grand case study v7 final 030310

8/7/2019 GRAND CASE STUDY V7 FINAL 030310

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OBJECTIVES

I. General Objective

This study aims to present the case of a patient diagnosed with Kawasaki

Disease and highlight the nursing management associated with the medical care

provided to a patient with such a disease.

II. Specific Objectives

The following serve as a guide the accomplishment of the main objective:

1. Since Kawasaki Disease is a rare yet potentially debilitating disease mostly

seen in children, one of the goals of this study is to expand the knowledge

and appreciation of the disease by presenting its clinical manifestations,

complications, treatment, and prognoses;

2. Kawasaki Disease is a systemic vasculitic disease with possible affectations

of the heart, coronary arteries, skin, and lymph vessels, hence, this study

aims to promote the nursing interventions needed for the symptomatictreatment of the disease;

3. The incidence and treatment of Kawasaki Disease in the Philippines is not

well documented, therefore, another goal of this study is to potentially serve

as a significant reference for other researchers who wish to expand local

knowledge about the disease.

INTRODUCTION

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I. Definition and History

Kawasaki Disease (KD) is an acute febrile vasculitic syndrome that affects

infants and young children. It is also known as Mucocutaneous Lymph Node

Syndrome (MLNS). KD is now the leading cause of acquired heart disease in

children in most developed countries. More than eighty-five percent (85%) of

cases are children below five years of age and the mortality rate is presently 0.1

to 2%. Mortality is based on complications, which include coronary arteritis,

coronary artery aneurysms and stenoses, and coronary thrombosis which may

lead to myocardial infarction, sudden death, or congestive heart failure. About

twenty-five percent (25%) of untreated KD patients develop coronary artery

aneurysms.

KD was first observed and diagnosed in 1961 by Dr. Tomisaku Kawasaki

at the Japan Red Cross Medical Center in Tokyo. Between 1961 to 1967, Dr.

Kawasaki reported fifty (50) infants and young children who presented with

several signs that included prolonged remittent fever, unilateral cervical

lymphadenitis, bilateral conjunctival injection, polymorphous erythematous rash,

erythema and edema of the hands and feet, inflammation of the lips and oralcavity, and subsequent desquamation of the fingers, toes, and periungual area.

He ruled out other possible diagnoses after negative laboratory results and was

convinced that he was treating a unique clinical syndrome. The first recorded

case that had cardiac involvement was in 1968, when Kawasaki and a colleague

reported a client manifesting with tachycardia, abnormal heart rhythm, and

cardiomegaly. Several years after, Kawasaki presented post-mortem evidence

of a number of patients diagnosed with KD who died due to coronary artery

complications.

KD is known to cause outbreaks in Japan, where the incidence of the

disease is about 150 to 175 cases per 100,000 children or more than 10,000 new

cases per year. In the United States, the incidence is about 15 per 100,000

children or less than 4,000 new cases per year.

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II. Possible Risk Factors

The main cause or root of Kawasaki Disease is unknown. However,

possible risk factors and causes have been researched and studied to identify

the cause of the disease

1. Age

More than 90% of KD cases occur in children less than ten years of age.

Eighty-five percent (85%) of cases were diagnosed in patients less than five

years old and 50% in children younger than two years of age.

2. Gender

The ratio of male to female patients with KD is 1.5:1 internationally. It is

evidently more common in males than in females.

3. Race

Worldwide, Japan has the highest rate of incidence with approximately

10,000 new cases yearly. KD has been known to cause outbreaks in Japan

usually during the winter and spring seasons. In the United States, the

incidence is roughly 4,000 new cases yearly with rates intermediate among

African-Americans and those with Asian and South Pacific ancestry other

than Japan. In the Philippines, concrete data about the annual rate of KD isnot present.

The cause of KD is idiopathic although some studies suggest it to be

infectious. The bases for this assumption are the outbreaks reported in Japan

and the United States during the winter and spring seasons where the incidence

of KD doubles compared to the summer and fall seasons. Another reason for

this assumption is the fact that the acute stage of KD is self-limiting even without

IVIG medication.

The following possible pathologic agents have been suggested:

1. Parvovirus and Rotavirus infection

2. HIV

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3. Rubella

4. Meningococcal septicemia

5. Klebsiella pneumoniae bacteremia

6. Coxiella burnettie

7. Human lymphotropic virus infection

III. Clinical Manifestations

Kawasaki Disease has diagnostic criteria to distinguish it from other

diseases with similar clinical manifestations.

1. Fever for at least 5 days with at least four (4) of the following features:

2. Bilateral conjuctival injection

3. Polymorphous exanthema or rashes

4. Changes in the lips and oral cavity (i.e. erythema, cracked lips, strawberry

tongue)

5. Changes in the peripheral extremities (i.e. edema in the hands and feet,

desquamation of fingers, toes, and periungual area)

6. Unilateral cervical lymphodenopathy (palpable; at least 1.5cm in diameter)

7. Exclusion of other diseases with similar presentations

The following signs and symptoms are present in the disease during its

stages:

Acute Stage (Days 1 to 11)

High fever

Irritability

Bilateral conjunctivitis

Rashes

Strawberry tongue and lip fissures (cracks)

Unilateral lymphadenitis

Mild hepatic dysfunction

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Myocarditis, pericarditis, mitral valve regurgitation, and depressed

myocardial functioning can be recorded by electrocardiogram

Sub-acute Stage (Days 11 to 30)

Persistent irritability, anorexia, and conjunctival injection

Thrombocytosis

Decreased temperature

Arthritis or arthralgia

Desquamation of fingers and toes beginning at the periungual region

Development of coronary aneurysms

NOTE: This is the stage with the highest mortality

Convalescent Stage (Day 30 and above)

Inflammatory markers return to normal

Disappearance of signs and symptoms

Expansion of aneurysm leading to possible myocardial infarction

Smaller aneurysms resolve independently (60% of cases)

