Acute Urticaria

1.

a. Assess and record pain and its characteristics: intensity, location, quality, frequency, and duration using FLACC scale. Rationale: Data assists in evaluationg pain and pain relief and identifying multiple sources and types of pain. The use of the FLACC scale allows the nurse to gage whether a child may be in pain by assessing their face, legs, activity, crying, and consolidability. (B.260)

b. Explain to the mother that the pain is real and will assist them in dealing with it. R: Fear that pain wont be accepted as real increses tension and anxiety and decreases pain tolerance (B.260)

c. Nurse will teach the mother additional strategies to relieve pain and discomfort within 24 hours. R: The use of these strategies along with analgesia may produce more effective pain relief. (B.260)

d. Nurse will obtain additional prescriptions from doctor and pharmacist as needed. R:inadequate pain relief results in an increased stress response, suffering, and prolonged hospitalizations. (B.260)

2.

a. Assess for signs and symptoms of infection every 4 hours (fever, skin temperature, color, and lab values). R: Assessing for infection every 4 hours allows the nurse to respond quickly if infection occurs; which will increase recovery time. (394 c.)

b. Assess the skin turgor, color, temperature, and peripheral pulses every hour. R: In early septic shock, warm, dry, flushed skin and bounding pulses are evident as a result of initial vasodilation. As the shock state continues, skin becomes cool, clammy, and cyanotic with reduced peripheral pulses. (394.c)

c. Teach the mother how to improve the patients nutritional status during hospital stay. R: The client's nutritional status must be adequate and a positive nitrogen balance must be maintained because skin will heal more slowly and is more resistant to treatment in clients with nutritional disorders. (189.B)

d. Collaborate with a physican to obtain PRN medication for if a fever occurs. R: PRN medicaitons allow the nurse to provide quicker care when an issue occurs. (260 B.)

3.

a. Assess skin for temperature, and color. R: Assessing the skin allows the nurse to see if the rash is progressing or getting better. (B. 852)

b. Perform skin care with warm water and mild soap. R: Cleansing the skin removes debris and bacteria, which promotes healing. (952. c)

c. Nurse will teach the mother about medication (what side effects may occur and when to seek medical help). R: Providing education to the caregiver will allow the child to recieve medication safely at home. (939.k)

d. Nurse will collaborate with a physican to prescribe medication for home use. R: The physican may order an over-the-counter medication to help relieve symptoms from hives. (260 B.)

Nursing Interventions:

Acute Urticaria

Nursing Diagnosis:

1. Acute Pain related to inflammatory response as evidenced by preoccupation with self, and changes in sleep pattern.

2. Risk for infection related to severe inflammation.

3. Impaired skin integrity related to inflammatory response AEB inflammation, pruritis, and redness.

Evaluation:

1. Outcome met, client showed no pain AEB a score of 0 on FLACC scale. Discontinue outcome/interventions.

2. Outcome met, client's remained infection free AEB warm skin, temperature of 98.7, and decrease of redness to body. Discontinue outcome/interventions.

3. Outcome met, client's mother was able to list more than 3 side effects of Diphenhydramine before discharge. Discontinue outcome/interventions.

Objective Data:

Expected Outcomes:

Female

14 months

Acute Urticaria

Weight: 10.49kg, Height: 75 cm

Growth Chart Percentiles: Ht - 95%, Wt - 50%

Latest vitals: T 98.7 F, P 127 bpm, R 24, BP 83/57.

Skin has areas of red raised patches located all over the back, right medial lower extremity, and right side of face near mouth .

Skin is warm, dry, it is uniformly thin with no edema.

Skin turgor is less than 2 seconds.

Capillary refill less than 2 seconds.

Active range of motion on all extremities.

Lungs are clear bilaterally to the posterior and anterior lobes with no wheeze, rales. or rhonchi.

1. Client will show no signs of pain within hospital stay AEB a score of zero on the FLACC scale (no particular expression, relaxed position, lying quielty, no crying, and content).

2. Client will remain free of infection within hospital stay AEB normal temperature, decreased or absence of redness, and a warm skin temperature.

3. Client's mother will list 3 side effects of medication prescribed (drowsiness, dizziness, and upset stomach) before discharge.

Concurent Medical Hx

Subjective Data:

Labs and Diagnostics:

• No current medical history

• No labs or diagnostics were performed.

• Client's mother states she noticed the urticaria the morning after the child had her immunizations (MMR, Hib, pneumococcal, and 2nd dose of flu).
• Client's mother states the rash keeps reappearing in new locations.
• Client's mother states she has not had any issues with feeding/intake.
• Client's mother states she has no known allergies.
• Client's mother states she lives with her mother, father, grandmother, grandfather, 14 year-old sister, and 9 year-old brother.

Medications:

• Diphenhyrdramine 12.5 mg PO

Thank You!