Page |1

I. INTRODUCTION

Scarlet fever is disease caused by exotoxin produced by group a beta-hemolytic Streptococcus. It occurs most commonly in age group 6-12 years. It may also occur in preschoolers. It is most common in temperate climates and occurs usually in late winter or early spring. It is characterized by sore throat, fever, bright red tongue with strawberry appearance (strawberry tongue). The characteristic of rash is fine, red and rough-textured. It appears 12-48 hours after the fever. The rash begins to fade three to four days after onset and desquamation (peeling) begins. Peeling from the palms and around the fingers occurs about a week later. Peeling also occurs in axilla, groin, and tips of the fingers and toes. The rash is the most striking sign of scarlet fever. It usually begins looking like bad sunburn with tiny bumps, and it may itch. The rash usually appears first on the neck and face, often leaving a clear unaffected area around the mouth. It spreads to the chest and back, then to the rest of the body. When scarlet fever occurs because of a throat infection, the fever typically stops within 3 to 5 days, and the sore throat passes soon afterward. The scarlet fever rash usually fades on the sixth day after sore throat symptoms started, and begins to peel (as above).The infection itself is usually cured with a 10-day course of antibiotics, but it may take a few weeks for tonsils and swollen glands to return to normal. In rare cases, scarlet fever may develop from a streptococcal skin infection like impetigo. In these cases, the person may not get a sore throat. If not treated properly, you can have serious problems with the heart and kidneys. Scarlet fever can also be fatal if not treated. On April 19, 2011, at 10:25 pm, patient Clendon, an 11-year old male from Amparo, Caloocan City was referred to the National Childrens Hospital due to complaints of fever and rashes. He was admitted by Dr. Toma and with an admitting diagnosis of Atypical Kawasaki disease.

Page |2

OBJECTIVES OF THE STUDY

This study aims to identify and determine the general health problems and needs of the patient diagnosed to have chronic Osteomyelitis. This study also intends to help the patient promote health and medical understanding of such condition through the application of nursing skills.

Objectives to the patient: o To establish a trusting and therapeutic relationship with the patient. o To give patient a free expressions of feelings and needs. o To share knowledge and to increase the level of awareness about the patients condition. o To teach ways that promotes patients independence. o To provide holistic nursing care to patient. o To assist patient in his activities of daily living. o To promote self esteem of the patient.

Objectives to the student/researcher: o To establish rapport with the patient o To acquire knowledge and to expand understanding regarding the case of the patient. o To familiarize the researcher/student with tests done in diagnosing Scarlet Fever. o To implement and evaluate SMART nursing care plan appropriate to the patients case. o To identify factors that could worsen the condition. o To know the different surgical and medical management and nursing management as well. o To keep confidentiality of information to the patients case. o To work professionally and treat patient as a whole. o To identify verbal and non-verbal cues by the patient. o To apply and familiarize the concepts learned in Maternal and Child Nursing.

Page |3

o To give respect whatever decision made by the patient regarding the plan of care. o To work collaboratively with other members of the health care team. o To discover new ways to care for the patient.

II. PERSONAL DATA

PATIENTS PROFILE
Name: Age: Birth date: Address: Sex: Religion: Nationality: Admission Date: Admission Time: Admitting Physician: Admitting Diagnosis: Chief Complaint: Clendon Llurag Ramos 11 years old March 17, 2000 Block-10 Amparo Subdivision, Amparo, Caloocan City Male Roman Catholic Filipino April 19, 2011 10:25 PM Dr. Toma Atypical Kawasaki fever and rashes

Page |4

III. NURSING HISTORY OF PAST AND PRESENT ILLNESS

Past history: Patient Clendon was born in Agusan Del Sur on March 17, 2000; he is the 2nd among the 3 siblings of Mr. and Mrs. Ramos. The researcher/student conducted an interview with the patient about his medical history but the patient is not able to give information so, the mother was interviewed by the researcher/student. According to his mother, her son has not yet completed his immunization, which is the MMR vaccine, because he suffers fever frequently. Her child has no allergies to food (sea food) and drugs. His diet composed of fish, meat and some vegetables such as Malunggay and Saluyot. He drinks 500ml of water daily. As a school aged child, playing is part of his routine. He plays chips or pogs and game cards or teks, he play together with his sister or sometimes to his neighbor playmates and he does playing after the class in the afternoon. Sometimes he is being scolded by his mother because he use much time in playing. Aside from playing, he also watches TV all through out the day especially during weekends. He can also do house hold chores like cooking rice which he does in the morning especially when his parents are out for work, they left them food which was cooked at night. Aside from cooking, he also washes his clothes. He has history of falls and it happened sometime when his mother sent him to school in a bicycle, while on the road to Amparo Elementary School, her mother lose control of the bike and they fell on the ground, he got scratches and bruises while his mother suffered wounds. He suffered common illnesses such as cough, cold and fever and his mother was able to give OTC and herbal (such as oregano leaves) medications. There are times that he feels dizzy and he used to rest for awhile.

Page |5

Family health history Father side has a history of hypertension and kidney stones. The patients grandfather (father side) was diagnosed to have those conditions in 1994. Until now, his grandpa has hypertension but is taking maintenance medications while the kidney stone has gone. There are no other serious diseases such as asthma and diabetes mellitus as claimed by the father of the patient.

