EASTWOOD PROFESSIONAL COLLEGE EASTWOOD PROFESSIONAL COLLEGE OF SCIENCE & TECHNOLOGYOF SCIENCE & TECHNOLOGY

CASE STUDYCASE STUDYOFOF

KAWASAKIKAWASAKI DISEASEDISEASE

JOHN KENNETH P. SANTOSJOHN KENNETH P. SANTOSBSN - 301BSN - 301

INTRODUCTION

Our human body is a very complex system. One functions for the benefit and or expense of another. Our subsystem is a vital as the other thus they are interrelated. Considering this fact, I have looked into the reality that in this diverse physiological wonder lies the infinite possibility of not only optimum functioning but of disparities and deviations as well.

In life, one continues to exist in oblivion. There are always uncertainties in every events and occurrences whirl through our lives. We do not know when is the exact point in time where our bodily homeostasis will be disturbed and when change will cease to happen. Some of the surprising changes can be considered blessings but most the time they are we fervently hope would not occur especially those that concern our health.

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.

Although Kawasaki disease is a multisystem disease, the cardiovascular system appears to be the primary site with coronary artery vasculitis, aneurysm development, thrombosis, and myocardial thrombosis progressing over days to weeks. Approximately 15% to 25% of patients develop cardiac complications (coronary thrombosis or rupture, myocardial infarction, heart failure, vasculitis of the aorta or peripheral arteries); however mortality is low.

Nurses play a significant role in the management and care of patient with conditions such as this. We play an essential part in symptom management associated with the disease and the therapy. I likewise form part in the patient’s support system, which is considerably a factor that has an immense effect on the cure and recovery of this type of disease.

People shouldn’t take Kawasaki Disease hideously more so to those who are concerned because management is the key. In life, hurdles and humps are sprayed to test us. It takes recognition and acceptance that even our anatomical and physiological features; God’s chisel is shaping us to be significant individual molded by pain and strength. This study does not only provide our readers of medical information but of a challenge and course of holistic spectacle as well.

What are the usual symptoms and signs of Kawasaki's disease?

The usual symptoms and signs of Kawasaki's disease include

fever, reddening of the eyes, cracked and inflamed lips and mucous membranes of the mouth with an inflamed

"strawberry" tongue, ulcerative gum disease (gingivitis), swollen lymph nodes in the neck (cervical lymphadenopathy), and a rash that is raised and bright red.

The rash appears in a glove-and-sock fashion over the skin of the hands and feet. The rash becomes hard, swollen (edematous), and then peels off.

CausesThe cause is not known. Microorganisms and toxins have been suspected, but

none has been identified to date. Kawasaki's disease is not felt to be a contagious illness. Genetic factors and the immune system seem to play roles in the disease, which is characterized by immune activation.

Treatment

Kawasaki's disease is treated with high doses of aspirin (salicylic acid) to reduce inflammation and to mildly thin the blood to prevent blood clot formation. Also used in treatment is gamma globulin administered through the vein (intravenous immunoglobulin or IVIG), together with fluids. This treatment has been shown to decrease the chance of developing aneurysms in the coronary arteries. Sometimes cortisone medications are given. Persisting joint pains are treated with anti-inflammatory drugs, such as ibuprofen (Advil) or naproxen (Aleve).

Plasma exchange (plasmapheresis) has been reported as effective in patients who were not responding to aspirin and gammaglobulin. Plasmapheresis is a procedure whereby the patient's plasma is removed from the blood and replaced with protein-containing fluids. By taking out portions of the patient's plasma, the procedure also removes antibodies and proteins that are felt to be part of the immune reaction that is causing the inflammation of the disease. Kawasaki's disease that is not responding to the traditional aspirin and gammaglobulin treatments can be deadly. Medications that block the effects of TNF (tumor necrosis factor), one of the messenger molecules in the inflammatory response, are being studied for use in these situations. Examples of TNF-blocking drugs are infliximab (Remicade) and etanercept (Enbrel). Further research is needed to design treatment programs for those who are failing conventional treatments. Pentoxifylline (Trental) is also being studied as a possible treatment for Kawasaki's disease.

ANATOMY AND PHYSIOLOGY

Kawasaki's disease is a poorly understood condition that affects young children. It causes severe inflammation in different areas of the body, including the heart and coronary arteries.

Scientists are not sure what causes inflammation of body organs seen in Kawasaki's disease. Many experts believe that a virus attacks the body, involving various organs and other tissues. Children with this disease have a severe flulike illness that usually goes away within a week or two. Twenty percent of the children with Kawasaki's disease have inflammation of the heart and coronary arteries.

