INTRODUCTION

1
 Drugs refer to substances widely used for treating diseases. Most therapeutic

regimens rely on the action of certain medicines. And that is a fact. But the common

people tend to overuse or misuse these aids not knowing that these practices may also

cause harm. And without proper guidance from a doctor or from any health specialist, do

these people aware themselves that frequent and improper drug use may also cause

disorders instead of fighting them? Now that’s the question.

Stevens - Johnson syndrome for instance; a type of a potentially fatal skin disorder

is thought to result from drug-related reaction involving antibiotics, sulfonamides,

antiseizure agents, NSAIDs and sulfonamides. According to research, it is a rare serious

disorder in which your skin and mucous membranes react severely to a medication or

infection and begins with flu-like symptoms, followed by a painful red or purplish rash

that spreads and blisters, eventually causing the top layer of your skin to die and shed.

Incidence ranges from 1.2 to 6 cases per million per year; the condition is fatal in 5% of

treated cases and in 15% of untreated cases. The mortality rate range from 30%-35%

affecting all ages and occur earlier in men than in women. (Brunner & Suddarth, 2008)

This is the case of Joana Ellah Encarquez, 4 years of age, admitted at Davao

Oriental Provincial Hospital and was diagnosed with hypersensitivity reaction t/c Stevens-

Johnson Syndrome.

To assist us student nurses as well as other health related practitioners in dealing

with the disease and to come up with the appropriate nursing care interventions, it is of

great need to immerse deeper into the attributes and pathology of the said disease. Thus

this study shall be presented.

2
OBJECTIVES

3
General Objectives:

In general, this study aims to provide a brief and concise presentation and

discussion on the disease process- Stevens-Johnson syndrome.

Specific Objectives:

Specifically, this study aims:

 To establish good interpersonal relationship with the patient as well as with the

client’s significant others to cater trust and cooperation.

 To provide a potential case subjected for study and presentation.

 To formulate specific, measurable and attainable objectives.

 To understand and provide a comprehensive definition of the disease process.

 To elaborate the anatomy and physiology involved in the disease process.

 To explain and give clarity to the pathophysiology of the disease.

 To identify the appropriate medical and nursing management for the disease.

4
 PATIENTS DATA

A. BIOGRAPHIC DATA

5
 Name: Encarquez, Joana Ellah

Room number: 107

Wad: Pedia Ward

Address: P-8 Mamacho, Libudon, mati Davao oriental

Birth Date: July 2, 2004

Age: 4 y/o

Gender: Female

Civil status: child

Religion: Roman Catholic

Father’s name: Noel Encarquez

Mother’s name: Winnie Encarquez

Attending physician: Kristine Faith Franco, MD

Source of medicare: none

Weight : 16kg

B. CLINICAL DATA

Date and time of admission: April 20, 2009 at 6:15 am

Chief complaint: cough, fever, rashes

Admission diagnosis: hypersensitivity reaction t/c Steven-Johnson Syndrome

Final diagnosis: hypersensitivity reaction t/c Steven-Johnson Syndrome

6
 HEALTH STATUS

Past and Present Health History:

The group’s patient Joana Ellah Encarguez, a four-year old girl was born via

Normal Spontaneous Vaginal Delivery (NSVD). She is the fourth child among the five

7
siblings of Mr. Noel Encarquez & Mrs. Winnie Encarquez, residents of P-8 Mamacho,

Libudon, Mati Davao Oriental.

In an interview, the child’s mother claimed that Joana is the sickliest child among

her children. She easily gets cough and fever especially during bad weather. Her mother

shared that at the age of 3 years old; Joana Ellah was admitted at Davao Oriental

Provincial Hospital (DOPH) due to Pneumonia. She added that Cotrimoxazole was the

drug ordered by the doctor as part of the treatment regimen. After hospitalization,

whenever Joana suffers cough and fever, she is brought to the nearest health center

wherein she is given Contrimoxazole consequently until buying it had become a practice

of the mother in treating the child’s recurrent condition.

After self medicating, Joanna experienced intermittent fever and cough and

afterwards developed rashes. Despite this condition, her parents did not bring her

immediately to the hospital, thinking it will be relieved by taking the medication. As her

condition worsens, the rash grows in number and was confined to the chest area of the

body and eventually spread to other areas. It developed into typical lesions that have the

appearance of a bull's eye target.

Last April 19, 2009, they decided to admit Joanna Ella in Davao Oriental

Provincial Hospital due to fever, cough and worsening rashes that she had. When

interviewed by the doctor, they later knew that it was the drug that has been persistently

used and was identified as the reason of Joanna’s condition.

