Nursing Diagnosis and Nursing Interventions

Nursing Diagnosis and Interventions for Stevens Johnson Syndrome - SJS

Stevens–Johnson syndrome, a form of toxic epidermal necrolysis, is a life-threatening skin condition, in which cell death causes the epidermis to separate from the dermis. The syndrome is thought to be a hypersensitivity complex that affects the skin and the mucous membranes. The most well-known causes are certain medications, but it can also be due to infections, or more rarely, cancers.

SJS usually begins with fever, sore throat, and fatigue, which is commonly misdiagnosed and therefore treated with antibiotics. Ulcers and other lesions begin to appear in the mucous membranes, almost always in the mouth and lips, but also in the genital and anal regions. Those in the mouth are usually extremely painful and reduce the patient's ability to eat or drink. Conjunctivitis of the eyes occurs in about 30% of children who develop SJS. A rash of round lesions about an inch across arises on the face, trunk, arms and legs, and soles of the feet, but usually not the scalp.

Nursing Diagnosis and Interventions for Stevens Johnson Syndrome - SJS

Nursing Diagnosis 1.

Impaired skin integrity related to inflammatory dermal and epidermal

Expected Outcomes:

Shows the skin and skin tissue intact.

Intervention:

1. Observation of skin turgor circulation daily notes and sensory as well as other changes that occur.
Rational: determining a baseline by which changes in status can be compared and appropriate intervention

2. Use a thin clothing and soft loom.
Rational: reduce irritation and pressure from the suture line of clothes, leave the incision open to air increases the healing process and reduce the risk of infection

3. Keep loom is used.
Rationale: to prevent infection


Nursing Diagnosis 2.

Imbalanced Nutrition Less Than Body Requirements related to difficulty swallowing

Expected Outcomes:

Demonstrate stable weight / weight gain

Intervention:

1. Assess food habits are preferred / not preferred.
Rational: give the patient / significant others a sense of control, increasing participation in treatment and may improve revenue

2. Give portions to eat little but often.
Rational: helps prevent gastric distension / discomfort

3. Serve in warm food.
Rationale: increased appetite

4. Collaboration with a dietitian.
Rational: calories, protein and vitamins to meet the increased metabolic demands, maintain weight and promote tissue regeneration.


Nursing Diagnosis 3.

Acute pain related to inflammation of the skin

Expected Outcomes:
  • Reported reduced pain
  • Facial expressions / body posture relaxed

Intervention:

1. Assess complaints of pain, note the location and intensity.
Rational: pain is almost always present in some degree of severity of tissue involvement

2. Provide basic comfort measures ex: massage at an area hospital.
Rational: increase relaxation, reduce muscle tension and general fatigue

3. Monitor vital signs.
Rational: IV method is often used in early to maximize the effects of the drug

4. Give analgesics as indicated.
Rational: to relieve pain
.

Nursing Diagnosis 4


Activity Intolerancerelated to physical weakness

Expected Outcomes:

  • Clients reported increased activity tolerance
Intervention:

1. Assess the individual response to the activity.
Rational: determine the level of the individual's ability to fulfill their daily activities.

2. Assist clients in meeting their daily activities with the limitations of the client.
Rational: the energy expended is more optimal

3. Explain the importance of energy restriction.
Rational: vital energy to help the body's metabolic processes

4. Involve the family in fulfilling client's activities.
Rationale: The client has the support of family psychology.

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Nursing Diagnosis - Nursing Interventions

NANDA NURSING

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