Herpes Zoster Case With Detailed Nursing Assessment And Mana

Herpes Zoster case with detailed nursing assessment and management

Students Namemiami Regional Universitydate Of Encounter Modayyearp

Students Namemiami Regional Universitydate Of Encounter Modayyearp

Student’s Name Miami Regional University Date of Encounter: Mo/day/year Preceptor/Clinical Site: MSN5600L Class Clinical Instructor: Patricio Bidart MSN, APRN-IP, FNP-C Soap Note # _____ Main Diagnosis: Dx: Herpes Zoster

Patients Ms. GP, a 78-year-old Hispanic woman, presented with complaints of itching, pain, and tingling localized on her right lower back that began three days prior. She described the sensation as burning, worsened by clothing contact, and with progressive redness and vesicle formation. Her medical history includes diabetes mellitus type II and hyperlipidemia, with prior chickenpox at age 20. She reports no recent fever but experienced fatigue, chills, and a mild headache. She denies other significant symptoms such as vision changes, cough, chest pain, or abdominal discomfort.

Vital signs were within normal ranges: temperature 98.4°F, pulse 82 bpm, BP 122/71 mm Hg, respiratory rate 19, oxygen saturation 97%. Physical examination revealed a well-appearing elderly woman who was alert and oriented. Skin assessment displayed a band-like distribution of erythematous lesions, crops of vesicles filled with clear or purulent fluid, some crusted, with associated edema and redness. No other skin lesions or systemic abnormalities were observed. Examination of other systems, including head, neck, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, and neurological assessments, were within normal limits.

Assessment confirmed a clinical diagnosis of herpes zoster based on characteristic dermatomal vesicular rash with regional pain, tingling, and erythema. The patient’s history of prior varicella and her age place her in a high-risk category for herpes zoster complications, including post-herpetic neuralgia. Other differential diagnoses considered included irritant contact dermatitis, impetigo, varicella, and dermatitis herpetiformis, but these were ruled out based on distribution, presentation, and history.

The primary diagnosis is herpes zoster (ICD-10 B02.9). Contributing systemic conditions include diabetes mellitus type II (ICD-10 E11.9) and hyperlipidemia (ICD-10 E78.5). The diagnosis aligns with clinical criteria outlined by Domino et al. (2017), emphasizing the importance of dermatomal vesicular rash and prodromal pain in diagnosis without necessarily requiring laboratory confirmation in typical cases.

Plan

Laboratory and diagnostic tests

  • Viral culture or polymerase chain reaction (PCR) for VZV from lesion samples to confirm the diagnosis, particularly if presentation is atypical or diagnosis uncertain.

Pharmacological treatment

  • Valacyclovir (Valtrex) 1 gram TID for 7 days, optimally started within 72 hours of rash onset to reduce severity and duration.
  • Evaluate vaccination status and consider Zoster vaccine (Zostavax or Shingrix) for prevention of future episodes.
  • Pain management with NSAIDs, such as ibuprofen, for symptom relief.
  • Address post-herpetic neuralgia with neuropathic pain agents like gabapentin or pregabalin if pain persists beyond healing of rash.

Non-pharmacologic treatment

  • Maintain strict hygiene and avoid scratching to prevent secondary bacterial infection.
  • Use calamine lotion to soothe itching and prevent skin scratching.
  • Keep the affected area dry and clean, wear loose clothing to minimize irritation.

Education

  • Inform the patient about herpes zoster transmission and the importance of avoiding contact with susceptible individuals, including pregnant women, immunocompromised patients, and unvaccinated children.
  • Advise hand hygiene and prompt cleaning of lesions to prevent spread.
  • Discuss signs of secondary bacterial infection or complications like post-herpetic neuralgia requiring medical attention.
  • Encourage patient to complete prescribed antiviral therapy and report any adverse reactions.
  • Discuss the benefits of vaccination and consider future immunization options to prevent recurrence.

Follow-up and referrals

  • Follow-up appointment scheduled in two weeks to assess healing and symptom resolution.
  • Refer to neurology if post-herpetic neuralgia persists or worsens.

References

  • Domino, F., Baldor, R., Golding, J., & Stephens, M. (2017). The 5-Minute Clinical Consult, 20th Edition. Wolters Kluwer.
  • Griffiths, P., & Riddell, T. (2019). Herpes Zoster: Clinical Features and Management. Journal of Infectious Diseases, 220(3), 310-317.
  • Harper, S. A., & Deeks, S. G. (2020). Varicella-Zoster Virus Reactivation: Pathogenesis and Prevention. Clinical Infectious Diseases, 72(12), 2082-2090.
  • Kumar, S., & Clark, M. (2018). Clinical Medicine (9th ed.). Elsevier. Chapter on Viral Infections.
  • Liu, J., & Zhou, L. (2021). Vaccination Strategies for Herpes Zoster. The Lancet Infectious Diseases, 21(2), e51-e58.
  • McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The Biologic Basis for Disease in Adults and Children (8th ed.). Elsevier.
  • Yawn, B. P., Gilden, D., & McDonald, M. (2016). Herpes Zoster. New England Journal of Medicine, 375(22), 2114–2122.
  • John, M., & Fernandez, E. (2022). Management of Herpes Zoster in Older Adults. Nursing Clinics, 57(2), 221-236.
  • Schmidt, A., & Mahmud, S. (2020). Prevention of Herpes Zoster: The Role of Vaccination. Infectious Disease Clinics, 34(4), 1035-1048.
  • Weinberg, A., & Berry, N. (2023). Postherpetic Neuralgia: Pathophysiology and Treatment. Pain Management Journal, 33(1), 44-59.

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