IV. Diagnostic Examinations and Medical Treatment

The laboratory findings in KD are non-specific, but indicative of illness:

Leukocytosis with neutrophilia (WBC in excess 15,000/mm3) with

predominance of immature or mature granulocytse

Elevated sedimentation rate (greater than 40mm/hour)

Anemia (Hgb is below 110g/L)

Thrombocytosis (Platelet count of more than 500,000/mm3)

Hypoalbuminemia and hyponatremia

Plasma lipid abnormalities

Sterile pyuria

Elevated serum transaminases

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The medical treatment for Kawasaki Disease is intravenous

immunoglobulin (IVIG) with supportive medication of aspirin for anti-platelet

therapy:

DRUG DOSAGE FREQUENCY

IVIG 2g/kg infusion over 10 to 12

hours OR;

400mg/kg/day

* IVIG may be repeated if fever

persists or recurs together with at

least one classic sign of KD

Single dose

For 4 days

Aspirin 80-100mg/kg/day then;

3-5mg/kg/day

In 4 divided

doses until

14h day of

illness and

patient is

afebrile for at

least 3-4 days

Once daily for

6 to 8 weeks

IVIG is a purified preparation of gamma globulin. It is derived from large

collections of human plasma composed of several classes of antibodies. The

effect that IVIG has in the treatment of KD is not exactly known, but prognosis is

greatly improved after its administration no later than the tenth (10 th) day of

illness. IVIG aids in the treatment of systemic inflammation, which causes the

vasculitis in KD.

High-dose aspirin is used for the treatment of inflammation in KD. Low-

dose aspirin is used to inhibit platelet aggregation.

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PATIENT PROFILE

I. Demographic Data

Name: Patient CDC

Age: 1.5 years old

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Address: Blk15 Lot 10, Our Mahogany 1 Village, Pulo, Cabuyao,Laguna

Birthday: July 10, 2008

Birth Place: San Pablo City, Laguna

Religion: Roman Catholic

Sex: F

Nationality: Filipino

Mothers Name: Roselia Age: 33 y/o Occupation: Employee (Human Resources)

Fathers Name: Dante Age: 38y/o Occupation: Employee (Quality Control)

II. Admission Data and Notes

Hospital: Philippine Childrens Medical Center

Date and Time of Admission: January 26, 2010 at 8:05pm (Emergency Room)

January 27, 2010 (Ward 1C)

Admission Diagnosis: ATP t/c Kawasaki Disease

Chief Complaint: Persistent fever

Attending Physicians: Dr. H. Lim and Dr. O. Teormoso

Patient Weight: 11.5 kg

Vital Signs: Temperature 39.5C

Cardiac Rate 120 bpm

Respiration Rate 30 cpm

Blood Pressure 90/60 mmHg

Doctors Admission Notes:

System: awake, irritable

EENT: cry, cracked lips

Neck: (-) clap

Lungs: SLE (-) retractions

Heart: (-) murmur

Extremities: good pulses, (+) edema

Skin: (+) erythematous maculopapular rash in extremities

(+) papular lesions in upper extremities and abdomen

III. History of Present Illness

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Patient CDC was admitted to the Emergency Room of the Philippine

Childrens Medical Center on January 26, 2010 at 8:05pm. He was later

transferred to Ward 1C (Non-Communicable Diseases) of PCMC on January 27.

The chief complaint of the patient was persistent fever as verbalized by the

mother.

Six (6) days prior to admission, patient had fever with minimal coughing.

Patient did not have rashes, diarrhea, or vomiting episodes. Patient was treated

with Paracetamol at 10ml per dose for fever. Patient still had good activity and

appetite.

Three (3) days prior to admission, patient still had fever associated with

erythema of the lips and eyes and rashes which erupted initially on the arms then

to the trunk. Mother was unable to document temperature due to unavailability of

thermometer.

Two (2) days prior to admission, patient still had fever and was seen at the

Laguna Health Center. Patient was given Paracetamol at 10ml per dose and

Chlorpheniramine three doses for allergy. The medications did not offer relief. In

the evening, the patient was given Cephalexin 125mg/5ml three times which also

offered no relief.

One (1) day prior to admission, patient was seen by a private doctor, whovisited patients home, due to persistent fever and papular rashes on the

extremities. CBC was done at ASJ Medical and Diagnostic Clinic and revealed

low platelet count. Patient was advised to be admitted to a hospital.

On the day of the admission, patient was seen by doctors in Jose Reyes

Memorial Medical Center. Patient was advised to go to PCMC.

IV. Past Medical History

Patient had no prior hospital confinements since birth. Patient did not

have any notable illnesses in the past.

V. Nutritional History

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Patient CDC was breastfed for the first 2 weeks after birth. A milk formula

was given from 2 weeks after birth to present. Ratio of formula is 1:1 milk to

water given 6 ounces every 2 hours.

Patient started eating cereals, meat, fruits, fish, and vegetables on the

sixth (6th) month. Twenty-four (24) hours prior to confinement, patient ate bread

and milk for breakfast, and rice and soup for lunch and dinner.

Patient is given Celine for vitamins.

Patient has no known food allergies.

VI. Growth and Development

For gross motor development, patient was reported to be able to stand

and walk alone by the time he was 1 year old.

For adaptive development, patient is able to indicate needs through

minimal verbal cues and crying.

For personal/social development, patient is able to use a spoon. Parents

indicate that patient is able to let them know if she has urinated or defecated.

Patient was able to do these after turning 1 year old.

According to the physicians notes, patients growth and development are

at par with age with no delays in development.

VII. Family Health History

Fathers Side: (+) cardiovascular accident

(+) hypertension

Mothers Side: (+) hyperthyroidism

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PHYSICAL ASSESSMENT

Name: Patient CDC

Age: 1 years old

Sex: Female

Department: Ward 1-C

Diagnosis: Kawasaki Disease.

