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In 1922, Stevens and Johnson first described 2 patients, boys aged 7 and 8 years, with “an extraordinary, generalized eruption with continued fever, inflamed buccal mucosa, and severe purulent conjunctivitis.” Both cases were misdiagnosed by primary care physicians as hemorrhagic measles. Erythema multiforme (EM), originally described by von Hebra in 1866, was part of the differential diagnosis in both cases, but it was excluded because of the “character of skin lesions, the lack of subjective symptoms, the prolonged high fever, and the terminal heavy crusting.” In spite of leukopenia in both cases, Stevens and Johnson in their initial report suspected an infectious disease of unknown etiology as the cause. In 1950, Thomas divided EM into 2 categories, as follows: erythema multiforme minor (von Hebra) and erythema multiforme major (EMM; also known as Stevens-Johnson syndrome, or SJS). Since 1983, the eponym of Stevens-Johnson syndrome had been used as a synonym for EMM. Stevens-Johnson Syndrome is a rare disorder characterized by inflammation of the mucous membranes of the mouth, throat, anogenital region, intestinal tract and membrane lining the eyelids (conjunctiva). Affected individuals may have abnormalities (lesions) of the skin and mucous membranes that are purplish or red in color. The abnormalities may be flat (macules) or small and raised (papules). In some cases, the lesions may develop raised fluid-filled centers (bullae or blisters). Affected individuals may also have blisters and/or bleeding in the mucous membranes of the lips, eyes, mouth, nasal passage, and genitals. In addition, abnormalities of the eyes may develop as a result of the lesions caused by Stevens-Johnson Syndrome (ocular sequelae). Such abnormalities may include infection of the delicate membrane of the eye and eyelids (conjunctiva) and inflammation associated with an abnormal discharge from the conjunctiva (purulent conjunctivitis).

Some researchers believe that Stevens-Johnson Syndrome is a severe form of Erythema Multiforme, an inflammatory disorder of the skin and mucous membranes (mucocutaneous) that is triggered by an allergic reaction. Other researchers believe that Stevens-Johnson Syndrome is an independent syndrome. It is uncertain exactly what causes the allergic reaction, but researchers think it may be triggered by an allergic reaction to certain drugs such as antibiotics, including sulfonamides, tetracyclines, amoxicillin, and ampicillin. In some cases, nonsteroidal anti-inflammatory medications and anticonvulsants, such as Tegretol and phenobarbitals, have also been implicated. In some cases, it is also possible that the disorder may be triggered by an infection. 50% of the cases are idiopathic.. Causes: Various etiologic factors (eg, infection, vaccination, drugs, systemic diseases, physical agents, food) have been implicated as causes of SJS. Drugs most commonly are blamed. Recent reports linked SJS to the use of drugs, rather than to other etiologic factors. Antibiotics are the most common cause of SJS, followed by analgesics, cough and cold medication, nonsteroidal anti-inflammatory drug (NSAID), psycho-epileptics, and antigout drugs. Other drugs also can be involved in the pathogenesis of SJS. Individuals with antigens human leukocyte antigen Bw44 (HLA-Bw44), a part of human leukocyte antigen B12 (HLA-B12), and human leukocyte antigen DQB1*0601 (HLA-DQB1*0601) appear to be more susceptible to developing SJS.

Patient Centered Objectives  To realize the significance of health in their lives  To obtain enlightenment on how to maintain health and prevent complications through health edification  To put the knowledge that he has acquired into practice  To enthusiastically partake in medical care procedures and nursing interventions that would hasten the healing process and expedite their recuperation  To manifest indications of positive changes in their current health situation Nurse Centered Objectives  To establish rapport and rehabilitative affinity with the patient  To discern various health issues and problems of the patient who is the center of this study  To accustom ourselves with the definition, etiology, occurrence, diagnostics and management of stevens-johnson’s disease  To master all the appropriate nursing interventions befitting stevens-johnson’s disease  To utilize the theoretical learning that we have acquired into actual setting particularly in this disease

A sebaceous gland (that secretes the oily coating of the hair shaft). urethra. modified epidermal cells. texture. Basal cells are the innermost layer of the epidermis. . The basic cell type of the epidermis is the keratinocyte. Two distinct layers occur in the skin: the dermis and epidermis. which contain keratin. feathers. the hair root extends from the surface to the base or hair bulb. The sweat glands open to the surface through the skin pores. these produce a solution that bacteria act upon to produce "body odor". which is thickened to form a lunula (or little moon). The dermis is a connective tissue layer under the epidermis. Follicles and Glands Hair follicles are lined with cells that synthesize the proteins that form hair. The integumentary system has multiple roles in homeostasis. Nails consist of highly keratinized. and small muscle are associated with each hair follicle. color. and elastic fibers. sensory reception. claws. anus. scales. and are larger and occur in the armpits and groin areas. The nail arises from the nail bed. Melanocytes produce the pigment melanin. Skin is continuous with. and nails are animal structures derived from skin. biochemical synthesis. and contains nerve endings. capillaries. temperature regulation. horns. a fibrous protein. and vagina. Hair and Nails Hair. Eccrine glands are a type of sweat gland linked to the sympathetic nervous system. with a surface area of 1-2 meters. The hair shaft extends above the skin surface. but structurally distinct from mucous membranes that line the mouth. Genetics controls several features of hair: baldness. All body systems work in an interconnected manner to maintain the internal conditions essential to the function of the body. and absorption. sensory receptors. nerve ending. they occur all over the body. and are also in the inner layer of the epidermis.Anatomy and Physiology of the Integumentary System The skin is the largest organ in the body: 12-15% of body weight. Cells forming the nail bed are linked together to form the nail. including protection. it becomes a skin blemish (or pimple). capillary bed. If the sebaceous glands becomes plugged and infected. Apocrine glands are the other type of sweat gland.

evaporation 2. water balance. Pacinian corpuscles respond to pressure. sensory reception. The hypothalamus also causes dilation of the blood vessels of the skin. and are very sensitive to touch. which are especially common in the tips of the fingers and lips. often resulting in a possibly life threatening problem if not treated. Acidic secretions from skin glands also retard the growth of fungi. allowing more blood to flow into those areas. Children lacking sufficient vitamin D develop bone abnormalities known as rickets. The skin also assists in the synthesis of vitamin D. The skin's primary functions are to serve as a barrier to the entry of microbes and viruses. sweating In hot weather up to 4 liters per hour can be lost by these mechanisms. which give the skin its color. Heat and cold receptors are located in the skin. or heat generation. causing heat to be convected away from the skin surface. the sweat glands constrict and sweat production decreases. When the body temperature rises. and temperature. Skin and Sensory Reception Sensory receptors in the skin include those for pain. and to prevent water and extracellular fluid loss. the body will engage in thermiogenesis. by raising the body's metabolic rate and by shivering. regulation of body temperature. cooling the body. . 1. the hypothalamus sends a nerve signal to the sweat-producing skin glands. pressure (touch). If the body temperature continues to fall.Skin and Homeostasis Skin functions in homeostasis include protection. Water loss occurs in the skin by two routes. When body temperature falls. When a microbe penetrates the skin (or when the skin is breached by a cut) the inflammatory response occurs. Temperature receptors: more cold ones than hot ones. and absorption of materials. Deeper within the skin are Meissner's corpuscles. synthesis of vitamins and hormones. Skin damaged by burns is less effective at preventing fluid loss. Skin and Synthesis Skin cells synthesize melanin and carotenes. Melanocytes form a second barrier: protection from the damaging effects of ultraviolet radiation. causing them to release about 1-2 liters of water per hour.

