Nursing Care Plan Stevens Johnson Syndrome

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.
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
2. Fulfillment of nutritional disorders: Less than body requirements related to the difficulty in swallowing.
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