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 (Gordon’s 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 patient’s 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 naïve 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 shouldn’t 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; God’s 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 patient’s 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: Jehovah’s 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 (Gordon’s 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 doesn’t 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 can’t 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 child’s 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 Jehovah’s 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 40-41۫C without colds
or cough. Father noticed rashes on the abdomen and the client’s 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: 38.3°C
> Pulse Rate: 140 bpm
> Respiratory Rate: 24 cpm

c. Integumentary
> Warm to touch; Afebrile, T: 38.3°C
> 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 Interpretations Implication
Diagnostic Test
Hemoglobin 106 g/L 130-180 normal >within normal
conditions
Hematocrit 0.32 % 0.40-0.54 normal >within normal
conditions
WBC Count 6.8 4.5 - 11x10 /L normal >within normal
conditions
COAGULATION
PROFILE
Platelet Count 605 150-450 increased > thrombocytosis
DIFFERENTIAL
COUNT
Neutrophil 72 50 – 70% increased > sufficient immune
system
Segmented
Lymphocytes 25 % 25-35% normal >>within normal
conditions
Eosinophil 1 % 1-5% normal >within normal
conditions
TOTAL 100 %

URINALYSIS REPORT (January 9, 2009)

NORMAL ACTUAL Interpretations Implication

COLOR Light or pale Light Yellow Normal > indicates good hydration
Yellow and urine concentration
CHARACTER Clear Slightly turbid Abnormal > increase fluid intake
GLUCOSE (-) (-) Normal > well hydrated
REACTION 4.6-8 6.5 pH Normal > there is normal hydrogen ion
concentration and extra
cellular fluid
SPECIFIC 1.010-1.025 1.010 Normal > the concentrating ability of
GRAVITY the kidney is normal
PUS CELL 0 5-8 Abnormal > indicates possible urinary
tract infection
> Administer antibiotic as
ordered
SQUAMOUS (-) Few normal > increase fluid intake
> Administer antibiotic as
ordered
BACTERIA (-) few normal > increase fluid intake
> increase intake of Vitamin C
 2-D echocardiogram

January 9, 2010
File no. CD-SLS-21-04
M-Mode

RSEULTS RESULTS RESULTS

GA 1.96 LVEDd 2.67 IVSD 0.79 RVEDd

AO 1.79 LEVSd 1.71 IVSs 1.00 RVESd
LA/AO 1.09 EF 68% LVPWd 0.92 PE dias
PA FS 36% LVPWs 0.88 PE syst

DOPPLER COLOR FLOW STUDIES:

VELOCIT RES RES RESU

Y ULT ULT LT
TV Trjet
MV 1.16 MVA/PH MVA/
T planimetry
MRjet LA area MR fraction
AoV 1.08/4.67 PG/AoV
ARjet AO annules 1.1 AR fraction
PV 1.07 PG/PV 4.54 PAT 70 PA pressure

DA 1.32 PG/DA 6.97 Pul annules 1.38 TVA 1.40

QpQs MVA 1.49

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: Precipitating Factors:

Age-1 year old Unknown yet linked with
Sex-Male unknown etiologic agent
Race-Asian 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 on
lymphatic capillaries Phagocytosis by neutrophils and
S/S: macrophages (antigens are
Redness localized and inflammation
Swelling happens
Heat

Increase pressure due

to inflammation and
entry of antibodies
 Systemic blood vessels
involvement
(inflammation of small &
medium size vessels)

If treated: If not treated:

Ampicillin Complications developed
Cetirizine
Diazepam
Ceftriaxone
Paracetamol
Pericarditis

Myocarditis
GOOD PROGNOSIS

Cardiomegaly

Myocardial infarction

Heart failure

Ruptured coronary
aneurysym

DEATH
XI. Nursing Care Plan

1 Actual

Assessment Diagnosis Rationale Expected Nursing Intervention Justification Evaluation

Outcome

Actual > Hyperthermia After 3 days Independent:

