Herpes Zoster Nursing Diagnosis & Care Plan

Herpes zoster, commonly known as shingles, is a viral infection caused by the reactivation of the varicella-zoster virus (VZV), the same virus that causes chickenpox. This condition can be painful and debilitating, often requiring comprehensive nursing care.

This article will explore the nursing diagnosis, assessment, interventions, and care plans for patients with herpes zoster.

Causes (Related to)

Herpes zoster can occur in individuals who have previously had chickenpox. The virus remains dormant in nerve tissue and can reactivate later in life, causing shingles. Common factors that can trigger this reactivation include:

• Weakened immune system due to age, stress, or illness
• Certain medications, especially those that suppress the immune system
• Chronic diseases such as cancer or HIV/AIDS
• Physical trauma or surgery
• Psychological stress

Signs and Symptoms (As evidenced by)

Herpes zoster presents with a variety of signs and symptoms. During a physical assessment, a patient with herpes zoster may present with one or more of the following:

Subjective: (Patient reports)

• Burning, tingling, or itching sensation in a specific area of the skin
• Severe pain that may be sharp, stabbing, or throbbing
• Sensitivity to touch in the affected area
• Fatigue
• Headache
• Sensitivity to light

Objective: (Nurse assesses)

• Rash that appears as a stripe of blisters on one side of the body or face
• Fever
• Chills
• Malaise
• Lymph node swelling

Expected Outcomes

The following are common nursing care planning goals and expected outcomes for herpes zoster:

• The patient will report decreased pain levels within 24-48 hours of treatment initiation
• The patient will demonstrate proper wound care techniques for the rash
• The patient will show no signs of secondary bacterial infection
• The patient will verbalize understanding of the disease process and treatment plan
• The patient will demonstrate improved quality of life and ability to perform daily activities

Nursing Assessment

1. Assess the rash characteristics:
   Examine the location, appearance, and extent of the rash. Herpes zoster typically presents as a unilateral, painful rash in a dermatomal distribution.
2. Evaluate pain levels:
   A standardized pain scale assesses the patient’s pain intensity and characteristics. Pain associated with herpes zoster can be severe and may persist even after the rash has healed (postherpetic neuralgia).
3. Monitor vital signs:
   Check for fever, which may indicate the presence of infection or complications.
4. Assess for complications:
   Look for signs of secondary bacterial infection, disseminated zoster, or involvement of the eyes or other organs.
5. Review the patient’s medical history:
   Identify any underlying conditions or medications that may have contributed to the virus’s reactivation or that may complicate treatment.
6. Evaluate the patient’s knowledge:
   Assess the patient’s understanding of herpes zoster, its treatment, and prevention of transmission.
7. Assess the impact on daily living:
   Determine how the condition affects the patient’s ability to perform activities of daily living, work, and maintain relationships.
8. Check vaccination status:
   Inquire about previous chickenpox infection or vaccination and shingles vaccination status.
9. Prepare for diagnostic tests:
   The healthcare provider may order tests such as:

• PCR test of blister fluid or skin lesion
• Tzanck smear
• Skin biopsy (in rare cases)

Nursing Interventions

1. Administer medications as prescribed:
   Antiviral medications (e.g., acyclovir, valacyclovir) should be started as soon as possible to reduce the severity and duration of the outbreak. Pain management medications may include analgesics, anticonvulsants, or topical agents.
2. Provide wound care:
   Keep the rash clean and dry. Apply cool, wet compresses to reduce pain and itching. Advise against scratching to prevent secondary infection.
3. Implement infection control measures:
   Use standard precautions. Advise the patient to avoid contact with individuals without chickenpox or the varicella vaccine, especially pregnant women and immunocompromised individuals.
4. Educate the patient:
   Provide information about the disease process, treatment plan, potential complications, and strategies to prevent transmission.
5. Promote comfort:
   Assist the patient in finding comfortable positions and suggest loose-fitting clothing to minimize irritation to the affected area.
6. Monitor for complications:
   Watch for signs of postherpetic neuralgia, secondary bacterial infection, or disseminated zoster.
7. Provide psychosocial support:
   Offer emotional support and refer to support groups or counseling if needed, as herpes zoster can significantly impact quality of life.
8. Encourage adequate nutrition and hydration:
   A balanced diet and proper hydration can support the immune system and promote healing.
9. Discuss prevention strategies:
   Educate about the shingles vaccine and its importance in preventing future outbreaks or reducing their severity.

