Nursing Care Plan Stevens Johnson Syndrome

February 18, 2011

Assessment

a. Subjective Data

  • Client said high fever, malaise, headache, cough, runny nose, and sore throat / difficulty in swallowing.

b. Objective Data
  • Skin erythema, papules, vesicles, bull fragile so that erosion is a widespread, often obtained purpura.
  • Black and thick crust on the lips or mucous membranes, stomatitis and pseudomembrane in the pharynx.
  • Conjunctiva, corneal ulcer bleeding sembefalon, iritis and iridosiklitis.

c. Supporting Data
  • Lab: leukocytosis or esosinefilia
  • Histopathology : mononuclear cell infiltrates, edema and extravasation of red blood cells, degeneration of the basal layer, epidermal cell necrosis, spongiosis and intracellular edema in the epidermis.
  • Immunology: deposis IgM and C3 and there is immune complex containing IgG, IgM, IgA.

Nursing Diagnosis and Nursing Intervention
  1. Impaired sense of comfort, fever, headache, throat related to a bull.
  2. Goal : Clients feel comfortable in a 2 x 24 hours Results Criteria :
    • Pain is reduced / lost
    • Relaxed face expression
    Intervention :
    • Give a cold compress
    • Provide a thin clothing of absorbing material
    • Avoid skin lesions of manipulation and pressure
    • Keep the patient can rest 7-8 hours a day.
    • Monitor fluid balance
    • Monitor temperature and pulse every 2 hours
  3. Fulfillment of nutritional disorders: Less than body requirements related to the difficulty in swallowing.
  4. Goal : Nutritional needs are met during treatment Result Criteria :
    • There are no signs of dehydration
    • Diet provided exhausted
    • Results of serum electrolytes within normal limits
    Intervention
    • Assess client's ability to swallow food
    • Give a liquid diet
    • Explain to the client and family about the importance of nutrition for healing clients
    • Monitoring fluid balance
    • Assess for signs of dehydration and disruption elekrolit
    • If necessary collaboration for the installation of NGT

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