8
9
 COMPREHENSIVE DEFINITION

OF THE DISEASE

Complete Definition of the Diagnosis

Diagnosis: Hypersensitivity t/c Stevens-Johnson Syndrome

Hypersensitivity:

Abnormal condition characterized by an exaggerated response of the immune

system to an antigen. It is also often called as allergen. There are four types of

hypersensitivity but prior to Stevens-Johnson Syndrome, it is classify as type III. A type

III or immunocomplex-mediated hypersensitivity reaction is a local or general

inflammatory response caused by formation of circulating antigen-antibody complexes

10
and their disposition in tissues. (MOSBY’S POCKET DICTIONARY of Medicine,

Nursing and Health Professsions 5thedition. MOSBY elsevier. Page 669-670)

Stevens-Johnson:

The name of the disease was derived from Dr. Albert Mason Stevens and Dr.

Frank Chambliss Johnson, American pediatricians who jointly published a description of

the disorder in 1922. (http://www.mayoclinic.com/health/stevens-johnson-

syndrome/DS00940)

Stevens-Johnson Syndrome was initially described by Stevens and Johnson in

1922 following a chance encounter with two young boys (aged seven and eight) who were

suffering from a mysterious skin disease. Stevens and Johnson described the boys'

condition as "extraordinary." The boys showed signs of inflamed buccal mucosa (mucous

lining of the cheeks) and severely puss-filled eyeballs (purulent conjunctivitis) in addition

to generalized skin lesions that are now commonly associated with Stevens-Johnson

Syndrome. (http://www.mediafact.com/sjs/history.php)

Syndrome:

• refers to the association of several clinically recognizable features, signs

(observed by a physician), symptoms (reported by the patient), phenomena

or characteristics that often occur together, so that the presence of one

feature alerts the physician to the presence of the others.

(http://en.wikipedia.org/wiki/Syndrome)

Stevens-Johnson syndrome-

11
 • is a rare, serious disorder in which your skin and mucous membranes react

severely to a medication or infection.

• begins with flu-like symptoms, followed by a painful red or purplish rash

that spreads and blisters, eventually causing the top layer of your skin to

die and shed.

• is a life-threatening condition affecting the skin in which cell death causes

the epidermis to separate from the dermis.

• is thought to be a hypersensitivity complex affecting the skin and the

mucous membranes

http://www.mayoclinic.com/health/stevens-johnson-syndrome/DS00940

Stevens-Johnson Syndrome

Images of the Disease:

12
 Stevens Johnson Syndrome is a serious disorder that affects the skin and mucous

membranes. It is a life-threatening condition affecting the skin in which cell death causes

the epidermis to separate from the dermis. It is known medically as an immune-complex-

mediated hypersensitivity (allergic reaction), that is a severe form of a lesser type of

hypersensitivity called erythema multiforme and a more severe type of hypersensitivity

called toxic epidermal necrolysis. SJS is typically caused by an underlying infection or

malignancy, or by an allergic reaction to a drug. The syndrome is thought to be a

hypersensitivity complex affecting the skin and the mucous membranes. Although the

majority of cases are idiopathic, the main class of known causes is medications, followed

by infections and (rarely) cancers. Currently, there are no SJS treatment methods in place

capable of stopping the progression of the disease.

13
 Distinctions of Charateristics:

Manifestations: Erythema Multiforme Stevens-Johnson Toxic Epidermal

Syndrome Necrolysis
Primary Lesion Round, erythematous Enlarged and coalesce, Large, flaccid bullae

papule, resembling an insect producing small plaques appear, followed by

bite. and appears as “target” denuded dermis.

or “iris” lesions.
Lesions’ Confined in chest and back Wide distribution of Large denuded area in the

location area lesions over body surface body.

area.
Diagnostic Occur after herpes simplex Involvement of less than Detachment of more than

Boundary infection and self-limiting. 10% of the body surface. 30% of the epidermis.

14
 ANATOMY AND PHYSIOLOGY

Integumentary System:

15
Skin is the largest organ of the body.

The skin consists of layers: the epidermis, the dermis and the subcutaneous layer.

Functions of the skin:

1. Physical barrier against friction and shearing forces.

2. Protection against infection, chemicals, ultraviolet irradiation, particles.

3. Prevention of excessive water loss or absorption.

4. Ultraviolet induced synthesis of vitamin D.

5. Temperature regulation.

16
5. Sensation (pain, touch and temperature).

