kawasaki final ru

8/3/2019 Kawasaki Final Ru

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Topic: Kawasaki Disease

Placement: First Semester, Level IV

Time Allotment: 1 hour

Topic Description: This topic focuses on the care of clients having Kawasaki disease. It includes the overview, clinical manifestations, diagnostic evaluation,

therapeutic management and specific nursing management appropriate for the said disease condition.

Central Objective: At the end of our 1-hour interactive-discussion, the learners shall gain concrete knowledge, manifest beginning skills and positive attitudes and

values toward the care of clients with Kawasaki disease, be able to identify its clinical manifestation and the different nursing considerations that should be

observed.

Specific Objectives Content T-A T-LActivities

Evaluation

At the end of the wardclass, the learner shallsatisfactorily:

•

Describe thedifferent termsrelated to the topic.

I. Definition of Terms:

•

Infantile Polyarteritis Nodosa (IPAN) - a rare and often fatal inflammatorydisease of small and medium arteries.

• Autoimmunity is the failure of an organism to recognize its own constituentparts as self , which allows an immune response against its own cells andtissues

.

• Mucocutaneous Lymph Node Syndrome – other name for Kawasakidisease.

- a syndrome of unknown origin that mainly affects young children which

causes fever , reddening of the eyes (conjunctivitis) and lips and mucous

membranes of the mouth, ulcerative gum disease (gingivitis), swollen glands

in the neck (cervical lymphadenopathy), and a rash that is raised and bright

red (maculoerythematous) in a glove-and-sock fashion over the hands and

feet.

5 min Game Active classparticipation

http://www.medterms.com/script/main/art.asp?articlekey=361








• Identify at leastfour (4) out of six(6) diagnosticcriteria for Kawasaki disease

disease in children in Japan and the United States.

C. EtiologyThe causative agent of Kawasaki disease is still unknown, but current theoriescenter primarily on immunological causes for the disease. Evidence increasinglypoints to an infectious etiology, but debate continues on whether the cause is aconventional antigenic substance or a superantigen. Per a Children’s Hospital

Boston / Harvard Medical school information page on the disease, “Some studieshave found associations between the occurrence of Kawasaki disease and recentexposure to carpet cleaning or residence near a body of stagnant water; however,cause and effect have not been established.”

An association has been identified with an SNP in the ITPKC gene, which codes anenzyme that negatively regulates T-cell activation. An additional factor thatsuggests genetic susceptibility is the fact that regardless of where they are living,Japanese children are more likely than other children to contract the disease. TheHLA-B51 serotype has been found to be associated with endemic instances of thedisease.

III. Diagnostic Criteria for Kawasaki DiseaseThere are six (6) diagnostic criteria for Kawasaki disease. The child must exhibit

five (5) out of the six (6) criteria for KD to be diagnosed. Diagnostic criteria for KD

include:

A. Changes in extremities consisting of enduration of the hands and feetwith erythematous palms and soles;

B. Polymorphous rash/exanthema;C. Bilateral conjunctival injection (inflammation) without exudation;D. Erythematous mouth and pharynx, strawberry tongue, and red, cracked

lips;E. Cervical lymphadenopathy (one lymph node 1.5 cm); andF. Changes in oral mucous membranes, such as erythema, dryness, and

fissuring of lips, oropharyngeal reddening, or “strawberry tongue” (largepapillae are exposed).

30min ConceptMaping



• Analyze anddifferentiate clinicalmanifestations,diagnostic exams,and nursing

interventionsappropriate for each of the four phases of thedisease condition.

IV.Phases of Kawasaki DiseaseA. Acute Phase: (1-10 days)

a.1 Assessment

Acute phase begins with the abrupt onset of high fever (greater than 39˚ C) that isunresponsive to antibiotics and antipyretics which lasts for about 1 to 2 weeks (day 0-

14). The child usually develops the remaining diagnostic symptoms and other acutesigns of illness thereafter. At this phase, the child exhibits significant irritability,bilateral conjunctival inflammation, erythema of the oropharynx, dryness and fissuringof the lips, “strawberry tongue”, cervical lymphadenopathy, a polymorphous rash,erythema of the urethral meatus, tachycardia, and edema of the extremities may benoted.

