Kawasaki Disease

Acknowledgement This case study would not be possible without the guidance and the help of several individuals who are in one way or another contributed and extended their valuable assistance in the preparation and completion of this study. My outmost gratitude to Ms. Maria Donna Duron, the school directress of St. Augustine School of Nursing Espana for her genuine sincerity and encouragement. To my adviser Ms. Cecilia J. Sarte for her patiently supervising and assisting us with their knowledge, as we gradually go through the process of doing the case study itself, sincerest thanks. To my clinical instructor Mr.

Joey M. Cadano for all the help and valuable insight he had shared To my instructor Mr. Paolo M. Zabat and all the faculty staff for their moral support and untiring effort in encouraging us to finish our study. To my classmates and friends who gave their moral support and help all the way despite the busy schedules in preparing their own case study. To my family for supporting me all the way, providing me with everything I need financially and emotionally. Last but not the least, to our Almighty Father for his unceasing guidance and blessings, for constantly giving me hope, courage and patience.

Truly none of this is possible without you. ii Table of Contents TitlePage Number I. Acknowledgementii II. Objectiveiv III. Introduction a. Definition1 b. Incidence1 c. Etiology2 d. Manifestations and Complications2 IV. Anatomy and Physiology3 V. Pathophysiology6 VI. Patient’s Profile a. Biographical Data7 b. Chief Complaint7 c. History of Present Illness7 d. Medical History8 e. Family History8 VII. Laboratory Findings9 VIII. Physical Assessment11 IX. Nursing Care Plan15 X. Drug Study20 XI. Discharge Plan23 iii II. Objectives General:

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Patient Centered ? Know when to seek help from the health care providers whenever the signs and symptoms may appear ? Understand the occurrence of Kawasaki Disease ? Know what other complications may arise, if left untreated ? Gather information about the therapeutic regimen iv III. Introduction Definition 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. Kawasaki Disease mainly affects the blood vessels, including coronary arteries. Blood vessels throughout the body get inflamed, and the most serious that could happen is on the heart. If left untreated after 10 days, children may have a higher risk to develop heart problems.

Kawasaki Disease manifests in three phases: acute, subacute, and convalescent. The acute phase begins with the abrupt onset of high fever that is unresponsive to antibiotics and antipyretics. The child then develops the remaining diagnostic symptoms. During this stage the child is typically very irritable. The subacute phase begins with the resolution of the fever and lasts until all clinical signs of KD have disappeared. During this phase the child is at greatest risk for the development of coronary artery aneurysms. Echocardiograms are used to monitor myocardial and coronary artery status.

In the convalescent phase, all the clinical signs of KD have resolved, but the laboratory values have not returned to normal (6 to 8 weeks after onset). At the end of this stage the child has regained his or her usual temperament, energy and appetite. The cause of Kawasaki Disease is unknown, but it is thought to be immunologic abnormalities that include increased activation of helper T-cells and increased level of immune mediators and anti-bodies that destroy endothelial cells have been detected during the acute phase of the disease.

It has been hypothesized that some unknown antigen, possibly a common infectious agent, triggers the immune response in a genetically predisposed child. Incidence Epidemics of Kawasaki disease primarily occur in the late winter and spring, at 2- to 3-year intervals. Approximately 3000 children with Kawasaki disease are hospitalized annually in the United States. The approximate annual race-specific incidence per 100,000 children younger than 5 years is 32. 5 cases for Americans of Asian and Pacific Island descent, 16. 9 cases for non-Hispanic African Americans, 11. cases for Hispanics, and 9. 1 cases for whites. Although Kawasaki disease has been reported in children of all ethnic origins, it occurs most commonly in Asian children, especially those of Japanese descent. Rates are intermediate among blacks, Polynesians, and Filipinos and are lowest among whites. Manifestations and Complications Manifestations: ? Fever for at least 5 days ? Polymorphous rash ? Strawberry tongue ? Cervical lymphadenopathy Complications: ? Changes in the extremities ? Conjunctival infection ? Vasculitis IV. Anatomy and Physiology [pic]

Cardiovascular System Knowing the functions of the cardiovascular system and the parts of the body that are part of it is critical in understanding the physiology of the human body. With its complex pathways of veins, arteries, and capillaries, the cardiovascular system keeps life pumping through you. The heart, blood vessels, and blood help to transport vital nutrients throughout the body as well as remove metabolic waste. They also help to protect the body and regulate body temperature. The cardiovascular system consists of the heart, blood vessels, and blood.

