OBJECTIVES

I.

General Objective
This study aims to present the case of a patient diagnosed with Kawasaki
Disease and highlight the nursing management associated with the medical care
provided to a patient with such a disease.

II.

Specific Objectives
The following serve as a guide the accomplishment of the main objective:
1. Since Kawasaki Disease is a rare yet potentially debilitating disease mostly
seen in children, one of the goals of this study is to expand the knowledge
and appreciation of the disease by presenting its clinical manifestations,
complications, treatment, and prognoses;
2. Kawasaki Disease is a systemic vasculitic disease with possible affectations
of the heart, coronary arteries, skin, and lymph vessels, hence, this study
aims to promote the nursing interventions needed for the symptomatic
treatment of the disease;
3. The incidence and treatment of Kawasaki Disease in the Philippines is not
well documented, therefore, another goal of this study is to potentially serve
as a significant reference for other researchers who wish to expand local
knowledge about the disease.

INTRODUCTION
1

I.

Definition and History

Kawasaki Disease (KD) is an acute febrile vasculitic syndrome that affects
infants and young children. It is also known as Mucocutaneous Lymph Node
Syndrome (MLNS). KD is now the leading cause of acquired heart disease in
children in most developed countries. More than eighty-five percent (85%) of
cases are children below five years of age and the mortality rate is presently 0.1
to 2%.

Mortality is based on complications, which include coronary arteritis,

coronary artery aneurysms and stenoses, and coronary thrombosis which may
lead to myocardial infarction, sudden death, or congestive heart failure. About
twenty-five percent (25%) of untreated KD patients develop coronary artery
aneurysms.
KD was first observed and diagnosed in 1961 by Dr. Tomisaku Kawasaki
at the Japan Red Cross Medical Center in Tokyo. Between 1961 to 1967, Dr.
Kawasaki reported fifty (50) infants and young children who presented with
several signs that included prolonged remittent fever, unilateral cervical
lymphadenitis, bilateral conjunctival injection, polymorphous erythematous rash,
erythema and edema of the hands and feet, inflammation of the lips and oral
cavity, and subsequent desquamation of the fingers, toes, and periungual area.
He ruled out other possible diagnoses after negative laboratory results and was
convinced that he was treating a unique clinical syndrome. The first recorded
case that had cardiac involvement was in 1968, when Kawasaki and a colleague
reported a client manifesting with tachycardia, abnormal heart rhythm, and
cardiomegaly. Several years after, Kawasaki presented post-mortem evidence of
a number of patients diagnosed with KD who died due to coronary artery
complications.
KD is known to cause outbreaks in Japan, where the incidence of the
disease is about 150 to 175 cases per 100,000 children or more than 10,000 new
cases per year. In the United States, the incidence is about 15 per 100,000
children or less than 4,000 new cases per year.
2

II.

Possible Risk Factors

The main cause or root of Kawasaki Disease is unknown.

However,

possible risk factors and causes have been researched and studied to identify
the cause of the disease
1. Age
More than 90% of KD cases occur in children less than ten years of age.
Eighty-five percent (85%) of cases were diagnosed in patients less than five
years old and 50% in children younger than two years of age.
2. Gender
The ratio of male to female patients with KD is 1.5:1 internationally. It is
evidently more common in males than in females.
3. Race
Worldwide, Japan has the highest rate of incidence with approximately
10,000 new cases yearly. KD has been known to cause outbreaks in Japan
usually during the winter and spring seasons.

In the United States, the

incidence is roughly 4,000 new cases yearly with rates intermediate among
African-Americans and those with Asian and South Pacific ancestry other
than Japan. In the Philippines, concrete data about the annual rate of KD is
not present.
The cause of KD is idiopathic although some studies suggest it to be
infectious. The bases for this assumption are the outbreaks reported in Japan
and the United States during the winter and spring seasons where the incidence
of KD doubles compared to the summer and fall seasons. Another reason for
this assumption is the fact that the acute stage of KD is self-limiting even without
IVIG medication.
The following possible pathologic agents have been suggested:
1. Parvovirus and Rotavirus infection
2. HIV
3

3. Rubella
4. Meningococcal septicemia
5. Klebsiella pneumoniae bacteremia
6. Coxiella burnettie
7. Human lymphotropic virus infection
III.