as well as steroid hormones such as estrogen. granulosum. E. dense irregular connective tissue Subcutaneous Layer Beneath the dermis. scopolamine (motion sickness). and (5) stratum corneum. columnar basal stem cells. and K. Thick Skin The epidermis of thick skin follows the contours of the dermal ridges. and the bases of hair follicles are found in the subcutaneous layer. diamond shaped cells containing keratohyalin granules. is composed of less dense connective tissue and is vascularized with capillary networks penetrating the papillae and (2) the underlying reticular dermis composed of avascular. a layer composed of adipose and loose/dense connective tissues make of the subcutaneous layer. and nicotine (for those trying to quit smoking). Patches have been used to deliver a number of therapeutic drugs in this manner. blood vessels. These include estrogen. with their ducts penetrating the dermis to enter the epidermis through the interpapillary pegs Also. a keratohyalin transformation product (not always seen). nitroglycerin (heart problems). producing the epidermal ridges of the fingerprint. The dermal ridges penetrate into the epidermis as true papillae. (4) stratum lucidum. sensory structures (pacinian corpuscles). but does project into the . These substances enter the bloodstream through the capillary networks in the skin. and are separated by epithelial downgrowths called interpapillary pegs Five layers of cells or cell products are found in the epidermis: (1) stratum germinativum. polyhedral cells with "spiny" projections: (3) stratum granulosum. Thin Skin The epidermis differs from that of thick skin in having thinner stratum spinosum. homogenous line composed of eleidin.Skin Is Selectively Permeable The skin is selectively soluble to fat-soluble substances such as vitamins A. nerve bundles. (2) stratum spinosum. Numerous structures are found in this layer. and corneum. a clear. D. and lacks the stratum lucidum . the keratin filled squames Dermis The dermis is composed of two layers: (1) the papillary dermis closest to the epithelium. The secretory portion of the eccrine sweat glands are found here. The dermis is not arranged in ridges.

no epidermal ridges are produced The pigment of the skin is produced by melanocytes. which take up residence in the basal layer (stratum germinativum) and produce melanin or pigment granules .epidermis as true papillae. However. .

Nursing Health History DEMOGRAPHIC DATA .

” PREVIOUS ILLNESS. 1.Name: Bienvinido de Leon Age: 65 years old Birthday: July 14. • After few more days. • The rashes became very itchy. • At about 7:30 in the morning of November 27. 2004. patient’s skin became very scaly and the rashes turned brownish.Able to cope up with ADL’s On a scale of 1 ( illness ) to ( 5 ) healthy • " Pakiramdam ko. hence. Chest Pain HISTORY OF SEEKING HEALTH CARE • On November 4. 2004. Tarlac Status: Married Religion: Roman Catholic DOA: November 27. was admitted. PERCEPTION OF HEALTH STATUS Rates himself as ( 2 ). Later on. He sought consultation at CLDH OPD. patient noted appearance of macules and lesions first on the extremities then after a few days. patient’s relatives noted difficulty of breathing with drowsiness. He had not undergone any major or minor surgery. He was not admitted to a hospital before. Martinez ADMITTING DIAGNOSIS: Psoriasis REASON FOR SEEKING HEALTH CARE: Drowsiness. 2004 @ 8:49 am Attending Physician: Dr. The condition persisted for 30 minutes. . para akong kandilang nauupos. This was his first time. 1938 Address: Blk. pahina ako ng pahina. HOSPITALIZATION AND SURGERY • • • The patient has hypertension. it spread all over the body. San Jose. the patient complained of chest pain.” • “Habang tumatagal kasi.

HS Imdur 60 mg. mumps and pneumonia during his childhood and teenage years. ALLERGIES • The client has no drug. food. IVP OD Nootropil 1 gm. Despair • • He had viewed his life as meaningful and fulfilling. he is happy that she was able to surpass all of them. He does not know any relative suffering from the disease same as his.CLIENT-FAMILY MEDICAL HISTORY • • The patient claimed that both his maternal and paternal side has hypertensive and cardiac disorders. or environmental allergies. He had chickenpox. 1 tab OD Flagyl 500 mg. CURRENT MEDICATIONS • • • • • • • Ulcepraz 40 mg. IVP every 8 hours Iselpin 1 gram 1 tab every 6 hours Laxoberal 1 tbsp. He had gone through a lot of hardships but through it all. IMMUNIZATIONS and COMMUNICABLE DISEASES • • The patient had his basic immunizations but not remember when and what kind. measles. IV Infusion every 8 hours Moriamin Forte 1 tab TID DEVELOPMENTAL LEVEL Erik Erikson Integrity vs. .

• He respects the dignity of human beings as individuals. Lawrence Kohlberg Kohlberg’s model states that the person’s ability to make moral judgments in a behave and a morally correct manner develops over a period of time. Freud’s theory stated unresolved gratification at a certain stage leads to a fixation of development at that stage. who is also his sexual partner.• Sigmund Freud According to Freud’s early theory. • He has developed an intimate relationship to his partner. • He follows laws and orders of the society. “ The goal of development is maximizing need gratification minimizing punishment and guilt using defenses to control anxiety. genital) at certain ages during the course of personality development. Jean Piaget Formal Operations (11+ years ) • The client is able to see relationships of objects. all behaviors are motivated by a desire to satisfy biological needs and release of tension. events and situations. • Thinks scientifically and solves complex problems. a conventional level when reasoning begins to focus or more abstract principles of right or wrong rather than established moral truths Level III: Postconventional • He understands that it is wrong to violate others' rights. • He has a successful marriage and a happy family. • He can reason in the abstract. Freud believed that gratification behavior is expressed primarily through different body zone (oral. Genital Stage (15 years to adulthood) • He has reached sexual maturity. based on obedience or punishment. Kohlberg identified three levels of morality: a preconventional level. . • He logically solves problems. anal.

• • • He has developed morality and ethics. His judgements are based on principles of justice. Approval and disapproval from significant others influence the formation of one’s personality." Harry Stack Sullivan Theorized that relationships with others influence how one’s personality develops. To form satisfying relationships with others. Mastery of task in one developmental stage is essential for mastery of tasks in subsequent stages. He lives by the saying that "Do to others as you would have them do to you. Late Adoloscence Has established an intimate and long lasting relationship with someone of the opposite sex. Havighurst Theorized that there are 6 developmental stages of life. it is learned for life. Has established satisfactory living arrangements · PSYCHOSOCIAL HISTORY The client’s usual source of stress includes several factors such as his job/ occupation and his illness. Stage of Late Maturity • • • • Adapted with his physiological changes and alterations in health status The client had adjusted to retirement. each with essential task to be achieved. an individual must complete six stages of development. he stated that he could easily cope up with these stresses as long as there are those . When a task in one stage is mastered. However.