Date and Time of Assessment: January 29, 2010 4:00 PM

I. General Survey

Received patient lying on bed, awake and responsive, not in any respiratory distress. With IVF of

0.9% NaCl 1000cc at right arm KVO. The patient measures 81cm in height and weighs 11.5kg. Patient appears to

be restless and irritable as evidenced by increased movement and uncontrollable crying. Patient does not appear

to be in respiratory distress.

II. Vital Signs

Techniques: Inspection, Palpation, Auscultation

Patient has temperature of 38.4C, axillary with cardiac rate of 121 beats per minute, regular respiratory rate

of 32 breaths per minute, and blood pressure of 90/60 mmHg.

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PART TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Skin Inspectionand

Palpation

Color varies from light todeep brown

No edema

Moisture in skin folds andaxillae

Skin temperature isuniform within normalrange

Erythematous andmaculopapular rashesare present on the back,abdomen, chest, andextremities

Hands and feet arereddish, edematous,

shiny, and dry-looking

Skin is moist especially onareas with folds; presenceof desquamation onfingers, toes, and labialarea

Skin temperature isuniformly warm due toelevated bodytemperature

Presence oferythematous andmaculopapular rashesis one criteria indiagnosis of KawasakiDisease

Changes in theperipheral extremities

such as edema anddesquamation arecriteria for diagnosingKawasaki Disease

Changes in theperipheral extremitiessuch as edema anddesquamation arecriteria for diagnosingKawasaki Disease

Temperature of 38.4Cupon assessment;persistent fever for atleast 5 days is theearliest sign ofKawasaki Disease

Source: Textbook ofPediatric InfectiousDiseases, Fifth Edition byFeigin, Ralph D. andCherry, James D.

Head Inspectionand

Palpation

Configuration isnormocephalic

No lesions or tenderness

Head is normocephalic inshape

Absence of lesions and nosigns of tenderness

Normal

Normal

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Anterior and posteriorfontanels are flat andclosed

Anterior and posteriorfontanels appear to be flatand closed

Normal

Hair Inspection Evenly distributed, thickhair, silky, resilient, noinfestation

Hair is thick, smooth,moist, and with no signs ofparasitic infestation

Normal

Eyes:Sclera

Cornea

Pupils

Eye Balls

Inspection

Inspection

Inspection

Inspection

Appears white

Transparent, shiny,smooth with cornealdetails visible

Black/brown in color;constricts whenilluminated and whenlooking at near objects;dilates when looking at farobjects

Symmetrically aligned

Eyeballs are symmetricalin size

Not protruding

Sclera is slightly reddish

Transparent, shiny,smooth; details apparent

Black in color; brisklyconstricts when illuminatedand dilates when notilluminated

Aligned

Eyeballs are symmetricalin shape and size

There is no protrusion

Bilateral non-purulentconjunctival injection

is one of the signs ofKawasaki Disease

Normal

Normal

Normal


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Palpebraland BulbarConjuctiva

Inspection Smooth, pink or red Bulbar conjunctiva areslightly reddish in color

Bilateral conjunctivalinjection is one of thecriteria in diagnosingKawasaki Disease

Source: Textbook ofPediatric InfectiousDiseases, Fifth Edition byFeigin, Ralph D. and

Cherry, James D.Ears Inspecton

andPalpation

Auricles fair in color

Symmetrical and alignedwith outer canthus of eyes

Auricles are flexible, firm,no tenderness

Absence of purulentdischarge in the externalcanal

Patient responds to sound

Auricles are fair in color,symmetrical in shape,flexible with no tenderness

There is no discharge fromthe ear canal

Responds to the voice ofmother and father

Normal

Normal

Normal

Nose Inspectionand

Palpation

Nares are patent

Septum on the midline

Mucosa is pinkish in color

Patent nares with septumon the midline

Mucosa is pinkish

Normal

Normal

Mouth Inspectionand

Palpation

Lips are moist and pinkishin color

Oral mucosa is pinkishwith no ulcerations

Lips are red in color, dry,and cracked

Oral mucosa is also deepred in color

Tongue is red and hasstrawberry-like texture

No ulcerations in oralmucosa

Changes in the mouthand oral mucosa are

some of the signs ofKawasaki Disease


Neck Inspectionand

Neck is symmetrical

Thyroid glands are not

Neck is symmetrical

Presence of a swollen

Normal

Unilateral cervical

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Palpation tender and enlarged

Neck muscles are equalin size

Trachea is positionedmidline upon palpation

lymph node on the leftside of the neck ; size ofthe lymph node isapproximately 1.5cm

Neck muscles are equal insize

Trachea is positionedmidline

lymphodenopathyappears in 50% to 75%of patients withKawasaki Disease

Normal

Normal

Source: Textbook of

Pediatric InfectiousDiseases, Fifth Edition byFeigin, Ralph D. andCherry, James D.

