CASE STUDY OUTLINE

Title Page
Approval Sheet (grand case)

I. INTRODUCTION

INTRODUCTION
Our human body is a very complex system. One functions for the benefit and or
expense of another. Our subsystem is a vital as the other thus they are
interrelated. Considering this fact we have looked into the reality that in this
diverse physiological wonder lies the infinite possibility of
not only optimum functioning hut of disparities and deviations as well.
In life, one continues to exist in oblivion. There are always uncertainties in every
events and occurrences whirl through our lives. We do not know when is the
exact point in time where our bodily homeosis will be disturbed and when
change will cease to happen. Some of the surprising changes can he considered
blessings het most the time they are we fervently one would
not occur especially those that concern our health . Kawasaki disease
(Mucoculaneous lymph node syndrome) is a form of vasculitis identified by an
acute febrile illness with multiple systems affected. The cause is unknown, but
autoimmunity, infection, and genetic predisposition are believed to be involved.
It affects
children between ages 3 months and 8 years: 80% are younger than age 5. It
occurs more commonly in Japanese children or those of Japanese decent . It has
seasonal epidemics, usually in late winter and curly spring. It was first described
in 1967 by Dr. Tomisuku Kawasaki in Japan.Although Kawasaki disease is a
multisystem disease, the cardiovascular system appears to
be the primary site with coronary artery Vasculitisis, aneurysm development
thrombosis, and Myocardial thrombosis progressing over days to weeks.
Approximately 1596 10 25% of patients develop cardiac complication (coronary
thrombosis or rapture, myocardial infraction,heart failure, vasculitis of tha aorta
or peripheral arteries)
II. OBJECTIVE
a. General
Able to choose a case study that will contribute and expand our knowledge and
improve our skills on Specific procedure.

b. Specific
-Select a relevant subject for case study:
-Establish good interpersonal and professional relationship with the patient and
his
Accompanying family member
-Formulate an introduction that can present a concise overview of the case
study.
-Identity its contribution in the fields of nursing education, practices , and
research
 -Formulate specific, measurable, attainable , realistic and time bounded
objectives
that will serve as a guide for the accomplistament of this study
-Collect data regarding the past and present health history of the patient.
-Determine and discuss the anatomy and physiology of the body systems
involved,
-identify the predisposing and precipitating factors that contribute to the onset
of the disease:
-Trace the pathophysiology of the disease process
-List the actual and possible symptoms that our patient my manifest.
-Share our knowledge and skills to our chosen patient
-Provide significant health teachings that would promote our patient's health and
wellness.

III. NURSING HEALTH HISTORY

a. Biologic Data

Name: A.K.A Baby P.R.A

Birth date: July 23, 2016
Age: 3 years old
Sex: Male
Birthplace:
Address:
Civil Status: Single
Religion: Roman Catholic
Nationality: Filipino
Educational Attainment: N/A
Room Number: Room 422 bed 2
Diagnosis: Kawasaki Disease
Attending Physician: Dr. David, reigner paul
Date of Admission: Dec,30,2019
Time of Admission: 9:00 AM

b. Chief Complaint & Clinical Diagnosis

The patient was brought to SLH due to rashes and fever and the admitting diagnosis
was t/c Kawasaki disease
c. History of current Illness
Two days prior the patient had undocument fever associated with rashes at
the back. No associated vomiting, consulted done in day one prior still with
fever 39.5 and rashes; now associated with sore throat and cough.
d. Past Medical History
Baby P.R.A born via NSD by her 33 yrs old mother. P.R.A mother said that her
son has completed his vaccine but was not verified because she didn't have
the baby book record with her.
e. Family History
For the maternal side, both the grand father and grand mother died because
of old age . For the paternal side, the grand father is still alive but is having
highblood pressure and the grand mother died because of old age.Our
 client's mother has no history of chronic diseases .In the other hand, his
father is having high blood pressure.
f. Socio-Economic History
g. Environmental History
h. Gordon’s Eleven Functional Patterns
BEFORE DURING INTERPRETATION
FUNCTION HOSPITALIZATION HOSPITALIZATION
Nutrition  Eats 3x a day  Mostly eat
 He loves to bread
eat bread &
processed
foods such as
hotdog,
tocino,and
others.
 He doesn’t eat
vegetables  To replace fluid loss
 Seldom drinks
water
 This time he
frequently
drinks water
Elimination  He is able to  He can still  His condition doesn’t
urinate & urinate but his affected urination but
defecate bowel his bowel movement
normally movement affected.
everyday by become
himself irregular.
 He doesn’t
have any
problem on
his elimination
Sleeping  Has a regular  Disturbed  Due to adherence to
sleeping sleeping time of medication,
pattern pattern vital signs monitoring
 Normal sleep and discomfort.
is 6-8 hrs. per
day but he
naps for 1-2
hrs in the
afternoon
Cognitive-  Has a normal  He is not  Due to pain he feels
Perceptual cognitive responsive he cannot
Pattern perception just like before communicate well
 Can because of
comprehend pain he feel
well
 He responds
appropriately
 to verbal &
physical
Role Relationship
Pattern
Sexuality-
Reproductive
Pattern
Coping Stress &   
Tolerance Pattern
Activity-Exercise  His daily  He interacts  He only focuses on
Pattern routine on with his simple things.
playing grandmother
computer. His & other
daily activities people around
were limited in him
waking up in  Cooperates
the morning to well to the
attend his doctor &
class & after nurses.
that going to
computer
shop.
Value-Belief  He is a  Due to their culture
Pattern Catholic preferences &
parent’s influence

