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Impaired Skin Integrity related to Stevens–Johnson syndrome

Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) is a skin disease caused by allergies or infection. The syndrome threatening skin condition resulting in the death of skin cells so that the epidermal peel / separate from the dermis. The syndrome is considered to be a hypersensitivity complex affecting the skin and mucous membranes.

Although in general this syndrome cases have no known cause (idiopathic), usually the main cause of the most common allergies are a result of certain medications, viral infections and or both, in some cases very rare syndrome that is associated with cancer.

Stevens-Johnson syndrome usually begins with fever, sore throat, fatigue, and pain in the joints. Most sufferers are misdiagnosed and treated with antibiotics. Ulcers and lesions begin to appear in the mucous membranes, almost always in the oral / mouth and also in the genital and anal area. These symptoms are very painful and can lead to decreased appetite and drinking for experiencing symptoms in the mouth. Eye conjunctivitis occurs approximately 30% in children with this syndrome. Rash lesions about an inch of skin appear on the face, arms and legs and hands, but do not usually appear on the scalp.

Stevens-Johnson syndrome and toxic epidermal necrolysis are sometimes confused and not the same as erythema multiforme / herpes infection. Although erythema multiforme is sometimes caused by allergies and reactions to the drug, but the case is more often caused by a type III hypersensitivity reaction to viral infection, which is mostly caused by the Herpes simplex virus and the relatively more benign. Although Stevens-Johnson syndrome and toxic epidermal necrolysis sometimes be caused by infection, but the sufferer is more often caused by allergies and side effects of certain drugs. However, this syndrome is more dangerous compared to herpes virus infection.

Nursing Diagnosis for Stevens–Johnson syndrome

Impaired Skin Integrity related to inflammatory dermal and epidermal

Goal: showing skin and skin tissue intact

Nursing Intervention

a. Record observations daily skin turgor circulation and sensory as well as other changes that occur.
Rational: determining the baseline where changes in status can be compared and appropriate intervention.

b. Use light clothing and soft looms
Rational: reduce irritation and pressure on the seam line dress, let the incision open to air up the healing process and reduce the risk of infection.

c. Keep your loom.
Rational: to prevent infection.

d. Collaboration with the medical team.
Rational: to prevent further infection

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