DMMA COLLEGE OF SOUTHERN PHILIPPINES College of Nursing Tigatto Road, Buhangin Davao City

In Partial Fulfillment of the Course Requirements In Nursing Care Management 104 Related Learning Experience

R/O Kawasaki Disease Mucocutaneous Lymph Node Syndrome Presented to: 4th year level clinical instructors of DMMA College of Southern Philippines

Presented by: Cagabhion, Joanna Mae, Apurada,Ingrid Katrina Padilla,Chucky Angelo, Arevalo,Hanneli Mae Falco,Gracelyn Joy, Cubero,Elden Joy, Martin,Joani Joel, Bermoy,Floridel, Caluban,Lilibeth, Lumasag,Mark, Callar,Jonna

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 but 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 homeostasis will be disturbed and when change will cease to happen. Some of the surprising changes can be considered blessings but most the time they are we fervently hope would not occur especially those that concern our health. In this particular case study, we wish to present the case of our patient, A.K.A. Baby James of Roxas Extension, Digos City. He was admitted at Medical Center of Digos Cooperative for the reason of high fever with the admitting diagnosis: ATP t/c Kawasaki Disease. Kawasaki disease (mucocutaneous 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 mostly 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 early spring. It was first described in 1967 by Dr. Tomisaku Kawasaki in Japan. Although Kawasaki disease is a multisystem disease, the cardiovascular system appears to be the primary site with coronary artery vasculitis, aneurysm development, thrombosis, and myocardial thrombosis progressing over days to weeks. Approximately 15% to 25% of patients

develop cardiac complications (coronary thrombosis or rupture, myocardial infarction, heart failure, vasculitis of the aorta or peripheral arteries); however mortality is low. Nurses play a significant role in the management and care of patient with conditions such as this. We play an essential part in symptom management associated with the disease and the therapy. We likewise form part in the patients support system, which is considerably a factor that has an immense effect on the cure and recovery of this type of disease. In the patients health care management as a whole, we nurses are like a soothing balm to their needs. This case study is meaningfully designed to provide awareness and thorough explanation to one of the rarest diseases that occur in our country. Our presentation aims to recognize the need of the people to understand the course of this disease. We have assent the implication of this research that it may encourage keenness and be a source of information to a number of people, who remains nave to this bodily infirmity. May this new means of learning be a valuable fount of vital information to people who wish to study the same disease. People shouldnt take Kawasaki Disease hideously more so to those who are concerned because management is the key. In life, hurdles and humps are sprayed to test us. It takes recognition and acceptance that even our anatomical and physiological features; Gods chisel is shaping us to be significant individual molded by pain and strength. This study does not only provide our readers of medical information but of a challenge and course of holistic spectacle as well.

OBJECTIVES General Objectives: That within our three weeks ward exposure (MMGH, DAH, MCDC), we may be able to choose a case study that will contribute and expand our knowledge and improve our skills on specific procedures. Our group has formulated the following Specific Objectives to guide us towards the completion of this case study. That within our three weeks ward exposure (MMGH, DAH, MCDC), we may be able to: Select a relevant subject for our case study; Establish good interpersonal and professional relationship with our patient and his accompanying family member; Formulate an introduction that can present a concise overview of the case study; Identify its contribution in the fields of nursing education, practice, and research; Formulate specific, measurable, attainable, realistic and time bounded objectives that will serve as a guide for the accomplishment of this study; Collect data regarding the past and present health history of our patient; Assess our patient in a cephalocaudal direction to serve as our baseline data in determining the changes in patients body; 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;

 Study and relate the significance of the diagnostic examinations done; Research on the drug study of the medication given to our patient; Enumerate the actual and possible medical and nursing management rendered; Formulate effective nursing care plan with three actual problems and two high risks problems; Share our knowledge and skills to our chosen patient; Work together with the health team providing continuous care; Provide significant health teachings that would promote our patients health and wellness; and List all the references used in the study.