The skin is a soft outer covering of an animal, in particular a vertebrate. The adjective cutaneous literally means "of the skin" (from Latin cutis, skin). In mammals, the skin is the largest organ of the integumentary system made up of multiple layers of ectodermal tissue, and guards the underlying muscles, bones, ligaments and internal organs. Because it interfaces with the environment, skin plays a key role in protecting (the body) against pathogens and excessive water loss. Its other functions are insulation, temperature regulation, sensation, and the protection of vitamin B folates.

Red rash usually first seen on the palms and soles that then spreads to involve the torso within a couple days. The most common appearance is a hive-like rash; however it may also resemble measles (morbilliform rash), erythemai multiforme or a scarletina like rash. It is more impressive on the hands and feet than the torso and the hands and feet generally develop some swelling as well.

The heart may be affected in as many as one of five children who develop Kawasaki disease. Damage sometimes occurs to the blood vessels that supply the heart muscle (the coronary arteries) and to the heart muscle itself. A weakening of a coronary artery can result in an enlargement or swelling of the blood vessel wall (an aneurysm). Infants less than 1 year old are usually the most seriously ill and are at greatest risk for heart involvement. The acute phase of Kawasaki disease commonly lasts 10 to 14 days or more. Most children recover fully. The likelihood of developing coronary artery disease later in life is not known, and remains the subject of medical investigation.

The tongue. Characteristics of strawberry tongue are sloughing of the filiform papillae (caused by the systemic inflammatory process) and persistence of the fungiform papillae, which form the "seeds" of the strawberry. Strawberry tongue is not specific to Kawasaki disease; it may also be present in streptococcal and staphylococcal toxin-mediated disease.

The lymph nodes. Edema is often seen in the hands and feet and the cervical lymph nodes are often enlarged.

IDEAL LABORATORY STUDIES:

2-D Echocardiogram

Patients who have had Kawasaki disease should have an echocardiogram every 1 - 2 years to screen for heart problems. Echocardiography may reveal signs of myocarditis, pericarditis, arthritis, aseptic meningitis, and inflammation of the coronary arteries.

The purpose of this study is to determine the size of your heart, to evaluate how well your heart is functioning or pumping and to assess the structure and function of the valves within the heart. A 2-D (or two-dimensional) echocardiogram is capable of displaying a cross-sectional "slice" of the beating heart, including the chambers, valves and the major blood vessels that exit from the left and right ventricle. A Doppler echocardiogram measures the speed and direction of the blood flow within the heart. It screens the four valves for leaks and other abnormalities. By assigning color to the direction of blood flow, (Color Flow Mapping), large areas of blood flow may be studied. These color flow mappings allow abnormal blood flow characteristics to be interpreted by the cardiologist.

CBC

The CBC test may be performed under many different conditions and in the assessment of many different diseases. It is a screening test used to diagnose and manage numerous diseases. The results can reflect problems with fluid volume (such as dehydration) or loss of blood. The test can reveal problems with red blood cell production and destruction, or help diagnose infection, allergies, and problems with blood clotting.

ESR

ESR stands for erythrocyte sedimentation rate. It is a test that indirectly measures how much inflammation is in the body. However, it rarely leads directly to a specific diagnosis. This test can be used to monitor inflammatory or cancerous diseases. It is a screening test, which means it cannot be used to diagnose a specific disorder.However, it is useful in detecting and monitoring tuberculosis, tissue death, and certain forms of arthritis, autoimmune disorders, and inflammatory diseases that cause vague symptoms.

UrinalysisUrinalysis is the physical, chemical, and microscopic examination of urine. It

involves a number of tests to detect and measure various compounds that pass through the urine.A urinalysis may be done:

As part of a routine medical exam to screen for early signs of disease,If you have signs of diabetes or kidney disease, or to monitor you if you are being treated for these conditions, To check for blood in the urine and to diagnose a urinary tract infection.

PATHOPHYSIOLOGY

Precipitating Factors:Unknown yet linked with unknown etiologic agent

and environmental factors

Predisposing factors:Age-1 year old

Sex-MaleRace-Asian

Autoimmune Response (possible if

tested of HLA-BN22J2 antigen)

Release of Chemical Mediators

(Histamine, bradykinin,

prostaglandin)

Vasodilation and Cellular Permeabilty

Attraction of Phagocytes and WBC

Entry of antigen on lymphatic capillaries

S/S:RednessSwellingHeat

Phagocytosis by neutrophils and macrophages (antigens are localized and inflammation happens

Increase pressure due to inflammation and entry of antibodies

Systemic blood vessels involvement

(inflammation of small & medium size vessels)

If treated:AmpicillinCetirizineDiazepam

CeftriaxoneParacetamol

If not treated:Complications developed

GOOD PROGNOSIS

Myocardial infarction

DEATH

Cardiomegaly

Myocarditis

Pericarditis

Heart failure

Ruptured coronary aneurysym

XI. Nursing Care Plan

1 Actual

Assessment Diagnosis Rationale Expected Outcome

Nursing Intervention Justification Evaluation

Actual

Objective:

> Increased in body temperature above normal range> flushed skin; warm to touch>increased RR, unstable BP

Subjective:

> “May lagnat yata sya” as verbalized by folks.

