You are on page 1of 25

I.

TITLE PAGE

UNIVERSITY OF ST. LA SALLE COLLEGE OF NURSING La Salle Avenue, Bacolod City

In Partial Fulfillment of the Course Requirements In Nursing Care Management 202 Related Learning Experience

Kawasaki Disease (Mucocutaneous Lymph Node Syndrome)

Submitted to: Ms. Geraldine Macainan, RN, MN

Submitted by: Jesse James Edjec BN3N

Date JANUARY 15, 2010

II. TABLE ON CONTENTS

I. Introduction --------------------------------------------------------------------II. Objectives ---------------------------------------------------------------------III. Anatomy and Physiology --------------------------------------------------IV. Definition of Terms ---------------------------------------------------------V. Baseline Data -----------------------------------------------------------------VI. Nursing History (Gordons Functional Health Pattern) ----------------VII. Health History --------------------------------------------------------------VIII. Assessment -----------------------------------------------------------------IX. Laboratory and Radiology -------------------------------------------------X. Pathophysiology --------------------------------------------------------------XI. Nursing Care Plan -----------------------------------------------------------XII. Drug Study ------------------------------------------------------------------XIII. Health Teaching -----------------------------------------------------------XIV. Bibliography ----------------------------------------------------------------

I.INTRODUCTION

Our human body is a very complex system. One functions for the benefit and or expense of another. Our subsystem is a vital as the other thus they are interrelated. Considering this fact, I have looked into the reality that in this diverse physiological wonder lies the infinite possibility of not only optimum functioning but of disparities and deviations as well. In life, one continues to exist in oblivion. There are always uncertainties in every events and occurrences whirl through our lives. We do not know when is the exact point in time where our bodily homeostasis will be disturbed and when change will cease to happen. Some of the surprising changes can be considered blessings but most the time they are we fervently hope would not occur especially those that concern our health. In this particular case study, I wish to present the case of my patient, A.K.A. K.B. of Brgy. Vito, Sagay City. He was admitted at CLMMRH for the reason of high fever with the admitting diagnosis: Kawasaki Disease. 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 decent. It has seasonal epidemics, usually in late winter and early spring. It was first described in 1967 by Dr. Tomisaku Kawasaki in Japan. Although Kawasaki disease is a multisystem disease, the cardiovascular system appears to be the primary site with coronary artery vasculitis, aneurysm development, thrombosis, and myocardial thrombosis progressing over days to weeks. Approximately 15% to 25% of patients develop cardiac complications (coronary thrombosis or rupture, myocardial infarction, heart failure, vasculitis of the aorta or peripheral arteries); however mortality is low. Nurses play a significant role in the management and care of patient with conditions such as this. We play an essential part in symptom management associated with the disease and the therapy. I likewise form part in the patients support system, which is considerably a factor that has an immense effect on the cure and recovery of this type of disease. This case study is meaningfully designed to provide awareness and thorough explanation to one of the rarest diseases that occur in our country. My presentation aims to recognize the need of the people to understand the course of this disease. I have assent the implication of this research that it may encourage keenness and be a source of information to a number of people, who remains nave to this bodily infirmity. May this new means of learning be a valuable fount of vital information to people who wish to study the same disease. People shouldnt take Kawasaki Disease hideously more so to those who are concerned because management is the key. In life, hurdles and humps are sprayed to test us. It takes recognition and acceptance that even our anatomical and physiological features; Gods chisel is shaping us to be significant individual molded by pain and strength. This study does not only provide our readers of medical information but of a challenge and course of holistic spectacle as well.

II. NURSING OBJECTIVE

A. GENERAL After days of nursing interventions I may be able to choose a case study that will contribute and expand my knowledge and improve my skills on specific procedures. To formulate the appropriate nursing intervention and plan of care to prevent complications as well as to promote wellness

B. SPECIFIC I have formulated the following Specific Objectives to guide me towards the completion of this case study. That within my 5 days ward exposure, I may be able to: Establish good interpersonal and professional relationship with our patient and his accompanying family member; Identify its contribution in the fields of nursing education, practice, and research; Formulate specific, measurable, attainable, realistic and time bounded objectives that will serve as a guide for the accomplishment of this study; Collect data regarding the past and present health history of our patient; Assess our patient in a cephalocaudal direction to serve as our baseline data in determining the changes in patients body; Determine and discuss the anatomy and physiology of the body systems involved, Identify the predisposing and precipitating factors that contribute to the onset of the disease; Trace the pathophysiology of the disease process; List the actual and possible symptoms that our patient my manifest; Study and relate the significance of the diagnostic examinations done; Research on the drug study of the medication given to our patient; Enumerate the actual and possible medical and nursing management rendered;

