Question

Sally Smith, 5 years old is in the ER with these following s/s: High fevers for over a week, strawberry tongue, red eyes, swollen joints and a rash on her body.

         A. What is the probable diagnosis?

         B. What some other assessment findings?

         C. What should the nurse expect and or include in the plan of care?

D. What would the nurse be sure to include in the discharge teaching plan for Sally and her family?

Answer 1

A) diagnosis: Kawasaki disease.

b) Extremity changes: 1) Erythema of the palms and soles, sometimes accompanied by firm and painful induration of the hands or feet that can impede ambulation

2) Desquamation of the fingers and toes which begins in the periungual region, within 2-3 weeks after the onset of fever

3) Beau's lines (deep transverse grooves across the nails) upto 1 to 2 months after onset of fever.

c) nurses observation should include:

• Acute febrile phase. The child appears severely ill and irritable; there is high, spiking fever for 5 or more days, bilateral conjuctival injection, oropharyngeal erythema, strawberry tongue, or red and dry lips, erythema and edema of hands and feet, periungual desquamation, erythematous generalized rash, and cervical lymphadenopathy greater than 0.6 inch (1.5 cm).
• Subacute phase. Acute symptoms of the acute stage subside; temperature returns to normal. The child remains irritable and anorectic.
• Convalescent phase. Check the child’s new set of diagnostic results to establish he disease’s status.
• Chronic pain related to inflammation of the myocardium or pericardium.
• Risk for decreased cardiac output related to accumulation of fluid in the pericardial sac.
• Activity intolerance related to inflammation and degeneration of myocardial muscle cells.
• Impaired skin integrity related to inflammatory process, altered circulation, and edema formation.
• Impaired oral mucous membrane related to inflammatory process, dehydration, and mouth breathing.

plan for:

• Monitor pain. Monitor pain level .
• Cardiac monitoring and assessment. Take vital signs as directed by conditions; assess for signs of mycocarditis and monitor for heart failure.
• Monitor I&O. Closely monitor intake and output, and monitor hydration status by checking skin turgor, weight, urinary output, specific gravity, and presence of tears.
• Plan periods of rest and activities. Allow the child periods of uninterrupted rest; encourage the child to move about freely under supervision; provide soft toys and quiet play and encourage use of hands and fingers; and provide quiet, peaceful environment with diversional activities.
• Provide oral care. Offer cool liquids (ice creams); progress to soft, bland foods; and give mouth care every 1 to 4 hours with special mouth swabs; use soft toothbrush only after healing has occurred.

d) discharge plan should include:

appointment with the doctor.

cardiac followup