I.

INTRODUCTION

A. Brief Description

Stevens - Johnson syndrome (SJS), also called erythema multiforme major is a life-

threatening condition affecting the skin in which cell death causes the epidermis to separate

from the dermis. SJS is a skin and mucous membrane disease characterized by an eruption of

macules, papules, nodules, vesicles, and/or bullae with characteristic "bull's-eye" lesions usually

occurring on the dorsal aspect of the hands and forearms. The syndrome is thought to be a

hypersensitivity complex affecting the skin and the mucous membranes that can also affect the

eyes. Although the majority of cases are idiopathic, the main class of known causes is

medications, followed by infections and (rarely) cancers.

Stevens-Johnson syndrome is a limited form of toxic epidermal necrolysis by destruction

and detachment of the skin epithelium and mucous membranes involving less than 10% of the

body surface area. SJS can be triggered by a drug allergy, more rarely, by infections or bone

marrow transplantation. In 25 to 30% of cases, the cause is unclear. Patients should be

admitted to an intensive care or burns unit as soon as the diagnosis is suspected.

Reepithelialization is rapid (2-3 weeks).

SJS may have full-thickness epidermal necrosis, but with lesser detachment of the

cutaneous surface; and mucous membrane involvement. Maculopapular exanthema and

hypersensitive skin syndrome are other spectrum of cutaneous drug reactions. Maculopapular

exanthema is characterized by cutaneous fine pink macules and papules, lesions which usually

fade within 1–2 weeks following cessation of drug treatment.

 It is a fatal allergic reaction to drugs and microorganisms. SJS can be caused by infections,

usually following viral infections such as herpes simplex virus, influenza, mumps, cat-scratch

fever, histoplasmosis, Epstein-Barr virus

Drugs precipitate over 50% of SJS cases and up to 95% of TEN cases. Sulfa drugs

(eg, co-trimoxazole, sulfasalazine ), antiepileptics

(eg, phenytoin , carbamazepine ,phenobarbital , valproate ), antibiotics (eg,

aminopenicillins, quinolones, cephalosporins), and miscellaneous individual drugs

(eg, piroxicam , allopurinol , chlormezanone) are most often implicated. Cases that

are not due to drugs are attributed to infection (mostly with Mycoplasma

pneumoniae), vaccination, and graft-vs-host disease. Rarely, a cause cannot be

identified.

Signs:

A. Distinctive Target or Iris skin lesion

1. Starts as erythematous Macule that becomes raised

2. Distribution: Symmetrical involvement

a. Onset on distal extremities (often dorsal hands)

b. Progress proximally (often extensor surfaces)

c. Oral Mucosal involvement may be present

3. Develops concentrically into target lesion by day 2

a. Center: Dusky erythema or Vesicle

b. Middle: Pale edematous ring

c. Outer: Dark band of erythema

4. Progresses

a. Central necrosis

b. Some lesions may coalesce into annular Plaques

5. Healing

a. Scarring

b. Postinflammatory Hyperpigmentation

A. Alternative presentations

1. Non-transient Urticarial Plaques

2. Vesicles or bullae form in prior Macule or wheal

 Symptoms:

A. Rash develops after prodrome

B. Mild prodrome for 7-10 days may be present

1. Malaise

2. Fever

3. Headache

4. Rhinorrhea

5. Cough

A. Statistics
International / Local

Stevens-Johnson Syndrome is listed as a "rare disease" by the Office of Rare Diseases

(ORD) of the National Institutes of Health (NIH). This means that Stevens-Johnson Syndrome,
or a subtype of Stevens-Johnson Syndrome, affects less than 200,000 people in the US
population.

SJS is a rare condition, with a reported incidence of around 2.6 per million people per
year. In the United States, there are about 300 new diagnoses per year.

I. OBJECTIVES

A. General Objectives
 At the end of the clinical exposure, I should be able to attain and enhance my
knowledge, skills and attitude to provide nursing care to our patient with Stevens - Johnson
syndrome.

B. Specific Objectives
During the exposure, I should be able to:

Cognitive:

➢ Discover how the patient acquired the disease through the nursing health history,
physical examinations, and some other some other factors that may contribute in relation
to Stevens - Johnson syndrome and be able to assess, organize and validate those data
efficiently.
➢ Understand Steven Johnson Syndrome, its causes and pathophysiology.
➢ Design a plan of care for patient with Stevens - Johnson syndrome (SJS).
➢ To be able to formulate those data into nursing diagnoses that may aid in the patient’s
current health condition.
➢ To be able to set priorities and goal outcomes in collaboration with the patient.

Skills:
➢ Conduct physical assessment and organize data efficiently.
➢ Perform nursing procedures effectively and correctly to attain his optimum level of
wellness.

Attitude:
➢ To be able to establish rapport with the patient and folks.
➢ To be able to develop respect and trust.