Present History: 7 days prior to admission his condition started when he had measles-like rashes in the abdomen and fever. His mother thought that he has measles. 5 days prior to admission he has still with fever, rashes starts to spread on the hands and feet and he complains of abdominal enlargement, chest tightness and complaints of swollen lymph nodes in the neck. Together with his mother, they went for check up at Tala Hospital in Caloocan. He was diagnosed to have atypical Kawasakis disease and was referred and admitted to the National Childrens Hospital on April 19, 2011. Because of desquamation in the palms and soles, Atypical Kawasaki was ruled out and the doctor came up with the diagnosis of Scarlet Fever. He underwent series of laboratory exams and was treated with drugs such as Paracetamol, Penicillin G sodium and Ranitidine, IV fluid of D5IMB and also went BT. 8 days after admission, the symptoms of scarlet starts to subside but the patient frequently experiences dizziness and he has antihypertensive drugs. When he feels dizzy, his BP rises and they administer antihypertensive to control his BP.

Page |6

IV. PEARSON ASSESSMENT COMPONENTS/AREAS

April 26, 2011 Patient C is 11 years old male, presently living at Block10 Amparo Subdivision, Caloocan City. He is silent person and he talks a little. He is the 2nd out of 3 siblings of Mr. and Mrs. Ramos. According to Erik Ericksons theory of Psychosocial Development, patient C is under industry versus inferiority stage. He is under industry because; he is able to do simple house works and knows what to do when his mother left them together with his sister specially when going to school.

April 27, 2011 Upon arrival to the ward, the patient is well groomed. Conscious and coherent He is in a good mood. Hes fully awake and conversant. He is tidy but weak looking. No feeling of boredom He is able give information. He talks when the student/researcher asks questions but with limited information.

P
psychosocial

Page |7

According to patient, he has tea-colored urine and voids He voided twice draining to tea colored output. at least 2 times daily. He doesnt experience nocturia. Still without pain on urination. This day, he passed a stool once With moist oral mucosa as examined by the researcher/student. Still with no nasal and eye discharges

E
elimination

This day he urinated twice. His urine is being measured. He does not experience nocturia. According to patient, he has no pain and difficulty in urinating.

According to patient he evacuates bowel at least once a He has not yet passed a stool. day. He has no complain of sweating though the room is hot.

According to patient, he sweats during his sleep at night and in the afternoon because the room is warm.

According to patient, no nasal and eye discharges are present.

The oral mucosa of the patient is not dry. This day, he passed a stool twice.

Page |8

Patient is sitting on bed with his mother beside him. According to him, he takes morning and afternoon naps when he is alone or has nothing to do.

The patient is able to do ADLs with assistance of his father. Patient is sitting on bed side He is playing cell phone games. He had a sound sleep last night and had sleep for 8 hours He woke up at 5:30 a.m. this morning.

A/R
activity/rest

He had a fair sleep last night. He slept 8 hours and woke up at 5:30 am this day. He has no other disturbances during his sleeps except when nurse take his vital signs at night.

He is aided by his mother in his activities of daily living. Patient is in his crib sitting. He has no allergy to sea foods and drugs.

He is aided by his father in his activities of daily living. He has no complaints of dizziness. He has no fever but skin is warm to touch

S
safety

With body temperature of 36.9 c, afebrile but skin is Still with skin peeling on the palms of his fingers and warm to touch. soles of his foot.

With desquamation or peeling of skin at abdomen, The lips are not dry and crackly. palms of both hands and soles of both feet. The environment is clean, fluorescent lights are on but ceiling fans are off.

With dry and crackly lips.

Page |9

The ward of the patient is clean, with fluorescent lights Still there is swelling on the previous IV site ( left arm) and ventilated with ceiling fans.

He felt dizzy and administered Enalapril 25 mg tab. Swelling is noted on the IV site (left arm)

O
oxygenation

BP is 130/90 mmHg RR is 22 cpm PR is72 bpm

RR is 23 cpm PR is 85 bpm No abnormality in pulse noted.

No rales, ronchi, and other adventitious breath sounds No DOB or SOB. noted. No adventitious sounds noted. No use of accessory muscles notified. Capillary refill time is 2 sec. No cyanosis in any part of the body With swelling on his right arm. With no IVF inserted.

No difficulty in breathing was observed. No use of accessory muscles notified. Capillary refill time is 2 secs. No cyanosis in the nail beds and lips was observed.

P a g e | 10

He has a good appetite. He drinks 500mL of water daily He eats every meal and takes meryenda between meals which composed of bread or biscuits and water.

He has good appetite. He ate his breakfast composing of sandwich and hot chocolate. He has not yet had his meryenda.

N
nutrition

He prefer eating fish and meat and sometimes with little The patient has no IVF vegetables.

He has an IVF of D5IMB liter regulated to 15 gtts. /min. at 450 cc level.

P a g e | 11

V. DIAGNOSTIC PROCEDURES A. IDEAL Complete Blood Count (CBC) Purpose: Provide information concerning the six components which are RBC count, hemoglobin (HGB), hematocrit (HCT), RBC indices: mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC), RBC distribution width; WBC; and differential WBC count. This is done to diagnose anemias such as macrocytic (aplastic, hemolytic and pernicious) and microcytic (Iron Deficiency) bleeding disorders and blood cell changes. Nursing responsibilities: 1. Check the doctors order. 2. Explain that the purpose for the laboratory tests is to identify the cause for the hematologic disorder. 3. Give a detailed explanation concerning the test procedures and the need for the clients compliance. 4. Inform the client of any food, fluid or drug restrictions. 5. Monitor the clients vital signs before, during and after the laboratory test procedures. 6. Listen to the clients expressed anxiety or fear concerning the tests and potential clinical problems. 7. Check laboratory results and report abnormal test reports. 8. Be supportive of the client and family members during test and treatment of disorders. Antistreptolysin O (ASO) Titer Purpose: To identify clients who are susceptible to specific autoimmune disorders (e.g., collagen disease).