6. Temperature regulation.

7. Antigen presentation/immunological reactions/wound healing.

The epidermis – the top most layer of skin is only 0.1 to 1.5 millimeters thick. It is made

up of five layers: the basal cell layer, the squamous cell layer, the stratum granulosum, the

stratum lucidum, and the stratum corneum. Working together, these layers continually

rebuild the surface of the skin from within, maintaining the skin’s strength and helping

thwart wear and tear.

 basal cell layer – the innermost layer of the epidermis. This layer houses small

round cells called basal cells. These cells constantly divide, with

the new cells constantly pushing older ones on a migration

toward the surface of the skin. The basal cell layer is also called

the stratum germinativum because it is constantly producing, or

germinating, new cells.

 squamous cell layer – just above the basal cell layer, also called the stratum

spinosum or “spiny layer” because the cells are held together

with spiny projections. Here lie the basal cells that have been

pushed upward; these maturing cells are now called squamous

cells, or keratinocytes. They have begun to produce keratin, a

tough, protective protein that makes up a large part of the

structure of the skin, hair, and nails. The squamous cell layer is

the thickest layer of the epidermis. This is the layer of the skin

17
 that helps to move certain substances in and out of the body; it’s

also where blisters form when the skin is chafed. The squamous

cell layer also contains cells called Langerhans cells, if the skin

becomes damaged, these cells latch onto invading antigens,

substances that are foreign to the body, and alert the immune

system to their presence.

 Stratum granulosum and the stratum lucidum – a two thin epidermal layers

where the keratinocytes from the squamous layer are pushed up.

As the cells migrate, they enlarge, flatten, and bond together,

then eventually become dehydrated and die. The process fuses

the cells into layers of tough, durable material, which continue

to rise toward the skin’s surface.

 Stratum corneum, - the outermost, visible layer of the epidermis. The stratum

corneum (or “horny layer,” because its cells are toughened like

an animal’s horn) is made up of 10 to 30 thin layers of these

dead cells. External pressure or friction can cause thickened

areas in the stratum corneum known as corns or calluses.

As the outermost cells give way to wear and tear, they are re-

placed from within by new layers of strong, long-wearing cells.

In the average adult, it takes nearly a month for the stratum

corneum to be completely replaced. The replacement process

generally slows with age, though in some people it becomes

abnormally accelerated, causing a flaky, scaly skin condition

known as psoriasis.

18
The dermis – which lies (just beneath the epidermis, is I .5 to 4 millimeters thick-the

thickest of the three layers of the skin. the main components of the dermis are collagen

and elastin. Collagen is a tough, insoluble protein found throughout the body in the

connective tissues that hold muscles and organs in place. In the skin, collagen supports the

epidermis, lending it its durability. Elastin, a similar protein, keeps the skin flexible. This

is the substance that allows the skin to spring back into place when stretched. It is home

of:

 Sweat and oil glands (sebaceous) - which secrete substances through openings in

the skin called pores, or comedos. Oil glands secretes oil which helps keep skin

waterproof and protects against an overgrowth of bacteria and fungi on the skin.

Sweat glands, numbering about 3 million in the average person, are the most

numerous and are classified according to two types: the apocrine glands and the

eccrine glands. Apocrine glands are specialized sweat glands that can be found

only in the armpits and pubic region. The eccrine glands are the true sweat glands

which are found over the entire body. These glands regulate body temperature by

bringing water via the pores to the surface of the skin, where it evaporates and

releases heat. These glands respond to heat, exercise, and fever, and some eccrine

glands, such as those on the palms, respond to emotional stress, as well.

 Hair follicles – cylindrical structures that house the roots of the hair.

 Nerve endings – these structures are responsible for the sense of touch, relaying

information to the brain for interpretation. They also signal temperature to the

brain and, if necessary, trigger shivering, an involuntary contraction and relaxation

of muscles. This muscle activity generates body heat.

19
  Blood and lymph nodes – bring nutrients and oxygen to the skin and remove cell

waste and cell products and also carry the vitamin D produced in the skin back to

the rest of the body. Enlarged vessels that can be seen through the skin are known

as spider veins or varicose veins. Broken blood vessels appear as bruises. The

lymph vessels bathe the tissues of the skin with lymph, a milky substance that

contains infection-fighting immune system cells.

 Scavenger cells - In the event that a foreign organism makes it past the epidermis,

these cells will engulf and destroy it

Subcutaneous tissue (hypodermis) – is the deepest layer of the skin. It is missing on

parts of the body where the skin is especially thin-

the eyelids, nipples, genitals, and shins.

Subcutaneous tissue acts both as an insulator,

conserving body heat, and as a shock absorber,

protecting internal organs from injury. It also

stores fat as an energy reserve in the event extra

calories are needed to power the body. The blood

vessels, nerves, lymph vessels, and hair follicles

also cross through this layer.

20
 Pathophysiology

Etiology

Predisposing Factors:

Predisposing Factors Rationale

21
 Most often, patients affected with this disease are in the second

Age to fourth decade of their lives during which they are exposed to

frequent use of drugs or medications. But, the illness could

occur at all ages.

Genes Carrying a gene called HLA-B12 may make you more

susceptible to Stevens-Johnson syndrome.

Gender There is a ratio of 2:1 between male and female sexes. Males are

more sexually active than females and tend to practice multiple

sexual relationships; thus they are prone to develop sexually

transmitted diseases that consequently suppress the immune

system.