Entry of
Related to of nursing After 3 days of nursing
Objective: pathogens in the 1. Monitor core - to evaluate interventions:
increased interventions,
metabolic rate systemic the client will temperature effects/degree of
> Increased in body circulation hyperthermia
temperature above and dehydration, be able to:
possibly as ↓
normal range 2. Provide tepid - To assist with measures 1- Goal met:
evidenced by Regulation of 1. Maintain
> flushed skin; warm sponge bath as to reduce body The client has able to
to touch increased body toxins in the body core demonstrate temperature
necessary temperature
>increased RR, temperature ↓ temperature within normal range from
unstable BP greater than Release of within normal - to promote wellness 38.1°c to 36.5°c.
3. Discuss importance of
normal range, pyrogen range adequate fluid intake to
Subjective: flushed skin, ↓ prevent dehydration
increased RR and Stimulation of the
> “mag hilanat siya tachycardia. 2. Identify Collaborative: 2- Goal met:
hypothalamus The client together with his
init init sa iya lawas” underlying
↓ - to reduce fever/ significant others
as verbalized by folks. Definition: cause/ 1. Administer
Body temperature Increase or contributing paracetamol as ordered headache understands causes of the
Risk: Knowledge deficit; alteration of disease and is ready to
elevated above factors and practice interventions to
financial assistance thermoregulation 2. Administer - to decrease
normal range importance of inflammation prevent hyperthermia.
↓ treatment. hydroxyzine as ordered
Strength: Faith in God;
Good family support Increase in body - to assist client with
3. Monitor periodic lab
temperature studies relative to correcting/ minimizing
↓ 3. Demonstrate general well-being & condition & promote 3.- Goal met:
Hyperthermia behaviors to status of specific optimal healing The client has able to
monitor and problems exhibit stable behaviors to
promote monitor and promote
normothermia. normothermia
1 Actual

Assessment Diagnosis Rationale Expected Nursing Intervention Justification Evaluation

Outcome

Actual > Impaired Skin Independent:

Inflammatory After 3 days After 3 days of nursing
integrity Related
process of nursing 1. Periodically remeasure/ - to monitor progress of interventions:
Objective: to inflammatory
interventions, photograph wound and wound healing
process as observe for
> Scaly skin, rough ↓ the client will
evidenced by be able to: complications.
>Peeling disruption of
>Itchiness skin surfaces, Swelling of 2. Keep the area - to assist body’s natural
> Reports of 1. Display 1- Goal met:
macular rash tissues timely healing
clean/dry, carefully process of repair
the client has able to
scratching of Upper dress wounds, support
extremities & Lower and skin of rash and incision, prevent exhibit optimum
extremities. desquamation. ↓ skin infection, & stimulate healing of rashes and
desquamation circulation to skin desquamation.
Subjective: Definition: Disruption of surrounding areas
Altered epidermis
skin surfaces - to promote circulation
> “Gapanit-panit iya and/or dermis 3. Encourage early
[The 2. Maintain ambulation/ and reduces risks 2- Goal met:
paa kag permi sya
integumentary ↓ optimal mobilization associated with the client has able to eat
gapangalut” as immobility
verbalize by folks system is the nutrition regularly 3 times a day.
largest Collaborative:
Skin
Risk: Knowledge multifunctional desquamation - to prevent irritation and
organ of the 3. Participate 1. Application of anti-
deficit; financial and Rash itch ointment. relieve skin itchiness.
assistance body.] in prevention 3.- Goal met:
↓ measures and the client has able to
Impaired skin comply with - to decrease partake in all treatment
Strength: Faith in 2. Administer
God; Good family integrity treatments. hydroxyzine as ordered inflammation concerning his health.
support
3. Monitor periodic lab - to assist client with
studies relative to correcting/ minimizing
general well-being & condition & promote
status of specific optimal healing
problems
1 Risk (NCP)

Assessment Diagnosis Rationale Expected Nursing Justification Evaluation

Outcome Intervention

Actual >Risk for Inflammation Independent:

(infection) After 3 days of After 3 days of nursing
Objective: altered
↓ nursing 1. Identify changes - To assess causative/ interventions:
peripheral interventions, related to systemic contributing factors
Altered immune
Altered blood pressure tissue the client will be and/or peripheral
function
outside of acceptable perfusion able to: alterations in
↓ circulation.
parameters Related to Increase in
inflammation antibody 1. Demonstrate 1- Goal met:
- To maximize tissue
production behavior Exhibit appropriate
Risk: poor eating habits & of blood 2. Perform assistive perfusion
change in usual foods ↓ changes to range-of-motion behavior to enhance
vessels improve
pattern Circulating immune exercises circulation
(Antibody – circulation
Strength: good family Definition: antigen) complex is
support and optimistic in 2. verbalize 3. Provide preoperative
life bind to vascular 2- Goal met:
Decrease in (folks) teaching appropriate - To promote wellness Client has able to
epithelium and
understanding for the situation. Perceive about the
oxygen cause inflammation
↓ of condition and present condition and
resulting in when to contact
Inflammation of Collaborative:
how to contact help in
failure to healthcare healthcare agencies.
blood vessels leads
nourish the to platelet provider
1. Administer
tissue at the accumulation. medications as - To maximize tissue
3. Exhibit 3- Goal met:
capillary level ↓ indicated (e.g. anti perfusion
increased Client has able to
Risk for altered dysrhythmics)
perfusion as maximize tissue
Source: NANDA
peripheral tissue individually 2. Review baseline . To note degree of perfusion and
perfusion appropriate vital ABG’s electrolytes, impairment/ organ demonstrate vital sign
sign’s within BUN/Cr, cardiac involvement which is within normal
clients’ normal enzymes ranges.
range.
XII. DRUG STUDY
Name of Drug Dosage Mechanism of action
Frequenc
y Route
Thought to produce analgesia
1. paracetamol 100mg, by blocking pain impulses by
IVTT q4h inhibiting synthesis of
CLASSIFICATION: PRN prostaglandin in the CNS or of
Analgesics (Non-Opioid) other substances that sensitize
& Antipyretics pain receptors to stimulation.
The drug may relieve fever
through central action in the
hypothalamic heat-regulating
center.
Unknown. Thought to produce
2. aspirin 300mg, analgesia by blocking pain
1 tab, TID impulses, by inhibiting
CLASSIFICATION: P.O. synthesis of prostaglandin in
Analgesics (Non-Opioid) the CNS or of other substances
& Antipyretics/ CNS drug 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.
3. ampicillin 250mg Inhibits cell-wall synthesis
1 tab q6 during bacterial multiplication.
CLASSIFICATION: P.O
Anti-infectives/
Penicillins
Indication Contraindication
> Mild pain > Contraindicated to
or fever patients hypersensitivity
-Headache, to drugs.
fever
associated w/ > Use cautiously in
colds. patients with long term
alcohol use because
therapeutic doses cause
hepatotoxicity in these
patients
> Mild pain > Contraindicated to
or fever, patients hypersensitivity
Kawasaki to drug and in those with
syndrome NSAID- induced
(mucocutaneo sensitivity reactions,
us lymph G6PD deficiency, or
node bleeding disorders, such
syndrome), as hemophilia.
>Use cautiously in
patients with GI lesions,
impaired renal function,
vitamin K deficiency.
> Fever/ > Contraindicated in
infections patients hypersensitivity
> Skin and to drug or other
skin-structure penicillins.
infections > 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.
Adverse reaction
Hematologic: hemolytic
anemia, neutropenia,
leucopenia, pancytopenia.
Hepatic: jaundice.
Metabolic: hypoglycemia
Skin: rash, urticaria.
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.
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.
Nursing considerations
> 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, don’t exceed five doses
in 24hrs.
> 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 aren’t 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.
> 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
> CARDIO EXERCISES
- to promote blood
circulation. Moderate
exercise in the morning
within the patient’s limit and
with rest. Inform client that
the normal activity can be
resumed after 3-4 weeks.
>ROM
-for circulation
improvement.
Exercises may not be
important, but it can
minimize the chance of
acquiring and spreading of
diseases.
Treatment
Medications
> 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 heat-
regulating 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.
Hygiene
Personal hygiene pertains to
hygiene practices performed
by an individual to care for
one’s 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
>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
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
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
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. Nurses’s Drug Handbook by George R. Spratto and
Adrienne L. Woods
4. Essentials of Human Anatomy And Physiology by Elaine N.
Marieb
5. Blackwell’s Nursing Dictionary
6. Nurse’s 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