steven johnson - Nursing Case Study

Pathophysiology

• Primary mechanism: Stevens-Johnson syndrome (SJS) is primarily a hypersensitivity reaction often triggered by medications or infections. The immune system mistakenly attacks the body's own cells in the skin and mucous membranes, leading to severe inflammation and damage. This triggers widespread apoptosis, or cell death, in the epidermis.

• Secondary mechanism: The widespread cell death in the skin and mucous membranes results in the formation of blisters and lesions. This damage can lead to the detachment of the top layer of skin from lower layers, a process known as epidermal necrolysis.

• Key complication: The extensive skin damage can lead to severe complications like infections and sepsis. Furthermore, the damage to the mucous membranes can affect the eyes, mouth, and genitals leading to difficulties in seeing, swallowing, and urinating.

Patient Profile

Demographics:

55-year-old male, construction worker

History:

• Key past medical history: Diagnosed with epilepsy, occasional smoker, no history of heart disease or diabetes

• Current medications: Anti-epileptic drug (Phenytoin)

• Allergies: No known drug or food allergies

Current Presentation:

• Chief complaint: Rash on the body with fever and fatigue

• Key symptoms: Started with flu-like symptoms progressing to red, painful rash which turned into blisters, eye irritation, mouth sores, difficulty swallowing and breathing

• Vital signs: Temperature: 101.2°F, Heart Rate: 105 bpm, Respiratory Rate: 24 breaths per minute, Blood Pressure: 140/90 mmHg, Oxygen Saturation: 93% on room air

Section 1

Change in Patient Status:

Steven's condition has significantly worsened over the past 24 hours. His temperature has increased to 103.5°F, and his heart rate has escalated to 120 bpm. His respiratory rate has also increased to 30 breaths per minute, and his blood pressure has dropped to 110/70 mmHg. His oxygen saturation has decreased to 90% on room air, indicating the need for supplemental oxygen. His skin condition has also deteriorated; the blisters have spread across larger areas of his body, and some areas have started showing signs of epidermal necrolysis. He experiences severe pain and discomfort due to these skin changes.

The damage to the mucous membranes has escalated, causing severe dryness and redness in his eyes, resulting in blurred vision. He complains of increased difficulty in swallowing, which has affected his nutritional intake. There has also been an increase in mouth sores, which has further aggravated his difficulty in swallowing. He has started experiencing difficulty in urination, indicating possible involvement of the urinary tract. These escalating symptoms and deteriorating vital signs indicate a possible advancing towards severe complications, including sepsis, due to the widespread skin and mucous membrane involvement. This calls for immediate and aggressive interventions.

Section 2

New Diagnostic Results:

The lab results have come back with some alarming findings. Steven's complete blood count (CBC) shows leukocytosis of 18,000/mm3, which could be indicative of an infection or inflammatory response. His blood culture is positive for Staphylococcus aureus, which is likely the source of his infection, leading to sepsis. His C-reactive protein (CRP) level is elevated at 120 mg/L, suggesting systemic inflammation. His serum creatinine is also elevated at 2.5 mg/dL, indicating possible renal impairment, which could be contributing to his difficulty in urination.

The skin biopsy results confirm the diagnosis of Stevens-Johnson syndrome, with signs of extensive epidermal necrolysis. His chest X-ray reveals some infiltrates, which could suggest the presence of pneumonia, given his increased respiratory rate and decreased oxygen saturation. The ophthalmology consultation reveals Steven has developed a corneal ulcer, which explains his blurred vision. These new diagnostic results indicate that Steven's condition is becoming critical and needs immediate, aggressive interventions to prevent further complications, such as renal failure, respiratory failure, or septic shock. This will require a coordinated multidisciplinary approach to manage his condition effectively.

Section 3

Change in Patient Status:

Over the next 24 hours, Steven's condition continues to deteriorate. His respiratory rate increases to 28 breaths per minute, and oxygen saturation drops to 88%, despite being on 2 liters of supplemental oxygen via nasal cannula. His blood pressure is also low, measuring at 90/60 mmHg, and his heart rate is elevated at 120 beats per minute. His temperature spikes to 39.5 degrees Celsius, indicating that his body is still fighting infection. His skin also shows signs of worsening, with increased blistering and skin sloughing.

Steven's level of consciousness also takes a turn for the worse. He becomes increasingly lethargic and disoriented, which could be an indication of sepsis progressing to severe sepsis or septic shock. He also complains of increasing abdominal pain, which could signify an underlying complication such as gastrointestinal bleeding or perforation, both of which are potential complications of Stevens-Johnson Syndrome. His urine output has decreased to less than 30 ml/hr, suggesting that his renal function may be further decreasing. These changes in Steven's condition underscore the seriousness of his situation, and the need for immediate and aggressive interventions.

Section 4

Change in Patient Status:

Over the next few hours, Steven's condition worsens and he becomes unresponsive. His respiratory rate shoots up to 35 breaths per minute and oxygen saturation plummets to 82% despite an increase to 4 liters of supplemental oxygen. His blood pressure further drops to 80/50 mmHg and his heart rate escalates to 140 beats per minute. His temperature continues to rise, measuring at 40.1 degrees Celsius. His skin condition aggravates, with more areas of his body showing signs of blistering and skin sloughing.

Upon reassessment, his abdomen is visibly distended and rigid to touch, further supporting the suspicion of a possible gastrointestinal complication. His urine output drops to a critical 15 ml/hr, indicating his kidneys are failing to filter toxins from his blood. His latest blood work shows an increase in white blood cell count to 21,000 cells/mcL, Serum Creatinine climbs to 3.0 mg/dL and Blood Urea Nitrogen (BUN) levels rise to 42 mg/dL. His lactate level is also elevated at 4 mmol/L, suggesting tissue hypoperfusion. These alarming changes in Steven's status necessitate immediate lifesaving interventions and a need to reconsider the current treatment approach.

Section 5

New Diagnostic Results:

Despite aggressive fluid resuscitation and vasopressor support, Steven's hemodynamic instability persists. His arterial blood gas (ABG) results show pH of 7.27, indicating metabolic acidosis, PaO2 of 72 mmHg, and PaCO2 of 35 mmHg suggesting hypoxemia and insufficient oxygen delivery. His HCO3- level drops to 17 mEq/L indicating a primary metabolic disturbance. The anion gap is elevated at 20 mEq/L, suggesting increased production or decreased elimination of acids.

A computed tomography (CT) scan of his abdomen reveals signs of bowel ischemia, possibly secondary to hypoperfusion. His chest x-ray shows bilateral infiltrates, raising suspicion for acute respiratory distress syndrome (ARDS), which could explain his deteriorating respiratory status. The blood culture report comes back positive for Staphylococcus aureus, supporting a diagnosis of sepsis. These new findings indicate that Steven's condition is escalating into multi-organ dysfunction syndrome (MODS) secondary to sepsis, and prompt an urgent need for a multidisciplinary approach involving a team of specialists, including an intensivist, nephrologist, gastroenterologist, and infectious disease specialist.