Precipitating Factors:

Precipitating Factors Rationale

Medications Several different types of hypersensitivity reactions to

1. sulfa drugs medications can occur and varied from person to person

2. antibiotic depending on the hypersensitivity of an individual. Reactions to

3. anti-epileptic drugs range from a mild localized rash to serious effects on

4. NSAIDS vital systems. The body's response can affect many organ

22
 systems, but the skin is the organ most frequently involved.

Symptomatology

Rationale

23
1. Conjuctival
The eyelids and the conjunctivae are the ones easily
burning or itching
affected in an allergic reaction.

2. Cutaneous Cutaneous tenderness is manifested because of the

Tenderness shedding of its layer seperating from the dermis layer of

the skin.

3. Fever Fever occurs because of the release of Cytokines and

other chemical mediator.

4. Cough Cough is present that might be an indication that the

epithelial cells lining the respiratory pathway are

sloughing that trigger reflexes.

5. Headache Headache is due to prostaglandin synthesis.

6. Malaise Malaise would be manifested because patient with SJS

continuously losses its fluid content in the body and

epidermal necrosis and epithelial and mucosal sloughing

increase metabolic needs during the pus cells.

Detachment of epidermis from the papillary dermis at

7. Large Sheets of the epidermal-dermal junction manifesting as a

epidermis are shedding papillomacular rash and bullae as a result of

24
 keratinocyte apoptosis.

8. Skin Blisters Shifting of fluids from the vascular compartment to the

epidermal layer.

Narrative Report

Exact mechanism is unknown, however one theory holds that altered drug

metabolism in some patients causes formation of reactive metabolites that binds to and

alter the cell proteins, triggering the T-cell mediated cytotoxic reaction to drug antigens in

keratinocytes. The medications like antibiotics, antiepileptic, sulfa drugs, and NSAIDS are

included in the list to cause Stevens - Johnson syndrome. The exact mechanisms in its

drug were definite in action and varied some cases.

25
 Antibacterial sulfonamides for example, target a bacterial metabolite pathway as

competitive inhibitors of the enzyme dihydropteroate synthetase. This enzyme is very vital

in the synthesis of folate, and folate is required for cells to synthesize nucleic acids, such

as DNA or RNA. So if the DNA molecules cannot be built, the cell cannot divide and the

effect is bacteriostatic rather than bactericidal. Sulfa drugs do not cause the same

disruption in animal cells, because our cells do not synthesize folate.

Another mechanism according to some research studies conducted by several

experts, the Fas and its ligand plays an important role through which the occurrence of the

syndrome process exists. FasL is a type II trans-membrane protein. Fas ligand is a

homotrimeic protein and signals through trimerization of Fas, which spans the membrane

of the target cell which usually lead to apoptosis, or cell death. Fas ligand-receptor

interactions play an important role in the regulation of the immune system .

Predisposing to the Stevens - Johnson syndrome are the age, sex and the gene.

Older people are more susceptible to the syndrome since they take more drugs and have

the accumulation of its metabolites to cause drug reactions than children. The sexes are

also controversial issue in acquiring the syndrome. According to some expert, men are

twice the ratio of having the condition than women. Men are more sexually active and

more susceptible in acquiring sexually transmitted disease and this factor can cause the

declination in the strength of immune system and resistance against any diseases. The

gene is also a predisposing factor. Those who inherit the dominant HLA alleles disorder

that thought to have cause on the altered drug metabolism in the body.

26
 After the Fas will bind to its ligand, this signals the cells that apoptosis will be in

progress and is a part of the disease process. The cell component especially the membrane

will become necrotic and the cell protein will become altered. The manifestation will be in

drastic point to have epidermal necrolysis, and epithelial cells will be sloughing. The dead

skin cells of epidermis will separate exposing the dermis layer of the skin. The condition

will also trigger the release of T-cell mediated cytotoxic reaction alarmed by the

Langerhan cells in keratinocytes of the skin to the immune system. This can cause

inflammation of the skin and there is extra vascular shifting of the fluids that will form

multiform erythema and blisters. The appearance of redness also occurs due to the

exposed dermis in which blood vessels are situated.

If the condition persists leading to a severe condition, keratoconjunctivitis,

burning, drying, and ithching occurs. Corneal ulceration might also lead to blurring of

vision and blindness. Sloughing of the epithelial cells lining the respiratory system will

cause sore throat and eruption of the lining mucosa. Gastrointestinal sloughing and almost

all of the alimentary canal may also be damaged because it is lined with epithelial cells.

Coughing and other reflexes in nasopharynx and other respiratory organs will be triggered.

Epistaxis due to mucosal damage will be manifested. The patient acquiring this condition

is susceptible to have pneumonia which may lead to respiratory failure.

The release of cytokines and other chemical mediators such as prostaglandin were

thought to cause fever, headache, and pain on the skin layers. The superficial layer of the

skin contains numerous numbers of nociceptors and chemical mediators that are mostly

27
algogenic. Extreme fatigue and fluid losses is prominent because of the sloughing and

apoptotic process which increase metabolic and caloric needs.

