{ "name": "Herpes Zoster (Shingles)", "slug": "herpes-zoster", "url": "https://nursingplex.com/care-plans/herpes-zoster", "category": "Infectious Diseases", "summary": "Reactivated varicella with dermatomal rash and neuropathic pain; contact precautions.", "nursing_diagnoses": [ "Acute pain", "Impaired skin integrity", "Risk for infection transmission" ], "overview": [ "Herpes zoster, or shingles, is the reactivation of varicella-zoster virus that has lain dormant in the dorsal root ganglia since a childhood chickenpox infection. Reactivation follows a fall in cell-mediated immunity from aging, illness, stress, chemotherapy or steroids, and produces a painful vesicular rash confined to a single dermatome that stops abruptly at the midline.", "Pain typically precedes the rash by 2–3 days as burning, itching or deep aching, then vesicles appear in clusters on an erythematous base, crust over in 7–10 days and resolve in 2–4 weeks. Antiviral therapy started within 72 hours of rash onset shortens the course and reduces the main long-term problem: postherpetic neuralgia, a persistent burning nerve pain that can outlast the rash by months or years.", "Two complications need specific vigilance. Ophthalmic involvement — vesicles on the nose tip, the Hutchinson sign — threatens vision and requires urgent ophthalmology referral. Disseminated zoster in the immunocompromised is a systemic emergency. Because the vesicle fluid contains live virus, patients can transmit chickenpox to non-immune contacts until every lesion crusts." ], "key_facts": [ { "label": "Distribution", "text": "Unilateral, dermatomal rash that never crosses the midline — the defining feature." }, { "label": "Treatment window", "text": "Start acyclovir, valacyclovir or famciclovir within 72 hours of rash onset for maximum benefit." }, { "label": "Contagion", "text": "Contagious to non-immune people (causing chickenpox) via vesicle fluid until all lesions crust over." }, { "label": "Hutchinson sign", "text": "Vesicles on the tip of the nose signal nasociliary involvement and possible sight-threatening eye disease." }, { "label": "Prevention", "text": "Recombinant zoster vaccine is recommended for adults 50 and over, including those who have had shingles." } ], "nursing_priorities": [ "Relieve acute neuropathic pain.", "Start antivirals within the 72-hour window.", "Prevent secondary bacterial infection of lesions.", "Prevent transmission to non-immune contacts.", "Detect ophthalmic and disseminated involvement.", "Prevent and manage postherpetic neuralgia." ], "assessment": { "subjective": [ "Burning, stabbing, itching or deep aching pain in a band-like distribution, often before any rash", "Extreme sensitivity so that clothing or bedsheets are unbearable (allodynia)", "Headache, malaise and low-grade fever", "Sleep disruption and low mood from unrelenting pain", "Eye pain, blurred vision or facial weakness" ], "objective": [ "Grouped vesicles on an erythematous base in a unilateral dermatomal band", "Progression from vesicles to pustules to crusts over 7–10 days", "Vesicles on the nose tip, eyelid or cornea involvement", "Facial droop, ear vesicles and hearing change in Ramsay Hunt syndrome", "Signs of secondary infection: purulence, spreading erythema, increasing pain, fever", "More than 20 lesions outside the primary dermatome, indicating dissemination" ], "related_factors": [ "Reactivation of latent varicella-zoster virus in sensory ganglia", "Decreased cell-mediated immunity from age, illness, stress or immunosuppression", "Inflammation and damage of sensory nerves", "Open vesicles providing a portal for bacteria" ] }, "goals": [ "The client will report pain reduced to an acceptable level and will sleep through the night.", "The client will have lesions crusted and healing without secondary infection.", "The client will begin antiviral therapy within 72 hours of rash onset.", "The client will identify and protect non-immune contacts until crusting is complete.", "The client will remain free of ocular complications or receive prompt referral.", "The client will state the plan for managing any persisting nerve pain." ], "interventions": [ { "title": "1. Controlling pain", "points": [ "Assess pain with a neuropathic-appropriate description — burning, shooting, electric — rather than only a 0–10 number.", "Give scheduled analgesia rather than as-needed dosing during the acute phase; nerve pain responds poorly to catch-up dosing.", "Anticipate adjuvants: gabapentin or pregabalin, tricyclic antidepressants, and topical lidocaine patches once lesions have crusted.", "Apply cool, moist compresses to lesions for 20 minutes several times daily; avoid heat.", "Use loose, soft cotton clothing and a bed cradle to keep sheets off hypersensitive skin.", "Add relaxation, distraction and music, which measurably reduce neuropathic pain perception." ] }, { "title": "2. Antiviral and medication management", "points": [ "Emphasize starting the antiviral within 72 hours of rash onset and completing the full course.", "Ensure adequate hydration with acyclovir to protect renal function and monitor creatinine in older adults.", "Administer corticosteroids only when specifically prescribed, usually combined with an antiviral.", "Review the medication list for interactions and teach the exact dosing schedule, which is frequent and easy to miss." ] }, { "title": "3. Skin care and infection prevention", "points": [ "Keep lesions clean and dry; use cool saline or Burow's solution compresses and pat dry.", "Do not rupture vesicles; teach the patient not to scratch and keep nails short.", "Apply calamine or prescribed topical preparations for itch; avoid occlusive ointments over weeping lesions.", "Assess daily for secondary bacterial infection and report increasing redness, warmth, purulence or fever.", "Cover lesions with a non-adherent dressing when the patient must be around others." ] }, { "title": "4. Preventing transmission", "points": [ "Explain that shingles cannot be caught, but the virus in the blisters can give chickenpox to someone who has never had it or been vaccinated.", "Avoid contact with pregnant women, newborns and immunocompromised people until all lesions have crusted.", "Use standard precautions for localized zoster with covered lesions; add airborne and contact precautions for disseminated zoster or immunocompromised patients.", "Ensure healthcare workers caring for the patient are immune." ] }, { "title": "5. Detecting complications", "points": [ "Inspect the face carefully: vesicles on the nose tip, eyelid, forehead or conjunctiva require same-day ophthalmology referral.", "Assess for facial weakness, ear pain, vesicles in the ear canal, hearing loss and vertigo — Ramsay Hunt syndrome needs urgent treatment.", "Count lesions outside the affected dermatome; more than about 20 suggests dissemination and warrants immediate escalation.", "Screen for depression and sleep disturbance at follow-up, both common with prolonged pain." ] } ], "patient_teaching": [ "Start and finish the antiviral exactly as prescribed; the earlier it is started the shorter and milder the illness.", "Keep the rash covered and stay away from pregnant women, newborns and anyone with a weak immune system until every blister has crusted.", "Do not scratch or open the blisters; keep the area clean, cool and dry.", "Report eye pain, blurred vision, blisters on your nose or face, facial droop or hearing change immediately.", "Tell your provider if pain persists after the rash heals — postherpetic neuralgia is treatable and should not be endured.", "Get the shingles vaccine when advised, even if you have already had shingles.", "Rest, hydrate and manage stress; both support recovery." ] }