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

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## 문제

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

## 보기

1. Apply topical antibiotics to all affected skin areas
2. Maintain strict fluid and electrolyte balance monitoring **✔ 정답**
3. Administer high-dose corticosteroids as prescribed
4. Provide frequent oral hygiene with antiseptic mouthwash

**정답: 2**

## 해설

Fluid and electrolyte balance monitoring is the highest priority due to massive losses from skin barrier disruption. Other interventions like topical antibiotics, corticosteroids, or oral hygiene are important but secondary to preventing life-threatening dehydration and shock.

## 심화 해설

Understanding the Priority: Fluid and Electrolyte Balance in SJS/TEN

In Stevens-Johnson syndrome (SJS) and its more severe counterpart, toxic epidermal necrolysis (TEN), the skin's barrier function is catastrophically compromised. You can think of the epidermis as a protective "wrap" that keeps vital fluids in and pathogens out. When widespread epidermal necrosis and detachment occur, this wrap is lost. The resulting massive transepidermal fluid loss is not just dehydration; it is a profound loss of protein-rich fluid and electrolytes that mirrors the pathophysiology of a severe burn. This fluid shift leads to hypovolemia, electrolyte imbalances, and can rapidly progress to hypovolemic shock and acute kidney injury. Therefore, meticulous fluid and electrolyte management is the cornerstone of survival, directly addressing the most immediate life-threatening physiological consequence.

The case report of the elderly patient with 55% body surface area involvement explicitly highlights that "electrolyte disturbances" were a primary challenge alongside the skin loss, with an expected mortality rate of 30-50% [2]. The primary goal of initial care is not to treat the skin lesions first, but to stabilize the patient's hemodynamic status by aggressively replacing what is being lost. Without this, every other intervention, including wound care, becomes futile.

Why the Other Options Are Not the Highest Priority

While all the listed interventions are components of comprehensive care for SJS/TEN, they do not take precedence over hemodynamic stabilization.

-   Option 1: Apply topical antibiotics to all affected skin areas. The evidence summary on skin-mucosal care emphasizes wound management, but the highest risk of mortality comes from sepsis originating from the denuded skin . While preventing wound infection is critical, the immediate, minutes-to-hours threat is fluid volume deficit. Furthermore, the application of topical agents is often controversial and must be guided by a specialist; indiscriminate application can cause further trauma or absorption issues. The priority is to cover the wounds with non-adherent, sterile dressings to minimize fluid loss and contamination, a task that directly supports fluid balance.

-   Option 3: Administer high-dose corticosteroids as prescribed. The use of systemic corticosteroids remains highly controversial and is not a universal standard of care. The evidence guiding optimal management for SJS/TEN, particularly from immune checkpoint inhibitors, remains limited, and therapies like corticosteroids are debated due to the increased risk of infection and delayed wound healing . Administering a prescribed medication is an important nursing function, but it is an intervention aimed at halting the disease process, not at managing the immediate, life-threatening complication of fluid loss. The nurse must first ensure the patient is hemodynamically stable to survive long enough for any disease-modifying therapy to potentially work.

-   Option 4: Provide frequent oral hygiene with antiseptic mouthwash. Mucosal involvement in SJS/TEN can be severe, causing painful oral erosions that impair oral intake. Oral care is an essential comfort and infection-prevention measure. However, in the acute, critical phase, the patient's inability to drink due to oral pain is a contributing factor to the fluid deficit, not the primary cause of it. The massive insensible fluid loss through the skin is the main culprit. Intravenous fluid replacement, guided by strict monitoring, is the direct solution, making it a higher priority than oral care, which can be initiated concurrently but as a secondary measure.References (research sources)

- [2]Nursing care of an elderly patient with toxic epidermal necrolysis: a case report.Case reportWang D, Yuan M, Ying Y. (2026) · DOI: 10.3389/fmed.2026.1824922

## 임상 시나리오

SJS/TEN Fluid Resuscitation GuideManaging the patient like a severe burn
Treat patients with SJS/TEN involving >10-15% BSA detachment using burn center fluid resuscitation protocols. Massive transepidermal fluid loss leads to hypovolemia and electrolyte disturbances.

Initiate strict intake and output monitoring with an indwelling catheter. Target urine output of 0.5-1 mL/kg/hr to guide fluid titration and prevent acute kidney injury.

Monitor serum electrolytes (sodium, potassium) frequently. Aggressive replacement of crystalloids is essential to correct imbalances and maintain hemodynamic stability.

CautionAvoid over-resuscitation which can worsen pulmonary and mucosal edema. Fluid balance is the highest priority intervention, taking precedence over wound care or pharmacological therapy.

## 핵심 개념

- **Stevens-Johnson Syndrome (SJS)** — A severe, life-threatening mucocutaneous reaction characterized by widespread epidermal necrosis and detachment, leading to massive fluid loss similar to a severe burn.
- **Transepidermal Fluid Loss** — The loss of protein-rich fluid and electrolytes through damaged skin when the protective epidermal barrier is compromised, causing hypovolemia and electrolyte imbalances.
- **Hypovolemic Shock** — A critical condition resulting from a significant decrease in intravascular volume, leading to inadequate tissue perfusion; a primary risk in SJS due to massive fluid shifts.

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