III. ANATOMY AND PHYSIOLOGY

Kawasaki's disease is a poorly understood condition that affects young children. It causes severe inflammation in different areas of the body, including the heart and coronary arteries. Scientists are not sure what causes inflammation of body organs seen in Kawasaki's disease. Many experts believe that a virus attacks the body, involving various organs and other tissues. Children with this disease have a severe flulike illness that usually goes away within a week or two. Twenty percent of the children with Kawasaki's disease have inflammation of the heart and coronary arteries. The skin is a soft outer covering of an animal, in particular a vertebrate. The adjective cutaneous literally means "of the skin" (from Latin cutis, skin). In mammals, the skin is the largest organ of the integumentary system made up of multiple layers of ectodermal tissue, and guards the underlying muscles, bones, ligaments and internal organs. Because it interfaces with the environment, skin plays a key role in protecting (the body) against pathogens and excessive water loss. Its other functions are insulation, temperature regulation, sensation, and the protection of vitamin B folates. Red rash usually first seen on the palms and soles that then spreads to involve the torso within a couple days. The most common appearance is a hive-like rash; however it may also resemble measles (morbilliform rash), erythemai multiforme or a scarletina like rash. It is more impressive on the hands and feet than the torso and the hands and feet generally develop some swelling as well. The heart may be affected in as many as one of five children who develop Kawasaki

disease. Damage sometimes occurs to the blood vessels that supply the heart muscle (the coronary arteries) and to the heart muscle itself. A weakening of a coronary artery can result in an enlargement or swelling of the blood vessel wall (an aneurysm). Infants less than 1 year old are usually the most seriously ill and are at greatest risk for heart involvement. The acute phase of Kawasaki disease commonly lasts 10 to 14 days or more. Most children recover fully. The likelihood of developing coronary artery disease later in life is not known, and remains the subject of medical investigation. The tongue. Characteristics of strawberry tongue are sloughing of the filiform papillae (caused by the systemic inflammatory process) and persistence of the fungiform papillae, which form the "seeds" of the strawberry. Strawberry tongue is not specific to Kawasaki disease; it may also be present in streptococcal and staphylococcal toxin-mediated disease. The lymph nodes. Edema is often seen in the hands and feet and the cervical lymph nodes are often enlarged.

IV. DEFINITION OF TERMS Abdomen: The belly, that part of the body that contains all of the structures between the chest and the pelvis. Abnormal: Not normal. Deviating from the usual structure, position, condition, or behavior. In referring to a growth, abnormal may mean that it is cancerous or premalignant (likely to become cancer ). Aspirin: A good example of a tradename that entered into the language, Aspirin was once the Bayer trademark for acetylsalicylic acid. Blood: The familiar red fluid in the body that contains white and red blood cells, platelets, proteins, and other elements. Breathing: The process of respiration, during which air is inhaled into the lungs through the mouth or nose due to muscle contraction, and then exhaled due to muscle relaxation. Coronary arteries: The vessels that supply the heart muscle with blood rich in oxygen. Disease: Illness or sickness often characterized by typical patient problems (symptoms) and physical findings (signs). Disruption sequence: Electrocardiogram: A recording of the electrical activity of the heart. An electrocardiogram is a simple, non-invasive procedure. Feet: The plural of foot, both an anatomic structure and a unit of measure. Fever: Although a fever technically is any body temperature above the normal of 98.6 degrees F. (37 degrees C.). Gamma globulin: A major class of immunoglobulins found in the blood, including many of the most common antibodies circulating in the blood. Also called immunoglobulin G (IgG). Genetic: Having to do with genes and genetic information. Gingivitis: Gum disease with inflammation of the gums. On inspection, the gums will appear red and puffy, and will usually bleed during tooth-brushing or dental examination. Treatment is by improved cleaning, with more-frequent and longer brushing and flossing.

