23358746 stevens johnson syndrome case
TRANSCRIPT
I. INTRODUCTION
A. Brief Description
Stevens - Johnson syndrome (SJS), also called erythema multiforme major is a life-
threatening condition affecting the skin in which cell death causes the epidermis to separate
from the dermis. SJS is a skin and mucous membrane disease characterized by an eruption of
macules, papules, nodules, vesicles, and/or bullae with characteristic "bull's-eye" lesions usually
occurring on the dorsal aspect of the hands and forearms. The syndrome is thought to be a
hypersensitivity complex affecting the skin and the mucous membranes that can also affect the
eyes. Although the majority of cases are idiopathic, the main class of known causes is
medications, followed by infections and (rarely) cancers.
Stevens-Johnson syndrome is a limited form of toxic epidermal necrolysis by destruction
and detachment of the skin epithelium and mucous membranes involving less than 10% of the
body surface area. SJS can be triggered by a drug allergy, more rarely, by infections or bone
marrow transplantation. In 25 to 30% of cases, the cause is unclear. Patients should be
admitted to an intensive care or burns unit as soon as the diagnosis is suspected.
Reepithelialization is rapid (2-3 weeks).
SJS may have full-thickness epidermal necrosis, but with lesser detachment of the
cutaneous surface; and mucous membrane involvement. Maculopapular exanthema and
hypersensitive skin syndrome are other spectrum of cutaneous drug reactions. Maculopapular
exanthema is characterized by cutaneous fine pink macules and papules, lesions which usually
fade within 1–2 weeks following cessation of drug treatment.
It is a fatal allergic reaction to drugs and microorganisms. SJS can be caused by infections,
usually following viral infections such as herpes simplex virus, influenza, mumps, cat-scratch
fever, histoplasmosis, Epstein-Barr virus
Drugs precipitate over 50% of SJS cases and up to 95% of TEN cases. Sulfa drugs
(eg, co-trimoxazole, sulfasalazine ), antiepileptics
(eg, phenytoin , carbamazepine ,phenobarbital , valproate ), antibiotics (eg,
aminopenicillins, quinolones, cephalosporins), and miscellaneous individual drugs
(eg, piroxicam , allopurinol , chlormezanone) are most often implicated. Cases that
are not due to drugs are attributed to infection (mostly with Mycoplasma
pneumoniae), vaccination, and graft-vs-host disease. Rarely, a cause cannot be
identified.
Signs:
A. Distinctive Target or Iris skin lesion
1. Starts as erythematous Macule that becomes raised
2. Distribution: Symmetrical involvement
a. Onset on distal extremities (often dorsal hands)
b. Progress proximally (often extensor surfaces)
c. Oral Mucosal involvement may be present
3. Develops concentrically into target lesion by day 2
a. Center: Dusky erythema or Vesicle
b. Middle: Pale edematous ring
c. Outer: Dark band of erythema
4. Progresses
a. Central necrosis
b. Some lesions may coalesce into annular Plaques
5. Healing
a. Scarring
b. Postinflammatory Hyperpigmentation
A. Alternative presentations
1. Non-transient Urticarial Plaques
2. Vesicles or bullae form in prior Macule or wheal
Symptoms:
A. Rash develops after prodrome
B. Mild prodrome for 7-10 days may be present
1. Malaise
2. Fever
3. Headache
4. Rhinorrhea
5. Cough
A. Statistics
International / Local
Stevens-Johnson Syndrome is listed as a "rare disease" by the Office of Rare Diseases
(ORD) of the National Institutes of Health (NIH). This means that Stevens-Johnson Syndrome,
or a subtype of Stevens-Johnson Syndrome, affects less than 200,000 people in the US
population.
SJS is a rare condition, with a reported incidence of around 2.6 per million people per
year. In the United States, there are about 300 new diagnoses per year.
I. OBJECTIVES
A. General Objectives
At the end of the clinical exposure, I should be able to attain and enhance my
knowledge, skills and attitude to provide nursing care to our patient with Stevens - Johnson
syndrome.
B. Specific Objectives
During the exposure, I should be able to:
Cognitive:
➢ Discover how the patient acquired the disease through the nursing health history,
physical examinations, and some other some other factors that may contribute in relation
to Stevens - Johnson syndrome and be able to assess, organize and validate those data
efficiently.
➢ Understand Steven Johnson Syndrome, its causes and pathophysiology.
➢ Design a plan of care for patient with Stevens - Johnson syndrome (SJS).
➢ To be able to formulate those data into nursing diagnoses that may aid in the patient’s
current health condition.
➢ To be able to set priorities and goal outcomes in collaboration with the patient.
Skills:
➢ Conduct physical assessment and organize data efficiently.
➢ Perform nursing procedures effectively and correctly to attain his optimum level of
wellness.
Attitude:
➢ To be able to establish rapport with the patient and folks.
➢ To be able to develop respect and trust.