PATIENTS DATA Name: A.K.A. Baby James Birth date: January 23, 2008 Age: 1 year old Sex: Male Birthplace: Digos City (MCDC) Address: Roxas Extension, Digos City Civil Status: N/A Religion: Roman Catholic Nationality: Filipino Educational Attainment: N/A Name of Father: Hermogenes Age: 50 years old Occupation: PNP-SPO3 Name of Mother: Corazon Age: 44 years old Occupation: House wife Siblings: Princess Ajessa-21 years old Prince Joshua-14 years old Prince Gabriel-5 years old Room Number: Room 131 Ward: Private Station 1 Diagnisos: ATP t/c Kawasaki Disease Attending Physician: Dr. Villegas Date of Admission: August 12, 2009 Time of Admission: 10:25 AM

HEALTH HISTORY Family Health History For the paternal side, the grand father died because of old age and the grand mother died because of throat cancer. For the maternal side, the grand father is still alive but is having high blood pressure and the grand mother died because of prostate cancer. Our clients mother, Corazon has no history of chronic diseases but she is ligated. On the other hand, his father, Hermogenes is having high blood pressure. The two sisters of Corazon suffered problems of the uterus. Teresita undergone already TAHBSO and has cholelethiasis. Also, Liberty was detected to have tumor in the uterus. Corazon the mother of our client is fortunate because among the three of them she didnt experience any problem in the uterus. Unfortunately, her two sisters were not able to bear a child due to such problem. The four sisters and 2 brothers of Hermogenes (father of baby james) are suffering from Diabetes Milletus. The brother of Hermogenes, Feliciano undergone kidney transplant.

Past Health History Baby James, born via caesarian section delivery with a weight of 71 pounds, by her 43 years old mother. His parents, realizing the essence of having a first line defense in the form of immunization, provided her all that is inevitable: BCG-1 DPT-3 OPV-3 Measles-2 Hib-3 Hepatitis B-3

Aside from his present problem, baby James was admitted last December 4, 2008 at Medical Center of Digos Due to cough. Baby James is not allergic to any food, drug, substances or even environmental allergies. So far, he is not experiencing childhood illnesses such as measles, mumps, rubella, chicken pox, etc. He didnt undergo to any surgeries. He didnt experience any serious accidents or any injuries.

Present Health History Present complaint of Baby James which is Fever started 1 week PTA. Prior to admission, onset of fever ranges at 38-39C without colds or cough. Mother noticed rashes on the abdomen and the clients lips are cracking. At the height of the fever, client experienced seizure thus prompt admission. Our client was admitted on August 12, 2009 under the supervision of Dr. Villegas. Due to her present complaint and assessment made by his AP, the first impression of Dr. was Acute Tonsilo Pharyngitis t/c Kawasaki Disease.

PHYSICAL ASSESSMENT

Name: Baby James Age: 1 year old Sex: Male

Department: Ward-Private Station 1 Dx: ATP t/c Kawasaki Disease. Attending Physician: Dr. Villegas

Date and time of Assessment: August 18, 2009, 4:00 PM GENERAL SURVEY Received patient lying on bed, awake and responsive, not in any respiratory distress. With IVF of D5IMB 500 cc at right arm at 60cc/hr. The patient measures 3 feet in height. He appears to be normal without any signs of distress. During assessment, he is conscious, coherent, and oriented upon inquiry.

VITAL SIGNS Patient has temperature of 36.7 degrees celcius, axillary, with regular heart rate (HR) of 121 beats per minute, regular pulse rate (PR) of 120 beats per minute; regular respiratory rate (RR) of 32 breaths per minute.

SKIN The patients skin is fair, warm, and slightly moist. It assumes shape after being picked up by two fingers thus, indicating good skin turgor. Minimal rashes are seen at the abdomen area. Rashes noted to be erythematous maculopapular.

HEAD

The heads configuration is normocephalic with no lesions or tenderness noted. Patients hair assumes the color black and is observed to be fine in consistency and soft in texture. The scalp is clean with no prescence of wounds, scars, or lesions. Patient has symmetrical facial movement and is able to elevate eyebrows, frown, close eyelids tightly, and smile.

EYES The clients eyelids and eyebrows are symmetrical in alignment and movement; the eyelashes are slightly curled outward. Noted to have bilateral bulbar nonpurulent conjunctivitis. Pupils are black in color, equal in size and are brisk when reacting to light. Lid margins are clear, mlacrimal duct openings are evident at the nasal side of the upper and lower lids.

EARS Auricles have the same color as the facial skin. They symmetrical and are aligned with the outer canthus of the eyes. Auricles are flexible, firm, and nontender. Upon assessment, no redness or purulent discharges were seen on the external canal. Patient is able to hear in a normal voice tone.