Clinical Manifestations
Kawasaki Disease has diagnostic criteria to distinguish it from other
diseases with similar clinical manifestations.
1. Fever for at least 5 days with at least four (4) of the following features:
2. Bilateral conjuctival injection
3. Polymorphous exanthema or rashes
4. Changes in the lips and oral cavity (i.e. erythema, cracked lips, strawberry
tongue)
5. Changes in the peripheral extremities (i.e. edema in the hands and feet,
desquamation of fingers, toes, and periungual area)
6. Unilateral cervical lymphodenopathy (palpable; at least 1.5cm in diameter)
7. Exclusion of other diseases with similar presentations
The following signs and symptoms are present in the disease during its
stages:
Acute Stage (Days 1 to 11)

High fever

Irritability

Bilateral conjunctivitis

Rashes

Strawberry tongue and lip fissures (cracks)

Unilateral lymphadenitis

Mild hepatic dysfunction

4

Myocarditis, pericarditis, mitral valve regurgitation, and depressed

myocardial functioning can be recorded by electrocardiogram

Sub-acute Stage (Days 11 to 30)

Persistent irritability, anorexia, and conjunctival injection

Thrombocytosis

Decreased temperature

Arthritis or arthralgia

Desquamation of fingers and toes beginning at the periungual region

Development of coronary aneurysms

NOTE: This is the stage with the highest mortality

Convalescent Stage (Day 30 and above)

IV.

Inflammatory markers return to normal

Disappearance of signs and symptoms

Expansion of aneurysm leading to possible myocardial infarction

Smaller aneurysms resolve independently (60% of cases)

Diagnostic Examinations and Medical Treatment

The laboratory findings in KD are non-specific, but indicative of illness:

Leukocytosis with neutrophilia (WBC in excess 15,000/mm 3) with

predominance of immature or mature granulocytse

Elevated sedimentation rate (greater than 40mm/hour)

Anemia (Hgb is below 110g/L)

Thrombocytosis (Platelet count of more than 500,000/mm 3)

Hypoalbuminemia and hyponatremia

Plasma lipid abnormalities

Sterile pyuria
5

Elevated serum transaminases

The

medical

treatment

for

Kawasaki

Disease

is

intravenous

immunoglobulin (IVIG) with supportive medication of aspirin for anti-platelet

therapy:
DRUG
IVIG

DOSAGE
2g/kg infusion over 10 to 12

FREQUENCY
Single dose

hours OR;

400mg/kg/day

For 4 days

In 4 divided

* IVIG may be repeated if fever

persists or recurs together with at
Aspirin

least one classic sign of KD

80-100mg/kg/day then;

doses until
14h day of
illness and
patient is
afebrile for at
least 3-4 days

3-5mg/kg/day

Once daily for

6 to 8 weeks

IVIG is a purified preparation of gamma globulin. It is derived from large

collections of human plasma composed of several classes of antibodies. The
effect that IVIG has in the treatment of KD is not exactly known, but prognosis is
greatly improved after its administration no later than the tenth (10 th) day of
illness. IVIG aids in the treatment of systemic inflammation, which causes the
vasculitis in KD.
High-dose aspirin is used for the treatment of inflammation in KD. Lowdose aspirin is used to inhibit platelet aggregation.

PATIENT PROFILE
I.

Demographic Data
Name: Patient CDC
Age: 1.5 years old
7

Address: Blk15 Lot 10, Our Mahogany 1 Village, Pulo, Cabuyao,Laguna

Birthday: July 10, 2008
Birth Place: San Pablo City, Laguna
Religion: Roman Catholic
Sex: F
Nationality: Filipino

II.

Mothers Name: Roselia

Age: 33 y/o

Occupation: Employee (Human Resources)

Fathers Name: Dante

Age: 38y/o

Occupation: Employee (Quality Control)

Admission Data and Notes

Hospital: Philippine Childrens Medical Center
Date and Time of Admission: January 26, 2010 at 8:05pm (Emergency Room)
January 27, 2010 (Ward 1C)
Admission Diagnosis: ATP t/c Kawasaki Disease
Chief Complaint: Persistent fever
Attending Physicians: Dr. H. Lim and Dr. O. Teormoso
Patient Weight: 11.5 kg
Vital Signs:

Temperature 39.5C
Cardiac Rate 120 bpm
Respiration Rate 30 cpm
Blood Pressure 90/60 mmHg

Doctors Admission Notes:

System: awake, irritable
EENT: cry, cracked lips
Neck: (-) clap
Lungs: SLE (-) retractions
Heart: (-) murmur
Extremities: good pulses, (+) edema
Skin: (+) erythematous maculopapular rash in extremities
(+) papular lesions in upper extremities and abdomen
III.