i. Review of System
i. General
ii. Skin
rashes or moles or non-healing sores (skin lesions) [YES] [NO]
Skin itch [YES] [NO]
Breast Lumps [YES] [NO]
Breast Pain [YES] [NO]
Nipple Discharge [YES] [NO]
Hair Loss [YES] [NO]
iii. Head, Eyes, Ears, Nose, Throat (HEENT)
Visual change [YES] [NO]
Hearing Changes [YES] [NO]
Ear Pain [YES] [NO]
Nasal Congestion [YES] [NO]
Sinus Pain [YES] [NO]
Hoarseness [YES] [NO]
sore throat [YES] [NO]
Swallowing Difficulty [YES] [NO]
iv. Neck
Swelling [YES] [NO]
Stiffness [YES] [NO]
Adenopathy [YES] [NO]
Goiter [YES] [NO]
 v. Breast
Pruritus [YES] [NO]
Rashes [YES] [NO]
Stria [YES] [NO]
Lesions [YES] [NO]
Wounds [YES] [NO]
Incisions [YES] [NO]
excessive dryness and discoloration [YES] [NO]
Breast pain [YES] [NO]
Soreness [YES] [NO]
Lumps [YES] [NO]
vi. Respiratory
Cough [YES] [NO]
Wheezing [YES] [NO]
Snoring [YES] [NO]
Shortness of Breath [YES] [NO]
vii. Cardiovascular
Chest Pain [YES] [NO]
Palpitations [YES] [NO]
Leg Swelling (Edema) [YES] [NO]
viii. Gastrointestinal
Nausea or Vomiting [YES] [NO]
Diarrhea [YES] [NO]
Constipation [YES] [NO]
Abdominal Pain [YES] [NO]
Bright red stools [YES] [NO]
Black tarry stools (melana) [YES] [NO]
Stool Incontinence [YES] [NO]
ix. Genito-Urinary
Pelvic Pain [YES] [NO]
Burning with urination (Dysuria) [YES] [NO]
Frequent Urination (Urinary Frequency) [YES] [NO]
Urgent urination (urinary urgency) [YES] [NO]
Blood in urine (Hematuria) [YES] [NO]
Sexually Transmitted Disease Exposure [YES] [NO]
x. Peripheral Vascular
xi. Musculoskeletal
Bone pain [YES] [NO]
Joint Pain or Joint Swelling [YES] [NO]
Muscle pain [YES] [NO]