P a g e | 12

To aid in determining the effect of beta-hemolytic streptococcus in secreting the enzyme streptolysin O.

Nursing responsibilities: 1. Check the doctors order. 2. Explain the procedure to the patient. 3. Note that antibiotic therapy decreases the antibody response. 4. Instruct the client and family that when the client has a sore throat he or she should have a throat culture taken to check for beta-hemolytic streptococcus. Erythrocyte Sedimentation Rate (ESR) Purpose: To compare with other laboratory values for diagnosing inflammatory conditions.

Nursing responsibilities: 1. Check the doctors order. 2. Explain the procedure to the patient. 3. Hold medications that can cause false-positive results for 24 hours before the test, with the health care providers permission. C - reactive protein (CRP) Purpose: To associate an increased CRP titer with an acute inflammatory process. To detect the risk of coronary heart disease. To compare test results with other laboratory tests. Nursing responsibilities:

1. Check the doctors order. 2. Explain the procedure to the patient. 3. Restrict food and fluids, except water, for 8-12 hours before the test. 4. Avoid heat, CRP is thermo labile.

P a g e | 13

Culture and Sensitivity (Throat Swab): Purpose: To isolate microorganism in the body tissue or body fluid.

Nursing responsibilities: 1. Check the doctors order. 2. Explain the procedure to the patient and significant others. 3. Wash hands before and after collection of the specimen. 4. Use sterile cotton swab. Swab the inflamed areas of the throat. 5. Place the applicator in a culture medium. Observe proper aseptic technique. 6. Immediately send the throat culture to the laboratory. 7. Obtain culture before antibiotic therapy. 8. Refer results to the physician.

B. ACTUAL NAME CBC (complete blood count) April 23,2011 RESULTS Hemoglobin 86 g/L Hematocrit .26 NORMAL VALUES NURSING IMPLICATION Low. It may suggest anemia and kidney disease. Low. Indicates recent bleeding or vitamin and mineral deficiency Normal

M: 140-180 g/L

M: 0.40-0.54

WBC 8.8 x 10 g/L WBC Differential: Lymphocyte 0.30 Neutrophils 0.66 Eosinophils 0.04 PLT count 455 x 10/L

5-10 x 10 g/L

0.20-0.45

Normal

0.40-.0.75 0.01-0.04 150-450

Normal Normal Increased may indicate malignancy, myeloproliferative disease

P a g e | 14

Nursing Responsibilities: The CBC does not require fasting or any special preparation but the procedure should be explained to the patient and patients watcher as well as the purpose.

AFTER CARE Discomfort or bruising may occur at the puncture site. Applying pressure to the puncture site until the bleeding stops. Warm packs relieve discomfort. If patient fell dizzy or faint after blood has been drawn, allow him/her to take a rest. Refer the result to the physician.

NAME

RESULTS

NORMAL

NURSING IMPLICATION Normal

URINALYSIS MACROSCOPIC: Color: reddish April 20, 2011 yellow

Varying degree of yellow

Transparency: hazy Reaction: acidic Specific gravity: 1.010 CHEMICAL Protein: +3

Clear Usually acidic 1.000-1.038

It may show presence of pus, blood cells or bacteria Normal Normal

(-)

Glucose/Sugar: (-) MICROSCOPIC: Cast Hyaline Others: coarse granular Bacteria Cells RBC Pus Cells Epithelial Cells Amorphous urates Others

(-)

Proteinuria, sensitive indicator of kidney dysfunction. Normal

Result 0-2/LPF 0-1/LPF Few Result Over 100/HPF 30-35/HPF Occasional Few Renal tubular epithelial=0-3/HPF

Indicate presence of infection It suggests presence of disease condition Indicates infection

P a g e | 15

Nursing Responsibilities: Check the doctors order. Explain the purpose of the procedure to client and significant others. Provide a sterile container for urine to the patient. Assist the patient in collecting urine or ask watcher to assist the patient if he cant do on his own. Teach the patients watcher to clean the head of the penis and the urethral meatus. Tell the patient or the one assisting him to collect the mid-stream urine. Label and transport the specimen immediately to the laboratory for examination. Refer the results to the physician.

NAME ASO TITER (antistreptolysin O titer) April 20, 2011

RESULTS 400IU/ML

NORMAL <200IU/ML

NURSING IMPLICATION Increase level suggests diseases such as AGN, collagen disease or Streptococcal upper respiratory tract infections.

Nursing Responsibilities: Check the doctors order. Explain the purpose of the procedure to client and significant others. Instruct the client and family that when the client has a sore throat he or she should have a throat culture taken to check for beta-hemolytic streptococcus. Check the urine output when serum ASO is elevated. Refer the results to the physician.

P a g e | 16

VI. ANATOMY AND PHYSIOLOGY The cardiovascular system includes the heart and the blood vessels. The heart pumps blood and the blood vessels channel and deliver it throughout the body. Arteries carry blood filled with nutrients away from the heart to all parts of the body. The blood is sometimes compared to a river, but the arteries are more like a river in reverse. Arteries are thick-walled tubes with a circular covering of yellow, elastic fibers, which contain a filling of muscle that absorbs the tremendous pressure wave of a heartbeat and slows the blood down. This pressure can be felt in the arm and wrist - it is the pulse. Eventually arteries divide into smaller arterioles and then into even smaller capillaries, the smallest of all blood vessels. One arteriole can serve a hundred capillaries. Here, in every tissue of every organ, blood's work is done when it gives up what the cells need and takes away the waste products that they don't need. Now the river comparison really does apply. Capillaries join together to form small veins, which flow into larger main veins, and these deliver deoxygenated blood back to the heart. Veins, unlike arteries, have thin, slack walls, because the blood has lost the pressure which forced it out of the heart, so the dark, reddish-blue blood which flows through the veins on its way to the lungs oozes along very slowly on its way to be reoxygenated. Back at the heart, the veins enter a special vessel, called the pulmonary arteries, into the wall at right side of the heart. It flows along the pulmonary arteries to the lungs to collect oxygen, and then back to the heart's left side to begin its journey around the body again.