I. ANATOMY AND PHYSIOLOGY OF THE DISEASE
THE SKIN
The skin is the largest organ in the human body. For the average adult human, the skin
has a surface area of between 1.5-2.0 square meters (16.1-21.5 sq ft.), most of it is between 2–
3 mm (0.10 inch) thick. The average square inch (6.5 cm²) of skin holds 650 sweat glands, 20
blood vessels, 60,000 melanocytes, and more than a thousand nerve endings.
The skin is the outer covering of the body. In humans, it is the largest organ of the
integumentary system made up of multiple layers of mesodermal tissue, and guards the
underlying muscles, bones, ligaments and internal organs. Skin of a different nature exists
in amphibians, reptiles, birds. Human skin is not unlike that of most other mammals except that
it is not protected by a pelt and appears hairless though in fact nearly all human skin is covered
with hair follicles. The adjective cutaneous literally means "of the skin" (from Latin cutis, skin).
Because it interfaces with the environment, skin plays a key role in protecting (the body)
against pathogens and excessive water loss. Its other functions are
insulation, temperature regulation, sensation, synthesis of vitamin D, and the protection
of vitamin B folates. Severely damaged skin will try to heal by forming scar tissue. This is often
discolored and depigmented.
In humans, skin pigmentation varies among populations, and skin type can range
fromdry to oily. Such skin variety provides a rich and diverse habit for bacteria which number
roughly a 1000 species from 19 phyla.
Skin has mesodermal cells, pigmentation, or melanin, provided by melanocytes, which
absorb some of the potentially dangerous ultraviolet radiation (UV) in sunlight. It also
contains DNA-repair enzymes that help reverse UV damage, and people who lack the genes for
these enzymes suffer high rates of skin cancer. One form predominantly produced by UV
light, malignant melanoma, is particularly invasive, causing it to spread quickly, and can often be
deadly. Human skin pigmentation varies among populations in a striking manner. This has led to
the classification of people(s) on the basis of skin color.
Skin layers
Skin is composed of three primary layers:
the epidermis, which provides waterproofing and serves as a barrier to infection;
the dermis, which serves as a location for the appendages of skin; and
the hypodermis (subcutaneous adipose layer).
1. Epidermis
Epidermis, "epi" coming from the Greek meaning "over" or "upon", is the outermost
layer of the skin. It forms the waterproof, protective wrap over the body's surface and is made
up of stratified squamous epithelium with an underlying basal lamina.
The epidermis contains no blood vessels, and cells in the deepest layers are nourished
by diffusion from blood capillaries extending to the upper layers of the dermis. The main type of
cells which make up the epidermis are Merkel cells, keratinocytes, with melanocytes and
Langerhans cells also present. The epidermis can be further subdivided into the
following strata (beginning with the outermost layer): corneum, lucidum (only in palms of hands
and bottoms of feet), granulosum, spinosum, basale. Cells are formed through mitosis at the
basale layer. The daughter cells move up the strata changing shape and composition as they
die due to isolation from their blood source. The cytoplasm is released and the protein keratin is
inserted. They eventually reach the corneum and slough off (desquamation). This process is
called keratinization and takes place within about 27 days. This keratinized layer of skin is
responsible for keeping water in the body and keeping other harmful chemicals
and pathogens out, making skin a natural barrier to infection.
Components
The epidermis contains no blood vessels, and is nourished by diffusion from the dermis.
The main type of cells which make up the epidermis
are keratinocytes, melanocytes, Langerhans cells and Merkels cells. The epidermis helps the
skin to regulate body temperature.
Sublayers
Epidermis is divided into the following 5 sublayers or strata:
Stratum corneum
Stratum lucidum
Stratum granulosum
Stratum spinosum
Stratum germinativum (also called "stratum basale")
1. Dermis
The dermis is the layer of skin beneath the epidermis that consists of connective tissue and
cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a
basement membrane. It also harbors many Mechanoreceptor/nerve endings that provide the
sense of touch and heat. It contains the hair follicles, sweat glands, sebaceous glands, apocrine
glands,lymphatic vessels and blood vessels. The blood vessels in the dermis provide
nourishment and waste removal from its own cells as well as from the Stratum basale of the
epidermis.
The dermis is structurally divided into two areas: a superficial area adjacent to the
epidermis, called the papillary region, and a deep thicker area known as the reticular region.
Papillary region
The papillary region is composed of loose areolar connective tissue. It is named for its
fingerlike projections called papillae that extend toward the epidermis. The papillae provide the
dermis with a "bumpy" surface that interdigitates with the epidermis, strengthening the
connection between the two layers of skin.
In the palms, fingers, soles, and toes, the influence of the papillae projecting into the
epidermis forms contours in the skin's surface. These are called friction ridges, because they
help the hand or foot to grasp by increasing friction. Friction ridges occur in patterns that are
genetically and epigenetically determined and are therefore unique to the individual, making it
possible to use fingerprints or footprints as a means of identification.
Reticular region
The reticular region lies deep in the papillary region and is usually much thicker. It is
composed of dense irregular connective tissue, and receives its name from the dense
concentration of collagenous, elastic, and reticular fibers that weave throughout it.
