Nursing Process: Care of the Patient With Toxic Epidermal Necrolysis

NURSING PROCESS:CARE OF THE PATIENT WITH TOXIC EPIDERMAL NECROLYSIS

Assessment

A careful inspection of the skin is made, including its appearance and the extent of involvement. The normal skin is closely ob-served to determine if new areas of blisters are developing. Seep-age from blisters is monitored for amount, color, and odor. Inspection of the oral cavity for blistering and erosive lesions is performed daily; the patient is assessed daily for itching, burning, and dryness of the eyes. The patient’s ability to swallow and drink fluids, as well as speak normally, is determined.

The patient’s vital signs are monitored, and special attention is given to the presence and character of fever and the respiratory rate, depth, rhythm, and cough. The characteristics and amount of respiratory secretions are reviewed. Assessment for high fever, tachycardia, and extreme weakness and fatigue is essential, be-cause these factors indicate the process of epidermal necrosis, increased metabolic needs, and possible gastrointestinal and res-piratory mucosal sloughing. Urine volume, specific gravity, and color are monitored. The insertion sites of intravenous lines are inspected for signs of local infection. Daily body weights are recorded.

The patient is asked to describe fatigue and pain levels. An at-tempt is made to evaluate the patient’s level of anxiety. The pa-tient’s basic coping mechanisms are assessed, and effective coping strategies are identified.

Diagnosis

NURSING DIAGNOSES

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

·      Impaired tissue integrity (ie, oral, eye, and skin) related to epidermal shedding

·      Deficient fluid volume and electrolyte losses related to loss of fluids from denuded skin

·      Risk for imbalanced body temperature (ie, hypothermia) re-lated to heat loss secondary to skin loss

·      Acute pain related to denuded skin, oral lesions, and possi-ble infection

·      Anxiety related to the physical appearance of the skin and prognosis

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

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

·      Sepsis

·       Conjunctival retraction, scars, and corneal lesions

Planning and Goals

The major goals for the patient may include skin and oral tissue healing, fluid balance, prevention of heat loss, relief of pain, reduced anxiety, and absence of complications.

Nursing Interventions

MAINTAINING SKIN AND MUCOUS MEMBRANE INTEGRITY

The local care of the skin is an important area of nursing man-agement. The skin denudes easily, even when the patient is lifted and turned; it may be necessary to place the patient on a circular turning frame. The nurse applies the prescribed topical agents that reduce the bacterial population of the wound surface. Warm compresses, if prescribed, should be applied gently to denuded areas. The topical antibacterial agent may be used in conjunction with hydrotherapy in a tank, bathtub, or shower. The nurse mon-itors the patient’s condition during the treatment and encourages the patient to exercise the extremities during hydrotherapy.

The painful oral lesions make oral hygiene difficult. Careful oral hygiene is performed to keep the oral mucosa clean. Pre-scribed mouthwashes, anesthetics, or coating agents are used fre-quently to rid the mouth of debris, soothe ulcerative areas, and control foul mouth odor. The oral cavity is inspected several times each day, and any changes are documented and reported. Petrolatum or a prescribed ointment is applied to the lips.

ATTAINING FLUID BALANCE

The vital signs, urine output, and sensorium are observed for in-dications of hypovolemia. Mental changes from fluid and elec-trolyte imbalance, sensory overload, or sensory deprivation may occur. Laboratory test results are evaluated, and abnormal results are reported. The patient is weighed daily (with a bed scale if necessary).

The nurse regulates intravenous fluids at prescribed infusion rates and assesses for systemic (ie, overinfusion or underinfusion) and local (eg, infection) complications. Oral lesions may result in dysphagia, making tube feeding or parenteral nutrition necessary. Prescribed enteral nourishment or enteral supplements can be administered by tube feeding until oral ingestion can be tolerated. A daily calorie count and accurate recording of all intake and out-put are essential.