This system has three main functions: ? Transport of nutrients, oxygen, and hormones to cells throughout the body and removal of metabolic wastes (carbon dioxide, nitrogenous wastes). ? Protection of the body by white blood cells, antibodies, and complement proteins that circulate in the blood and defend the body against foreign microbes and toxins. Clotting mechanisms are also present that protect the body from blood loss after injuries. ? Regulation of body temperature, fluid pH, and water content of cells. [pic] Lymphatic System

An important supplement to the cardiovascular system in helping to remove toxins from the body, the lymphatic system is also a crucial support of the immune system. Unlike blood, lymph only moves one way through your body, propelled by the action of nearby skeletal muscles. The lymph is pushed into the bloodstream for elimination. Appreciating the importance of the lymphatic system in filtering, recycling, and producing blood as well as filtering lymph, collecting excess fluids, and absorbing fat-soluble materials is necessary to the understanding of human physiology.

The lymphatic system consists of lymphatic vessels, a fluid called lymph, lymph nodes, the thymus, and the spleen. This system supplements and extends the cardiovascular system in the following ways: ? The lymphatic system collects excess fluids and plasma proteins from surrounding tissues (interstitial fluids) and returns them to the blood circulation. Because lymphatic capillaries are more porous than blood capillaries, they are able to collect fluids, plasma proteins, and blood cells that have escaped from the blood.

Within lymphatic vessels, this collected material forms a usually colorless fluid called lymph, which is transported to the right and left subclavian veins of the circulatory system. ? The lymphatic system absorbs lipids and fat-soluble materials from the digestive tract. ? The lymphatic system filters the lymph by destroying pathogens, inactivating toxins, and removing particulate matter. Lymph nodes, small bodies interspersed along lymphatic vessels, act as cleaning filters and as immune response centers that defend against infection. V.

Pathophysiology VI. Patient’s Profile Biographical Data Name: S. T. Age: 3 years old Gender:Male Address:Quezon City Birth date: January 14, 2010 Religion: Catholic Nationality:Filipino Informant: “Mother” Date of Admission:February 17, 2013 Admission Data Chief Complaint: “High Fever” Initial Diagnosis: Urinary Tract Infection Final Diagnosis: Kawasaki Disease Attending Physician: Dr. K. D. History of Present illness Patient’s present condition started 5 days prior to admission when patient have fever at 38. 5°C associated with rash from face to neck.

The patient was brought to Capitol Medical Center and diagnosed with UTI due to bacteria present in his urine. He was given paracetamol and antibiotics for the treatment. They allowed to go home. 4 days PTA, still with fever documented at 39. 5°C and rash. Swelling of face and lips are cracked. The mother noticed short, quick breathing. The patient was brought again to the hospital, strawberry tongue is noted upon physical examination. The patient was referred to Infectious Disease (ID) Specialist and confirmed having Kawasaki Disease upon conformatory and other laboratory finding.