P a g e | 17

THE INTEGUMENTS (SKIN) The integumentary system (From Latin integumentum, from integere 'to cover'; from in+ tegere 'to cover') is the organ system that protects the body from damage, comprising the skin and its appendages (including hair, scales, feathers, and nails). The integumentary system has a variety of functions; it may serve to waterproof, cushion, and protect the deeper tissues, excrete wastes, and regulate temperature, and is the attachment site for sensory receptors to detect pain, sensation, pressure, and temperature. In humans the integumentary system also provides vitamin D synthesis. The integumentary system is the largest organ system. In humans, this system accounts for about 16 percent of total body weight and covers 1.5-2m2 of surface area. It distinguishes, separates, protects and informs the animal with regard to its surroundings. Small-bodied invertebrates of aquatic or continually moist habitats respire using the outer layer (integument). This gas exchange system, where gases simply diffuse into and out of the interstitial fluid, is called integumentary exchange. Layers of the skin: EPIDERMIS This is the top layer of skin made up of epithelial cells. It does not contain blood vessels. Its main function is protection, absorption of nutrients, and homeostasis. In structure, it consists of a keratinized stratified squamous epithelium comprising four types of

P a g e | 18

cells: keratinocytes, melanocytes, Merkel cells, and Langerhans' cells. The major cell of the epidermis is the keratinocyte, which produces keratin. Keratin is a fibrous protein that aids in protection. Millions of dead keratinocytes rub off daily. The majority of the skin on the body is keratinized, meaning waterproofed. The only skin on the body that is non-keratinized is the lining of skin on the inside of the mouth. Non-keratinized cells allow water to "stay" atop the structure. The epidermis contains different types of cells: The most common are squamous cells, which are flat, scaly cells on the surface of the skin; basal cells, which are round cells; and
melanocytes, which give the skin its color. The epidermis also contains Langerhan's cells, which

are formed in the bone marrow and then migrate to the epidermis. They work in conjunction with other cells to fight foreign bodies as part of the body's immune defense system. Granstein cells play a similar role. Melanocytes create melanin, the substance that gives skin its color. These cells are found deep in the epidermis layer. Accumulations of melanin are packaged in melanosomes (membrane-bound granules). These granules form a pigment shield against UV radiation for the keratinocyte nuclei. The epidermis itself is made up of four to five layers. From the lower to upper epidermis, the layers are named: stratum basale, stratum spinosum, stratum granulosum, stratum lucidum(the extra layer that occurs in places such as palms and soles of the feet), and the stratum corneum. The stratum basale is the only layer capable of cell division, pushing up cells to replenish the outer layer in a process called terminal differentiation. The stratum corneum is the most superficial layer and is made up of dead cells, proteins, and glycolipids. The protein keratin stiffens epidermal tissue to form fingernails. Nails grow from thin area called the nail matrix; growth of nails is 1 mm per week on average. The lunula is the crescent-shape area at the base of the nail; this is a lighter colour as it mixes with the matrix cells. DERMIS The dermis is the middle layer of skin, composed of dense irregular connective tissues such as collagen with elastin arranged in a diffusely bundled and woven pattern. These layers serve to

P a g e | 19

give elasticity to the integument, allowing stretching and conferring flexibility, while also resisting distortions, wrinkling, and sagging. The dermal layer provides a site for the endings of blood vessels and nerves. Many chromatophores are also stored in this layer, as are the bases of integumental structures such as hair, feathers, and glands. SUBCUTANEOUS LAYER Although technically not part of the integumentary system, the subdermis is the layer of tissue directly underneath the dermis. It is composed mainly of connective and adipose tissue or fatty tissue. Its physiological functions include insulation, the storage of energy, and aiding in the anchoring of the skin.

FUNCTIONS OF THE SKIN: The integumentary system has multiple roles in homeostasis. All body systems work in an interconnected manner to maintain the internal conditions essential to the function of the body. The skin has an important job of protecting the body and acts as the bodys first line of defense against infection, temperature change, and other challenges to homeostasis. Functions include:

Protect the bodys internal living tissues and organs Protect against invasion by infectious organisms Protect the body from dehydration Protect the body against abrupt changes in temperature, maintain homeostasis Help excrete waste materials through perspiration Act as a receptor for touch, pressure, pain, heat, and cold (see Somatosensory system) Protect the body against sunburns Generate vitamin D through exposure to ultraviolet light Store water, fat, glucose, and vitamin D

P a g e | 20

VII. PATHOPHYSIOLOGY A. ALGORITHM

If left untreated, the disease may affect the kidneys which will cause complication such AGN. Other than kidney, it may also affect the heart which causes rheumatic fever

Risk Factors:
Age: 6-12 years old Previous streptococcal upper respiratory tract infection Lowered immune system Expose to GABHS(group A beta hemolytic streptococcus)

Antigen-antibody reaction in the glomeruli Deposition of antigenantibody complex in the glomerulus Increased production of epithelial cells lining the glomerulus

Invasion of pathogen through droplet and airborne transmission Hematogenous spread (Blood) Appearance of scarlet rashes which starts from abdomen and spread all through out the body

Release of bacterial exotoxin( erythrogenic toxin)

Leukocytes infiltrate the glomerulus Thickening of the glomerular filtration membrane Scarring and loss of glomerular filtration membrane Decreased glomerular filtration rate *AGN was elaborated in the pathophysiology because the patient was also thought to have such disease due to the results of laboratory exam such as CBC and U/A but it was ruled out.

