NursingEnglishroundsofachildwithKawasakidisease一例川崎病患兒的護(hù)理英文查房華中科技大學(xué)同濟(jì)醫(yī)學(xué)院附屬同濟(jì)醫(yī)院兒童感染消化科王夢月

辛玉麒王艷爽

周星雨01病例導(dǎo)入目錄CONTENTS

CaseintroductionNursingdiagnosisandinterventions02疾病介紹03護(hù)理診斷及措施04健康宣教HealtheducationCaseDiseaseintroduction

Caseintroduction

病例導(dǎo)入PART0101Patientprofile姓名：睿睿性別：女年齡：3歲5個(gè)月入院時(shí)間：2023年6月27日診斷：膿毒血癥川崎??？主訴：反復(fù)高熱五天，嘔吐3次現(xiàn)病史：抗生素＋抗病毒＋地塞米松治療無效·Name:ruiruiGender:girl·Age:threeyearsandfivemonths·Admissiontime:June27,2023·Diagnosis:Sepsis

Kawasaki

disease

?·Chiefcomplaint:

repeated

highfeverfor

fivedays,vomiting3times

·Historyofpresentillness:thetreatmentwith

antibiotics,antiviraldrugsanddexamethasonewasineffective1-1新生兒?？坪喗锳dmissionsignT：39.2℃P：120beat/minR：30beat/minOutofmind,moresleepandpoordiet精神欠佳，睡眠較多飲食較差Theneckbehindthelefteartoucheda5×2cmhotredenvelope左側(cè)耳后頸部觸及5×2cm大小發(fā)熱發(fā)紅包塊Pharyngealcongestionwasevident,andbilateraltonsilswereonceswollen咽充血明顯,雙側(cè)扁桃體一度腫大Bilateralsubcutaneouslymphnodesincreasedinvolume雙側(cè)頸部皮下淋巴結(jié)部分體積增大Enlargementoftherightparotidgland,heterogeneousparenchymalecho(consideringinflammatorylesions)右側(cè)腮腺體積增大實(shí)質(zhì)回聲不均勻（考慮炎性病變）1-1新生兒專科簡介6.276.297.57.66.307.2Thehighestbody

temperaturewas40.0℃,andtheskincolorisred.Thetemperaturewasnormal,andtheppatientwasdischargedaccordingtothedoctor'sadvice.Easytostartleandconvulsion,slightlycongestedeyelidsandconjunctiva,redlips,obviouspharyngealcongestion,bilateraltonsilswithdegreeIswellingRedhandsandfeet,roughrespiratorysoundsinbothlungsExamination:Atrialseptaldefect,pericardialeffusionDryandcrackedlips,strawberrytongueScatteredlightredrashescanbeseenonthetrunkandlimbs,withobviouspeelingonthefingertipsofthefingersusion7.1Admissionsign單擊此處添加文本具體內(nèi)容6.27單擊此處添加文本具體內(nèi)容6.29單擊此處添加文本具體內(nèi)容6.30單擊此處添加文本具體內(nèi)容7.2單擊此處添加文本具體內(nèi)容7.5AdmissionsignWBC（5.0-12.0）*10^9/LHb（120—220）/LPLT（100–300）*10^9

D—二聚體0～0.5mg/LHypercoagulabilityoftheblood血液高凝狀態(tài)參考范圍：LaboratoryassistedexaminationresultsDiseaseintroduction

疾病介紹

ThefirstpartofthediseasePART02021-1新生兒?？坪喗镈iseaseintroduction

川崎病是一種以全身中小動(dòng)脈炎為主要病變的急性發(fā)熱出疹性的疾病，主要影響6個(gè)月至5歲的兒童（男孩多于女孩）。1967年由日本醫(yī)生川崎富首次報(bào)道，曾稱為皮膚黏膜淋巴結(jié)綜合癥（MCLS），屬于自身免疫性血管炎綜合征，其病因至今仍不完全清楚。其危害主要是引起冠狀動(dòng)脈損害，是兒科最常見的后天性心臟病。Kawasaki