These protein fibers give the dermis its properties of strength, extensibility, and elasticity.
Also located within the reticular region are the roots of the hair, sebaceous glands, sweat
glands, receptors, nails, and blood vessels.
Tattoo ink is held in the dermis. Stretch marks from pregnancy are also located in the dermis.
2. Hypodermis
The hypodermis is not part of the skin, and lies below the dermis. Its purpose is to attach the
skin to underlying bone and muscle as well as supplying it with blood vessels and nerves. It
consists of loose connective tissue and elastin. The main cell types
are fibroblasts, macrophagesand adipocytes (the hypodermis contains 50% of body fat). Fat
serves as padding and insulation for the body.
Microorganisms like Staphylococcus epidermidis colonize the skin surface. The density of
skin flora depends on region of the skin. The disinfected skin surface gets recolonized from
bacteria residing in the deeper areas of the hair follicle, gut and urogenital openings.
Skin performs the following functions:
1. Protection - an anatomical barrier from pathogens and damage between the internal
and external environment in bodily defense; Langerhans cells in the skin are part of
the adaptive immune system.
2. Sensation - contains a variety of nerve endings that react to heat and cold, touch,
pressure, vibration, and tissue injury.
3. Heat regulation - the skin contains a blood supply far greater than its requirements
which allows precise control of energy loss by radiation, convection and conduction.
Dilated blood vessels increase perfusion and heatloss, while constricted vessels greatly
reduce cutaneous blood flow and conserve heat.
4. Control of evaporation - the skin provides a relatively dry and semi-impermeable
barrier to fluid loss. Loss of this function contributes to the massive fluid loss in burns.
5. Aesthetics and communication - others see our skin and can assess our mood,
physical state and attractiveness.
6. Storage and synthesis: acts as a storage center for lipids and water, as well as a means
of synthesis of vitamin D by action of UV on certain parts of the skin.
7. Excretion - sweat contains urea, however its concentration is 1/130th that of urine,
hence excretion by sweating is at most a secondary function to temperature regulation.
8. Absorption - Oxygen, nitrogen and carbon dioxide can diffuse into the epidermis in
small amounts, some animals using their skin for their sole respiration organ (contrary to
popular belief, however, humans do not absorb oxygen through the skin). In addition,
medicine can be administered through the skin, by ointments or by means of
adhesive patch, such as the nicotine patch or iontophoresis. The skin is an important
site of transport in many other organisms.
9. Water resistance - The skin acts as a water resistant barrier so essential nutrients
aren't washed out of the body.
I. VITAL INFORMATION
Name (initials): R.A
Age: 65 years old
Sex: Female
Address: Panay, Capiz
Civil Status: Married
Religion: Roman Catholic
Occupation: --------
Date and Time admitted: November 11, 2009 at 3:50 pm
Ward: Intensive Care Unit (ICU) Cubicle F
Chief Complaint: Unresponsiveness
Admitting Diagnosis: T/C Anaphylactic Shock, T/C Stevens - Johnson syndrome,
S/P CVA, T/C Restroke
Attending Physician/s: Dr. J.B
II. CLINICAL ASSESSMENT
A. Nursing History
2 days prior to admission, Mrs R.A was noted to have appearance of maculopapular
rashes on the trunk progressing to whole body, and was noted to have oral sores. She is
febrile and Mrs. R.A was noted to be unresponsive.
B. Past Health Problem / Status
Past Illnesses: Mr. R.A is a 65 year old Female positive from Cerebrovascular disease,
Renal disease, Hypertension, and Cardiovascular disease diagnosed last October 2009 and
she is having her maintenance.
C. Family History of Illness
Both of her parents have hypertension, diabetes mellitus type -2 and a history of,
Cardiovascular disease. Some of her siblings have it too.
N.A56P.A69
T/C Anaphylactic Shock, T/C Stevens - Johnson syndrome, S/P CVA, T/C Restroke
HPNLEUKEMIA
MOTOR RIDE
ACCIDENT
P.A
92
M.A83
M.A63
R.A65
G.A60
A.A
53
L.A
59
B.A4183
F.L
50
F.A39
N.A
41
C.Z37
R..L
29
J.L
32
H.B26
J.L
24
HPN
Dm -2, HPN, CVA
DM -2, HPN
DM -2, HPN
Legend:
Deceased male
Deceased female
Indicates patient
Living male
Living female
FAMILY GENOGRAMFAMILY GENOGRAM
I. BRIEF SOCIAL, CULTURAL AND RELIGIOUS BACKGROUND
A. Educational Background
Mr. R.A is an elementary graduate.
B. Occupational Background
She is being supported by her children.
C. Religious Background
She is a Roman Catholic and attends mass on Sundays and prays the rosary at
night together with her family.
D. Economic Status
They belong to a middle class type of family and most of her children have works
already.