Chest Inspection,Palpation,Auscultation

Full and symmetric andnot bulging

Breathing is abdominaland posterior mobility andposture of thorax issymmetrical uponrespiration

Clear breath sounds

Chest is not bulging andappears symmetrical

Abdominal breathing ispresent (pediatric) withthoracic movementsymmetrical

No presence of harsh

breath sounds; patient wascrying and irritable duringassessment

Normal

Normal

Normal

Heart Auscultation S1 usually heard at allsites but louder at apicalarea

S2 usually heard at allsites but louder at base ofthe heart

S1 and S2 are heardaudibly on apical and baseareas of the heart

No murmur or gallops (S3and S4)

Normal

Breast Inspection Symmetrical in size andshape

Symmetrical in size andshape

Normal

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Areola is round or ovaland color is light pink todark brown

Nipples are round, andequal in size

Areola is small and brownin color

Nipples are round andalmost in size

Normal

Normal

Finger andToe Nails

Inspectionand

Palpation

Vascular and pinkish incolor

Smooth texture

Intact epidermis

Capillary refill in 3-5seconds

Fingers and toes aredesquamated,

edematous, and reddishin color

Smooth texture

Intact epidermis

Capillary refill of 3 seconds

Changes inextremities such as

edema, desquamation,and redness are signsof Kawasaki Disease

Normal

Normal

Normal


Abdomen Inspection,Auscultation,

Palpation

Unblemished skin,uniform in color

no evidence of liverenlargement

Audible bowel sounds

Presence oferythematous andpolymorphous rashes on

the trunk

no evidence of liverenlargement

Audible bowel sounds at12 per minute; abdomenproduces a growling sound

Presence ofpolymorphousexanthema or rashes

is one sign ofKawasaki Disease

Normal

Normal


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Muscles Inspection,Palpation

Equal size on both sidesof the body; nocontractures

Good muscle tone, firmwith smooth coordinatedmovements

Symmetrical in size onboth sides of the body

Good muscle tone with nosigns of uncoordinatedmotor movement

Normal

Normal

Source of Normal Figures: Fundamentals of Nursing: Concepts, Process, and Practice Seventh Edition by Kozier, Barbara and

Erb, Glenora

Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family Fifth Edition byPillitteri, Adele

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ANATOMY

Kawasaki Disease, otherwise known as Mucocutaneous Lymph Node Syndrome,

is an acute, self-limiting, and febrile systemic vasculitis that may cause cardiac

complications. The most common sequel of KD is coronary thrombosis (stagnant blood

clot) that possibly leads to the development of a coronary aneurysm. Having these

definitions and descriptions of the disease in mind, the following body systems and

structures will be discussed briefly to illustrate the physiological effects of KD.

I. Heart

The heart functions as the primary organ for blood circulation in the

human body. It is responsible for delivering un-oxygenated blood from the

venous system to the lungs and oxygenated blood from the lungs to the arterial

circulation. Additionally, the heart propels blood throughout the systemic

(arterial) circulation to bring nutrients, vital enzymes, hormones, and drugs to the

tissues and organs of the body. The image of the heart, its parts and functions,

are illustrated in Figure 1 and Table 1 respectively.

FIGURE 1: THE HEART AND ITS STRUCTURES

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TABLE 1: THE PARTS OF THE HEART AND CORRESPONDING FUNCTION

STRUCTURAL PARTS FUNCTION

Superior Vena Cava (SVC) One of the two main veins that drains un-

oxygenated blood to the right atrium

Blood from the head and upper body

drain into the SVC

Inferior Vena Cava (IVC) The second main vein that drains un-

oxygenated blood to the right atrium

Blood from the legs and lower torso drain

into the IVC

Aorta The largest single blood vessel in the

body

Passageway for oxygen-rich blood from

the left ventricle into the systemic

circulation

Pulmonary Artery The only artery in the body that carries

deoxygenated blood

Passageway of deoxygenated blood from

the right ventricle to the lungs

Pulmonary Vein The only vein in the body that carries

oxygenated blood

Carries oxygenated blood from the lungs

to the left atrium

Right Atrium A chamber of the heart that receives

deoxygenated blood from the SVC and

IVC

Pumps blood into the right ventricle via

the tricuspid valveRight Ventricle Receives deoxygenated blood from the

right atrium via the tricuspid valve

The tricuspid valve closes after the right

ventricle fills up with blood and the

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pulmonary valve opens to allow

deoxygenated blood to flow into the

pulmonary artery

Left Atrium Receives oxygenated blood from the

pulmonary vein

Blood from this chamber empties into the

left ventricle via the mitral valve

Left Ventricle Arguably the largest chamber of the

heart, receives oxygenated blood from

the left atrium via the mitral valve

The mitral valve is open as the left

ventricle fills up with blood from the leftatrium and it closes once the left ventricle

is filled. The aortic valve opens as the

left ventricle contracts, sending

oxygenated blood into the aorta and into

the systemic circulation

Atrioventricular Valves The tricuspid and mitral valves ensure

one-way blood flow within the chambers

of the heart

The tricuspid valve is the gateway

between the right atrium and the right

ventricle

The mitral valve is the gateway between

the left atrium and the left ventricle

Semilunar Valves The pulmonary and aortic valves ensure

one-way blood flow into the pulmonary

artery and aorta respectively

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II. Coronary Arteries

The coronary arteries constitute the coronary circulation that supplies

oxygenated blood to the heart itself. These arteries receive their blood supply

from openings in the aorta called the coronary ostia.

A major complication of Kawasaki Disease is the development of coronary

aneurysms and coronary thrombosis, thus making the discussion of the coronary

arteries relevant. Ruptured coronary aneurysms lead to massive bleeding and

ischemia, eventually resulting to myocardial infarction.

The main branches of the coronary arteries and the areas of the heart

they supply are detailed below (Figure 2 and Table 2).

Figure 2: The Coronary Circulation

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Table 2: The Branches of the Coronary Arteries

BRANCHES OF THE

CORONARY ARTERIES

PARTS SUPPLIED

Left Coronary Artery Divides into two branches: the left anterior

descending artery and the circumflex artery

Left Anterior Descending Artery Delivers blood to sections of the left and

right ventricles and majority of the

interventricular septum

Circumflex Artery Supplies blood to left atrium and the lateral

wall of the left ventricle

Right Coronary Artery Three major branches: conus, right marginal

branch, and posterior descending branch

The conus supplies blood to the right upper

ventricle, the right marginal branch supplies

the right ventricle up to the apex, and the

posterior descending branch supplies

minority sections of the ventricles

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III. Vascular System

The vascular system is made up of the arteries and veins of the body.

