TARLAC STATE UNIVERSITY COLLEGE OF NURSING Lucinda Campus,Brgy. Ungot, Tarlac City Philippines 2300 Tel No.

: (045) 982-6062 Fax: (045) 982-0110 website: www.tsu.edu.ph

A Case Study on Kawasaki Disease

In Partial Fulfillment of the Requirements of the Subject Nursing Care Management 102 RLE

Presented to the Faculty Of the Tarlac State University College of Nursing Presented by: BSN III - C Group C4 Querido, Richen Raiz, Jayscent Rodriguez II, Rolando Sabat, Aprillyn Santos, Marivic Santos, Willa Milafrosa Sotelo, Jeffrey Suarez, Christine Karen Sumang, Jerico Sumaoang, Maria Luisa Date Submitted: February 2, 2010

INTRODUCTION

Kawasaki disease (mucocutaneous lymph node syndrome) is a form of vasculitis identified by an acute febrile illness with multiple systems affected. The cause is unknown, but autoimmunity, infection, and genetic predisposition are believed to be involved. It affects mostly children between ages 3 months and 8 years; 80% are younger than age 5. It occurs more commonly in Japanese children or those of Japanese descent. It has seasonal epidemics, usually in late winter and early spring. It was first described in 1967 by Dr. Tomisaku Kawasaki in Japan. Kawasaki disease occurs more often in boys than in girls (ratio of about 1.5:1). Approximately 80 percent of affected children are less than five years old. Fewer than 2 percent of children have recurrences. Kawasaki is described a unique illness that was characterized by fever, rash, conjunctival injection, cervical lymphadenitis, inflammation of the lips and oral cavity, and redness and swelling of the hands and feet. Although initially thought to be a benign childhood illness, the disease was found to be responsible for the death of a number of Japanese children, primarily less than two years of age, who had appeared to be improving or to have recovered from the illness.2 Autopsies demonstrated thrombosis occlusion of coronary artery aneurysms and resultant myocardial infarction. It is now known that coronary artery abnormalities develop in approximately 20 to 25 percent of children with untreated Kawasaki disease The disease occurs year-round, but a greater number of cases are reported in the winter and spring. Annual incidence rates in the United States and Canada range from about six to 11 cases per 100,000 children less than five years old. Each year in this country, as many as 3,500 children are hospitalized because of Kawasaki disease. Although the absolute number of U.S. cases is greatest in white children, the incidence rates in North America are highest in children of Asian ethnicity (especially those of Japanese or Korean background).

Objectives General: The objective of our case study is to develop and acquire understanding, skills, and knowledge about the disease, and health promotion to prevent further complication on the condition of the patient. Specific: Nurse Centered To assess the patients overall health status To impart necessary health teachings to the patient To perform appropriate nursing care in conjunction with the condition of the patient To be more familiarized with the nurses roles in caring the patient and to educate patient regarding her condition. To widen and enhance the student nurses knowledge and skills through additional research about the nature of the disease, its signs and symptoms, its pathophysiology, its diagnosis and treatment. Patient Centered To know when to seek help from the health care providers whenever the signs and symptoms may appear. To understand the occurrence of Kawasaki Disease. To know what other complications may arise, if left untreated. To gather information about the therapeutic regimen

Reasons in choosing the Case Study Our group chose this case study to gain more additional knowledge about the disease. The group wants to know more about the disease, its treatment, and the proper nursing management for patients with this kind of disease. The case will help the group in dealing with patient with this condition. Promotion of health, prevention of diseases and illnesses, rehabilitation and restoration of good health are important in doing the case. In the accomplishment of case study, the group will be able to know and develop more fully our skills in assessment, planning, nursing care plans, implementation/interventions and evaluation for this particular chosen condition. Importance of the Study
The case study is primarily important because it enhances the students skills, knowledge and attitude on the practice of the nursing process. It provides broader comprehension about the condition chosen through research and actual observation as it serves as a training ground and practice in developing learned skills in the assessment and management of Kawasaki Disease.

Through this case study, a holistic approach in assessing patients health will be delivered, where it can be immediately attended to and given proper interventions. It serves as a way to familiarize the students with the different medical approaches toward the ongoing curative phase. This study serves as a tool for future upcoming nursing students of the school. To share to other student nursing colleagues to understand the dynamics of Kawasaki Disease as to the book based management and actual clinical interventions. Furthermore, this study may be used as a spring board for a more advanced and in-depth study that is in accordance to changing and developing society.