I. ANATOMY AND PHYSIOLOGY OF THE DISEASE

THE SKIN
 The skin is the largest organ in the human body. For the average adult human, the skin

has a surface area of between 1.5-2.0 square meters (16.1-21.5 sq ft.), most of it is between 2–

3 mm (0.10 inch) thick. The average square inch (6.5 cm²) of skin holds 650 sweat glands, 20

blood vessels, 60,000 melanocytes, and more than a thousand nerve endings.

The skin is the outer covering of the body. In humans, it is the largest organ of the

integumentary system made up of multiple layers of mesodermal tissue, and guards the

underlying muscles, bones, ligaments and internal organs. Skin of a different nature exists

in amphibians, reptiles, birds. Human skin is not unlike that of most other mammals except that

it is not protected by a pelt and appears hairless though in fact nearly all human skin is covered

with hair follicles. The adjective cutaneous literally means "of the skin" (from Latin cutis, skin).

Because it interfaces with the environment, skin plays a key role in protecting (the body)

against pathogens and excessive water loss. Its other functions are

insulation, temperature regulation, sensation, synthesis of vitamin D, and the protection

of vitamin B folates. Severely damaged skin will try to heal by forming scar tissue. This is often

discolored and depigmented.

In humans, skin pigmentation varies among populations, and skin type can range

fromdry to oily. Such skin variety provides a rich and diverse habit for bacteria which number

roughly a 1000 species from 19 phyla.

 Skin has mesodermal cells, pigmentation, or melanin, provided by melanocytes, which

absorb some of the potentially dangerous ultraviolet radiation (UV) in sunlight. It also

contains DNA-repair enzymes that help reverse UV damage, and people who lack the genes for

these enzymes suffer high rates of skin cancer. One form predominantly produced by UV

light, malignant melanoma, is particularly invasive, causing it to spread quickly, and can often be

deadly. Human skin pigmentation varies among populations in a striking manner. This has led to

the classification of people(s) on the basis of skin color.

Skin layers

Skin is composed of three primary layers:

 the epidermis, which provides waterproofing and serves as a barrier to infection;

 the dermis, which serves as a location for the appendages of skin; and

 the hypodermis (subcutaneous adipose layer).

1. Epidermis
Epidermis, "epi" coming from the Greek meaning "over" or "upon", is the outermost

layer of the skin. It forms the waterproof, protective wrap over the body's surface and is made

up of stratified squamous epithelium with an underlying basal lamina.

The epidermis contains no blood vessels, and cells in the deepest layers are nourished

by diffusion from blood capillaries extending to the upper layers of the dermis. The main type of

cells which make up the epidermis are Merkel cells, keratinocytes, with melanocytes and

Langerhans cells also present. The epidermis can be further subdivided into the

following strata (beginning with the outermost layer): corneum, lucidum (only in palms of hands

and bottoms of feet), granulosum, spinosum, basale. Cells are formed through mitosis at the

basale layer. The daughter cells move up the strata changing shape and composition as they

die due to isolation from their blood source. The cytoplasm is released and the protein keratin is

inserted. They eventually reach the corneum and slough off (desquamation). This process is

called keratinization and takes place within about 27 days. This keratinized layer of skin is

responsible for keeping water in the body and keeping other harmful chemicals

and pathogens out, making skin a natural barrier to infection.

Components

The epidermis contains no blood vessels, and is nourished by diffusion from the dermis.

The main type of cells which make up the epidermis

are keratinocytes, melanocytes, Langerhans cells and Merkels cells. The epidermis helps the

skin to regulate body temperature.

Sublayers

Epidermis is divided into the following 5 sublayers or strata:

 Stratum corneum

 Stratum lucidum

 Stratum granulosum

 Stratum spinosum

 Stratum germinativum (also called "stratum basale")

1. Dermis
The dermis is the layer of skin beneath the epidermis that consists of connective tissue and

cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a

basement membrane. It also harbors many Mechanoreceptor/nerve endings that provide the

sense of touch and heat. It contains the hair follicles, sweat glands, sebaceous glands, apocrine

glands,lymphatic vessels and blood vessels. The blood vessels in the dermis provide

nourishment and waste removal from its own cells as well as from the Stratum basale of the

epidermis.

The dermis is structurally divided into two areas: a superficial area adjacent to the

epidermis, called the papillary region, and a deep thicker area known as the reticular region.

Papillary region

The papillary region is composed of loose areolar connective tissue. It is named for its

fingerlike projections called papillae that extend toward the epidermis. The papillae provide the

dermis with a "bumpy" surface that interdigitates with the epidermis, strengthening the

connection between the two layers of skin.

