Herpes zoster, commonly known as shingles, is an infection caused by the varicella-zoster virus (VZV), the same virus responsible for chickenpox (varicella).

The incubation period spans approximately 7 to 21 days.

The illness typically lasts from 10 days to 5 weeks from the start until complete recovery.

Risk Factors

• Advanced age, with risk significantly increasing after 50 years old.

• Compromised immune function due to conditions such as cancer, HIV infection, and immunosuppressant medications.

• Prolonged and unresolved emotional or physical stress.

Pathophysiology

Following a chickenpox infection, the virus remains inactive within the nerve cell bodies (ganglia) of the spinal nerves.

The virus can reactivate later, traveling along the peripheral nerves to the skin’s surface.

Here, it replicates and leads to the formation of painful, fluid-filled blisters (vesicular eruptions).

It is most frequently observed in older individuals and those with weakened immune systems.

While VZV commonly affects the torso, it can also appear on the buttocks or face.

If the ophthalmic branch of the trigeminal nerve is involved, the patient may experience keratitis, corneal ulceration, and potentially vision loss.

Infection of the lesions due to scratching is a frequent complication.

Clinical Features

The initial symptom is often a tingling feeling in the affected area.

Painful blisters develop within the region supplied by a single nerve root, typically affecting only one side of the body.

Significant pain and discomfort may precede the rash by about five days.

Red bumps (papules) evolve into blisters, which then scab over and heal within approximately three to four weeks.

General discomfort (malaise) and fever are common, and this, combined with the pain, can make shingles a debilitating condition.

Diagnosis

• History of prior chickenpox infection.

• The pain and rash pattern of shingles is characteristically one-sided (unilateral).

• Onset may occur following a period of weakness or illness.

• Culture and sensitivity testing may be performed if a secondary bacterial infection is suspected.

Assessment

• Subjective Data:

  • Pain, burning sensations

  • Numbness, tingling sensations

  • Itching

  • Headache

  • Sensitivity to light

  • Fatigue, tiredness

• Objective Data:

  • Rash presenting as clusters of fluid-filled blisters (vesicles)

  • Rash follows a dermatomal distribution (along a nerve pathway)

Nursing Management

• Evaluate pain intensity using a pain scale.

• Note the specific location and nature of the pain.

• Determine the duration of the pain.

• Observe non-verbal indicators of pain.

• Identify factors that provide pain relief.

• Recognize that severe nerve pain (burning sensation) is the primary complaint, often preceded by tingling or itching.

• Monitor for signs and symptoms of bacterial skin infections and obtain a culture and sensitivity test as indicated.

• Assess for any changes in vision and the presence of a rash on the forehead or tip of the nose, indicating potential eye involvement.

Specific Nursing Care

• Apply cool, moist compresses to itchy lesions to provide relief.

• Avoid extremes of temperature in the environment and bathwater.

• Instruct the patient to avoid rubbing or scratching the skin or lesions to prevent secondary infection.

• Recommend loose-fitting clothing made of natural fibers like cotton for comfort.

• Keep the rash area dry to promote healing.

• Encourage rest, particularly when feeling unwell.

• Promote herpes zoster vaccination as a preventive measure.

• Explain the necessity of isolation precautions to the patient.

• Limit visitors to prevent transmission, especially to vulnerable individuals.

• Advise keeping fingernails short to minimize damage from scratching.

• Utilize personal protective equipment while providing care to the patient.

Medical Management

• Antiviral medications (such as acyclovir or its prodrugs valacyclovir and famciclovir) are administered to reduce the severity and duration of symptoms.

• Oral pain relievers (including opioids for severe pain) are prescribed to manage acute pain.

• Antidepressants and antiepileptic drugs may be used to manage post-herpetic neuralgia.

• Topical corticosteroids can be used for their anti-inflammatory effects.

• Antihistamines can help relieve itching, particularly at bedtime.

• Topical pain relievers can provide localized pain relief.

Complications

• Ear-related issues like tinnitus (ringing in the ears), vertigo (dizziness), hearing impairment, or facial paralysis on one side (Bell’s palsy).

• Persistent nerve pain after the rash has healed (post-herpetic neuralgia), which can be intense and long-lasting.

• Eye problems such as corneal erosion or ulceration, dry eyes, or inflammation of the optic nerve.

Nursing Diagnoses

1. Acute Pain or Chronic Pain related to nerve pain (most frequently affecting cervical, lumbar, sacral, thoracic, or the ophthalmic branch of the trigeminal nerve) as evidenced by changes in muscle tone, facial expressions of pain, reports of burning, dull, or sharp pain, and reports of pain localized to the affected nerve pathway.

2. Deficient Knowledge related to the complexity of treatment and the herpes zoster outbreak, as evidenced by inadequate adherence to instructions, questioning healthcare team members, and expressing inaccurate information.

3. Risk for Infection related to crusted-over lesions, itching, scratching, and the presence of skin lesions (papules, vesicles, pustules).

4. Risk for Disturbed Body Image related to preoccupation with the altered body part and the visible skin lesions.

Nursing Interventions

1. Educate the patient about contact isolation measures. VZV is spread through direct contact with fluid from the lesions containing the virus.

2. Instruct the patient to avoid contact with pregnant individuals and those with compromised immune systems, as active lesions are contagious and these populations are more susceptible to infection.

3. Employ standard precautions when caring for the patient to prevent the spread of the disease to oneself or other patients. VZV can be transmitted to susceptible individuals and cause chickenpox.

4. Suggest the use of gauze pads to separate lesions in skin folds. This helps to reduce irritation, itching, and the potential for cross-contamination.

5. Discourage the scratching of lesions. Advise the patient to keep their fingernails trimmed short. These actions help prevent the opening of lesions, cross-contamination, and secondary bacterial infections.

6. Educate the patient on the proper use of prescribed antiviral medications. Antiviral agents are most effective when initiated within the first 72 hours of the outbreak, when viral replication is at its peak. Common medications include acyclovir, famciclovir, and valacyclovir.

7. Instruct the patient on the use of systemic corticosteroids, if prescribed, for their anti-inflammatory effects. The use of steroids remains a topic of debate and is typically reserved for severe cases.

8. Assist the patient in developing responses to inquiries from others regarding the lesions and the risk of infection. Patients may benefit from guidance on how to address comments about their skin’s appearance. Rehearsing prepared responses to anticipated questions can provide reassurance.

9. Suggest wearing concealing clothing when the lesions can be easily covered. This can be helpful for patients who are experiencing difficulties adjusting to changes in their body image