RECREATION and HOBBIES The client usually spends his leisure time (free day) breeding chickens and training them for “sabong”. VALUES and BELIEFS The client claimed that he believes in hilots . He gives credence to God. tawas and pag-aatang ( offering of food sacrifices) mainly because of his social status and their background as a typical Filipino. NUTRITION The client claimed that he has a good eating habit not until he became ill. He belongs to the economic status letter B.people who are close to him who are always there to support him. Guava leaves) as their primary treatment. When he became ill. Best of all. he said that his family is a God fearing family. As a Roman Catholic. LIFE STYLE The client reported that he used to smoke around 10-15 sticks a day. and his children. He says he puts MSG in almost all their viands. meat and rice. he does not eat meat during Holy Week. ECONOMIC and SOCIO-CULTURAL DATA Our client is an elementary undergraduate of San JoseElementary School. albularyos . He eats more meat than fish and vegetables. He drinks plenty of water. . these people comprise of his family especially his . SLEEP PATTERN The client usually sleeps at around 8-9:00 in the evening and wakes up at around 5 in the morning. He also said that he also resort to traditional/ herbal medicines (eg. wife. he almost sleeps the entire day because of severe weakness. at least 7 glasses per day. He is a Kapampangan in ethnic affiliation. He likewise stated that he is an occasional drinker. He eats typical Filipino food comprising mainly of vegetables. Specifically.

GARBAGE With regards to their sanitation. HOUSING. According to him. They also dispose off their garbage by means of boring a hole at the ground and through burning. they usually clean their house everyday and also their surroundings. from brownish. yellow overtones to olive UNIFORMITY: uniform except Generally in areas Uniformity: Varies . TOILET. from ruddy from reddish. They get their water from an artesian pump. Cephalo-Caudal Assessment BODY PART  SKIN METHOD  Inspection NORMAL FINDINGS ACTUAL FINDINGS INTERPRETA TION COLOR: Varies from light to COLOR: The color varies NOT deep brown. Their toilet is with flush.SANITATION. black and NORMAL pink to light pink. Their house is concrete walled. the house is well-ventilated and welllighted. WATER SOURCE.

and raised nevi (moles). skin. no erythema. some flat Presence of papules. either sloughing. areas of because some areas are NOT lighter pigmentation (palms. skin springs back to previous state When pinch skin slowly springs back to previous NORMAL state.  Inspection and Palpation SKIN MOISTURE: Moisture in skinfolds and in axillae (varies with environmental There is severe dryness of temperature and to the sun. crusting. NOT body temperature and NORMAL activity) SKIN TURGOR: When pinched. necrosis. swollen NORMAL lips. skinned people SKIN LESIONS: Freckles. nail beds) in dark or necrotic. some birthmarks. NOT NORMAL abrasions or other lesions scaling. .

COLOR. normocephalic NORMAL SYMMETRY: Rounded and symmetric. darkskinned clients may have brown or black pigmentation in longitudinal steaks Tissue surrounding TISSUE SURROUNDING: epidermis is scaly Intact epidermis erythematous the and NOT NORMAL  SKULL AND FACE  Inspection SKULL SIZE. brittle texture. Uneven curvature. AND Rounded. HAIR  Inspection EVENNESS OF GROWTH: Patches of hair loss due to NOT Evenly distributed hair lesions and erythema in NORMAL the scalp THICKNESS/THINNESS. parietal. SHAPE. angle between nail bed about 160 degrees TEXTURE: Smooth texture Rough. NORMAL NORMAL NOT NORMAL  NAILS Upper extremities  Inspection  Palpation NAIL BED COLOR: Highly Pale in color vascular and pink in light skinned clients. LENGTH: Thick hair Thin NORMAL INFESTATIONS: No No infestations NORMAL infections or infestations SHAPE: Convex curvature. (normocephalic and symmetric. . with frontal.

symmetric nasolabial Symmetric folds movements. palpebral fissures equal in size. skin intact because of scaling in the NORMAL Eyebrows symmetrically face aligned. scaling and papules Symmetric facial features. equal movement EYELASHES: Equally Absence of eyelashes. absence of nodules or masses  Palpation Smooth and there is no NOT presence of nodules. NORMAL presence of erythema. FACIAL MOVEMENTS: Symmetric facial movements  Inspection EXTERNAL STRUCTURES EYEBROWS: Hair evenly Uneven distribution of hair NOT distributed. curled slightly NORMAL outward Swollen. NOT distributed. uniform consistency. boggy. FACIAL FEATURES: Symmetric or slightly asymmetric facial features. NORMAL  Inspection facial NORMAL  EYE STRUCT URES AND VISUAL AQUITY .and occipital prominences). smooth skull NODULES/MASSES/LESIO NS: Smooth.

equal in NORMAL in size. pupils converge when near object is moved toward nose VISUAL FIELD PERIPHERAL FIELD: When VISUAL When looking ahead. in diameter. looking straight client can see Pupils constrict when looking at near object. smooth border. no discoloration. smooth round. iris flat and round REACTION TO LIGHT: Illuminated pupil constricts (direct response) Nonilluminated pupil constricts (consensual response) Illuminated pupil constricts (direct response) Nonilluminated pupil NORMAL constricts (consensual response) NORMAL ACCOMMODATION: Pupils constrict when looking at near object. normally 3 to 7 mm size. round. equal Black in color. pupils dilate when looking at far object. iris flat and round NORMAL border. no edematous discharge. Lids close symmetrically Presence of conjunctivitis NOT NORMAL NOT PUPIL: Black in color. pupils dilate when looking at far object. pupils converge when near object NORMAL is moved toward nose  Inspection and Palpation  Inspection .EYELIDS: Skin intact.

SIX OCULAR move in unison. imaginary line drawn from the top to the bottom of the ear varies no more than 10 degrees from the vertical. pinna recoils after it is NORMAL folded. firm. client can objects in the periphery NORMAL see objects in the periphery Both eyes coordinated. Line drawn from lateral angle of eye to point where top part of auricle joins head is horizontal. with MOVEMENTS: Both eyes parallel alignment NORMAL coordinated. Line NORMAL drawn from lateral angle of eye to point where top part of auricle joins head is horizontal. firm. and tender. Color same as facial skin NORMAL Symmetric position. NOT Mobile.  Palpation Mobile.straight ahead. move in unison. with parallel alignment  Inspection  EARS AND HEARING AURICLES Color same as facial skin Symmetric position. and not tender. swollen pinna recoils after it is folded EXTERNAL AND EAR CANAL TYMPHANIC Distal third contains hair NORMAL . imaginary line drawn from the top to the bottom of the ear varies no more than 10 degrees from the vertical.

semitransparent NORMAL Pearly gray color. grayish-tan cerumen in various shades color. grayish-tan NORMAL color. wet Dry cerumen. or sticky. or sticky. wet of brown cerumen in various shades NORMAL of brown Pearly gray color. semitransparent Normal voice tones audible NORMAL Normal voice tones audible GROSS HEARING ACUITY TEST Able to repeat nonconsecutive numbers Able to repeat nonconsecutive numbers . Inspection MEMBRANE Distal third contains follicles and glands hair follicles and glands Dry cerumen.

watery discharge No lesions NOT NORMAL NORMAL NASAL SEPTUM: Nasal septum intact and in NORMAL Nasal septum intact and in midline. with lesions Air moves freely as the Air moves freely as the client breathes through the client breathes through NORMAL nares the nares LINING OF NARES: Mucosa pink Clear. midline  MOUTH AND  Inspection LIPS AND MUCOSA BUCCAL Lips are edematous and . no lesions Tender. NOSE AND SINUSES Inspection NOSE Symmetric and straight No discharge or Symmetric and straight discharge or flaring NORMAL NORMAL flaring No Uniform color Uniform color Not tender. watery discharge No lesions Mucosa pink Clear.

to Not NORMAL be NORMAL NOT Smooth . white. firm texture to gums TONGUE/FLOOR MOUTH OF Teeth appear complete. swollen. shiny tooth enamel Pink gums (bluish or dark patches in dark-skinned clients) Moist. unable to purse Not normal eg. smooth texture Symmetry of contour. and presence of NORMAL tarry black regions specifically at the molar and pre molar region. Ability to purse lips  Inspection and Palpation INNER LIPS AND BUCCAL MUCOSA Reddish. NOT NORMAL Gums have blackish discoloration specially at the upper region of the oral cavity. in lips Mediterranean groups and dark-skinned clients) Soft. bluish hue. . swollen Uniform pink color (freckled brown pigmentation in darkskinned clients) TEETH AND GUMS 32 adult teeth Smooth.OROPHA RYNX Uniform pink color (darker. moist.