I. CLINICAL INSPECTION
A. Vital Signs
Upon Admission During CareTemperature 39°C 36.3°CPulse Rate 96 bpm 58 - 112 bpmRespiration 18 bpm 16 - 24 bpm
Blood
Pressure 60 / 90mmHg 60/80 - 170/100 mmHgCardiac Rate 100 bpm 60 - 115 bpm
B. Height, Weight, BMI – no data
C. Physical Assessment
General
Mrs. R.A is unresponsive and restless. (+)
erythematous, (+) maculopapular rashes.
Skin, Hair, Nails
Dry and scaly skin, uniform in color, (+) hematoma
in right arm. Hair is black with visible white hair, no
lice and dandruff and dry scalp. Fingernails are
dirty and untrimmed.
H ead, Face, Lymphatics
No head injuries, round in shape and oily face.
HEENT
Color of the eyes is dark brown, anicteric sclera
with pale conjunctiva. His right & left ear canal are
not clean, (-) discharges, brown in color,
symmetrical in shape. Hearing is good with no pain
and infections. Have frequent colds. No discharges
or secretions and nosebleeds. Lips are dry and
choppy, (+) oral sores. NGT and O2 at 3L/min via
Nasal Cannula noted.
Neck and Upper extremities
No lumps or swollen glands. Arms are not able to
move freely. GCS of 5 – 11.
Chest, Breast and Axilla
Normal respiration upon admission with RR of 18
bpm and abnormal during care 16- 24 bpm.
Respiratory System ( Chest and Lungs )
Thorax is symmetric. RR is above normal. (+)
dyspnea, (+) slightly tachycardic .CXR results:
Dextroscoliosis, Thoracic spine, Atheromatous
aorta
Cardiovascular System
Blood pressure upon admission is 60 / 80, during
my care is 60 / 90 – 170 / 100. (+) dyspnea, (+)
slightly tachycardic, Cardiac rate is above normal
with AR of 70 – 115 bpm and respiration of 16 - 24
bpm.
Gastrointestinal System
Feeding is through NGT with Diben at 250 cc every
4 hours.
Genito – Urinary System
Foley catheter noted. Sometimes her urine output
is low but sometimes it’s normal. 700 – 1500 cc /
shift.
Musculoskeletal System
(+) weakness, (+) limitation of motion or activity, (+)
grossly, (+) maculopapular rashes, Legs are not
able to move freely. GCS of 5 – 11 (+)
erythematous.
D. General Appraisal
Speech: Mrs. R.A is unresponsive.
Language: Mrs. R.A is unresponsive, she cannot respond to any verbal command.
Hearing: Mrs. R.A’s hearing is quite good but she cannot response.
Mental Status: Mrs. R.A is not coherent, she cannot communicate.
Emotional status: Mrs. R.A sometimes cries.
I. LABORATORY AND DIAGNOSTIC DATA
A. Hematology
Hematology or hematology is the branch of biology (physiology), pathology, clinical
laboratory, internal medicine, and pediatrics that is concerned with the study of blood, the blood
of forming organs, and blood diseases. Hematology includes the study of etiology, diagnosis,
treatment, prognosis, and prevention of blood diseases.
Test Result Normal
Values
Significance
Date: 11/12/09WBC count 15.6x10^9/L 4.5-11.0 ↑ InfectionRBC count 4.90x10^12/L 4.2-5.4 The result is Within Normal
Range.Hemoglobin 140g/L 120-160 The result is Within Normal
Range.Hematocrit 0.40 vol.fr 0.37-0.47 The result is Within Normal
Range.Bands 0.01
Segmenters 0.98 % 50 – 65% ↓Eosinophils 4 0-3 ↑ Allergic reactionsBasophils 0.0% 0-1 The result is Within Normal
Range.Lymphocytes 0.01% 20-45 ↓ It signifies severe
debilitating illnesses.Monocytes 5% 0-8 The result is Within Normal
Limits.
A. Blood Chemistry
The serum chemistry profile is one of the most important initial tests that are commonly
performed on sick or aging patient. A blood sample is collected from the patient. The blood is then
separated into a cell layer and serum layer by spinning the sample at high speeds in a machine
called centrifuge. The serum layer is drawn off and a variety of compounds are then measured.
These measurements aid the veterinarian in assessing the function of various organs and body
systems.
Test Result Normal Values SignificanceDate: 11/12 /09
Glucose 11.52
mmol/L
4.10 – 5.90 ↑ Hyperglycemia
Sodium 125.3
mmol/L
137.0 – 145.0 ↓ Renal insufficiency,
uremiaCreatinine 210.9
ummol/L
71.0 – 133.0 ↑ Impaired renal function,
shockCholesterol 2.44
mmol/L
0.00 – 5.20 The result is Within Normal
Range.Direct HDLC .58 mmol/L 1.00 – 1.60 ↓ Indicates risks in CAD
LDL 1.20
mmol/L
1.71 – 4.60 The result is Within Normal
Range.VLDL 1.65
mmol/L
0.00 – 1.03 ↑ Elevation indicates
increase risk in CADPotassium 4.72
ummol/L
3.5– 5.10 The result is Within Normal
Range.Triglycerides 1.42 mmol /
L
0.00 – 1.69 The result is Within Normal
Range.Urea 26.66
mmol /L
2.50 – 6.10 ↑ Impaired renal function
A. ABG Analysis
It is also called arterial blood gas (ABG) analysis, is a test which measures the amounts
of oxygen and carbon dioxide in the blood, as well as the acidity (pH) of the blood. It indicates
how well the lungs and kidneys are interacting to maintain normal blood pH (acid-base balance).
