A nurse is caring for a patient with Stevens-Johnson syndrom… | 마이메르시 MyMerci
Adult Health
문제

A nurse is caring for a patient with Stevens-Johnson syndrome (SJS). Which nursing intervention should be the highest priority?

해설
Airway management is the highest priority in Stevens-Johnson syndrome due to potential mucosal involvement that can cause respiratory distress and airway obstruction. Other interventions like topical antibiotics, hydration, or pain management are important but secondary to maintaining airway patency.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question tests the priority nursing intervention for a patient with Stevens-Johnson Syndrome (SJS), a severe, life-threatening mucocutaneous reaction. The core pathophysiology involves widespread apoptosis (programmed cell death) of the epidermis, leading to detachment of the skin and mucous membranes. Mucosal involvement of the respiratory tract (oropharynx, trachea, bronchi) can cause edema, blistering, and sloughing, which directly threatens Key Point! airway patency and is the leading cause of early mortality in SJS.

Answer Rationale: Key Point! The highest priority in any emergency or critical care situation follows the ABC (Airway, Breathing, Circulation) framework. In SJS, airway compromise is a real and immediate threat. Therefore, monitoring for signs of respiratory distress (stridor, hoarseness, increased work of breathing) and maintaining airway patency is the undisputed top priority. This aligns with the nursing process where life-threatening issues are addressed first.

Distractor Analysis:
• Watch out for confusion! Option ① (Apply topical antibiotics): While preventing secondary infection of denuded skin is crucial, it is not the highest priority. Furthermore, indiscriminate application of topical agents to large areas can increase systemic absorption and risk of toxicity or allergic reaction.
• Option ② (Encourage oral fluid intake): Maintaining hydration and electrolyte balance is vital due to massive fluid loss through damaged skin. However, in the acute phase, severe oral mucosal involvement may make oral intake impossible, necessitating IV fluids. Airway management still takes precedence.
• Option ④ (Administer pain medication): Pain management is a critical component of compassionate care for SJS, as the condition is extremely painful. Yet, ensuring the patient can breathe is a more fundamental physiological need that must be secured before addressing comfort.

Related Concepts: SJS and its more severe form, Toxic Epidermal Necrolysis (TEN), are medical emergencies often triggered by medications (e.g., sulfonamides, anticonvulsants, allopurinol). Nursing care also focuses on wound care akin to burns, fluid resuscitation, nutritional support, meticulous infection control, and monitoring for sepsis.

Concept Summary • Pathophysiology: Immune-mediated keratinocyte apoptosis → epidermal detachment. • Priority: Always ABCs. Airway is #1 due to mucosal sloughing. • Key Interventions: Airway management, fluid resuscitation, aseptic wound care, pain control, infection prevention, nutritional support. • Common Triggers: Medications (most common), infections (e.g., Mycoplasma).
Side-by-Side Comparison!
ConditionKey FeaturePriority Nursing Concern
Stevens-Johnson Syndrome (SJS)Skin detachment < 10% of body surface area (BSA). Mucosal involvement.Airway patency (mucosal sloughing).
Toxic Epidermal Necrolysis (TEN)Skin detachment > 30% BSA. Considered a continuum with SJS.Airway patency & Burn-like fluid resuscitation (massive fluid loss).
Erythema MultiformeTarget lesions. Limited mucosal involvement. Less severe.Symptom management (pain, itching), identify & remove trigger.

Anatomy, Physiology & Pharmacology Points • Mucosa at Risk: Oropharynx, conjunctiva, genitalia, and respiratory epithelium. Inflammation here causes airway obstruction. • Fluid Loss: The denuded skin loses its barrier function, leading to insensible fluid loss, hypovolemia, and electrolyte imbalances. • Common Culprit Drugs: Allopurinol, sulfonamides (e.g., Bactrim), anticonvulsants (e.g., lamotrigine, phenytoin), NSAIDs, nevirapine.
Memory Tips • ABCs for SJS: "Airway Before Comfort (or Creams)". This reminds you that breathing comes before pain meds or topical treatments. • Trigger Mnemonic: "All Sorts of Anti's Need Care" (Allopurinol, Sulfonamides, Anticonvulsants, NSAIDs, Chemotherapy agents).
High-Frequency NCLEX Topics NCLEX loves to test prioritization and ABCs. SJS/TEN is a classic scenario where a dermatologic condition has a critical systemic (airway) complication. Expect questions asking for the first action, priority assessment, or most urgent intervention.
Watch Out for Question Variations! • Instead of asking for the priority intervention, it might ask: "Which assessment finding requires immediate intervention?" (Answer: Stridor or dyspnea). • It could be combined with medication knowledge: "A patient on lamotrigine develops a rash and oral ulcers. What is the nurse's priority?" (Answer: Stop the drug and assess airway). • It might test the difference between SJS and other rashes: "What differentiates SJS from a mild drug rash?" (Answer: Mucosal involvement and systemic symptoms).