Antiseptic mouthwashes may also be recommended. Heart: The muscle that pumps blood received from veins into arteries throughout the body. Heart muscle: A type of muscle with unique features only found in the heart. The heart muscle, or cardiac muscle, is medically called the myocardium ("myo-" being the prefix denoting muscle). Ibuprofen: A non-steroidal anti-inflammatory drug (NSAID) commonly used to treat pain, swelling, and fever. Common brand names for Ibuprofen include Advil, Motrin, and Nuprin. Immune: Protected against infection. The Latin immunis means free, exempt. Immune system: A complex system that is responsible for distinguishing us from everything foreign to us, and for protecting us against infections and foreign substances. The immune system works to seek and kill invaders Inflammation: A basic way in which the body reacts to infection , irritation or other injury, the key feature being redness, warmth, swelling and pain . Inflammation is now recognized as a type of nonspecific immune response Lungs: The lungs are a pair of breathing organs located with the chest which remove carbon dioxide from and bring oxygen to the blood. There is a right and left lung. Lymph: An almost colorless fluid that travels through vessels called lymphatics in the lymphatic system and carries cells that help fight infection and disease. Lymph node: Also sometimes referred to as lymph glands, lymph nodes are small rounded or bean-shaped masses of lymphatic tissue surrounded by a capsule of connective tissue, Lymphadenopathy: Abnormally enlarged lymph nodes. Commonly called "swollen glands." Mouth: The upper opening of the digestive tract, beginning with the lips and containing the teeth, gums, and tongue. Mucous: Pertaining to mucus, a thick fluid produced by the lining of some tissues of the body. Muscle: Muscle is the tissue of the body which primarily functions as a source of power. Naproxen: A non-steroidal anti-inflammatory drug (NSAID) used for the management of mild to moderate pain, fever, and inflammation. Pain: An unpleasant sensation that can range from mild, localized discomfort to agony. Plasma: The liquid part of the blood and lymphatic fluid, which makes up about half of its volume. Rash: Breaking out (eruption) of the skin. Medically, a rash is referred to as an exanthem. Skin: The skin is the body's outer covering. It protects us against heat and light, injury, and infection. It regulates body temperature and stores water, fat, and vitamin D. weighing about 6 pounds, the skin is the body's largest organ. Throat: The throat is the anterior (front) portion of the neck beginning at the back of the mouth , consisting anatomically of the pharynx and larynx . The throat contains the trachea

and a portion of the esophagus. Tongue: The tongue is a strong muscle anchored to the floor of the mouth. It is covered by the lingual membrane which has special areas to detect tastes. Vein: A blood vessel that carries blood low in oxygen content from the body back to the heart. Vessel: A tube in the body that carries fluids: blood vessels or lymph vessels.

V. BASELINE DATA

Name: K. R. Birth date: February 14, 2008 Age: 1 year and 11 months old Sex: Male Birthplace: Cebu City Address: Brgy. Vito, Sagay City Civil Status: N/A Religion: Jehovahs witnesses Nationality: Filipino Educational Attainment: N/A Name of Father: Teodorico Rebadonia Age: 41 years old Occupation: Driver Name of Mother: Arlyn Alsado Age: 37years old Occupation: House wife No. of siblings: 7 (pt. K.B. as youngest) Ward: CL Pedia Ward

Diagnosis: Kawasaki Disease Attending Physician: Dr. Abaja Date of Admission: January 8, 2010 Time of Admission: 1:32 PM Chief complaint: High fever, Skin Rashes
VI. NURSING HISTORY (Gordons Functional health pattern)

1. HEALTH MAINTENANCE PERCEPTION PATTERN > The client consults his doctor whenever he experiences some changes regarding his health; this includes stomach pain, high fever, and any other health problems. He never believed in hilots or any natural remedies. He takes medicines such as biogesic or tempra for fever, solmux for occasional cough and some antibiotics.

2. NUTRITION METABOLIC PATTERN > Patient eats 3 times a day and drinks water at same time. Has good appetite and has no significant dietary restrictions. They said that he is heavier before than the present. He likes to eat different kinds of foods, especially biscuits. He doesnt like foods that is not sweet and crunchy, he takes snacks at anytime and whenever he wants to.

3. ELIMINATION PATTERN > Patient approximately voids 5 times a day and defecates everyday. This is his elimination pattern before his hospitalization. Under normal conditions, client has normal elimination pattern, but due to his illness, his elimination pattern is also altered.

4. ACTIVITY AND EXERCISE PATTERN > Client is only 2 years old. He is between babyhood and early childhood stage. Characterized by rapid physical growth; increase in independence and decrease in helplessness. Also maximum learning can be attained by children at this stage; minds are like sponges which soak up knowledge. Appearance of teachable moments and control of environment is manifested.

5. SLEEP AND REST PATTERN > Client has no problem when it comes to rest or sleep periods. He sleeps 8 hours a day, from 9pm till 7 in the morning; he sometimes takes a nap in the afternoon. This is his

pattern before hospitalization, but due to his illness, he became unstable and irritable, thus sleep periods are altered.