disease（KD）isanacutefebrileanderuptivediseasewithsystemicarteritisasthemainlesion,whichmainlyaffectsboysandchildrenbetweentheagesof6monthsand5years（Moreboysthangirls）.ItwasfirstreportedbyJapanesedoctorTomizuKawasakiin1967.Itwascalledmucocutaneouslymphnodesyndrome(MCLS),whichbelongstoautoimmunevasculitissyndrome.Itsharmismainlycausedbycoronaryarterydamage,whichisthemostcommonacquiredheartdiseaseinpediatrics.1-1新生兒專科簡介Diseaseintroduction診斷不明原因發(fā)熱5天以上四肢變化:急性期掌距紅斑，手足硬性水腫，恢復(fù)期指趾端膜狀脫屑軀干、四肢多形性紅斑雙側(cè)眼結(jié)合膜充血，非化膿性口唇潮紅、皺裂，口腔黏膜充血、草莓舌頸淋巴結(jié)非化膿性腫大注:伴上列6項(xiàng)中5項(xiàng)者，排除其他疾病，即可診斷，如5項(xiàng)中不足4項(xiàng)，但超聲有冠狀動(dòng)脈損害，亦可診斷。DiagnosisFeverofunknowncauseformorethan5days.Changesoflimbs:palmardistanceerythemainacutestage,rigidedemaofhandsandfeet,membranousdesquamationattheendoffingersandtoesinrecoverystage.Erythemamultiformeoftrunkandlimbs.Bilateralocularconjunctivalhyperemia,non-suppurative.Lipflush,crease,oralmucosacongestion,strawberrytongue.Non-suppurativeswellingofcervicallymphnode.Note:Patientswith5oftheabove6items,excludingotherdiseases,canbediagnosed,iflessthan4ofthe5items,butthereiscoronaryarterydamageonultrasound,canalsobediagnosed.Country國家Morbidity發(fā)病率Japan1/500UnitedStates20/100,000China50/100,000Morbidity

發(fā)病率KDwasfirstdiscoveredinJapan,

Butitaffectschildrenallovertheworld川崎病首先是在日本發(fā)現(xiàn)的，但全球的兒童都會(huì)發(fā)病TheincidencerateofchildreninChinaisaboutonefifthofthatinJapan.中國兒童的發(fā)病率約為日本的五分之一。1-1新生兒專科簡介Etiology

病因

LOREMIPSUMDOLOR

EB病毒，逆轉(zhuǎn)錄病毒或鏈球菌丙酸桿菌感染。病因一：感染環(huán)境污染化學(xué)藥物病因三：其他機(jī)體對感染源的過敏反應(yīng)參與了發(fā)病機(jī)制病因二：免疫反應(yīng)010203Causeone:infectionEpstein-Barrvirus,retrovirus,orstreptococcuspropionibacteriuminfection.Causetwo:immuneresponseThebody'sallergicreactiontothesourceofinfectionisinvolvedinthepathogenesisCausethree:OthersEnvironmentalpollutionChemicaldrugTypicalclinicalmanifestations典型臨床表現(xiàn)Highfever（overfivedays）StrawberrytonguewithredlipserythemaCongestionofeyelidconjunctivaHandswellingandpeelingFeetswellingandpeelingVallatepapillaFiliformpapillaFoliatepapillaBacterialpapillaWhydoesKDappearstrawberrytongue川崎病患兒的舌背呈草莓狀外觀改變可能源于絲狀乳頭的角化上皮脫落，裸露的舌背充血呈紅色外觀，其表面點(diǎn)綴著發(fā)炎和肥大的菌狀乳頭(草莓籽)Thestrawberry-likeappearanceofthebackofthetongueinchildrenwithKawasakidiseasemaybeduetotheremovalofthekeratinizedepitheliumofthefilamentarypapillae.Thebarebackofthetonguehasacongestedredappearanceanditssurfaceisdottedwithinflamedandhypertrophicbacterialpapillae(strawberryseeds).1995年至2017年間，有4346名兒童被診斷為KD。每100000名兒童中KD的年發(fā)病率分別為22.0(<5歲)、6.1(5-9歲)和0.6(10-18歲)。所有年齡組的KD發(fā)病率都顯著增加，包括每100000名5歲以下兒童中有184例增加到250例。90天死亡率發(fā)生在≤5名兒童(≤0.1%)。川崎病發(fā)病率在所有年齡組，男性和女性都有顯著增加。KD已在超過60個(gè)國家報(bào)告，并且由于亞洲發(fā)病率的上升，全球發(fā)病率也在上升。ClinicalstageBystagesVariationcharacteristicsPhaseIAbout1~2weeks,itischaracterizedby:①inflammatorychangesofarterioles,venulesandmicrovesselsandtheirsurroundingtissues;②inflammatorychangesofmediumandlargearteriesandtheirsurroundingtissues;③Infiltrationandlocaledemaoflymphocytesandotherleukocytes.PhaseIIAbout2~4weeks,itscharacteristicsareasfollows:①theinflammatorychangesofsmallbloodvesselsarealleviated;②Inflammatorychangesofmiddlearteryarethemainchanges,whicharemorecommonincoronaryvasculitis,forminganeurysmsandthrombi;③Totalvasculitisofaortaisrare;④Theinfiltrationornecrosisofmonocyteschangedsignificantly.PhaseIIIAbout4~7weeks,itscharacteristicsareasfollows:①theinflammatorychangesofsmallvesselssubsided;②Granulomaoccurredinthemiddleartery.PhaseIVAbout7weeksormore,theacuteinflammatorychangesofbloodvesselsaremostlysmall,replacedbycoronarythrombosis,stenosis,obstruction,intimalthickening,aneurysmandscarformation.TheHazardsofKawasakiDisease（危害）Damagetheheart損害心臟Carditis（Endocarditis,valvulitis、pericarditis）90％

