Saturday, January 7, 2012

Impaired Skin Integrity Nanda Nursing Diagnosis - Stevens-Johnson Syndrome (SJS)

Stevens Johnsons Syndrome is a dangerous problem of the skin. It is thought to be a hypersensitivity complex affecting the skin and the mucous membranes.

Stevens Johnson Syndrome (SJS) is a severe and deadly allergic reaction to certain drugs, some proscription and some over the counter, which causes the severe burning of skin and mucosal membranes from the inside out. 15% of people who develop Stevens Johnson Syndrome will die as a direct result. Many drugs which have been known to cause SJS do not have warning labels notifying users about the very real danger of Stevens Johnson Syndrome.

The skin rash of SJS consists of erythematous (red) papules, vesicles, bullae. There may also be iris lesions. The mucosal lesions include conjunctivitis as well as oral and genital ulcers. The most frequent complications of SJS are keratitis, uveitis, and perforation of the globe of the eye all of which may result in permanent visual impairment.

Nanda Nursing Diagnosis : Impaired skin integrity related to inflammatory dermal and epidermal

Expected Outcomes:

Shows the skin and skin tissue intact.

Intervention:

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

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

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

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