In the palms, fingers, soles, and toes, the influence of the papillae projecting into the

epidermis forms contours in the skin's surface. These are called friction ridges, because they
help the hand or foot to grasp by increasing friction. Friction ridges occur in patterns that are

genetically and epigenetically determined and are therefore unique to the individual, making it

possible to use fingerprints or footprints as a means of identification.

Reticular region

The reticular region lies deep in the papillary region and is usually much thicker. It is

composed of dense irregular connective tissue, and receives its name from the dense

concentration of collagenous, elastic, and reticular fibers that weave throughout it.

These protein fibers give the dermis its properties of strength, extensibility, and elasticity.

Also located within the reticular region are the roots of the hair, sebaceous glands, sweat

glands, receptors, nails, and blood vessels.

Tattoo ink is held in the dermis. Stretch marks from pregnancy are also located in the dermis.

2. Hypodermis
The hypodermis is not part of the skin, and lies below the dermis. Its purpose is to attach the

skin to underlying bone and muscle as well as supplying it with blood vessels and nerves. It

consists of loose connective tissue and elastin. The main cell types

are fibroblasts, macrophagesand adipocytes (the hypodermis contains 50% of body fat). Fat

serves as padding and insulation for the body.

Microorganisms like Staphylococcus epidermidis colonize the skin surface. The density of

skin flora depends on region of the skin. The disinfected skin surface gets recolonized from

bacteria residing in the deeper areas of the hair follicle, gut and urogenital openings.

Skin performs the following functions:

1. Protection - an anatomical barrier from pathogens and damage between the internal

and external environment in bodily defense; Langerhans cells in the skin are part of

the adaptive immune system.

2. Sensation - contains a variety of nerve endings that react to heat and cold, touch,

pressure, vibration, and tissue injury.

3. Heat regulation - the skin contains a blood supply far greater than its requirements

which allows precise control of energy loss by radiation, convection and conduction.

Dilated blood vessels increase perfusion and heatloss, while constricted vessels greatly

reduce cutaneous blood flow and conserve heat.

4. Control of evaporation - the skin provides a relatively dry and semi-impermeable

barrier to fluid loss. Loss of this function contributes to the massive fluid loss in burns.

5. Aesthetics and communication - others see our skin and can assess our mood,

physical state and attractiveness.

6. Storage and synthesis: acts as a storage center for lipids and water, as well as a means

of synthesis of vitamin D by action of UV on certain parts of the skin.

7. Excretion - sweat contains urea, however its concentration is 1/130th that of urine,

hence excretion by sweating is at most a secondary function to temperature regulation.

8. Absorption - Oxygen, nitrogen and carbon dioxide can diffuse into the epidermis in

small amounts, some animals using their skin for their sole respiration organ (contrary to

popular belief, however, humans do not absorb oxygen through the skin). In addition,

medicine can be administered through the skin, by ointments or by means of

adhesive patch, such as the nicotine patch or iontophoresis. The skin is an important

site of transport in many other organisms.

9. Water resistance - The skin acts as a water resistant barrier so essential nutrients

aren't washed out of the body.

I. VITAL INFORMATION
 Name (initials): R.A
Age: 65 years old
Sex: Female
Address: Panay, Capiz
Civil Status: Married
Religion: Roman Catholic
Occupation: --------
Date and Time admitted: November 11, 2009 at 3:50 pm
Ward: Intensive Care Unit (ICU) Cubicle F
Chief Complaint: Unresponsiveness
Admitting Diagnosis: T/C Anaphylactic Shock, T/C Stevens - Johnson syndrome,
S/P CVA, T/C Restroke
Attending Physician/s: Dr. J.B

II. CLINICAL ASSESSMENT

A. Nursing History
2 days prior to admission, Mrs R.A was noted to have appearance of maculopapular
rashes on the trunk progressing to whole body, and was noted to have oral sores. She is
febrile and Mrs. R.A was noted to be unresponsive.

B. Past Health Problem / Status

Past Illnesses: Mr. R.A is a 65 year old Female positive from Cerebrovascular disease,
Renal disease, Hypertension, and Cardiovascular disease diagnosed last October 2009 and
she is having her maintenance.

C. Family History of Illness

Both of her parents have hypertension, diabetes mellitus type -2 and a history of,
Cardiovascular disease. Some of her siblings have it too.
 FAMILY GENOGRAM

P.A
DM -2, M.A Dm -2, HPN,
HPN 83 92 CVA

N.A
P.A
56
69

L.A A.A F.L

R.A M.A G.A B.A
65 63 60 59 53 50 41
83
HPN
T/C Anaphylactic Shock, DM -2, LEUKEMIA
T/C Stevens - Johnson HPN
syndrome, S/P CVA, T/C
Restroke

J.L
MOTOR RIDE Legend:
N.A J.L R..L
F.A C.Z H.B ACCIDENT
39 37 26 Deceased male
41 32 29 24

HPN
Deceased female

Indicates patient

Living male

Living female
 I. BRIEF SOCIAL, CULTURAL AND RELIGIOUS BACKGROUND

A. Educational Background
Mr. R.A is an elementary graduate.

B. Occupational Background
She is being supported by her children.

C. Religious Background
She is a Roman Catholic and attends mass on Sundays and prays the rosary at
night together with her family.