心臟炎（心內(nèi)膜炎、瓣膜炎、心包炎

）90％Coronaryarterydisease（冠狀動(dòng)脈病變）coronaryarteritis50%

（冠狀動(dòng)脈炎50%）coronaryarteryaneurysm（CAA）25~30%

（冠狀動(dòng)脈瘤25~30%）Ischemiclesions（缺血性病變）

angina（心絞痛）

Myocardialinfarction:Threequartershappenwithinayear

心肌梗塞：3/4發(fā)生在1年內(nèi)

TheHazardsofKawasakiDisease（危害）jeopardize消化系統(tǒng)digestivesystemAbdominalpain,diarrhea,vomitingBowelobstructionGallbladderenlargementjaundice腹痛腹瀉嘔吐腸梗阻膽囊腫大黃疸TheHazardsofKawasakiDisease（危害）jeopardize神經(jīng)系統(tǒng)nervoussystemMentalDisordersofconsciousnessConvulsionViralmeningitis精神意識(shí)障礙驚厥病毒性腦膜炎TheHazardsofKawasakiDisease（危害）urinarysystem泌尿系統(tǒng)Proteinuria

蛋白尿Urethritis

尿道炎Pulmonarylesion肺部損害Pulmonaryarteritis

肺動(dòng)脈炎Interstitialpneumonia

間質(zhì)性肺炎arthropathy關(guān)節(jié)病變Arthritis

關(guān)節(jié)炎Auxiliaryexamination輔助檢查添加標(biāo)題Bloodtest血液檢查Cardiovascularsystemexamination心血管系統(tǒng)檢查Others其他（胸片、尿常規(guī)等）彩超

冠狀動(dòng)脈擴(kuò)張、冠狀動(dòng)脈瘤、冠狀動(dòng)脈狹窄心電圖

R波和T波下降，是預(yù)測冠狀動(dòng)脈病變的主要線索冠狀動(dòng)脈造影Cardiovascularsystemexamination心血管系統(tǒng)檢查Colourultrasound：Coronaryarterydilated,coronary

arterytumor,Coronaryarterystenosis.

electrocardiogram(ECG)：ThedecreaseofRwaveandTwaveisthemaincluetopredictcoronaryarterydiseaseCoronaryangiographyTherapy治療Treatmentprinciple:nospecificdrugs,useanticoagulation,anti-inflammatorycontrolvasculitis,preventionofcoronaryarterydamageandmyocardialinfarction治療原則：無特效藥，采用抗凝，抗炎控制血管炎，預(yù)防冠脈損害和心肌梗塞Drugtherapy（藥物治療）