NOSE The nares of the patients nose upon assessment appears to be normal with its septum in midline. The mucosa is pinkish in color and both nares are patent. Symmetrical olfactory organs thus, in good condition.

MOUTH

The lips of our patient are red in color, dry and cracking. His mucosa also is red in color. Her tongue is reddish in color and is in midline. The gums are also red in color, smooth. Upon inspection of the mother there are no lesions or any bleeding.

PHARYNX The patients uvula is min midline. Tonsils noted to be obstructive. Thus, patients appetite is not good. Patient has difficulty swallowing.

NECK The patients 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. Trachea is positioned in the midline upon palpation.

CHEST AND LUNGS The chest upon inspection in not bulging. The patients breathing is regular. Posterior mobility and posture of the thorax upon respiration is symmetrical. Lung expansion and vocal tactile fremitus is symmetrical. Breath sounds upon auscultation is resonant.

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). Heart sounds are regular at S1-S2 base. No murmurs or skip beats noted. 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 upon palpation.

ABDOMEN The abdomen is generally symmetrical in configuration and has normal growling sounds of 12. Upon percussion, the abdomen is tympanic in sound. No masses or pain noted upon palpation.

GENITO- URINARY No data collected-client is irritable. Mother that his genitals has no any problem. There are no lesions as verbalized by the mother. Excretion and elimination of wastes are every day. Patient is using diaper. Stool yellowish in color and urine is light yellow in color.

BACK AND EXTREMITIES The peripheral pulses are regular when assessed. His nails and nail beds appear to be pinkish in color. Erythyma of the hands are noted. Soles of the feet are reddened. Range of motion is full. His muscle tone and strength on both extremities are equally strong. Spine is in midline and body position, stature and gait is coordinated.

DIAGNOSIS Diagnostic Criteria for Kawasaki Disease Presence of at least 4 of the ff. 6 signs

Fever lasting for at least 5 days: Bilateral bulbar conjunctival injection, generally nonpurulent Changes in the mucosa of the oropharynx, including injected pharynx, injected and/or dry fissured lips, strawberry tongue Changes of the peripheral extremities, such as edema and/or erythema of the hands or feet in the acute phase; or periungual desquamation in the subacute phase Rash, primarily truncal; polymorphous or nonvesicular Cervical adenopathy, > 1.5 cm., usually unilateral lymphadenopathy illness not explained by other known disease process DIAGNOSIS OF THE GROUP

Subsequent to assessing the different manifestations of the client, the group believed that the client indeed has this Kawasaki disease. This diagnosis was made because the person has met the Major diagnostic criteria established by the Centers for Disease Control and Prevention (CDC). The CDC requires that fever and four of the six other criteria listed above demonstrated. To our patient, five out of six symptoms were manifested.

PATHOPHYSIOLOGY

Predisposing factors: Age-1 year old Sex-Male Race-Asian

Precipitating Factors: Unknown yet linked with unknown etiologic agent and environmental factors

Autoimmune Response (possible if tested of HLA-BN22J2 antigen)

Release of Chemical Mediators ( histamine, bradykinin, prostaglandin)

Vasodilation and Cellular Permeabilty Attraction of Phagocytes and WBC

Entry of antigen lymphatic capillaries S/S: Redness Swelling Heat

on Phagocytosis by neutrophils and macrophages (antigens are localized and inflammation happens

Increase blood vessels Systemic pressure due to inflammation and involvement (inflammation of entry of antibodies small & medium size vessels)

If treated: Ampicillin Cetirizine Diazepam Ceftriaxone Paracetamol

If not treated: Complications developed

Pericarditis

Myocarditis GOOD PROGNOSIS Cardiomegaly

Myocardial infarction

Heart failure

Ruptured coronary aneurysym DEATH

DOCTORS ORDER 8/12/09 @ 10:25 pm

 Please admit under the service of Dr. Villegas VS q4 Diet for Age Labs CBC, U/A Start venoclysis with D5 .3 NaCl 500cc @ 60cc/hr. Medications: 1. Ampicillin 250mg IVTT q6h ANST 2. Paracetamol 100g/ml 1.2ml q4h RTC 3. Paracetamol 90mg IVTT q4h PRN for T>38.5C 4. Diazepam 2.5mg IVTT for active seizure TSB for T-38.5C Refer accordingly O2 inhalation @ 2-3Lpm for active seizure 8/13/09 S: (-) fever well active S: (+) rashes