Nursing Care Plans

Care Plan 1: Acute Pain

Nursing Diagnosis: Acute Pain related to inflammation and nerve involvement secondary to herpes zoster infection as evidenced by patient’s report of severe burning pain, rated 8/10 on pain scale, and visible unilateral rash.

Related factors/causes:

• Inflammation of affected nerves
• Skin lesions and blisters
• Viral reactivation in nerve ganglia

Nursing Interventions and Rationales:

1. Assess pain characteristics, intensity, and location every 4 hours.
   Rationale: Regular pain assessment helps evaluate the effectiveness of pain management strategies and guides adjustments to the treatment plan.
2. Administer prescribed antiviral medications and analgesics as ordered.
   Rationale: Antiviral drugs can reduce the severity and duration of the outbreak, while analgesics provide pain relief.
3. Apply cool, moist compresses to the affected area for 20 minutes every 2 hours while awake.
   Rationale: Cool compresses can provide local pain relief and reduce inflammation.
4. Teach relaxation techniques such as deep breathing and guided imagery.
   Rationale: These techniques can help manage pain and reduce stress, which may exacerbate symptoms.
5. Educate the patient about avoiding tight clothing and direct contact with the rash.
   Rationale: Minimizing irritation to the affected area can help reduce pain and prevent secondary infection.

Desired Outcomes:

• The patient will report pain reduction to 4/10 or less on the pain scale within 48 hours of intervention implementation.
• The patient will demonstrate non-pharmacological pain management techniques by the end of the shift.
• The patient will verbalize understanding of pain management strategies and medication regimen before discharge.

Care Plan 2: Risk for Infection

Nursing Diagnosis: Risk for Infection related to compromised skin integrity secondary to herpes zoster lesions.

Related factors/causes:

• Open skin lesions from herpes zoster rash
• Potential for scratching due to itching
• Weakened immune system

Nursing Interventions and Rationales:

1. Assess the rash daily for signs of secondary bacterial infection (increased redness, warmth, swelling, purulent discharge).
   Rationale: Early detection of secondary infection allows for prompt treatment and prevention of complications.
2. Teach proper hand hygiene and wound care techniques to the patient and caregivers.
   Rationale: Proper hygiene reduces the risk of introducing bacteria to the lesions.
3. Keep the affected area clean and dry using gentle cleansing methods.
   Rationale: Maintaining a clean environment around the lesions promotes healing and reduces infection risk.
4. Advise the patient to avoid scratching the rash and to keep nails short and clean.
   Rationale: Scratching can introduce bacteria and cause further skin damage.
5. Administer prescribed topical or oral antibiotics if secondary bacterial infection occurs.
   Rationale: Prompt treatment of secondary infections prevents further complications.

Desired Outcomes:

• The patient will demonstrate proper wound care techniques before discharge.
• The patient will show no signs of secondary bacterial infection throughout treatment.
• The patient will verbalize understanding of infection prevention strategies by the end of the education session.

Care Plan 3: Impaired Skin Integrity

Nursing Diagnosis: Impaired Skin Integrity related to viral-induced inflammation and blistering secondary to herpes zoster infection as evidenced by visible unilateral rash with fluid-filled vesicles.

Related factors/causes:

• Viral reactivation causing skin lesions
• Inflammation of affected dermatome
• Potential for scratching due to discomfort

Nursing Interventions and Rationales:

1. Assess the characteristics of the rash daily, including size, distribution, and stage of lesions.
   Rationale: Regular assessment allows for monitoring of disease progression and the effectiveness of treatment.
2. Apply prescribed topical medications as ordered, using a gentle technique.
   Rationale: Proper application of topical treatments can promote healing and provide symptomatic relief.
3. Educate the patient on proper bathing techniques, including lukewarm water and mild, unscented soap.
   Rationale: Gentle cleansing helps maintain skin hygiene without irritating the affected area.
4. Recommend loose-fitting, breathable clothing to minimize friction on the affected area.
   Rationale: Reducing irritation to the skin can promote comfort and healing.
5. Teach the patient about the stages of lesion healing and expected progression.
   Rationale: Understanding the healing process can reduce anxiety and promote treatment adherence.

Desired Outcomes:

• The patient will demonstrate improved skin integrity with progressive healing of lesions within 7-10 days of treatment initiation.
• The patient will verbalize understanding of skin care measures by the end of the education session.
• The patient will report decreased discomfort associated with skin lesions within 48 hours of intervention implementation.