History of Present Illness

8

Patient CDC was admitted to the Emergency Room of the Philippine

Childrens Medical Center on January 26, 2010 at 8:05pm.

He was later

transferred to Ward 1C (Non-Communicable Diseases) of PCMC on January 27.

The chief complaint of the patient was persistent fever as verbalized by the
mother.
Six (6) days prior to admission, patient had fever with minimal coughing.
Patient did not have rashes, diarrhea, or vomiting episodes. Patient was treated
with Paracetamol at 10ml per dose for fever. Patient still had good activity and
appetite.
Three (3) days prior to admission, patient still had fever associated with
erythema of the lips and eyes and rashes which erupted initially on the arms then
to the trunk. Mother was unable to document temperature due to unavailability of
thermometer.
Two (2) days prior to admission, patient still had fever and was seen at the
Laguna Health Center. Patient was given Paracetamol at 10ml per dose and
Chlorpheniramine three doses for allergy. The medications did not offer relief. In
the evening, the patient was given Cephalexin 125mg/5ml three times which also
offered no relief.
One (1) day prior to admission, patient was seen by a private doctor, who
visited patients home, due to persistent fever and papular rashes on the
extremities. CBC was done at ASJ Medical and Diagnostic Clinic and revealed
low platelet count. Patient was advised to be admitted to a hospital.
On the day of the admission, patient was seen by doctors in Jose Reyes
Memorial Medical Center. Patient was advised to go to PCMC.
IV.

Past Medical History

Patient had no prior hospital confinements since birth. Patient did not
have any notable illnesses in the past.

V.

Nutritional History

Patient CDC was breastfed for the first 2 weeks after birth. A milk formula
was given from 2 weeks after birth to present. Ratio of formula is 1:1 milk to
water given 6 ounces every 2 hours.
Patient started eating cereals, meat, fruits, fish, and vegetables on the
sixth (6th) month. Twenty-four (24) hours prior to confinement, patient ate bread
and milk for breakfast, and rice and soup for lunch and dinner.
Patient is given Celine for vitamins.
Patient has no known food allergies.
VI.

Growth and Development

For gross motor development, patient was reported to be able to stand
and walk alone by the time he was 1 year old.
For adaptive development, patient is able to indicate needs through
minimal verbal cues and crying.
For personal/social development, patient is able to use a spoon. Parents
indicate that patient is able to let them know if she has urinated or defecated.
Patient was able to do these after turning 1 year old.
According to the physicians notes, patients growth and development are
at par with age with no delays in development.

VII.

Family Health History

Fathers Side: (+) cardiovascular accident
(+) hypertension
Mothers Side: (+) hyperthyroidism

10

PHYSICAL ASSESSMENT
Name: Patient CDC
Age: 1 years old
Sex: Female
Department: Ward 1-C
Diagnosis: Kawasaki Disease.
Date and Time of Assessment: January 29, 2010 4:00 PM
I.

General Survey
Received patient lying on bed, awake and responsive, not in any respiratory distress. With IVF of
0.9% NaCl 1000cc at right arm KVO. The patient measures 81cm in height and weighs 11.5kg. Patient appears to
be restless and irritable as evidenced by increased movement and uncontrollable crying. Patient does not appear
to be in respiratory distress.

II.