Stevens-Johnson syndrome, although rare due to the above mentioned causes, is a

fatal type of skin disorder that must be given greater attention to save the life of the

affected patient.

28
 SCHEMATIC DIAGRAM

Predisposing Factors: Precipitating Factors:

• AGE • MEDICATIONS
• SEX -Sulfonamides
• GENES -Antibiotics
-Antiepileptic
Altered Drug -NSAIDS
metabolism

Formation of Drug Metabolites

And binding of Fas ligand with its
receptor

Bind to and alter the cell protein

Epidermal Necrolysis Trigger a T-cell mediated Release of

Cytotoxic reaction to drugs Cytokines and
In keratinocytes other chemical
mediators

Sloughing of the Keratoconjunctivitis Increased

epithelial cells lining Metabolic needs Fluid shifting Fever Pain Headache
the respiratory Epidermal from the vascular
pathways Shedding Corneal compartment
ulceration to the epidermis

29
 Blindness Extreme Blisters occur
Fatigue
Pneumonia Epistaxis

Inflammation

Coughing

30
31
 MEDICAL MANAGEMENT

The goals of the treatment include control of fluid and electrolyte balance, prevention of

sepsis, and prevention of ophthalmic complications. Supportive care is the mainstay of treatment.

All nonessential medications are discontinued immediately. If possible, the patient is treated in a

regional burn center, because aggressive treatment similar to that for severe burns is required.

Skin loss may approach 100% of the total body surface area. Surgical debridement or

hydrotherapy may be performed to remove involved skin.

Treatment is initially similar to that of patients with thermal burns, and continued care

can only be supportive (e.g. IV fluids) and symptomatic (e.g. analgesic mouth rinse for mouth

ulcer); there is no specific drug treatment (2002). Use of topical pain anesthetics and antiseptics

as well as maintaining a warm environment are also indicated.

Every attempt should be made to identify a precipitating agent, and to remove it if

possible. Antibiotics are appropriate if superinfection (a fresh infection added to one of the same

nature already present) is suspected, or if bacterial disease, such as mycoplasma, is suspected to

be the cause. Intensive supportive care is important in severe cases, including specialized care in

a burn unit.

Fluid replacement is often required, and meticulous oral hygiene is necessary to prevent

super infection. Examination by an ophthalmologist is recommended for patients with eye

lesions so that precautions can be taken to avoid permanent eye damage. Oral and topical

corticosteroids are often used.

32
 DRUG STUDY

GENERIC BRAND CLASSIFICA INDICATION CONTRAINDICATI ADVERSE ACTIONS HEALTH TEACHING

NAME NAME TION ON REACTION

Ceftriaxone Rocephin Antibiotic Serious Contraindicated in Dizinness, fever, Hinders or kills • Tell patient to

Na infections of patients headache, susceptible promptly

lower hypersensitive to diarrhea, nausea, bacteria, inhibit repot adverse

respiratory and drug or other phlebitis, rash, cell-wall reactions and

urinary tracts cephalosporin hypersensitivity synthesis signs and

reactions, pain, symptoms of

Skin infections duration and super

tenderness at infection

injection site. • Instruct

patient to

report pain at

1
 the IV site.

• Tell patient to

notify

proscriber if

loose stools or

diarrhea

occurs.

GENERIC BRAND CLASSIFICA INDICATION CONTRAINDICATI ADVERSE ACTIONS HEALTH TEACHING

2
NAME NAME TION ON REACTION

Amikacin Amikin Antibiotic Short term Contraindicated in Ototoxicity, Inhibits protein • Instruct

Sulfate (aminoglyco treatment of patients apnea, synthesis by patient to

sides) serious hypersensitive to hypotension binding directly promptly

infections due drug or other to the 30s report adverse

to susceptible aminoglycosides ribosomal reactions to

gram negative subunit; prescriber

strains bactericidal • Encourage

Maybe of use in patient to

the treatment of maintain

brown or adequate fluid

suspected intake.

staphyloccal

disease.

3
GENERIC BRAND CLASSIFICATION INDICATION CONTRAINDI ADVERSE ACTIONS HEALTH TEACHING

NAME NAME CATION REACTION

Mupirocin Bactrobon Topical anti- Treatment of Inhibits • Tell patient to

cream infectives primary and Hypersensitivi Burning bacterial notify prescriber

secondary skin ty sensation, protein immediately if

infections due to itching, synthesis condition doesn’t

susceptible erythema by improve or gets

organisms; and dryness reversibly worse in 3-5 days

prevention of localized to and • Tell patient not to

contamination of area of specificall use other nasal

small cuts, application y binding products with

wounds, to mupirocin

abrasions, bacterial • Warn patient

incisions and isoleucyl about local

other lesions transfer- adverse reactions

4
RNA related to drug

synthesis use.

