Student Name Dates of Care: Date Submitted: #2 Nursing Diagnosis: Impaired Verbal Communication This is a high priority nursing

diagnosis due to the impact on nursing care. If the patient is unwilling to participate or allow nursing assessments and interventions it is very difficult to asses changes in status, providing treatments as well evaluating their effectiveness. NANDA Definition: Decreased, Delayed or absent ability to receive, process, or transmit, and/or use a system of symbols Related to: Difference related to developmental age and regression in communication and other behaviors As manifested by: Patient was unable or reluctant to communicate and showed signs of verbal regression due to her illness. She mumbles and spoke very softly making it difficult to discern what she was saying. She turned away when asked a question, said no (appropriate for age) and used her mother to facilitate communication. Scientific Rationale: Pain and discomfort can cause regressive behaviors, including developmental regression in communication. #1 Short term Outcome Establish a means of communication that is effective, i.e. using puppets or drawing to communicate.
Interventions Rationale Evaluation

#1 Assess contributing #1 Pain or discomfort may factors that may affect the disrupt the ability to patients ability to communicate. communicate such as strawberry tongue and dry cracked lips associated with Kawasakis Disease #2 Evaluate mental status (fatigue and irritability contribution) and willingness to establish #2 Malaise and fatigue as well as discomfort contribute to willingness to cooperatively

#1. Evaluate pain level and effectiveness of medication. Hydration status by evaluating I/O Monitor vital signs #2 Assess level of comfort after allowing patient to rest uninterrupted and offer

#2 Long term outcome

other means of communication. Allow adequate uninterrupted rest periods. Acceptance and increased voluntary communication. Facilitate age appropriate communication. #3 Assist the patient to establish a means of communication to express needs, wants, ideas and questions

communicate

analgesics or other comfort measures.

#3 Using different forms of communication may facilitate a more satisfactory and comfortable means of interaction. Using age appropriate tools to help in crossing the barriers to communicate #4 Increasing the comfort level offers an environment that contributes to effective learning and communication

#3 Compare which means of communication is best for the patient and allow them to participate in choosing the means of communication. Assess the most effective way to communicate #4 Assess patients ability and willingness to communicate after a period of uninterrupted rest in a comfortable and quiet environment.

Outcomes must be measurable

#4 Reduce environmental noise, lighting that may interfere with patients comfort level and contribute to anxiety and regressive behavior

#2 Nursing Diagnosis (3 parts) Impaired Oral Mucous Membrane Related to: Strawberry tongue and dry, cracking lips associated with Kawasakis disease manifestations and dehydration As manifested by: Swollen and inflamed red tongue, dry cracked lips, decrease in hydration and elevated temperature Definition: Disruption of the lips and/or soft tissues of the oral cavity Scientific Rationale: Kawasaki disease causes vasculitis, an increases the permeability and inflammatory reaction. The tongue is highly vascular and becomes inflamed and irritated during the acute phase of the disease process. High fever associated with the disease can cause dehydration and consequently the dry and cracked lips and white coating on the tongue. #1 Short term Outcome Reduce Fever
Interventions Rationale Evaluation

#1 Analgesic (aspirin)

#1 Decreasing the fever

#1 Monitor Temperature

therapy

will decrease the quantity of hydration needed making it easier to maintain proper hydration level. Analgesics also decrease pain and inflammation and therefore decreasing pain allowing for an increase in PO fluid intake. #2 Increase hydration of lips and tongue. Decrease pain associated with inflammation and dehydration of tongue and lips. #3 Reduce long-term consequences of inadequate oral hygiene including gingivitis, halitosis and cavities. Decrease tongue coating and provide comfort. #4 Provide moisture and protection to lips

and Pain level

#2 Long term goals

#2 Increase fluid intake

#2. Monitor I/Os, skin integrity and elasticity

Reduce inflammation and #3 Provide oral care coating on tongue. Reduce dryness and cracking of lips

#3 Monitor inflammation (color and size) of tongue

Outcomes must be measurable

#4 Apply vasoline or petroleum jelly to lips

#4 Monitor cracking of lips and pain

Kapiolani Community College Associate Degree Nursing Program Nurs255 Nursing Care Plan

Student Name Dates of Care: Date Submitted: #1 Nursing Diagnosis (3 parts): Risk for decreased cardiac output This is the highest priority nursing diagnosis because it is the most life threatening and one that can have life long consequences. Related to: Kawasaki disease can cause inflammation of blood vessels in the arteries, especially the coronary arteries. This inflammation can lead to aneurysms. An aneurysm can lead to a heart attack even in young children. It can also be related to a decrease in fluid volume and electrolyte imbalance. As manifested by: Variations n hemodynamic parameters, arrhythmias, ECG changes, rales, tachypnea, dyspnea, cough and abnormal ABGs, Decreased urine output, anxiety, restlessness, weakness and fatigue. Definition: Inadequate blood pumped by the heart to meet the metabolic demands of the body Scientific Rationale: Inflammation of the blood vessels and arteries leads to aneurysms, heart attacks and coronary heart disease. #1 Short term Outcome
Interventions Rationale Evaluation

Patient maintains BP within normal range, has warm dry skin, regular cardiac rhythm, clear lung sounds and strong bilateral and equal peripheral pulses #2 Long term goals

#1 Administer chewable aspirin as prescribed and within normal dosage range. Monitoring responses, side effects and toxic reactions #2 Maintain fluid balance either PO or IV depending

#1 Reduce inflammatory response, fever and pain associated with Kawasaki Disease

#1 Monitor any changes in vital signs, skin turgor and integrity and LOC

#2 Fluid intake increases extracellular fluid volume

#2 Monitor I/Os,

on orders Maintain good cardiac function with no long term impairment due to inflammation of the coronary arteries and heart valves Outcomes must be measurable #3 Assess peripheral pulses

to raise cardiac output #3 Weak pulses are sign of decrease in cardiac output #3 Monitor for changes in peripheral pulses, symmetry, rate quality, rhythm and capillary refill #4 Monitor heart sounds for S3 or S4, rate, rhythm, and quality. Monitor lungs for adventitious breath sounds. Skin color and LOC

#4 Assess heart and lung sounds

#4 Abnormal heart sounds indicate cardiac abnormalities. Crackles are manifestations of accumulation of fluid secondary to impaired left ventricular emptying.