Vital Signs
Techniques: Inspection, Palpation, Auscultation
Patient has temperature of 38.4C, axillary with cardiac rate of 121 beats per minute, regular respiratory rate
of 32 breaths per minute, and blood pressure of 90/60 mmHg.
11

PART
Skin

Head

TECHNIQUE
Inspection
and
Palpation

Inspection
and
Palpation

NORMAL FINDINGS
Color varies from light to
deep brown

No edema

Hands and feet are

reddish, edematous,
shiny, and dry-looking

Moisture in skin folds and

axillae

Skin is moist especially on

areas with folds; presence
of desquamation on
fingers, toes, and labial
area

Skin temperature is
uniform within normal
range

Skin temperature is
uniformly warm due to
elevated body
temperature

Configuration is
normocephalic
No lesions or tenderness

12

ACTUAL FINDINGS
Erythematous and
maculopapular rashes
are present on the back,
abdomen, chest, and
extremities

Head is normocephalic in
shape
Absence of lesions and no
signs of tenderness

INTERPRETATION
Presence of
erythematous and
maculopapular rashes
is one criteria in
diagnosis of Kawasaki
Disease
Changes in the
peripheral extremities
such as edema and
desquamation are
criteria for diagnosing
Kawasaki Disease
Changes in the
peripheral extremities
such as edema and
desquamation are
criteria for diagnosing
Kawasaki Disease
Temperature of 38.4C
upon assessment;
persistent fever for at
least 5 days is the
earliest sign of
Kawasaki Disease

Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
Normal

Normal

Anterior and posterior

fontanels are flat and
closed
Evenly distributed, thick
hair, silky, resilient, no
infestation

Anterior and posterior

fontanels appear to be flat
and closed
Hair is thick, smooth,
moist, and with no signs of
parasitic infestation

Normal

Normal

Hair

Inspection

Eyes:
Sclera

Inspection

Appears white

Sclera is slightly reddish

Bilateral non-purulent
conjunctival injection
is one of the signs of
Kawasaki Disease

Cornea

Inspection

Transparent, shiny,
smooth with corneal
details visible

Transparent, shiny,
smooth; details apparent

Normal

Pupils

Inspection

Black/brown in color;
constricts when
illuminated and when
looking at near objects;
dilates when looking at far
objects
Symmetrically aligned

Black in color; briskly

constricts when illuminated
and dilates when not
illuminated

Normal

Aligned

Eyeballs are symmetrical

in size
Not protruding

Eyeballs are symmetrical

in shape and size
There is no protrusion

Normal

Eye Balls

Inspection

13

Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.

Palpebral
and Bulbar
Conjuctiva

Ears

Inspection

Inspecton
and
Palpation

Nose

Mouth

Inspection
and
Palpation
Inspection
and
Palpation

Smooth, pink or red

Auricles fair in color

Symmetrical and aligned
with outer canthus of eyes
Auricles are flexible, firm,
no tenderness
Absence of purulent
discharge in the external
canal
Patient responds to sound
Nares are patent
Septum on the midline
Mucosa is pinkish in color
Lips are moist and pinkish
in color
Oral mucosa is pinkish
with no ulcerations

Neck

Inspection
and

Neck is symmetrical
Thyroid glands are not

14

Bulbar conjunctiva are

slightly reddish in color

Auricles are fair in color,

symmetrical in shape,
flexible with no tenderness
There is no discharge from
the ear canal
Responds to the voice of
mother and father

Bilateral conjunctival
injection is one of the
criteria in diagnosing
Kawasaki Disease

Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
Normal

Normal

Normal

Patent nares with septum

on the midline
Mucosa is pinkish
Lips are red in color, dry,
and cracked
Oral mucosa is also deep
red in color
Tongue is red and has
strawberry-like texture
No ulcerations in oral
mucosa

Normal

Normal
Changes in the mouth
and oral mucosa are
some of the signs of
Kawasaki Disease

Neck is symmetrical
Presence of a swollen

Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
Normal
Unilateral cervical

Palpation

tender and enlarged

Chest

Heart

Inspection,
Palpation,
Auscultation

Auscultation

Inspection

lymphodenopathy
appears in 50% to 75%
of patients with
Kawasaki Disease
Normal

Normal

Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
Normal

Full and symmetric and

not bulging

Chest is not bulging and

appears symmetrical

Breathing is abdominal
and posterior mobility and
posture of thorax is
symmetrical upon
respiration

Abdominal breathing is
present (pediatric) with
thoracic movement
symmetrical

Normal

Clear breath sounds

Normal

S1 usually heard at all

sites but louder at apical
area
S2 usually heard at all
sites but louder at base of
the heart
Symmetrical in size and
shape