Aspirin

阿司匹林

Intravenousimmunoglobulin

丙種球蛋白

Glucocorticoids

糖皮質(zhì)激素Operativetreatment（手術(shù)治療）

Coronaryarterybypassgrafting

（冠狀動(dòng)脈旁路移植術(shù)）

Coronaryangioplasty（冠狀動(dòng)脈血管成形術(shù)）

Aspirin

阿司匹林（ASA）抗炎，抗凝30～50mg/kg/dpotid退熱后3d逐漸減量至3~5mg/kg/d療程：1～3月首選FirstchoiceAnti-inflammatory，anticoagulation30～50mg/kg/daypotidAfterthefeversubsided,thedosagewasgraduallyreducedto3~5mg/kg/dayCourseoftreatment：1~3monthsimmunoglobulin

免疫球蛋白（IVIG）Thebestsolutionatpresent:ASA+IVIGItcanshortentheheatcourseandreducetheincidenceofcoronaryaneurysmCommonsolution:1~2g/kg·times,8~12htofinishBetterresultswithin10days.Iftheeffectisnotgood,itcanbereused目前最佳方案：ASA+IVIG可以縮短熱程，降低冠狀動(dòng)脈瘤的發(fā)生率常用方案：1～2g/kg·次，8～12h輸完10天內(nèi)應(yīng)用效果更好。效果不好者，可重復(fù)使用Foranti-infectionandcoronaryarteryprotection,whichcaneffectivelyreducecoronaryarteryinjury.用于抗感染和保護(hù)冠狀動(dòng)脈，能夠有效降低冠狀動(dòng)脈損傷Duringtheinfusionofproglobulin,ensurethatitisinthebloodvesselanddoesnotleakout.丙球蛋白輸注時(shí)，確保在血管內(nèi)，禁止外漏。Glucocorticoids

糖皮質(zhì)激素Shouldnotbeusedalone,shouldbeusedwithASAanddipyridamineapplication,2mg/kg/d,2~4W.Methylprednisolone,prednisone.不宜單獨(dú)使用，配合ASA和潘生丁應(yīng)用，2mg/kg/d，2～4W。甲強(qiáng)龍，潑尼松

Nursingdiagnosisandmeasures護(hù)理診斷及措施PART0303Diagnosis

護(hù)理診斷Hyperthermia體溫過高Relatedtoinfectionandimmunefactors.與感染、免疫反應(yīng)等因素有關(guān)Riskofdamagetoskinintegrity有皮膚完整性受損的危險(xiǎn)RelatedtosmallVasculitis.與小血管炎有關(guān)Riskofdamagetotheoralmucosa有口腔黏膜受損的危險(xiǎn)RelatedtosmallVasculitis.與小血管炎有關(guān)Theriskofbleeding有出血的危險(xiǎn)Relatedtotheuseofanticoagulantdrugs.與使用抗凝藥物有Thereisariskofbloodclotsforming有血栓形成的風(fēng)險(xiǎn)Relatedtothehypercoagulabilityoftheblood.與血液高凝狀態(tài)有關(guān)Malnutrition:lessthanthebodyneeds營養(yǎng)失調(diào)：低于機(jī)體需要量Relatedtoinsufficientenergyintakeandexcessiveconsumption.與能量攝入不足和消耗過多有關(guān)Anxiety、fear焦慮、恐懼Relatedto

notadapttotheenvironment與不適應(yīng)環(huán)境有關(guān)Lackofknowledge知識(shí)缺乏LackofunderstandingofKDandthetreatment.缺乏對川崎病疾病及治療的了解Potentialcomplication潛在并發(fā)癥Relatedtocardiovasculardisease.與心血管病變等有關(guān)1-1新生兒?？坪喗镠yperthermiacaremeasuresDrugcooling:ParacetamolDiclofenacsodium藥物降溫：對乙酰氨基酚/雙氯芬酸鈉Regularmonitoringofbodytemperature

定期監(jiān)測體溫Physicalcooling

物理降溫Temperatureandhumidity：Roomtemperature20~22C°Humidity50%~60%.