Hemolytic reaction or destruction of RBC

Inflammatory response in the body

Epidermal Inflammation

Hyperkeratosis Signs and symptoms (manifested by the patient) include: Fever Swollen cervical lymph node Abdominal pain and enlargement Rashes Desquamation or peeling of the skin Laboratory result: Positive ASO titer of 400IU/ML (normal: <200IU/ML) Other symptoms include: Straw berry tongue Sore throat

Desquamation or peeling of skin which follows after rash fades

P a g e | 21

B. EXPLANATION How it happens: Normally, Group a beta-hemolytic streptococci are part of the normal flora in the URT. Group A streptococci can cause pharyngitis, skin infections (including erysipelas pyoderma and cellulitis), pneumonia, bacteremia, and lymphadenitis. Scarlet fever is usually associated with pharyngitis; however, in rare cases, it follows streptococcal infections at other sites. Scarlet fever happens when a GABHS travels in the blood. It produces exotoxin (erythrogenic Toxin) which capable of destroying the RBCs (hemolysis). These hemolytic reactions in the circulation causes red rash seen on skin. The rash is the most striking sign of scarlet fever, it is rough (sand paperlike) and usually appears first on the neck and face, often leaving a clear unaffected area around the mouth. In the patients case, it started in the abdomen and spread eventually to the armpit, neck, hands, groin, feet and other parts of the body. Areas with rashes turn white and usually begin to fade followed by desquamation or peeling. Epidermal inflammation causes hyperkeratosis which causes the white appearance of rashes and desquamation. Other signs and symptoms include fever, swollen lymph nodes in the neck, sore throat and strawberry tongue. If scarlet fever is left untreated, it might be fatal. It may also cause problems in the heart and kidney. AGN is one of the complications associated with scarlet fever. It affects the kidney especially in the glomerular system where antigen-antibody reaction happens. Clumping and inflammatory process occurs as leukocyte infiltrates the area. It causes thickening and scarring of the glomerular membrane which leads to destruction and decrease glomerular filtration.

P a g e | 22

VIII. MANAGEMENT

A. Medical and Surgical Management

Surgery is not indicated to patients with scarlet fever. Management is therapeutic and the goal is to control and treat the infection process. For Scarlet fever Non-pharmacologic management: TSB for management of fever. Provide adequate ventilation. Follow droplet precaution prior to hospitalization. Comfort measures such as applying calamine lotion to the skin. Rashes of scarlet fever tend to be pruritic. Soft or liquid diet for few days until throat soreness has diminished.

Pharmacologic: Antipyretic such as paracetamol for management of fever. Antibiotic such as penicillin as full course treatment for 10 days to control the infection.

For Increase in blood pressure: Non pharmacologic: Provide enough rest and sleep. Rise slowly when getting up in bed. Assist patient in ADLs. Deep breathing exercises. Monitor V/S specially BP.

Pharmacologic: Antihypertensive drugs such Enalapril and nifedipine to control blood pressure.

B. NCP with Evaluation

P a g e | 23

Nursing Care Plan

CUES/DATA Subjective: ang init tsaka nahihilo ako As verbalized by pt. Clendon Objective: Skin is warm to touch but affebrile. Vital Signs: BP130/90mmHg PR-72bpm RR-22cpm TEMP-36.9 C NURSING DIAGNOSIS P: ineffective tissue perfusion E: related to Increased blood pressure S: as evidence by : blood pressure of 130/90mmHg verbalization of warm feeling and dizziness experienced by the patient ANALYSIS warm/hot environment vasodilation/increase diameter of the lumen of the arteries of the arteries increase vascular resistance increase pumping ability of the heart increase in blood pressure increase pressure in the brain ineffective tissue perfusion OBJECTIVES April 26, 2011 7:00 a.m. After 1 hour of nursing care and management, the patients blood pressure will decrease from 130/90-110/80 mmHg and will not have complaints of dizziness. NURSING INTERVENTION INDEPENDENT: Establish rapport with the patient Monitor patients vital sign specially BP. RATIONALE EVALUATION April 26, 2011 8:00 a.m. LEVEL OF ATTAINMENT: GOAL MET After 1 hour of nursing care and management, the patients blood pressure decreased from 130/90110/80mmHg To gain trust and cooperation of the patient. To provide baseline data and to assess effectiveness of intervention. To promote circulation and to alleviate dizziness. Deep breathing promotes oxygenation and lung expansion. Patient has no more To provide complaints of oxygenation to the dizziness. body. Resting replenishes loss energy and decreases demands for oxygen. An antihypertensive drug that inhibits the action of angiotensin activity and decrease aldosterone secretion.

Place patient in a comfortable position; may assume sitting or lying position. Instruct patient to take a deep breath. Provide adequate ventilation Promote rest and nonstimulating environment

DEPENDENT/COLLABORATIVE Administer Enalapril 2.5 mg tab

P a g e | 24

CUES/DATA Subjective: ang init tsaka nahihilo ako As verbalized by pt. Clendon Objective: Skin is warm to touch but affebrile. Vital Signs: BP130/90mmHg PR-72bpm RR-22cpm TEMP-36.9 C

NURSING DIAGNOSIS P: risk for injury E: related to Increased blood pressure S: as evidence by : blood pressure of 130/90mmHg verbalization of warm feeling and dizziness experienced by the patient

ANALYSIS Increase in blood pressure Increase blood flow in the brain Increase pressure brain Decrease Oxygen supply in the brain Dizziness Risk for injury

OBJECTIVES April 26, 2011 8:00 a.m. After 1hour of nursing care and management, the patient and watcher will understand recognize need for assistance to prevent accidents/injuries

NURSING INTERVENTION INDEPENDENT: Establish rapport with the patient Include the primary care giver in the care of the patient

RATIONALE

EVALUATION April 26, 2011 9:00 a.m. LEVEL OF ATTAINMENT: GOAL MET After 1 hour of nursing care and management, the patient and watcher was able to understand and recognize need for assistance to prevent accidents/injuries.