TONGUE  Inspection Central Position Central Position NORMAL

Pink in color (some brown Darkish red in color, has pigmentation on tongue abundant whitish Not Normal borders in dark skinned pigmentation clients); moist; slightly rough; thin whitish coathing Moves freely; no tenderness NORMAL Moves freely; no NORMAL Smooth tongue base with tenderness prominent veins Smooth tongue base has prominent veins NECK MUSCLES  Inspection Muscle equal in size; head Muscle equal in size; head NORMAL centered centered Coordinated, movements discomfort smooth Uncoordinated, with no movements discomfort Muscle weakness NOT with NORMAL NOT NORMAL


Equal muscle strength LYMPH NODES

 Palpation

Not palpable  Palpation TRACHEA

Not Palpable NORMAL

Central alignment in midline Central alignment in of neck; spaces are equal on midline of neck; spaces NORMAL both sides are equal on both sides  Inspection  Palpation THYROID GLAND Not Visible Lobes may not be palpated If palpated, lobes are small, smooth, centrally located, painless, and rise freely with swallowing Not Visible NORMAL Lobes may not be palpated , lobes are small, smooth, NORMAL centrally located, painless, and rise freely with swallowing


POSTERIOR THORAX  Inspection   Palpation Skin intact; temperature uniform Skin is scaly erythematous no Chest wall tenderness intact; and NOT NORMAL Chest symmetric Chest symmetric NORMAL

Chest wall intact; tenderness masses

Full and symmetric chest expansion (ie, when the client takes a deep breath, your thumbs should move apart an equal distance and at the same time; normally the thums separate 3 to 5 cm [1 ½ to 2 in] during deep inspiration)  Palpation VOCAL FREMITUS: (TACTILE)

with NOT NORMAL Full and symmetric chest expansion when the client takes a deep breath, the NORMAL thumbs separate 3 to 5 cm [1 ½ to 2 in] during deep inspiration)

 Percussion

Bilateral symmetry of Bilateral symmetry of vocal vocal fremitus fremitus Low-pitched voices of Low-pitched voices of males males are more readily are more readily palpated palpated than higherthan higher-pitched voices pitched voices of females of females Percussion notes resonate THORAX: Percussion notes resonate Resonance is felt at the Lowest point of resonance is diaphragm at the level of at the diaphragm (ie, at the


Full symmetric excursion. temperature uniform Skin is th level of the 8th to 10th rib the 8 to 10 rib posteriorly) posteriorly) NOT Percussion on the rib Percussion on the rib NORMAL  Auscultation normally elicits dullness normally elicits dullness CHEST: Vesicular and Crackles heard bronchovesicular breath sounds NOT NORMAL ABnormal pattern breathing NOT NORMAL  Palpation ANTERIOR THORAX Normal breathing pattern Skin intact. no Chest wall intact. with NOT papules NORMAL Chest wall intact. with tenderness tenderness masses Full symmetric excursion. thumbs normally separate thumbs normally separate 3 3 to 5 cm to 5 cm NORMAL .

 ABDO MEN Inspection There should be no lesions. It should be clear. parts are swollen and NORMAL reddish . Skin is scaly and some NOT nodules.

fingers are complete no lesion. thready pulse. symmetrical joint movement. NORMAL • U Inspection. with crusting and NORMAL papules. with crusting NOT and papules. Hypoactive bowel sound. moist. No abnormal findings noted. palpation PPER EXTRE MITIE S All peripheral pulses should be present. Weak. skin is dry and has poor skin turgor. discoloration. fingers are complete. moist. symmetrical joint movement. skin NOT is scaly. No abnormal findings noted. flat surface NORMAL NORMAL Percussion Dull sound heard. no lesion.Auscultation Palpation No abnormal findings Hollow sound heard. infection or any skin break. Smooth. OWER palpation EXTRE MITIE S . discoloration. skin is dry NORMAL and has poor skin turgor. limited range of motion because of severe body weakness skin is scaly. All peripheral pulses should be present. limited range of motion because of severe body weakness • L Inspection. infection or any skin break. noted.

Non-productive cough noted Difficulty of breathing noted CARDIOVASCULAR SYSTEM  Patient’s BP is 140/80 mmHg & CR is 80 bpm. Hypoactive bowel sounds Constipation Presence of erythema. Patient’s RR is 20 cpm. Hemoglobin and hematocrit RESPIRATORY SYSTEM     Crackles auscultated.  The nails of upper and lower extremities are also pale in color. rashes. exhibits poor capillary refill  His blood study shows a low number of RBC.Review of Systems PERIPHERAL PERFUSION  Patient is pale looking and appears weak. scaling in the abdomen .  His maternal and paternal side had a history of Hypertensive diseases and as well as having heart diseases GASTROINTESTINAL     The patient has no episodes of diarrhea.

married smoker (10-15 sticks a day) . Bowel movement was noted at the descending colon with characteristics of normal activity No dysuria nor hematuria noted. There is no pain reported during micturation and defacation PERSON P • • 65 year old male.MUSCULOSKELETAL  Has difficulty of moving because of weakness  The patient is unable to sustain ADLs and needs assistance and support  He also claimed that he has no muscle spasm or loss of sensation from his bony to muscular prominence NEUROLOGIC     The patient in general felt weakness and felt a sense of uselessness Exhibits no difficulty of hearing Has slurred speech because of the inability of the lips to close Reflexes are poor GENITOURINARY     Exhibits normal micturation/voiding pattern.

Hgb and Hct lower than the normal range Albumin lower than normal range Stool exam positive for occult blood With lesions. pancreas.• • • • alcohol drinker lives with his family Past History: .History of chickenpox. Devout Roman Catholic Expressed some concern over the prognosis of his disease whether he could still recover or not E • • • • • • • Voiding with no difficulty Clear and yellow urine Voids in the bed using a bedpan Defecates with difficulty because he still has to exert effort No laxatives used at home Normoactive bowel sounds No distention or tenderness on palpation R • • • No sleep aids used at home ROM limited on both upper and lower extremities Performs ADL's with difficulty due to severe weakness S • • • • • • RBC. spleen. kidneys as shown in the ultrasound Chest X-ray done: Impression: PTB Moderately advanced O . mumps and measles (childhood years) Practicing. gallbladder.No surgeries .No hospitalizations . skin breaks and scaling on the entire body Normal liver.

