VILLANUEVA, Roccabeth J.

NU 203

A mother has come to urgent care with her 3-year-old son because of a
fever for ve days. Upon examination, the nurse noticed a red tongue, lips,
and eyes. The hands are swollen and there is an enlargement of cervical
lymph nodes.

A. What is the tentative medical diagnosis? Justify your answer.

Based on the symptoms described, the tentative medical diagnosis for the
3-year-old boy could be Kawasaki disease. Kawasaki disease is a rare but
serious illness that primarily a ects children under the age of 5. It is
characterized by in ammation of the blood vessels throughout the body,
including the coronary arteries. The disease can cause a high fever that lasts for
more than ve days, along with other symptoms such as a red tongue, cracked
lips, swollen hands and feet, and enlarged lymph nodes in the neck. The
presence of a fever for ve days, along with the other symptoms described,
strongly suggest Kawasaki disease.

B. What are the 3 priority nursing diagnoses, their nursing interventions, and the
rationale appropriate for the patient with Kawasaki disease mentioned above?

1. Risk for decreased cardiac output related to in ammation of the

coronary arteries.
Interventions:

• Monitor vital signs, heart rate, and rhythm continuously.

• Administer prescribed medications to manage fever and prevent clotting,

such as intravenous immunoglobulin (IVIG) and aspirin.

• Provide a calm, quiet environment to minimize stress on the heart.

• Encourage rest to decrease oxygen demand on the heart.

Rationale:

Kawasaki disease can cause in ammation of the coronary arteries, which can
lead to the formation of blood clots, aneurysms, or other cardiac complications.
By monitoring vital signs and administering prescribed medications, the nurse
can help manage the patient's fever and prevent clotting. Providing a calm
environment and encouraging rest can also help minimize stress on the heart
and decrease oxygen demand.

2. Impaired skin integrity related to the development of a rash and

peeling skin.
Interventions:

• Assess the patient's skin frequently for changes in color, texture, or

moisture.

• Apply emollients or ointments to soothe dry, peeling skin.

• Provide frequent oral hygiene to prevent irritation of the lips and mouth.

• Encourage uid intake to maintain hydration.

Rationale:

Kawasaki disease can cause a rash, skin peeling, and in ammation of the
mucous membranes, which can lead to impaired skin integrity. By assessing the
patient's skin frequently, applying emollients, and encouraging hydration, the
nurse can help prevent skin breakdown and promote healing.

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3. Risk for infection related to immune system suppression from IVIG
treatment.

Interventions:

• Monitor for signs of infection, such as fever, increased heart rate, and
white blood cell count.

• Encourage the patient and family members to practice good hand

hygiene.

• Limit exposure to individuals who are sick or have infections.

• Administer prophylactic antibiotics as prescribed.

Rationale:

IVIG treatment can suppress the immune system, increasing the risk for
infection. By monitoring for signs of infection, encouraging good hand hygiene,
limiting exposure to sick individuals, and administering prophylactic antibiotics,
the nurse can help prevent infection and promote the patient's recovery.

C. What are the potential complications? Justify your answer.

Kawasaki disease can cause several potential complications, some of which can
be serious and life-threatening. These complications include:

1. Coronary artery aneurysms: In ammation of the coronary arteries can

cause weakened areas to bulge out, forming aneurysms. These aneurysms
can increase the risk of blood clots, heart attacks, and other cardiac
events.


2. Myocarditis: In ammation of the heart muscle can cause myocarditis,

which can lead to heart failure and other cardiac problems.


3. Pericarditis: In ammation of the pericardium (the sac surrounding the heart)

can cause pericarditis, which can lead to chest pain and other cardiac
problems.


4. Kawasaki disease shock syndrome: This is a rare but serious complication

of Kawasaki disease that can cause low blood pressure and organ failure.


5. Joint pain and arthritis: Some children with Kawasaki disease may develop
joint pain and arthritis, which can be painful and limit mobility.

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 4. Complete the table below:

DEFECT BRIEF DESCRIPTION SIGNS AND SYMPTOMS MEDICAL AND

RELATED TO THE SURGICAL
CONDITION MANAGEMENT

A. VSD
A ventricular septal defect (VSD) is a • Poor feeding or slow Medical management
type of congenital heart defect where weight gain in infants
may involve
there is an abnormal opening or hole • Shortness of breath, medications to
in the wall (septum) between the two especially during manage symptoms,
lower chambers (ventricles) of the physical activity
such as diuretics to
heart. This can cause oxygen-rich • Fatigue or weakness
reduce uid buildup
and oxygen-poor blood to mix, which • Rapid or irregular and medications to
can put extra strain on the heart and heartbeat
control blood pressure
lungs, • Sweating
and heart rate.
• Frequent respiratory Antibiotics may also
infections
be prescribed to
• Bluish tint to the skin, prevent infection of
lips, and nails the heart lining
(cyanosis) in severe (endocarditis) in
cases
people with certain
• Decrease cardiac types of VSD.