II. Nursing Process

A. Demographic data:

Name: Sex: Age: Civil Status: Birth date: Place of Birth: Chief complaint: Date of Admission: Admitting Diagnosis: Final Diagnosis: Nationality: Role in the Family: Religion: Health Care Financing: Usual Source of Medical Care:

Kid Honda Male 2 years old Single November 17, 2007 Capas, Tarlac Fever January 20, 2010 T/C Kawasaki Disease Kawasaki Disease Filipino 2nd eldest son Roman Catholic PhilHealth RHU/Gov. Hospital

B. Environmental Status Kid Honda lives in Sto. Rosario, Capas, Tarlac. They are five among the members in the family who lives in the house. The patients mother narrated that she is the one who maintains the cleanliness of the house and that they use mosquito coils as deterrent for mosquitoes especially at night. Mixed materials were used in the construction of their house. The house has no room and they usually cook their foods, eat, and sleep at their sala. The mother also said that their familys source of water is through water pump, which is located 4 meters away from their house. According to the patients mother, they have no other source of entertainment aside from their television set. Their garbage is collected thrice a week by local garbage collectors. He does not have any allergies on foods, medications, or animals. C. Lifestyle According to the mother of Kid Honda, her son usually has 8 to 10 hours of sleep. He usually sleeps at around 9:00 pm and wakes up at 7:00 am in the morning. They usually have 3 - 4 meals per day. He is fond of eating foods with sugar like candies, ice cream, chocolates, and also junk foods like piatos, cheese ring, etc, He spent several hours watching television and take a nap at noon. He also plays with his playmates during afternoon.

IV. FAMILY HISTORY OF HEALTH AND ILLNESS Paternal Side 58 HTN 35 HTN 3 0 A&W 5 4 A&W 26 A&W 24 AST 27 A&W 53 ART Maternal Side 4 1 HTN 19 A&W 16

3 9 A&W

2 2 HTN

A&W

3 A&W Legend: Male Female Patient - Deceased Male - Deceased Female HTN Hypertension

2 KD

2 mos

A&W

A&W Alive & Well AST - Asthma ART Arthritis

KD Kawasaki Disease

V. History of Past illness

According to the mother of Mr. , he had experienced measles, and mumps. He had also experienced cough, colds, and fever. When he is having a fever, it usually lasts for two days, and during those times, he usually take Over-the-counter (OTC) drugs such as Tempra. With respect to his immunization record, according to her mother, Kid Honda had completed his immunization in a health center in their Barangay at Sto Rosario, Capas, Tarlac. The mother also stated that her child had never been admitted to hospital for any serious illness or accidents aside from his present condition.

VI. History of Present illness

The patient was admitted at Capas Hospital last January 13, 2010, and was observed for 6 days. Prior to admission, he had fever and convulsion for 2 days. On January 16, 2010, rashes are found on the neck and are greatly distributed to the whole body of Mr. Honda. His scrotum is affected, enlarged, and inflamed. The mother seeks the attention of a pediatrician and she was advised to go to Tarlac Provincial Hospital because the doctor said that her child has a Kawasakis Disease. He is admitted at Tarlac Provincial Hospital on January 20, 2010 with the admitting diagnosis of T/C kawasaki Disease by the attending physician.

Patients name: Kid Honda Sex: Male VIII. DIAGNOSTIC AND LABORATORY PROCEDURE

Diagnostic/ Laboratory procedures

Date Ordered and Indication/s Date Resulted purposes

or

Normal Values (units used in the Result/s hospital)

Analysis interpretation Results

and of

WBC 4.1-10.9 G /L

WBC

20.1 G/L

Increased. Increased WBC was due to presence of infection. Increased. Increased LYM will lead to signs of viral infection. Normal

LYM

0.6-4.1%

LYM 7.3 36.3%L

MID

0.01.8

MID 1.6 8.0%M Increased. Increased GRAN will lead to signs of infection/inflammation of the tissues caused by injury.

Hematology Report

January 20, 2010

Complete blood count (CBC) is a GRAN 2.0 7.8 determination of the number of red and white blood cells per cubic millimeter of blood. A CBC is one of the most routinely performed tests in a clinical RBC 4.206.3 T/L laboratory and one of the most valuable screening HGB 120-180 g/L and diagnostic techniques. It also helps the health professional to check the patients condition, such as HCT 0.370-0.510 anemia, infection L/L and some

GRAN 11.2 55.7%G

Normal RBC HGB 4.07 T/L 94 g/L Decreased Decreased HGB leads to symptoms of anemia. Decreased Decreasd HCT leads to symptoms of anemia. Decreased.

HCT

0.284 L/L

Nursing responsibilies: Before: Inform the client that he/she will going to undergone CBC and blood typing. During: Assist the client while getting blood. Assist the venipuncture site for bleeding after. After: Make sure that the specimen is labeled & the laboratory requisition carry the correct information & attached them securely to the specimen.

