One Case of wound care in Toxic Epidermal Necrolysis patient

Background Toxic Epidermal Necrolysis (TEN) is cutaneous reaction that it is a rare, life-threatening drug induced. Due to the rapid development to large area skin pine solution, so skin peeling area often reach more than 50% of the whole body surface area, or even more than 90%, and the TEN patients wound care is the key to the disease outcomes. Case introduction Patient is female of 14 years old and for sore throat, fever symptoms after taking Contac happened large body rash and skin yellow dye. Diagnosis is TEN and with liver and lung damage organs. There is visible skin sclera severe yellow dye and the body skin erythema of blockbuster. Part of the erythema basis with differ size saw blister and blister liquid is clear, blister wall loose solution and Nikolsky sign is positive. Head, neck, torso and limb skin mucous membrane in loose peeling solution, its lesions area amounted to 85% of whole body. Objective Explore wound care method of TEN patients and prevent wound infection. Protect patient eyes and prevent patient blindness. Methods The first step is a full assessment of the wound and the influence factors of the wound to heal. Then, according to the assessment of the situation, make individual wound care measures that is including nutrition support, ward and bed unit disinfection, wound the bacteria cultures, skin clean, choose to moist healing dressings, mucosa protection and psychological support. Finally, evaluate the effect of nursing measures. Result Patients of body 85% loose skin peeling solution without the wound infection, wound healing. Eye protection is very good and mucosa damaged area to healing. Conclusion Objective and accurate assessment of the wound for wound care and wound healing is very important. Implementation of the wound nursing measures can effectively promote the wound healing.