Assist the patient when doing ADLs.

Provide enough rest and sleep.

Institute safety measures: o Raise side rails. o Keep bed in low position. Teach the patient alternative ways to do ADLs.

To gain trust and cooperation of the patient. To help assist the nurse and the patient in the promotion of care. To monitor patient activity and to prevent potential accident or injury that may happen. Resting replenishes loss energy and decreases demands for oxygen. To prevent patient from injury/accidents such as falls. To promote patients independence.

P a g e | 25

CUES/DATA Subjective: nung una akala ko tigdas lang kasi nagkatigdas silang tatlo eh sya lang ang hindi pa gumaling As verbalized by the patients mother. Objective: Skin is warm to touch but affebrile. Peeling of skin noted at palms and soles. Dry and crackly lips. Vital signs: TEMP-36.9 C

NURSING DIAGNOSIS P: impaired skin integrity E: related to disease condition( scarlet fever) S: as evidence by : Peeling of skin noted at palms and soles.

ANALYSIS Scarlet fever scarlet rashes epidermal inflammation hyperkeratosis peeling/desquamation of the skin Impaired skin integrity

OBJECTIVES April 27, 2011 9:00 a.m. After 30 min. of nursing care and management, the patient and SO will understand demonstrate proper skin care.

NURSING INTERVENTION INDEPENDENT: Establish rapport with the patient Include the primary care giver in the care of the patient Assess patients and SOs level of knowledge.

RATIONALE

EVALUATION April 27, 2011 9:30 a.m. LEVEL OF ATTAINMENT: GOAL MET After 30 min. of nursing care and management, the patient and SO was able understand and demonstrate proper skin care. The patient and SO was able to enumerate proper skin care.

Proper hygiene

Use non irritating soap in bathing or hand washing. Increase fluid intake

To gain trust and cooperation of the patient. To help assist the nurse and the patient in the promotion of care. To provide information appropriate to the level of understanding of the patient and watcher. Proper hygiene protects the body from infection and prevents infection. To prevent skin dryness. Rehydrates the body as well as the skin. To keep the skin moisturized and to prevent dryness and itching.

DEPENDENT/COLLABORATIVE Administer Calamine lotion

P a g e | 26

C. Promotive and Preventive Management PROMOTIVE MANAGEMENT The following are management indicated/applicable to the patient who suffered from scarlet fever and frequently feels dizziness. Nutritional Management: Increase the amount of carbohydrates such as bread, rice and pastries and protein such as fish, meat and beans in the diet to aid in the caloric demand and healing. Increase amounts of Vitamin C in the diet to help boost the immune system. Add extra servings of fruits and vegetables rich in Vitamin C such as oranges and mangoes. Assess patients tolerance of food. Maintain fluid balance.

Safety: Raise side rails. Keep bed at lowest position. Tell the SO/watcher to assist the patient with ADLs Instruct patient to take a rest when he feels dizzy. Administer medications such as Enalapril 25 mg to relieve dizziness if the cause of dizziness is increased blood pressure. Check vitals signs of the patient. Specially the blood pressure.

PREVENTIVE MANAGEMENT Management is directed toward prevention of possible reoccurrence and development of new infection and prevention of complications. Infection prevention: Maintain the integrity of the skin. Proper skin care. Proper hygiene daily. Eat food rich in Vitamin C to improve immune systems function against foreign bodies

P a g e | 27

Instruct patient to report signs of infection such as febrile episodes, sore throat, swollen lymph nodes.

Monitor temperature to check for febrile episodes. Antibiotics such as Penicillin Na as a course of therapy to prevent development of bacterial resistance.

Avoid contact with people who have untreated strep infections. Do not share cups, utensils, towels, bed linen, or personal items with infected people. Wash your hands often, especially after touching someone who may have an infection.

Complication Prevention: Adherence to treatment regimen. Provide client and family education with respect to prophylactic antibiotic therapy to reduce the risk of developing complications such as AGN and rheumatic fever.

IX. DRUG STUDY

P a g e | 28

DRUG STUDY
NAME AND DOSAGE Nifedipine 5 mg PRN for BP> 130/100 S.L INDICATION Hypertension MECHANISM OF ACTION Inhibits the influx of calcium ions into cardiac and smoothmuscle cells; reduces strength of heartmuscle contraction, reduces conduction of impulses in the heart and causes vasodilation. Reduces blood pressure and prevents angina. CONTRAINDICATION Contraindicated in patients hypersensitive to drug or any of its components. Use cautiously in patients in those with heart failure or hypotension. Use extended-release tablets cautiously in patients with severe GI narrowing because obstructive symptoms may occur. ADVERSE EFFECTS CNS: headache, dizziness CV: flushing, heart failure, hypotension GI: abdominal discomfort, diarrhea, nausea NURSING RESPONSIBILITIES Observe the 10 rights in administering the drug. Right drug Right dose Right patient Right manner and route Right time and frequency Right documentation Right assessment Right education Right evaluation Right to refuse medication Assess patients condition before during and after therapy Monitor blood pressure regularly thereafter Monitor patients potassium level. Avoid taking drug with grape juice. Do not crush or chew extended release tablet. Do not give the drug if the blood pressure is below 100 or 60

Penicillin Sodium 940,000 units IV

Bacteria(Strep tococcal) infection such

Inhibits cell wall synthesis during microorganism

Contraindicated in patients hypersensitive to the drug or other

CV: thrombophlebitis, Hematologic: hemolytic anemia,

Observe the 10 rights in administering the drug. Assess patients condition before during and after therapy.