It evaluates how effectively the lungs are delivering oxygen to the blood and how efficiently they
are eliminating carbon dioxide from it.
Test Result Normal Values SignificanceDate: 11/11/09
pH 7.39 7.35 – 7.45 The result is Within Normal
Limits.pO2 296.1 mmHg 80 – 100 mmHg ↑
HCO3 19.2 mmol/L 22 – 26 mmol/L ↓ Acidosis
PaCO2 32.2 mmol/L 35 - 45mmol/L ↓ Alkalosis ABE -4.2 mmol/L -2 - +2SBE -48 mmol/LSBC 21 mmol/L
O2 saturation 99.8% 97 – 100% The result is Within Normal
Limits.TCO2 45.2 mmol/L
A. Urinalysis
A urinalysis is a test performed on a patient's urine sample to diagnose
conditions and diseases such as urinary tract infection, kidney infection, kidney stones,
inflammation of the kidneys, or screen for progression of conditions such as diabetes
and high blood pressure.
Test Result Normal Range SignificanceDate: 11/11/09
(Macroscopic)
Color Dark Straw Straw, Amber,
TransparentTransparency Cloudy Clear Abnormal results. It
indicates infection like
pyuria or bacteuriapH 5.0 4.5 – 8.0 The result is Within Normal
Limits.
Specific Gravity 1.030 1.010- 1.030 The result is Within Normal
Limits.Glucose Negative Negative The result is Within Normal
Limits.(Microscopic)
Amorph. U/P many InfectionRBC/hpf 0 - 1WBC/hpf 0 – 2
Epith. Cells many InfectionMucus thread moderate Infection
B. HbAIc Determination
The use of hemoglobin A1c (HbAIc) is for monitoring the degree of control of glucose
metabolism in diabetic patients.
Test Result Normal Values SignificanceDate: 11/12/09
HbAIc -7.9 % -4.2 – 6.2% ↑ DM
A. CXR AP(Mobile)
Hypersensitivity - caused by many drugs, viral infections, and malignancies.Formation of reactive
metabolites that bind to and alter cell proteins.
Immune complexes formed by auto antibodies and autoantigens
combining.
STEVENS-JOHNSON SYNDROME
Inflammatory response in tissues.
Triggering a T-cell–mediated cytotoxic reaction to drug antigens in
keratinocytes.
B. Troponin I Determination
I. PATHOPHYSIOLOGY
II.
Test Findings ImpressionDate: 11/12/09CXR (anterior) The lung fields are clear,
The cardiac shadow is not enlarged,
Curvilinear calcific opacity is noted in
the aortic arch,
There is a lateral curvature of the
thoracic spine with convexity to the
Right,
The CP angles, diaphragm, and soft
tissue structures are unremarkable.
Dextroscoliosis,
Thoracic spine
Atheromatous aorta
Test Result Date: 11/11/09Trop. I < 0.01 ug/L
Predisposing Factors:
Age: 65 y.o
Family History: hypertension, diabetes mellitus type -2, Cardiovascular disease
Precipitating factors:
Lifestyle: Smoking, Eating fatty foods.
Certain disease: Cardiovascular disease diagnosed last October 2009, Hypertension, Renal
III. MEDICAL MANAGEMENT
A. Drug Study
Name of the
Drug with
Dosage
Generic Name Action Mechanism of
Action
Indications Side Effects Contraindications Nursing Responsibilities
Hiza
30mg, 1 tab
BID
Lansoprozole Antisecretory
drug
Proton pump
inhibitor
Gastric acid –
pump inhibitor.
Suppresses
gastric acid
secretion by
specific inhibition
of the hydrogen –
potassium
ATPase enzyme
system at the
secretory surface
of the gastric
parietal cells;
blocks the final
step of acid
production.
Short term treatment (up to 8 weeks) of gastric ulcer.
Healing of NSAID-related gastric ulcer.
Maintenance therapy for healing of erosive esophagitis, duodenal ulcers.
Dizziness
Headache
Nausea
Vomiting
Diarrhea
Contraindicated with
hypersensitivity to
lansoprozole or any
of its compartments.
1. Administer before meals.
2. Let the patient swallow the
capsule whole, not chew,open
or crush.
3. For NGT, place 15 or 30 mg
tablet and draw 4 – 10 ml of
water, shake gently for quick
dispersal.
4. Report severe headache,
worsening of symptoms, fever,
and chills.
5. Arrange to have a regular
medical follow – up care while
taking this drug.
