# A nurse is caring for a patient diagnosed with Stevens-Johnson syndrome (SJS). Which nursing intervention is the highest priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540961 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a patient diagnosed with Stevens-Johnson syndrome (SJS). Which nursing intervention is the highest priority? ## 보기 1. Apply topical antibiotics to all affected skin areas to prevent infection 2. Administer oral corticosteroids as prescribed to reduce inflammation 3. Provide emotional support and counseling to address psychological distress 4. Monitor for signs of infection and maintain strict aseptic technique **✔ 정답** **정답: 4** ## 해설 Infection prevention is the highest priority in SJS due to compromised skin barrier and high mortality from sepsis. Strict aseptic technique and monitoring for signs of infection are critical, while other interventions are supportive but secondary. ## 심화 해설 Understanding the Priority: Infection Control in SJS/TEN In Stevens-Johnson syndrome (SJS) and its more severe counterpart, toxic epidermal necrolysis (TEN), widespread epidermal necrosis causes the skin to detach from the underlying dermis. This pathophysiological process effectively eliminates the body's primary mechanical barrier against pathogens. The resulting extensive denuded areas are physiologically analogous to massive partial-thickness burns. Consequently, the patient is not merely at risk for a localized skin infection; they face a constant, systemic threat of bacterial invasion, which can rapidly progress to sepsis and multi-organ failure. The foundational principle of care, strongly emphasized in the literature, is that meticulous infection prevention directly reduces mortality by minimizing these life-threatening complications [1][3]. Why Infection Prevention is the Highest Priority In the hierarchy of nursing priorities for a patient with a compromised integumentary system, airway, breathing, and circulation (ABCs) are always paramount. However, when the primary disease process creates a direct portal for systemic infection across a large body surface area, infection control becomes an integrated component of maintaining hemodynamic stability. The provided case reports consistently identify a "high risk of infection" as the primary nursing issue [3]. The rationale is clear: a patient with 55% body surface area involvement has an expected mortality rate of 30-50%, with sepsis being a leading cause of death [4]. Therefore, nursing interventions that preserve the patient's sterile barrier are not simply wound care tasks; they are critical, life-sustaining measures. Maintaining a strict aseptic technique during all procedures, including wound care, line management, and respiratory suctioning, is the most direct nursing action to prevent the introduction of pathogens. Continuous monitoring for early signs of infection, such as subtle changes in temperature, heart rate, or wound appearance, allows for prompt intervention before systemic involvement occurs. This proactive surveillance is the cornerstone of reducing mortality in this patient population [1][3]. Analysis of Other Options - Option 1: Apply topical antibiotics to all affected skin areas to prevent infection. This is a delegated medical intervention, not an independent nursing priority, and its application is not universal. The primary nursing responsibility is to create the environment for healing through asepsis. Indiscriminate application of topical agents can sometimes disrupt the wound bed or contribute to antimicrobial resistance. The evidence focuses on systemic infection prevention through meticulous care protocols, not solely on topical prophylaxis [1][3]. - Option 2: Administer oral corticosteroids as prescribed to reduce inflammation. The use of systemic corticosteroids in SJS/TEN remains controversial and is not a universally accepted standard of care due to the potential for increased infection risk and delayed wound healing. Even if prescribed, medication administration is a dependent nursing function. The nurse's independent, highest-priority action is to mitigate the most immediate life threat, which is the risk of sepsis from skin barrier loss, not to administer a medication with debatable efficacy [1][4]. - Option 3: Provide emotional support and counseling to address psychological distress. While addressing the profound psychological distress associated with SJS/TEN is an essential component of holistic nursing care, it does not take precedence over a physiological threat to survival. Psychosocial support is a critical intervention during the recovery and rehabilitation phases, but in the acute phase, preventing death from sepsis is the immediate priority. The nursing plan must first stabilize the patient physiologically before deeper psychosocial interventions can be effectively implemented [4].References (research sources) - [1]The Effects of Nursing Care Applied in the Intensive Care Unit on a Case of Toxic Epidermal Necrolysis: A Case Report.Case reportGulsoy Z, Özdemir Kol İ. (2026) · DOI: 10.1111/nicc.70513 - [3]Nursing care for a patient with intracerebral hemorrhage complicated with toxic epidermal necrolysis: a case report.Case reportZhang D, Zhang Q, Li H, Lai W, Chen P. (2025) · DOI: 10.3389/fmed.2025.1587979 - [4]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 Infection Control ProtocolManaging the Patient as a Massive Burn Injury Patients with Stevens-Johnson syndrome have widespread epidermal loss, destroying the skin's barrier function. This creates a risk for systemic infection and sepsis equivalent to a partial-thickness burn. The highest priority intervention is strict aseptic technique with all patient contact. This includes meticulous hand hygiene, sterile linens, and barrier precautions to prevent introducing pathogens to denuded skin. Continuous monitoring for signs of infection is essential. Track vital signs, WBC count, and wound appearance. Early recognition of sepsis signs like fever, tachycardia, or hypotension allows for rapid intervention. CautionAvoid routine use of topical antibiotics unless specifically ordered for a cultured pathogen. Focus on environmental control and aseptic handling to prevent infection without disrupting the wound bed. ## 핵심 개념 - **Stevens-Johnson Syndrome (SJS)** — A severe immune-mediated reaction causing widespread epidermal necrosis and detachment, creating a high risk for infection and sepsis. - **Aseptic Technique** — A strict set of practices and procedures performed to prevent contamination from pathogens, crucial for protecting patients with compromised skin barriers. - **Sepsis** — A life-threatening organ dysfunction caused by a dysregulated host response to infection, a primary cause of mortality in SJS/TEN patients. ## 같은 주제 문제 - [A nurse is assessing a patient with suspected Stevens-Johnson syndrome (SJS). 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