Diagnosis laboratory procedures

& Purpose

Normal Values (book based) Color : straw amber, transparent

Actual Results

Interpretation

Color yellow

Concentrated urine

Urinalysis

To determine urine composition & possible abnormal components or infection.

Appearance: clear Specific gravity: 1.010-1.022 bacteria : negative

Appearanc e: slightly turbid Specific gravity: 1.010 bacteria : moderate

cloudy

normal

With presence of bacteria

Puss Cells None RBC 0-2/hpf

pus cells : 3-6 RBC 0-2

With pus normal

Nursing Responsibility: Before: Collect the specimen for the client and assist the client when assistance is needed. During: Specimen must be free from any contamination. After: Make sure that the specimen is labeled & the laboratory requisition carry the correct information & attached them securely to the specimen.

IX.I.) PATHOPHYSIOLOGY (Book Based)

Non Modifiable Factors: Age (2 5 y/o) Gender Race (asian)
Modifiable Factors:

Unknown yet linked with unknown etiologic agent and environmental factors

T Cell and macrophage activation Secretion of cytokines Polyclonal B cell hyperactivity Formation of auto - antibodies Endothelial muscle cells Smooth muscle cells

Acute vasculitis and perivasculitis of small vessels (arterioles, venules, and capillaries) Small vessels changes, resemble those of microscopic polyangitis Larger arteries in the body (including the coronary arteries may be affected)

Myocarditis

Pericarditis Aneurysm formation

Valvulitis

Thrombosis with myocardial infarction

Signs and symptoms: High remittent Fever, bilateral bulbar conjunctival injection, changes in the mucosa of the oropharynx, including injected pharynx, injected and/or dry fissured lips, strawberry tongue, changes of the peripheral extremities, such as edema and/or erythema of the hands or feet in the acute phase; or periungual desquamation in the subacute phase, rash, primarily truncal, scrotal swelling

KAWASAKI DISEASE

IX.II.) PATHOPHYSIOLOGY (Patient Based)

Non Modifiable Factors: Age (2y/o) Gender (male) Race (asian)
Modifiable Factors:

Unknown yet linked with unknown etiologic agent and environmental factors

T Cell and macrophage activation Secretion of cytokines Polyclonal B cell hyperactivity Formation of auto - antibodies Acute vasculitis and perivasculitis of small vessels (arterioles, venules, and capillaries) Small vessels changes, resemble those of microscopic polyangitis
Signs and symptoms: Fever, bilateral bulbar conjunctival injection, dry, cracked lips, strawberry tongue, changes of the peripheral extremities, such as edema and/or erythema of the hands or feet in the acute phase; or periungual desquamation in the subacute phase, rash, primarily truncal, scrotal swelling

KAWASAKI DISEASE

Cephalocaudal Assessment (IPPA) DATE PERFORMED 01-22-10 (10:00am) General Appearance AREA/REGION METHOD USED Auscultation Inspection Palpation Respi. Rate: 40cpm Respi. Rate: 20-30 cpm Temp: 38.3oC FINDINGS NORMAL FINDINGS Temp: 36.5 - 37.2oC Not normal. All this symptoms are present due to hyperthermia with manifestations of increased respiratory rate and cardiac rate. . (Potts & Mandleco, 2002) Cardiac Rate: 143 bpm Pallor Fatigue Cardiac rate: 70-110 bpm No pallor Without signs of fatigue INTERPRETATION/ANALYSIS

Bipedal non pitting edema

No edema *based on G&A Notes (2005)

Accumulation of fluid in the extremities because of prolong staying in bed, and excessive accumulation of fluid in the third spaces, edema developed.

01-22-10

Skin

Palpation Inspection

With nonpitting edema

No edema

Not normal due to excessive accumulation of fluid in the third spaces, edema developed.

Warm to touch

Skin is mildly warm to touch.

Temperature exceeds the normal temperature because of the presence of infection that causes the skin to be warm.

Peeling ) palms and soles

Without peeling, smooth

(desquamation must be soft and

With a capillary refill of 4 seconds Rashes seen on the truncal area 01-22-10 Eyes Inspection Palpation Extremely red eyes (conjunctivitis ) without thick discharge 01-22-10 Mouth Inspection Red mucous membranes in the mouth. Dry lips

Capillary refill is less than 3 seconds.

Poor capillary refill results in poor oxygenation.

No discharge coming from the eyes.

Due to inflammation of blood vessels of the eyes.

No infection, swelling and moist lips

Not normal because there is increase inflammation of the blood vessels causing it to be red in color.

