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Far Eastern UniversityInstitute of Nursing

Hand, foot, mouth disease

Submitted To:

C. I Susan Romero

Submitted By: BSN 402-Group 6

Alcayde, Catherine Jane

Bustillo, Faustine Claire

Cavestani, Princess

Chanco, Carlo Dane

Claravall, Kirstie Loraine

Cunanan, Kenneth Bernadeth

Dimaranan, Krischelle

Domingo, Marc Clarence

Farolan, Jomar

Fernandez, John Michael

OVERVIEW OF THE DISEASE

Hand, foot, and mouth disease is a common viral illness that usually affects infants and children younger than 5 years old. However, it can sometimes occur in adults. Symptoms of hand, foot, and mouth disease include fever, blister-like sores in the mouth (herpangina), and a skin rash. It is caused by viruses that belong to the Enterovirus genus (group). This group of viruses includes polioviruses, coxsackieviruses, echoviruses, and enteroviruses.

The viruses that cause hand, foot, and mouth disease (HFMD) can be found in an infected person’s nose and throat secretions (such as saliva, sputum, or nasal mucus), blister fluid, and feces (stool). An infected person may spread the viruses that cause hand, foot, and mouth

disease through close personal contact, the air (through coughing or sneezing), contact with feces, and contaminated objects and surfaces.

There is no specific treatment for hand, foot and mouth disease. However, some things can be done to relieve symptoms, such as taking over-the-counter medications to relieve pain and fever and using mouthwashes or sprays that numb mouth pain

I. BIOGRAPHIC DATA

Name: “Child NNER”

Address: Tondo, Manila

Age: 1 year old, 7 mos

Gender: Male

Place of Birth: Tondo, Manila

Date of Birth: January 14, 2012

Nationality: Filipino

Religious Affiliation: Roman Catholic

Date and time of confinement: July 23, 2013 – 12:25pm

Reason for confinement: Fever, cough and rashes

Admitting diagnosis: hand, Foot and mouth disease

Attending physician: Dr. Miranda

Source of information: Patient’s Mother and Patient’s Chart

II. NURSING HISTORY

A. Past Health History

According to the mother, Child NNER was born through normal spontaneous delivery. His mother said that she had no complications and had taken vitamin supplements and nutritious foods during her pregnancy with Child NNER. Child NNER has completed his immunization appropriate for his age and has no known allergies to foods or medicines. He also hasn’t experienced any kind of accidents. According to the mother, it is Child NNER’s first time to be hospitalized and his previous visits to the hospital were because of the child

baby wellness checkups since he was a newborn. The patient is not taking any medication before his hospitalization and before he was discharged, he has been receiving drugs namely Ampicillin, Acyclovir, Nystatin, Paracetamol, Zinc SO4, and Protexin. The patient has no foreign travels.

B. History of Present Health Illness

It all started with fever and a little cough. Child NNER started experiencing elevation of temperature last Sunday, July 21, 2013 which was followed by cough. Mrs. Reyes said, “Sumunod bigla nung Monday na nagkaroon sya ng rashes sa bandang ari nya. Akala pa namin diaper rash lang e kaso dumami na ng sumunod na time.” She said that the rashes reached Child NNER’s legs and arms and a little on the client’s chest and back. “Nag-alala na kami kaya dinala namin sya dito nung Martes,” said Child NNER’s mother. Mrs. Reyes also said that the rashes of Child NNER do not hurt because she tried touching the lesions in her child’s legs and inguinal area before putting some ointment that was prescribed by the doctor but he is not complaining. The lesions are reddish during his first confinement and his temperature was above normal.

C. Family Background

Child NNER is third among the 3 children of Mr. and Mrs. Reyes. Their family is from Tondo, Manila. They are staying in their own house there where all 5 of them in the family with Mrs. Reyes’ mother and her older sister. Mr. and Mrs. Reyes are married. According to authority, the family is patriarchal for the father is the one who makes decisions within the house and health matters.

The family’s source of income is from Mr. Reyes’ job who is a police officer and Mrs. Reyes’ little buy and sell business of breads and meat (tocino, tapa).

When it comes to the educational attainment of the family, only Mr. Reyes is a college graduates. He finished BS Criminology while Mrs. Reyes is a high school graduate. Their eldest child is currently in 3rd grade and their middle child is in 1st grade.

In terms of family diseases, Mrs. Reyes verbalized that the only disease she knows that her parents and one of her sisters have is asthma while the family of her husband, Mr. Reyes, have diabetes mellitus and hypertension.