• • • Crackles auscultated RR: 18 Breaths per minute With non productive cough N • • • • • • • • • Soft diet because of swollen buccal mucosa States hospital food is "not bad at all" States that he is not "picky" with regards to foods Prefers to eat vegetables. Electrolytes and other chemistries may be needed to help manage related problems. meat and lots of rice Height: 5 feet 7 in. • • • • . A severely elevated WBC count indicates the possibility of a superimposed bacterial infection. Swollen lips and buccal mucosa Without dentures Redness in the gums IDEAL Diagnostic and Laboratory Examinations Lab Studies: • No laboratory studies (other than biopsy) exist that can aid the physician in establishing the diagnosis. urine. Determine renal function and evaluate urine for blood. Weight: approx. Cultures of blood. 80 kg. and wounds are indicated when an infection is clinically suspected. A complete blood count (CBC) may reveal a normal white blood cell (WBC) count or a nonspecific leukocytosis.

Perivascular areas are infiltrated with lymphocytes . Epidermal cell necrosis may be noted. Otherwise. Other Tests: • Skin biopsy is the definitive diagnostic study but is not an emergency department (ED) procedure. routine plain films are not indicated.Imaging Studies: • Chest radiography may indicate the existence of a pneumonitis when clinically suspected. o o o Skin biopsy demonstrates that the bullae are subepidermal.

8 sec 13.27 . 2004 Patient’s Time Control Time % Activity EHR 11. 2004 AF 67 umol/L 3.0 mmol/L Creatinine Potassium PROTHROMBIN TIME December 2.6 mmol/L RV 71-133umol/L 3.December 1.6-5.5-14.90-1.5 sec 101% 0.99 Normal Value 10-14 sec 9.3 sec 70-130% 0.

54 mmol/L 19 g/L RV 3.9 3.7 31.December 5. 2004 AF 5.5-5.5-5. 2004 Potassium Albumin AF 4.5 13-17 40-50 150-400 20-40 2-10 40-80 .62 10.3 mmol/L 39-50 g/L WBC RBC HGB HCT PLT Lymphocytes Monocytes Neutrophils Routine Blood Count December 5.6 238 12 17 71 RV 4-10 4.

WBC RBC HGB HCT PLT Lymphocytes Monocytes Neutrophils Routine Blood Count December 1. 2004 AF 6.41 10.7 169 13.3 3.0 29.5 13-17 40-50 150-400 20-40 2-10 40-80 Patient’s Diagnostic and Laboratory Exams .5-5.8 RV 4-10 4.3 77.9 8.

Routine Stool Exam December 4. Medical Management • Emergency Department Care: Most patients present early and prior to obvious signs of hemodynamic compromise. The gallbladder shows no calculus. No calculus or hydronephrosis is noted. The urinary bladder is unremarkable. The intrahepatic and common ducts are not dilated. No peritoneal fluid or mass is noted. Both kidneys are normal in size and echopattern. The prostate gland is not enlarged. 2004 The liver is normal in size. 2004 Occult Blood: Positive Abdominal Ultrasound December 6. No parenchymal mass noted. . The single most important role for the ED physician is to detect SJS early and initiate the appropriate ED and inpatient management. Pancreas and spleen are normal in size.

Patients with SJS should then be treated with special attention to airway and hemodynamic stability. Skin lesions are treated as burns. plasmapheresis. wound/burn care. and pain control. o o o • Manage oral lesions with mouthwashes. . Treatment with systemic steroids has been associated with an increased prevalence of complications. the symptomatic treatment of patients with SJS does not differ from the treatment for patients with extensive burns. In principal. Some authors believe that they are contraindicated.• • • Care in the ED must be directed to fluid replacement and electrolyte correction. but none of those should be considered standard at this time. Offending drugs must be stopped. Areas of denuded skin must be covered with compresses of saline or Burow solution. hemodialysis and immunoglobulin. The use of systemic steroids is controversial. Treatment of SJS is primarily supportive and symptomatic. Topical anesthetics are useful in reducing pain and allowing the patient to take in fluids. most patients are treated symptomatically. o Fluid management is provided by macromolecules and saline solutions during the first 24 hours. • • • Supportive systemic therapy: Management of patients with SJS usually is provided in ICUs or burn centers. No specific treatment for SJS exists. Some have advocated cyclophosphamide. • Underlying diseases and secondary infections must be identified and treated. Address tetanus prophylaxis. fluid status. therefore.

similar to that present in burn patients. a sudden drop in fever. usually in 2 weeks. Heat shields and infrared lamps are used to help reduce heat loss. Skin allotransplantation reduces pain. Leaving the involved epidermis that has not yet peeled off in place and using biologic dressings only on raw dermis also has been recommended. o o o o o o o o o o o . commonly used in burn units. Cultures of blood. Sterile handling and/or reverse-isolation nursing techniques are essential to decrease the risk of nosocomial infection.o After the second day of hospitalization. oral intake of fluids provided by nasogastric tube often is begun. to paint and bathe the affected skin areas. Because of impaired pharmacokinetics. instead. Hyperbaric oxygen also can improve healing. The diagnosis of sepsis is difficult. improves heat control. such as 0. bronchial aspiration. Extensive debridement of nonviable epidermis. use another antiseptic. gastric tubes. Pulmonary care includes aerosols. Environmental temperature raised to 30-32°C reduces caloric loss through the skin.or collagen-based skin substitutes. Because of the association between SJS and sulfonamides. indicating the need for antibiotic therapy. Several skin care approaches have been described.5% silver nitrate or 0. avoid the use of silver sulfadiazine. Patients with SJS are at a high risk of infection. Prophylactic systemic antibiotics are not recommended. cryopreserved cutaneous allografts. such as porcine cutaneous xenografts. and deterioration of the patient's condition. so that intravenous fluids can be tapered progressively and discontinued. Monitoring the serum levels is necessary to adjust the dosage. and prevents bacterial infection. catheters. Anticoagulation with heparin for the duration of hospitalization is recommended. Fluidized air beds are recommended if a large portion of the skin on the patient's backside is involved. are among the recommended treatments. the administration of high doses may be required to reach therapeutic levels. Antacids reduce the incidence of gastric bleeding. and physical therapy.05% chlorhexidine. The first signs of infection are an increase in the number of bacteria cultured from the skin. Tranquilizers are used to the extent limited by respiratory status. and amnion. followed by immediate cover with biologic dressings. and urinary tubes must be performed regularly. The choice of antibiotic usually is based on the bacteria present on the skin. Massive parenteral nutrition is necessary as soon as possible to replace the protein loss and to promote healing of cutaneous lesions. minimizes fluid loss. Intravenous insulin therapy may be required because of impaired glycoregulation. Carefully consider the decision to administer systemic antibiotics.

