N213: Health Differences Across the Life Span 3

N213: Health Differences Across the Lifespan 3 Study Guide ©2017 Achieve Test Prep Page 57 of 204 Impaired skin integrity related to herpes lesions • Risk for pain related to herpes simplex virus, secondary to sensory nerve involvement • Knowledge deficit related to disease process and transmission risks Nursing interventions for herpes simplex: • Monitor for increased pain levels and administer analgesics per MDorder • Teach patient about hygiene and transmission prevention: condoms and food utensil sharing • Encourage patient to wear loose fitting clothing duringoutbreaks • Administer antiviral medications per MDorders: o cyclovir (Zovirax): Side effects include drowsiness, vision changes, sensitivity to sunlight, and dizziness o Famciclovir (Famvir): Side effects include headache, migraine, and paresthesia; it can also cause gastrointestinal upset and fatigue o Valacyclovir (Valtrex): Side effects include constipation, seizures, headache, dizziness, loss of appetite, depression, and elevated liver panels • Offer patients warm sitz baths to soothe genital area and assist with healing process • Give good skin care to prevent breakdown while lesions heal • Offer salt water rinses for mouth and throat • Encourage increased fluids • If urination is painful, prepare for urinary catheterization per MDorder • Offer anti-itch medication per MD order for itching Expected outcomes for herpes simplex: • Verbalizes relief of symptoms including pain, itching, and burning • Demonstrates good skin care routine, hygiene, and healing of lesions without infection • Verbalizes knowledge of medication routine, disease transmission, and infection control Cytomegalovirus Cytomegalovirus, or CMV, is a type of herpes that many people have. It is asymptomatic. Most people with the virus do not have symptoms and are fine, but those who are pregnant or have an underlying disease are at risk for complications. It is most dangerous in pregnant women and can cause birth defects in an unborn fetus. It can also be passed to an infant during birth or at daycare facilities. The main mode of transmission is body fluids, sexual contact, urine, and feces. Nursing diagnosis for herpes simplex: •