A nurse is caring for a client admitted to the intensive care unit for toxic epidermal necrolysis. Which interventions should be included in this client's care plan? Select all that apply.

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Toxic epidermal necrolysis is an acute skin disorder, most commonly associated with a medication reaction, that results in widespread erythema, blistering, epidermal shedding, keratoconjunctivitis, and skin erosion (ie, denuded skin). It is a severe form of Stevens-Johnson syndrome. The major cause of death related to toxic epidermal necrolysis is sepsis; therefore, infection prevention is critical. Basic supportive care includes: Wound care: Sterile, moist dressings are applied to open areas of skin (Option B). Infection prevention: Strict sterile technique and reverse isolation decrease infection risk. The nurse should also monitor for any signs of infection (eg, fever) (Option C). Fluids and nutrition: Vital signs and urine output are monitored for signs of hypovolemia. Oral feeding should be initiated early to promote wound healing; a nasogastric tube may be necessary. Hypothermia prevention: Maintain a room temperature of 85 F (29.4 C) or more, and use passive rewarming methods such as sterile, single-use warming blankets or digitally regulated warming pads (Option D). Pain management: Analgesics are administered around the clock and before painful procedures. Eye care: Sterile, cool compresses are applied to relieve discomfort. Lubricants may relieve dryness and prevent corneal abrasion (Option A). (Option E) Massage is inappropriate due to cutaneous tenderness and epidermal shedding. Educational objective: Toxic epidermal necrolysis is a life-threatening condition that causes large areas of denuded skin and mucosa. Nursing care focuses on preventing complications, including sepsis, fluid and electrolyte imbalance, hypothermia, and ophthalmic issues.

A Nurse Is Caring for a Client Admitted to the Intensive