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 At the end of the ward class, the learner shall satisfactorily: Describe the different terms related to the topic. Content T-A T-L Activities Evaluation

I. Definition of Terms: . Mucocutaneous Lymph Node Syndrome other name for Kawasaki disease. - 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. Infantile Polyarteritis Nodosa (IPAN) - a rare and often fatal inflammatory disease of small and medium arteries. Autoimmunity is the failure of an organism to recognize its own constituent parts as self, which allows an immune response against its own cells and tissues 5 min Game Active class participation

 Conjunctival Injection is the symptom of redness of the white sclera of the eye. It is a sign of inflammation of the conjunctiva and also may represent inflammation in the eye. Coronary heart disease (CHD)- also called coronary artery disease, is a condition in which plaque (plak) builds up inside the coronary arteries. Kawasaki Disease - an acute systematic vasculitis of unknown origin or cause. Idiopathic Facial Palsy(Bells Palsy) - palsy is a disorder of the nerve that controls movement of the muscles in the face.Damage to this nerve causes weakness or paralysis of these muscles.

II. Overview of Disease Condition State in their own A. History words a brief Kawasaki disease got its name from the first person who described it. It was first description of described in 1967 by Tomisaku Kawasaki, a Japanese pediatrician. At that time, he Kawasaki disease as a disease reported 50 children from 1961-1967 who presented with a distinctive clinical illness condition. characterized by fever and rash, which was then thought to be a benign childhood illness. B. Brief Description Kawasaki disease or syndrome is a self-limiting, acute systematic, childhood vasculitis of unknown origin or cause. It is formerly known as mucocutaneous lymph node syndrome or infantile polyarteritis nodosa which is descriptive of a disease characterized by the typical changes in the mucus membranes that usually line the lips and mouth, and by enlarged and tender lymph nodes. Kawasaki disease is a condition widespread worldwide. It has been noted that there is high incidence of Kawasaki disease among Asians, thus Asian children are at greatest risk of contracting the disease. It is the most common cause of acquired heart 10min Socialized Discussion Oral questioning: Give at least 2 causes of Kawasaki and briefly explain how.

disease in children in Japan and the United States. C. Etiology The causative agent of Kawasaki disease is still unknown, but current theories center primarily on immunological causes for the disease. Evidence increasingly points to an infectious etiology, but debate continues on whether the cause is a conventional antigenic substance or a superantigen. Per a Childrens Hospital Boston / Harvard Medical school information page on the disease, Some studies have found associations between the occurrence of Kawasaki disease and recent exposure 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 an enzyme that negatively regulates T-cell activation. An additional factor that suggests genetic susceptibility is the fact that regardless of where they are living, Japanese children are more likely than other children to contract the disease. The HLA-B51 serotype has been found to be associated with endemic instances of the disease. III. Diagnostic Criteria for Kawasaki Disease There are six (6) diagnostic criteria for Kawasaki disease. The child must exhibit Identify at least five (5) out of the six (6) criteria for KD to be diagnosed. Diagnostic criteria for KD four (4) out of six include: (6) diagnostic criteria for A. Changes in extremities consisting of enduration of the hands and feet Kawasaki disease with 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); and F. Changes in oral mucous membranes, such as erythema, dryness, and fissuring of lips, oropharyngeal reddening, or strawberry tongue (large papillae are exposed).

30min

Concept Maping

Analyze and differentiate clinical manifestations, diagnostic exams, and nursing interventions appropriate for each of the four phases of the disease condition.

IV.Phases of Kawasaki Disease A. Acute Phase: (1-10 days) a.1 Assessment Acute phase begins with the abrupt onset of high fever (greater than 39 C) that is unresponsive to antibiotics and antipyretics which lasts for about 1 to 2 weeks (day 014). The child usually develops the remaining diagnostic symptoms and other acute signs of illness thereafter. At this phase, the child exhibits significant irritability, bilateral conjunctival inflammation, erythema of the oropharynx, dryness and fissuring of the lips, strawberry tongue, cervical lymphadenopathy, a polymorphous rash, erythema of the urethral meatus, tachycardia, and edema of the extremities may be noted. 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 is usually 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, and o unresponsive to antibiotic therapy, if given. Irritability - Out of proportion to the degree of fever or other signs. Remember

Presentation of Pictures

Oral Questioning: Distinguish each phase from the other.

that aseptic meningitis may coexist.

a. b.

