A nurse is caring for a 6-year-old child in an emergency department. Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Explanation & Rationale
Potential Condition: Kawasaki Disease Kawasaki disease is a systemic vasculitis that primarily affects children under the age of 5 but can occur in older children. It presents with prolonged fever (lasting more than 5 days), conjunctival injection (red eyes without exudate), mucosal inflammation (strawberry tongue, red lips), maculopapular rash, and extremity changes (edema and peeling skin on hands and feet). Elevated inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), high WBC count, and thrombocytosis (elevated platelets) are consistent with Kawasaki disease. If untreated, it can lead to coronary artery aneurysms. Actions to Take: Plan to administer high dose of aspirin: High-dose aspirin is given to reduce inflammation and prevent thrombosis in coronary arteries, as Kawasaki disease increases the risk of coronary artery aneurysms. Assess for neurological changes: Neurological changes, such as irritability, can indicate aseptic meningitis or other central nervous system involvement, which can occur in Kawasaki disease. Parameters to Monitor: Daily weights: Monitoring daily weights is essential to assess for fluid retention or overload, as Kawasaki disease can cause myocarditis and cardiac dysfunction. Reports of chest pain or pressure: Monitoring for chest pain or pressure is crucial to detect early signs of myocardial ischemia or coronary artery involvement, which are potential complications of Kawasaki disease.