Cracked lips Strawberry tongue noted Swollen tongue also noted 01-22-10 01-22-10 Ears Nose Inspection Inspection Reacts to loud noises Symmetrical and patent Reactive/responsive to noises Symmetrical and patent Normal Normal

01-22-10

Chest, thorax and lungs

Inspection Auscultation Palpation

Thorax is rounded, breath sounds are resonant, use of accessory muscle (abdominal muscle, trapezius muscle, and sternocleidom astoid muscle), increased in respiratory rate-40cpm, increased heart rate-143 bpm, Inability to

Breath sounds are resonant, thorax is rounded, normal RR20-30 cpm, normal PR-90-120 bpm, no use of accessory muscles in breathing.

Not normal. Use of accessory muscle (abdominal muscle, trapezius muscle, and sternocleidomastoid muscle) and increased RR signifies fatigue and hyperthermia.

01-22-10

Musculoskeletal

Inspection

No restriction in

Not normal due to process of the

and neurological status

tolerate activities, weak in appearance, irritable and lethargic Abdominal girth: 54 cm Abdominal distention

activities, no weakness and alert

disease and infection. Weakness is due to lack of energy needed to do normal activities

01-22-10

Abdomen

Inspection Palpation

No abdominal distention.

Abnormal. This is caused by accumulation of excessive fluid in the body.

01-22-10

Genitourinary

Inspection

noted With difficulty There should no pain in urination. Color of the urine is yellow. Scrotal swelling noted felt when voiding. Protein is not evident in the urine. Normal urine output is 500-1,000cc/day or equivalent to 2025cc/hr based on Potts and Mandleco Pediatric Nsg.

Abnormal. Pain was caused by the presence of bacteria in the urine causing the scrotum to be swollen.

Book 01-22-10 Lower Extremeties Inspection Palpation Non-pitting feet noted There should no swelling present. Abnormal. This is also caused by accumulation of excessive fluid in the body

edema on both edema, tenderness, or

ANATOMY AND PHYSIOLOGY

The cardiovascular system can be thought of as the transport system of the body. This system has three main components: the heart, the blood vessel and the blood itself. The heart is the system's pump and the blood vessels are like the delivery routes. Blood can be thought of as a fluid which contains the oxygen and nutrients the body needs and carries the wastes which need to be removed. The following information describes the structure and function of the heart and the cardiovascular system as a whole. Function and Location of the Heart The heart's job is to pump blood around the body. The heart is located in between the two lungs. It lies left of the middle of the chest. Structure of the Heart The heart is a muscle about the size of a fist, and is roughly cone-shaped. It is about 12cm long, 9cm across the broadest point and about 6cm thick. The pericardium is a fibrous covering which wraps around the whole heart. It holds the heart in place but allows it to move as it beats. The wall of the heart itself is made up of a special type of muscle called cardiac muscle. Chambers of the Heart

The heart has two sides, the right side and the left side. The heart has four chambers. The left and right side each have two chambers, a top chamber and a bottom chamber. The two top chambers are known as the left and right atria (singular: atrium). The atria receive blood from different sources. The left atrium receives blood from the lungs and the right atrium receives blood from the rest of the body. The bottom two chambers are known as the left and right ventricles. The ventricles pump blood out to different parts of the body. The right ventricle pumps blood to the lungs while the left ventricle pumps out blood to the rest of the body. The ventricles have much thicker walls than the atria which allow them to perform more work by pumping out blood to the whole body. Blood Vessels Blood Vessel are tubes which carry blood. Veins are blood vessels which carry blood from the body back to the heart. Arteries are blood vessels which carry blood from the heart to the body. There are also microscopic blood vessels which connect arteries and veins together called capillaries. There are a few main blood vessels which connect to different chambers of the heart. The aorta is the largest artery in our body. The left ventricle pumps blood into the aorta which then carries it to the rest of the body through smaller arteries. The pulmonary trunk is the large artery which the right ventricle pumps into. It splits into pulmonary arteries which take the blood to the lungs. The pulmonary veins take blood from the lungs to the left atrium. All the other veins in our body drain into the inferior vena cava (IVC) or the superior vena cava (SVC). These two large veins then take the blood from the rest of the body into the right atrium. Valves Valves are fibrous flaps of tissue found between the heart chambers and in the blood vessels. They are rather like gates which prevent blood from flowing in the wrong direction. They are found in a number of places. Valves between the atria and ventricles are known as the right and left atrioventricular valves, otherwise known as the tricuspid and mitral valves respectively. Valves between the ventricles and the great arteries are known as the semilunar valves. The aortic valve is found at the base of the aorta, while the pulmonary valve is found the base of the pulmonary trunk. There are also many valves found in veins throughout the body. However, there are no valves found in any of the other arteries besides the aorta and pulmonary trunk. The cardiovascular system refers to the heart, blood vessels and the blood. Blood contains oxygen and other nutrients which your body needs to survive. The body takes these essential nutrients from the blood. At the same time, the body dumps waste products like carbon dioxide, back into the blood, so they can be removed. The main function of the cardiovascular system is therefore to maintain blood flow to all parts of the body, to allow it to survive. Veins deliver used blood from the body back to the heart. Blood in the veins is low in oxygen (as it has been taken out by the body) and high in carbon dioxide (as the body has unloaded it back into the blood). All the veins drain into the superior and inferior vena cava which then drains into the right atrium. The right