III. PATTERNS OF FUNCTIONING

1. PSYCHOLOGICAL HEALTH

Patient NNER is an active and friendly baby. His mother verbalized, “Takot lang siya sa mga nakaputi eh. Umiiyak pa siya pag may lumapit na mga nurses saka doctor.” The patient’s mother also added that her son plays with the health care team as they get along well and as long as the child doesn’t get hurt. She mentioned that as long as the child is with his mother, he stays calm and comfortable.

Analysis:

According to Erickson’s Psychosocial Theory, as the child enters the toddler years, gaining a greater sense of personal control becomes increasingly important. Tasks such as learning how to use the toilet, selecting foods and choosing toys are ways that children gain a greater sense of independence. Based on the theory of psychosexual by Freud, the anal stage is directly related to a child’s awareness of bowel control and gaining pleasure through the act of eliminating or retaining feces. 

Interpretation:

Since the patient’s developmental functioning falls at the right time, the patient will not have any problems in the future regarding the autonomy, patient wont doubt and be ashamed on the things she wishes to do. Since the patient is not yet able to be toilet trained, he just wears diaper. However, this is still unremarkable since toilet training can be developed during toddler and he is just at the start of the said stage. Moreover, the patient displays mistrust to strangers.

2. SOCIO-CULTURAL PATTERN

The patient’s family’s primary spoken language is Filipino. The patient lives with her parents and 2 other siblings. His mother is from Batangas while his father was raised in Manila. Regarding his recreational pattern, his mother said he spends most of his time watching TV especially cartoons and playing with his family. His relationship with his family is good. His siblings visit him every day. Regarding the family’s tradition on health, the mother said, “Minsan, nagpapahilot kami lalo na sa likod.” Aside from this, they don’t practice any other traditional practices regarding health. In addition, the patient’s environment according to his mother is good. She stated, “Maayos naman at malinis sa bahay namin kasi sakto lang yung laki niya tapos maayos din yung mga drainage sa kalsada yun nga lang meron pa ring mga basura sa paligid.”

Analysis:

Culture plays a critical role in the socialization agenda of a person through particular views of child development. (Kozier pp. 120). Environmental factors that support positive change should be used to reinforce the clients efforts to change lifestyle. All groups of people face issues in adapting to their environment; providing nutrition and shelter, controlling disease and maintenance of health. (Kozier pp.133) Family members support one another and have the ability to listen, empathize, and reach out to one another in times of crisis. When the needs of family members are met, they are able to reach out to meet the needs of others in society. (Kozier, p.193)

Interpretation:

The child is able to socialize well with others especially with his family who is the one supporting and caring for him. The family members reach out and help one another in

caring for patient NR. The patient’s environment is good and secured especially with his caring family who is concerned with him. The contexts of family and environment are where the child develops his feelings and experiences.

3. SPIRITUAL HEALTH

Patient NNER and his family’s religion is Roman Catholic. According to the patient’s mother, they are only able to attend masses twice a month. She verbalized, “Madalang lang kaming magsimba eh. Wala kasing oras.” However, the patient mother added that they pray every day especially for their son, patient NR.

Analysis:

Spiritual health is the ability to develop one’s inner nature to its fullest potential Spiritual beliefs can affect a person’s interpretation of events in his or her life. (Kozier pp. 284)

Interpretation:

Even if the family rarely attends to church services, they still value their spirituality. Moreover, it is an unexceptional thing that his family shares common religious beliefs which can influence each member of the family.

D. Developmental History

Psychosexual Theory of Development by Sigmund FreudSigmund Freud thinks that from birth, humans have instinctual sexual appetites

(libido) which unfold in a series of stages. Each stage is characterized by the erogenous zone that is the source of the libidinal drive during that stage. These stages are, in order: oral, anal, phallic, latency, and genital.

Stage Description Result JustificationAnal Stage This occurs about age 1 to 3 years

old. Here, individuals have their first encounter with rules and regulations, as they have to be toilet trained. This encounter with rules and regulations will dictate the later behavior with rules and regulations. The libido is focused anally, and frustration may arise from having to learn a complex cognitive and motor response.

NOT YET ACHIEVED In this psychosexual

developmental stage, Child NNER is still in the process of controlling the drives that come along with it. Although he still doesn’t show off startling degree of independency wherein he can be left along by his mother to some strangers without any complains, it was observed that Child NNER could be obedient to some commands made by his

Being fixated at this stage can result in stinginess, stubbornness, or orderliness, as well as messiness. Essentially, behavior related to retention and expulsion may be related to experiences at this stage.

mother. The child is not yet toilet trained since he is still at the beginning of this stage. Although he is confined and is having an IV infusion on his right foot, he can still manage himself around his crib with or without his mother beside him.

IV. ACTIVITIES OF DAILY LIVING

ADLBefore

HospitalizationDuring

HospitalizationInterpretation and Analysis

Nutrition According to the mother the client has no problem regarding food consumption. She verbalized, “Matakaw pa nga yan sa pagdedede eh.” She said that her child seldom eats solid or soft foods and seldom drinks beverages like orange and apple juices. Child NNER’s usual diet is either breast milk or formula milk and ¼ glass of water.