適宜溫濕度：室溫20~22C°，濕度50%～60%Stayinbed臥床休息

feverDrinkplentyofwater，intravenousrehydrationifnecessary

多飲水，必要時(shí)靜脈補(bǔ)液Skinintegritydamagemeasures加強(qiáng)護(hù)理，注意局部皮膚黏膜清潔勤剪指甲，以免抓傷擦傷對半脫的痂皮用干凈剪刀剪掉，切忌強(qiáng)行撕脫，防止出血和繼發(fā)感染。StrengthennursingcareandpayattentiontolocalskinandmucosacleaningCutyournailsoftentoavoidscratchesandbruisesCutoffthehalf-detachedcrustwithcleanscissors,andavoidforcedavulsiontopreventbleedingandsecondaryinfection.1-1新生兒專科簡介Oralmucosadamagemeasures

每日做好口腔護(hù)理，保持口腔清潔。用軟毛牙刷刷牙，避免食用油炸、帶刺或含骨頭的食物、質(zhì)硬（如甘蔗）等易造成口腔粘膜機(jī)械性損傷的食物。

Dooralcareeverydayandkeepyourmouthclean.Brushyourteethwithasofttoothbrushtoavoideatingfried,pricklyorbone-containingfood,hardfood(suchassugarcane)andotherfoodsthatareeasytocausemechanicaldamagetooralmucosa.1-1新生兒?？坪喗镺ralmucosadamagemeasures

餐前餐后及時(shí)漱口，保持口腔衛(wèi)生，防止繼發(fā)感染，以增進(jìn)食欲，口唇干裂碘甘油局部應(yīng)用。漱口液1%～2%碳酸氫鈉溶液，生理鹽水，3%硼酸溶液Mouthwash1%-2%sodiumbicarbonatesolution,normalsaline,3%boricacidsolutionRinsemouthintimebeforeandaftermeals,maintainoralhygiene,preventsecondaryinfection,toimproveappetite,drylipsiodineglycerinlocalapplication.1-1新生兒?？坪喗镹ursingmeasuresforpreventingbleeding

1.皮膚出血的護(hù)理

避免皮膚摩擦及肢體受壓，勤剪指甲，避免人為創(chuàng)傷。2.使用阿司匹林后：密切觀察，有無出血現(xiàn)象，觀察患兒大便的顏色、量及性質(zhì)。3.使用潑尼松后：觀察患兒惡心嘔吐及消化道出血現(xiàn)象。1.Skinbleedingcaretoavoidskinfrictionandlimbpressure,oftencutnails,toavoidartificialtrauma.2.Aftertheuseofaspirin:closelyobservewhetherthereisbleeding,andobservethecolor,quantityandnatureofthechild'sstool.3.Aftertheadministrationofprednisone:thesymptomsofnausea,vomitingandgastrointestinalbleedingwereobserved.EyecareInfantswithred,swollenandchappedeyelidsshouldwashtheireyeswithnormalsalineonceortwiceaday.Whentheyaredry,apply

erythromycineyeointmenttotheeyelidsandchappedparts.眼瞼紅腫、干裂的嬰幼兒，用生理鹽水洗眼1～2次/天，待干后，用紅霉素眼膏涂抹于眼瞼及干裂處。Avoidbrightlightstimulation避免直接強(qiáng)光刺激WhatisthecauseofthrombosisinKD?

川崎病的血栓形成的原因是什么？

炎癥內(nèi)皮功能障礙血小板數(shù)量增高黏附性增加凝血因子活化嚴(yán)重?cái)U(kuò)張部位的異常血流Highriskfactorsforthrombosis血栓形成的高危因素inflammationEndothelialdysfunctionIncreasedplateletcountIncreasedadhesionActivationofcoagulationfactorsAbnormalbloodflowinseverelydilatedareasPrinciplesofanticoagulanttherapy抗凝治療的原則Preventandinhibitthrombosis,dissolvethrombus,increasecoronaryarterybloodflow,preventandrelievecoronaryarteryspasm,andreduceheartworkload.預(yù)防、抑制血栓形成、并溶解血栓、增加冠狀動(dòng)脈血流、預(yù)防和解除冠狀動(dòng)脈痙攣、降低心臟工作負(fù)擔(dān)。PreventionofdeepveinthrombosisBasicprevention

Protectlowerlimbveins:AvoidlowerlimbpunctureandintravenousinfusionEarlyfunctionalexerciseanklepumpexerciseElevationofaffectedlimb:20°-30°aboveheartlevelDrinkmorewaterduringbed,>1500ml/day,avoidbloodconcentration,keepstoolunobstructed

PhysicalpreventionGradientstretchsocks,elasticbandages:asshortasonemonth,aslongasseveralmonths.Drugprophylaxis基礎(chǔ)預(yù)防保護(hù)下肢靜脈：避免下肢穿刺和靜脈輸液

