NCP - Nursing Care Plan for Stevens Johnson Syndrome
Stevens-Johnson syndrome (SJS) is an immune-complex–mediated hypersensitivity complex that is a severe expression of erythema multiforme. It is known by some as erythema multiforme major, but disagreement exists in the literature. Most authors and experts consider Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) different manifestations of the same disease. For that reason, many refer to the entity as SJS/TEN. SJS typically involves the skin and the mucous membranes. While minor presentations may occur, significant involvement of oral, nasal, eye, vaginal, urethral, GI, and lower respiratory tract mucous membranes may develop in the course of the illness. GI and respiratory involvement may progress to necrosis. SJS is a serious systemic disorder with the potential for severe morbidity and even death. Missed diagnosis is common.
Although several classification schemes have been reported, the simplest breaks the disease down as follows :
- Stevens-Johnson syndrome - A "minor form of TEN," with less than 10% body surface area (BSA) detachment
- Overlapping Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) - Detachment of 10-30% BSA
- Toxic epidermal necrolysis - Detachment of more than 30% BSA
Causes of Stevens Johnson Syndrome
Stevens Johnson Syndrome is thought to arise from a disorder of the immune system.
It can be caused by infections (usually following infections such as herpes simplex virus, influenza, mumps, cat-scratch fever, histoplasmosis, Epstein-Barr virus, mycoplasma pneumoniae or similar).
It can be caused by adverse effects of drugs (allopurinol, diclofenac, etravirine, Isotretinoin, aka Accutane, fluconazole, valdecoxib, sitagliptin, oseltamivir, penicillins, barbiturates, sulfonamides, phenytoin, azithromycin, oxcarbazepine, zonisamide, modafinil, lamotrigine, nevirapine, pyrimethamine, ibuprofen, ethosuximide, carbamazepine, nystatin, and gout medications).
Although Stevens–Johnson Syndrome can be caused by viral infections, malignancies or severe allergic reactions to medication, the leading cause appears to be the use of antibiotics and sulfa drugs.
Medications that have traditionally been known to lead to SJS, erythema multiforme and toxic epidermal necrolysis include sulfonamides (antibiotics), penicillins (antibiotics), barbiturates (sedatives), lamotrigine and phenytoin (e.g. Dilantin) (anticonvulsants). Combining lamotrigine with sodium valproate increases the risk of SJS.
Non-steroidal anti-inflammatory drugs are a rare cause of SJS in adults; the risk is higher for older patients, women and those initiating treatment. Typically, the symptoms of drug-induced SJS arise within a week of starting the medication. People with systemic lupus erythematosus or HIV infections are more susceptible to drug-induced SJS.
SJS has also been consistently reported as an uncommon side effect of herbal supplements containing ginseng. SJS may also be caused by cocaine usage.
In some East Asian populations studied (Han Chinese and Thai), carbamazepine- and phenytoin-induced SJS is strongly associated with HLA-B*1502 (HLA-B75), an HLA-B serotype of the broader serotype HLA-B15. A study in Europe suggested that the gene marker is only relevant for East Asians. Based on the Asian findings, similar studies were performed in Europe which showed 61% of allopurinol-induced SJS/TEN patients carried the HLA-B58 (B*5801 allele - phenotype frequency in Europeans is typically 3%). One study concluded "even when HLA-B alleles behave as strong risk factors, as for allopurinol, they are neither sufficient nor necessary to explain the disease."
Nursing Care Plan for Stevens Johnson Syndrome
Nursing Care Plan : 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 Care Plan : Nursing Diagnosis
- Impaired sense of comfort, fever, headache, throat related to a bull.
- Fulfillment of nutritional disorders: Less than body requirements related to the difficulty in swallowing.
- Impaired skin integrity related to the fragile bull.
- Lack of knowledge about the disease process associated with less information.
- Potential secondary infections associated with side effects and therapeutic steroid infusion installed.
Nursing Intervention for Stevens Johnson Syndrome