The client is on diet as tolerated.

The mother uses breast milk in feeding Child NNER. During their 3rd day in the hospital, she fed her child with rice and a little amount of soup in it and an estimation of 60ml of orange juice and some sips of water.

During nights of their stay, Child NNER is being breastfed but his mother.

The client is not choosy when it comes to eating foods.

His appetite does not change even he is in the hospital. Moreover, it is

also good that the child is still being breastfed by his mother.

Analysis:An individual’s food preferences and habits are often a major factor affecting actual food intake. Habits about eating are influenced by developmental considerations , gender , ethnicity and culture, beliefs about food, personal preferences , religious practices, lifestyle economics, medications and therapy, health , alcohol , consumption, advertising and physiological factors.Breast milk is the most desirable complete food for the first 6 months of child’s life.

Ref. (p.1237 , Kozier and Erb’s Fundamentals of Nursing , 8th

Edition , Volume II)

Elimination The mother verbalized that before the child was hospitalized, she changes Child NNER’s diaper 3 to 5 times a day. She said that sometimes it has soft brown stools, or just filled with light yellow colored urine.

Mrs. Reyes also said that Child NNER usually likes to drink either water, breast milk or formula milk that makes him have his diaper full of urine.

The mother said that she frequently changes her child’s diaper about 4 to 6 times from morning that her child wakes up until the night he sleeps. During his stay, Mrs. Reyes said that last July 25, the client has been defecating yellow watery stool frequently which started in the morning and lessened during the night. The urine appeared to be light yellow in color.

Interpretation:The client urinates and defecates normally even before and during hospitalization.

Analysis:Successful elimination in human beings depends on individual having an intact and fully functional urinary tract, gastrointestinal tract and nervous system. Through variation of what is normal occur in every individual, there is a pattern in elimination that every individual must have.

(Fundamentals of Nursing 2th edition pp.257 by Jose Quiambao - Udan)

Hygiene The mother bathes the client twice daily.

She said that she trims her kids’ nails every week.

Child NNER’s parents usually carry him around the house because he needs assistance before wearing slippers inside and outside the house.

The mother cleans the patient while in bed or seated in her lap.

She is also able to trim Child NNER’s nails during their stay in the hospital.

Interpretation:Normal since the mother gives importance to the client’s hygiene, but the day he has been confined to the hospital there is no regular bath.

Analysis: Hygiene is the science of health and its maintenance. Personal hygiene is the self-care by which people attend to such functions as bathing, toileting, general body weight and grooming. Hygiene is highly a personal matter determined by individual values and practices.

(Fundamentals of nursing 7th edition p.1164, by Kozier)

Sleep and Rest

According to his mother the client usually sleeps 9 - 10

According to his mother the client usually sleeps 8-10

Interpretation:The sleep pattern of the client is normal since. Most infants

hours at night.

The client doesn’t have any difficulties in sleeping.

hours at night but sometimes, his sleeping pattern is being disturbed due to the visits of his doctors and/or the nurses on duty.

between require about 12-14 hours of sleep a day.

He gets enough of sleep. There is no sleep deprivation.

Analysis:Sleep is the basic human need. It is biological process common to all people. We require sleep to cope with daily stresses, to prevent fatigue, to conserve energy, to restore the mind and body and to enjoy life more fully. Sleep enhances daytime functioning. It is vital for not optimal psychological functioning but also psychological functioning as rate of healing of damaged tissue is greatest during sleep. It is an important factor in person’s quality of life.

(Fundamentals of nursing 7th edition p.1164, by Kozier)

V. PHYSICAL ASSESSMENT

VI. PATHOPHYSIOLOGY

PREDISPOSING FACTORS Age: <10 years old

PRECIPITATING FACTORS Contact with someone who is

affectedCausative agent: Coxsachievirus A16

Exposure to pathogen

Virus particles implanted initially in the buccal and ileal mucosa/ GI tract

Spread into the bloodstreamViremia develops

-Lymphocyte 0.61-increase rate of

infection

VII. PROBLEM IDENTIFICATION

Cues Inference Nursing Diagnosis

Invasion of the skin and mucous membrane

Hand Foot Mouth DiseaseComplications:- Viral meningitis-Encephalitis

Medications:- Ampicillin 250mg TIV q 8hrs Acyclovir 200mg / 5ml q 6hrs PONystatin drops 1ml 3x a day 1hr NPO after intakeParacetamol drops 1ml q 4hrs PRNZinc s04 drops 1ml ODProtexin (restore) OD

Nursing interventions:- Promote hand hygiene especially after changing diaper-Instruct to avoid close contact with children with HFMD-Administer medication prescribed by the Doctor -Encourage to drink cold beverages such as milk or ice water and avoid citrus fruits and acidic food.-Instruct to increase fluid intake-Avoid salty or spicy foods

Laboratory:- Throat swab

-Stool specimen

-Painful blister like lesion in the buccal mucosa, tongue, gums,

and hard palate.

