EASTWOOD PROFESSIONAL COLLEGE

OF SCIENCE & TECHNOLOGY

CASE STUDY
OF
KAWASAKI
DISEASE

JOHN KENNETH P. SANTOS

BSN - 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.

Causes
The 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.

Urinalysis
Urinalysis 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

Predisposing factors: Precipitating Factors:

Age-1 year old Unknown yet linked with
Sex-Male unknown etiologic agent
Race-Asian and environmental factors

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 Phagocytosis by neutrophils and
S/S: macrophages (antigens are
Redness localized and inflammation
Swelling happens
Heat

Increase pressure due

to inflammation and
entry of antibodies
 Systemic blood vessels
involvement
(inflammation of small &
medium size vessels)

If treated: If not treated:

Ampicillin Complications developed
Cetirizine
Diazepam
Ceftriaxone
Paracetamol
Pericarditis

Myocarditis
GOOD PROGNOSIS

Cardiomegaly

Myocardial infarction

Heart failure

Ruptured coronary
aneurysym

DEATH
XI. Nursing Care Plan

1 Actual

Assessment Diagnosis Rationale Expected Nursing Intervention Justification Evaluation

Outcome

Actual > Hyperthermia After 3 days Independent:

Entry of
Related to of nursing After 3 days of nursing
Objective: pathogens in the 1. Monitor core - to evaluate interventions:
increased interventions,
metabolic rate systemic the client will temperature effects/degree of
> Increased in body circulation hyperthermia
temperature above and dehydration, be able to:
possibly as ↓
normal range 2. Provide tepid - To assist with measures 1- Goal met:
evidenced by Regulation of 1. Maintain
> flushed skin; warm sponge bath as to reduce body The client has able to
to touch increased body toxins in the body core demonstrate temperature
necessary temperature
>increased RR, temperature ↓ temperature within normal range from
unstable BP greater than Release of within normal - to promote wellness 38.1°c to 36.5°c.
3. Discuss importance of
normal range, pyrogen range adequate fluid intake to
Subjective: flushed skin, ↓ prevent dehydration
increased RR and Stimulation of the
> “May lagnat yata tachycardia. 2. Identify Collaborative: 2- Goal met:
hypothalamus The client together with his
sya” as verbalized by underlying
↓ - to reduce fever/ significant others
folks. Definition: cause/ 1. Administer
Body temperature Increase or contributing paracetamol as ordered headache understands causes of the
Risk: Knowledge deficit; alteration of disease and is ready to
elevated above factors and practice interventions to
financial assistance thermoregulation 2. Administer - to decrease
normal range importance of inflammation prevent hyperthermia.
↓ treatment. hydroxyzine as ordered
Strength: Faith in God;
Good family support Increase in body - to assist client with
3. Monitor periodic lab
temperature studies relative to correcting/ minimizing
↓ 3. Demonstrate general well-being & condition & promote 3.- Goal met:
Hyperthermia behaviors to status of specific optimal healing The client has able to
monitor and problems exhibit stable behaviors to
promote monitor and promote
normothermia. normothermia
1 Actual

Assessment Diagnosis Rationale Expected Nursing Intervention Justification Evaluation

Outcome

Actual > Impaired Skin Independent:

Inflammatory After 3 days After 3 days of nursing
integrity Related
process of nursing 1. Periodically remeasure/ - to monitor progress of interventions:
Objective: to inflammatory
interventions, photograph wound and wound healing
process as observe for
> Scaly skin, rough ↓ the client will
evidenced by be able to: complications.
>Peeling disruption of
>Itchiness skin surfaces, Swelling of 2. Keep the area - to assist body’s natural
> Reports of 1. Display 1- Goal met:
macular rash tissues timely healing
clean/dry, carefully process of repair
the client has able to
scratching of Upper dress wounds, support
extremities & Lower and skin of rash and incision, prevent exhibit optimum
extremities. desquamation. ↓ skin infection, & stimulate healing of rashes and
desquamation circulation to skin desquamation.
Subjective: Definition: Disruption of surrounding areas
Altered epidermis
skin surfaces - to promote circulation
> “Kamut sya ng and/or dermis 3. Encourage early
[The 2. Maintain ambulation/ and reduces risks 2- Goal met:
kamot tapos
integumentary ↓ optimal mobilization associated with the client has able to eat
nagsusugat” as immobility
verbalize by folks system is the nutrition regularly 3 times a day.
largest Collaborative:
Skin
Risk: Knowledge multifunctional desquamation - to prevent irritation and
organ of the 3. Participate 1. Application of anti-
deficit; financial and Rash itch ointment. relieve skin itchiness.
assistance body.] in prevention 3.- Goal met:
↓ measures and the client has able to
Impaired skin comply with - to decrease partake in all treatment
Strength: Faith in 2. Administer
God; Good family integrity treatments. hydroxyzine as ordered inflammation concerning his health.
support
3. Monitor periodic lab - to assist client with
studies relative to correcting/ minimizing
general well-being & condition & promote
status of specific optimal healing
problems
1 Risk (NCP)

Assessment Diagnosis Rationale Expected Nursing Justification Evaluation

Outcome Intervention

Actual >Risk for Inflammation Independent:

(infection) After 3 days of After 3 days of nursing
Objective: altered
↓ nursing 1. Identify changes - To assess causative/ interventions:
peripheral interventions, related to systemic contributing factors
Altered immune
Altered blood pressure tissue the client will be and/or peripheral
function
outside of acceptable perfusion able to: alterations in
↓ circulation.
parameters Related to Increase in
inflammation antibody 1. Demonstrate 1- Goal met:
- To maximize tissue
production behavior Exhibit appropriate
Risk: poor eating habits & of blood 2. Perform assistive perfusion
change in usual foods ↓ changes to range-of-motion behavior to enhance
vessels improve
pattern Circulating immune exercises circulation
(Antibody – circulation
Strength: good family Definition: antigen) complex is
support and optimistic in 2. verbalize 3. Provide preoperative
life bind to vascular 2- Goal met:
Decrease in (folks) teaching appropriate - To promote wellness Client has able to
epithelium and
understanding for the situation. Perceive about the
oxygen cause inflammation
↓ of condition and present condition and
resulting in when to contact
Inflammation of Collaborative:
how to contact help in
failure to healthcare healthcare agencies.
blood vessels leads
nourish the to platelet provider
1. Administer
tissue at the accumulation. medications as - To maximize tissue
3. Exhibit 3- Goal met:
capillary level ↓ indicated (e.g. anti perfusion
increased Client has able to
Risk for altered dysrhythmics)
perfusion as maximize tissue
Source: NANDA
peripheral tissue individually 2. Review baseline . To note degree of perfusion and
perfusion appropriate vital ABG’s electrolytes, impairment/ organ demonstrate vital sign
sign’s within BUN/Cr, cardiac involvement which is within normal
clients’ normal enzymes ranges.
range.
DRUG STUDY
Name of Drug Dosage Mechanism of action
Frequenc
y Route
Thought to produce analgesia
1. paracetamol 100mg, by blocking pain impulses by
IVTT q4h inhibiting synthesis of
CLASSIFICATION: PRN prostaglandin in the CNS or of
Analgesics (Non-Opioid) other substances that sensitize
& Antipyretics pain receptors to stimulation.
The drug may relieve fever
through central action in the
hypothalamic heat-regulating
center.
Unknown. Thought to produce
2. aspirin 300mg, analgesia by blocking pain
1 tab, TID impulses, by inhibiting
CLASSIFICATION: P.O. synthesis of prostaglandin in
Analgesics (Non-Opioid) the CNS or of other substances
& Antipyretics/ CNS drug 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.
3. ampicillin 250mg Inhibits cell-wall synthesis
1 tab q6 during bacterial multiplication.
CLASSIFICATION: P.O
Anti-infectives/
Penicillins
Indication Contraindication
> Mild pain > Contraindicated to
or fever patients hypersensitivity
-Headache, to drugs.
fever
associated w/ > Use cautiously in
colds. patients with long term
alcohol use because
therapeutic doses cause
hepatotoxicity in these
patients
> Mild pain > Contraindicated to
or fever, patients hypersensitivity
Kawasaki to drug and in those with
syndrome NSAID- induced
(mucocutaneo sensitivity reactions,
us lymph G6PD deficiency, or
node bleeding disorders, such
syndrome), as hemophilia.
>Use cautiously in
patients with GI lesions,
impaired renal function,
vitamin K deficiency.
> Fever/ > Contraindicated in
infections patients hypersensitivity
> Skin and to drug or other
skin-structure penicillins.
infections > 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.
Adverse reaction
Hematologic: hemolytic
anemia, neutropenia,
leucopenia, pancytopenia.
Hepatic: jaundice.
Metabolic: hypoglycemia
Skin: rash, urticaria.
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.
CNS: lethargy, hallucinations,
seizures, anxiety, confusion,
agitation, depression,
dizziness, fatigue
CV: vein irritation,
thrombophlebitis.
GI: nausea, vomiting, diarrhea
GU: interstitial nephritis,
nephropathy, vaginitis.
Skin: pain at injection site
Other: hypersensitivity
reactions.
Nursing considerations
> 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.
> 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.
> 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
` 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.
Exercise Treatment Hygiene Outpatient Diet
Medications Personal hygiene > Continue
> CARDIO pertains to hygiene prescription drugs Practice of ingesting
EXERCISES > Aspirin practices performed by if symptoms comes food in a regulated
-Thought to an individual to care back fashion to achieve or
- to promote produce analgesia for one’s bodily health maintain a controlled
blood circulation. by blocking pain and well being through >Compliance to weight. In most cases
Moderate exercise in impulses, by cleanliness. Conditions follow up check ups the goal is weight
the morning within inhibiting synthesis and practices that serve loss in those who are
the patient’s limit of prostaglandin in to promote or preserve > Continue ROM overweight or obese,
and with rest. Inform the CNS or of health. and Cardio but some athletes
client that the normal other substances exercises aspire to gain weight
activity can be that sensitize pain Personal hygiene - to avoid further (usually in the form
resumed after 3-4 receptors to practices include: complications to of muscle) and diets
weeks. stimulation. seeing a doctor, seeing health can also be used to
> Ampicillin a dentist, regular maintain a stable
-Inhibits cell-wall washing (bathing or > Adequate fluids body weight.
synthesis during showering) of the - for hydration
>ROM bacterial body, regular hand > Balanced diet
multiplication. washing, brushing and > - Eat fresh fruits and
-for circulation >Paracetamol flossing of the teeth, Prevention/Promoti vegetables for
improvement. - relieve fever and healthy eating. on of diseases must essential nutrients
Exercises may not be through central be implemented and minerals
important, but it can action in the >self-help bath/Bed - strengthen
minimize the chance hypothalamic heat- bath immunity
of acquiring and regulating center. > Rest for comfort
spreading of >Tepid sponge bath > Avoid junk
diseases. Laboratory test > Careful handling and street
>Brushing and flossing of items in the foods
>Regular the teeth environment, to - to avoid GIT
monitoring of CBC - to remove dental minimize viral infections
(platelets) plaque contamination. - to prevent
- To prevent complications such
lowering of >providing special oral as amoeba and
platelets that may care hepatitis.
cause spontaneous -to maintain intactness
bruising & of health of lips, > Regular bowel
bleeding tongue and mucus elimination
> Urinalysis membranes of the
- serves as mouth.
indication for -to prevent oral
infection. infections

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.