Past Health History Patient’s mother verbalized that all needed immunizations since birth has been done to the patient. The patient has only experience stomach pain and minor health problems such as occasional cough, cold, and mild fever. Family History | |Mother |Father | |Hypertension |- |+ | |PTB – |- | |Cancer |- |- | |Allergies |- |- | VII. Laboratory Findings Urinalysis Report |Normal |Actual |Interpretations |Implication | |Color |Light or Pale yellow |Light Yellow |Normal |indicates good hydration and | | | | | |urine concen | | | | | |tration | |Character |Clear |Slightly Turbid |Abnormal |increase fluid intake | |Glucose |(-) |(-) |Normal |well hydrated | |Reaction |4. 6-8ph |6. ph |Normal |there is normal hydrogen ion | | | | | |concentration and extracellular| | | | | |fluid | | | | | | | | | | | | | | | | | | | |Specific Gravity |1. 010-1. 025 |1. 010 |Normal |the concentrating ability of | | | | |the kidney is normal | | | | | | | | | | | | | | | | | | | |PUS cell |0 |5-8 |Abnormal |indicates possible urinary | | | | | |tract infection | | | | | |Administer antibiotic as | | | | | |ordered | | | | | | | | | | | | | | | | | | | |Squamous |(-) |Few |Abnormal |increase fluid intake | | | | | | | |Bacteria |(-) |Few |Abnormal |increase fluid intake | | | | | |increase intake of Vitamin C | | | | | | | | | | | | | | | | | | | Hematology Report Laboratory/ Diagnostic |Results |Normal Values |Interpretation |Implication | |Procedures | | | | | |Hemoglobin |106 g/L |130-180 |decrease |Decresed hemoglobin leads | | | | | |to symptoms of anemia | |Hematocrit |0. 32 % |0. 40-0. 54 |decrease |Decreased hematocrit leads| | | | | |to symptoms of anemia | |WBC Count |20. 07 |5. 0-10. |increase |Increased WBC was due to | | | | | |presence of infection | |Coagulation Profile | | | | | |Platelet Count |605 |150-450 |increase |Increased PLT points to | | | | | |abnormal conditions of | | | | | |excess clotting | |Differential Count | | | | | |Neutrophil |65 % |50-70 % |normal |Within normal condition | |Lymphocytes |45 % |25-35 % |increase |Will lead to signs of | | | | | |viral infection | |Eosinophil |1 % |1-5 % |normal |Within normal condition | VIII. Physical Assessment |AREA/ REGION |METHOD USED |NORMAL FINDINGS |ACTUAL |INTERPRETATION/ ANALYSIS | | | | |FINDINGS | | | | | | | | |General Appearance | |>Temp: 36. 5-37. 2°C |> Temp: 39. 5°C |Not normal.

All this symptoms are | | | | | |present due to hyperthermia with | | | |>Resp. Rate: 20-30 cpm | |manifestations of increased respiratory| | |Inspection | |> Resp. Rate: 35cpm |rate and cardiac rate. Fundamentals of | | | |>Pulse Rate: 80-130 cpm | |Nursing, Kozier & Erbs 8th Edition, | | | | |> Pulse Rate: |pp. 529. | |Auscultation |> No Pallor |140bpm | | | | | | | | | | |> Without signs of fatigue |> Pallor | | | |Inspection | | | | | | |> No edema |> Fatigue | | | | | | |Accumulation of fluid in the | | | | | |extremities because of prolong staying | | | | |> Bipedal non- pitting edema |in bed, and excessive accumulation of | | |Palpation | | |fluid in the third spaces, edema | | | | | |developed. Fundamentals of Nursing, | | | | | |Kozier & Erbs 8th Edition, pp. 579. | | | | | | | | | | | | | | | | |Not normal due to excessive | | | | | |accumulation of fluid in the third | | | | | |spaces, edema developed.

Fundamentals | | | |> No edema | |of Nursing, Kozier & Erbs 8th Edition, | | | | | |pp. 579. | | | | |> With non- pitting edema | | |Skin | | | | | | |Palpation | | | | | | | | |Not normal.

Temperature exceeds the | | | | | |normal temperature because of the | | | | | |presence of infection that causes the | | | | | |skin to be warm. | | | | | | | | | | | |Not normal.

A skin lesion is an | | | |> Skin is mildly warm to | |alteration in a client’s normal skin | | | |touch |> Warm to touch |appearance. Fundamentals of Nursing, | | | | | |Kozier & Erbs 8th Edition, pp. 576. | | | | | | | | | | | |Not normal. Poor capillary refill | | | | | |results in poor oxygenation. | | | | | | | | |> Without peeling, must be | | | | | |soft and smooth |> Peeling (desquamation) palms |Not normal because there is increase | | | | |and soles |inflammation of the blood vessels | | | | | |causing it to be red in color. | |Inspection | | | | | | | | | | | | | | | | | | |> Capillary refill is less | | | | | |than 3 seconds |> With a capillary refill of 5 | | | | | seconds | | | | | | |Normal | | | |> No infection, swelling and| | | | |Palpation |moist lips | | | | | | |> Red mucous membranes in the | | | | | |mouth |Normal | | | | | | | |Mouth | | |> Dry lips | | | |Inspection | | | | | | | |> Cracked lips |Not normal due to infection. | | | | | |Fundamentals of Nursing, Kozier & Erbs | | | | |> Strawberry tongue noted |8th Edition, pp. 607 | | | |> Reactive/ responsive to | | | | | |noises |> Reacts to loud noises |Not normal.

