Steven Johnsons Syndrome

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Pres. Diosdado Macapagal Blvd.,Metropolitan Park, Pasay City

Nursing Process

STEVENS-JOHNSON


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I. Assessment

A. General Data

Patients Name: DGAddress: Valenzuela City Informant: Wife of patienAge: 47 Date of admission: Sept. 20,

2011Sex: Male Order of Admission: viawheelchairDate of Birth:July 11, 1964Civil Status: MarriedOccupation: Company Messenger

B. Chief complaints"Dinala ko na siya sa ospital dahil sobrang dami niya ng rashes sa katawanat dahil na din sa sore eyes sore throat at lagnat niya as verbalized by th


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to his medicine, he was advised to be confined but there is no availabroom.

1 hour prior to hospitalization the patient was brought to ValenzueGeneral Hospital with a chief complaint of sore eyes, sore throat, rashes aover his body and fever. The patient was then subsequently admitted.

D. Past History

1. Childhood Illness: chickenpox2. Adult Illness: hypertension3. Operations: none4. Serious Injuries: none5. Medication prior to admission: gentamycin 1gtt 3x/day, allopurinol1x/day for 14 days.6. Allergies:Tuyo

A.System Review - Gordons Eleven Functional Areas


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food.

During hospitalization, Mrs. SD verbalized that pumayat siya kahindi pa siya nakaka-kain 4 na araw na dahil hindi niya maigalaw yung lipniya kasi sobrang sakit daw. Kahit mapatakan lang ng tubig nasasaktan nsiya, instead her husband gets his energy from his dextrose

3. Elimination Pattern

Prior to hospitalization, the wife of the patient verbalized that Mr. D

doesnt have any problem urinating and defecating. He urinates every daand its yellowish in color and his stool is foul in odor and is semi formedepending on what he eats. She verbalized that her husband doesnt usany laxative. He defecates once a day usually in the mornin

During hospitalization the patient is assisted by his wife whe

urinating. He uses bedpan to urinate but he is not yet defecating since thday he was admitted, he was not prescribed with any laxative. Mrs. Sverbalized that the patient doesnt feel any pain while urinating but he cango to the bathroom because his foot are swollen and it aches when movewith a pain scale of 9/10 he was not prescribed with pain relieve


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During hospitalization, the wife of the patient verbalized that thpatient just sleeps because he cant do anything else aside from sleeping

resting. The wife of the patient verbalized that the patient is irritabbecause of the pains that he fee

11. Values/Beliefs

Prior to hospitalization, the wife of the patient verbalized that they aboth catholic and they are both GOD fearing persons. They also believe things that cant be seen by bare eye

During hospitalization, the wife of the patient verbalized that their faith GOD becomes stronger and she also said that they always pray for hhusbands progressio

B.Family Assessment


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one side. Instead hes open to allpossibilities, weighing them and

then making

A. Physical Examination

Date: September 24, 2011Time: 1:00 PM

General Appearance

The patient was untidy during the interview. He was conscious ancoherent, oriented to time, date, place and people around him. He was lyinon bed with limited range of motion, and positive with erythematous.

Initial Vital Signs:PR- 83 bpm Initial Weight: 64 Kg.

RR- 20 cpm Latest Weight: 59 Kg.BP- 130/90 mmHg Temperature- 37.7C

A. Skin


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Inspection:

Patients neck is head centered With difficulty in moving his head

No lumps or swollen gland

(+) rashes

Palpation:

There are no palpable lymph nodes

I. Spine

Inspection:

(+) skin rashes

Palpation:Not performed

J. Thorax and Lungs

Inspection:


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With IV inserted on left metacarpal vein

Able to grasp object

With lessen range of motion (+) rashes

Palpation:

Warm to touch in the left and right hand

Pain upon palpation on legs and feet

Lower

Inspection:

Able to move with restrictive range of motion

(+) rashes

inflamed lower extremities

Palpation:

Warm to touch

O. Genitals

Patient refused to inspect with (+) rashes as verbalized by patient


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ModifiableFactors

- Medication

Non- ModifiableFactors

- Condition

Etiology:Idiopathic

have a family bonding, after lunch the patient will just rest for a while thehe will have his nap and he will wake up at 4 or 5 in the afternoon then h

will play with his children or help them do their assignments. They will etheir dinner at 7 in evening while watching television. Then he will sleep 10 or 10:30 in the evening.Rank in Family: fatherTravel: none


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Cough Headache Fever AchingFollowed by red rash across face and trunk of body which

continues to spread to other parts of the body

Rash can form to blisters (Eyes, Mouth, Abdominal Area)

Inflammed Skin peels away in sheets

Infection

IV. Laboratory Results

H t l R lt F


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Cues/Data

NursingDiagnosis

Rationale Plans &Objectives

Nursing Interventions Rationale Evaluatio

Subjective:

Hindibumababa anglagnatniyasimulanung na-admitsiya, asverbalized by thepatientswife.