D. Economic Status
They belong to a middle class type of family and most of her children have works
already.

I. CLINICAL INSPECTION

A. Vital Signs

Upon Admission During Care

Temperature 39°C 36.3°C
Pulse Rate 96 bpm 58 - 112 bpm
Respiration 18 bpm 16 - 24 bpm
Blood
Pressure 60 / 90mmHg 60/80 - 170/100 mmHg
Cardiac Rate 100 bpm 60 - 115 bpm

B. Height, Weight, BMI – no data

C. Physical Assessment

General
 Mrs. R.A is unresponsive and restless. (+)
erythematous, (+) maculopapular rashes.

Skin, Hair, Nails

Dry and scaly skin, uniform in color, (+) hematoma
in right arm. Hair is black with visible white hair, no
lice and dandruff and dry scalp. Fingernails are
dirty and untrimmed.

Head, Face, Lymphatics

No head injuries, round in shape and oily face.

HEENT
Color of the eyes is dark brown, anicteric sclera
with pale conjunctiva. His right & left ear canal are
not clean, (-) discharges, brown in color,
symmetrical in shape. Hearing is good with no pain
and infections. Have frequent colds. No discharges
or secretions and nosebleeds. Lips are dry and
choppy, (+) oral sores. NGT and O2 at 3L/min via
Nasal Cannula noted.

Neck and Upper extremities

No lumps or swollen glands. Arms are not able to
move freely. GCS of 5 – 11.
Chest, Breast and Axilla
Normal respiration upon admission with RR of 18
bpm and abnormal during care 16- 24 bpm.

Respiratory System (Chest and Lungs)

Thorax is symmetric. RR is above normal. (+)
dyspnea, (+) slightly tachycardic .CXR results:
Dextroscoliosis, Thoracic spine, Atheromatous
aorta

Cardiovascular System
Blood pressure upon admission is 60 / 80, during
my care is 60 / 90 – 170 / 100. (+) dyspnea, (+)
slightly tachycardic, Cardiac rate is above normal
with AR of 70 – 115 bpm and respiration of 16 - 24
bpm.

Gastrointestinal System
Feeding is through NGT with Diben at 250 cc every
4 hours.

Genito – Urinary System

Foley catheter noted. Sometimes her urine output
is low but sometimes it’s normal. 700 – 1500 cc /
shift.

Musculoskeletal System
(+) weakness, (+) limitation of motion or activity, (+)
grossly, (+) maculopapular rashes, Legs are not
able to move freely. GCS of 5 – 11 (+)
erythematous.

D. General Appraisal
 Speech: Mrs. R.A is unresponsive.
Language: Mrs. R.A is unresponsive, she cannot respond to any verbal command.
Hearing: Mrs. R.A’s hearing is quite good but she cannot response.
Mental Status: Mrs. R.A is not coherent, she cannot communicate.
Emotional status: Mrs. R.A sometimes cries.

I. LABORATORY AND DIAGNOSTIC DATA

A. Hematology
Hematology or hematology is the branch of biology (physiology), pathology, clinical
laboratory, internal medicine, and pediatrics that is concerned with the study of blood, the blood
of forming organs, and blood diseases. Hematology includes the study of etiology, diagnosis,
treatment, prognosis, and prevention of blood diseases.

Test Result Normal Significance

Values
Date: 11/12/09
WBC count 15.6x10^9/L 4.5-11.0 ↑ Infection
RBC count 4.90x10^12/L 4.2-5.4 The result is Within Normal
Range.
Hemoglobin 140g/L 120-160 The result is Within Normal
Range.
Hematocrit 0.40 vol.fr 0.37-0.47 The result is Within Normal
Range.
Bands 0.01
Segmenters 0.98 % 50 – 65% ↓
Eosinophils 4 0-3 ↑ Allergic reactions
Basophils 0.0% 0-1 The result is Within Normal
Range.
Lymphocytes 0.01% 20-45 ↓ It signifies severe
debilitating illnesses.
Monocytes 5% 0-8 The result is Within Normal
Limits.

