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Message 1Herpes Zoster (Shingles)PathophysiologyHerpes zoster, also known as shingles, is an acute, viral illness that occurs from reactivation of the varicella-zoster virus (VZV), which also causes varicella (chickenpox). When a client has experienced chickenpox as a child, varicella migrates to the dorsal root ganglia of the sensory nerves, where it can lay dormant (asymptomatic) for years. As the client ages and the immune system weakens, the virus can become reactivated, causing the client to begin expressing symptoms. Dermatomal distribution y A dermatome is an area of skin that is innervated by a specific sensory nerve. y When the virus reactivates, it travels down the sensory nerve, presenting as nerve pain and a rash along the dermatome associated with the sensory nerve.
2Transmission y VZV can be transmitted through direct contact with lesions or discharge from lesions or aerosol droplets from sneezing or coughing. ○ The virus can be transmitted until all lesions have crusted over, with chickenpox manifesting as the primary infection. y The incubation period, or the period between exposure to the appearance of symptoms, is 14-16 days.
3Risk Factors ● Immunosuppressive medications or conditions ○ HIV infection ○ Corticosteroids ○ Chemotherapy ● Advanced age ● Vaccination status ○ Has not received varicella vaccination ● Previous varicella infection Manifestations ● Fever ● Malaise ● Painful, vesicular rash ○ Rash begins as small, erythematous macules that turn into oozing vesicular lesions. ○ Often appears in a linear pattern along an area of skin innervated by spinal nerves (dermatomal distribution) ○ A yellow-brown crust eventually forms around the original lesion. ○ May also involve the trigeminal and ophthalmic nerves. ● Burning, tingling sensation preceding rash ○ Early indication of shingles The virus is most contagious and infectious when lesions on the client are weeping and oozing.
4ComplicationsComplications are based on which sensory nerve and dermatome have been affected. ● Reactivation within the trigeminal ganglion most often affects the ophthalmic division of the trigeminal nerve (cranial nerve V), leading to the development of a vesicular rash within the V1 distribution. ○ Unilateral forehead ○ ○ Periorbital area Changes in vision and ocular pain should be reported to the health care provider because ophthalmic nerve involvement can lead to acute keratitis (corneal inflammation or infection) and result in corneal scarring and permanent blindness.
5 ● Postherpetic neuralgia (PHN) ○ Persistent neuropathic pain (>3 months) in the affected region typically described as:• • Tingling• Burning sensation ○ Occurs because of hypersensitive nerve function ○ Pain is triggered or worsened by light touch. ○ Often improves over time, but resolution may take years ● Bell palsy ○ Occurs due to destruction of sensory nerve InterventionsLocalized Symptoms Disseminated Symptoms y y Airborne and contact precautions until lesions have crusted and are no longer weeping
6Antivirals y Acyclovir, famciclovir, valacyclovir y Reduce viral replication and lessen the duration of the outbreak y Administer within 72 hours of symptom onset to shorten the duration of illness y Do not prevent the client from having future outbreaksAnalgesics y NSAIDs, acetaminophen, short-acting opioids y Administer as needed for neuropathic pain.Anticonvulsants y Gabapentin, pregabalin y Indicated for PHNTricyclic antidepressants y Amitriptyline y Indicated for PHNTopical treatments y Capsaicin, lidocaine y Reduce pain associated with PHN
7 ● Necessary if rash involves or is close to the eye to rule out ocular damage or other complications ● Wear lightweight, loose cotton clothing. ○ Assists in keeping the skin dry and cool ● Provide a cool environment ● Apply wet compresses ○ Prevents the skin from drying out and decreases irritation, itching, and painClient Teaching ● Are immunocompromised ● Have not received the VZV vaccination ● Have not previously been infected with VZV or chickenpox ● Wash hands thoroughly and frequently. ○ Prior to touching lesions to prevent secondary infection ○ After touching lesions to prevent the spread of infection ● Removing crusts can promote scarring. ● Risk for Bell palsy ● Educate high-risk clients on availability and importance of shingles vaccine y Older adults y Clients with previous chickenpox infection ● Clients who have had shingles should still receive the shingles vaccine because VZV reactivation can occur multiple times.
8Check for Understanding 1The nurse is caring for a client with localized herpes zoster (shingles). There are no weeping lesions. Which of the following infection control precautions should the nurse implement?a) droplet precautions b) airborne precautions c) contact precautionsd) standard precautionsCheck for Understanding 2The nurse has attended a staff education program about herpes zoster (shingles). Which of the following statements by the nurse would indicate a correct understanding of the program?a) "The varicella-zoster virus migrates and travels down a sensory nerve pathway."b) "Clients who have had herpes zoster do not need to receive the shingles vaccine."c) "The first sign of herpes zoster infection is a rash, followed by burning sensations."d) "The varicella-zoster virus can reactivate and cause shingles only one time in a client."Check for Understanding 3The nurse is assessing a client with herpes zoster (shingles). Which of the following findings would be a priority to follow up?a) unilateral facial drooping b) neuropathic pain in the affected regionc) ocular pain with vision changesd) weeping vesicular lesions in a linear pattern on the backAnswers1) d2) a3) c