P a g e | 29

Q6

as scarlet fever

multiplication.
Kills susceptible

penicillins. Use cautiously in patients with other drug allergies, especially to cephalosporins and cephamycins.

bacteria.

leucopenia,thrombocytopenia Other: hypersensitivity reactions.

Enalapril 2.5 mg tab BID P.O

Hypertension

Inhibits the action of angiotensin, which results in decreased vasopressor activity and decreased aldosterone secretion. Lowers blood pressure.

Contraindicated in patients hypersensitive to drug or any of its components. In patients with history of angioedema from ACE inhibitor. In patients with renal impairment, especially those with bilateral renal artery stenosis in a single or unilateral renal artery stenosis in a single functioning kidney.

CNS: dizziness, headache, fatigue CV: hypotension GI: abdominal pain, diarrhea

Obtain history of allergy to penicillin and cephalosporin before giving first dose. Obtain culture and sensitivity before giving the first dose. When given intravenously, inject slowly. Monitor renal and hematopoietic function. Increase fluid intake. Continue the medication even after the disease is gone for 1 week. Observe the 10 rights in administering the drug. Obtain patients blood pressure before giving first dose. If angioedema occur, notify the physician and stop the drug immediately. Monitor patients vital signs specially BP. Instruct patient to avoid sodium substitutes. Monitor potassium level. Monitor CBC before, during and after therapy. Rise slowly to avoid orthostatic hypotension. Report signs of angioedema such as difficulty of breathing and swelling of face, eyes, lips or tongue.

P a g e | 30

For mild pain or fever

Paracetamol 250 mg tab Q4 PRN

Relieves pain and reduces fever

Hypersensitivity to drug. In patients with history of liver diseases and chronic alcoholism.

Hematologic: hemolytic anemia, leukopenia, neutropenia, pancytopenia, thrombocytopenia Hepatic: liver damage, jaundice Metabolic: hypoglycaemia

Light-headedness can occur especially during first few days of therapy. Observe the 10 rights in administering the drug Assess pts pain or temp. before and during therapy Be alert for adverse reactions and drug interactions. Monitor liver function. Do not take with alcohol. Maybe taken without food. Observe the 10 rights in administering the drug. Assess GI condition before starting the therapy. Take drug with or without food. Take drug once daily at bed time. Should not be taken with antacid, it may interfere the absorption.

Ranitidine 25 mg IV Q8

Self medication for occasional heartburn, acid indigestion and sour stomach

Inhibits the action of H2-receptor sites of parietal cells, decreasing gastric acid secretion. Relieves GI discomforts.

Hypersensitivity to drug or any of its components. Use cautiously in patients with hepatic dysfunction.

CNS: vertigo. GI: abdominal discomfort, constipation,diarrhea, nausea and vomiting Hematologic: reversible leukopenia, pancytopenia, thrombocytopenia Skin: rash Other: anaphylaxis, angioedema, burning sensation at injection site.

P a g e | 31

X. DISCHARGE PLANNING

MEDICATIONS
Penicillin G sodium Drug of choice in treating scarlet fever. Inhibits cell wall synthesis during microorganism multiplication. Contraindicated in patients hypersensitive to this drug. Use cautiously in patients with history of allergy to cephalosporin. Adverse effects include thrombophlebitis, hemolytic anemia, leucopenia, thrombocytopenia and hypersensitivity reactions. Monitor V/S, hematopoietic and renal function studies. Infuse IV drug continuously or intermittently over 30 min. to prevent thrombophlebitis. Enalapril 2.5 mg Tab For increased blood pressure accompanied by dizziness. Inhibits the action of angiotensin, which results in decreased vasopressor activity and decreased aldosterone secretion. Lowers blood pressure. Contraindicated in patients hypersensitive to drug t and patients with history of angioedema. Monitor V/S. Rise slowly to prevent orthostatic hypotension. Nifedipine 5 mg PRN for BP> 130/100 mmHg For increased blood pressure greater than 130/100mmHg. Reduces blood pressure and prevents angina. Contraindicated in patients hypersensitive to drug or any of its components. Use cautiously in patients in those with heart failure or hypotension. Adverse effect includes headache, dizziness, flushing, heart failure, hypotension, abdominal discomfort, diarrhea, nausea. Check first BP before giving. Avoid taking with grape juice.

EXERCISE
Avoid doing strenuous activities. Active range of motion exercises. Primary Care giver should assist patient with ADL
Provide time to play and with moderation. Deep breathing exercise to promote lung expansion and provide oxygenation.

TREATMENT MODALITIES
TSB for fever management. Calamine lotion for itching and dryness of the skin. Enalapril 2.5 mg for increased blood pressure.

HEALTH TEACHINGS
PROMOTE PROPER HYGIENE/PREVENTION OF INFECTION Since the immune system is compromised, every effort should be maintained to prevent infection. Frequent hand washing is the best way to control infection. Wash hands thoroughly with hot, soapy water, especially before eating or preparing food and after using the toilet. Carry an alcohol-based hand sanitizer during times when water is not available.