However. plasmapheresis. In case of exposure keratopathy. o Steroids may enhance the risk of sepsis. One report suggests that prompt. short-term corticosteroid therapy appears to be a strategic key to minimize damage from SJS. particularly with cyclosporin. and penetrating keratoplasty. The only rationale for the use of corticosteroids was based on the concept that SJS is a delayed-type hypersensitivity reaction. Maintenance of ocular integrity can be achieved through the use of adhesive glues. but none of the studies has been conclusive. o After an acute phase of SJS with persistent or recurrent ocular inflammation. Visual rehabilitation in patients with visual impairment can be considered once the eye has been quiet for at least 3 months. . or cyclophosphamide. and delay epithelization. lamellar grafts. and symblepharon lysis. a mortality rate of 91% in the steroidtreated group of patients with acute SJS caused by infection is suggestive of an iatrogenic source of mortality. Long-term steroid therapy may delay the onset of SJS. follow-up care. Conversely. increase protein catabolism. this argument has not been accepted widely. tarsorrhaphy may be required. but it does not halt its progression. SJS can occur in patients who undergo long-term glucocorticosteroid therapy. azathioprine. As inflammation and cicatricial changes ensue. patients may benefit from short-term systemic corticosteroids and/or long-term immunosuppressive therapy. most ophthalmologists use topical steroids. o It has been argued that the use of systemic corticosteroids should be a standard therapy in the acute phase of SJS and that a prospective randomized trial is not adequate because of ethical reasons. In one study. either in the acute phase or in subsequent. thalidomide. antibiotics. This treatment may reduce the severity of conjunctivitis and improve the prognosis quod visum by reducing the damage to the ocular surface. immunosuppressive therapy) have been used in the acute phase of SJS. Studies suggest that treatment with glucocorticosteroids is associated with an increased morbidity and mortality. o The use of systemic corticosteroids is most controversial. Symptomatic treatment remains the mainstay in the management of SJS.• Immunomodulatory therapy: Several specific therapeutic approaches (eg. intravenous immunoglobulin. Surgical Care: • Treatment of acute ocular manifestations o o o o o Treatment of acute ocular manifestations usually begins with aggressive lubrication of the ocular surface.

usually long-term. keratoprosthesis may be considered as the procedure of last resort. persistent epithelial defects with subsequent corneal neovascularization. limbal stem cell transplantation with superficial keratectomy removing conjunctivalized or keratinized ocular surface can follow. In addition to lubrication. a long-term use of gas permeable scleral contact lenses may be necessary to protect the ocular surface. Removal of keratinized plaques from posterior lid margins. is difficult and often frustrating for both the patient and the physician. o • Subsequently. Patients with persistent corneal opacity require lamellar or penetrating keratoplasty in the next step. To preserve corneal clarity after the visual reconstruction. limbal stem cell deficiency. The visual rehabilitation in patients with severe ocular involvement resulting in profound dry eye syndrome with posterior lid margin keratinization. and frank corneal opacity with surface conjunctivalization and keratinization. relationship between the patient and the physician needs to be established to achieve the best possible result.• Treatment of chronic ocular manifestations o In the case of mild chronic superficial keratopathy. If the ocular surface repeatedly fails to heal upon multiple surgical interventions. Preferably. a skilled oculoplastic surgeon with specific experience on patients with SJS should perform this procedure. some patients may require a cosmetically acceptable long-term lateral tarsorrhaphy. Long-term management frequently involves treatment of trichitic lashes and/or eyelid margin repair for distichiasis or entropion. long-term lubrication may be sufficient. is usually the first step and one of the most important determining factors for future success of corneal surgeries. Clinical Manifestations • Ocular symptoms o o o o o Dry eye Pain Blepharospasm o o o Itching Grittiness Heavy eyelid Red eye Tearing . along with mucous membrane grafting. A close.

sore throat. chills. Clusters of outbreaks last from 2-4 weeks. o • Mucocutaneous lesions develop abruptly. red eye) Entropion Skin lesions Nasal lesions Mouth lesions Discharge ( 14-day prodrome during which fever. • . and malaise may be present. mucous. The lesions are typically nonpruritic. however. fever has been reported to occur in up to 85% of cases. membranous • Typically. A history of fever or localized worsening should suggest a superimposed infection. the disease process begins with a nonspecific upper respiratory tract infection. headache. catarrhal. o This usually is part of a 1. Vomiting and diarrhea are occasionally noted as part of the prodrome.o Foreign body sensation o o Decreased vision Burn sensation o o Photophobia Diplopia Physical: • External examination o o o o o o Conjunctival hyperemia (ie.

The typical lesion has the appearance of a target. urticarial plaques. or necrotic. Urticarial lesions typically are not pruritic. bullae. Lesions may become bullous and later rupture. purpuric. Infection may be responsible for the scarring associated with morbidity. Patients with genitourinary involvement may complain of dysuria or an inability to void. The target is considered pathognomonic. o o o The center of these lesions may be vesicular.• Involvement of oral and/or mucous membranes may be severe enough that patients may not be able to eat or drink. Recurrences may occur if the responsible agent is not eliminated or if the patient is reexposed. A history of a previous outbreak of SJS or of erythema multiforme may be elicited. or confluent erythema. The skin becomes susceptible to secondary infection. Typical symptoms are as follows: o o o o • • • Cough productive of a thick purulent sputum Headache Malaise Arthralgia • The rash can begin as macules that develop into papules. leaving denuded skin. vesicles. o o .

o Although lesions may occur anywhere. sloughing. o o • The following signs may be noted on examination: o o o o o Fever Orthostasis Tachycardia Hypotension Altered level of consciousness o o o o o Epistaxis Conjunctivitis Corneal ulcerations Erosive vulvovaginitis or balanitis Seizures. soles. ulceration. dorsum of hands. Mucosal involvement may include erythema. blistering. The rash may be confined to any one area of the body. coma Drug Study GENERIC NAME BRAN D NAME DRUG CLASS ES ACTION DOSA GE INDICATION CONTRA INDICATION SIDE EFFECT DRUG TO DRUG INTERACTIO N . most often the trunk. edema. the palms. and extensor surfaces are most commonly affected. and necrosis.

IV trichomonac infusio ide and nq8 amebicide that works at both intestinal and extraintestin al sites. fever Cimetidine: Increased risk of metronidazole toxicity of blood dyscrasia or CNS disorder. flushing. It inhibits synthesis causing cell death. nausea. pruritus. diarrhea. syncope. . Antipro tozoals Bacterial infections caused by anaerobic microorganis ms Contraindicat ed in patients hypersensitiv e to drug Vertigo. headache.  Use cautiously in patients with history  Monitor liver function tests carefully. It is thought to enter the cells of microorgani sm that contains nitroreducta se. rhinitis. dizziness.Metronidazole Flagyl NURSING CONSIDERATI ON A direct 500 acting mg. abdominal pain. vomiting. rashes.

anxiety. Acute anginal attacks. DRUG TO DRUG INTERACTIO N Antihypertens ives: May increase hypotensive effects NURSING CONSIDERATI ON  Use cautiously in patients with blood volume depletion and hypotension. hallucinatio n. .GENERIC NAME Isosorbide dinitrate BRAN D NAME Imdur DRUG CLASS ES Antianginal s ACTION DOSA GE 60 mg. depression GI: nausea. vomiting. diarrea. Drug also may increase blood flow through the collateral coronary vessels. epigastric distress. seizures. dizziness.  Monitor blood pressure frequently. i tab OD INDICATION CONTRA INDICATION Contraindicat ed in patients hypersensitiv ity to nitrates SIDE EFFECT CNS: lethargy. Thought to reduce cardiac oxygen demand by decreasing preload and afterload.