Ecosta
20 mg, 1 tab
BID
Simvastatin Antihyperlipid
emic
HMG-CoA
Inhibits HMG-
CoA reductase,
the enzyme that
catalyzes the first
Adjunct to diet
in the
treatment of
elevated total
Nausea
Headache
Contraindicated with
allergy to simvastatin,
fungal byproducts.
1. Take drug in the evening.
2. Explain to patient not to
drink grapefruit juice while
Impaired gas exchange r/ t Ventilation perfusion imbalance specifically altered blood flow.Objective/s:
(+) Restlessness, (+) DOB, (+) Crackles, (+) Pallor, (+) Decreased, (+) Tachycardia, RR- 24 bpm, AR – 70 - 115 bpm, BP - 60/80 - 170/100 mmHg, O2
Sat. – 97 – 100%, O2 via nasal cannula at
3L/min.
Pulse Oximeter attached.
3. Infection r/t invasion of bacterial microorganism in the lungs
Objective/s:
Based on the Laboratory results:
Eosinophils 4.0% (0-3%), WBC 15.6x10^9/L (4.5 – 11.0 X 10 ^ 9/L), (+) whitish
productive cough, (+), Temperature. 37.9°C
2. Altered thermoregulation related to invasion of pathogens
Objective/s:Temp. 37.9 C, Skin warm toTouch, Weak inAppearance, WBC 15.6x10^9/L (N.V - 4.5-11.0),
Lymphocytes 0.01% (N.V - 20-45)
5. Impaired skin integrity r/t bed sores at the right buttock.
Objective/s:
(+) bed sore at the Right buttock (coccyx area), (+) Maculopapular rashes all over the body, (+) Dry and scaly skin, (+) Scratching of the skin, (+) Dirty nails,
untrimmed.
4. Ineffective peripheral perfusion r/t decreased arterial flow AEB decreased pulses, pale / cool feet, thick brittle nails.
Objective/s:(+) Paleness, (+) Weakness, (+) Pallor, (+) Cold clammy skin, (+) dry and chopped lips, (+) pale / cool feet, RR – 24 bpm, BP - 60/80 - 170/100 mmHg, P – 58 bmp, Blood Glucose – 11.52 mmol/L (4.10 – 5.90)
Direct HDLC - .58 mmol/L (1.00 – 1.60)
VLDL - 1.65 mmol/L (0.00 – 1.03)
LDL - 1.20 mmol/L (1.71 – 4.60)
HbAIc - -7.9 % (-4.2 – 6.2%)
Intake – 1056cc
Output – 745 cc
4.0% (0-3%)
WBC
15.6x10^9/L (4.5 – 11.0 X 10 ^ 9/L)
(+) whitish
productive cough
(+) Temperature.
– 37.9°C
CC: UnresponsivenessDx: t/c Stevens-Johnson
Syndrtome
I. NURSING MANAGEMENT
A. Concept Map of Nursing Problems
ASSESSMENT NURSING
DIAGNOSIS
PLANNING NURSING
INTERVENTION/S
RATIONALE NURSING
THEORIST/S
EVALUATION
Objective/s:
• (+) Restlessness
• (+) DOB
• (+) Crackles
• (+) Pallor
• (+) Decreased
• (+) Tachycardia
• RR- 24 bpm
• AR – 70 - 115 bpm
• BP - 60/80 - 170/100 mmHg
• O2 Sat. – 97 – 100%
• O2 via nasal cannula at 3L/min.
• Pulse Oximeter attached.
Impaired gas
exchange r/ t
Ventilation
perfusion
imbalance
specifically
altered blood
flow.
After 4 hours of
nursing intervention,
MRS. RA will have
decrease in difficulty
of breathing AEB
decrease RR.
Independent:
1. Position
MRS. RA in semi
fowler’s position and
change position every
2 hours
2. Provide back
tapping to MRS. RA.
3. Suction as
Indicated.
1. Lowers
diaphragm
promoting chest
expansion and
decrease pressure
on the abdomen
3. This will allow
mobilization and
expectorations of
secretions.
1. Clears airway
from
secretions.
Lydia Hall’s theory
of Care - Nurturance
Virginia
Henderson’s theory
of 14 Basic Needs
(Doing the for the
patient what they
cannot do for
themselves)
Faye Abdellah’s
theory of 21 Nursing
Problems (Doing the
for the patient what
they cannot do for
themselves)
Goal partially met.
After 4hours of
nursing intervention.
MRS. RA was able
to re-establish
normal breathing
pattern but some of
the secretions are
still present.
4. Note rate,
rhythm and
depth of
respiration.
Dependent:
1. Administer O2
therapy 3 L/min
2. Nebulization
1L/m with combivent
Collaborative:
2. The
respirations
become
shallow, and
the patient will
begin to
hypoventilate.
1. To relieve o2
deficit.
2. To loosen and
liquefy secretions.
Ernestine
Weidenback (Nurse
meets through
identification of
needs)
Dorothy Johnson’s
theory of Human
Behavioral System
(Medicine focus:
Cure)
Florence
Nightingale’s theory
of Environment
(Alleviate
unnecessary source
of pain and
suffering).