PREVENTING HYPOTHERMIA

The patient with TEN is prone to chilling. Dehydration may be made worse by exposing the denuded skin to a continuous cur-rent of warm air. The patient is usually sensitive to room tem-perature changes. Measures implemented for a burn patient, such as cotton blankets, ceiling-mounted heat lamps, and heat shields, are useful in maintaining body temperature. To minimize shiv-ering and heat loss, the nurse should work rapidly and efficiently when large wounds are exposed for wound care. The patient’s temperature is monitored frequently.

RELIEVING PAIN

The nurse assesses the patient’s pain, its characteristics, any fac-tors that influence the pain, and the patient’s behavioral re-sponses. Prescribed analgesics are administered, and the nurse documents pain relief and any side effects. Analgesics are admin-istered before painful treatments are performed. Providing thor-ough explanations and speaking calmly to the patient during treatments can allay the anxiety that may intensify pain. Offering emotional support and reassurance and implementing measures that promote rest and sleep are basic in achieving pain control. As the pain diminishes and the patient has more physical and emo-tional energy, self-management techniques for pain relief, such as progressive muscle relaxation and imagery, may be taught.

REDUCING ANXIETY

Because the lifestyle of patients with TEN has been abruptly changed to one of complete dependence, an assessment of their emotional state may reveal anxiety, depression, and fear of dying. Patients can be reassured that these reactions are normal. They also need nursing support, honest communication, and hope that their situation can improve. They are encouraged to express their feelings to someone they trust. Listening to their concerns and being readily available with skillful and compassionate care are important anxiety-relieving interventions. Emotional support by a psychiatric nurse, chaplain, psychologist, or psychiatrist may be helpful to promote coping during the long recovery period.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Sepsis

The major cause of death from TEN is infection, and the most common sites of infection are the skin and mucosal surfaces, lungs, and blood. The organisms most often involved are S. au-reus, Pseudomonas, Klebsiella, Escherichia coli, Serratia, and Can-dida. Monitoring vital signs closely and noticing changes inrespiratory, renal, and gastrointestinal function may quickly de-tect the beginning of an infection. Strict asepsis is always main-tained during routine skin care measures. Hand hygiene and wearing sterile gloves when carrying out procedures are necessary. When the condition involves a large portion of the body, the pa-tient should be in a private room to prevent possible cross-infection from other patients. Visitors should wear protective garments and wash their hands before and after coming into contact with the patient. People with any infectious disease should not visit the pa-tient until they are no longer a danger to the patient.

Conjunctival Retraction, Scars, and Corneal Lesions

The eyes are inspected daily for signs of itching, burning, and dryness, which may indicate progression often to keratoconjunc-tivitis, the principal eye complication. Applying a cool, damp cloth over the eyes may relieve burning sensations. The eyes are kept clean and observed for signs of discharge or discomfort, and the progression of symptoms is documented and reported. Ad-ministering an eye lubricant, when prescribed, may alleviate dryness and prevent corneal abrasion. Using eye patches or re-minding the patient to blink periodically may also counteract dryness. The patient is instructed to avoid rubbing the eyes or putting any medication into the eyes that has not been prescribed or approved by the physician.

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include the following:

1)    Achieves increasing skin and oral tissue healing

a)     Demonstrates areas of healing skin

b)    Swallows fluids and speaks clearly

2)    Attains fluid balance

a)     Demonstrates laboratory values within normal ranges

b)    Maintains urine volume and specific gravity within ac-ceptable range

c)     Shows stable vital signs

d)    Increases intake of oral fluids without discomfort

e)     Gains weight, if appropriate

3)    Attains thermoregulation

a)     Registers body temperature within normal range

b)    Reports no chills

4)    Achieves pain relief

a)     Uses analgesics as prescribed

b)    Uses self-management techniques for relief of pain

5)    Appears less anxious

a)     Discusses concerns freely

b)    Sleeps for progressively longer periods

6)    Absence of complications, such as sepsis and impaired vision

a)     Body temperature within normal range

b)    Laboratory values within normal ranges

c)     Has no abnormal discharges or signs of infection

d)    Continues to see objects at baseline acuity level

e)     Shows no signs of keratoconjunctivitis