Arteries branch into smaller arterioles, which branch further into capillaries.

Capillaries serve as the site where nutrient exchange between the blood and

tissues occur. Blood from the capillaries then enter venules that eventually join

together to form larger veins. The arteries serve as the channels for oxygenated

blood (systemic circulation) and the veins serve as the channels for

deoxygenated blood.

As a systemic vasculitic disease, Kawasaki Disease causes inflammation

of the blood vessels resulting to edema, increased permeability of the vessels,

and coronary aneurysms (weakening of the blood vessel walls). Figure 3 and

Table 3 briefly discuss the structure and functions of the vascular components.

Figure 3: The Vascular System

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Table 3: Comparison of Arteries and Veins

ARTERIES PARTS VEINS

Thinner than the tunica

media

Tunica Adventitia (outer

layer)

Thickest layer

Thicker than the tunicaadventitia allowing

vasoconstriction and

vasodilation

Tunica Media (middlelayer)

Thinner in veins

Same Tunica Intima (inner layer) Same

Narrower Lumen Wider to accommodate

valves

Absent Presence of Valves Present; to ensure the one-

way flow of blood back to

the heart

Fastest in arteries and gets

slower when entering the

arterioles and capillaries

Blood Flow Slow in the venules, but

increases speed as it

passes through the veins

(valve-related)

Aorta (largest), pulmonary

artery, carotid arteries,

subclavian artery,

brachiocephalic, abdominal

aorta, common iliac, brachial

Major Blood Vessels Superior and inferior vena

cavae, jugular veins,

subclavian veins, hepatic,

iliac, femoral, hepatic portal

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Figure 4: Arteries of the Body

Figure 5: Veins of the Body

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IV. Lymph Nodes

The lymph nodes are some of the major structures of the lymphatic

system, which works closely with the circulatory system to bring interstitial fluid

back into the blood circulation. Functionally, however, lymph nodes are part of

the hematologic and immune systems because large numbers of lymphocytes,

monocytes, and macrophages reside in these nodes. These cells are mobilized

and join the circulating blood during infection or inflammation.

In Kawasaki Disease, there is unilateral lymphodenopathy, meaning that

the lymph nodes enlarge due to inflammation. What causes this inflammation is

still unknown, but since unilateral lymphodenopathy is one criterion in diagnosing

KD, it is worth to include it in the anatomy section of this study.

Figure 6: Parts of a Lymph Node

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PATHOPHYSIOLOGY

Sources:

1. Textbook of Pediatric Infectious Diseases Fifth Edition by Feigin, Ralph D. andCherry, James D.

2. Kawasaki Disease by Scheinfeld, Noah S. and Jones, Elena L.

http://emedicine.medscape.com/article/965367-overview

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Diagnostic indicators

Complications if untreatedwithout IVIG 10 days after onset

of fever

Signs and symptoms inpatient

Diagnosis of KawasakiDisease based on

diagnostic criteria ofdisease;

Age is the only probablepredisposing factor in

patient

(+) fever

(+) maculopapularerythematous rashes onhands, feet, trunk, and

abdomen;(+) edema of hands and

feet;(+) desquamation of

fingers, toes, andperiungual area

(+) palpable unilateral

cervicallymphadenopathy at

1.5cm

(+) bilateral nonpurulentconjunctivitis

(+) cracked lips;(+) strawberry tongue;

Remittent fever for 6days PTA;

T = 39.5C on DOA

Platelet level of 411 x103 g/L based on CBC;

ESR of 112 mm/hrbased on CBC

WBC count of 19.7 g/L

based on CBC;Segmenter count of 0.85

hpf based on CBC

Coronary aneurysm;Coronary thrombosis;

Coronary stenosis;Coronary arteritis

Myocardial infarction;Congestive heart

failure;Death
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Discussion:

The etiology of Kawasaki Disease is still unknown. Studies have failed to identify

a pathologic agent that causes the disease. Most clinicians believe the disease has an

infectious nature due to the presence of seasonal outbreaks in Japan. The only non-

modifiable risk factors with considerable theoretical basis are age and race. Most casesinvolve children below 10 years of age and Japanese children appear to be at a higher

risk of acquiring the disease. However, the incidence of KD in Asians and other Pacific

Islanders is higher compared to Westerners of Caucasian or African descent.

The patient manifested 5 out of the 6 signs in the criteria for diagnosing

Kawasaki Disease. The patient had remittent fever for 6 days, had rashes that started

in the arms and spread to the trunk, oral cavity changes manifested by cracked lips,

strawberry tongue, and reddened oral mucosa, bilateral conjunctivitis, and a palpable

lymph node on the lefts side of the neck. These clinical manifestations were supported

by the hematological test and vital signs of the patient: a temperature of 39.5C,elevated platelet (thrombocytosis) and ESR (inflammatory response) levels, and a left

shift (increased production of mature leukocytes) in the patients WBC differential

results. The hematological results further provide evidence of the multi-system

affectations of the disease indicating signs of inflammation (vasculitis in KD), formation

of blood clots, and abnormal increase in WBCs (manifested in lymphadenopathy.

Twenty-five percent (25%) of cases result to coronary artery complications

without IVIG therapy and 3% of cases lead to the same complications even with IVIG

therapy. The coronary artery complications include formation of blood clots, arterial

stenosis, arteritis, and aneurysms. If these complications are not detected, the worst-case prognoses are myocardial infarction, congestive heart failure, and death. KD has a

0.1 to 2% mortality rate globally.