Clinical Manifestations The child appears severely ill and irritable. Major diagnostic criteria established by the Centers for Disease Control and Prevention (CDC) are as follows:

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. b. c. d. e. f. g. elevated ESR and platelet count (as high as 700,00/mm3), positive C-reactive protein, leukocytosis with left shift, slight decrease in red blood cells and hemoglobin, hypoalbuminemia, increased 2-globulin, and 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 by disruption of skin surface/macular rash Impaired oral mucous membrane r/t inflammatory process/dehydration Deficient fluid volume r/t failure of regulatory mechanisms as evidenced by fever/hyperthermia

a.3 Nursing Responsibilities Monitor pain level and childs 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 as ordered. 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 appearance and 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 sleep and 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 Clinical Manifestations Acute symptoms of stage I subside as temperature returns normal. The child remains 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 by disruption of skin surface and desquamation Fluid volume deficit related to vomiting/diarrhea Risk for decreased cardiac output r/t inflammation of coronary arteries and alterations in rate/rhythm of conduction Impaired oral mucous membrane r/t inflammatory process/dehydration Imbalanced nutrition: Less than body requirements r/t inflamed oral mucosa/gingivitis Altered Comfort: pain r/t swelling of joints Disturbed Sensory Perception: Photosensitivity r/t inflamed conjunctiva as 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 is present, and check the site and amount hourly. Perform passive range of motion exercises every 4 hours while the child is 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 likely to breakdown. -Elevate edematous extremities. -Use smooth sheets.

-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 weeks after 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 to treatment. a. The child appears well. b. Transverse grooves of fingers and toenails (Beaus lines). c. Coronary thrombosis, aneurysms may occur. Diagnostic/Laboratory Exams a. Electrocardiogram, echocardiogram, cardiac catheterization, and angiocarddiography may be required to diagnose cardiac abnormalities. b. . CBC

c. Platelet count d. . 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 triglyceride level. 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 Laboratory exams 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 Clinical Manifestations It lasts 40 days to 4 years after illness onset wherein coronary complications persists to adulthood. Children may exhibit dislipidemia as evidenced by mild to

moderate low-density lipoproteins or lower high-density lipoproteins. Diagnostic/Laboratory Exams Abdominal or chest X-rays CT scan and ultrasonography MRI Arteriography allows visualization of aneurysm and vessel. Lipid Profile Monitoring Myocardial Enzyme Levels d.2 Nursing Diagnosis Impaired gas exchange r/t ventilation perfusion imbalance Altered tissue perfusion related to narrowing of the coronary artery associated with atherosclerosisor thrombosis Activity intolerance related to pulmonary congestion and decreased blood supply to meet the demands of the body Pain related to swelling and inflammation of the heart or surrounding tissue 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 and prognosis.

1. 2. 3. 4. 5.

Identify and discuss briefly 75% of the given complications 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.

5 mins

Active class participation

V. Complications Kawasaki 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 Abnormalities Coronary artery abnormalities or disease refers to any abnormal condition that may affect the hearts 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 Infarction Myocardial infarction (MI) refers to necrosis of a portion of the cardiac muscles caused 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.

Arrhythmias Arrhythmia refers to changes in the normal pattern of the heartbeat or abnormal functioning of some heart valves can also occur. Vasculitis Vasculitis refers to the inflammation of the blood vessels. This can be particularly dangerous because it can affect the coronary arteries, which supply 5 mins blood to the heart.

Discuss comprehensively with 75% competency level the appropriate medical management for Kawasaki disease.

Active class participation

Myocarditis or Pericarditis Myocarditis refers to the inflammation of the myocardium while pericarditis refers to the inflammation of the pericardium. Myocarditis is caused by viral, bacterial or fungal infection, serum sickness, rheumatic fever, or it may be a complication 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 Globulin The current treatment of KD includes high-dose IV immune globulin (IVIG) along with salicylate therapy. IVIG reduces the duration of fever and the incidence 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 is recommended. Aspirin Aspirin is an analgesic, antipyretic, and anti-inflammatory drug prescribed to reduce fever and relieve pain and inflammation. It is given initially in an antiinflammatory dose (80 to 100 mg/kg/day in divided doses every 6 hours) to control fever and symptoms of inflammation. Once fever has subsided, aspirin is continued at an antiplatelet dose (3 to 5 mg/kg/day). Low-dose aspirin is continued in patients without echocardiographic evidence of coronary abnormalities until the platelet count has returned to normal (6 to 8 weeks).

Salicylate Therapy Salicylate refers to any of several drugs derive form salicylic acid. They exert analgesic, antipyretic, and anti-inflammatory actions. If the child develops coronary abnormalities, salicylate therapy is continued indefinitely. Coumadin Warfarin sodium is an oral anticoagulant prescribed for prophylaxis and treatment of thrombosis, atrial fibrillation, and embolism. Additional anticoagulatory therapy, such as warfarin (Coumadin), may be indicated in those children with giant aneurysms (>8 mm), who are at the greatest risk for morbidity and mortality. Evaluation Open Forum

5mins

Question and answer

VII. VIII.

References:

Potter, P. A., & Perry, A. G. (2001). Fundamentals of nursing (5th ed.). Missouri: Mosby, Inc. Smeltzer, S. C., & Bare, B. G. (2004). Brunner& Suddarths 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). Mosbys 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).

COLLEGE OF NURSING Silliman University Dumaguete City

Syllabus on KAWASAKI DISEASE

Prepared by: Alviola, Charlene Valerie C. Submitted to: Asst. Prof. Charmain Joy Quilnet

Date Submitted: November 11, 2011 VISION MISSION STATEMENT

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