atrium pumps blood into the right ventricle. Then the right ventricle pumps blood to the pulmonary trunk, through the pulmonary arteries and into the lungs. In the lungs the blood picks up oxygen that we breathe in and gets rid of carbon dioxide, which we breathe out. The blood is becomes rich in oxygen which the body can use. From the lungs, blood drains into the left atrium and is then pumped into the left ventricle. The left ventricle then pumps this oxygen-rich blood out into the aorta which then distributes it to the rest of the body through other arteries. The main arteries which branch off the aorta and take blood to specific parts of the body are:

Carotid arteries, which take blood to the neck and head Coronary arteries, which provide blood supply to the heart itself Hepatic artery, which takes blood to the liver with branches going to the stomach Mesenteric artery, which takes blood to the intestines Renal arteries, which takes blood to the kidneys Femoral arteries, which take blood to the legs

The body is then able to use the oxygen in the blood to carry out its normal functions. This blood will again return back to the heart through the veins and the cycle continues. The cardiac cycle is the sequence of events that occurs in one complete beat of the heart. The pumping phase of the cycle, also known as systole, occurs when heart muscle contracts. The filling phase, which is known as diastole, occurs when heart muscle relaxes. At the beginning of the cardiac cycle, both atria and ventricles are in diastole. During this time, all the chambers of the heart are relaxed and receive blood. The atrioventricular valves are open. Atrial systole follows this phase. During atrial systole, the left and right atria contract at the same time and push blood into the left and right ventricles, respectively. The next phase is ventricular systole. During ventricular systole, the left and right ventricles contract at the same time and pump blood into the aorta and pulmonary trunk, respectively. In ventricular systole, the atria are relaxed and receive blood. The atrioventricular valves close immediately after ventricular systole begins to stop blood going back into the atria. However, the semilunar valves are open during this phase to allow the blood to flow into the aorta and pulmonary trunk. Following this phase, the ventricles relax that is ventricular diastole occurs. The semilunar valves close to stop the blood from flowing back into the ventricles from the aorta and pulmonary trunk. The atria and ventricles once again are in diastole together and the cycle begins again. The adult heart beats around 70 to 80 times a minute at rest. When you listen to your heart with a stethoscope you can hear your heart beat. The sound is usually described as "lubb-dubb". The "lubb" also known as the first heart sound, is caused by the closure of the atrioventricular valves. The "dubb" sound is due to the closure of the semilunar valves when the ventricles relax (at the beginning of ventricular diastole). Abnormal heart sounds are known as murmurs. Murmurs may indicate a problem with the heart valves, but many types of murmur are no cause for concern.

ASSESSMENT Subjective: Objective: >warm to touch > flushed skin >pale in appearance >weak in appearance >restless >teary eye >Temperature=38.3 C

SCIENTIFIC EXPLANATION ENTRY OF PATHOGENS IN THE SYSTEMIC CIRCULATION REGULATION OF TOXINS IN THE BODY RELEASE OF PYROGEN STIMULATION OF THE HYPOTHALAMUS INCREASE OR ALTERATION OF THERMOREGULATION INCREASE IN BODY TEMPERATURE

PLANNING Within 30 hours of effective nursing intervention, the patients temperature will decrease from 38.3C to normal level.

INTERVENTION Independent: Monitor core temperature q 1 .

RATIONALE

EXPECTED OUTCOME Within 30 mins. of effective nursing intervention, the patients temperature will decrease from 38.3C to normal is level. by

Temperature of 38.9-41.1C suggests acute infectious disease process.

Note presence or absence of sweating as body attempts to increase heat loss by evaporation.

Diagnosis: Hyperthermia r/t presence of infection

Evaporation decreased environmental factors of high humidity and high ambient temperature as well as body factors producing loss of ability to sweat. To support circulating volume and tissue perfusion. To reduce metabolic demands/oxygen consumption.

Increase oral fluid intake.

