Nursing Process: Care of the Patient With Blistering Diseases

NURSING PROCESS:CARE OF THE PATIENT WITH BLISTERING DISEASES

Assessment

Patients with blistering disorders may experience significant dis-ability. There is constant itching and possible pain in the de-nuded areas of skin. There may be drainage from the denuded areas, which may be malodorous. Effective assessment and nurs-ing management become a challenge.

Disease activity is monitored clinically by examining the skin for the appearance of new blisters. Areas where healing has oc-curred may show signs of hyperpigmentation. Particular atten-tion is given to assessing for signs and symptoms of infection.

Diagnosis

NURSING DIAGNOSES

Based on nursing assessment data, the patient’s major nursing di-agnoses may include the following:

·      Acute pain of skin and oral cavity related to blistering and erosions

·      Impaired skin integrity related to ruptured bullae and de-nuded areas of the skin

·      Anxiety and ineffective coping related to the appearance of the skin and no hope of a cure

·      Deficient knowledge about medications and side effects

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Based on the assessment data, potential complications include the following:

·      Infection and sepsis related to loss of protective barrier of skin and mucous membranes

·      Fluid volume deficit and electrolyte imbalance related to loss of tissue fluids

Planning and Goals

The major goals for the patient may include relief of discomfort from lesions, skin healing, reduced anxiety and improved coping capacity, and absence of complications.

Nursing Interventions

RELIEVING ORAL DISCOMFORT

The patient’s entire oral cavity may be affected with erosions and denuded surfaces. A necrotic slough may develop over these areas, adding to the patient’s discomfort and interfering with food in-take. Weight loss and hypoproteinemia may result. Meticulous oral hygiene is important to keep the oral mucosa clean and allow the epithelium to regenerate. Frequent rinsing of the mouth is prescribed to rid the mouth of debris and to soothe ulcerated areas. Commercial mouthwashes are avoided. The lips are kept moist with lanolin, petrolatum, or lip balm. Cool mist therapy helps to humidify environmental air.

ENHANCING SKIN INTEGRITY AND RELIEVING DISCOMFORT

Cool, wet dressings or baths are protective and soothing. The pa-tient with painful and extensive lesions should be premedicated with analgesics before skin care is initiated. Patients with largeareas of blistering have a characteristic odor that decreases when secondary infection is controlled. After the patient’s skin is bathed, it is dried carefully and dusted liberally with nonirritat-ing powder, which enables the patient to move freely in bed. Fairly large amounts are necessary to keep the patient’s skin from sticking to the sheets. Tape should never be used on the skin be-cause it may produce more blisters. Hypothermia is common, and measures to keep the patient warm and comfortable are pri-ority nursing activities. The nursing management of patients with bullous skin conditions is similar to that for patients with exten-sive burns.

REDUCING ANXIETY

Attention to the psychological needs of the patient requires lis-tening to the patient, being available, giving expert nursing care, and educating the patient and the family. The patient is encour-aged to express freely anxieties, discomfort, and feelings of hope-lessness. Arranging for a family member or a close friend to spend more time with the patient can be supportive. When pa-tients receive information about the disease and its treatment, uncertainty and anxiety are reduced, and the patient’s capacity to act on his or her own behalf is enhanced. Referral for psycho-logical counseling may assist the patient in dealing with fears, anxiety, and depression.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Infection and Sepsis

The patient is susceptible to infection because the barrier func-tion of the skin is compromised. Bullae are also susceptible to in-fection, and sepsis may follow. The skin is cleaned to remove debris and dead skin and to prevent infection.

Secondary infection may be accompanied by an offensive odor from skin or oral lesions. C. albicans of the mouth (ie, thrush) commonly affects patients receiving high-dose corticosteroid therapy. The oral cavity is inspected daily, and any changes are reported. Oral lesions are slow to heal.

Infection is the leading cause of death in patients with blister-ing diseases. Particular attention is given to assessment for signs and symptoms of local and systemic infection. Seemingly trivial complaints or minimal changes are investigated, because cortico-steroids can mask or alter typical signs and symptoms of infection. The patient’s vital signs are taken, and temperature fluctuations are monitored. The patient is observed for chills, and all secre-tions and excretions are monitored for changes suggesting in-fection. Results of culture and sensitivity tests are monitored. Antimicrobial agents are administered as prescribed, and response to treatment is assessed. Health care personnel must perform ef-fective hand hygiene and wear gloves.

In the hospitalized patient, environmental contamination is reduced as much as possible. Protective isolation measures and standard precautions are warranted.

Fluid and Electrolyte Imbalance

Extensive denudation of the skin leads to fluid and electrolyte im-balance because of significant loss of fluids and sodium chloride from the skin. This sodium chloride loss is responsible for many of the systemic symptoms associated with the disease and is treated by intravenous administration of saline solution.

A large amount of protein and blood is lost from the denuded skin areas. Blood component therapy may be prescribed to main-tain the blood volume, hemoglobin level, and plasma protein concentration. Serum albumin, protein, hemoglobin, and hema-tocrit values are monitored.

The patient is encouraged to maintain adequate oral fluid intake. Cool, nonirritating fluids are encouraged to maintain hydration. Small, frequent meals or snacks of high-protein, high-calorie foods (eg, Ensure, Sustacal, eggnog, milkshakes) help maintain nutritional status. Parenteral nutrition is considered if the patient cannot eat an adequate diet.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include the following:

1)    Achieves relief from pain of oral lesions

a)     Identifies therapies that reduce pain

b)    Uses mouthwashes and anesthetic or antiseptic aerosol mouth spray

c)     Drinks chilled fluids at 2-hour intervals

2)    Achieves skin healing

a)     States purpose of therapeutic regimen

b)    Cooperates with soaks and bath regimen

c)     Reminds caregivers to use liberal amounts of nonirri-tating powder on bed linens

3)    Is less anxious and better able to cope

a)     Verbalizes concerns about condition, self, and relation-ships with others

b)    Participates in self-care

4)    Experiences no complications

a)     Has cultures from bullae, skin, and orifices that are neg-ative for pathogenic organisms

b)    Has no purulent drainage

c)     Shows signs that skin is clearing

d)    Has normal temperature

e)     Keeps intake record to ensure adequate fluid intake and normal fluid and electrolyte balance

f)      Verbalizes the rationale for intravenous infusion therapy

g)     Has urine output within normal limits

h)    Has serum chemistry and hemoglobin and hematocrit values within normal limits