# A nurse is caring for a patient with Stevens-Johnson syndrome (SJS). Which nursing action should be the highest priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540964 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a patient with Stevens-Johnson syndrome (SJS). Which nursing action should be the highest priority? ## 보기 1. Maintain strict aseptic technique and monitor for signs of infection **✔ 정답** 2. Administer prescribed corticosteroids to reduce inflammation 3. Apply topical antibiotics to all affected skin areas 4. Encourage oral fluid intake to prevent dehydration **정답: 1** ## 해설 The highest priority is maintaining strict aseptic technique and monitoring for infection because SJS causes widespread skin loss, leading to high risk of secondary bacterial infections, the main cause of mortality. Other interventions like corticosteroids or topical antibiotics are less critical or may increase risks. ## 심화 해설 Priority Nursing Intervention for Stevens-Johnson Syndrome The correct answer is 3. Monitor for signs of respiratory distress and maintain airway patency. In the initial management of Stevens-Johnson syndrome (SJS), the nursing priority follows the airway, breathing, and circulation (ABC) framework. SJS involves widespread epithelial necrosis that can extend to the respiratory mucosa, leading to sloughing of the tracheobronchial epithelium, airway obstruction, and acute respiratory failure [1]. This makes airway compromise the most immediate life-threatening complication, taking precedence over integumentary or comfort interventions. Why the Other Options Are Lower Priority While all listed interventions are important components of holistic care for SJS, they are secondary to securing a patent airway. - Option 1 (Apply topical antibiotics) is incorrect as the highest priority. Wound care and infection prevention are critical for reducing the high mortality associated with secondary sepsis in SJS [1][2]. However, meticulous skin management is a time-intensive intervention that is addressed after the patient’s respiratory and hemodynamic status is stable. - Option 2 (Encourage oral fluid intake) is incorrect. Hydration and nutritional support are vital due to fluid loss from denuded skin and a hypermetabolic state [1][3]. However, if the oropharyngeal mucosa is involved, swallowing may be compromised, and oral intake could increase aspiration risk. Fluid resuscitation is typically managed intravenously, not by encouraging oral intake during the acute phase. - Option 4 (Administer pain medication) is incorrect. Pain management is a fundamental aspect of comfort care for the severe mucocutaneous pain these patients experience [1]. Nonetheless, administering analgesics does not address an immediate threat to life and is prioritized after airway and breathing concerns are managed. Deep Dive: The Pathophysiology of Airway Risk The prioritization of airway management is rooted in the disease process. SJS is a severe mucocutaneous reaction, often drug-induced, characterized by keratinocyte apoptosis and full-thickness epidermal necrolysis [1][4]. This process is not limited to the skin; it frequently affects the mucous membranes of the eyes, oral cavity, and, most critically, the respiratory tract. Epithelial detachment in the bronchioles can manifest as dyspnea, stridor, and hypoxemia, progressing rapidly to complete airway obstruction [1]. Nursing assessment must include continuous monitoring for tachypnea, increased work of breathing, hoarseness, and declining oxygen saturation, with emergency airway equipment readily available. Clinical Integration: The Multidisciplinary Care Continuum Once airway patency is confirmed and maintained, the nurse’s focus expands to the other critical domains highlighted in the evidence. A comprehensive care plan, as illustrated in case studies, integrates several key elements to reduce the high mortality rate, which can range from 30-50% in severe cases like toxic epidermal necrolysis (TEN) [3]. - Infection Prevention and Wound Care: Because the loss of the skin’s protective barrier creates a massive portal for pathogens, meticulous aseptic technique during wound care and environmental control is paramount to prevent sepsis, a leading cause of death [2][4]. This involves non-adherent dressings, strict hand hygiene, and careful monitoring for signs of systemic infection. - Fluid and Nutritional Support: The extensive epidermal loss results in significant fluid and protein exudate, creating a hypermetabolic state. Aggressive intravenous fluid resuscitation and early enteral nutrition are cornerstones of treatment to support wound healing and prevent catabolism, especially in vulnerable populations like elderly patients with comorbidities [3]. - Pain and Psychosocial Management: Severe pain from widespread mucocutaneous lesions requires a multimodal analgesic approach. This is managed concurrently with other interventions to reduce suffering and psychological distress, which is a complex need in these patients [1]. The nursing care of a patient with SJS begins with a rapid, focused assessment of the airway, as respiratory failure is the most acute and preventable cause of early mortality. The subsequent success of wound care, infection control, and nutritional support depends on the patient’s initial stabilization through the maintenance of a patent airway [1][4].References (research sources) - [1]Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Guide for Nurses.Research articleHanson LM, Bettencourt AP. (2020) · DOI: 10.4037/aacnacc2020634 - [2]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 - [3]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 - [4]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 ## 임상 시나리오 Clinical Practice Guide: Infection Prevention in SJS Priority Nursing Action The highest priority is maintaining strict aseptic technique during all wound care and patient contact. Sepsis from secondary skin infection is the leading cause of death in Stevens-Johnson syndrome. Key Interventions - Perform meticulous hand hygiene and use sterile gloves and gowns for wound care. - Use sterile or clean non-adherent dressings depending on wound status and facility protocol. - Monitor vital signs, wound appearance, and laboratory values (WBC, cultures) for early signs of infection. - Minimize invasive devices and maintain asepsis of any necessary lines or catheters. Clinical Rationale Extensive epidermal detachment destroys the skin's protective barrier, creating portals for bacterial invasion. Without rigorous infection control, localized wound infections rapidly progress to systemic sepsis, significantly increasing mortality risk. ## 핵심 개념 - **Stevens-Johnson syndrome (SJS)** — A severe mucocutaneous reaction with widespread epidermal necrosis and detachment, leading to loss of skin barrier function. - **Sepsis** — A life-threatening organ dysfunction caused by a dysregulated host response to infection, the leading cause of mortality in SJS. - **Aseptic technique** — A set of practices and procedures performed under carefully controlled conditions to minimize contamination by pathogens. ## 같은 주제 문제 - [A nurse is assessing a patient with suspected Stevens-Johnson syndrome (SJS). Which assess…](https://mymerci.kr/pages/nclex_q.php?qn_id=540955) - [A nurse is assessing a 28-year-old patient who was admitted with suspected Stevens-Johnson…](https://mymerci.kr/pages/nclex_q.php?qn_id=540956) - [A nurse is assessing a patient with suspected Stevens-Johnson syndrome (SJS). 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