1. Monitor Pulse
oximeter for
oxygenation.
2. Monitor arterial
blood gases
and note
changes.
1. This tool is useful to detect changes in oxygenation. Oxygen saturation should be maintained at 90% or greater.
2. PaCO2 and PaO2 may fluctuate. These are the signs of respiratory failure.
Lydia Hall’s theory
of Components of
Nursing / Caring
(Core and Cure
-shared with other
health care
providers)
Lydia Hall’s theory
of Components of
Nursing / Caring
(Core and Cure
-shared with other
health care
providers)
ASSESSMENT NURSING
DIAGNOSIS
PLANNING NURSING
INTERVENTION
RATIONALE NURSING
THEORY AND
THEORIST
EVALUATION
Objective/S:
• Temp. 37.9 C
• Skin warm to
Touch
• Weak in
Appearance
• WBC result
15.6x10^9/L
(N.V - 4.5-11.0)
•• Lymphocytes L
0.01% (N.V - 20-
45)
Altered
thermoregulation
related to invasion
of pathogens
After 2 hours of
nursing
intervention, the
patient’s
temperature will
decrease from
37.9 C to 36.3 C
within the shift.
Independent:
1. Provide tepid
sponge bath.
2. Provide a cool
and calm
environment.
3. Monitor
patient’s
temperature
1. May help reduce
fever and provide
comfort.
2. Room
temperature/
number of
blankets should
be altered to
maintain near
normal body
temperature.
3. Temperature
elevation may
occur because of
Betty Neuman
(Help the client’s
system attain,
maintain and
regain system
stability.)
Betty Neuman
(On the whole
person and
reaction to stress.)
Betty Neuman
(Help the client’s
system attain,
maintain and
Goal met.
Temperature is
decreased from
37.9°C to 36.3°C
every hour.
Dependent:
1. Administer
Paracetamol
300 mg IV. (by
NOD)
various factors
such as presence
of infection.
1. To help reduce
fever by acting
directly on the
heat regulating
system
regain system
stability.)
Dorothy
Johnson’s theory
of Human
Behavioral System
(Medicine focus:
Cure)
ASSESSMENT NURSING
DIAGNOSIS
PLANNING INTERVENTION/S RATIONALE NURSING
THEORIST/S
EVALUATION
Objective/s:
Based on the
Laboratory results:
○ Eosinophils
4.0% (0-3%)
○ WBC
15.6x10^9/L (4.5 –
11.0 X 10 ^ 9/L)
• (+) whitish
productive cough
• (+)
Temperature.
– 37.9°C
Infection r/t invasion
of bacterial
microorganism in the
lungs
To prevent the
severity of infection
with the hospital
stay AEB by
decreased
temperature and
expelled mucus
secretions.
Independent:
1. Note for
physical evidence
of infection
2. Implement
appropriate
measures to protect
the patient from
potential infection
sources.
3. Monitor
heart rate and
blood
pressure.
1. Infections
must be treated to
stop the immune
response .
2. Hand washing
by all people in
contact with the
patient is the
primary method to
reduce the risk of
infection.
3. Th
ere is an
increase in
cardiac output
reflected by
tachycardia
and normal or
elevated BP.
Ernestine
Weidenback
(Nurse meets
through
identification of
needs)
Dorothea Orem’s
theory of Nursing
Concepts
(Identifies what
Nursing Care is
needed)
Ernestine
Weidenback
(Nurse meets
through
identification of
needs)
Ernestine
Goal Partially Met.
After 8 hours of
nursing intervention
MRS. R.A was able
to cough out mucus
secretions and her
temperature
decreased to
36.3 °C.
ASSESSMENT NURSING
DIAGNOSIS
PLANNING NURSING
INTERVENTION/S
RATIONALE NURSING
THEORIST/S
EVALUATION
Objective/s:
• (+) Paleness
• (+) Weakness
• (+) Pallor
• (+) Cold clammy skin.
• (+) dry and chopped lips
• (+) pale / cool feet
• RR – 24 bpm
• BP - 60/80 - 170/100 mmHg
• P – 58 bmp
• Blood Glucose – 11.52 mmol/L (4.10 – 5.90)
• Direct HDLC - .58 mmol/L (1.00 – 1.60)
Ineffective
peripheral
perfusion r/t
decreased
arterial flow AEB
decreased
pulses, pale /
cool feet, thick
brittle nails.
After 8 hours of
nursing
intervention, MRS.
RA will maintain
adequate level of
hydration to
maximize
perfusion, AEB
balanced intake /
output, moist skin /
mucous
membrane.
Independent:
1. Elevate feet
using pillow or
elevate the leg
part of the bed.
2. Note for
dehydration.
Monitor intake
and output.
3. OTF 200 cc of
Diben given
through patent
NGT.
Independent:
1. Minimize interruption of blood flow, reduces venous pooling.
2. Glycosuria may result in dehydration with consequent reduction of circulating volume and further impairment of peripheral circulation.