Promote bed rest, encourage relaxation skills and divertional

activities. Provide TSB as needed Promote surface cooling, loosen clothing and cool environment Review specific risk factors/causes, signs and symptoms with the interventions required Discuss importance of adequate fluid intake and protein diet Collaborative: Administer antipyretic medications as indicated To treat underlying causes Heat is loss by evaporation and conduction. Heat is loss by convection, radiation and conduction. To promote wellness

To prevent dehydration

Maintain replacement fluids and electrolytes to support circulating volume and tissue perfusion

To support circulating volume and tissue perfusion

ASSESSMENT Subjective: Objective: >weak in appearance >refuses to eat >refuses to take

SCIENTIFIC EXPLANATION Inadequate food intake will lead to problems in nutritional status of the body.

PLANNING Within 2 hours of proper nursing intervention, patient will be able to tolerate to eat foods and take medications

INTERVENTION Emphasize to the mother the importance of giving balance diet. Tell mother to accompany her child at meal time.

RATIONALE To let the mother determine the importance of giving balanced diet

EXPECTED OUTCOME

Within 2 hours of proper nursing intervention, patient will be able to tolerate to eat foods To encourage and take nutritional intake medications

medications >with chapped lips >with strawberry tongue >crying at times >vomiting at times Diagnosis: Imbalanced nutrition:less than body requirements r/t destruction of buccal tissues

Instruct patients significant others to increase intake of water Encourage mother to give fruits and vegetables to the patient.

To replenish water loss

It will help patient recovering.

the in

ASSESSMENT

SCIENTIFIC EXPLANATION

PLANNING

INTERVENTION

RATIONALE

EXPECTED OUTCOME

Subjective: Objective: >Localized erythema >desquamation of the skin >Redness of the skin noted >with bipedal non pitting edema >scrotal swelling Diagnosis: Impaired skin integrity related to inflammatory response secondary to infection.

Pressure on soft Within 2 hours of tissues between rendering nursing bony prominences intervention, patient will be able to Compresses demonstrate capillaries & preventive measures occludes blood flow to avoid further complications. Pressure not relieved Microthrombin formation + occlusion in capillaries & blood flow Formation of blister

Assess skin. Noted color, turgor, and sensation.

Establishes comparative baseline providing opportunity for timely intervention.

Demonstrate good skin hygiene, e.g., wash thoroughly and pat dry carefully.

After 2 hours of rendering nursing intervention, patient will be able to demonstrate preventive measures Maintaining clean, to avoid further dry skin provides a complications. barrier to infection. Patting skin dry instead of rubbing reduces risk of dermal trauma to fragile skin. Skin friction caused by stiff or rough clothes leads to irritation of fragile skin and increases risk for infection Improved nutrition and hydration will improve skin condition. RATIONALE EXPECTED OUTCOME

Instruct family to maintain clean, dry clothes, preferably cotton fabric (any T-shirt). Emphasize importance of adequate nutrition and fluid intake

ASSESSMENT

SCIENTIFIC EXPLANATION

PLANNING

INTERVENTION

Subjective: Objective: >RR 40 cpm >weak in appearance >pale looking >restless >teary eye Diagnosis: Ineffective breathing pattern r/t fatigue

Presence of secretions in the bronchi will result into a blockage of air that will enter the body and thus producing insufficient air needed by the body. And inability to maintain clear airway. This obstruction is further heightened by bronchospasm due to the contraction of the smooth muscles in the Bronchi.

Within 2 hours of effective nursing interventions, the patients mother will be able to understand the cause of having difficulty of breathing.

Establish rapport. Assess pt.s condition Monitor vital signs of the patient. Auscultate breath sounds and assess airway pattern. Elevate head of the bed and change position of the pt. every 2 hours. Encourage deep breathing and coughing

To gain pt.s trust.

After 2 hours of effective nursing To obtain baseline interventions, the data. patients mother was able to Serve to track understand the important changes. cause of having difficulty of To check for the breathing. presence of adventitious breath sounds. To minimize difficulty in breathing. To promote relaxation to the pt.

XII. Medical Management/Treatment Date Ordered/ Date Performed/ Date Change /Date Discontinue Date ordered: January 20 24, 2010

Medical Management/ Treatment

General Description

Indication/s or Purpose/s

Clients Reaction to Treatment

1. 5% Dextrose in0.3% Sodium Chloride 37-38 mgtts/min

Dextrose and Sodium Chloride solutions are sterile and nonpyrogenic. The solutions contain no bacteriostat, antimicrobial agent or added buffer and each is intended only as a single-dose injection. When smaller doses are required the unused portion should be discarded. The solutions are parenteral fluid, nutrient and electrolyte replenishes.

Intravenous solutions containing dextrose and sodium chloride are indicated for parenteral replenishment of fluid, minimal carbohydrate calories, and sodium chloride as required by the clinical condition of the patient.

There were no signs of inflammation or infiltration during the infusion.

NURSING RESPONSIBILITIES: 1. Explain the procedure to the patient. 2. Secure consent from patient before IV infusion.

