhinitis, abdominal pain, nausea, vomiting, diarrhea, pruritus, rashes, fever

of blood dyscrasia or CNS disorder.

Cimetidine: Increased risk of metronidazole toxicity

GENERIC NAME

BRAN D NAME

DRUG CLASS ES

ACTION

DOSA GE

INDICATION

CONTRA INDICATION

SIDE EFFECT

Isosorbide dinitrate

Imdur

Antianginal s

Thought to reduce cardiac oxygen demand by decreasing preload and afterload. Drug also may increase blood flow through the collateral coronary vessels.

60 mg. i tab OD

Acute anginal attacks.

Contraindicat ed in patients hypersensitiv ity to nitrates

CNS: lethargy, seizures, anxiety, dizziness, hallucinatio n, depression GI: nausea, vomiting, diarrea, epigastric distress,

NURSING CONSIDERATI ON

 Use cautiously in patients with blood volume depletion and hypotension.  Monitor blood pressure frequently.

DRUG TO DRUG INTERACTIO N Antihypertens ives: May increase hypotensive effects

GENERIC NAME Sodium picosulfate

NURSING CONSIDERAT ION

BRAN D NAME

DRUG CLASS ES

ACTION

Laxobe ral

Laxativ es

Stimulant laxative that increases peristalsis.

DOSA GE 1 tbsp @ HS

INDICATION

CONTRA INDICATION

SIDE EFFECT

Acute constipation

Contraindicat ed in pts with ulcerative bowel lesions, fecal impaction, intestinal obstruction.

nausea, vomiting and diarrhea, loss of normal bowel function, electrolyte imbalance

 Determine whether patient has adequate fluid intake, exercise, diet.  Avoid exposing product to heat or light.  Drug is for short-term use.

DRUG TO DRUG INTERACTIO N

GENERIC NAME

BRAND NAME

DRUG CLASS ES

Sucralfate

Iselpin

Antiulc er drugs

NURSING CONSIDERA TION

 Use cautiously in pts with chronic renal failure.  Monitor for severe constipation.

GENERIC NAME

BRAN D

DRUG CLASS

ACTION

Protects surface of ulcer by forming a barrier.

ACTION

DOSA GE 1 tab q6

DOSAG E

INDICATION

CONTRA INDICATION

SIDE EFFECT

Short term treatment for duodenal ulcers

No known contraindicat ions

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

INDICATIO N

CONTRAINDIC ATION

SIDE EFFECT

DRUG TO DRUG INTERACTIO N Antacids: May decrease binding of drug to gastroduoden al mucosa, impairing effectiveness.

DRUG TO DRUG

NAME Pantoprazole sodium

Ulcepr az

NURSING CONSIDERATI ON

GENERIC NAME

AntiUlcer Drugs

Suppress es gastric acid secretion

40 mg. IVP OD

Treatment of erosive esphagitis

Contraindicated in patients hypersensitive to the drug

headache, dizziness, mental confusion, anorexia, nausea, vomiting, flatulence, abdominal pain, GI disorder, rectal disorderba ck pain, neck pain

INTERACTIO N Ampicillin, Ketoconazole : MAy decrease absorption of these drugs

 Drug can be given without regard to meals.  Drug should not be used within 16 weeks.

BRAND NAME

DRUG CLASS

ACTION

DOSAG E

INDICATIO N

CONTRAINDIC ATION

SIDE EFFECT

DRUG TO DRUG INTERACTIO N

Levocarnitin e (L-Carnitine)

NURSING CONSIDER ATION

Carnicor

Miscellan eous Drugs

Facilitates transport of long chain fatty acids into cellular mitochond ria. The fatty acids are then used to produce energy.

330 mg. 1 tab TID

Carnitine deficiency

No known contraindicatio ns

nausea, vomiting, cramps, diarrhea, body odor

Valproic Acid: Increased requirements for carnitine. Adjust dosage.

 Don’t use oral formulations in patients with end stage renal disease, those on dialysis.  Monitor blood chemistry results as well as vital signs.