5
GENERIC NAME BRAND CLASSIFICATI INDICATION CONTRAINDI ADVERSE ACTIONS HEALTH TEACHING

NAME ON CATION REACTION

Ceftriaxone Rocephin Anti-infective Treatment of skin Hypersensitivi Seizures, Binds to the • Instruct patient to

and skin structure ty, inborns diarrhea, cell wall take medication at

infections, bone errors of vomiting, membrane, evenly spaced

and joint metabolism nausea, causing cell times and to finish

infections, cramps death , the medication

urinary and completely, even

gynecologic if feeling better.

infections or • Advise patient to

respiratory tract report signs of

infections. superinfection or

discharge.

6
GENERIC BRAND CLASSIFICATIO INDICATION CONTRAINDICA ADVERSE ACTIONS HEALTH TEACHING

NAME NAME N TION REACTION

Acetamino Paraceta- Antipyretic; Mild pain or Contraindicated Hematolo-gic: Inhibits the 1. Many OTC and
phen mol nonopioid fever in patients with Hemolytic prostaglandins prescri-ption products
analgesics history of anemia thatmay serve as the contain aceta-minophen;
osteoarthritis chronic alcohol mediators of pain and be aware of this when
abuse because Hepatic: fever, primarily, in ths calculating total daily
hepatoxicity Jaundice CNS. Have no dose.
occur after significant anti- 2. Use liquid form for
therapeutic Metabolic: inflammatory children and patients
doses. Hypoglycemia properties. who have difficulty
swallowing.
Skin: Rash, 3.In children, don’t
urticaria exceed five doses in 24
hours.

7
GENERIC BRAND CLASSIFICATIO INDICATION CONTR ADVERSE ACTIONS HEALTH TEACHING

NAME NAME N AINDIC REACTION

ATION

Albuterol Salbutamol Bronchodilators Used as a Hyperse Nervousnes Decreased • Instruct patoent to

bronchodilators to nsitivity s, intracellular take albuterol exactly as

control and restlessnes, calcium directed.

prevent reversible headsche, relaxes • Instruct patient to

airway insomnia, smooth contact health care

obstruction chest pain. muscle professional

caused by asthma airways. immediately if shortness

or COPD. Relaxation of breath is not relieved

Inhaln: Used as a of airway by medication or is

quick-relief agent smooth accompanied by

for acute muscle with diaphoresis, dizziness,

bronchospasm. subsequent palpitations or chest

8
bronchodilati pain.

on.

9
1
 NURSING CARE AND MANAGEMENT

The following table describes the major areas of focus for nursing:

Organ/System Nursing Care

Eye Meticulous eye care including saline rinses and proper lubrication (as often as q 1-2

hours).
Lungs Sore throat or pharyngitis are seen early with SJS patients, mucosal sloughing occurs

and intubation is often required. ET tube care and frequent suctioning required.
GI Tract Mucosal sloughing can occur at the lips, mouth esophagus, stomach and rectum.

Antacids, early nutritional support (prevents negative nitrogen balance and promotes

wound healing). TPN for those who cannot tolerate oral or enteral feeding.
GU Tract Mucosal sloughing leads to UTI are in 37% of patients and renal failure in 17%. Foley

and close monitoring of I&O.

Skin Proper wound care and dressing changes BID and PRN. Assure adequate pain

management during wound and skin care. Be sure to avoid hypothermia during wound

care. Warmed IV’s and heat lamps may help.

Metabolic Aggressively treat and maintain fluid and electrolyte balance.
Immune Strict adherence of hand hygiene and other infection control procedures. Culture all

purulent drainage.
Neuropsych Anxiety, depression and altered body image must be assessed for and treated promptly
and often.

2
NURSING CARE PLAN

Name: Encarquez, Joana Ellah Civil Status: Child Date of Admission: 4/19/09
Age: 4y/o Room #: 107 Chief Complaint: cough, fever, rashes;
hypersensitivity t/c Steven-Johnsons Syndrome
Attending Physician : Dr. Kristine Faith R. Franco, MD

PROBLEM SCIENTIFIC GOAL / NURSING INTEVENTIONS EVALUATION

BASIS OBJECTIVE WITH RATIONALE

GOAL MET

4/ 20/09 At the end of my 8 • Establish rapport with the At the end of my 8 hour

11-7 hour span of care, child to gain cooperation span of care, my patient

S- “Gikalintura na my patient will be: • Instruct folks to increase was able to:

pud siya, nurse” as • able to oral fluid intake to promote • maintain

verbalized by the maintain hydration temperature

patient’s mother temperature • Monitor vital signs, to within normal

OBJECTIVES: within supervise client progress range as

• increased normal • Keep environment clean and evidenced by

temperature range comfortable. temperature of

of (38.10C) • appear • Promote surface cooling by 36.8’ C.