IV. PHYSICAL ASSESSMENT

a. General Survey
Received patient lying on bed, awake and crying With IVF of D5LR 500 cc at
right arm to run at 55cc/hr. The patient measures 3 feet and 4 inches in
height. During assessment, he is conscious and not cooperative.
b. Vital Signs
  Temp- 36.3
 RR- 26
 PR- 125
 O2 stat- 98%
c. Skin
The patient's skin is fair and warm, it assume shape after being picked up by
two finger indicating good skin turgor. Some rashes where seen in the
abdomen,palm and sole.
d. Head
Head's configuration is normal with no lesion or tenderness. Patient hair is
color black and is observe to be fine in consistency and soft texture. The scalp
is clean with no present of wounds and lesion.
e. Eyes
The client's eyelids and eyebrows are symmetrical in alignment and
movement. Has a bilateral bulbar conjunctivitis. Pupils are black, equal in size
and are brisk reacting to light.
f. Ear
Ears have same color as the facial skin, they symmetrical and are aligned with
the outer canthus of the eye. No redness were seen on the external canal.
g. Nose
The nares of the client nose upon assessment appears to be normal. The
mucosa is pinkish in color symmetrical olfactory organ in good condition.
h. Oral Cavity
The lips of our patient are light purple in color, dry and cracking. His mucosa
also is red in color.Her tongue is dark red in color with white spot The gums
are also red in color, smooth. Upon talking the mother said there are no
bleeding happen.
i. Neck
The patient's neck is symmetrical. Upon palpation, swollen lymph nodes in the neck
noted.Thyroid glands not tender and not enlarged. Neck muscles are equal in size.
j. Breast And Axilla
Breast sizes are equal, slightly rounded and symmetrical. Nipples are similar,
small,rounded and with a fair brown color. Areolas are round and bilaterally
the same. Axilla is smooth without lesions. No enlarged lymph nodes or
masses were noted.
k. Thorax And Lungs
The chest upon inspection in not bulging. The patient's breathing is regular.
Posterior mobility and posture of the thorax upon respiration is
symmetrical.Breath sounds upon auscultation is resonant.
l. Heart
The apical beat of the heart is heard over the apex of the heart which is
located at the fifth intercostals space (point of maximal impulse). murmurs
sound noted.No skip beats noted.
m. Vascular System
n. Abdomen
The abdomen is generally symmetrical in configuration and has normal
growling sounds No masses or pain noted upon palpation but has a minimal
rashes in stomach area.
 o. Lower Extremities
The peripheral pulses are regular when assessed. His nails and nail beds
appear to be pinkish in color. Soles of the feet are reddened. Range of motion
is full. His muscle tone and strength on both extremities are equally strong..
p. Neurologic
i. Level of Consciousness
ii. Mental Status (Orientation, Mood, Memory, Thinking etc.)
iii. Cranial Nerves
iv. Motor Function
v. Sensory Function
vi. Reflexes
V. LABORATORY EXAMINATION ANALYSIS
Urinalysis
Color Yellow Lt. Yellow -Amber
Transparency (clarity) Slightly turbid clear
CHEMICAL ANALYSIS
Glucose Negative 5.5 mmol/L
Bilirubin 17 umol/L (+2) 5 umol/L
Ketone 0.5 umol/L (TRACE) 0.4mmo/L
Specific Gravity 1.030 1.005-1.035
Blood 10/ uL (TRACE) 9/uL
Ascorbic Acid Negative 0.5 mmol/L
Creatinine 17.7 mmol/L 1.0 mmol/L
pH 5.5 5.00-8.00
Protein 3.0g/L (+3) 0.1g/L
Urobilinogen 17 umol/L (+1) 4 umol/L
Examination Result Normal values Analysis
Nitrite negative negative
Leukocytes 500/ ul (+3) 14/uL
Micro Albumin 150mg/dL 10 mg/L
Calcium 2.5 mmol/L 2.4 mmol/L

Examination Result Normal values Analysis

RBC 4 (TRACE/RARE) 0-2
WBC 63 (+3/MODERATE) 0-4
Squamous Epithelial 3 (/LPF) 0-82
Cells
Amorphous 505 (+2/FEW) 0-80
urate/phosphates
Mucus Threads 297 (+1/OCCASIONAL) 0-82

Examination Result Normal values Analysis

GRAM STAIN
EPHITHELIAL CELLS GRAM (+) cocci, GS INTERPRETATION:
short long chain +(1-9/OIO)++(10-
19/OIO)+++(20/OIO)
GRAM (+)
coccobacilli
 GRAM (+) diplococci

VI. ANATOMY AND PHYSIOLOGY

Circulatory system

The circulatory system is made up of blood vessels that carry blood away from and
towards the heart. Arteries carry blood away from the heart and veins carry blood
back to the heart.
The circulatory system carries oxygen, nutrients, and hormones to cells, and
removes waste products, like carbon dioxide. These roadways travel in one direction
only, to keep things going where they should.

The circulatory system consists of three independent systems that work

together: the heart (cardiovascular), lungs (pulmonary), and arteries,
veins, coronary and portal vessels (systemic). The system is responsible
for the flow of blood, nutrients, oxygen and other gases, and as well as
hormones to and from cells. An average adult has 5 to 6 quarts (4.7 to 5.6
liters) of blood, which is made up of plasma, red blood cells, white blood
cells and platelets.

The heart is a muscular organ with four chambers. Located just behind
and slightly left of the breastbone, it pumps blood through the network of
arteries and veins called the cardiovascular system.

The systemic circulation is a major portion of the circulatory system. The

network of veins, arteries and blood vessels transports oxygenated blood
from the heart, delivers oxygen and nutrients to the body's cells and then
returns deoxygenated blood back to the heart.
 Arteries carry oxygen-rich blood from the heart through the body. Veins
carry oxygen-poor blood back to the heart.

