Incidence and prevalence of the disorder.
Shingles, also known as herpes zoster is a painful rash that appears in certain areas of the body. According to The Centers for Disease Control and Prevention (CDC, 2019), about 1 out of every 3 people in the United States will develop shingles. An estimated 1 million people get shingles each year in this country. Individuals with chickenpox are at risk for shingles and the risk of getting shingles increases as an individual gets older. According to Galloway (2016), more than 50,000 cases of shingles occur in people over the age of 70 each year. 1,400 cases are so severe that they result in hospital admission. It is estimated that in people aged 70 years and over, around one in 1,000 cases results in death.
Pathophysiology from an advanced practice perspective
According to Galloway (2016), shingles is caused by reactivation of a latent varicella-zoster virus (VZV), years after the primary infection that causes chickenpox. 90% of the adult population has been exposed to chickenpox, therefore they are at risk of developing shingles later in life. VZV remains dormant in the sensory dorsal root ganglia, where it establishes a permanent latent infection, which is kept in check by the immune system. However, with old age, our immunity reduces; meaning immune senescence or immunosuppression can cause the virus to be reactivated. The most usual site of reactivation is the thoracic nerves, followed by the ophthalmic division of the trigeminal nerve. According to Conceicao (2018), the fluid within the vesicles is highly contagious for individuals who never contracted the virus. It is only infectious as a result of direct contact with the fluid from open vesicles.
Physical assessment and examination
Upon examination, the provider may note a unilateral rash on the face or body associated with pain itching, tingling, or numbness. According to Galloway (2016), patients may experience pain, abnormal skin sensations, itching, headache, photophobia, malaise, and fever before the rash appears. When it does appear, the rash has fluid-filled vesicles that occur across the face and trunk. Diagnosis is usually made based on the presence of typical lesions on a single dermatome. In straightforward cases, further investigation is not generally useful as scrapings for smears and cultures are usually negative.
Evidence-based treatment plan and patient education
After completing a focused assessment, the patient will be educated and treated accordingly. The patient should keep the rash clean and dry to prevent secondary bacterial infection. According to The CDC (2019), OTC or prescribed pain medicine may help relieve the pain. Wet compresses, calamine lotion, and colloidal oatmeal baths (a lukewarm bath mixed with ground-up oatmeal) may help relieve itching. The patient should avoid wearing clothes and fibers that may irritate their skin. The patent can be taught how to effectively manage pain with relaxation techniques and the provider may refer to a pain management specialist if necessary. Galloway (2016) stated topical antiviral treatment is not recommended, although topical antibiotic treatment may be needed if a secondary bacterial infection develops. Galloway (2016) explained antiviral drugs may be used to reduce the severity and duration of shingles, but there is little evidence to suggest that they prevent Postherpetic neuralgia (PHN) which is a complication of shingles.
Valaciclovir and Famciclovir are two antiviral drugs that are given. According to Conceicao (2018), there are no specific guidelines for the treatment of shingles, however, the Royal College of Physicians (RCP) suggests to treat shingles with antiviral drugs within 72 hours of the onset of symptoms to maximize the effectiveness of the therapy and reduce its complications. Antivirals work by stopping the spreading of the rash, the pruritus, and the intensive pain, and reducing the period where the virus is still contagious. Medication should be administered within 72 hours of the first signs of the virus, particularly in patients with ophthalmic involvement and who are immunosuppressed or immunocompromised.
Follow up and Evaluation
The patient is to follow up with their provider if they should experience an increase in pain and formation of new lesions. According to Epocartes (2020), patients with a new lesion and with neurological, ocular, motor, and cutaneous complications after a 7-day course of antiviral treatment should be monitored closely. The provider will then decide if they need to extend treatment. The patient may also be treated for complications. Patients with ocular complications will be referred to an Ophthalmologist.
Centers for Disease Control and Prevention. (2019). Shingles (Herpes Zoster) Retrieved from https://www.cdc.gov/shingles/about/index.html
Conceicao, V. (2018). Prevention and management of shingles and associated complications. Journal of Community Nursing, 32(6), 40–43.
Galloway, M. (2016). Shingles: Prevention and management. Practice Nurse, 46(9), 18–22.
Shingles. (2020). In Epocrates Essential for Apple iOS (Version 20.2) [Mobile Application Software]. Retrieved from http://www.epocrates.com/mobile/iphone/essentials