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DIAGNOSTIC EXAMINATIONS

Hematology Section - PCMC

Name: Patient CDC

Date received: January 26, 2010 - 9:34 pm

Date released: January 26, 2010 - 10:34 pm

PARAMETERS RESULTS NORMAL

VALUES

FINDINGS ANALYSIS

Hemoglobin

(HGB)

107.6 116-140g/L Below normal Indicative of

anemia, which

is a diagnostic

predictor ofKawasaki

Disease

Hematocrit

(HCT)

0.34 0.35-0.41g/L Slightly below

normal

Lysis of RBC

is possibly

due to

vasculitic

affects of

disease

RBC 4.36 3.6-50g/L Normal There is noabnormal

finding

WBC 19.7 5-10g/L Remarkably

above normal

Indicative of

leukocytosis

secondary to

infection or

inflammation

Differential Count

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VALUES

FINDINGS ANALYSIS

Eosinophils 0.01 0.02-0.07hpf Slightly below

normal

Possibly due to

allergic

reactions

Segmenter 0.85 0.55-0.65 hpf Remarkably

above normal

Overproduction

of mature

leukocytes

indicative of

increased

autoimmune

response

Lymphocytes 0.14 0.25-0.35 hpf Remarkably

below normal

Indicative of

immunosupp-

ression

Platelet Count 411 150-350 x

103 /L hpf

Remarkably

above normal

Indicative of

thrombocytosis,

which appears

on the 2nd week

of Kawasaki

Disease

ESR 112 0 -20 mm/hr Remarkably

above normal

Indicative of

inflammatory

response

ASJ Medical and Diagnostic Clinic

Hematology

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Date of Release: January 25, 2010


VALUES

FINDINGS ANALYSIS

Hemoglobin

(HGB)

106 116-140g/L Below normal Indicative of

anemia

Hematocrit

(HCT)

0.32 0.35-0.41g/L Slightly below

normal

Indicative of

low RBC

count due to

hematologic

factors

ErythrocyteCount

3.7 3.6-50g/L Normal Within normal

range

LeukocyteCount

5.75 5-10g/L Normal Within normal

range

Platelet Count 98,000 150,000

300,000

Below normal Indicative of

thrombocyto-

penia

Differential Count


VALUES

FINDINGS ANALYSIS

Eosinophils 0.03 0.02-0.07hpf Normal Within normal

range

Segmenter 0.55 0.55-0.65 hpf Normal Within normal

range

Lymphocytes 0.40 0.25-0.35 hpf Slightly above

normal

Indicative of

autoimmune

response

Monocytes 0.02 0.02-0.05 Normal Within normal

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range

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DRUG STUDY

DRUG DOSAGE MECHANISM OF

ACTION

INDICATION CONTRAINDICATION ADVERSE

EFFECT

NURSING

RESPONSIBILITIES

Drug Name:

IMMUNOGLOB-ULIN IV

Drug Class:

Passive immune-globulin

2.5g/50ml 10 vials:

Test Dose I:0.01x11.5kgx60= 7cc for 30mins

Test Dose II:0.02x11.5kgx60=14cc

Test Dose III:0.03x11.5kgx60=21cc

Test Dose IV:0.04x11.5kgx60=28cc

Translateremaining 390cc to24cc/hr for 16hrs

Improves immunityby binding to and

neutralizing

pathogens, thereby

increasing

antibodies against

bacterial, viral,

parasitic, and

mycoplasmic

antigens. Acts

through

antimicrobial and

antitoxin

neutralization.

KawasakiSyndrome

Prophylaxis after

exposure to

Hepatitis A

B-cell chronic

lymphocytic

leukemia

Pediatric HIV

infection

Patients withanaphylactic reaction to

IGIV

Tenderness,muscle stiffness at

injection site,

nausea, vomiting,

chills, fever,

headache.

- Do not administer topatients with history of

allergy to gammaglobuli

- Instruct patient to repor

symptoms occurring

during or after therapy.

- Use with caution in

pregnant women-

Pregnancy C; safety not

established

- Have epinephrine 1:10

immediately available at

time of injection in case

anaphylactic reaction

- Do not mix immune

globulin with any other

medications

- Monitor patients VS

continuously

- Provide or teach patien

to provide safety

measures.

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- Advise patient to avoid

live-virus vaccines for 3

months after therapy; dr

may delay or inhibit body

response to vaccine.

- Provide patient with

written record of injection

and dates for follow-up

injections as needed.

DRUG DOSAGE MECHANISM OF

ACTION

INDICATION CONTRAINDICATION ADVERSE

EFFECT

NURSING

RESPONSIBILITIES

Drug Name:

ASPIRIN

Classification:

Antipyretic,analgesic, NSAID

300mg/tab; 1 tab

q6 PO

It acts in the

thermoregulatory

center of the

hypothalamus to

block effects of

pyrogen

Also has anti-

inflammatory, anti-

platelet, and

analgesic

properties

Mild to moderate

pain

Fever

Inflammatoryconditions-

rheumatic fever,

rheumatoid

arthritis,

osteoarthritis

Allergy to NSAID or

salicylates

Hemophilia;

hemorrhagic states;

impaired renal function;chickenpox; pregnancy

Acute aspirin

toxicity: tachypnea,

hemorrhage,

excitement,

confusion

GI: nausea,

dyspepsia,

heartburn,

epigastric

discomfort,

anorexia

- Give drug with food or

after meals if GI upset

occurs.

- Use the drug only as

suggested; avoidoverdose.

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NURSING CARE PLAN

The following nursing problems were based on the data gathered for this study:

I. Actual Nursing Problems

1. Elevated body temperature related to systemic inflammation of blood

vessels secondary to present disease

2. Impaired skin integrity related to accumulation of fluid in the interstitial

spaces of hands and feet secondary to present disease

3. Impaired oral mucous membrane related to inflammation of oral mucosa

secondary to present disease

II. Potential Nursing Problems

1. Risk for decreased cardiac output related to possible coronary artery

complications secondary to present disease

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ACTUAL NURSING PROBLEMS

1. Elevated body temperature related to systemic inflammation of blood vessels secondary to present disease

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATIONSubjective:NONE

Objective:

Temp 38.4C;

Warm to touch;

Irritable andrestless;

Uncontrolledcrying

Elevated bodytemperaturerelated tosystemic

inflammationof bloodvesselssecondary topresentdisease

Presentdisease

Systemicinflammationof bloodvessels

Release ofpyrogens

Elevated bodytemperature

Short-term:

After 2 hoursof nursing

intervention,the patientstemperaturewill normalizeat 37.5C.