3
 • warm to relaxed and means of removing • appear relaxed

touch rested (eg. unnecessary clothes, and rested as

• weakness Sleeping) because of heat loss by evidenced by

noted radiation and conduction long intervals of

NURSING • Provide tepid sponge bath, sleep.

DIAGNOSIS: as ordered, to help reduce

Hyperthermia r/t fever.

increase • Administer replacement of

prostaglandin fluids and electrolytes with

synthesis as an IVF of D5IMB @55

evidenced by the gtts/min as ordered, to

increased
support circulating
temperature of
volume and tissue
0
38.9 C related to
perfusion
Stevens-Johnson
• Administer antipyretics,
Syndrome
orally as ordered

(paracetamol), to reduce

4
 fever.

PROBLEM SCIENTIFIC BASIS GOALS / OBJECTIVE NURSING EVALUATION

5
 INTEVENTIONS

GOAL MET:

4/ 20/09 At the end of my 8 hour span • Monitor vital signs At the end of my 16-

11-7 of care, my patient will be and record to serve hour span of care, my

S-“Nagkasamad- able to: as baseline data patient was able to:

samad na dyod  No increase in • Inspect skin turgor  No

ang iyang panit, tissue damage. and skin integrity to increase in tissue

maam,” as • Skin shows signs of assess severity of damage as

verbalized by the granulation and shedding evidence by not

watcher. healing. . • Frequent turning and finding another

OBJECTIVES: • Lessen signs of preventative care to area of tissue

infection. check and prevent degradation upon

• Disrupted redness/ swelling assessment.

skin and prevent • Skin shows

surface worsening of skin signs of

noted infection. granulation

• Damaged • Keep environment and healing.

6
 and allergen- free and • Lessen signs

destroyed free from hazardous of infection

tissue. objects to avoid as evidenced

• Itchiness injury and further by decrease

of the skin breakdown temperature

affected • Instruct watcher to of 36.8”C

area avoid keeping area

reported wet to prevent

• Purple growth of

rashes microorganism

noted. causing infection.

• Skin • Encourage patient to

shedding increase oral fluid

noted. intake to provide

• Temp of hydrotherapy

38.1’C. • Educate patient and

SO about the

disorder and avoid

7
NURSING scratching of skin to

DIAGNOSIS: lessen infection

Impaired tissue development.

integrity r/t • Apply warm

epidermal compress gently as

shedding prescribed to reduce

secondary to denuded areas

Steven-Johnsons • Apply prescribed

Syndrome topical agents to

reduce wound and

bacterial invasion

• Explain the

importance of the

hypo-allergenic diet

• Provide diversional

activity as non-

pharmacological

therapy:
8
 (back rub)

PROBLEM SCIENTIFIC GOAL / OBJECTIVE NURSING INTEVENTIONS EVALUATION

BASIS

GOAL MET:

4/ 21/09 At the end of my 8 hour span • Monitor vital signs and recorded, At the end of my 8
9
11-7 of care, my patient will be: to serve as baseline data hour span of care,

S- “Nagasakit • Assesses presence and my patient was able

akong mga • Appear relaxed characteristic of pain, behavioral to:

samad”, as • Reduced pain responses and factors that

verbalized by the • Relieved discomfort influence pain; itchiness of skin • Appear

patient. • Apply warm compress to relaxed

OBJECTIVES: promote vasodilatation • Reduce pain

• RR-36cpm • Encourage patient to increases as

oral fluid intake, to promote evidenced

• CR- hydration by pain

120bpm • Promote non-pharmacological scale of 1

• Grimaced management of pain;(touch out of 5 as

face noted therapy and back massage) the highest.

• Irritability • Provide diversional activities • Be relieved

noted (short stories, talk theapy) from

Pain scale 3 out of • Provide quiet environment to discomfort

5 promote relaxation as

PAIN SCALE: • Apply topical agets to reduce evidenced

10
 0- no hurt itchiness by long

1- hurts little • Assist patient in comfortable intervals of

bit position. sleep.

2- huts little

more

3- hurts even

moe

4- huts whole

lot

5- hurts worst

6-

NURSING

DIAGNOSIS:

Acute pain r/t

denuded skin 20 to

Stevens-Johnsons

Syndrome

11
PROBLEM SCIENTIFIC GOAL / NURSING INTEVENTIONS EVALUATION

BASIS OBJECTIVE WITH RATIONALE

GOAL

4/ 21/09 At the end of my 8 • Maintain frequent contact with At the end of my 8

11-7 hour span of care, the client/ family, to provide hour span of care, the

S- “Dili dyod ni patient others will be assurance that client/family is patient’s significant

namo makaya nga able to: not alone o rejected others was able to:

problema, Maam”, • verbalize • Encourage open • verbalize

12
as verbalized by the goals of communication to convey goals of
treatment. treatment
patient’s mother respect for acceptance of the
• demonstrate • demonstrate
OBJECTIVES: knowledge of person. knowledge of
support support
• Poor systems. • Limit use of isolation clothing systems

concentration and masks, to foster trust

• express fears • express fears
and lack of • Provide accurate, consistent
and concerns. and concerns.
goal directed information regarding

behavior prognosis, to reduce anxiety

upon and enable client/family to

interview. make decisions

• Inablility to • Avoid arguing about their

meet role perceptions of the situation,

expectation. because choices are based on

• Decrease use realities.

