Herpes zoster, also known as shingles, is a common viral skin eruption that is estimated to affect 300,000 to 500,000 persons a year in the United States. Approximately 95% of adults in the United States have antibodies to the varicella zoster virus (VZV), which means they have been exposed to it. The virus causes acute unilateral inflammation of a dorsal root ganglion. Each nerve innervates a particular skin area on the body called a dermatome, which bends around the body in a pattern that has been mapped corresponding to the vertebral source. Generally, herpes zoster eruptions occur in the thoracic region and, less commonly, affect a single cervical, facial (trigeminal nerve), lumbar, or sacral ganglion.
Most patients recover completely, but approximately 12% experience complications that include postherpetic neuralgia (PHN), uveitis, motor deficits, infection, and systemic involvement such as meningoencephalitis, pneumonia, deafness, or widespread dissemination. In some patients, the scars are permanent.
The varicella zoster virus, which causes chickenpox, remains dormant in a nerve ganglion and may be reactivated later in life. A decrease in cellular immunity may allow the latent virus to become active and spread along the nerve, resulting in clinical zoster. Conditions that are associated with reactivation include acute systemic illness, acquired immunodeficiency syndrome (AIDS), lymphoma, Hodgkin’s disease, lupus erythematosus, and situations in conjunction with immunosuppressive therapy such as steroids or antineoplastic drugs.
Nursing care plan assessment and physical examination
Generally, patients will describe a history of itching, numbness, tingling, tenderness, and pain in the affected area for 1 to 2 days before skin lesions develop. The rash begins as maculopapules (discolored patches on the skin mixed with elevated red pimples) that rapidly develop into crops of vesicles (blisters) on an erythematous (diffuse redness) base. New lesions continue to appear for 3 to 5 days as the older lesions ulcerate and crust. Malaise, lowgrade fever, and adenopathy may accompany the rash. The patient will report a history of chickenpox.
Observe the rash, noting the color, temperature, and appearance of lesions and their location and distribution over the body. Note lesion grouping and identify the type. The involved skin may reveal redness, warmth, swelling, vesicles, or crusted areas. This area is generally tender to touch. Determine if lesions are present in the patient’s mouth. The appearance of the lesions changes over time. The initial maculopapules and blisters may evolve in 10 days to scabbed dry blisters and in 2 weeks to small, red nodular skin lesions spread around the area of the dermatome. The patient usually experiences intermittent or continuous pain for up to 4 weeks, although, in rare situations, intractable neurological pain may persist for years.
Assess the patient’s ability to cope with a sudden, unexpected illness that is generally very painful. Assess the amount of pain and degree of relief obtained. Some patients with facial palsy or visible skin lesions may have an altered body image that may cause anxiety.
Nursing care plan primary nursing diagnosis: Pain (acute or chronic) related to nerve root inflammation and skin lesions.
Nursing care plan intervention and treatment plan
The goals of therapy are to dry the lesions, relieve pain, and prevent secondary complications. These goals are met primarily through pharmacologic therapy. A wet-to-dry compress application of a Burow’s solution (aluminum acetate) three to four times a day will help dry the lesions. Normally, the only patients treated in the hospital for a herpes zoster infection are those with a primary disease that leads to immunosuppression and can place them at risk for shingles. The most important nursing intervention focuses on prevention of complications. Monitor for signs and symptoms of infection. Since involvement of the ophthalmic branch of the trigeminal nerve may result in conjunctivitis and possible blindness, be alert for lesions in the eye, and refer the patient to an ophthalmologist. Patients with involvement of sacral dermatomes may have changes in patterns of urinary elimination from acute urinary retention. Monitor intake and output to identify this complication.
Pain may be reduced by splinting the affected area with a snug wrap of nonadherent dressings and covering with an elastic bandage. Manage malaise and elevated temperature with bedrest and a quiet environment. Encourage diversionary activities and teach relaxation techniques to help the patient manage pain without medication. If oral lesions are painful, encourage use of a soft toothbrush and swishing and rinsing every 2 hours with a mouthwash based on a normal saline solution. A soft diet may be necessary during periods of painful oral lesions. Discuss communicability of the disease. Although herpes zoster is not itself infectious, the
patient can transmit chickenpox to those who have not had it or to those people who are immunocompromised.
Nursing care plan discharge and home health care guidelines
Explain that there is no means for eliminating the varicella virus from the nerve ganglia. (A varicella vaccine, however, is currently under development and may help with prevention of primary chickenpox and therefore might help with decreasing the incidences of herpes zoster.) Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Instruct the patient to report redness, swelling, or drainage of the rash to
the primary healthcare provider.