A. Blood Chemistry
The serum chemistry profile is one of the most important initial tests that are commonly
performed on sick or aging patient. A blood sample is collected from the patient. The blood is then
separated into a cell layer and serum layer by spinning the sample at high speeds in a machine
called centrifuge. The serum layer is drawn off and a variety of compounds are then measured.
These measurements aid the veterinarian in assessing the function of various organs and body
systems.
 Test Result Normal Values Significance
Date: 11/12 /09
Glucose 11.52 4.10 – 5.90 ↑ Hyperglycemia
mmol/L
Sodium 125.3 137.0 – 145.0 ↓ Renal insufficiency,
mmol/L uremia
Creatinine 210.9 71.0 – 133.0 ↑ Impaired renal function,
ummol/L shock
Cholesterol 2.44 0.00 – 5.20 The result is Within Normal
mmol/L Range.
Direct HDLC .58 mmol/L 1.00 – 1.60 ↓ Indicates risks in CAD
LDL 1.20 1.71 – 4.60 The result is Within Normal
mmol/L Range.
VLDL 1.65 0.00 – 1.03 ↑ Elevation indicates
mmol/L increase risk in CAD
Potassium 4.72 3.5– 5.10 The result is Within Normal
ummol/L Range.
Triglycerides 1.42 mmol / 0.00 – 1.69 The result is Within Normal
L Range.
Urea 26.66 2.50 – 6.10 ↑ Impaired renal function
mmol /L

A. ABG Analysis
It is also called arterial blood gas (ABG) analysis, is a test which measures the amounts
of oxygen and carbon dioxide in the blood, as well as the acidity (pH) of the blood. It indicates
how well the lungs and kidneys are interacting to maintain normal blood pH (acid-base balance).
It evaluates how effectively the lungs are delivering oxygen to the blood and how efficiently they
are eliminating carbon dioxide from it.

Test Result Normal Values Significance

Date: 11/11/09
pH 7.39 7.35 – 7.45 The result is Within Normal
Limits.
pO2 296.1 mmHg 80 – 100 mmHg ↑
HCO3 19.2 mmol/L 22 – 26 mmol/L ↓ Acidosis
 PaCO2 32.2 mmol/L 35 - 45mmol/L ↓ Alkalosis
ABE -4.2 mmol/L -2 - +2
SBE -48 mmol/L
SBC 21 mmol/L
O2 saturation 99.8% 97 – 100% The result is Within Normal
Limits.
TCO2 45.2 mmol/L

A. Urinalysis
A urinalysis is a test performed on a patient's urine sample to diagnose
conditions and diseases such as urinary tract infection, kidney infection, kidney stones,
inflammation of the kidneys, or screen for progression of conditions such as diabetes
and high blood pressure.

Test Result Normal Range Significance

Date: 11/11/09
(Macroscopic)
Color Dark Straw Straw, Amber,
Transparent
Transparency Cloudy Clear Abnormal results. It
indicates infection like
pyuria or bacteuria
pH 5.0 4.5 – 8.0 The result is Within Normal
Limits.

Specific Gravity 1.030 1.010- 1.030 The result is Within Normal

Limits.
Glucose Negative Negative The result is Within Normal
Limits.
(Microscopic)
Amorph. U/P many Infection
RBC/hpf 0-1
WBC/hpf 0–2
Epith. Cells many Infection
Mucus thread moderate Infection

B. HbAIc Determination

The use of hemoglobin A1c (HbAIc) is for monitoring the degree of control of glucose
metabolism in diabetic patients.

Test Result Normal Values Significance

Date: 11/12/09
HbAIc -7.9 % -4.2 – 6.2% ↑ DM

A. CXR AP(Mobile)
 Test Findings Impression
Date: 11/12/09
CXR (anterior) The lung fields are clear, Dextroscoliosis,
The cardiac shadow is not enlarged, Thoracic spine
Curvilinear calcific opacity is noted in Atheromatous aorta
the aortic arch,
There is a lateral curvature of the
thoracic spine with convexity to the
Right,
The CP angles, diaphragm, and soft
tissue structures are unremarkable.

Test Result
Date: 11/11/09
Trop. I < 0.01 ug/L

B. Troponin I Determination

I. PATHOPHYSIOLOGY

Precipitating
STEVENS-JOHNSON
Triggering
Immune
Hypersensitivity
Inflammatory
Formation
complexes
a T-cell–mediated
Predisposing ofresponse
-reactive
caused
formedinby
Factors: by
cytotoxic
many drugs, factors:
auto
metabolites
antibodies
viral
reaction
infections,
that
tissues.
to
and
bind
drug
autoantigens
to
and
antigens
and
malignancies.
alterin
Age: 65 SYNDROME
y.o
cell
combining.
keratinocytes.
proteins. II.
Lifestyle: Smoking, Eating
Family History: fatty foods.
hypertension, diabetes
mellitus type -2, Certain disease:
Cardiovascular disease Cardiovascular disease
diagnosed last October
2009, Hypertension, Renal
III. MEDICAL MANAGEMENT
A. Drug Study
Name of the
Drug with Generic Name Action Mechanism of Indications Side Effects Contraindications Nursing Responsibilities
Dosage Action