Use of accessory muscle | | | | | |(abdominal muscle, trapezius muscle, | | | |> Symmetrical and patent | |and sternocleidomastoid muscle) and | | | | |> Symmetrical and patent |increased RR signifies fatigue and | | | | | |hyperthermia. | |Ears | |> Not palpable | |Fundamentals of Nursing, Kozier & Erbs | | | | |> Enlarged, palpable |8th Edition, pp. 548. | | | | | | | | | | | | |Nose | | | | | | |Inspection |> Breath sounds are resonant|>Breath sounds are resonant | | | | | | | | | | | |> Thorax is rounded | | |Lymph Nodes | |> thorax is rounded | | | | |Inspection | | | | | |Palpation |>normal RR 20-30cpm, |> RR 35cpm |> Not normal due to inflammation of the| | | | | |skin lesions | | | |> normal PR 80-130bpm | | | |Chest, Thorax and Lungs | | |>HR 140bpm | | | |Percussion |> no use of accessory | | | | | |muscles in breathing. | | | | | | |> Use of accessory muscle | | | |Inspection | |(abdominal muscle, trapezius | | | | | |muscle, and sternocleidomastoid |> Not normal due to process of the | | | |> Unblemished skin |muscle) |disease and infection.

Weakness is due | | |Palpation | | |to lack of energy needed to do normal | | | |> No tenderness; relaxed |> Presence of rash |activities. | | | |abdomen with smooth, | | | | | |consistent tension | |Not normal. Pain was caused by the | | | | |> Tenderness and |presence of bacteria in the urine. | | |> No restriction in |hypersensitivity | | | |Inspection |activities, no weakness and | | | | |Auscultation |alert | | | | | | | | | | | | | | | | | | |> Inability to tolerate | | |Abdomen | |> There should no pain felt |activities, weak in appearance, | | | | |when voiding |irritable and lethargic | | | |Inspection | | | | | |> Protein is not evident in | | | | | |the urine | | | | |Palpation | |> With difficulty in urination. | | | | | |Color of the urine is yellow | | | | |> Normal urine output is | |Not normal.

This is also caused by | | | |500-1000cc/day or equivalent| |accumulation of excessive fluid in the | |Musculoskeletal and | |to 20-25cc hr | |body | |neurolo- | | | | | |gical status |Inspection | | | | | | |> There should no edema, | | | | | |tenderness, or swelling | | | | | |present | | | | | | | |. |Genitourinary | | | | | | | | | | | | |Inspection | | | | | | | | | | | | | > Non-pitting edema on both feet| | | | | |noted | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |Lower Extremities | | | | | | | | | | | | |Inspection Palpation | | | | IX. Nursing Care Plan X. Drug Study XI. Discharge Plan Medication Patient is given discharge maintenance drug for 2 weeks of 120 mg of aspirin every day or 30 mg QID. Exercise/ Activity The patient can resume his usual activities as soon his condition become normal. There is no restriction with regard to physical activities as long as it is tolerable to the patient’s health status. Treatment Allow the child to rest for faster recovery. Since the patient is taking anti-platelet medications, precautionary measures are discussed to avoid bleeding tendency.

The patient is instructed to return to his attending physician within one week after date discharge for a follow up consultation. He is also required to have CBC, platelet count and ESR during that visit. Health Teaching Good hygiene is encouraged. Soft toothbrush are recommended. Petroleum jelly can be applied to dry cracked lips. Use mild soap in cleaning the skin and a mild lotion can be applied to protect skin from drying and peeling. Instill artificial tears to sooth conjunctiva as instructed. Outpatient Orders Remind the family on their follow-up check-up with their physician. Maintain good and safe environment to evaluate the progress of the treatment.

Diet Soft or pureed diet is advised when the child’s oral mucosa is still inflamed. Cool liquids like ice chips and ice pops can also be offered. Diet will return to usual when the child is able to tolerate it. Provide high protein diet to promote faster recover. Increase fluid intake to prevent dehydration. A Case Presentation of Kawasaki Disease In Partial Fulfilment of the requirement in Maternal and Child Nursing II A Compilation Presented to: St. Augustine School of Nursing Espana, Manila Presented By: Julie Anne G. Lumbera PN-4A Ms. Cecilia J. Sarte MCN II Instructor and Adviser Mr. Joey M. Cadano Clinical Instructor KAWASAKI DISEASE [pic]

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