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse on a medical unit. A 28-year-old female was admitted 24 hours ago for a new rash after starting Bactrim for a UTI. Overnight, her rash has worsened into large blisters, and she now complains of painful mouth sores and a sore throat. Her voice sounds slightly hoarse.

Nursing Intervention Strategy: 1. Immediate Assessment (ABCs): Listen for stridor, assess respiratory rate and effort, check oxygen saturation. Inspect the oropharynx (with caution). Notify the provider immediately of any airway concerns. Have emergency airway equipment at the bedside. 2. Collaborative Care: The patient will likely be transferred to an ICU or burn unit. Discontinue the offending drug. Collaborate with wound care specialists for sterile, non-adherent dressings (e.g., petroleum gauze, silicone dressings). 3. Comprehensive Management: • Fluids & Nutrition: Establish IV access for hydration and parenteral nutrition if oral intake is not possible. • Infection Control: Implement strict reverse isolation. Meticulous hand hygiene. Monitor for signs of sepsis (fever, tachycardia, hypotension). • Pain & Comfort: Administer IV opioids via PCA (Patient-Controlled Analgesia) for severe background pain. Provide gentle oral care with saline or prescribed rinses. • Psychosocial Support: This is a traumatic, disfiguring illness. Provide emotional support and clear explanations.

Patient Safety and Precautions: • Skin Care: Do not rupture blisters. Handle the patient with extreme care to prevent further skin shear. Use a lift sheet. • Medication Alert: Document the suspected drug reaction prominently in the chart and educate the patient/family. This is a lifelong contraindication. • Eye Care: Consult ophthalmology daily. Conjunctival involvement can lead to scarring and blindness.
Nursing Procedure & Medication Flow • Airway Monitoring: Assess every 1-2 hours in acute phase: listen to lung sounds, observe for accessory muscle use, monitor SpO2. • Wound Dressing Change: Use aseptic technique. Pre-medicate for pain. Gently cleanse with sterile saline or antiseptic solutions per protocol. Apply prescribed topical agents (e.g., silver sulfadiazine, antimicrobial dressings). • Medication Administration: Common drugs include IV corticosteroids (controversial, institution-dependent) and IV immunoglobulin (IVIG). Administer IVIG per protocol, monitoring for infusion reactions (fever, chills, hypotension).
A Word from Your Senior Nurse "Stevens-Johnson syndrome is one of those 'don't just see the skin, see the system' conditions. That hoarse voice isn't just a nuisance; it's a red flag waving at you, saying 'check my airway NOW!' In clinical practice, your keen assessment skills are your patient's first line of defense. When you're studying, always link the patho (mucosal sloughing) to the priority (airway). This kind of critical thinking is exactly what the NCLEX tests and what will make you an exceptional nurse who catches problems before they become catastrophes."

핵심 개념

  • Stevens-Johnson Syndrome — A severe, life-threatening mucocutaneous disorder characterized by widespread epidermal detachment and blistering of the skin and mucous membranes, often drug-induced.
  • Toxic Epidermal Necrolysis — The most severe form of SJS, involving skin detachment of >30% of body surface area. Managed similarly to major burns.
  • ABC Priority — The fundamental framework for assessment and intervention: Airway, Breathing, Circulation. Life-threatening airway issues are always the top priority.
  • Mucosal Involvement — Involvement of the mucous membranes (oral, ocular, respiratory, genital). In SJS/TEN, this is a hallmark and the source of major complications like airway obstruction.
  • Apoptosis — Programmed cell death. In SJS/TEN, widespread apoptosis of keratinocytes leads to the separation of the epidermis from the dermis.

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