• Health History Taking

Most children submit to consultation because of concern of a prolonged fever.

Diagnosis requires fever of at least 5 days duration (though some believe that

experienced clinicians may make the diagnosis earlier in otherwise classic

presentations). Parents may note that the fever began abruptly. Antibiotic therapy

may have been initiated for other diagnoses, but fever persists. The affected child isusually more irritable than would be expected by the degree of fever.

Key historical clues include the following:

• Fever o at least 5 days in duration,o often abrupt in onset, ando unresponsive to antibiotic therapy, if given.

• Irritability - Out of proportion to the degree of fever or other signs. Remember that aseptic meningitis may coexist.

• Clinical Manifestations

a. The child appears severely ill and irritable. b. Major diagnostic criteria established by the Centers for Disease Control and

Prevention (CDC) are as follows:

Presen-tation of Pictures

Oral Questioning:Distinguish eachphase from theother.



1. High, spiking fever for 5 days or more.2. Bilateral conjunctival injection.3. Oropharyngeal erythema, “Strawberry “ tongue, or red dry lips.4. Erythema and edema of hands and feet, periungal desquamation.5. Erythematous generalized rash.6. Cervical lymphadenopathy greather than 0.6 inch (1.5cm)

c. Pericarditis, myocarditis, cardiomegaly, heart failure, and pleural effusion.

d. Other associated findings include meningitis, arthritis, sterile pyuria, vomiting,and diarrhea.

• Diagnostic/Laboratory Exams

a. elevated ESR and platelet count (as high as 700,00/mm3),b. positive C-reactive protein,c. leukocytosis with left shift,d. slight decrease in red blood cells and hemoglobin,e. hypoalbuminemia,f. increased α2-globulin, andg. sterile pyuria.

a.2 Nursing Diagnosis

• Ineffective thermoregulation: Hyperthermia r/t Autoimmune response s/t.Kawasaki disease

• Altered Comfort: Acute Pain r/t inflammation and edema/swelling of tissues (eg. Hands/feet )

• Impaired skin integrity r/t inflammatory response as evidenced bydisruption of skin surface/macular rash

• Impaired oral mucous membrane r/t inflammatory process/dehydration

• Deficient fluid volume r/t failure of regulatory mechanisms as evidencedby fever/hyperthermia

a.3 Nursing Responsibilities

• Monitor pain level and child’s response to analgesics.

• Administration on antipyretics.

• Take vital signs as directed by condition; report abnormalities.



• Closely monitor intake and output, and administer oral and I.V fluids asordered.

• Monitor hydration staus by checking skin turgor, weight, urinary output,specific gravity, and presence of tears.

• Observe mouth and skin frequently for signs of infection.

• Allow the child periods of uninterrupted rest

•

Perform comfort measures related to the eyes.-Conjunctivities can cause photosensitivity, so darken the room, offer sunglasses.-Apply cool compress.-Discourage rubbing the eyes.-Instill artificial tears to soothe conjunctiva.-Provide sponge bath if temperature above normal.-Provide care measures for oral mucous membrane.-Offer cool liquids like ice chips and ice pops.-Use soft toothbrush only.-Apply petroleum jelly to dried, cracked lips.

• Offer clear liquids every hour when the child is awake.

• Infuse I.V fluids through a volume control device if dehydration is

present, and check the site and amount hourly.• Practice relaxation techniques with child, such as relaxation breathing,

guided imagery, and distraction.

a.3 Evaluation

• Vital Signs within normal range.

• Normal fluid and electrolyte balance as noted by well hydrated appearanceand normal serum electrolyte values.

• Capillary Refill less than 2 seconds. Good skin turgor and mobility.

• The child will rest comfortably, as evidenced by periods of uninterrupted sleepand express decreased pain on an age-appropriate pain assessment tool.

• Mouth care done as necessary.