of social • Provide open environment in

support. which client/family feels safe

NURSING to discuss feelings or to refrain

DIAGNOSIS: from talking, to help client feel

13
Ineffective Patient accepted in her present

Coping secondary to condition without feeling

Stevens-johnson judged and promotes sense of

Syndrome dignity and control.

• Give information that feelings

are normal and are to be

appropriately expressed,

because acceptance of feelings

allows client to begin to deal

with situation,

• Explain procedures providing

opportunity for questions and

honest answers, because

accurate information allows

client to deal more effectively

with the reality of the situation,

thereby reducing anxiety and

fear of the unknown.

14
• Provide reliable and consistent

information and support for

SO, because this allow for

better interpersonal interaction

and reduction of anxiety.

• Always inform the significant

others/family when major

decisions are to be made, to

ensure a support system for

client.

15
PROBLEM SCIENTIFIC BASIS GOALS / NURSING INTEVENTIONS EVALUATION

OBJECTIVE

4/ 21/09 Exte

11-7 nsive denudation of the At the end of my 8 • Assess skin turgor, mucous GOAL MET:

O= skin may leads and a hour span of care, my membrane and thirst to At the end of my 8

Risk Factors: threat to fluid imbalance patient will be able to: indicate fluid status hour span of care, my

• Loss of because of the • Maintain • Monitor vital signs, to monitor patient will be able

fluid from significant loss of fluids hydration as patient’s progress to:

denuded and sodium chloride evidence by • Monitor urinary output. • maintained

skin. from the skin. This loss moist mucous Increased specific gravity/ hydration as

• Dry skin is responsible for the membranes. decreasing urinary output evidence by

and many systemic • Maintain stable reflects altered renal perfusion moist mucous

mucous symptoms of the vital signs or circulatory volume. membranes.

membrane disease. • Monitor oral intake and • maintained

. encourage pt. to increase fluids stable vital

16
NURSING to at least 2500 ml/ day, to signs
Source:
DIAGNOSIS: maintain fluid balance, reduce

Risk for deficient Brunner & Suddarth’s thirst and keeps mucous VS= 4:00AM

fluid volume r/t Textbook of Medical membrane moist BP=

loss of fluid from Surgical Nursing 11th • Weigh daily; sudden T=

denuded skin edition ,pp 1973 fluctuations of weight reflect P=

secondary to state of hydration R=

Steven-Johnson • Make fluids easily accessible

Syndrome to patient to enhance fluid

intake.

• Provide fluid replacement to

prevent dehydration.

• Apply petroleum jelly as

ordered to moisten the skin.

17
 BIBLIOGRAPHY

• Deglin, Judith H. and April H. Vallerand. Davis Drug Guide for Nurses,

10th Edition.. Philadelphia. F.A Davis Company. 2007

• Doenges, Marilyn; Mary Frances Moorhouse and Alice C. Murr. Nurses’s

Pocket Guide .10th Edition. F.A. Davis Company. Philadelphia, USA. 2006

• Kee, Joyce L.; et. al. Pharmacology: a Nursing Process Approach, 5th Edition.

Elsevier Inc.,USA. 2006

• Kemper, Donald W.; et. al. Medical Health Handbook, Fourteenth Edition.

Health Wise Publications, USA. 1999

• Kozier, Barbara; et. al. Fundamentals of Nursing; Seventh Edtion. Pearson

Education, Inc. New Jersey. 2004

• McCance, Kathryn; et. al. Pathophysiology: The Biologic Basis for Disease in

Adults and Children. Mosby – Year Book Inc., Missouri, USA. 1994

• Marieb, Elaine. Essentials of Human Anatomy and Physiology, 8th Edition.

Pearson Education, Inc. Philippines 2006

• Mattson, Carol Porth. Essential of Pathophysiology: Concepts of Altered Health

States, 2nd Edition. Lippincott Williams and Wilkins. Philadelphia, USA 2007

• Mosby’s Pocket Dictionary of Medicine, Nursing and Health Professions

• Pillitteri, Adele. Maternal and Child Health Nursing, Fifth Edition. Lippincott,

Williams and Wilkins. 2007

• Seeley, Rod; et al. Essentials of Anatomy and Physiology, 5th edition. New York

McGraw Hill Education Company. 2005.

18
• Smeltzer, Suzanne; et. al. Medical-Surgical Nursing, Eleventh Edition.Lipincott,

Williams and Wilkins. 2007

19