6. COGNITIVE PERCEPTION > Client has moderate level of visual, auditory, olfactory and gustatory functioning and still cant speak or pronounce words clearly. Mental process such as perceiving, remembering, reasoning, deciding and problem solving is still in progress.

7. SELF-PERCEPTION SELF-CONCEPT PATTERN > Client is on early childhood, he learns to exercise will, to make choices and explore their world independently. If not he becomes uncertain about the world and themselves and doubt that they can do anything by themselves. Self-will exercise choice and self-restraint, no self control, and low self esteem.

8. ROLE RELATIONSHIP PATTERN > Client is the youngest from the 7 children. He learns to initiate activities and enjoy their accomplishments as play. If not, they are feeling guilty for their attempts at independence in any problem.

9. SEXUALITY RELATIONSHIP PATTERN > Client is 2 years old, and has not experienced any problem with regards to his reproductive organs and sexual response. The demand for toilet training may conflict with the childs instinctual pleasure in having bowel movements at will.

10. COPING-STRESS PATTERN > Client is 2 years old, and he tend to cry or play things/toys to cope his stress

11. VALUES AND BELIEF PATTERN > Client has no beliefs in other religions. The parents are Jehovahs witnesses and they have their own values in life that has been taught by their church. Blood transfusion and organ transplants are against their religion.

VII. HEALTH HISTORY

1. History of Present Illness Present complaint of Baby K.R. 1&11months old is Fever started 5 days PTA. Prior to admission, onset of fever ranges at 40-41C without colds or cough. Father noticed rashes on the abdomen and the clients lips are cracking. At the height of the fever, client was unstable thus seek consultation on January 5, 2009 to Vicente Gustilo District Hospital in Escalante city. Medications and care was given but still no relief. Swelling of extremities both upper extremities & lower extremities with progression of maculopapular rash all over his body was noted. Due to no improvement of above signs & symptoms, was referred to CLMMRH and subsequently admitted. January 8, 2009. 2. Past Health History a. Childhood illness > The client has only experienced stomach pain and minor health problems such as occasional cough, colds, and mild fever. b. Past Hospitalization > Patient has no previous hospitalization, no history of Hypertension, Diabetes, Cancer, no known allergies. c. Serious/ chronic illness > The client has no experience of any serious or chronic illness. He only experienced stomach pain and minor health problems such as occasional cough, colds, and mild fever. d. Previous Surgery > No previous history of surgical operation.

3. Family/ Social History Only the mother has Hypertension. But no diabetes, pulmonary tuberculosis, cancer, allergies and other hereditofamilial diseases was present.

VIII. ASSESSMENT

Systems Review Cephalo Caudal a. General appearance > Neat Appearance with light complexion and short curly hair > Wearing T-shirt and diapers only b. Vital signs > Blood Pressure: 90/60 mmHg > Temperature: 38.3C > Pulse Rate: 140 bpm > Respiratory Rate: 24 cpm c. Integumentary > Warm to touch; Afebrile, T: 38.3C > With good skin turgor > Erythematous maculopapular rashes noted d. Cardiovascular > With heplock at right small saphenous vein > Blood pressure of 90/60 mmHg, Pulse rate of 140 bpm > With good capillary refill at less than 3 seconds > No murmurs or skip beats noted. e. Respiratory > Breathes spontaneously to room air at 24 cpm > With symmetrical rise and fall of chest upon respiration > Breath sounds upon auscultation is resonant f. Abdomen > Normal growling sounds of 12. Upon percussion > Abdomen is tympanic in sound > No masses or pain noted upon palpation g. Gastrointestinal Tract > On NPO as ordered > Has not defecated upon assessment > Able to pass out flatus upon assessment > With normoactive bowel sounds at 12 cpm

h. Gastrourinary Tract > Able to void freely to a light yellow colored urine i. EENT > Pupils Equally Round and Reactive to Light Accommodation > Strawberry like tongue noted no lesions or any bleeding > Dry, red, cracking mucous membrane > With pinkish conjunctiva j. Musculoskeletal > Moderately active, moving freely; ambulatory
IX. LABORATORY AND RADIOLOGY HEMATOLOGY REPORT Test requested: CBC, Platelet (January 8, 2009) Laboratory/ Results Normal values Diagnostic Test Hemoglobin 106 g/L 130-180 Hematocrit WBC Count COAGULATION PROFILE Platelet Count DIFFERENTIAL COUNT Neutrophil Segmented Lymphocytes Eosinophil TOTAL 0.32 % 6.8 0.40-0.54 4.5 - 11x10 /L