Objective

:

T: 37.7 C-Skin iswarm totouch

Hyperthermia

related toillness

High fever inpatients ma becaused byinfection of therespiratory orurinary tract,

drug reactions.Slight elevationof temperaturemay be causedby dehydration.Such elevationsmust becontrolled,because theincreasedmetabolicdemands of thebrain can exceedcerebral

circulation andoxygenation,resulting incerebraldeterioration. Thepatientstemperature ismonitoredfrequently.

Reference:Brunner &SuddarthsTextbook of

After 30 minutesof nursinginterventions, theclient will be ableto decreasetemperature from37.7C to 37.0 C

1. Promote surface cooling bymeans of undressing; coolenvironment and/or fans; cooltepid sponge bath.

2. Encourage patient toincrease fluid intake

3. Monitor / record all sourcesof fluid loss such as urine

4. Note presence/absence ofsweating as body attempts toincrease heat loss byevaporation, conduction anddiffusion.

5. Maintain bed rest.

- Heat loss byconduction, convection,evaporation.

- To preventdehydration

- To reduce metabolicdemands/oxygenconsumption

After minutes nursinginterventios, the gowas fumet evidencedbytemperatuof 37.0 C


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Medical-SurgicalNursing; EleventhEdition; P.1976 &2167

Cues/Data NursingDiagnosis


Nursing Interventions Rationale Evaluatio

Subjective:

Wala siyangibangginagawakundi humigadahil hindisiya gaanongmakakilos

dahil masakityung paaniya, asverbalized bythe wife ofthe patient.

Objective:

Pain scale of8/10 uponpalpation of

patients legs

ActivityIntolerancerelated to

GeneralizedWeakness

Patientswith SJSwithinvolvement of largeareas okskin requirecare that issimilar to

that of patientswiththermalburns.Patientsmayexperienceweaknessthat mayresult todecrease in

mobility.

After 24-72hours of nursinginterventions,the patient willbe able toverbalizewellness asevidenced by:

- participatewillingly innecessaryactivities

- reportmeasurableincrease inactivitytolerance.

1. Evaluate clients actualand perceived limitations.

2. Note clients report ofweakness

3. Ascertain ability tomove and degree ofassistance needed

4. Plan care to carefullybalance rest periods withactivities5. Provide comfortmeasures and providerelief of pain6. Encourage patient tomaintain positive attitude;encourage to participate inactivities appropriate forsituation

7. Give patient information

- Provides comparativebaseline and providesinformation about neededintervention- Symptoms may be resultto intolerance of activity

- To determine currentstatus and needs

associated withparticipation in desiredactivity- To reduce fatigue

- To enhance ability toparticipate in activities- To enhance sense ofwell-being

After hours nursinginterventios, the gowas partiamet.


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and feet.

Patient needsto be assisteduponmovement

Reference:Brunner &SuddarthsTextbook ofMedical-SurgicalNursing;EleventhEdition; P.1976

that provides evidence ofdaily progress



Nursing Interventions Rationale Evaluation

Subjective:

Nagka-paltosna ata siyadahil lagi langsiyangnakahiga, asverbalized by

patients wife

Objective:

- (+) blisters

- (+) separationof dermis andepidermis

- Dry & crackedskin

ImpairedSkin

Integrityrelated toPhysical

Immobilizat

ion asevidencedby skinlesions,woundsand bed

sores

Patientswith SJS areusuallyprone tohaving skinproblemssuch as

blisters,rashes etc.,because ofthe illness.

After 3days of nursinginterventions, clientwill be ableto gain fastwound

healing

1. Inspect skin on daily basis,describing lesions and changesobserved.2. Use appropriate paddingdevices when indicated

3. Instruct patient/significantother with proper skin hygiene

4. Encourage early ambulation

5. Emphasize importance ofproper fit clothing, use of barrierdressings and skin protectiveagents.6. Advise to have a turningposition every 2 hours

- To monitorprogress of woundhealing- To reduce pressureon/enhancecirculation tocompromisedtissues.

- Promotescirculation andreduces risksassociated withimmobility.- To protect thewound orsurrounding tissues

- To prevent havingbedsores

After 3 days nursinginterventions,the goal wmet evidenced manifestationof time

healing of sklesions abedsoreswithoutcomplications


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physicalandemotionalenergy.