Hiza Lansoprozole Antisecretory Gastric acid –

Short term
Dizziness Contraindicated with 1. Administer before meals.
drug pump inhibitor. treatment (up hypersensitivity to
Suppresses to 8 weeks) of Headache lansoprozole or any 2. Let the patient swallow the
30mg, 1 tab gastric ulcer.
Proton pump gastric acid of its compartments. capsule whole, not chew,open
BID Healing of
inhibitor secretion by Nausea or crush.
NSAID-related
specific inhibition
gastric ulcer.
of the hydrogen – Vomiting 3. For NGT, place 15 or 30 mg
potassium Maintenance tablet and draw 4 – 10 ml of
therapy for
ATPase enzyme healing of Diarrhea water, shake gently for quick
system at the erosive dispersal.
secretory surface esophagitis,
duodenal
of the gastric 4. Report severe headache,
ulcers.
parietal cells; worsening of symptoms, fever,
blocks the final and chills.
step of acid
production. 5. Arrange to have a regular
medical follow – up care while
taking this drug.

Ecosta Simvastatin Antihyperlipid Inhibits HMG- Adjunct to diet Nausea Contraindicated with 1. Take drug in the evening.
emic CoA reductase, in the allergy to simvastatin,
20 mg, 1 tab the enzyme that treatment of Headache fungal byproducts. 2. Explain to patient not to
BID HMG-CoA catalyzes the first elevated total drink grapefruit juice while
 I. NURSING MANAGEMENT
A. Concept Map of Nursing Problems

es at the
usion right buttock.
imbalance specifically
3. Infectionaltered
2. Altered CC:blood flow.
r/tthermoregulation
Unresponsiveness
invasion of related
bacterial to invasioninofthe
microorganism
rial flow AEB decreased pulses,Dx: palet/c Stevens-Johnson
pathogens
/ cool lungs
feet, thick brittle nails.
Objective/s:
+) Pallor, (+) Decreased, (+) Tachycardia, RR- 24 bpm, AR – 70 - 115 bpm, BP - 60/80 - 170/100 mmHg, O 2 Sat. – 97 – 100%,
Syndrtome
Objective/s:
cyx area), (+) Maculopapular rashes all over
to the body, (+) Dry and scaly skin, (+) Scratching of the skin, (+) Dirty nails,
Temp. 37.9 C, Skin warmObjective/s:
my skin, (+) dry Touch,
and chopped
Weak inlips, (+) pale / cool feet, RR – 24 bpm, BP - 60/80 - 170/100 mmHg, P – 58 bmp, Blood Glucose – 11.52
Appearance, WBC 15.6x10^9/L
Based on the Laboratory results: (N.V - 4.5-11.0),
Lymphocytes 0.01% (N.V - 20-45)
Eosinophils 4.0% (0-3%),
WBC 15.6x10^9/L (4.5 – 11.0 X 10 ^ 9/L), (+) whitish
productive cough, (+), Temperature. 37.9°C
 ASSESSMENT NURSING PLANNING NURSING RATIONALE NURSING EVALUATION
DIAGNOSIS INTERVENTION/S THEORIST/S

Objective/s: Impaired gas After 4 hours of Independent: Goal partially met.

• (+) exchange r/ t nursing intervention, 1. Position 1. Lowers Lydia Hall’s theory
Restlessness
Ventilation MRS. RA will have MRS. RA in semi diaphragm of Care - Nurturance After 4hours of
• (+) DOB perfusion decrease in difficulty fowler’s position and promoting chest nursing intervention.
imbalance of breathing AEB change position every expansion and MRS. RA was able
• (+) Crackles
specifically decrease RR. 2 hours decrease pressure to re-establish
• (+) Pallor
altered blood on the abdomen normal breathing
• (+) Decreased flow. pattern but some of
2. Provide back 3. This will allow Virginia the secretions are
• (+) Tachycardia
tapping to MRS. RA. mobilization and Henderson’s theory still present.
• RR- 24 bpm
expectorations of of 14 Basic Needs
• AR – 70 - 115 secretions. (Doing the for the
bpm
patient what they
• BP - 60/80 - cannot do for
170/100 mmHg
themselves)
• O2 Sat. – 97 –
100%
3. Suction as 1. Clears airway Faye Abdellah’s
• O2 via nasal Indicated. from theory of 21 Nursing
cannula at
secretions. Problems (Doing the
3L/min.
for the patient what
they cannot do for
• Pulse Oximeter
attached. themselves)
 4. Note rate, 2. The Ernestine
rhythm and respirations Weidenback (Nurse
depth of become meets through
respiration. shallow, and identification of
the patient will needs)
begin to
hypoventilate.

Dependent:
1. Administer O2 1. To relieve o2 Dorothy Johnson’s
therapy 3 L/min deficit. theory of Human
Behavioral System
(Medicine focus:
Cure)
2. Nebulization 2. To loosen and
1L/m with combivent liquefy secretions. Florence
Nightingale’s theory
of Environment
(Alleviate
unnecessary source
of pain and
suffering).