Interpretations normal normal normal

Implication >within conditions >within conditions >within conditions > thrombocytosis normal normal normal

605

150-450

increased

72 25 1 100 % % %

50 70% 25-35% 1-5%

increased normal normal

> sufficient system >>within conditions >within conditions

immune normal normal

URINALYSIS REPORT (January 9, 2009) COLOR CHARACTER GLUCOSE REACTION NORMAL Light or pale Yellow Clear (-) 4.6-8 ACTUAL Light Yellow Slightly turbid (-) 6.5 pH Interpretations Implication Normal > indicates good hydration and urine concentration Abnormal > increase fluid intake Normal > well hydrated Normal > there is normal hydrogen ion concentration and extra cellular

SPECIFIC GRAVITY PUS CELL

1.010-1.025 0

1.010 5-8

Normal Abnormal

SQUAMOUS BACTERIA

(-) (-)

Few few

normal normal

fluid > the concentrating ability of the kidney is normal > indicates possible urinary tract infection > Administer antibiotic as ordered > increase fluid intake > Administer antibiotic as ordered > increase fluid intake > increase intake of Vitamin C

2-D echocardiogram
January 9, 2010 File no. CD-SLS-21-04 M-Mode RSEULTS GA AO LA/AO PA 1.96 1.79 1.09 LVEDd LEVSd EF FS RESULTS 2.67 1.71 68% 36% IVSD IVSs LVPWd LVPWs RESULTS 0.79 1.00 0.92 0.88 RVEDd RVESd PE dias PE syst

DOPPLER COLOR FLOW STUDIES: VELOCIT Y TV MV 1.16 Trjet MVA/PH T MRjet PG/AoV ARjet PG/PV PG/DA 4.54 6.97 RES ULT MVA/ planimetry LA area AO annules PAT Pul annules 1.1 70 1.38 MR fraction AR fraction PA pressure TVA MVA 1.40 1.49 RES ULT RESU LT

AoV PV DA QpQs

1.08/4.67 1.07 1.32

ANATOMIC DESCRIPTION: Abdominal sinus solitus Atrial situs solitus Atrioventricular and centriculoarterial concordance Intact interatrial and interventricular septae Normal coronary arteries in views seen LCA 2.1mm. RCA 1.5mm. Normal chamber dimensions Good cardiac contractility

No obstruction to ventricular inflow and outflow Left-sided aortic arch No patent dustus arteriosus No coarctation Very minimal pericardial effusion INTERPRETATIONS: Very minimal pericardial effusion Normal coronary arteries in views seen Normal chamber dimensions Good cardiac contractility Normal pulmonary artery pressure

IDEAL LABORATORY STUDIES:

2-D Echocardiogram
Patients who have had Kawasaki disease should have an echocardiogram every 1 - 2 years to screen for heart problems. Echocardiography may reveal signs of myocarditis, pericarditis, arthritis, aseptic meningitis, and inflammation of the coronary arteries. The purpose of this study is to determine the size of your heart, to evaluate how well your heart is functioning or pumping and to assess the structure and function of the valves within the heart. A 2-D (or two-dimensional) echocardiogram is capable of displaying a cross-sectional "slice" of the beating heart, including the chambers, valves and the major blood vessels that exit from the left and right ventricle. A Doppler echocardiogram measures the speed and direction of the blood flow within the heart. It screens the four valves for leaks and other abnormalities. By assigning color to the direction of blood flow, (Color Flow Mapping), large areas of blood flow may be studied. These color flow mappings allow abnormal blood flow characteristics to be interpreted by the cardiologist.

CBC
The CBC test may be performed under many different conditions and in the assessment of many different diseases. It is a screening test used to diagnose and manage numerous diseases. The results can reflect problems with fluid volume (such as dehydration) or loss of blood. The test can reveal problems with red blood cell production and destruction, or help diagnose infection, allergies, and problems with blood clotting.

ESR
ESR stands for erythrocyte sedimentation rate. It is a test that indirectly measures how much inflammation is in the body. However, it rarely leads directly to a specific diagnosis. This test can be used to monitor inflammatory or cancerous diseases. It is a screening test, which means it cannot be used to diagnose a specific disorder. However, it is useful in detecting and monitoring tuberculosis, tissue death, and certain forms of arthritis, autoimmune disorders, and inflammatory diseases that cause vague symptoms.