Reference:Brunner &

SuddarthsTextbook ofMedical-SurgicalNursing;EleventhEdition;P.1976

8. Provide quiet environment



Nursing Interventions Rationale Evaluation

Subjective:

Pumayat siya

kasi hindi pasiyanakakakain ng4 na araw dahilhindi niyamaigalaw yunglabi niya kasisobrang sakitdaw. Kahitmapatakanlang ng tubignasasaktan nasiya, as

ImbalancedNutrition

less thanbody

requirements relatedto inabilityto swallow

asevidenced

by sore andinflamedbuccalcavity

Oral lesionsmay resultin dyshagia

(difficulty inswallowing); Swellingof facialstructuremay makeit difficultfor thepatient toopen themouth.

After 3 days ofnursinginterventions,

the patient willverbalizewellness asevidenced by:

- Progressiveweight gaintoward goal.

- Be free ofsigns of dehydration.

1. Determine ability to chew,swallow and taste food.

2. Assess weight of patient.

3. Instruct patient to tryeating foods which are easyto swallow.

4. Instruct patient to usealternative utensils such asstraw.

5. Maintain patency andregulate IV fluid as ordered.

- All factors thancan affectingestions of

nutrients.

- For easierdigestion.

- To maintainproper hydration.

After 3 days nursinginterventions,

the goal wpartially met evidenced latest weight 59 Kg bshowed signs improvement skin frodehydration.


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verbalized bythe wife of theclient.

Objective:- Sore andinflamed buccalcavity- Weakness ofmusclesrequired forswallowing andmastication-Initial Wt: 64Kg.- Dry skin

Reference:Brunner &SuddarthsTextbook ofMedical-SurgicalNursing;EleventhEdition;

P.1976;P1146


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XI.Ongoing Appraisal

- The patient was admitted last September 20, 2011 at 9:10 in the evening with a chief complaint of rashes all over his body, sore eyes, sand fever. He was brought to the ER and was diagnosed to have Steven Johnsons Syndrome. He was hooked with D5NSS to run for 8 130/80; PR: 86; RR: 24; Temp: 38.2

- September 20, 2011, 11:40 in the evening, he was requested to have laboratory examinations of CBC, APC, BUN crea, ESR, BUA, NA, K andphysician advised that the patient may have sips of water and be observed for aspiration, he should also be placed on a high back rest. ODrops were instilled to both eyes and he was given with Paracetamol through IV 300 mg.

- September 21, 2011, 7:00 in the morning, patient complaint of pain on both eyes; ointment instilled. The patient is still in fever 37.7 spwas done by the wife of the patient.4pm patients temperature was 38.4 and was given Paracetamol through IV and sponge bath was done to the patient by his wife.

- September 22, 2011, 8:00 in the morning, the physician ordered general liquid diet for the patient. There are still rashes all over the patistill with sore eyes, sore throat and fever.

- September 23, 2011 the patient was noted to have difficulty in swallowing. Still with sore eyes, sore throat, rashes and fever.

- September 24, 2011 above symptoms are still present. Latest temperature is 37.7.

- September 25, 2011 temperature went down to 37.0 C

- September 27, 2011, with continuous medications; the patient was able to open his eyes widely and was able to move his lips and speak.

- September 28, 2011, the patient was able to stand and go to the bathroom with assistance from his wife.


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XII. DISCHARGE PLAN

M MedicationsMedications prescribed by the physician should be taken properly, to help patient lessen unusual condition.

E Exercise

Encourage relatives to help the patient to have an active range of motion exercises thrice daily to maintain his/her muscle strength.Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to avoid relapse.

T TreatmentGive supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed. Treatment is one of the main factor

restoration of health and curing of the failure in the body system. Treatments are given to the patient for specific time until treatment is notneeded by the patient.

H-- Health EducationEncourage relatives of the patient to wash hands. The hands come in daily contact with germs that can cause infections. These germs

ones body when he touch his eyes or rub his nose. Washing hands through and often can help reduce the risk.

O OPD follow-up

Keep all of follow- up appointments, even though the patient feels better. Its important to have the doctor monitor his progress.

D DietDrink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help loosen mucus in the lungs.Advice the patient not to eat foods that is high in cholesterol such as the fatty portion of the pork that may increase level of his/her b

pressure but to eat more green and leafy vegetables.

S Signs and SymptomsInform the physician if the patient have a fever, rash or sores in the mouth after starting a new medicine and if the skin is red and hur

Steven Johnsons Syndrome

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