Collaborative:
1. Monitor Pulse 1. This tool is Lydia Hall’s theory
oximeter for useful to of Components of
detect
oxygenation. changes in Nursing / Caring
oxygenation. (Core and Cure
Oxygen -shared with other
saturation
health care
should be
maintained providers)
at 90% or
greater.

Lydia Hall’s theory

2. Monitor arterial 2. PaCO2 and of Components of
blood gases PaO2 may Nursing / Caring
fluctuate.
and note These are (Core and Cure
changes. the signs of -shared with other
respiratory health care
failure.
providers)
 ASSESSMENT NURSING PLANNING NURSING RATIONALE NURSING EVALUATION
DIAGNOSIS INTERVENTION THEORY AND
THEORIST

Objective/S: Altered After 2 hours of Independent: Goal met.

• Temp. 37.9 C thermoregulation nursing 1. Provide tepid 1. May help reduce Betty Neuman
related to invasion intervention, the sponge bath. fever and provide (Help the client’s Temperature is
• Skin warm to
of pathogens patient’s comfort. system attain, decreased from
Touch
temperature will maintain and 37.9°C to 36.3°C

• Weak in
decrease from regain system

Appearance 37.9 C to 36.3 C stability.)

within the shift.
• WBC result 2. Provide a cool 2. Room Betty Neuman
15.6x10^9/L and calm temperature/ (On the whole
(N.V - 4.5-11.0) environment. number of person and
•
blankets should reaction to stress.)
• Lymphocytes L
be altered to
0.01% (N.V - 20-
maintain near
45)
normal body
temperature.
Betty Neuman
3. Monitor 3. Temperature (Help the client’s
patient’s elevation may system attain,
temperature occur because of maintain and
 every hour. various factors regain system
such as presence stability.)
of infection.
Dependent: Dorothy
1. Administer 1. To help reduce Johnson’s theory
Paracetamol fever by acting of Human
300 mg IV. (by directly on the Behavioral System
NOD) heat regulating (Medicine focus:
system Cure)
 ASSESSMENT NURSING PLANNING INTERVENTION/S RATIONALE NURSING EVALUATION
DIAGNOSIS THEORIST/S

Objective/s: Infection r/t invasion To prevent the Independent: Goal Partially Met.
Based on the of bacterial severity of infection 1. Note for 1. Infections Ernestine
Laboratory results: microorganism in the with the hospital physical evidence must be treated to Weidenback After 8 hours of
○ Eosinophils lungs stay AEB by of infection stop the immune (Nurse meets nursing intervention
4.0% (0-3%) decreased response . through MRS. R.A was able
temperature and identification of to cough out mucus
○ WBC expelled mucus needs) secretions and her
15.6x10^9/L (4.5 – secretions. temperature
11.0 X 10 ^ 9/L) 2. Implement 2. Hand washing Dorothea Orem’s decreased to
appropriate by all people in theory of Nursing 36.3 °C.
• (+) whitish measures to protect contact with the Concepts
productive cough the patient from patient is the (Identifies what
potential infection primary method to Nursing Care is
• (+) sources. reduce the risk of needed)
Temperature. infection.
– 37.9°C
3. Monitor 3. Th Ernestine
heart rate and ere is an Weidenback
blood increase in (Nurse meets
pressure. cardiac output through
reflected by identification of
tachycardia needs)
and normal or
elevated BP. Ernestine
ASSESSMENT NURSING PLANNING NURSING RATIONALE NURSING EVALUATION
DIAGNOSIS INTERVENTION/S THEORIST/S
Objective/s: Ineffective After 8 hours of Independent: Goal partially met.
• (+) Paleness peripheral nursing
perfusion r/t intervention, MRS. 1. Elevate feet 1. Minimize Virginia After 8 hours of
• (+) Weakness
decreased RA will maintain using pillow or interruption of Henderson’s nursing
• (+) Pallor blood flow,
arterial flow AEB adequate level of elevate the leg theory of 14 Basic intervention. MRS.
reduces
• (+) Cold decreased hydration to part of the bed. venous Needs (Doing the RA was able to
clammy skin. pooling.
pulses, pale / maximize for the patient what maintain adequate
• (+) dry and cool feet, thick perfusion, AEB they cannot do for level of hydration
chopped lips
brittle nails. balanced intake / themselves) AEB Pulse – 90
• (+) pale / cool output, moist skin / bpm,
feet
mucous 2. Note for Ernestine Intake – 1145cc
2. Glycosuri
• RR – 24 bpm membrane. dehydration. Weidenback and Output of
a may result
Monitor intake in dehydration (Nurse meets 1100cc.
• BP - 60/80 -
170/100 and output. with through
mmHg consequent
identification of
reduction of
circulating needs)
• P – 58 bmp volume and
further
3. OTF 200 cc of Ernestine
• Blood Glucose impairment of
– 11.52 Diben given peripheral Weidenback
mmol/L (4.10 through patent circulation. (Nurse meets
– 5.90)
NGT. through
identification of
3. Antidiab
• Direct HDLC - needs)
etic diet.
.58 mmol/L Independent:
(1.00 – 1.60)
 1. Administer Dorothy
Simvastatin Johnson’s theory
• VLDL - 1.65
mmol/L (0.00 of Human
– 1.03)
Behavioral System
(Medicine focus:
• LDL - 1.20
mmol/L (1.71 – 1. Antihyperlipidemic Cure)
4.60) Collaborative:
Lydia Hall’s theory
• HbAIc - -7.9 % 1. M of Components of
(-4.2 – 6.2%)
onitor Blood Nursing / Caring
Chemistry (Core and Cure
• Intake –
1056cc Profile. -shared with other
health care
1. To know the
• Output – 745 providers)
changes in the
cc
previous result.

