Mr. Lee is a 55-year-old man with a history of head trauma three months ago after falling from a ladder. He is seen in the emergency department today after experiencing a seizure at work. Mr. Lee received a loading dose of phenytoin in the emergency department and is admitted for a thorough work-up.

Upon arrival to the nursing unit, Mr. Lee is alert and oriented but lethargic. The following day, Mr. Lee has received two doses of phenytoin, and he has not had a seizure since admission. His lethargy has resolved. Midafternoon, Mr. Lee calls for the nurse. He shows the nurse his arms and hands and asks, “Look at these red splotches and blisters. What do you think this is from?” The nurse asks Mr. Lee if he has any other symptoms. He replies, “My eyes are itchy and burning and my throat is a little sore. Maybe I am allergic to the laundry detergent the hospital uses to wash the bed sheets.” Assessment reveals symmetric reddish-purple macules and bullae on his arms, hands, chest, and back. Mr. Lee’s vital signs are within normal limits except his temperature, which is 102.1°F (38.9°C).

1. Should the nurse be concerned that upon arrival to the nursing unit Mr. Lee is lethargic? 2. What is the rationale for prescribing phenytoin for Mr. Lee? 3. Mr. Lee’s plan of care includes seizure precautions. Explain how the nurse implements these precautions.  4. What do you believe is the cause of Mr. Lee’s skin condition? 5. Discuss three critical interventions upon diagnosing Mr. Lee’s reaction. 6. Mr. Lee is transferred to the burn unit. Explain the rationale for this transfer. 7. Identify four treatment goals the nurse will include while documenting Mr. Lee’s plan of care.  8. Mr. Lee’s wife notices that the nurse checked the thermostat in Mr. Lee’s room even though Mr. Lee did not express discomfort with the room temperature. Why was the nurse checking the temperature in the room?  9. Mr. Lee’s laboratory results are hemoglobin (Hgb) 18 g/dL, hematocrit (Hct) 57%, potassium (K+) 6.5 mEq/L; his sodium (Na2+) level is 126 mEq/L; and his bicarbonate (HCO3-) is 15 mEq/L. Are these results within normal limits? If not, explain what is causing any abnormal result.  10. The nurse dons a protective gown, mask, gloves, and cap prior to changing Mr. Lee’s dressings. Why is this precaution necessary? 11. Is Stevens Johnson Syndrome self-limiting or life threatening? Explain your answer.  12. Briefly discuss three potential complications the nurse will watch for as Stevens Johnson Syndrome progresses.  13. Mr. Lee’s coworker comes to visit and brings a beautiful vase full of flowers from her garden. The nurse asks that the visitor not bring the floral arrangement into Mr. Lee’s room. What is the rationale for the nurse’s request? 14. Clients with Stevens Johnson Syndrome sometimes suffer long-term effects. Briefly discuss three long-term complications that may result. 15. Identify five nursing diagnoses appropriate for Mr. Lee’s plan of care while being cared for on the burn unit. Prioritize the diagnoses you have identified.  16. While providing discharge teaching, what should the nurse tell Mr. Lee (and his family) about preventing a recurrence of this adverse medication reaction in the future?  17. What resource can the nurse suggest to help provide support once Mr. Lee is discharged from the hospital?

ANSWER

Lethargy Upon Arrival
Yes, the nurse should be concerned that Mr. Lee is lethargic upon arrival to the nursing unit. Lethargy can be indicative of various underlying issues, especially considering Mr. Lee’s history of head trauma and recent seizure. It could be a sign of neurological impairment, medication side effects, or an adverse reaction.

Rationale for Phenytoin Prescription
Phenytoin is prescribed for Mr. Lee to prevent seizures. Given his history of head trauma and the recent seizure episode, he is at risk for further seizures. Phenytoin is an antiepileptic medication that helps stabilize neuronal membranes and prevent excessive electrical activity in the brain, reducing the likelihood of seizures.

Implementation of Seizure Precautions
The nurse implements seizure precautions by:
Ensuring that the bed is in a low position and side rails are up.
Keeping the environment free from potential hazards.
Placing necessary equipment and supplies within reach.
Educating the patient and family about the importance of not leaving Mr. Lee unattended, especially during activities that could put him at risk during a seizure.