Independent:

Checktemperature and

other vital signsprior tointerventions;

Administer tepidsponge bath tolowertemperature;

Provide a changeof clothes andsheets to promote

increasedcomfort;

Regularly checkdiapers if soiled;

Assessmentof all vital

signs isintegral toplanning andintervention;

TSB is anindependentnursingfunction thatlowers coretemperature;

Increasingpatientcomfort can

ease irritabilityandrestlessnessassociatedwith fever;

Soiled diaperscauseadditionaldiscomfort;

After 2 hours ofnursingintervention, thepatients body

temperaturewas lowered to37.8C; tocontinueinterventionsuntil bodytemperaturenormalizes

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Follow feedingschedule toprovide nutritionalsupport;

Watch out forsigns ofdehydration

Dependent:Administer aspirinas ordered;

Check the flowrate of IVIG andwatch out forsigns of adverseeffects

Infants requiresufficientnutritionespeciallyduring timesof illness andimmuno-suppression;

Dehydration iscommon ininfants withpersistentfever

Aspirin servesas anantipyretic,anti-inflammatoryand anti-platelet drug

in KawasakiDiseaseProperregulation ofIVIG infusionis important toprevent sideeffects

2. Impaired skin integrity related to accumulation of fluid in the interstitial spaces of hands and feet secondary to

present disease

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ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATIONSubjective:NONE

Objective:

+ 1 edema ofhands and feet;

Skin appears dryand shiny;

With erythema ofhands and feet;

desquamation offingers and toes

Impaired skinintegrityrelated toaccumulationof fluids ininterstitialspaces of

hands andfeetsecondary topresentdisease

Presentdisease

Systemicinflammation

of blood

vessels

Increase inhistaminerelease

Greaterpermeability

of bloodvessels

Vascular fluid

moving tointerstitialspaces ofhands and

feet

Impaired skin

Short-term:After 6 hoursof nursingintervention,skin integrityimproved asevidenced by

controlleddryness of theskin

Long-term:

After 3 to 4days ofnursingintervention,skin integrityproblemsrelated toedema willresolve as

evidenced byedema scoreof 0 from +1

Independent:

Assess the handsand feet for extentof dryness andedema;

Assess mobility offingers, toes,hands, feet,wrists, andankles;

Apply RICEtechnique inmanagement ofedema;

Apply lotion to dry

Assessmentof sites ofedema willdictateprovision

interventions;

Mobility is asign ofsufficientblood flow tosites;

R- rest;I ice todecreaseinflammation;C compressionto promote

venous returnand lymphaticdrainage offluid;E elevateabove theheart forvenous return;

Lotion can

After 6 hours ofnursingintervention,skin integrityimproved withcontrolleddryness of the

skin ; skin ismore moist onsites of edema

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integrity areas of skin for moisture andlubrication;

Do not peel offdesquamatedskin;

Watch out forwounds and signsof infection andloss of function

Dependent:Administer aspirinas prescribed;

Check flow ofIVIG asprescribed

hasten furtherdrying of theskin due toedema;

Desquamatedskin will peeloff naturally;you can cutloose skin atthe ends;

Edema anddryness makeskinsusceptible towounds

Aspirin hasanti-inflammatoryproperties;

IVIG therapyaids in abatinginflammation,thus reducingedema

3. Impaired oral mucous membrane related to inflamed oral mucosa secondary to present disease

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATIONSubjective: Impaired oral Present Short-term: Independent: After 3 hours of

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NONE

Objective:

With fissured,cracked lips;

Witherythematouslips;

red and inflamedoral mucosa;

Strawberry-liketongue withpapules;

Irritable whenbeing givenfeedings

mucousmembranerelated toinflamed oralmucosasecondary topresentdisease

disease

Inflamed oralmucosa

Poor bloodperfusion tooral mucousmembrane

Impaired oralmucous

membrane(evidenced bycracked lips)

After 3 hoursof nursingintervention,fissures andcracks in thelips will becontrolled andlessened

Long-term:

After 3 to 4days ofnursingintervention,fissures andcracks willresolve asevidenced bymoist lips withthe absenceof cracks and

fissures

Assess the extent,characteristic, andseverity of thefissures andcracks on the lips;

Assess if there isdifficulty inswallowing oralterations infeeding;

Provide oralrinses using tapwater or salinedrops to moistenmucosa;

Provide regularoral care hygieneby giving oralrinses;Encouragesufficient fluid

Assessmentof the fissuresand cracks onthe lips willaffectinterventionsto be given;

Fissured andcracked lipscan causedifficulty infeeding,especially ininfants;

Moisteningdried mucosawill preventworsening ofcracks andprevent new

ones fromdeveloping

Non-alcoholicrinses willpreventinfectionDehydrationcan contribute

nursinginterventions,fissured andcracked lipswere managedas evidenced bycontrolleddryness of thelips

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intake asprescribed andtolerated;

Instruct mother toavoid giving acidicfluids;

Instruct mother tocontinue feedingpractices asprescribed byphysician

Watch out forsigns of infection

Independent:

Administer aspirinas prescribed

to mucosaldryness andworsencracked lips;

Juices andother acidicbeveragescause pain inopen oralmucosa;

Feedingpracticesshould beencouraged inspite ofcondition

Further dryingof mucosa canlead to ulcersand result to

infection

Aspirin hasanalgesic andanti-inflammatoryproperties

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Potential Nursing Problems

1. Risk for decreased cardiac output related to possible coronary artery complications secondary to present disease

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATIONSubjective:None

Objective:

Risk fordecreasedcardiac outputrelated to

Presentdisease

Short-term:

After 2 hoursof nursing

Independent:

Assess thepatients cardiac

It is importantto retrieve

After 2 hours ofnursingintervention, theparents were

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None possiblecoronaryarterycomplicationssecondary topresentdisease

Increasedplatelet

production

Formation ofblood clots inblood vessels,

particularlythe coronary

arteries

Blood clotscan causeblockage,

aneurysms,and stenosisof coronary

arteries

All these

complicationscan causedecreased

cardiac output

intervention,the parentswill be able toverbalizeunderstandingof the cardiaccomplicationsof presentdisease

vital signs prior todischarge;

Discuss withparents the natureof KawasakiDisease and thepossiblecomplicationseven with IVIGtherapy;

Provide parentswith aninformation sheetregarding post-drug therapy carefor patients withKawasakiDisease;

Instruct parents topromote adequaterest and sleep 2-3days afterdischarge fromhospital;

Instruct parents togradually

baseline VSprior todischarge forreference;

Clienteducation isimportant incomprehen-sion of illness

A quickreferenceguide canincreaseunderstan-ding ofdisease;

Patients fullrecovery hasto be ensured;

Gradualreintroduction

able tounderstand therisk for cardiaccomplicationsas evidenced byverbalization oftheircomprehensionof healthteachings

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reintroducepatient toactivities;

Educate patientson signs ofcardiac problems;

Promote abalanced diet withlow sodiumcontent;

Advise parentsregarding followup check-up anddiagnosticprocedures

to activitieswill helppatient adaptefficiently afterillness;

Signs ofcardiaccomplicationsinvolveshortness ofbreath, activityintolerance,difficulty inbreathing,dizziness,lethargy, andchest pain;

Propernutrition willensure growthand

development;

Follow upcheck-ups willhelpdeterminedevelopmentof any cardiacabnormalitiesor coronary

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arteryaffectations

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DISCHARGE PLANNING

Medication

Discuss all take home medications to patient's mother

Aspirin: advise parents to give drug after meals to prevent gastric irritation

Aspirin: advise parents regarding side effects of drug such as nausea,vomiting, abdominal pain, and headache

Aspirin: advise parents to adhere to frequency, dosage, and timeliness ofdrug administration

IVIG: educate parents regarding immunosuppressive effects of drug

IVIG: educate parents regarding side effects of drug such as chills, fever,

and headache

Advise parents to report any changes in the patient related to drugs beingtaken

Exercise

Advise parents of adequate rest and sleep for up to 2 to 3 days after discharge topromote recovery

Advise parents to gradually increase activities; start with light activities until

tolerated before engaging in more strenuous activities

Encourage parents to have patient engage in normal activities of daily living suchas self-feeding, dressing, and walking

Constantly monitor activity and exercise pattern to detect any abnormalities suchas cardiac affectations/sequelae of Kawasaki Disease

Treatment

Explain to the patients that drug therapy should continue as prescribed byphysician

Educate parents regarding potential sequelae of Kawasaki Disease such ascoronary artery and cardiac problems

Health Teachings

Advise parents to promote proper hygiene to decrease possibility of infection

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Encourage parents to promote a safe, comfortable, and clean environmentconducive to recovery of patient

Provide nutritional teaching to parents to foster improved nutritional and fluidintake as well as promote balanced diet

During recovery, patient should not be brought to crowded places to preventcommunity-acquired infections

Advise mother to complete all immunizations and booster shots for patient oncecleared by physician

Promote regular hand washing especially during food preparation to avoidcontamination of food

Out Patient

Remind the family on their follow up check up with their physician

Encourage to take routine cardiac diagnostic examinations (i.e. MRI, CTscans of

the heart, and 2D echocardiography) to determine presence of cardiac

affectations/complications of disease

Diet

Encourage to have the three basic food groups in the diet while controlling salt

intake

Encourage to increase fluid intake

Encourage to prepare foods that are rich in vitamins and minerals to improve

immune system

Continue milk feeding and solid food combination and introduce new viands to

improve appetite and expand food variety

Spiritual

Guided by the family, help the patient to establish deep personal relationship withGod in everyday of her waking moment

With guidance from parents and family, help the patient find happiness in her

present situation

Aid patient in holistic development of self to promote overall wellness

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REFERENCES

Books

Feigin, Ralph D. et al., Textbook of Pediatric Infectious Diseases Volume 1. Fifth

Edition. Elsevier Inc., Philadelphia, USA: 2004.

Huether, Sue E. and McCance, Kathryn L.,Understanding Pathophysiology 3 rd Edition.

Mosby Inc., Singapore: 2004.

Kozier, Barbara et al., Fundamentals of Nursing: Concepts, Process, and Practice

Seventh Edition. Prentice Hall, New Jersey, USA: 2004.

Pillitteri, Adele, Maternal & Child Health Nursing: Care of the Childbrearing &

Childrearing Family Volume 2 Fifth Edition. Lippincott Williams & Wilkins, USA:

2007.

Internet

Gordon, John B. et al. When Children with Kawasaki Disease Grow Up: Myocardial and

Vascular Complications in Adulthood., Journal of the American College of

Cardiology as seen on http://www.medscape.com/viewarticle/712188

Moran, Adrian M. et al. Abnormal Myocardial Mechanics in Kawasaki Disease: Rapid

Response to Gamma-Globulin., American Heart Journal 02/01/2000 as seen on

http://www.medscape.com/viewarticle/409087

Scheinfeld, Noah S. and Jones, Elena L. Kawasaki Disease., 10/20/2009 as seen on

http://emedicine.medscape.com/article/965367-overview

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