Pathophysiology Predisposing Factors: Autoimmune Disorders, Heredity, Use of Sulfonamides, Antibiotics, NSAIDs, Allopurinol, AntiConvulsants

Patient’s liver improperly breaks down the drug

Liver cannot properly excrete the drug By-products of faulty drug metabolism build up in the body

By-products bind with epidermal proteins

Keratinocytes pick up signal to

self destruct Formation of antigenic compounds

Massive keratocyte apoptosis

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 Sloughing

Rapid, progressing exfoliative changes Multisystem organ involvement Death

Extensive Epidermal

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

CUES

NURSIN G DIAGNO SIS

SCI. EXPLANATIO N

GOAL

INTERVENTION

RATIONALE

EVALUATIO N

S; " Masakit ang buong katawan ko dahil sa mga sugat ko. " Pasin Scale: 4/5 O: - gener alized weakn ess - with scaling , erythe ma, lesions and necros is in the entire body - with lesions in mouth , buccal mucos a

Acute pain R/T inflammat ion, swelling, lesions of the entire body

The pt experiences unpleasant sensation due to stimulation of pain receptors. This happens when pain substance were release and transmit it in the brain via the spinal cord and once it has been sent can perceived as PAIN.

After 1 hour of nursing interven tion, patient' s pain will be lessene d.

Encourage reports of pain, noting location, duration, and quality of pain. -Maintain immobilization of affected part. -Explain procedures before beginning them.

-Provide alternate comfort measures such as massage, backrub, and position changes. -Encourage use of stress management techniques such as progressive relaxation, deep breathing exercises. -Identify divertional activities appropriate for

Influences choice of/ GOAL:MET monitors The patient's effectiveness of pain interventions. decreased from 4/5 to 2/5. -Relieves pain and prevent bone displacement/extensi on of tissue injury. -Allows patient to prepare mentally for activity as well as to participate in controlling level of discomfort. -Improves general circulation; reduces areas of local pressure and muscle fatigue. -Refocuses attention, promotes sense of control, and may enhance coping abilities in the management of pain. -Prevents boredom, reduces tension, and can increase muscle strength; may enhance self-esteem

-

-

-

with swolle n conjun ctiva with reddis h, swolle n gums V/S: BP140/8 0 CR85 RR18 T37.2

patient age, physical abilities, and personal preferences. Administer analgesics as prescribed.

and coping abilities. -This provides relief of pain.

CUES S: " Hindi ako makagalaw ng mabuti dahil sa mga sugat ko" O; " Masakit ang buong katawan ko dahil sa mga sugat ko. " Pasin Scale: 4/5 O - generalized weakness - with scaling, erythema, lesions and necrosis in the entire body - Inability to purposefully move within the physical environment , including bed mobility, transfer and ambulation - Limited ROM - Decreased muscle

NURSING DIAGNOSI S Impaired physical Mobility R/T pain

SCI.EXP LANATIO N The pt experienc es a limitation of ability for independ ent physical movemen t due to pain.

GOAL

INTERVENTION

RATIONALE

At the end of 4 hours of nursin g interv ention the patien t will be able to increa se streng th /functi on of affect ed and comp ensat ory body parts.

-Assess degree of immobility produced by injury / treatment and note patient's perception of immobility.

-Patient maybe restricted by selfview/self perception out of proportion with actual physical limitation.

-Encourage participation in divertional/ recreational activities. Maintain stimulating environment. Instruct patient/ assist with active/passive ROM exercises of affected and unaffected extremities. -Assist with/encourage self activities . -Provide/assist with mobility by means of wheelchair

EVALUAT ION

GOAL:MET At the end of 4hours of nursing interventio n the patient Provides opportunity was able for release of energy to and refocuses increase attention. strength/f unction of affected and -Increases blood compensa flow to muscles and tory body bone to improve parts. muscle tone, maintain joint mobility. -Improves muscle strengthened circulation and promotes selfdirected wellness. -Early mobility Reduces complications of bed rest.

-

strength Imposed restrictions of movement

crutches.

CUES S: O: - generaliz ed weakness - with scaling, erythema , lesions and necrosis in the entire body - with lesions in mouth, buccal mucosa - with swollen conjuncti va - with reddish, swollen gums V/S: BP140/80 CR- 85 RR-18 T-37.2

NURSING DIAGNOS IS Risk for further infection. related to inadequat e primary defenses (broken skin and traumatize d tissue)

SCI. EXPLANATIO N The pt is at risk for being invaded by pathogenic organisms due to damage tissue which may be a portal of entry to other microorganis m.

GOAL At the end of 8 hours of nursing interven tions, the patient will maintain stable vital signs.

NURSING INTERVENTION Maintain aseptic technique when caring for wound. Inspect d wound; note characteristics of drainage.

RATIONALE Minimizes opportunity for introduction of bacteria.

Monitor vital signs.

Early detection of developing infection provides opportunity for timely intervention and prevention for further infections.

Instruct the patient not to touch the wound site.

Temperature elevation/ tachycardia may reflect developing sepsis.

Administer antibiotics as indicated.

Minimize the opportunity for contamination. Wide- spectrum antibiotics may be used prophylactically, or antibiotic therapy my be geared toward specific organisms.

