Remember! Your nursing diagnoses depend no the medical diagnoses. This is what you base them on.
You have to understand how Kawasaki's affects the body so think about it. The more usual signs & symptoms are fever, conjunctivitis, gingivitis, an exfoliative rash at the hands & feet with edema and joint inflammation. How a disease affects the body is what you'll be dealing with as a nurse. If it causes fevers, you'll give Tylenol, initiate cooling measures, monitor the temp, and so on. Understand?
Once you come up with a nursing diagnosis (dx), support it with evidence. You state this AEB (as evidenced by) or M/B (manifested by).
Okay. So start with fever. Fever: "altered body temperature M/B
T 101.8 - 103.2F".
Conjunctivitis: "L & R eye redness and yellow drainage" (Doesn't need evidence. This IS the evidence)
Gingivitis: "Gum irritation M/B redness and swelling at upper and lower gums"
Rash: "Impaired Skin Integerity at bilateral hands M/B red rash with exfoliation"
"Impaired Skin Integrity at bilateral feet M/B red rash with exfoliation"
Hand edema: "Impaired Tissue Integrity M/B 2+ pitting edema at bilateral hands"
Foot edema: "Impaired Tissue Integrity M/B 3+ pitting edema at bilateral feet"
Joint inflammation: "Pain M/B warmth, redness and swelling at bilateral knees and pt. states 6/10 pain on 0-10 P/S"
A care plan for this pt. would be lengthy, several pages. And this pt. is vulnerable to pericarditis and meningitis. Think of the dxs for those! Now can you come up with appropriate goals, time frames, interventions, rationales and realistic outcomes?
