Nursing Diagnosis: Actual and Potential Problems

Risk for Acute Pain: Related to enlarged lymph nodes and erythematous skin rash that progresses to desquamation, peeling, and denuding of the skin.

Kawasaki Disease
A Systemic Vasculitis with Coronary Arteritis

In order to be diagnosed with Kawasaki Disease an individual must have a fever for five days or more along with four out of five of the following conditions: (1) Bilateral (non-purulent) Conjunctivitis Inflammation and redness in both eyes. (2) Polymorphous rash a rash in a variety of forms (shape, size, location, etc.). (3) Changes in the lips and mouth reddened, dry or cracked lips, strawberry tongue, diffuse erythema (supercicial reddening) of oral or pharyngeal mucosa. (4)Changes in the extremeties erythema of palms or soles, indurative edema of hands or feet, desquamation of skin if hands,

Clinical Manifestations and Potential Complications

Outcomes: Decrease pain-related behaviors, able to perform activities of recovery and activities of daily living easily as determined by clients
condition. Risk for Impaired Oral Mucous Membrane: Related to inflamed mouth/pharynx and swollen lips that become dry, cracked, and fissured. Outcomes: Maintain intact, moist oral mucous membrane that is free of ulceration, inflammation, infection, and debris. Demonstrate measures to maintain or regain intact oral mucous membranes. Risk for Decreased Cardiac Tissue Perfusion: Related to cardiac involvement of the disease process.
(Ladwig, 2011)

References:
Huether, S., McCance, K. (2012). Understanding Pathophysiology (Fifth edition). Elsevier Mosby Inc.: St. Louis, Missouri. Ladwig, G., Ackley, B. (2011), Mosbys Guide to Nursing Diagnosis (Third Edition) Mosby Elsevier Inc.: Maryland Heights, Missouri. Royle, J., Burgner, D. and Curtis, N. (2005), The diagnosis and management of Kawasaki disease. Journal of Pediatrics and Child Health, 41: 8793. doi: 10.1111/j.1440-1754.2005.00555.x Uehara, R., Yashiro, M., Nakamura, Y. and Yanagawa, H. (2011), Parents with a history of Kawasaki disease whose child also had the same disease. Pediatrics International, 53: 511514. doi: 10.1111/j.1442200X.2010.03267.x

feet, and perineum.

(5) Cervical Lymphadenopathy

NCLEX Questions

Explanation of the The signs and symptoms of Kawasaki disease Disease (KD), also known as
Mucocutaneous lymph node syndrome, were first discovered in 1967. KD is a systemic inflammation of the blood vessels and coronary artery walls; primarily occurring is children younger than five years of age. It is currently the leading cause of acquired cardiac disease. The cause of Kawasaki Disease remains unknown and consequently there are no specific diagnosis tests. KD progresses through 3 phases: Early/Acute: small capillaries, arterioles, venules and heart become inflamed. Subacute: inflammation spreads to larger vessels and aneurysms of the coronary arteries may develop. Convalescent: medium-size arteries begin the granulation process and may cause coronary artery thickening with increase risk for thrombosis. After the convalescent phase, inflammation wanes with potential

Lifespan and Cultural Considerations

Kawasaki Disease primarily occurs in children with 80% of the cases seen in children younger than five years of age. Males are slightly more affected than females. KD occurs worldwide, but is most often seen in the Asian population. Occasionally, KD will be seen in the Caucasian population and rarely in African Americans. The probability that parents of children with Kawasaki Disease also had a history with Kawasaki disease is significantly higher. This suggests that there is a genetic component when is comes to the development of the

Significance to Nursing
Treatment of Kawasaki Disease: Untreated KD, or that treated with aspirin alone, leads to coronary lesions in 2040% of patients, whereas appropriate therapy with IVIG and aspirin reduces the incidence of coronary lesions to less than 5%. IVIG and

aspirin should be given as soon as possible after diagnosis.

Intravenous Immunoglobulin (IVIG): 2 g/kg infused over 10 hours (unless cardiovascular compromised). Aspirin: 10 mg/kg every 8 hours (Antiinflammatory dose) until fever subsides, then reduce dose to 3-5 mg/kg every day (antiplatelet dose) for 6-8 weeks. Recurrent KD is rare, with 12% recurrence rates reported in the Japanese and less than 1% in Caucasian populations. The lack of knowledge about Kawasaki disease and the etiology is potentially a serious and harmful problem if the disease would increase. Healthcare providers would need to be particularly familiar with the clinical manifestations and disease process to identify and treat KD earlier and prevent permanent harmful affects. Also, educating parents on Kawasaki disease and the signs and symptoms is pertinent.

(Huether, 2012, pp.

Answers: 1-A, 2B

1. The RN realizes that additional teaching is not needed when the parents of a child with Kawasaki syndrome states, "It is a(n): A. Systemic, acute inflammatory disease, also known as Mucocutaneous lymph node syndrome. B. Inflammatory disorder caused by group A beta-hemolytic streptococcus infection. C. Circulatory deficit with decrease cardiac output. D. Mixed cardiac defect that affects both the systemic and pulmonary circulations. 2. The RN is caring for a client with Kawasaki syndrome who is in the subacute phase. Which symptom would the RN expect to find? A. Conjuctival hyperemia. B. Sloughing off of the skin on the lips, hands, and feet. C. Swollen hands and feet. D. Enlarged cervical lymph nodes.