NURSING NURSING
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE THEORY AND EVALUATION
THEORIST
Objective/s: Impaired skin To display timely Independent: Goal Partially met.
• (+) bed sore integrity r/t bed healing of bed 1. Protec 1, The poor Ernestine
at the Right sores at the right sores without t skin from peripheral circulation Weidenback After 8 hours of
buttock buttock. complications within trauma and of PAD places the (Nurse meets Nursing
(coccyx area). the hospital stay. prolonged patient at high risk for through intervention,
pressure. injury. identification of affected area is
• (+) needs) maintained dry and
Maculopapular cleaned. Bed sores
rashes all over 1. To prevent Betty Neuman is still noted.
the body. infections. (Help the client’s
2. Keep system attain,
• (+) Dry and the infected maintain and regain
scaly skin. area dry system stability.)
always.
• (+) Scratching 2. Scratching can Ernestine
of the skin. cause lesions and open Weidenback
sores. (Nurse meets

• (+) Dirty nails, 3. Note for through

scratching identification of
untrimmed.
skin and of needs)
keeping finger
nails short 3. Mittens prevent Betty Neuman
and clean. excessive (Help the client’s
scratching. system attain,
 maintain and regain
4. Put mittens system stability.)
on hands if
necessary. 4. Immobility is greater Ernestine
risk for skin Weidenback
breakdown. (Nurse meets
through
5. Note the identification of
patient’s needs)
ability to
move. 5. To avoid pressure Betty Neuman
on affected area (Help the client’s
causing for the system attain,
severity. maintain and regain
system stability.)
6. Position
patient on the
non infected
area.
 I. DISCHARGE PLANNING

M – edications
Medications prescribed by the physician should be taken properly, to help the patient
lessen unusual condition. (MRS. RA is still admitted in the hospital)

E – xercise and Activity

Encourage folks to help MRS. RA to have an active range of motion exercises thrice
daily to maintain her muscle strength.
Get plenty of rest. Adequate rest is important to maintain progress toward full recovery
and to avoid relapse.

T – reatment
Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when
needed.
Treatment is one of the main factors in restoration of health and curing of the failure in
the body system. Treatments are given to the patient for a specific time until treatment is not
more needed by the patient.

H – ome Teaching/s
Encourage the folks to wash patient’s hands. The hands come in daily contact with
germs that can cause infections. These germs enter one’s body when he touch his eyes or rub
his nose. Washing hands thoroughly and often can help reduce the risk.
Tell folks to avoid exposing the patient to an environment with too much pollution
(e.g. smoke). Smoking damages one’s lungs’ natural defenses against respiratory infections.
O – ut patient follow up
Keep all of follow-up appointments, even though the patient feels better. It’s important to
have the doctor monitor his progress.

D – iet
Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated
and help loosen mucus in the lungs.
Advice the patient not to eat foods that is high in cholesterol such as the fatty portion of
the pork that may increase the level of her blood pressure but to eat more green and leafy
vegetables.

S – pirituality and Sexuality

In order to improve her spiritual aspects, he may attend holy masses or listen to gospel readings
and pray the holy rosary or she may seek for divine providence to the Lord. Assist the patient
that may include spiritual resources to help her deal with it.
XIV.BIBLIOGRAPHY / REFERENCES

• Nursing Care Plan Diagnosis and Interventions 8th Ed

By: Gulanick and Myers

• Nursing Diagnosis Handbook A Guide for Planning Care 7th Ed.

 By: Betty J. Ackley and Gail b. Ladwig

• Drug Information Handbook for Nursing 2nd Ed.

By: Lilley, Harrington and Snyder

• MIMS 2008 - 2009 Ed.

• Professional Guide to Pathophysiology 2nd Ed.

By: Kozier and Erbs