-Fever-Sorethroat

Red rashes, sore blister -palm, soles of the foot,buttocks, genital area

Cough Common coldInfluenza (flu)Inhaling an irritantPneumoniaAsthmaAllergies

Ineffective airway clearance r/t secretions secondary to infection

“rashes sa bandang ari nya” as verbalized by the mother.

rashes on both legs and arms and a little on the client’s chest and back

Viral infectionVirusesIf the child also has a cold, a cough, or diarrhea

Impaired tissue integrity r/t inflammatory response secondary to viral infection

VIII. PROBLEM PRIORITIZATION

Nursing Problems Identified

Cues Justification

Ineffective airway clearance r/t secretions secondary to infection

Cough Maslow’s Hierarchy

The problem is on physiologic needs of the client

Degree of Problem

This the highly prioritized problem because according to Maslow’s hierarchy of needs under biological and physiological needs, it stated that air together with food, water, shelter, rest, sleep, activity and temperature maintenance are crucial for survival of an individual. Oxygen is necessary for proper functioning of all living cells. Secretions in the airway could affect breathing of the client for it blocks the entrance and exit of air in the lungs going to the different organs. If it is not treated further complication will occur and even

death.

Interpretation

This is highly prioritized because this is an actual problem. The nurse or the health care provider has the necessary resources to solve this problem such as time, skills, knowledge and money. Eliminating this problem may help to prevent further complications and completely eliminate the actual problem.

Reference:

Kozier and Erb. Fundamentals of Nursing, 8th edition. Volume 1, pp. 273-274

Kozier and Erb. Fundamentals of Nursing, 8th edition. Volume 2, p. 1357

Impaired tissue integrity r/t inflammatory response secondary to viral infection

Subjective:

“rashes sa bandang ari nya” as verbalized by the mother.

-rashes on both legs and arms and a little on the client’s chest and back

Maslow’s Hierarchy

The problem is on the physiologic need of the client

Degree of Problem

The problem is moderately prioritized because the problem needs immediate action yet it isn’t life threatening.

Interpretation

This is moderately prioritized because this is an actual problem. The nurse or the health care provider has the necessary resources to solve this problem such as time, skills, knowledge and money. Eliminating this problem may help to prevent

further complications and completely eliminate the actual problem.

DISCHARGE PLAN

Medications Make sure that the client will take all his medications listed such asAmpicillin 250mg TIV q 8hrs Acyclovir 200mg / 5ml q 6hrs PONystatin drops 1ml 3x a day 1hr NPO after intakeParacetamol drops 1ml q 4hrs PRNZinc s04 drops 1ml ODProtexin (restore) OD

Describe the importance of regularly taking of prescribed medications including the potential unpleasant effects of non compliance.

Instruct the mother of the client to continue with follow up medical care.

Advise the mother of the client not to miss the intake of medications given by their physician upon discharge.

Environment And Exercise Maintain a quiet, environment to promote relaxation. Provide clean and comfortable environment.

Encourage client to continue deep breathing exercises, also instruct the family for the exercise needed. This is to promote circulation of blood, relaxation also.

Exercise that appropriate for the clients age . Such as active and passive range of motion.

Treatments Continue home medications.

For the follow-up check-up repeat.

Encourage patient to take multivitamins for immunity.

Follow doctors adviseHealth Teachings Instruct the mother of the client that the client

must always wash his hands.Perform good oral and personal hygieneProvide a clean environmentIt can reduce the risk of having foot- mouth disease by always performing hand washingDisinfect common areasTeach good hygiene. Show your children how to practice good hygiene and how to keep themselves clean. Explain to them why it's best not to put their fingers, hands or any other objects in their mouths.

Encourage the client to Increase fluid intake

Out Patient Follow up Patient will be advised to go back in the hospital in a specific date to have a follow-up check up after discharge.

Consult doctor for any problems or complications encountered such as: -Vomiting -Fever of 100.4oF or higher -Shaking Chills

Also if the physician advise the client to go back for a follow up check up for continuity of care

Diet Depends on physician order but here are some home remedies

Low salt low fat diet

Drink cold beverages, such as milk or ice water

Avoid acidic foods and beverages, such as citrus fruits, fruit drinks and soda

Avoid salty or spicy foods

Eat soft foods that don't require much chewing

Rinse your mouth with warm water after meals