Urinalysis
Urinalysis is the physical, chemical, and microscopic examination of urine. It involves a

number of tests to detect and measure various compounds that pass through the urine. A urinalysis may be done: As part of a routine medical exam to screen for early signs of disease, If you have signs of diabetes or kidney disease, or to monitor you if you are being treated for these conditions, To check for blood in the urine and to diagnose a urinary tract infection.

X. PATHOPHYSIOLOGY

Predisposing factors: Age-1 year old Sex-Male Race-Asian

Precipitating Factors: Unknown yet linked with unknown etiologic agent and environmental factors

Autoimmune Response (possible if tested of HLA-BN22J2 antigen)

Release of Chemical Mediators (Histamine, bradykinin, prostaglandin)

Vasodilation and Cellular Permeabilty Attraction of Phagocytes and WBC Entry of antigen lymphatic capillaries S/S: Redness Swelling Heat on Phagocytosis by neutrophils and macrophages (antigens are localized and inflammation happens

Increase pressure due to inflammation and entry of antibodies

Systemic blood vessels involvement (inflammation of small & medium size vessels)

If treated: Ampicillin Cetirizine Diazepam Ceftriaxone Paracetamol

If not treated: Complications developed

Pericarditis

Myocarditis GOOD PROGNOSIS Cardiomegaly

Myocardial infarction

Heart failure

Ruptured coronary aneurysym DEATH

XI. Nursing Care Plan 1 Actual Assessment


Actual

Diagnosis

Rationale

Expected Outcome

Nursing Intervention

Justification

Evaluation

> Hyperthermia Related to Objective: increased metabolic rate and > Increased in body dehydration, temperature above possibly as normal range evidenced by > flushed skin; warm increased body to touch temperature >increased RR, greater than unstable BP normal range, flushed skin, Subjective: increased RR and > mag hilanat siya init tachycardia. init sa iya lawas as Definition: verbalized by folks. Body temperature Risk: Knowledge deficit; elevated above financial assistance normal range
Strength: Faith in God; Good family support

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 Hyperthermia

After 3 days of Independent: nursing 1. Monitor core interventions, temperature the client will be able to: 1. Maintain core temperature within normal range 2. Identify underlying cause/ contributing factors and importance of treatment. 3. Demonstrate behaviors to monitor and promote normothermia. 2. Provide tepid sponge bath as necessary
3. Discuss importance of adequate fluid intake to prevent dehydration Collaborative: 1. Administer paracetamol as ordered 2. Administer hydroxyzine as ordered 3. Monitor periodic lab studies relative to general well-being & status of specific problems

- to evaluate effects/degree of hyperthermia - To assist with measures to reduce body temperature - to promote wellness

After 3 days of nursing interventions:

1- Goal met: The client has able to demonstrate temperature within normal range from 38.1c to 36.5c.

- to reduce fever/ headache - to decrease inflammation - to assist client with correcting/ minimizing condition & promote optimal healing

2- Goal met: The client together with his significant others understands causes of the disease and is ready to practice interventions to prevent hyperthermia.

3.- Goal met: The client has able to exhibit stable behaviors to monitor and promote normothermia

1 Actual Assessment Actual Diagnosis Rationale Expected Outcome After 3 days of nursing interventions, the client will be able to: 1. Display timely healing of rash and skin desquamation Nursing Intervention
Independent: 1. Periodically remeasure/ - to monitor progress of photograph wound and wound healing observe for complications. 2. Keep the area clean/dry, carefully dress wounds, support incision, prevent infection, & stimulate circulation to surrounding areas 3. Encourage early ambulation/ mobilization Collaborative: 1. Application of antiitch ointment. 2. Administer hydroxyzine as ordered 3. Monitor periodic lab studies relative to general well-being & status of specific problems - to prevent irritation and relieve skin itchiness. - to decrease inflammation - to assist client with correcting/ minimizing condition & promote optimal healing - to assist bodys natural process of repair

Justification

Evaluation

> Impaired Skin integrity Related Objective: to inflammatory process as > Scaly skin, rough evidenced by >Peeling disruption of >Itchiness skin surfaces, > Reports of scratching macular rash and of Upper extremities & skin Lower extremities. desquamation.
Subjective: > Gapanit-panit iya paa kag permi sya gapangalut as verbalize by folks Risk: Knowledge deficit; financial assistance Strength: Faith in God; Good family support Definition: Altered epidermis and/or dermis [The integumentary system is the largest multifunctional organ of the body.]

Inflammatory process Swelling of tissues Disruption of skin surfaces Skin desquamation and Rash Impaired skin integrity

After 3 days of nursing interventions:

1- Goal met: the client has able to exhibit optimum healing of rashes and skin desquamation.