EVALUA TION GOAL:ME T At the end of 8 hours of nursing interventi ons, the patient achieve timely wound healing.

CUES

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATIO N

GOAL

NURSING INTERVENTION

RATIONALE

OUTCOME

S: “ Nahihirapa n ako pag dumudumi dahil madalas, matigas.” O: Decreased bowel sounds Decreased activity level -With abdominal distension

Constipation R/T immobility

The pt experiences a change in normal bowel habits characterized by a decrease in frequency and passage of hard dry stools due to immobility that decreases his peristalsis.

After 4 hours of nursing intervention , the pt will reestablish normal patterns of bowel functioning.

Note abdominal distention and auscultate bowel sounds.

Use bedpan until allowed out of bed.

Distention and absence of bowel sounds indicate that bowel is not functioning, possibly due to sudden loss of parasympathetic enervation of the bowel. Promotes comfort, reduces muscle tension.

Provide privacy.

Promotes psychologic comfort.

Begin progressive diet as tolerated.

Solid foods are not started until bowel sounds have returned or flatus passed.

Provide rectal tube, suppositories and enemas as needed.

Administer laxatives, stool

Maybe necessary to relieve abdominal distension, promote resumption of normal bowel habit. Soften stool, promotes normal

After 4 hours of nursing intervention, GOAL MET, the pt was able to reestablished normal patterns of bowel functioning.

softeners, as indicated.

CUES

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATIO N

GOAL

NURSING INTERVENTION

bowel habits and decreases straining.

RATIONALE

OUTCOME

S: O: Decrease d activity level - Inabili ty to purpo sefully move within the physic al enviro nment , includi ng bed mobili ty, transf er and ambul ation - Limite d ROM - Decre ased muscl e streng th

Risk for further impaired skin integrity in the bony prominences of the right and left heel, sacrum and pelvis R/T physical immobilizati on

Because the patient is unable to move freely, he uses his right and left heels to move himself in the bed. The pt’s skin is adversely altered due to immobilization, which causes an impaired circulation to an immobilized area, thus, causing a high risk of impaired skin integrity.

After 1 hour of nursing interventi on, the pt will demonstr ate technique s to prevent skin breakdow n.

Anticipate and use preventive measures in pts who are at risk for skin breakdown. Assess nutritional status and initiate corrective measures, as indicated. Provide balance diet, e.g. adequate proteins, vitamins and minerals. Maintain strict skin hygiene. Perform passive ROM exercises. . Keep sheets and bedclothes clean, dry and free from wrinkles, crumbs and other irritating materials.

Decubitus ulcers are difficult to heal, and prevention is the best treatment. An improved nutritional state can help prevent skin breakdown and promotes ulcer healing.

To protect susceptible skin from breakdown. Improves circulation, muscle tone and joint motion and promotes pt participation. Avoids friction/abrasions of skin.

Provide for safety during ambulation.

Loss of muscle control and debilitation may result in impaired coordination.

Limit exposure to

Decreased sensitivity to pain/heat/cold

After 1 hour of nursing intervention , GOAL MET, the pt was able to demonstrat e techniques to prevent skin breakdown.

Imposed restrictio ns of movemen t

temperature extremes/ use of heating pad or ice pack. Examine feet and nails routinely and provide foot and nail care as indicated. Observe for decubitus ulcer development and treat immediately according to protocol. Administer nutritional supplements and vitamins as indicated.

increases risk of tissue trauma. Foot problems are common among pts who are debilitated. Timely intervention may prevent extensive damage.

Aids in healing/cellular regeneration.

Discharge Plan Medications  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. These promote 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 provide ongoing 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 collagen formation 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 •

•

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

•

Gastroenterologic - Esophageal strictures

Pulmonary - Tracheobronchial shedding with resultant respiratory failure

Cutaneous - Scarring and cosmetic deformity, recurrences of infection through slowhealing ulcerations Prognosis:

•

•

Individual lesions typically should heal within 1-2 weeks, unless secondary infection occurs. 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)

STEVENSJOHNSON

SYNDRO ME GROUP II A

BSN 4 -

Lea Marie Salazar

Jennelyn Pascual

Rey Raniaga

Michelle Sidoro

Loredel Melegrito

Jennilyn Dampil

Shiela Tomas

Aleda Pineda

Mayleen Mutuc

Michael Tan

Kristine Padlan

Raymond Lorenzo

Melissa Matusalem

Hermel Joseph Paras

Giovanni Tebia

A Ca s e S t ud y

Su b m i t t ed T o M s . Od et t e Ta n ed o , R . N. Dec em b er 9 , 2 0 0 4