KAWASAKI DISEASE

KAWASAKI disease causes swelling (inflammation) in the walls of medium-sized

arteries throughout the body. It primarily affects children. The inflammation tends to
affect the coronary arteries, which supply blood to the heart muscle.

NURSING CARE PLAN

ALTERATION OF BODY TEMPERATURE A condition in which the
normal regulation or exchange between heat produced by The body and heat lost by the body is
disturbed. In such condition either body temperature increases above the normal or decreases

ASSESMENT DIAGNOSIS OUTCOME PLANNING INTERVENTION EVALUATION

IDENTIFICATION
Alteration in After 4 hours of  Check the  Monitor After 4 hours of
Subjective:
body comprehensive record temperature comprehensive
“mainit po ang nursing
temperature nursing and vital every 4 hours;
balat ng anak ko” interventions:
related to intervention, the signs
as verbalized by every 2 hours if
increased patient will: every 4
the patient’s elevated.
metabolic rate  Maintain hours
mother: Rationale: Kawasaki
and normal  Assess
disease initially begins 1- Goal met:
dehydration, as temperature of skin for
Objective: with a high fever (102° to The patient has
evidenced by 37.5°C texture,
Skin warm to 104°F) for 5 or more days able to
increased body  Be free of turgor, demonstrate
touch with a in duration.
temperature dehydration color, temperature
temperature of
greater than  Maintain vital moisture, within normal
39.7°C  Provide sponge
normal 39.30 C signs at normal and range from
↑RR: 28cpm baths for
levels integrity. 38.1°c to 36.5°c.
↑HR:102bpm temperature  ove
Weakness r 101°F.
observed
Dry mucous Rationale: Tepid sponge
membranes bath promotes heat loss 2- Goal met:
through conduction and The patient has
Flushed Skin evaporation. no sign of
dehydration
 Provide
3- Goal met:
adequate rest The patient has a
periods. result of normal
Rationale: Bed rest level of vital
decreases metabolic signs.
demands and oxygen
consumption.


Use a cooling
blanket for higher
temperatures
that do not
respond to
antipyretics.
Rationale: Extra
wrapping of extremities
prevents shivering;
shivering promotes
further heat.

 Encourage
adequate fluid
intake as
indicated.
Rationale: If the child is
dehydrated or
diaphoretic, fluid loss
contributes to fever.

Administer  medication  a
s indicated.

 Aspirin
Rationale: It is an anti-
inflammatory drug that is
given to reduce
inflammation.

 IV
immunoglobulin
Rationale: It is given in
single dose to treat and
reduce inflammation and
thereby lessen the
duration of fever.
 NURSING CARE PLAN
Impaired oral mucous is the alteration of the lips or soft tissue of the oral cavity that
may be caused by drying or being NPO for more than 24 hours.set of point.

ASSESMENT DIAGNOSIS OUTCOME PLANNING INTERVENTION EVALUATION

IDENTIFICATION
Impaired oral  After 2 days  Check for  Assess for After 2 days of
Subjective: “ang
mucous of nursing the changes in nursing
kirot po ng
membrane interventions, changes the lips and interventions:
lalamunan ko di po
related to Child’s oral in the lips oral cavity.
ako makapag salita
inflammatory mucosa will and oral Goal met: the
at maka nguya ng
process as be free from cavity Rationale: Typical patient has
maayos” as
evidenced by dryness and changes of the manifested a
verbalized by the
presence of irritation mucous membrane normal oral
patient.
bright red  The patient’s include redness of mucosa.
tongue. mucous the
Objective:
membranes mouth,  strawberry Goal met: the
 Dry mouth
will appear tongue, and red, dry patient’s
 Red
moist and fissured lips. mucous
strawberry
tongue
pink with 48  Provide soft, membranes
hours. nonirritating appeared moist
 Inflamed
foods such and pink.
tongue
as gelatin.

Rationale: Soft food

requires less
chewing and
provides less
irritation to the oral
mucosa.
  Provide
cool
liquids
such as ice
chips

Rationale:
Maintains
hydration and
decreases mouth
tenderness.
 Apply
soothing
ointments
to the lips.

Rationale: Keep the

lips lubricated to
avoid soreness.

 Instruct
the use a
soft-bristle
brush or a
padded
tongue
blade
during
mouth
care.
Rationale: Soft-
bristle brush limits
mucosal irritation.

 Provide
regular oral
care with
alcohol-free
mouthwash.
Rationale: Limits
the bacterial
accumulation that
can cause  infection.
 NURSING CARE PLAN
Impaired skin integrity a nursing diagnosis accepted by the North American Nursing
Diagnosis Association, defined as alteration in the epidermis and/or dermis. The skin is subject to
injury from a variety of external and internal factors.

ASSESMENT DIAGNOSIS OUTCOME PLANNING INTERVENTION EVALUATION

IDENTIFICATION

Impaired  Monitor  Assess skin for After 3 days of

skin site of skin texture, turgor, comprehensive
Subjective: “nag After 3 days of
integrity impairmen color, moisture, nursing
babalat po yung sa nursing
related to t at least and integrity. interventions:
labi ko at medyo po interventions,
altered once a day
sa parteng kamay as the client will be
circulation for color
verbalized by the able to observe
as evidence changes, Rationale: Classical skin Goal met: the
patient. healing of
by rashes redness, features of Kawasaki patient has
peripheral
all over the swelling, disease involves erythema, manifested a
erythema. healing of
palms and warmth, swelling, and
Objective: the sole. pain, or peripheral
desquamation affecting the
other signs erythema.
 Erythematou skin of the extremities and
s generalized of a polymorphous rash.
rash infection.
 Edema of  Dress the child in a
hands and light clothing.
feet
 Dry, cracked Rationale: Heavy clothing
lips with may constrict and irritate
fissures the rashes.

 Discourage the use

 of soaps.

Rationale: The use of soaps

makes the skin dry and
predispose to skin
breakdown.

 Remove wet and

wrinkled bed
linens.

Rationale: Moisture
promotes skin breakdown.

 Apply cool, moist

compress to the
itching skin areas.
Rationale:
Provide comfort and
reduces itchiness.

 Encourage
adequate fluid
intake.
Rationale: Extra fluid intake
helps maintain hydration
and
decrease  mouth  tendernes
s.

 Encourage intake
of protein-rich
foods such as eggs,
beans, chicken.
Rationale: Protein is
essential for the formation,
repair, and maintenance of
the skin.