早期功能鍛煉踝泵運(yùn)動(dòng)。

抬高患肢：高于心臟水平20°-30°臥床期間多飲水，＞1500ml/日，避免血液濃縮，保持大便通暢物理預(yù)防梯度彈力襪，彈力繃帶：時(shí)間短至一個(gè)月，長至數(shù)月藥物預(yù)防PreventionofdeepveinthrombosisAntiplateletdrugs抗血小板藥物Aspirin阿司匹林dipyridamole雙嘧達(dá)莫

clopidogrel氯吡格雷Anticoagulationtherapy抗凝治療Lowmolecularweightheparin低分子肝素(LMWH)Ifcardiacultrasoundindicatesthrombosis,thetherapeuticdoseofLMWHisgivenuntilthethrombusdisappears,theaneurysmisstableanddoesnotcontinuetoexpand,anditisexcessivetotakewarfarinorally.

若心臟超聲提示合并有血栓形成，給予治療量低分子肝素，直至血栓消失，動(dòng)脈瘤穩(wěn)定不再繼續(xù)擴(kuò)張，過度至華法林口服。Thrombolyticdrugs溶栓藥物

Tissueplasminogenactivator組織纖維溶酶原激活劑0.5mg/(kg·h)wasinjectedintravenouslywithmicropumpfor6hours.(mostpreferred)0.5mg/(kg·h)微泵靜脈注射，共6h。（最優(yōu)選）Nutritionalsupport飲食上要選擇清淡、高熱量、高蛋白、高維生素的流食或者半流質(zhì)Thedietshouldchooselight,highcalorie,highprotein,highvitaminliquidorsemi-liquid.eggsbeefskiwiscarrotstomatoesEggs,beefs,lambs,butalsoeatsomefreshfruitsandvegetables,apples,crystalpears,kiwis,cabbages,carrots,tomatoes,andsoon.雞蛋，牛肉，羊肉，也要多吃一些新鮮的瓜果和蔬菜，蘋果，水晶梨，獼猴桃，大白菜，胡蘿卜，西紅柿等Foodrecommended川崎病小孩血小板有不同程度升高，避免飲食過于油膩，少吃油炸熏烤類食物，造成血液進(jìn)一步黏稠，有發(fā)生血栓風(fēng)險(xiǎn)。ChildrenwithKawasakidiseasehavevaryingdegreesofelevatedplatelets,avoideatingtoogreasy,eatlessfried,smokedandgrilledfoods,resultinginfurtherviscousbloodandtheriskofthrombosisFoodtoavoidChildanxietyandfearnursingmeasures1.Establishatrustingnurse-patientrelationship.2.Helpthemadapttothenewenvironmentassoonaspossibleandreducepressure.3.Teachrelaxationtechniques:

①Encouragechildrentoexpresstheiremotionsinaverbalway②Supervisethechildtorelax,suchasplayinggameswiththenurse'sguidanceandmusicinasoftlightenvironment③Encouragethemtoparticipateinrecreationalactivities,soastodivertattentionandreduceanxiety.1·建立信任的護(hù)患關(guān)系2·幫助其盡快適應(yīng)新的環(huán)境,減少壓力3·教導(dǎo)放松技巧①鼓勵(lì)患兒以語言表達(dá)的方式疏泄情緒②督導(dǎo)患兒進(jìn)行放松,如在光線柔和的環(huán)境里,隨著護(hù)士的指導(dǎo)語和音樂進(jìn)行游戲③鼓勵(lì)其多參加娛樂活動(dòng)，從而轉(zhuǎn)移注意力，減輕焦慮情緒。Knowledgelackscaremeasures

Patientlyexplaintothefamilythediseaseandtreatmentplan,thenaturalcourseofthedisease,sothattheygetrelevantknowledge,andgivepsychologicalsupport,providehealthguidanceforthechild,dietplan.

向家屬耐心解釋疾病和治療方案，疾病的自然轉(zhuǎn)歸過程，使之得到有關(guān)知識(shí)，并給予心理支持，提供患兒健康指導(dǎo)，飲食方案。PotentialcomplicationIntheacutephase,absolutebedrest,vitalsignsweremeasuredevery4h,ultrasoundcardiogramandECGmonitoringwereperformed,andafterdischarge,itwasstillnecessary