@ 9:20 am IVF TF- D5 IMB 500cc @ 11:35 am For U/A Paracetamol p.o RTC x 2 doses then PRN IVF to ff D5IMB 500cc @ SR Repeat CBC platelet @6:30 pm IVFTF: D5IMB 500cc@ SR Cetirizine oral drops 1ml q 12 8/14/09 S: Still with fever S: Conjunctivitis panopopular rash @12:35pm IVFTF D5IMB 500cc @ SR Ent meq @6pm IVFTF D5IMB @ 500cc @SR Continue meds. 8/15/09 S: D4 fever rash

Conj. Epem @11:30 am IVF to D5IMB 500cc @SR Continue meds. Start cefuroxime 100 g/ts 2.5ml q 12h Last dose of ampule @ 12noon 8/16/09 @ 6:05am IVF TF D5IMB 500cc @ 9:00am Still has intermittent fever Continue meds. @4:00pm Repeat CBC platelet IVF TF D%IMB 500cc@ SR Continue meds. @8:30pm IVF TF: D5IMB 500cc @SR 8/17/09 @12:15pm @8:15pm @6pm

For typhidat For stool exam Incorporate 1amp. B&C to present IVTT IVF TF D5IMB 500@60cc

Transfer IV site For chest x-ray APL in AR Ceftriaxone 500mg ivttq12h ANST To consume cefuxime For possible LP in AM Secure consent

IVF TF D5IMB 500cc@SR 8/18/09@ 12nn C/T IVF Retain for heplock Continue for other meds.

DIAGNOSTIC AND LABORATORY TESTS EXAMINATION RESULT NORMAL CLINICAL

RANGE HEMATOLOGY August 12,2009 WBC LYM GRAN RBC HCT MCV MCH MCHC RDW PLT MPV HGB 15.7 10EQ/L 4.5 %L 10.3 %G 4.53 10E12/L 34.5 % 76.1 fL 24.7 pg 325 g/L 15.6 % 420 10E9/L 9.2 fL 112 5.0-13.0 0.6-34.1 2.0-7.8 3.80-5.40 39.0-47.0 80-97.0 25.0-32.0 310-360 11.5-14.5 150-400 0.0-99.8 120-150 g/L

SIGNIFICANCE

High-viral & bacterial infection High-viral & bacterial infection HighNormal Low-acute blood loss Low-microcytic anemia Low-microcytic anemia Normal High High-malignancy Normal Lowanemia/dehydration Amorphous Urates/Phosphates-

URINALYSIS August 13, 2009 General Color-Yellow Transparency-Clear Reaction-7.0 Specific Gravity-1.000 Chemical Albumin-Positive Sugar-Negative Microscopic Pus cells-1-3/hpf

few/hpf Mucus threads-Occasional/hpf

TYPHI DOT Miscellaneous Specimen: Wholeblood Examination: Salmonella 1g6/1gm Result-Negative

DRUG STUDY

Brand Name: Novo-Ampicillin Generic Name: Ampicillin Classification: Antibiotic Indication: Used to treat respiratory tract infections. Action: Synthetic, broad-spectrum antibiotic suitable for gram-negative bacteria. Acid resistant, destroyed by penicillin-ase. Route/Dosage: IVTT Children: 150-200 mg/kg/day. Side effects: Diarrhea, Nausea and Vomiting, urinary retention, chills, mucosal bleeding. Contraindication: Hepatic Dysfunction Nursing responsibilities: Know the Ten Rights of the patient, Document the type, onset, and characteristics of symptoms, Assess for Diarrhea and S&S of super Infection, Report any evidence of adverse effects including rash; sore throat and enlarged lymph nodes.

Brand Name: Zyrtec Generic Name: Cetirizine Classification: Antihistamine Indication: relief of symptoms associated with seasonal allergic rhinitis. Action: Potent H-receptor antagonist. Mild bronchodilator ,that protects against histamine-induced bronchospasm. Rapidly absorbed after PO Administration. Route/Dosage: PO Children, 6 months 2yrs: 2.5mg once daily. In children, 12-23 months, dose can be increased to a maximum of 5mg/day given as 2.5 mg q 12hr. Side Effects: Somnolence, dry mouth, fatigue, pharyngitis, and dizziness, Convulsion. Contraindications: Lactation. In children less than 6 years of age with impaired renal and hepatic function. Nursing Responsibilities: Know Ten Rights of the Patient, Document onset, clinical presentation, and characteristics of symptoms; note any triggers and Assess VS and I&O.