Cause of Skin Condition
The skin condition on Mr. Lee’s arms, hands, chest, and back is likely due to an adverse drug reaction. Given his recent administration of phenytoin, it could be a hypersensitivity reaction, possibly Stevens-Johnson Syndrome (SJS) or toxic epidermal necrolysis (TEN).

Critical Interventions for Mr. Lee’s Reaction
Critical interventions include:
Discontinuing the suspected medication (phenytoin) immediately.
Informing the healthcare provider and documenting the reaction.
Administering supportive care, including fluids, pain management, and wound care.
Monitoring for signs of SJS/TEN progression, such as mucous membrane involvement or skin detachment.

Rationale for Transfer to Burn Unit
Mr. Lee is likely transferred to the burn unit because Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe and potentially life-threatening conditions that require specialized care. The burn unit is equipped to manage these types of skin reactions and provide necessary treatments.

Treatment Goals for Plan of Care
The nurse will include treatment goals such as:
Halting the progression of the skin reaction.
Preventing secondary infections.
Managing pain and discomfort.
Promoting fluid balance and hydration.
Monitoring for systemic involvement and complications.

Nurse Checking Room Temperature
The nurse is checking the room temperature to ensure that it is within a comfortable range for Mr. Lee. SJS/TEN can lead to significant skin detachment, making the body less able to regulate temperature. A stable room temperature helps prevent further discomfort and complications.

Laboratory Results Interpretation
Hemoglobin (Hgb) and hematocrit (Hct) levels are elevated, indicating hemoconcentration due to dehydration. The potassium (K+) level is high (hyperkalemia), which can be caused by tissue damage and cell breakdown associated with SJS/TEN. Sodium (Na+) level is low (hyponatremia), possibly due to fluid loss, while bicarbonate (HCO3-) is low, indicating metabolic acidosis.

Precaution for Dressing Change
The precaution of wearing protective gown, mask, gloves, and cap is necessary to prevent potential exposure to infectious agents, prevent cross-contamination, and protect the healthcare provider from contact with the patient’s compromised skin. This precaution also prevents the spread of infectious agents from the patient to the healthcare environment.

Stevens-Johnson Syndrome (SJS) Self-Limiting or Life-Threatening
Stevens-Johnson Syndrome (SJS) is life-threatening. It is a severe hypersensitivity reaction that causes skin detachment, mucosal involvement, and can lead to systemic complications, organ failure, and death if not managed promptly.

Potential Complications of SJS
Potential complications of SJS include:
Sepsis from skin barrier disruption.
Fluid and electrolyte imbalances due to extensive skin loss.
Respiratory complications from mucosal involvement.
Ocular complications leading to vision problems or blindness.

Rationale for Restricting Flowers
Patients with SJS/TEN often have severe skin and mucosal involvement, making them highly susceptible to infections. Flowers can carry bacteria and pathogens, increasing the risk of infection for the patient.

Long-Term Complications of SJS
Long-term complications of SJS can include:
Scarring and disfigurement.
Ocular complications affecting vision.
Respiratory issues from mucosal damage.
Psychological distress due to appearance changes.

Nursing Diagnoses for Mr. Lee’s Plan of Care
1. Impaired Skin Integrity related to blister formation and skin detachment.
2. Acute Pain related to skin inflammation and blistering.
3. Risk for Infection related to compromised skin barrier.
4.Risk for Fluid Volume Deficit related to fluid loss from skin detachment.
5. Ineffective Coping related to the psychological impact of the condition.

Discharge Teaching to Prevent Recurrence
To prevent recurrence of adverse medication reactions in the future, the nurse should advise Mr. Lee to always inform healthcare providers about his history of SJS, avoid the use of medications associated with SJS, and carry a medical alert bracelet indicating his allergy.

Resource for Support Post-Discharge
A resource that the nurse can suggest for support post-discharge is a patient advocacy group or foundation that focuses on Stevens-Johnson Syndrome. These organizations provide information, support, and resources for individuals who have experienced SJS and their families.