Risk: Knowledge deficit; financial assistance

Strength: Faith in God; Good family support

> Hyperthermia Related to increased metabolic rate and dehydration, possibly as evidenced by increased body temperature greater than normal range, flushed skin, increased RR and tachycardia.

Definition: Body temperature elevated above normal range

Entry of pathogens in the

systemic circulation

↓Regulation of

toxins in the body↓

Release of pyrogen

↓Stimulation of the

hypothalamus↓

Increase or alteration of

thermoregulation↓

Increase in body temperature

↓Hyperthermia

After 3 days of nursing interventions, the client will be able to:

1. Maintain core temperature within normal range

2. Identify underlying cause/ contributing factors and importance of treatment.

3. Demonstrate behaviors to monitor and promote normothermia.

Independent:

1. Monitor core temperature

2. Provide tepid sponge bath as necessary

3. Discuss importance of adequate fluid intake to prevent dehydration

Collaborative:

1. Administer paracetamol as ordered

2. Administer hydroxyzine as ordered

3. Monitor periodic lab studies relative to general well-being & status of specific problems

- to evaluate effects/degree of hyperthermia

- To assist with measures to reduce body temperature

- to promote wellness

- to reduce fever/ headache

- to decrease inflammation

- to assist client with correcting/ minimizing condition & promote optimal healing

After 3 days of nursing interventions:

1- Goal met: The client has able to demonstrate temperature within normal range from 38.1°c to 36.5°c.

2- Goal met:The client together with his significant others understands causes of the disease and is ready to practice interventions to prevent hyperthermia.

3.- Goal met:The client has able to exhibit stable behaviors to monitor and promote normothermia

1 Actual

Assessment Diagnosis Rationale Expected Outcome

Nursing Intervention Justification Evaluation

Actual

Objective:

> Scaly skin, rough>Peeling >Itchiness> Reports of scratching of Upper extremities & Lower extremities.

Subjective:

> “Kamut sya ng kamot tapos nagsusugat” as verbalize by folks

Risk: Knowledge deficit; financial assistance

Strength: Faith in God; Good family support

> Impaired Skin integrity Related to inflammatory process as evidenced by disruption of skin surfaces, macular rash and skin desquamation.

Definition: Altered epidermis and/or dermis [The integumentary system is the largest multifunctional organ of the body.]

Inflammatory process

↓

Swelling of tissues

↓

Disruption of skin surfaces

↓

Skin desquamation

and Rash↓

Impaired skin integrity

After 3 days of nursing interventions, the client will be able to:

1. Display timely healing of rash and skin desquamation

2. Maintain optimal nutrition

3. Participate in prevention measures and comply with treatments.

Independent:

1. Periodically remeasure/ photograph wound and observe for complications.

2. Keep the area clean/dry, carefully dress wounds, support incision, prevent infection, & stimulate circulation to surrounding areas

3. Encourage early ambulation/ mobilization

Collaborative:

1. Application of anti-itch ointment.

2. Administer hydroxyzine as ordered

3. Monitor periodic lab studies relative to general well-being & status of specific problems

- to monitor progress of wound healing

- to assist body’s natural process of repair

- to promote circulation and reduces risks associated with immobility

- to prevent irritation and relieve skin itchiness.

- to decrease inflammation

- to assist client with correcting/ minimizing condition & promote optimal healing

After 3 days of nursing interventions:

1- Goal met: the client has able to exhibit optimum healing of rashes and skin desquamation.

2- Goal met:the client has able to eat regularly 3 times a day.

3.- Goal met:the client has able to partake in all treatment concerning his health.