3. Verify physicians order indicating the type of solution, amount to be administered, and rate of flow of the infusion. 4. Inspect IV site for signs of infiltration or inflammation. 5. Check IV flow rate and monitor fluid volume overload. 6. Monitor intake and output.

Name of Drugs

Date ordered, Date Taken/ Given /Date Changed

Route of Admin & Dosage, and Frequency of Admin.

General Action. Mech. of Action

Indication/s or Purpose/s

Clients Reaction to Medication

Ranitidine

Date ordered: January 20, 2010

12mg IVP q6 hours for abdominal pain

Competitively inhibits gastric acid secretion by blocking the effect of histamine on histamine H2 receptors. Both daytime and nocturnal basal gastric acid secretion, as well as food and pentagastrin stimulated gastric acid are inhibited Interferes with bacterial cell wall synthesis during active multiplication causing cell wall death and resultant

Short term (48 weeks) and maintenance treatment of duodenal ulcer and abdominal The drug is pain. not given to the patient because he does not experienced abdominal pain.

Benzilpenici llin

300, 000 U IVP q6 hours

Date ordered and date taken/given:

Severe infections caused by sensitive organism streptococci.

The patients mother understands the importance

January 20 26, 2010

bactericidal against susceptible bacteria. Inhibits the synthesis of prostaglandin that may serves as mediators of pain, fever primarily in CNS. Exhibits antipyretic, anti inflammatory and analgesic effect. The antipyretic effect is due to an action on the hypothalamus, resulting in heat loss by vasodilatation of peripheral vessels. Anti inflammatory effects are mediated by the decrease prostaglandin synthesis. It also decreases platelet aggregation.

of administeri ng the medication to her child. The patients For mild pain, mother fever reports that fever was reduced with drug.

Paracetamol

Date ordered and date taken/given: January 20 21, 2010

120mg IVP q4 hours for Temperatu te >37.8 C

Aspirin

Date ordered and date taken/given: January 21 26, 2010

300mg 1 tablet q6 hours, orally

For pain, integumentary structures, myalgia, neuralgia, headache.

The patients mother understands the importance of administeri ng the medication to her child.

Nursing Responsibilities:

Before administration: Monitor vital signs. Assist in administering medication. During the administration: Measure and record the vital signs, especially the temperature. After the medication: Monitor the clients body temperature. Be alert to adverse reactions and drug interaction. Date Ordered, date Started, Date Changed General Description Specific Foods Taken Clients Response and/or Reaction to the Diet

Type of Diet

NPO

Date ordered: Strictly, not NONE January 21 allowed to take 22, 2010 any kind of food or liquids by mouth.

The patients mother understood the procedure.

Soft Diet

Date ordered: A diet that allows Lugaw January 23 fruits and 26, 2010 vegetables with low-cellulose content as well as fish and meat with no or very little connective tissues.

He was glad that finally he could eat foods.

NURSING RESPONSIBILITIES: Before, during and after the administration of the diet: 1. 2. 3. 4. 5. Explain the procedure. Teach the family about the diet. Check the patients food. Observe tolerance for eating. Check the patients readiness for the next diet.

6. Document the procedure.

Type of Exercise

Date Ordered, Date Started, Date Changed

General Description

Indication/s or Purpose/s

Clients response / reaction to the activity / exercise Relaxed and comfortable.

Bed Rest

Date ordered: January 20 25, 2010

Is a medical For fast treatment refers recovery of the to staying in patient. bed day and night as a treatment for an illness or medical condition. Ambulation is the recommended for a healthy lifestyle, and has numerous environmental benefits. For progress and early recovery of the patient.

Ambulation

Date ordered: January 26, 2010

He can tolerate walking with the assistance of his mother.

NURSING RESPONSIBILITIES:

1. Educate the patient about the importance of ambulation and bed rest, and the appropriate way of doing the exercise. 2. Assisted the patient in ambulation.

SUBJECTIVE

OBJECTIVE >warm to touch > flushed skin >pale in appearance >weak in appearance >restless >teary eye >Temperature=38.3C

ANALYSIS Hyperthermia r/t presence of infection

PLANNING Within 30 mins. Of effective nursing intervention, the patients temperature will decrease from 38.3C to normal level.

INTERVENTION Independent: Monitored core temperature q 1 . Noted presence or absence of sweating as body attempts to increase heat loss by evaporation. Increased oral fluid intake. Promoted bed rest, encourage relaxation skills and divertional activities. Provided TSB as needed Promoted surface cooling, loosen clothing and cool environment

EVALUATION After 30 mins. of effective nursing intervention, the patients temperature decreased from 38.3C to normal level.