3. Antidiabetic diet.
Virginia
Henderson’s
theory of 14 Basic
Needs (Doing the
for the patient what
they cannot do for
themselves)
Ernestine
Weidenback
(Nurse meets
through
identification of
needs)
Ernestine
Weidenback
(Nurse meets
through
identification of
needs)
Goal partially met.
After 8 hours of
nursing
intervention. MRS.
RA was able to
maintain adequate
level of hydration
AEB Pulse – 90
bpm,
Intake – 1145cc
and Output of
1100cc.
• VLDL - 1.65 mmol/L (0.00 – 1.03)
• LDL - 1.20 mmol/L (1.71 – 4.60)
• HbAIc - -7.9 % (-4.2 – 6.2%)
• Intake – 1056cc
• Output – 745 cc
1. Administer
Simvastatin
Collaborative:
1. M
onitor Blood
Chemistry
Profile.
1. Antihyperlipidemic
1. To know the changes in the previous result.
Dorothy
Johnson’s theory
of Human
Behavioral System
(Medicine focus:
Cure)
Lydia Hall’s theory
of Components of
Nursing / Caring
(Core and Cure
-shared with other
health care
providers)
ASSESSMENT DIAGNOSIS PLANNING
NURSING
INTERVENTION RATIONALE
NURSING
THEORY AND
THEORIST
EVALUATION
Objective/s:
• (+) bed sore
at the Right
buttock
(coccyx area).
• (+)
Maculopapular
rashes all over
the body.
• (+) Dry and
scaly skin.
• (+) Scratching
of the skin.
• (+) Dirty nails,
untrimmed.
Impaired skin
integrity r/t bed
sores at the right
buttock.
To display timely
healing of bed
sores without
complications within
the hospital stay.
Independent:
1. Protec
t skin from
trauma and
prolonged
pressure.
2. Keep
the infected
area dry
always.
3. Note for
scratching
skin and of
keeping finger
nails short
and clean.
1, The poor
peripheral circulation
of PAD places the
patient at high risk for
injury.
1. To prevent
infections.
2. Scratching can
cause lesions and open
sores.
3. Mittens prevent
excessive
scratching.
Ernestine
Weidenback
(Nurse meets
through
identification of
needs)
Betty Neuman
(Help the client’s
system attain,
maintain and regain
system stability.)
Ernestine
Weidenback
(Nurse meets
through
identification of
needs)
Betty Neuman
(Help the client’s
system attain,
Goal Partially met.
After 8 hours of
Nursing
intervention,
affected area is
maintained dry and
cleaned. Bed sores
is still noted.
4. Put mittens
on hands if
necessary.
5. Note the
patient’s
ability to
move.
6. Position
patient on the
non infected
area.
4. Immobility is greater
risk for skin
breakdown.
5. To avoid pressure
on affected area
causing for the
severity.
maintain and regain
system stability.)
Ernestine
Weidenback
(Nurse meets
through
identification of
needs)
Betty Neuman
(Help the client’s
system attain,
maintain and regain
system stability.)
I. DISCHARGE PLANNING
M – edications
Medications prescribed by the physician should be taken properly, to help the patient
lessen unusual condition. (MRS. RA is still admitted in the hospital)
E – xercise and Activity
Encourage folks to help MRS. RA to have an active range of motion exercises thrice
daily to maintain her muscle strength.
Get plenty of rest. Adequate rest is important to maintain progress toward full recovery
and to avoid relapse.
T – reatment
Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed.
Treatment is one of the main factors in restoration of health and curing of the failure in the body system. Treatments are given to the patient for a specific time until treatment is not more needed by the patient.
H – ome Teaching/s
Encourage the folks to wash patient’s hands. The hands come in daily contact with germs that can cause infections. These germs enter one’s body when he touch his eyes or rub his nose. Washing hands thoroughly and often can help reduce the risk.
Tell folks to avoid exposing the patient to an environment with too much pollution (e.g. smoke). Smoking damages one’s lungs’ natural defenses against respiratory infections.
O – ut patient follow up
Keep all of follow-up appointments, even though the patient feels better. It’s important to have the doctor monitor his progress.
D – iet
Drink 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 the level of her blood pressure but to eat more green and leafy
vegetables.
S – pirituality and Sexuality
In order to improve her spiritual aspects, he may attend holy masses or listen to gospel readings
and pray the holy rosary or she may seek for divine providence to the Lord. Assist the patient
that may include spiritual resources to help her deal with it.
XIV.BIBLIOGRAPHY / REFERENCES
• Nursing Care Plan Diagnosis and Interventions 8th Ed
By: Gulanick and Myers
• Nursing Diagnosis Handbook A Guide for Planning Care 7th Ed.
By: Betty J. Ackley and Gail b. Ladwig
• Drug Information Handbook for Nursing 2nd Ed.
By: Lilley, Harrington and Snyder
• MIMS 2008 - 2009 Ed.
• Professional Guide to Pathophysiology 2nd Ed.
By: Kozier and Erbs