1 Risk (NCP)

Assessment Diagnosis Rationale Expected Outcome

Nursing Intervention

Justification Evaluation

Actual

Objective:

Altered blood pressure outside of acceptable parameters

Risk: poor eating habits & change in usual foods pattern

Strength: good family support and optimistic in life

>Risk for altered peripheral tissue perfusion Related to inflammation of blood vessels

Definition:

Decrease in oxygen resulting in failure to nourish the tissue at the capillary level

Source: NANDA

Inflammation (infection)

↓Altered immune

function↓

Increase in antibody

production↓

Circulating immune (Antibody –

antigen) complex is bind to vascular epithelium and

cause inflammation↓

Inflammation of blood vessels leads

to platelet accumulation.

↓Risk for altered peripheral tissue

perfusion

After 3 days of nursing interventions, the client will be able to:

1. Demonstrate behavior changes to improve circulation

2. verbalize (folks) understanding of condition and when to contact healthcare provider 3. Exhibit increased perfusion as individually appropriate vital sign’s within clients’ normal range.

Independent:

1. Identify changes related to systemic and/or peripheral alterations in circulation.

2. Perform assistive range-of-motion exercises

3. Provide preoperative teaching appropriate for the situation.

Collaborative:

1. Administer medications as indicated (e.g. anti dysrhythmics)

2. Review baseline ABG’s electrolytes, BUN/Cr, cardiac enzymes

- To assess causative/ contributing factors

- To maximize tissue perfusion

- To promote wellness

- To maximize tissue perfusion

. To note degree of impairment/ organ involvement

After 3 days of nursing interventions:

1- Goal met: Exhibit appropriate behavior to enhance circulation

2- Goal met:Client has able to Perceive about the present condition and how to contact help in healthcare agencies.

3- Goal met: Client has able to maximize tissue perfusion and demonstrate vital sign which is within normal ranges.

DRUG STUDYName of Drug Dosage

Frequency Route

Mechanism of action Indication Contraindication Adverse reaction Nursing considerations

1. paracetamol

CLASSIFICATION:Analgesics (Non-Opioid) & Antipyretics

100mg,IVTT q4hPRN

Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. The drug may relieve fever through central action in the hypothalamic heat-regulating center.

> Mild pain or fever-Headache, fever associated w/ colds.

> Contraindicated to patients hypersensitivity to drugs.

> Use cautiously in patients with long term alcohol use because therapeutic doses cause hepatotoxicity in these patients

Hematologic: hemolytic anemia, neutropenia, leucopenia, pancytopenia.Hepatic: jaundice.Metabolic: hypoglycemiaSkin: rash, urticaria.

> Many OTC and prescription products contain acetaminophen; be aware of this when calculating total daily dose.> Use liquid form for children and patients who have difficulty swallowing.> In children, don’t exceed five doses in 24hrs.

2. aspirin

CLASSIFICATION: Analgesics (Non-Opioid) & Antipyretics/ CNS drug

300mg,1 tab, TIDP.O.

Unknown. Thought to produce analgesia by blocking pain impulses, by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation. Drug may relieve fever by central action in the hypothalamic heat-regulating center and exert its anti inflammatory effect by synthesis of inhibiting prostaglandin and that of other mediators of the inflammatory response as well.

> Mild pain or fever, Kawasaki syndrome (mucocutaneous lymph node syndrome),

> Contraindicated to patients hypersensitivity to drug and in those with NSAID- induced sensitivity reactions, G6PD deficiency, or bleeding disorders, such as hemophilia.

>Use cautiously in patients with GI lesions, impaired renal function, vitamin K deficiency.

EENT: tinnitus, hearing loss.Hematologic: leukopenia, thrombocytopenia, prolonged bleeding time. GI: nausea, GI distress, occult bleeding, dyspepsia, GI bleeding.Hepatic: hepatitis.Skin: rash, bruising, urticaria.Other: angioedema, hypersensitivity reactions.

> For inflammatory conditions, rheumatic fever, and thrombosis, give aspirin on a schedule rather than p.r.n.>Because enteric-coated and sustained release tablets are slowly absorbed, they aren’t suitable for rapid relief of acute pain, fever, or inflammation. They cause less GI bleeding and may be better suited for long-term therapy, such as treatment of arthritis.

3. ampicillin

CLASSIFICATION:Anti-infectives/ Penicillins

250mg1 tab q6P.O

Inhibits cell-wall synthesis during bacterial multiplication.

> Fever/ infections> Skin and skin-structure infections

> Contraindicated in patients hypersensitivity to drug or other penicillins.> Use cautiously in patients with other drug allergies. Because of possible cross-sensitivity, and in those with mononucleosis, because of high risk of maculopapular rash.

CNS: lethargy, hallucinations, seizures, anxiety, confusion, agitation, depression, dizziness, fatigueCV: vein irritation, thrombophlebitis.GI: nausea, vomiting, diarrheaGU: interstitial nephritis, nephropathy, vaginitis.Skin: pain at injection siteOther: hypersensitivity reactions.