Reviewed specific risk factors/causes, signs and symptoms with the interventions required Discussed importance of adequate fluid intake and protein diet Collaborative: Administered antipyretic medications as indicated Maintained replacement fluids and electrolytes to support circulating volume and tissue perfusion

SUBJECTIVE

OBJECTIVE >weak in

ANALYSIS Imbalanced

PLANNING Within 2 hours of

INTERVENTION Emphasized to the

EVALUATION After 2 hours of

appearance >refuses to eat >refuses to take medications >with chapped lips >with strawberry tongue >crying at times >vomiting at times

nutrition:less than body requirements r/t destruction of buccal tissues

proper nursing intervention, patient will be able to tolerate to eat foods and take medications

mother the importance of giving balance diet. Told mother to accompany her child at meal time. Instructed patients significant others to increase intake of water Encouraged mother to give fruits and vegetables to the patient.

proper nursing intervention, patient was able to tolerate to eat foods and take medications as evidenced by eating and taking medications at the right time

SUBJECTIVE

OBJECTIVE >Localized erythema >desquamation of the skin >Redness of the skin noted

ANALYSIS Impaired skin integrity related to inflammatory response secondary to infection.

PLANNING Within 2 hours of rendering nursing intervention, patient will be able to demonstrate preventive measures

INTERVENTION Assessed skin. Noted color, turgor, and sensation. Demonstrated good skin hygiene, e.g.,

EVALUATION After 2 hours of rendering nursing intervention, patient was able to demonstrate preventive measures

>with bipedal non pitting edema >scrotal swelling

to avoid further complications and minimize spread of infection.

wash thoroughly and pat dry carefully. Instructed family to maintain clean, dry clothes, preferably cotton fabric (any T-shirt). Emphasized importance of adequate nutrition and fluid intake

to avoid further complications and minimize spread of infection such as performing proper hygienic measures

SUBJECTIVE

OBJECTIVE Objective: >RR 40 cpm >weak in appearance >pale looking >restless >teary eye

ANALYSIS Ineffective breathing pattern r/t fatigue

PLANNING Within 2 hours of effective nursing interventions, the patients mother will be able to understand the cause of having difficulty of breathing.

INTERVENTION Established rapport. Assessed pt.s condition Monitored vital signs of the patient. Auscultated breath

EVALUATION After 2 hours of effective nursing interventions, the patients mother will be able to understand the cause of having difficulty of breathing.

sounds and assess airway pattern. Elevated head of the bed and change position of the pt. every 2 hours. Encouraged deep breathing and coughing.

DISCHARGE PLANNING:

MEDICATIONS: EXERCISE: Have adequate rest and sleep. This recharges the energies to function better, both physically and mentally. TREATMENT: Explain the treatment and medication purposes to be continued at home. It is needed for maintenance and control of disease. HEALTH TEACHINGS: Instructed the family to increase the fluid intake of the patient to 8 glasses of water per day. Emphasized hand washing technique. Encouraged the family to prepare foods that are nutritious such as fruits and vegetables. OUTPATIENT ORDERS: Remind the family on their follow-up check-up with their physician. Maintain a good and safe environment. Return to Tarlac Provincial Hospital (TPH) Out Patient Department on February 2, 2010, Tuesday, for his follow-up check up. DIET The physicians order is to have the patient on soft diet such as lugaw. Discuss all take home medications to the patient and significant others. Encourage to take drugs with food if not contraindicated. Inform them that the drugs may exhibit undesirable side effects. This enables them to know what drugs to be taken and its desired doses. Some drugs may cause GI irritation if taken with empty stomach. The patients medications upon discharge are Co Amoxiclab 1 tsp/day, and Aspirin 100mg tab once per day.

CONCLUSION: The therapeutic management for this problem the patient is placed on bed rest either in the hospital or at home and administers medications as prescribed. All objectives were constructed for our patients benefit in able for the group to have prioritized nursing action. The group constructed and considered all the objectives that we gathered from our patient. For our objectives, the group had evaluated it as good and successful actions because the goals were achieved and all appropriate nursing interventions are rendered to our patient.

RECOMMENDATIONS: The group recommends that the mother and her child should visit the physician to check the patients condition to detect if there is improvement in his condition. We also recommend that the patient must continue his medications to achieve a better condition.

BIBLIOGRAPHY:

 Fundamentals of Nursing, Daniels Fundamentals of Nursing: Process, Concepts and Practice, 7th Edition Health Assessment and Physical Examination, 3rd edition by Mary Ellen Zator Estes Friedman and Smith, 1998 Nursing Diagnosis Handbook, 5th Edition 2006 by Ackley and Ludwig www.yahoo.com www.google.com www.scribd.com www.nursingcrib.com Brunner and Suddarths Medical Surgical Book, 8th Edition