2. Maintain optimal nutrition 3. Participate in prevention measures and comply with treatments.

- to promote circulation and reduces risks associated with immobility

2- Goal met: the client has able to eat regularly 3 times a day.

3.- Goal met: the client has able to partake in all treatment concerning his health.

1 Risk (NCP) Assessment


Actual

Diagnosis

Rationale Inflammation (infection) Altered immune function Increase in antibody production Circulating immune (Antibody antigen) complex is bind to vascular epithelium and cause inflammation Inflammation of blood vessels leads to platelet accumulation.

Expected Outcome After 3 days of nursing interventions, the client will be able to: 1. Demonstrate behavior changes to improve circulation 2. verbalize (folks) understanding of condition and when to contact healthcare provider 3. Exhibit increased perfusion as individually appropriate vital signs within clients normal range.

Nursing Intervention
Independent: 1. Identify changes related to systemic and/or peripheral alterations in circulation. 2. Perform assistive range-of-motion exercises 3. Provide preoperative teaching appropriate for the situation. Collaborative: 1. Administer medications as indicated (e.g. anti dysrhythmics) 2. Review baseline ABGs electrolytes, BUN/Cr, cardiac enzymes

Justification

Evaluation

Objective: Altered blood pressure outside of acceptable parameters


Risk: poor eating habits & change in usual foods pattern Strength: good family support and optimistic in life

>Risk for altered peripheral tissue perfusion Related to inflammation of blood vessels Definition: Decrease in oxygen resulting in failure to nourish the tissue at the capillary level
Source: NANDA

- To assess causative/ contributing factors

After 3 days of nursing interventions:

- To maximize tissue perfusion

1- Goal met: Exhibit appropriate behavior to enhance circulation 2- Goal met: Client has able to Perceive about the present condition and how to contact help in healthcare agencies.
3-

- To promote wellness

Risk for altered peripheral tissue perfusion

- To maximize tissue perfusion . To note degree of impairment/ organ involvement

Goal met: Client has able to maximize tissue perfusion and demonstrate vital sign which is within normal ranges.

XII. DRUG STUDY Name of Drug

Dosage Frequenc y Route


100mg, IVTT q4h PRN

Mechanism of action
Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center. Unknown. Thought to produce analgesia by blocking pain impulses, by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. Drug may relieve fever by central action in the hypothalamic heat-regulating center and exert its anti inflammatory effect by synthesis of inhibiting prostaglandin and that of other mediators of the inflammatory response as well. Inhibits cell-wall synthesis during bacterial multiplication.

Indication

Contraindication

Adverse reaction

Nursing considerations

1. paracetamol CLASSIFICATION: Analgesics (Non-Opioid) & Antipyretics

> Mild pain or fever -Headache, fever associated w/ colds.

> Contraindicated to patients hypersensitivity to drugs. > Use cautiously in patients with long term alcohol use because therapeutic doses cause hepatotoxicity in these patients > Contraindicated to patients hypersensitivity to drug and in those with NSAID- induced sensitivity reactions, G6PD deficiency, or bleeding disorders, such as hemophilia. >Use cautiously in patients with GI lesions, impaired renal function, vitamin K deficiency.

Hematologic: hemolytic anemia, neutropenia, leucopenia, pancytopenia. Hepatic: jaundice. Metabolic: hypoglycemia Skin: rash, urticaria.

> Many OTC and prescription products contain acetaminophen; be aware of this when calculating total daily dose. > Use liquid form for children and patients who have difficulty swallowing. > In children, dont exceed five doses in 24hrs.

2. aspirin CLASSIFICATION: Analgesics (Non-Opioid) & Antipyretics/ CNS drug

300mg, 1 tab, TID P.O.

> Mild pain or fever, Kawasaki syndrome (mucocutaneo us lymph node syndrome),

EENT: tinnitus, hearing loss. Hematologic: leukopenia, thrombocytopenia, prolonged bleeding time. GI: nausea, GI distress, occult bleeding, dyspepsia, GI bleeding. Hepatic: hepatitis. Skin: rash, bruising, urticaria. Other: angioedema, hypersensitivity reactions.

> For inflammatory conditions, rheumatic fever, and thrombosis, give aspirin on a schedule rather than p.r.n. >Because enteric-coated and sustained release tablets are slowly absorbed, they arent suitable for rapid relief of acute pain, fever, or inflammation. They cause less GI bleeding and may be better suited for long-term therapy, such as treatment of arthritis.

