# A nurse is caring for a client diagnosed with Stevens-Johnson syndrome (SJS). Which nursing intervention should be the highest priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540962 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client diagnosed with Stevens-Johnson syndrome (SJS). Which nursing intervention should be the highest priority? ## 보기 1. Apply topical antibiotics to all affected skin areas 2. Monitor for signs of respiratory distress and airway compromise **✔ 정답** 3. Administer prescribed corticosteroids immediately 4. Encourage oral fluid intake to prevent dehydration **정답: 2** ## 해설 Airway monitoring is the highest priority in SJS due to mucosal involvement that can rapidly lead to respiratory compromise. Other interventions like topical antibiotics, corticosteroids, and hydration are important but secondary to airway management. ## 심화 해설 Understanding the Priority: Airway and Breathing in SJS/TEN Stevens-Johnson syndrome (SJS) and its more severe counterpart, Toxic Epidermal Necrolysis (TEN), are not merely dermatologic conditions; they are acute, life-threatening mucocutaneous hypersensitivity reactions. The disease process involves widespread apoptosis and necrosis of the epidermis, but critically, it also affects the mucous membranes of multiple organ systems [2]. The highest priority for nursing care stems from the fact that the respiratory tract is a mucosal surface. Epithelial sloughing in the oropharynx and bronchial tree is a hallmark of the acute phase and a direct cause of rapid clinical deterioration [1,2]. When the airway epithelium becomes necrotic, it loses its protective barrier function and sloughs off, creating a high risk for airway obstruction. This obstruction can occur from the accumulation of necrotic debris, formation of a pseudomembrane, or progressive edema. This is not a slow process; respiratory distress can develop suddenly and progress to complete airway compromise. Therefore, continuous assessment for subtle signs like tachypnea, stridor, hoarseness, dysphagia, or increased work of breathing is the most critical intervention. Failure to recognize these early signs can lead to a respiratory arrest that is difficult to manage due to the friable and edematous nature of the airway tissue. Analysis of Other Options While all the listed interventions are components of comprehensive care for a patient with SJS, they are not the immediate priority over a patent airway. - Option 1: Apply topical antibiotics to all affected skin areas. Wound care and infection prevention are central to the long-term management and prognosis of SJS/TEN, as the denuded skin is a massive portal for pathogens . However, this is a secondary prevention measure. A meticulous, sterile wound care approach is vital, but it does not take precedence over a threat to the airway, breathing, and circulation (ABCs). - Option 3: Administer prescribed corticosteroids immediately. The use of systemic corticosteroids remains a debated topic in the acute management of SJS/TEN and is not a universally established, first-line, life-saving measure in the way that airway protection is. The evidence for their efficacy is not definitive, and their administration is a dependent nursing action that follows a provider's specific order. The nurse's independent, highest-priority action is to assess and monitor for the most lethal complication: airway loss . - Option 4: Encourage oral fluid intake to prevent dehydration. Hydration and nutritional support are crucial because the extensive skin loss leads to massive fluid and electrolyte shifts, similar to a severe burn [1,3]. However, oral intake may be impossible due to painful oral mucositis and the risk of aspiration if the patient has a compromised airway or difficulty swallowing. While fluid balance is critical, maintaining a patent airway is the foundational first step in the ABC framework. An individualized care plan, as described for a patient with 55% body surface area involvement, would prioritize airway and hemodynamic stability before focusing on nutritional routes . Clinical Reasoning and Multidisciplinary Context The rationale for prioritizing airway monitoring is deeply rooted in the pathophysiology and the multidisciplinary nature of care. The acute phase of SJS requires recognition that the disease is a systemic process with the potential for rapid decompensation [2]. The nurse's role at the bedside is to perform continuous surveillance for these changes. A patient who is clinically stable one moment can develop stridor the next. This monitoring directly informs the need for immediate intervention, which may include calling a rapid response team, preparing for emergency intubation, or assisting with a bedside tracheostomy. The complexity of these patients, often managed in a specialized burn or intensive care unit, demands that the nurse’s primary focus is on the most immediate threats to life, with airway compromise being the most urgent [1,3].References (research sources) - [2]Multidisciplinary care in Stevens-Johnson syndrome.Research articleShanbhag SS, Chodosh J, Fathy C, Goverman J, Mitchell C, Saeed HN. (2020) · DOI: 10.1177/2040622319894469 ## 임상 시나리오 Airway First in SJS/TENEarly recognition of respiratory distress prevents fatal obstruction The airway is the absolute priority in Stevens-Johnson syndrome. Epithelial sloughing in the oropharynx and bronchial tree creates necrotic debris and pseudomembranes, leading to rapid obstruction. Assess for early, subtle signs of compromise: tachypnea, stridor, hoarseness, dysphagia, drooling, or increased work of breathing. These can precede a sudden, difficult-to-manage respiratory arrest. CautionDo not delay airway assessment for wound care or medication administration. The friable, edematous airway tissue makes emergent intubation extremely challenging; early intervention is critical. ## 핵심 개념 - **Stevens-Johnson syndrome (SJS)** — A severe, acute mucocutaneous hypersensitivity reaction characterized by widespread epidermal necrosis and mucosal involvement, often triggered by medications or infections. - **Airway compromise** — A state in which the upper airway is obstructed or at risk of obstruction, often due to edema, debris, or sloughing of mucosal tissue, leading to respiratory failure. - **Epithelial sloughing** — The detachment or shedding of the epithelial layer of the skin or mucous membranes, a key pathological feature of SJS/TEN that can obstruct the airway. - **Toxic Epidermal Necrolysis (TEN)** — A more severe form of SJS involving detachment of more than 30% of the body surface area, with a high mortality rate often related to sepsis or respiratory failure. ## 같은 주제 문제 - [A nurse is assessing a patient with suspected Stevens-Johnson syndrome (SJS). 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