The superior vena cava carries oxygen-poor blood into the heart. The
aorta carries oxygenated blood from the heart to organs and tissues.

The immune system is made up of special organs, cells and chemicals that fight infection .
The main parts of the immune system are: white blood cells, antibodies, the complement
system, the lymphatic system, the spleen, the thymus, and the bone marrow. These are the
parts of your immune system that actively fight infection.

White blood cells

White blood cells are the key players in your immune system. They are made in your bone
marrow and are part of the lymphatic system.

White blood cells move through blood and tissue throughout your body, looking for foreign
invaders (microbes) such as bacteria, viruses, parasites and fungi. When they find them,
they launch an immune attack.

White blood cells include lymphocytes (such as B-cells, T-cells and natural killer cells), and
many other types of immune cells.

Antibodies
Antibodies help the body to fight microbes or the toxins (poisons) they produce. They do
this by recognizing substances called antigens on the surface of the microbe, or in the
 chemicals they produce, which mark the microbe or toxin as being foreign. The antibodies
then mark these antigens for destruction. There are many cells, proteins and chemicals
involved in this attack.

Complement system

The complement system is made up of proteins whose actions complement the work done
by antibodies.

Lymphatic system
The lymphatic system is a network of delicate tubes throughout the body. The main roles of
the lymphatic system are to:
 manage the fluid levels in the body
 react to bacteria
 deal with cancer cells
 deal with cell products that otherwise would result in disease or disorders
 absorb some of the fats in our diet from the intestine.

The lymphatic system is made up of:

 lymph nodes (also called lymph glands) -- which trap microbes
 lymph vessels -- tubes that carry lymph, the colorless fluid that bathes your body's tissues
and contains infection-fighting white blood cells
 white blood cells (lymphocytes).

Spleen

The spleen is a blood-filtering organ that removes microbes and destroys old or damaged
red blood cells. It also makes disease-fighting components of the immune system (including
antibodies and lymphocytes).

Bone marrow

Bone marrow is the spongy tissue found inside your bones. It produces the red blood cells
our bodies need to carry oxygen, the white blood cells we use to fight infection, and the
platelets we need to help our blood clot.

Thymus

The thymus filters and monitors your blood content. It produces the white blood cells called
T-lymphocytes.
 VII. PATHOPHYSIOLOGY
VIII. MEDICAL SURGICAL NURSING MANAGEMENT

 Monitoring and assessment for complications; report arrhythmias.

 Take vital signs as directed by condition; report abnormalities.
 Assess for signs of myocarditis (tachycardia and chest pain).
 Closely monitor intake and output, and administer oral and I.V fluids as
ordered.
 Monitor hydration status by checking skin turgor, weight, urinary
output,specific gravity, and presence of tears.
 Observe mouth and skin frequently for signs of infection.
 Perform comfort measures related to the eyes.
 Apply cool compress.
 Discourage rubbing the eyes.
 Instill artificial tears to soothe conjunctiva.
 Monitor temperature every 4 hours. Provide sponge bath if temperature
above normal.
 Perform passive range of motion exercises every 4 hours while the child is
awake because movement may be restricted.
 Provide quiet and peaceful environment with diversional activities.
 Provide care measures for oral mucous membrane.
 Use soft toothbrush only.
 Apply prescribe ointment to dried, cracked lips.
 Provide skin measures to improve skin integrity.
 Avoid use of soap because it tends to dry skin and make it more
likely to breakdown.
 Elevate edematous extremities.
 Use smooth sheets.
 Apply emollients to skin as ordered.
 Protect peeling of skin, observe for signs of infection.
 Offer clear liquids every hour when the child is awake.
 Encourage the parents and child to verbalize their concerns, fears, and
questions.
 Practice relaxation techniques with child, such as relaxation breathing.
 Keep the family informed about progress and reinforce stages and
prognosis.

IX. DRUG STRUDY

Generic Brand Dosage Indication Drug Action Contra- Adverse Nursing
Name Name indication Reaction Responsibilities
Paracetamol Tempra Oral Used to Decrease Renal Few when Know the Ten
liquid reduce fever by insufficiency,anemia. in usual Rights of the
120mg/ml fever in hypothalamic Clients with cardiac therapeutic patient. Do not
dose bacteria effect leading or pulmonary doses.
 or viral to swelling disease are more Chronic exceed a dose
infection. and susceptible to and even a dose of 4
vasidalition. acetaminophen acute g/24 hr in
Also inhibits toxicity. toxicity can adults and 75
the effect of develop mg/kg/day in
pyrogens on after long children.
the symptom- Document
hypolthalamic free presence and
heat- usage. level of fever.
regulating Monitor
center. Vital Signs
especially
Temperature
30mins after
the
administration.