Care Plan 4: Anxiety

Nursing Diagnosis: Anxiety related to acute illness and fear of complications secondary to herpes zoster diagnosis as evidenced by expressed worry, restlessness, and increased inquiries about prognosis.

Related factors/causes:

• Uncertainty about disease progression
• Fear of pain and discomfort
• Concerns about potential complications (e.g., postherpetic neuralgia)

Nursing Interventions and Rationales:

1. Assess the patient’s level of anxiety using a standardized scale.
   Rationale: Quantifying anxiety levels helps in evaluating the effectiveness of interventions.
2. Provide clear, concise information about herpes zoster, its treatment, and expected course.
   Rationale: Knowledge can help reduce fear of the unknown and promote a sense of control.
3. Encourage the patient to express concerns and ask questions.
   Rationale: Open communication allows for addressing specific worries and misconceptions.
4. Teach stress-reduction techniques such as progressive muscle relaxation or mindfulness meditation.
   Rationale: These techniques can help manage anxiety and improve overall well-being.
5. Refer to support groups or counseling services if anxiety persists or significantly impacts daily functioning.
   Rationale: Professional support can provide additional coping strategies and emotional assistance.

Desired Outcomes:

• The patient will report decreased anxiety levels within 48 hours of intervention implementation.
• The patient will demonstrate using at least one stress-reduction technique by the end of the shift.
• The patient will verbalize an accurate understanding of the herpes zoster prognosis and treatment plan before discharge.

Care Plan 5: Disturbed Sleep Pattern

Nursing Diagnosis: Disturbed Sleep Pattern related to pain and discomfort secondary to herpes zoster as evidenced by patient reports of difficulty falling asleep and frequent nighttime awakenings.

Related factors/causes:

• Acute pain from herpes zoster lesions
• Anxiety about the condition
• Itching or burning sensations

Nursing Interventions and Rationales:

1. Assess sleep patterns and factors affecting sleep quality.
   Rationale: Identifying specific sleep disturbances helps in tailoring interventions.
2. Administer pain medications as prescribed, timing the doses to provide maximum relief during sleep hours.
   Rationale: Effective pain management can significantly improve sleep quality.
3. Promote a comfortable sleep environment (e.g., adjust room temperature, reduce noise, provide extra pillows for positioning).
   Rationale: A comfortable environment is conducive to better sleep.
4. Teach sleep hygiene techniques, such as establishing a consistent bedtime routine and avoiding stimulants before bed.
   Rationale: Good sleep hygiene practices can improve sleep quality and duration.
5. Collaborate with the healthcare provider to address persistent sleep issues, which may require additional interventions or medications.
   Rationale: Some patients may benefit from short-term use of sleep aids or adjustment of pain management strategies.

Desired Outcomes:

• The patient will report improved sleep quality and duration within 3 days of intervention implementation.
• The patient will demonstrate an understanding of sleep hygiene principles by the end of the education session.
• The patient will verbalize feeling more rested upon awakening by discharge.

References

1. Albrecht, M. A. (2021). Clinical manifestations of varicella-zoster virus infection: Herpes zoster. UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-of-varicella-zoster-virus-infection-herpes-zoster
2. Centers for Disease Control and Prevention. (2019). Shingles (Herpes Zoster). Retrieved from https://www.cdc.gov/shingles/index.html
3. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales (15th ed.). F.A. Davis Company.
4. Johnson, R. W., & Whitton, T. L. (2004). Management of herpes zoster (shingles) and postherpetic neuralgia. Expert Opinion on Pharmacotherapy, 5(3), 551-559. doi: 10.1517/14656566.5.3.551
5. Mallick-Searle, T., Snodgrass, B., & Brant, J. M. (2016). Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. Journal of Multidisciplinary Healthcare, 9, 447-454. doi: 10.2147/JMDH.S106340
6. Nursing Diagnosis: Definitions and Classification 2021-2023. (2021). NANDA International, Inc.
7. Saguil, A., Kane, S., Mercado, M., & Lauters, R. (2017). Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. American Family Physician, 96(10), 656-663.
8. Yawn, B. P., & Gilden, D. (2013). The global epidemiology of herpes zoster. Neurology, 81(10), 928-930. doi: 10.1212/WNL.0b013e3182a3516e