Assessment Diagnosis Planning Intervention Rationale Evalution

Objective: Impaired skin Short term Independent Short term

Edema in hands integrity related to (Goal met)
and fee inflammatory After 4hrs of Assess skin for Classical skin
Cracked lips with process, altered nursing intervention texture, turgor, features of After 4hrs of nursing
fissures circulation, and the patient will color, moisture, and Kawasaki disease intervention the
Erythematous edema formation of manifest healing of integrity. involves erythema, patient will able to
generalized rash hands and feet dry, peripheral swelling, and manifest healing of
cracked lips with erythema. desquamation peripheral
fissures, affecting the skin of erythema.
Erythematous the extremities and
generalized rash Long Term a polymorphous
rash. Long Term
After 8 hours of the (Partially met)
nursing intervention
the patient will Dress the child in a Heavy clothing may After 8 hours of the
decrease the sign light clothing. constrict and irritate nursing intervention
of edema in hands the rashes. the patient will able
and feet to decreased the
Discourage the use The use of soaps sign of edema in
of soaps. makes the skin dry hands and feet
and predispose to
skin breakdown.

The use of soaps Moisture promotes

makes the skin dry skin breakdown.
and predispose to
skin breakdown.

Apply cool, moist Provide comfort and

compress to the reduces itchiness.
itching skin areas.

Encourage Extra fluid intake

adequate fluid helps maintain
intake. hydration and
 decrease mouth
tenderness.

Encourage intake Protein is essential

of protein-rich foods for the formation,
such as eggs, repair, and
beans, chicken. maintenance of the
skin