P a g e | 32

ADHERE TO TREATMENT REGIMEN Adherence to the treatment regimen is essential in order to prevent reoccurrence of the disease and to prevent complications. Most common cause of relapse is loss to compliance. Medications should be administered at proper time and proper dosage. PROMOTE SAFETY Institute safety measures since the patient suffers dizziness and prone to fall and accident. Therefore, patients should not be left alone. Instead they should be with companions all the time. PROPER SKIN CARE Because of impaired skin integrity due to desquamation, care should be observed not to cause any form of injury to the skin. Any injury will be a good source of infection. Practice proper skin care such as the use of moisturizing soap when bathing or moisturizing lotion to prevent dryness of the skin and avoid too much exposure to sunlight. MEETING NUTRITIONAL AND FLUID NEEDS Bear in mind the food preferences of the child when planning for menus. Presenting the food in an attractive manner increases the interest of the child. Socialization during meals may also the childs appetite.

OUT PATIENT BASIS TREATMENTS

The patient can have a check-up when signs and symptoms of the disease manifest again. Among the signs and symptoms: Sore throat, fever, swelling of lymph nodes in the nape and rashes.

DIET
HIGH PROTEIN and CARBOHYDRATE Since there is marked hypoproteinemia brought about by protein excretion in the urine, diet rich in proteins is highly encouraged. These foods include: egg whites, meat, beans and legumes, etc. School age children are active; their diet must be composing of high carbohydrates to increase their bodies caloric demand. Among the source of carbohydrates is bread, rice, pastries. LOW SALT AND LOW FAT The patient suffers from high blood pressure so care must be considered especially in his diet and safety. Salt must be regulated in the diet because it increases blood volume by attracting more water in the blood circulation and it may cause edema. Low fat in the diet to prevent build up or increase level of triglyceride in the body which is responsible in the formation of atherosclerotic plague in the arteries. HIGH FLUID Fluid intake must be increased to keep the body hydrated and provide skin moisture and prevents it from drying. It helps the kidney from flushing toxins and existing remnants of previous infection.

P a g e | 33

XI. UPDATES

Health Tip: Treating Strep Throat

Suggestions to help you feel better By Diana Kohnle Wednesday, February 2, 2011Related age Streptococcal Infections (HealthDay News) -- Strep throat can cause a nasty sore throat while you're getting over the associated bacterial infection. The American Academy of Family Physicians says antibiotics are prescribed to treat the infection and help prevent serious complications. The group offers these suggestions, meanwhile, to tame the burn in your throat: Take an over-the-counter pain reliever, such as acetaminophen or ibuprofen (never aspirin for children). Gargle with a solution of 1/4 teaspoon of salt mixed in 1 cup of warm water. Suck on a ice pop, throat lozenge, or hard candy (but note that these remedies pose a choking hazard to very young children). Stick to foods that are soft and easy on the throat (applesauce and yogurt are good choices) or warm and soothing (such as broth or tea). Stay away from anything spicy or acidic. Get lots of sleep and drink a lot of water.

Strep Infection Experts Warned Of Deadly Streptococcal Infection

Tuesday, April 12th, 2011 | Posted by Matthew Bennett

Strep infections can turn deadly when the immune system mistakes a structure formed by a bacterial protein for a blood clot and overreacts Infection with some strains of strep turn deadly when a protein found on their surface triggers a widespread inflammatory reaction. In a report published April 7 in the journal Nature, researchers describe the precise architecture of a superstructure formed when the bacterial protein called M1 links with a host protein, fibrinogen, that is normally involved in clotting blood. The proteins form scaffolds with M1 joints and fibrinogen struts that assemble into dense superstructures. Frontline immune cells called neutrophils mistake these thick networks for blood clots and overreact, releasing a chemical signal that can dilate vessels to the point where they leak, the team reports. We knew that M1 plus fibrinogen was inflammatory, but how was unknown. By determining the structure of this complex, we were able to identify the characteristics that lead to a sepsis response, said Partho Ghosh, Ph.D., professor of chemistry and biochemistry at the University of California, San Diego who studies the structure of virulence factors and led this project. Ghosh and colleagues found that the density of the M1-fibrinogen structure was a critical characteristic. Looser structures or separate fibers formed by altered versions of M1 failed to trigger a pathological response. This research provides the first snapshot of the interaction between this key bacterial virulence factor and its human target at the atomic level, said Victor Nizet, M.D., professor of pediatrics and pharmacy and a co-author of the report. Difficult to treat once they set in, the leaking blood vessels and organ failure of strep-induced toxic shock prove fatal for 30 percent of patients. Ghosh and Nizet have a long-standing collaboration aimed at designing treatments to counteract the toxic effects of strep protein. Contact: Partho Ghosh pghosh@ucsd.edu University of California San Diego

P a g e | 34

XII. BIBLIOGRAPHY Smeltzer, S. C.; Bare, B.; Wilkinson, J. M. Brunner and Suddarths textbook of medical surgical nursing, 10th Edition, Prentice Hall: Nursing Diagnosis Handbook, 8th Ed. Doenges, M. E.; Moorehouse, M. F.; Murr, A. C. (2006) Nursing care plans: Guidelines for individualizing client care across the lifespan. Pennsylvania, F. A. Davis Co. Kee, Joyce Lefever; A Look at Laboratory and Diagnostic Tests with Nursing Implications 17th Edition

Internet sources:
http://nursingcareplanforpinoy.blogspot.com/2010/11/pathophysiology-signs-and-symptoms_13.html http://www.lifescript.com/Health/A-Z/Conditions_AZ/Conditions/S/Scarlet_fever.aspx?utm_source=kosmix&utm_medium=cpc&utm_campaign=Health http://emedicine.medscape.com/article/803974-overview#showall http://en.wikipedia.org http://www.nlm.nih.gov/medlineplus/streptococcalinfections.html http://starglobaltribune.com/2011/strep-infection-experts-warned-of-deadly-streptococcal-infection-7705