3. ampicillin CLASSIFICATION: Anti-infectives/ Penicillins

250mg 1 tab q6 P.O

> Fever/ infections > Skin and skin-structure infections

> Contraindicated in patients hypersensitivity to drug or other penicillins. > Use cautiously in patients with other drug allergies. Because of possible cross-sensitivity, and in those with mononucleosis, because of high risk of maculopapular rash.

CNS: lethargy, hallucinations, seizures, anxiety, confusion, agitation, depression, dizziness, fatigue CV: vein irritation, thrombophlebitis. GI: nausea, vomiting, diarrhea GU: interstitial nephritis, nephropathy, vaginitis. Skin: pain at injection site Other: hypersensitivity reactions.

> Before giving drug, ask patient about allergic reactions to pennicilins. A negative history of penicillin allergy is no guarantee against a future allergic reaction. > Obtain specimen for culture and sensitivity tests before giving first dose. Therapy may begin pending results.

XIII. HEALTH TEACHING

Medication
` Paracetamol for fever -Headache, fever associated w/ colds. `Aspirin for Mild pain or fever, Kawasaki syndrome `Ampicillin for fever/ infection
`Teach the patient & folks about the indications of the drugs and let them know the effect & adverse effects of the medications. Client must understand the importance of drugs to their body and why they must acquire it. Remind them to question and not to administer medication that have been, improperly stored, look discolored, or do not look like their usual medication. Advise the patient to always read the label before taking a drug, to take it exactly as prescribed, and never to share prescription drugs. Encourage them to ask further questions about their drugs. After discussion make sure the client understands and ask to repeat if verification is needed.

Exercise

Treatment
Medications

Hygiene
Personal hygiene pertains to hygiene practices performed by an individual to care for ones bodily health and well being through cleanliness. Conditions and practices that serve to promote or preserve health. Personal hygiene practices include: seeing a doctor, seeing a dentist, regular washing (bathing or showering) of the body, regular hand washing, brushing and flossing of the teeth, and healthy eating. >self-help bath/Bed bath >Tepid sponge bath

Outpatient
> Continue prescription drugs if symptoms comes back >Compliance to follow up check ups > Continue ROM and Cardio exercises - to avoid further complications to health > Adequate fluids - for hydration > Prevention/Promotion of diseases must be implemented > Rest for comfort > Careful handling of items in the environment, to minimize viral contamination.

Diet

> CARDIO EXERCISES - to promote blood circulation. Moderate exercise in the morning within the patients limit and with rest. Inform client that the normal activity can be resumed after 3-4 weeks. > Aspirin -Thought to produce analgesia by blocking pain impulses, by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. > Ampicillin -Inhibits cell-wall synthesis during bacterial multiplication. >Paracetamol - relieve fever through central action in the hypothalamic heatregulating center. Laboratory test >Regular monitoring of CBC (platelets) - To prevent lowering of platelets that may cause spontaneous bruising & bleeding > Urinalysis - serves as indication for infection.

Practice of ingesting food in a regulated fashion to achieve or maintain a controlled weight. In most cases the goal is weight loss in those who are overweight or obese, but some athletes aspire to gain weight (usually in the form of muscle) and diets can also be used to maintain a stable body weight. > Balanced diet - Eat fresh fruits and vegetables for essential nutrients and minerals - strengthen immunity > Avoid junk and street foods - to avoid GIT infections - to prevent complications such as amoeba and hepatitis. > Regular bowel elimination

>ROM -for circulation improvement. Exercises may not be important, but it can minimize the chance of acquiring and spreading of diseases.

>Brushing and flossing the teeth - to remove dental plaque >providing special oral care -to maintain intactness of health of lips, tongue and mucus membranes of the mouth. -to prevent oral infections

XIV. BIBILIOGRAPHY

1. Brunner and Suddarth's Textbook of Medical-Surgical Nursing i. by Suzanne C. Smeltzer and Brenda G. Brade 2. Fundamentals of Nursing by Kozier 3. Nursess Drug Handbook by George R. Spratto and Adrienne L. Woods 4. Essentials of Human Anatomy And Physiology by Elaine N. Marieb 5. Blackwells Nursing Dictionary 6. Nurses Pocket Guide by Marilyn E. Doenges 7. Pathophysiology by Thomas J. Nowak 8. (http://www.radiology.rsnajnls.org ) http://radiology.rsnajnls.org/cgi/content-nw/full/215/2/337/
9. http://www.aafp.org/afp/991101ap/2027.html

10.

www.medicinenet.com