Continuing or restarting the offending medication can be fatal; verify it is discontinued.
Before you read
Test yourself first: 3 questions
Question 1 of 3
A client with acute coronary syndrome is having chest pain and receives sublingual nitroglycerin. After the first tablet, the pain persists. What is the nurse's appropriate action?
Answer: B. For ongoing chest pain, the standard teaching is to give one sublingual nitroglycerin tablet every 5 minutes for up to 3 doses, checking blood pressure between doses because nitroglycerin causes vasodilation and hypotension. If pain is unrelieved, emergency care or provider notification is needed. Giving all three at once, waiting 30 minutes, or doubling the dose are unsafe.
Question 2 of 3
A nurse scores a newborn with neonatal abstinence syndrome. Which findings are consistent with NAS?
Answer: A. NAS produces central nervous system signs (high-pitched cry, tremors, irritability, hypertonia, exaggerated Moro, poor sleep), autonomic signs (sweating, sneezing, yawning, nasal stuffiness, fever), and GI signs (poor feeding, vomiting, diarrhea, frantic sucking). A consistently calm, easily consoled infant who sleeps well is not exhibiting NAS.
Question 3 of 3
A client receiving IV vancomycin develops flushing of the face and neck, pruritus, and hypotension during a rapid infusion. Which is the priority nursing action?
Answer: B. Vancomycin infusion reaction (formerly called red man syndrome) results from rapid infusion causing histamine release. The priority is to stop or slow the infusion; the reaction is usually prevented by infusing over at least 60 minutes.
Keep the streak going with more questions like these, each with a full rationale.
What is stevens-johnson syndrome?
It begins with flu-like symptoms followed by a painful blistering rash and sloughing of skin and mucous membranes. When more than 30% of body surface is involved it is called toxic epidermal necrolysis (TEN). It is a dermatologic emergency managed much like a severe burn, with fluid loss and infection as major dangers.
Key points to remember
- Common triggers include sulfonamides, anticonvulsants (lamotrigine, carbamazepine, phenytoin), allopurinol, NSAIDs, and antibiotics.
- Prodrome of fever, sore throat, and malaise precedes the rash by 1 to 3 days.
- Painful erythematous or purpuric macules progress to blisters and widespread epidermal sloughing.
- A positive Nikolsky sign means the skin shears off with light lateral pressure.
- Mucous membranes of the mouth, eyes, and genitals are involved, causing severe pain and potential blindness.
- Massive skin loss causes fluid and electrolyte loss, hypothermia, and high infection/sepsis risk.
Common causes
- Drug rxn: sulfa, allopurinol, AEDs
- Lamotrigine, phenytoin triggers
Signs & symptoms
- Flu-like, then painful rash
- Blisters, skin sloughs off
- +Nikolsky, mucous membranes
Nursing priorities
- Stop the causative drug immediately and ensure it is documented as an allergy.
- Maintain airway, fluid, and electrolyte balance; manage the patient like a major burn, often in a burn or ICU unit.
- Use strict aseptic technique and protective isolation to prevent sepsis through denuded skin.
- Provide meticulous skin and mucous-membrane care, pain control, and warm environmental temperature.
- Coordinate ophthalmology care to protect the eyes and prevent permanent vision loss.
Labs & values
Patient teaching
- Wear a medical alert bracelet listing the causative drug and never take it again.
- Inform all future providers and pharmacists of the drug allergy.
- Seek immediate care for any new rash with blistering, mouth sores, or eye pain after starting a medication.
Red flags: report now
- Continuing or restarting the offending medication can be fatal; verify it is discontinued.
- Airway involvement, signs of sepsis, or rapid skin sloughing require emergency escalation.
- Eye involvement can cause permanent blindness; obtain urgent ophthalmology consult.
- Never apply adhesive dressings or tape directly to fragile skin.
References
Clinical references for this topic