No presence of harsh
breath sounds; patient was
crying and irritable during
assessment
S1 and S2 are heard
audibly on apical and base
areas of the heart
No murmur or gallops (S3
and S4)

Normal

Symmetrical in size and

shape

Normal

Breast

Neck muscles are equal

in size
Trachea is positioned
midline upon palpation

lymph node on the left

side of the neck ; size of
the lymph node is
approximately 1.5cm
Neck muscles are equal in
size
Trachea is positioned
midline

15

Areola is round or oval

and color is light pink to
dark brown
Nipples are round, and
equal in size

Vascular and pinkish in

color

Smooth texture
Intact epidermis
Capillary refill in 3-5
seconds

Finger and
Toe Nails

Abdomen

Inspection
and
Palpation

Inspection,
Auscultation,
Palpation

Areola is small and brown

in color

Normal

Nipples are round and

almost in size

Normal

Fingers and toes are

desquamated,
edematous, and reddish
in color

Smooth texture
Intact epidermis
Capillary refill of 3 seconds

Changes in
extremities such as
edema, desquamation,
and redness are signs
of Kawasaki Disease
Normal
Normal
Normal

Unblemished skin,
uniform in color

Presence of
erythematous and
polymorphous rashes on
the trunk

no evidence of liver
enlargement
Audible bowel sounds

no evidence of liver
enlargement
Audible bowel sounds at
12 per minute; abdomen
produces a growling sound

16

Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
Presence of
polymorphous
exanthema or rashes
is one sign of
Kawasaki Disease
Normal

Normal

Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and

Muscles

Cherry, James D.
Normal

Inspection,
Palpation

Equal size on both sides

Symmetrical in size on
of the body; no
both sides of the body
contractures
Good muscle tone, firm
Good muscle tone with no
Normal
with smooth coordinated
signs of uncoordinated
movements
motor movement
Source of Normal Figures: Fundamentals of Nursing: Concepts, Process, and Practice Seventh Edition by Kozier, Barbara and
Erb, Glenora
Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family Fifth Edition by
Pillitteri, Adele

17

ANATOMY
Kawasaki Disease, otherwise known as Mucocutaneous Lymph Node Syndrome,
is an acute, self-limiting, and febrile systemic vasculitis that may cause cardiac
complications. The most common sequel of KD is coronary thrombosis (stagnant blood
clot) that possibly leads to the development of a coronary aneurysm. Having these
definitions and descriptions of the disease in mind, the following body systems and
structures will be discussed briefly to illustrate the physiological effects of KD.
I.

Heart
The heart functions as the primary organ for blood circulation in the
human body.

It is responsible for delivering un-oxygenated blood from the

venous system to the lungs and oxygenated blood from the lungs to the arterial
circulation.

Additionally, the heart propels blood throughout the systemic

(arterial) circulation to bring nutrients, vital enzymes, hormones, and drugs to the
tissues and organs of the body. The image of the heart, its parts and functions,
are illustrated in Figure 1 and Table 1 respectively.
FIGURE 1: THE HEART AND ITS STRUCTURES

18

TABLE 1: THE PARTS OF THE HEART AND CORRESPONDING FUNCTION

STRUCTURAL PARTS
Superior Vena Cava (SVC)

FUNCTION
One of the two main veins that drains unoxygenated blood to the right atrium

Inferior Vena Cava (IVC)

Blood from the head and upper body

drain into the SVC

The second main vein that drains unoxygenated blood to the right atrium

Aorta

Blood from the legs and lower torso drain

into the IVC

The largest single blood vessel in the
body

Passageway for oxygen-rich blood from

the left ventricle into the systemic

Pulmonary Artery

circulation
The only artery in the body that carries
deoxygenated blood

Pulmonary Vein

Passageway of deoxygenated blood from

the right ventricle to the lungs

The only vein in the body that carries
oxygenated blood

Right Atrium

Carries oxygenated blood from the lungs

to the left atrium

A chamber of the heart that receives
deoxygenated blood from the SVC and
IVC

Right Ventricle

Pumps blood into the right ventricle via

the tricuspid valve

Receives deoxygenated blood from the
right atrium via the tricuspid valve

The tricuspid valve closes after the right

ventricle fills up with blood and the
19

pulmonary valve opens to allow

deoxygenated blood to flow into the
Left Atrium

pulmonary artery
Receives oxygenated blood from the
pulmonary vein

Left Ventricle

Blood from this chamber empties into the

left ventricle via the mitral valve

Arguably the largest chamber of the
heart, receives oxygenated blood from
the left atrium via the mitral valve