Generic Brand Dosage Indication Drug Action Contraindication Adverse Nursing

Name Name Reaction Responsibility
Cetirizine Zytec PO Relief of Potent H- Lactation In Somnolence, Know Ten
Children, symptoms receptor children less dry mouth, Rights of the
6 months - associated antagonist. than 6 years of fatigue, Patient,
2yrs: with Mild age with pharyngitis, Document
2.5mg seasonal bronchodilator impaired renal and onset, clinical
once allergic that protects and hepatic dizziness, presentation,
daily. In rhinitis. against function. Convulsion. and
children, histamine- characteristics
12-23 induced of symptoms;
months, bronchospasm. note any
dose can Rapidly triggers and
be absorbed after Assess VS
increase PO and I&0.
to Administration.
maximum
5mg/day
given as
2.5 mg.

Generic Brand Dosage Indication Drug Contraindication Adverse Nursing

Name Name action Reaction Responsiblity
Ampicillin Novo- IVTT Used to Synthetic, Hepatic Diarrhea, Know the Ten
ampicililin Children: treat broad- dysfunction Nausea Rights of the
150- respiratory spectrum and patient,
200mg/day tract antibiotic vomiting, Document the
infection. suitable for urinary type, onset,
gram- retention, and
negative chills, characteristics
bacteria. mucosal of symptoms,
bleeding. Assess for
 Acid Diarrhea and
resistant, S&S of super
destroyed Infection,
by Report any
penicillin- evidence
ase. of adverse
effects
including
rash; sore
throat and
enlarged
lymph nodes.

X. NURSING CARE PLAN

XI. DISCHARGE PLAN
 Medication
 Discuss all take home medication to the patient.
 Encourage to take drugs with food if not contraindicated.
 Inform them that the drug may exhibit undesirable side effects.
 Adverse reaction is with life threatening effects to the
patient.immdiate consultation is necessary to prevent untoward
injuries.
 Exercise
 Have a adequate rest and sleep.
 This recharge the energies to function better both physically and
mentally.
 Treatment
 Explain the treatment and medication purpose to be continue at
home.
 It is needed for maintenance control of disease health teaching.
 Instruct relative to increase fluid intake to 8 glasses of water a
day.
 Emphasized hand washing
 Encourage relative to prepare foods that are nutritious such as
vegetable and fruits.
 Outpatient order
 Remind the family on their follow-up check up with the physician.
 Maintain a good and safe environment.

 Diet
 Encourage to have three basic food group in the diet with low salt
and low fat.
 Provide balance diet.
 Hygiene
 Have a personal hygiene daily.
 Keep the patient's skin intact and free of lesion.
 Remove dirt and maintain germ-free in physical appearance.
  To prevent skin breakage that may be a contributing factor in the
entry of microorganism.
XII. APPENDIX
XIII. REFERENCES
https://www.webmd.com/children/what-is-kawasaki-disease
https://www.medicalnewstoday.com/articles/303087.php
https://www.khanacademy.org/science/high-school-biology/hs-human-body-systems/hs-
the-circulatory-and-respiratory-systems/a/hs-the-circulatory-system-review
https://www.ncbi.nlm.nih.gov/books/NBK279250/

Special Reminders:
 Case Study should be type written and should be compiled in a folder or book bind
 Use A4 type of bond paper
 Margins should be 1 inch in all four sides
 Font should be Arial Narrow size 12
 Follow the given case study outline, with major headings on bold and capitalized, while the
subheading are on bold only.

Special Format on Case Study

A. Gordon’s Eleven Functional Patterns

During
Pattern of Functioning Before Hospitalization Hospitalization Analysis/Interpretation

B. Laboratory / Diagnostic Exam

Name of Examination:
Date and Time of Examination:

Examination Result Normal values Analysis

(e.g.) RBC ct, PLT ct.

* Two paragraphs should follow after the table. The first paragraph should define the
laboratory/diagnostic examination and mention the importance and significance of the test to the case
of the patient. The second paragraph should explain the interpretation of the results with regards to the
case of the patient. For diagnostic exams that cannot utilize the table (e.g. ECG, CT Scan) just present
your data in a paragraph form.

C. Pathophysiology – it should be in a pathway form

D. Drug Study
Generic Brand Dosage Indication Drug Contra- Adverse Nursing Responsibilities
Name Name Action indication Reaction

E. Nursing Care Plan

Cues Nursing Scientific Nursing Nursing Rationale Evaluation

Diagnosis Inference Goals Interventions