> Before giving drug, ask patient about allergic reactions to pennicilins. A negative history of penicillin allergy is no guarantee against a future allergic reaction.> Obtain specimen for culture and sensitivity tests before giving first dose. Therapy may begin pending results.

HEALTH TEACHING

Medication Exercise Treatment Hygiene Outpatient Diet

` Paracetamol for fever-Headache, fever associated w/ colds.`Aspirin for Mild pain or fever, Kawasaki syndrome`Ampicillin for fever/ infection

`Teach the patient & folks about the indications of the drugs and let them know the effect & adverse effects of the medications.Client must understand the importance of drugs to their body and why they must acquire it.

Remind them to question and not to administer medication that have been, improperly stored, look discolored, or do not look like their usual medication.

Advise the patient to always read the label before taking a drug, to take it exactly as prescribed, and never to share prescription drugs.

Encourage them to ask further questions about their drugs.After discussion make sure the client understands and ask to repeat if verification is needed.

> CARDIO EXERCISES

- to promote blood circulation. Moderate exercise in the morning within the patient’s limit and with rest. Inform client that the normal activity can be resumed after 3-4 weeks.

>ROM

-for circulation improvement. Exercises may not be important, but it can minimize the chance of acquiring and spreading of diseases.

Medications

> Aspirin -Thought to produce analgesia by blocking pain impulses, by inhibiting synthesis of prostaglandin in the CNS or of other substances that sensitize pain receptors to stimulation.> Ampicillin -Inhibits cell-wall synthesis during bacterial multiplication.>Paracetamol - relieve fever through central action in the hypothalamic heat-regulating center.

Laboratory test >Regular monitoring of CBC (platelets)- To prevent lowering of platelets that may cause spontaneous bruising & bleeding> Urinalysis - serves as indication for infection.

Personal hygiene pertains to hygiene practices performed by an individual to care for one’s bodily health and well being through cleanliness. Conditions and practices that serve to promote or preserve health.

Personal hygiene practices include: seeing a doctor, seeing a dentist, regular washing (bathing or showering) of the body, regular hand washing, brushing and flossing of the teeth, and healthy eating.

>self-help bath/Bed bath

>Tepid sponge bath

>Brushing and flossing the teeth - to remove dental plaque

>providing special oral care-to maintain intactness of health of lips, tongue and mucus membranes of the mouth.-to prevent oral infections

> Continue prescription drugs if symptoms comes back

>Compliance to follow up check ups

> Continue ROM and Cardio exercises- to avoid further complications to health

> Adequate fluids - for hydration

> Prevention/Promotion of diseases must be implemented

> Rest for comfort

> Careful handling of items in the environment, to minimize viral contamination.

Practice of ingesting food in a regulated fashion to achieve or maintain a controlled weight. In most cases the goal is weight loss in those who are overweight or obese, but some athletes aspire to gain weight (usually in the form of muscle) and diets can also be used to maintain a stable body weight.

> Balanced diet- Eat fresh fruits and vegetables for essential nutrients and minerals- strengthen immunity

> Avoid junk and street foods- to avoid GIT infections - to prevent complications such as amoeba and hepatitis.

> Regular bowel elimination

Prognosis

Kawasaki's disease generally resolves on its own after four to eight weeks.

However, the outcome is not so favorable in every case. Rarely, Kawasaki's disease can cause death from blood clots forming in abnormal areas of widening (aneurysms) of the heart arteries (coronary arteries). Those children with larger aneurysms have a worse prognosis because of this risk.

Researchers are searching for methods of detecting which children are at risk for the development of aneurysms of the coronary arteries. Further research is under way to investigate a variety of criteria for atypical variants of Kawasaki's disease that do not have classical presentations.

How can Kawasaki's disease cause serious complications?

Children with Kawasaki's disease can develop inflammation of the arteries of various parts of the body. This inflammation of the arteries is called vasculitis. Arteries that can be affected include the arteries that supply blood to the heart muscle (the coronary arteries). Vasculitis can cause weakening of the blood vessels and lead to areas of vessel widening (aneurysms). Coronary aneurysms have been reported in up to 25% of those with Kawasaki's disease.

Because of the potential for heart injury and coronary aneurysms, special tests are performed to examine the heart. Children are typically evaluated with an electrocardiogram (EKG) and an ultrasound test of the heart (echocardiogram). Other arteries that can become inflamed include the arteries of the lungs, neck, and abdomen. These effects can lead to breathing problems, headaches, and pain in the belly, respectively.