output

• A murmur can be Surgical management

heard in the heart. may be necessary for
larger or symptomatic
VSDs. Surgical
options may include
open-heart surgery to
patch the hole in the
septum, or catheter-
based procedures to
insert a device to
close the hole. In
some cases, surgery
may need to be
postponed until the
child is older to allow
for more complete
development of the
heart and to reduce
the risk of
complications.
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 B. COA Coarctation of the aorta (CoA) is a CoA may not cause Medical
congenital heart defect where the any symptoms until management may
aorta, the main artery that carries later in life. However, involve medications
oxygen-rich blood from the heart common signs and to manage
to the body, is narrowed or symptoms may symptoms, such as
constricted in a certain area. This include:
medications to
narrowing can restrict the ow of • High blood pressure lower blood
blood to the lower part of the in the arms and pressure or to help
body and may cause high blood head, but lower the heart pump
pressure in the upper body, blood pressure in more e ectively.

including the arms and head. CoA the legs and feet

can range in severity from mild to • Headaches

Surgical
severe, and some cases may not • Dizziness or fainting
management is
cause symptoms until later in life.
• Shortness of breath, often required for
especially during signi cant CoA. The
physical activity
preferred surgical
• Chest pain or option is to remove
tightness
the narrowed
• Cold feet or legs
segment of the
• Leg cramps or aorta and reconnect
weakness
the two healthy
• Abnormal heartbeat ends. In some
or palpitations cases, an arti cial
graft may be used to
replace the removed
section of the aorta.
Catheter-based
procedures may
also be used to
place a stent in the
narrowed area to
widen it and
improve blood ow.
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 C. TOF Tetralogy of Fallot (TOF) is a Symptoms of TOF in Medical
congenital heart defect that infants may include:
management may
a ects the structure of the heart • Cyanosis (blue- include medications
and the ow of blood to the lungs tinged skin)
to manage
and the rest of the body. It is • Rapid breathing or symptoms such as
characterized by four heart di culty breathing, oxygen therapy,
abnormalities: a ventricular septal especially during which can increase
defect (VSD), pulmonary stenosis feeding
the amount of
(narrowing of the pulmonary valve • Poor weight gain
oxygen in the blood
or artery), an overriding aorta (the • Fatigue or irritability

and improve
aorta sits above the VSD and • Fainting or loss of breathing, and
receives blood from both the right consciousness
medications to help
and left ventricles), and right the heart pump
ventricular hypertrophy Symptoms of TOF in more e ectively. In
(thickening of the right ventricular children may include:
some cases,
muscle).
medications may be
• Cyanosis
used to manage
• Shortness of Breath
arrhythmias or other
• Fatigue
heart-related
• Fainting
complications.

• May also have

developmental Surgical
delays problems management for
with physical TOF may involve
activity. repairing the
ventricular septal
defect (VSD),
widening the
pulmonary valve or
artery, and/or
repositioning the
aorta. In some
cases, a temporary
shunt may be
placed to improve
blood ow until the
patient is strong
enough to undergo
more complex
surgical procedures.

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 D. PDA Patent ductus arteriosus (PDA) is • Shortness of breath Medical
a congenital heart defect in which or di culty management for
a blood vessel called the ductus breathing
PDA may involve
arteriosus, which connects the • Fatigue or medications such as
aorta and pulmonary artery in the weakness
indomethacin or
fetus, fails to close after birth. • Rapid or pounding ibuprofen, which
This causes oxygen-rich blood to heartbeat
can help to
ow from the aorta into the • Poor growth or stimulate the closure
pulmonary artery, and as a result, failure to thrive in of the ductus
the heart has to work harder to infants
arteriosus. These
pump blood to the body. PDA is a • Recurrent medications are
common condition that can range respiratory typically used in
in severity from mild to severe. In infections
infants and are most
some cases, PDA may close on • Sweating or e ective when the
its own, but in other cases, becoming easily PDA is diagnosed
treatment may be necessary to tired during soon after birth.

prevent complications.
feedings in infants
Surgical
• Enlarged heart or management for
heart failure in PDA may involve a
severe cases
procedure called
• A machinery-like ductal closure,
murmur is present
which can be
• Signs of heart failure performed through a
in infant
small incision or via
• Widened pulse a catheter-based
pressure and approach. During
bounding pulses this procedure, the
ductus arteriosus is
closed using a
device or a suture.
This procedure is
typically performed
under general
anesthesia and may
require a short
hospital stay.

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