• Joint pains relieved.• Verbalization of relief from eye irritation.



B. Subacute Phase: (11-25 days)Stage 2 or subacute phase begins with the resolution of fever and ends until all

other clinical signs have disappeared which lasts 2 to 4 weeks after the onset of the

disease process. At this phase, the child is at risk of contracting coronary artery

aneurysms.

b.1 assessment


Acute symptoms of stage I subside as temperature returns normal. The childremains irritable and anorectic.

Dry, cracked lips with fissures.

Desquamation of toes and fingers.

Coronary thrombus, aneurysm, myocardial infarction, and heart failure.

Thrombocytosis peaks at 2 weeks.

Other Manifestations:

Tachycardia

Transient diarrhea

facial palsy

sensorineural hearing loss

sudden death syndrome.

Joint pain/join swelling

• Diagnostic/Laboratory Exams

CBC

elevated ESR and platelet count (as high as 700,00/mm3),

positive C-reactive protein

IgM, IgA, IgG, and IgF – transiently elevated

Lipid profile – low high density lipoprotein and high triglyceride level.

Echocardiogram



b.2 Nursing Diagnosis

• Impaired skin integrity r/t inflammatory response as evidenced bydisruption of skin surface and desquamation

• Fluid volume deficit related to vomiting/diarrhea

• Risk for decreased cardiac output r/t inflammation of coronary arteriesand alterations in rate/rhythm of conduction

• Impaired oral mucous membrane r/t inflammatory process/dehydration

• Imbalanced nutrition: Less than body requirements r/t inflamed oralmucosa/gingivitis

• Altered Comfort: pain r/t swelling of joints

• Disturbed Sensory Perception: Photosensitivity r/t inflamed conjunctivaas evidenced by conjunctival injection

b.3 Nursing Responsibilities

• Institute continual cardiac monitoring and assessment for complications;report arrhythmias.

• Assess for signs of myocarditis (tachycardia, gallop rhythm, chest pain)

• Monitor for heart failure (dyspnea, nasal flaring, grunting, retractions,cyanosis, orthopnea, crackles, moist respirations, distended jugular veins, edema).

• Infuse I.V fluids through a volume control device if dehydration ispresent, and check the site and amount hourly.

• Perform passive range of motion exercises every 4 hours while the childis awake because movement may be restricted.

• Provide quiet and peaceful environment with diversional activities.

• Provide skin measures to improve skin integrity.

-Avoid use of soap because it tends to dry skin and make it more likelyto breakdown.

-Elevate edematous extremities.

-Use smooth sheets.

http://nursingcrib.com/nursing-notes-reviewer/fundamentals-of-nursing/passive-range-of-motion-exercises/

http://nursingcrib.com/nursing-notes-reviewer/fundamentals-of-nursing/passive-range-of-motion-exercises/



-Apply emollients to skin as ordered.

-Protect peeling of skin, observe for signs of infection.

• Monitoring intravenous immunoglobulin (IVIG) therapy

• Administration of analgesics for joint pains

b.3 Evaluation

• Normal vital signs.

• Relief from irritating macular rashes.

• Positive response to ROM without any assistance.

• Positive response to IVIG therapy

• Skin will be free of scratches from itching.

C. Covalescent Phase: (Until sedimentation rate and platelet count normalize)

Convalescent phase or stage 3 is the point in the disease process where signs of

KD are resolved but laboratory results have not normalized. This lasts for 6 to 8 weeksafter onset and is completed after laboratory results have normalized. At the end of

this phase, the child has regained his/her usual temperament, energy, and appetite.

c.1 assessment

• Clinical Manifestations-Clinical manifestations at this phase are positively responsive totreatment.

a. The child appears well.b. Transverse grooves of fingers and toenails (Beau’s lines).c. Coronary thrombosis, aneurysms may occur.