Brand Name: Diazemuls Generic Name: Diazepam Classification: Antianxiety Indication: Management of anxiety disorders or for short term relief symptoms of anxiety. Action: The skeletal muscle relaxant effect of diazepam may be due to enhancement of GABAmediated presynaptic inhibition at the spinal level as well as in the brain stem reticular formation. Route/Dosage: PO ; 1-2.5 mg 3-4 times per day. Contraindications: Lactation, and parenterally in children under 12 years. Side effects: Prolonged CNS depression, anorexia, nausea and vomiting, weakness. Nursing Responsibilities: Know the Ten Rights of the Patient. Report any adverse side effects or lack of response . Reduce drug gradually to avoid withdrawal symptoms. Monitor Vital Signs.

Brand Name: Rocephin Generic Name: Ceftriaxone

Classification: Cephalosporin, third generation. Indication: treatment in Lower Respiratory tract infections Action: t : Approximately 6-8hr. significantly protein bound. Serum levels after 1g IV: 151 mcg/ml. One third to two-thirds excreted unchanged in the urine. Route/Dosage: IVTT 100 mg/kg/day, not exceed total daily dose of 4 g given once daily or in equally divided doses q 12 hr for 7-14 days. Side effects: Increased in serum creatinine, presence of casts in the urine. Nursing Responsibilities: know the ten rights of the patient. Do not mix drug with other antibiotic. Report adverse side effects such as bruising, bleeding and diarrhea. Monitor Vital Signs.

Brand Name: Tempra Generic Name: Paracetamol

Classification: Anti-Pyretic, Analgesic Indication: Used to reduce fever in bacterial or viral infections. Action: Decreases fever by a hypothalamic effect leading to sweating and vasodilation. Also inhibits the effect of pyrogens on the hypothalamic heat-regulating centers. Route/Dosage: Oral liquid. 1-2years; 120mg/dose. Side effects: few when in usual therapeutic doses. Chronic and even acute toxicity can develop after long symptom-free usage. Contraindications: Renal insufficiency, anemia. Clients with cardiac or pulmonary disease are more susceptible to acetaminophen toxicity. Nursing Responsibilities: Know the Ten Rights of the patient. Do not exceed a dose a dose of 4 g/24 hr in adults and 75 mg/kg/day in children. Document presence and level of fever. Monitor Vital Signs especially Temperature 30mins after the administration.

MANAGEMENT Pharmacologic interventions:

Immune globulin (gamma globulin) I.V. therapy IVGG (2g/kg/day) is initiated during stage I in one 8 to 10 hour infusion to reduce the incidence of coronary artery abnormalities.

Aspirin therapy Thrombolytic therapy may be required during stages I, II, or III.

Monitoring 1. Monitor pain level and childs response to analgesics. 2. Institute continual cardiac monitoring and assessment for complications; report arrhythmias. o Take vital signs as directed by condition; report abnormalities. o Assess for signs of myocarditis (tachycardia, gallop rhythm, chest pain). o Monitor for heart failure (dyspnea, nasal flaring, grunting, retractions, cyanosis, orthopnea, crackles, moist respirations, distended jugular veins, edema). 1. Closely monitor intake and output, and administer oral and I.V fluids as

ordered. 2. Monitor hydration staus by checking skin turgor, weight, urinary output,

specific gravity, and presence of tears. 3. Supportive care Observe mouth and skin frequently for signs of infection.

1. Allow the child periods of uninterrupted rest. Offer pain medication routinely rather than as needed during stage I. Avoid NSAIDS if the child is in aspirin therapy. 2. Perform comfort measures related to the eyes.
o o o o

Conjunctivities can cause photosensitivity, so darken the room, offer sunglasses. Apply cool compress. Discourage rubbing the eyes. Instill artificial tears to soothe conjunctiva.