.  Drug is for short-term use. Acute constipation NURSING CONSIDERAT ION  Determine whether patient has adequate fluid intake. exercise. diet.  Avoid exposing product to heat or light. electrolyte imbalance DRUG TO DRUG INTERACTIO N Stimulant laxative that increases peristalsis. intestinal obstruction.GENERIC NAME Sodium picosulfate BRAN D NAME Laxobe ral DRUG CLASS ES Laxativ es ACTION DOSA GE 1 tbsp @ HS INDICATION CONTRA INDICATION Contraindicat ed in pts with ulcerative bowel lesions. fecal impaction. vomiting and diarrhea. loss of normal bowel function. SIDE EFFECT nausea.

nausea. impairing effectiveness. sleepiness. NURSING CONSIDERA TION  Use cautiously in pts with chronic renal failure. GENERIC NAME BRAN D DRUG CLASS ACTION DOSAG E INDICATIO N CONTRAINDIC ATION SIDE EFFECT DRUG TO DRUG . vomiting. headache. dry mouth. Short term treatment for duodenal ulcers DRUG TO DRUG INTERACTIO N Antacids: May decrease binding of drug to gastroduoden al mucosa.  Monitor for severe constipation.GENERIC NAME Sucralfate BRAND NAME Iselpin DRUG CLASS ES Antiulc er drugs ACTION DOSA GE 1 tab q6 INDICATION CONTRA INDICATION No known contraindicat ions SIDE EFFECT dizziness. flatulence Protects surface of ulcer by forming a barrier. vertigo.

rectal disorderba ck pain.  Drug should not be used within 16 weeks. GI disorder. abdominal pain. neck pain INTERACTIO N Ampicillin. IVP OD Treatment of erosive esphagitis Contraindicated in patients hypersensitive to the drug headache. dizziness. nausea. Ketoconazole : MAy decrease absorption of these drugs NURSING CONSIDERATI ON  Drug can be given without regard to meals. vomiting. flatulence. anorexia. GENERIC NAME BRAND NAME DRUG CLASS ACTION DOSAG E INDICATIO N CONTRAINDIC ATION SIDE EFFECT DRUG TO DRUG INTERACTIO N .NAME Pantoprazole sodium Ulcepr az AntiUlcer Drugs Suppress es gastric acid secretion 40 mg. mental confusion.

vomiting. Adjust dosage. Allopurinol. 1 tab TID Carnitine deficiency No known contraindicatio ns nausea. 330 mg. AntiConvulsants . NSAIDs.  Monitor blood chemistry results as well as vital signs. diarrhea.Levocarnitin e (L-Carnitine) Carnicor Miscellan eous Drugs Facilitates transport of long chain fatty acids into cellular mitochond ria. Heredity. Use of Sulfonamides. body odor Valproic Acid: Increased requirements for carnitine. Antibiotics. cramps. those on dialysis. Pathophysiology Predisposing Factors: Autoimmune Disorders. The fatty acids are then used to produce energy. NURSING CONSIDER ATION  Don’t use oral formulations in patients with end stage renal disease.

Patient’s liver improperly breaks down the drug Liver cannot properly excrete the drug By-products of faulty drug metabolism build up in the body By-products bind with epidermal proteins self destruct Formation of antigenic compounds Keratinocytes pick up signal to Massive keratocyte apoptosis .

progressing exfoliative changes Multisystem organ involvement Death .Patient’s immune system responds by mounting an exaggerated attack on all keratinocytes of the skin and mucous membranes that have drug particles bound to them Sloughing Cellular Suicide Extensive Epidermal Rapid.

Farrell said forcefully. to seek drug-free alternatives for one's ailments if and when they arise. however. "I was shocked to find out after my reaction that my father and brother both had developed skin rashes when they took sulfa drugs for short periods in their lives. With adverse drug reactions being the 4th leading cause of death in North America." It makes more sense. . any drug?" . knowledge is power and the group felt that more education about drug reactions and SJS are all that we need. Nevertheless. consider yourself at risk and avoid the drug. it behooves each person to think carefully before taking something. You're warned not to give aspirin to children.Evaluation SJS is definitely a nightmare. "If only I'd known." Callejo said. If a blood relative has had an allergic reaction to a drug in the past. even a mild one. "It is so tragic. but there is hope. . How can you not tell people about a lifethreatening reaction to a drug .


This happens when pain substance were release and transmit it in the brain via the spinal cord and once it has been sent can perceived as PAIN. and position changes. erythe ma. -Encourage use of stress management techniques such as progressive relaxation. and may enhance coping abilities in the management of pain. swelling. patient' s pain will be lessene d. and can increase muscle strength. -Refocuses attention. Encourage reports of pain.with lesions in mouth . and quality of pain. -Prevents boredom. promotes sense of control. reduces areas of local pressure and muscle fatigue. Influences choice of/ GOAL:MET monitors The patient's effectiveness of pain interventions. reduces tension. -Identify divertional activities appropriate for .gener alized weakn ess .S.with scaling . -Relieves pain and prevent bone displacement/extensi on of tissue injury. duration. -Allows patient to prepare mentally for activity as well as to participate in controlling level of discomfort. backrub. " Pasin Scale: 4/5 O: . deep breathing exercises. lesions of the entire body The pt experiences unpleasant sensation due to stimulation of pain receptors. noting location. -Maintain immobilization of affected part. -Explain procedures before beginning them. buccal mucos a Acute pain R/T inflammat ion. " Masakit ang buong katawan ko dahil sa mga sugat ko. lesions and necros is in the entire body . may enhance self-esteem -Provide alternate comfort measures such as massage. After 1 hour of nursing interven tion. decreased from 4/5 to 2/5. -Improves general circulation.

swolle n gums V/S: BP140/8 0 CR85 RR18 T37. Administer analgesics as prescribed. . physical abilities. -This provides relief of pain. and personal preferences. and coping abilities.- - - with swolle n conjun ctiva with reddis h.2 patient age.

generalized weakness . transfer and ambulation . strength/f unction of affected and -Increases blood compensa flow to muscles and tory body bone to improve parts. Maintain stimulating environment.Decreased muscle NURSING DIAGNOSI S Impaired physical Mobility R/T pain SCI. including bed mobility. Instruct patient/ assist with active/passive ROM exercises of affected and unaffected extremities. maintain joint mobility.Limited ROM . EVALUAT ION GOAL:MET At the end of 4hours of nursing interventio n the patient Provides opportunity was able for release of energy to and refocuses increase attention. -Improves muscle strengthened circulation and promotes selfdirected wellness. INTERVENTION -Assess degree of immobility produced by injury / treatment and note patient's perception of immobility. -Early mobility Reduces complications of bed rest. erythema. GOAL At the end of 4 hours of nursin g interv ention the patien t will be able to increa se streng th /functi on of affect ed and comp ensat ory body parts. .CUES S: " Hindi ako makagalaw ng mabuti dahil sa mga sugat ko" O. lesions and necrosis in the entire body . muscle tone. -Assist with/encourage self activities . " Masakit ang buong katawan ko dahil sa mga sugat ko.EXP LANATIO N The pt experienc es a limitation of ability for independ ent physical movemen t due to pain.Inability to purposefully move within the physical environment . -Encourage participation in divertional/ recreational activities. " Pasin Scale: 4/5 O . -Provide/assist with mobility by means of wheelchair RATIONALE -Patient maybe restricted by selfview/self perception out of proportion with actual physical limitation.with scaling.

.- strength Imposed restrictions of movement crutches.