•

Diagnostic/Laboratory Examsa. Electrocardiogram, echocardiogram, cardiac catheterization, andangiocarddiography may be required to diagnose cardiac abnormalities.

b. . CBC

http://nursingcrib.com/medical-laboratory-diagnostic-test/cardiac-catheterization/

http://nursingcrib.com/medical-laboratory-diagnostic-test/cardiac-catheterization/



c. Platelet countd. . IgM, IgA, IgG, and IgF.e. Myocardial enzyme levels (serum CK-MB) suggest MI if elevated.f. Liver enzymes (AST, ALT) – moderately elevated.g. Lipid profile – low high density lipoprotein and high triglyceridelevel.

c.2 Nursing Diagnosis

• Risk for decreased cardiac output r/t degeneration of cardiac muscles

• Risk for Altered Comfort : Acute pain r/t ischemia of myocardial tissue

c.3 Nursing Responsibilities

• Continue monitoring of diagnostic findings or results of Laboratoryexams from 2nd Phase

• Continue treatment of 2nd phase.

c.3 Evaluation

• Vital Signs within normal range.

• Absence of adventitious heart sounds.

• Good capillary refill

• Normal findings in the diagnostic and Laboratory Exams.

• Verbalization of relief from chest pain.

D. Chronic Phase:-Chronic phase is the last stage of KD development.

d.1 assessment


It lasts 40 days to 4 years after illness onset wherein coronary complicationspersists to adulthood. Children may exhibit dislipidemia as evidenced by mild to



moderate low-density lipoproteins or lower high-density lipoproteins.

• Diagnostic/Laboratory Exams1. Abdominal or chest X-rays2. CT scan and ultrasonography MRI3. Arteriography allows visualization of aneurysm and vessel.

4. Lipid Profile Monitoring5. Myocardial Enzyme Levels

d.2 Nursing Diagnosis

• Impaired gas exchange r/t ventilation perfusion imbalance

• Altered tissue perfusion related to narrowing of the coronary arteryassociated with atherosclerosisor thrombosis

• Activity intolerance related to pulmonary congestion and decreasedblood supply to meet the demands of the body

• Pain related to swelling and inflammation of the heart or surroundingtissue

d.3 Nursing Responsibilities.

• Monitor Vital signs

• Monitor diagnostic.laboratory Exams

• Promote adequate rest and sleep.

• Encourage to engage in relaxation techniques as pain management:such deep breathing exercises, diversional toys for children.

• Oxygen Therapy

• Administration of betablockers, anticoagulants as ordered.

• Encourage the child to eat meals and snack with adequate protein.

• Prepare the child for cardiac surgery or thrombolytic therapy if complications develop.

• Keep the family informed about progress and reinforce stages andprognosis.



• Identify anddiscuss briefly 75%of the givencomplications of the disease.

d.3 Evaluation

• Vital signs within normal range.Absence of tachycardia.

• Normal heart sounds from auscultation.

• Frequent rest periods.

• Normal diagnostic and Laboratory findings.

V. ComplicationsKawasaki disease is usually self-limited, but coronary artery abnormalities,

including aneurysms develop in 20% of untreated patients. Fatalities are rare and

occur with myocardial infarctions secondary to thrombosis within a coronary artery

aneurysm. Complications of KD include:

• Coronary Artery AbnormalitiesCoronary artery abnormalities or disease refers to any abnormal condition thatmay affect the heart’s arteries and produce various pathologic effects

especially the reduced flow or nutrients and oxygen to the myocardium.Coronary atherosclerosis is the most common type of CAD.

• Aneurysms

Aneurysm refers to a localized dilation of the wall of a blood vessel. It may be

caused by atherosclerosis and hypertension, trauma, infection or congenital

weakness in the vessel wall.

• Myocardial InfarctionMyocardial infarction (MI) refers to necrosis of a portion of the cardiac musclescaused by obstruction in a coronary artery through atherosclerosis, thrombus,or spasm. It is characterized by a crushing, viselike pain that may radiate to

the left arm, neck, jaw, or epigastrium.

5 mins Active classparticipation



• Discusscomprehensivelywith 75%competency levelthe appropriatemedicalmanagement for Kawasaki disease.