3. Monitor temperature every 4 hours. Provide sponge bath if temperature above normal. 4. Perform passive range of motion exercises every 4 hours while the child is awake because movement may be restricted. 5. Provide quiet and peaceful environment with diversional activities. 6. Provide care measures for oral mucous membrane.
o o o

Offer cool liquids like ice chips and ice pops. Use soft toothbrush only. Apply petroleum jelly to dried, cracked lips.

7. Provide skin measures to improve skin integrity.

o

Avoid use of soap because it tends to dry skin and make it more likely to breakdown.

o o o o

Elevate edematous extremities. Use smooth sheets. Apply emollients to skin as ordered. Protect peeling of skin, observe for signs of infection.

8. Offer clear liquids every hour when the child is awake.

9. Encourage the child to eat meals and snack with adequate protein. 10. Infuse I.V fluids through a volume control device if dehydration is present, and check the site and amount hourly. 11. Explain all procedures to the child and family. 12. Encourage the parents and child to verbalize their concerns, fears, and questions. 13. Practice relaxation techniques with child, such as relaxation breathing, guided imagery, and distraction. 14. Prepare the child for cardiac surgery or thrombolytic therapy if complications develop. 15. Keep the family informed about progress and reinforce stages and prognosis.

PROGNOSIS

CRITERIA Onset of illness

POOR

FAIR

GOOD

JUSTIFICATION Upon the onset of fever and seizure. Family was able to bring the patient

Duration of illness

for

check-up

and

was

soon

submitted for further management The parents were very willing to go to the hospital for medical

management and further treatment even though of financial instability. The disease precipitating factor

Precipitating Factor

includes environmental factors. We stress the environment as one of the strongest factor contributing to the development But of our factor Kawasaki patients does to not the

disease.

environmental predispose Willingness to take medication our

patient

development of Kawasaki disease. Our patient is immensely willing and participative in the medical measures set by his physician. Even though he is only 1 and a half

Age of patient

old but he is so participative. Being 1 and a half year old, our patient belongs to the bracket of age when this particular disease peaks

and affects young adults more so, that our patient is male, another considerable factor. Also, being an

Environment

Asian is such a considerable factor. Our patients environment does not predispose our patient to the

development of Kawasaki disease nor place our patient health at risk Our patients family is very supportive with our patients current

Family support

plight. They are not only supportive of him financially but more so, emotionally. They are most of the time with him her as she struggles with his disease and throughout the course of her actual and possible treatment

POOR- 1------------------------------------------------------1x1=1 FAIR-0--------------------------------------------------------0x2=0 GOOD-6------------------------------------------------------6x3=18 --------------19/7=2.71 or 3

Overall Prognosis:GOOD

With our general result as our primary basis, our patient is evidently with good prognosis. Considering the fact that Kawasaki disease is one of the most curable disease, our patient is really with good prognosis. Our patient is in the first phase of the disease and the family was able to admit the patient for medical management. The current condition and the course of our patients treatment is heading towards the good road and could positively result to our patients total wellness and may lead to the recurrence of our patients optimum health and wellness

DISCHARGE PLAN MEDICATIONS Discuss all take home medications to the patient and significant others. Encourage to take drugs with food if not contraindicated. Inform them that the drugs may exhibit undesirable side effects.

 This enables them to know what drugs to be taken and its desired doses. Some drugs may cause GI irritation if taken with empty stomach. Adverse reaction is with life threatening effects to the patient. Immediate consultation is necessary to prevent untoward injuries. EXERCISE Have adequate rest and sleep. This recharges the energies to function better, both physically and mentally. TREATMENT Explain the treatment and medication purpose to be continued at home. It is needed for maintenance and control of disease. HEALTH TEACHINGS Instructed S.O to increase fluid intake to 8 glasses of water a day. Emphasized hand washing technique. Encouraged S.O to prepare foods that are nutritious such as vegetables and fruits. OUTPATIENT ORDERS Remind the family on their follow-up check-up with their physician. Encourage them to carry out follow-up diagnostic exam. Maintain a good and safe environment. To evaluate the progress of the treatment. To evaluate worsening condition of the patient that needs medical attention. May facilitate fast recovery and prevent the patient from further injury. DIET

 Encourage to have three basic food groups in the diet with low salt low fat. To provide balance diet and decrease progress of ACS. HYGIENE Have personal hygiene daily; Keep the patients skin intact and free of lesions These remove dirt, and maintain germ-free physical appearance. To prevent skin breakage that may be a contributing factor in the entry of microorganisms .