Administer antibiotics as indicated. erythema .with swollen conjuncti va . EXPLANATIO N The pt is at risk for being invaded by pathogenic organisms due to damage tissue which may be a portal of entry to other microorganis m. EVALUA TION GOAL:ME T At the end of 8 hours of nursing interventi ons.with reddish. or antibiotic therapy my be geared toward specific organisms.85 RR-18 T-37. swollen gums V/S: BP140/80 CR.2 NURSING DIAGNOS IS Risk for further infection. Minimize the opportunity for contamination.with scaling. RATIONALE Minimizes opportunity for introduction of bacteria. note characteristics of drainage. NURSING INTERVENTION Maintain aseptic technique when caring for wound. the patient will maintain stable vital signs.generaliz ed weakness . lesions and necrosis in the entire body .with lesions in mouth. GOAL At the end of 8 hours of nursing interven tions. Temperature elevation/ tachycardia may reflect developing sepsis. Wide.CUES S: O: . Early detection of developing infection provides opportunity for timely intervention and prevention for further infections.spectrum antibiotics may be used prophylactically. related to inadequat e primary defenses (broken skin and traumatize d tissue) SCI. . Inspect d wound. the patient achieve timely wound healing. buccal mucosa . Monitor vital signs. Instruct the patient not to touch the wound site.


Soften stool. suppositories and enemas as needed. Begin progressive diet as tolerated. stool . Maybe necessary to relieve abdominal distension. matigas.S: “ Nahihirapa n ako pag dumudumi dahil madalas. Distention and absence of bowel sounds indicate that bowel is not functioning. reduces muscle tension. After 4 hours of nursing intervention . Note abdominal distention and auscultate bowel sounds. Promotes psychologic comfort. Provide rectal tube. promote resumption of normal bowel habit. the pt was able to reestablished normal patterns of bowel functioning. possibly due to sudden loss of parasympathetic enervation of the bowel. After 4 hours of nursing intervention. GOAL MET. Promotes comfort. Administer laxatives. Provide privacy. Solid foods are not started until bowel sounds have returned or flatus passed.” O: Decreased bowel sounds Decreased activity level -With abdominal distension Constipation R/T immobility The pt experiences a change in normal bowel habits characterized by a decrease in frequency and passage of hard dry stools due to immobility that decreases his peristalsis. the pt will reestablish normal patterns of bowel functioning. promotes normal Use bedpan until allowed out of bed.


Provide balance diet. To protect susceptible skin from breakdown.S: O: Decrease d activity level .Decre ased muscl e streng th Risk for further impaired skin integrity in the bony prominences of the right and left heel. Maintain strict skin hygiene. Limit exposure to Decubitus ulcers are difficult to heal.g. he uses his right and left heels to move himself in the bed. . the pt was able to demonstrat e techniques to prevent skin breakdown. adequate proteins. sacrum and pelvis R/T physical immobilizati on Because the patient is unable to move freely. muscle tone and joint motion and promotes pt participation. dry and free from wrinkles. An improved nutritional state can help prevent skin breakdown and promotes ulcer healing. e. thus. Keep sheets and bedclothes clean. which causes an impaired circulation to an immobilized area.Limite d ROM . Perform passive ROM exercises. Loss of muscle control and debilitation may result in impaired coordination. Decreased sensitivity to pain/heat/cold . as indicated. GOAL MET.Inabili ty to purpo sefully move within the physic al enviro nment . Anticipate and use preventive measures in pts who are at risk for skin breakdown. After 1 hour of nursing intervention . Avoids friction/abrasions of skin. Improves circulation. After 1 hour of nursing interventi on. The pt’s skin is adversely altered due to immobilization. causing a high risk of impaired skin integrity. the pt will demonstr ate technique s to prevent skin breakdow n. includi ng bed mobili ty. transf er and ambul ation . vitamins and minerals. and prevention is the best treatment. Provide for safety during ambulation. crumbs and other irritating materials. Assess nutritional status and initiate corrective measures.

Administer nutritional supplements and vitamins as indicated. Foot problems are common among pts who are debilitated. increases risk of tissue trauma. . Examine feet and nails routinely and provide foot and nail care as indicated. Aids in healing/cellular regeneration. Observe for decubitus ulcer development and treat immediately according to protocol. Timely intervention may prevent extensive damage.Imposed restrictio ns of movemen t temperature extremes/ use of heating pad or ice pack.

Health Teachings         Provide patient a thorough explanation of the disease process. prevents excessive fatigue and conserves energy for healing. Encourage alternating rest period and activity. especially antibiotics. Discuss need for safe environment (removing scattered drugs) at home and use of assistive devices because of impaired mobility. Advise SO to provide comfort measures and divers ional activities such as music. Teach client to avoid stress.  Gentle increasing exercise is helpful. Maintain nutritional status and promote overall health by encouraging good oral intake. These promote relaxation and helps refocus attention. OPD/ Follow-Up . Treatment  Instructed patient to treat wounds properly. treatment regimen and follow-up. healthy diet and adequate rest. Instruct the patient to finish all prescribed medications. Exercise  Advised to perform activities according to tolerance for relaxation and endurance. (as prescribed)  Relaxation and deep breathing exercises especially in the morning. as prescribed by the physician.Discharge Plan Medications  Instructed client to religiously take medications prescribed by the physician. television.  Advised to do aseptic technique when cleaning the wound. Teach the importance of follow-up care.

Complications and Prognosis . meat and fish to facilitate tissue formation. This will provide ongoing monitoring of progression and resolution of disease process.  Instructed patient to eat foods rich in protein such as eggs.  Maintain a balanced diet to improve body’s ability to heal itself. Diet  Adequate hydration and nutrition to promote wellness and health. Advise patient to come back after 1 week of discharge for follow-up check-up at the OPD.  Advise patient to increase intake of foods rich in vitamin C like fruits and vegetables for collagen formation that promotes tissue regeneration and healing of wound.

• Up to 15% of all patients with SJS die as a result of the condition.Esophageal strictures • Genitourinary . anterior uveitis. blindness • Gastroenterologic .Tracheobronchial shedding with resultant respiratory failure • Cutaneous . recurrences of infection through slowhealing ulcerations Prognosis: • Individual lesions typically should heal within 1-2 weeks. and blindness. • Development of serious sequelae. renal failure.Scarring and cosmetic deformity. panophthalmitis. determines prognosis in those affected. such as respiratory failure.Corneal ulceration.Complications: • Ophthalmologic . . penile scarring.Renal tubular necrosis. unless secondary infection occurs. vaginal stenosis • Pulmonary . The majority of patients recover without sequelae. renal failure.

Nursing Care Plans • Acute pain R/T inflammation. sacrum and pelvis R/T physical immobilization • Risk for further infection. swelling. lesions of the entire body • Constipation R/T immobility • Impaired physical Mobility R/T pain • Risk for further impaired skin integrity in the bony prominences of the right and left heel. related to inadequate primary defenses (broken skin and traumatized tissue) .



Lea Marie Salazar Rey Raniaga Loredel Melegrito Shiela Tomas Mayleen Mutuc Kristine Padlan Melissa Matusalem Giovanni Tebia Jennelyn Pascual Michelle Sidoro Jennilyn Dampil Aleda Pineda Michael Tan Raymond Lorenzo Hermel Joseph Paras A Ca s e S t ud y .

Su b m i t t ed T o M s . Dec em b er 9 . N. Od et t e Ta n ed o . 2 0 0 4 . R .