• ArrhythmiasArrhythmia refers to changes in the normal pattern of the heartbeat or abnormalfunctioning of some heart valves can also occur.

VasculitisVasculitis refers to the inflammation of the blood vessels. This can beparticularly dangerous because it can affect the coronary arteries, which supply

blood to the heart.

• Myocarditis or PericarditisMyocarditis refers to the inflammation of the myocardium while pericarditisrefers to the inflammation of the pericardium. Myocarditis is caused by viral,bacterial or fungal infection, serum sickness, rheumatic fever, or it may be acomplication of a collagen disease. It may further lead to acute heart failure.On the other hand, pericarditis is associated with trauma, neoplastic disease,infection, uremia, myocardial infarction, collagen disease, or unknown cause.

VI.Medical Management

• Gamma GlobulinThe current treatment of KD includes high-dose IV immune globulin (IVIG)along with salicylate therapy. IVIG reduces the duration of fever and theincidence of coronary artery abnormalities when given within the first 10 days of the illness. A single large infusion of 2 g/kg over 10 to 12 hours isrecommended.

• AspirinAspirin is an analgesic, antipyretic, and anti-inflammatory drug prescribed toreduce fever and relieve pain and inflammation. It is given initially in an anti-inflammatory dose (80 to 100 mg/kg/day in divided doses every 6 hours) tocontrol fever and symptoms of inflammation. Once fever has subsided, aspirinis continued at an antiplatelet dose (3 to 5 mg/kg/day). Low-dose aspirin is

continued in patients without echocardiographic evidence of coronaryabnormalities until the platelet count has returned to normal (6 to 8 weeks).

5 mins Active classparticipation



• Salicylate TherapySalicylate refers to any of several drugs derive form salicylic acid. They exertanalgesic, antipyretic, and anti-inflammatory actions. If the child developscoronary abnormalities, salicylate therapy is continued indefinitely.

• CoumadinWarfarin sodium is an oral anticoagulant prescribed for prophylaxis and

treatment of thrombosis, atrial fibrillation, and embolism. Additionalanticoagulatory therapy, such as warfarin (Coumadin), may be indicated inthose children with giant aneurysms (>8 mm), who are at the greatest risk for morbidity and mortality.

VII. Evaluation

VIII . Open Forum

5mins Question andanswer



References:

Potter, P. A., & Perry, A. G. (2001). Fundamentals of nursing (5th ed.). Missouri: Mosby, Inc.

Smeltzer, S. C., & Bare, B. G. (2004). Brunner& Suddarth’s textbook of medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins

lack, J. M., Hawks, J. H., & Keene, A. M. (2001). Medical-surgical nursing: Clinical management for positive outcomes (6th ed.). Pennsylvania: W.B. Saunders

Company

Mosby. (2002). Mosby’s pocket dictionary of medicine, nursing, & allied health (4th ed.). Singapore: Elsevier (Singapore) Pte Ltd.

Medline Plus. (2006). Kawasaki disease. http://www.nlm.nih.gov/medlineplus/ency/article/000989.htm (25 August 2007).

http://www.nlm.nih.gov/medlineplus/ency/article/000989.htm%20(25

http://www.nlm.nih.gov/medlineplus/ency/article/000989.htm%20(25



COLLEGE OF NURSINGSilliman UniversityDumaguete City

Syllabuson

KAWASAKI DISEASE

Prepared by:

Alviola, Charlene Valerie C.Submitted to:

Asst. Prof. Charmain Joy Quilnet



Date Submitted:November 11, 2011

VISION – MISSION STATEMENT

VISION

As a leading Christian institution of learning in Asia, Silliman University is committed to total human development for societal and environmental well-being.

MISSION

In this regard, the University

• provides opportunities for all the members of the academic community to seek truth, justice, and love.

• pursues excellence in excellence in every dimension of injury, learning and teaching.

• instills in all members of the university community including all its integral units an enlightened social consciousness, a profound sense of involvement, and agenuine compassion for every person.

• enhances national development and unity by making its life and programs relevant to the total environment.

kawasaki final ru

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