Question

Edna Jones, a 56-year-old patient, is admitted to the burn unit with the diagnosis of toxic epidermal necrolysis. The patient developed the rapid onset of skin erythema and mucous membranes with large sheets of epidermis being shed, leaving the dermis exposed and painful. There are several painful lesions in her mouth. Her fingernails and toenails fell off as the skin sloughed. The patient had received a sulfonamide and had this reaction. The sulfonamide has been discontinued

a.       What assessment should the nurse conduct?

b.      What nursing interventions should the nurse provide?

Answer 1

Diagnosis: Toxic epidermal necrolysis

Patient received Sulfonamide and has developed reactions to it.

a) Assessment includes:

• Stop the injection sulphonamide drip immediately.
• Assess the patient's condition & vital signs (Temperature, Pulse, Respiration, SpO² saturation, Pain)
• Assess for any other medication whose side effect may have cause this reaction.
• NOTE: To avoid such reaction, ask patient about allergy to any medications if so should document it & put an allergy band on wrist to avoid such reactions.
• Test dose of Sulfonamide would also help to detect such reactions early.

b) Intervention includes:

After the assessment,

• Reassure the patient
• Inform the consultant about it
• Carry out the necessary treatment ( antibiotics, strict infection control practices, pain management, dressing with aseptic procedure)
• Reassess the patient's condition especially for pain (pain scale : numerical or Wong bakers pain scale)
• Document it in nursing Intervention
• Inform the nursing supervisor and fill in CQI (Continuous Quality Improvement) form for the Root cause analysis.