Nursing Care Plan Stevens Johnson Syndrome
Nursing Care Plan Stevens Johnson Syndrome
Assessment
a. Subjective Data
- Client said high fever, malaise, headache, cough, runny nose, and sore throat / difficulty in swallowing.
b. Objective Data
- Skin erythema, papules, vesicles, bull fragile so that erosion is a widespread, often obtained purpura.
- Black and thick crust on the lips or mucous membranes, stomatitis and pseudomembrane in the pharynx.
- Conjunctiva, corneal ulcer bleeding sembefalon, iritis and iridosiklitis.
c. Supporting Data
- Lab: leukocytosis or esosinefilia
- Histopathology : mononuclear cell infiltrates, edema and extravasation of red blood cells, degeneration of the basal layer, epidermal cell necrosis, spongiosis and intracellular edema in the epidermis.
- Immunology: deposis IgM and C3 and there is immune complex containing IgG, IgM, IgA.
Nursing Diagnosis and Nursing Intervention
- Impaired sense of comfort, fever, headache, throat related to a bull.
- Pain is reduced / lost
- Relaxed face expression
- Give a cold compress
- Provide a thin clothing of absorbing material
- Avoid skin lesions of manipulation and pressure
- Keep the patient can rest 7-8 hours a day.
- Monitor fluid balance
- Monitor temperature and pulse every 2 hours
- Fulfillment of nutritional disorders: Less than body requirements related to the difficulty in swallowing.
- There are no signs of dehydration
- Diet provided exhausted
- Results of serum electrolytes within normal limits
- Assess client's ability to swallow food
- Give a liquid diet
- Explain to the client and family about the importance of nutrition for healing clients
- Monitoring fluid balance
- Assess for signs of dehydration and disruption elekrolit
- If necessary collaboration for the installation of NGT
Goal :
Clients feel comfortable in a 2 x 24 hours
Results Criteria :
Intervention :
Goal :
Nutritional needs are met during treatment
Result Criteria :
Intervention
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