The mitral valve is open as the left

ventricle fills up with blood from the left
atrium and it closes once the left ventricle
is filled. The aortic valve opens as the left
ventricle contracts, sending oxygenated
blood into the aorta and into the systemic

Atrioventricular Valves

circulation
The tricuspid and mitral valves ensure
one-way blood flow within the chambers
of the heart

The tricuspid valve is the gateway

between the right atrium and the right
ventricle

Semilunar Valves

The mitral valve is the gateway between

the left atrium and the left ventricle

The pulmonary and aortic valves ensure
one-way blood flow into the pulmonary
artery and aorta respectively

20

II.

Coronary Arteries
The coronary arteries constitute the coronary circulation that supplies
oxygenated blood to the heart itself. These arteries receive their blood supply
from openings in the aorta called the coronary ostia.
A major complication of Kawasaki Disease is the development of coronary
aneurysms and coronary thrombosis, thus making the discussion of the coronary
arteries relevant. Ruptured coronary aneurysms lead to massive bleeding and
ischemia, eventually resulting to myocardial infarction.
The main branches of the coronary arteries and the areas of the heart
they supply are detailed below (Figure 2 and Table 2).
Figure 2: The Coronary Circulation

21

Table 2: The Branches of the Coronary Arteries

BRANCHES OF THE
CORONARY ARTERIES
Left Coronary Artery
Left Anterior Descending Artery

PARTS SUPPLIED

Divides into two branches: the left anterior

descending artery and the circumflex artery

Delivers blood to sections of the left and
right ventricles and majority of the

Circumflex Artery
Right Coronary Artery

interventricular septum
Supplies blood to left atrium and the lateral

wall of the left ventricle

Three major branches: conus, right marginal
branch, and posterior descending branch

The conus supplies blood to the right upper

ventricle, the right marginal branch supplies
the right ventricle up to the apex, and the
posterior descending branch supplies
minority sections of the ventricles

22

III.

Vascular System
The vascular system is made up of the arteries and veins of the body.
Arteries branch into smaller arterioles, which branch further into capillaries.
Capillaries serve as the site where nutrient exchange between the blood and
tissues occur. Blood from the capillaries then enter venules that eventually join
together to form larger veins. The arteries serve as the channels for oxygenated
blood (systemic circulation) and the veins serve as the channels for
deoxygenated blood.
As a systemic vasculitic disease, Kawasaki Disease causes inflammation
of the blood vessels resulting to edema, increased permeability of the vessels,
and coronary aneurysms (weakening of the blood vessel walls). Figure 3 and
Table 3 briefly discuss the structure and functions of the vascular components.
Figure 3: The Vascular System

23

Table 3: Comparison of Arteries and Veins

ARTERIES
Thinner than the tunica

PARTS
Tunica Adventitia (outer

media
Thicker than the tunica

layer)
Tunica Media (middle

adventitia allowing

VEINS
Thickest layer
Thinner in veins

layer)

vasoconstriction and
vasodilation
Same
Narrower
Absent

Tunica Intima (inner layer) Same

Lumen
Wider to accommodate
Presence of Valves

valves
Present; to ensure the oneway flow of blood back to

Fastest in arteries and gets

Blood Flow

the heart
Slow in the venules, but

slower when entering the

increases speed as it

arterioles and capillaries

passes through the veins

Aorta (largest), pulmonary

Major Blood Vessels

(valve-related)
Superior and inferior vena

artery, carotid arteries,

cavae, jugular veins,

subclavian artery,

subclavian veins, hepatic,

brachiocephalic, abdominal

iliac, femoral, hepatic portal

aorta, common iliac, brachial

24

Figure 4: Arteries of the Body

Figure 5: Veins of the Body

25

IV.

Lymph Nodes
The lymph nodes are some of the major structures of the lymphatic
system, which works closely with the circulatory system to bring interstitial fluid
back into the blood circulation. Functionally, however, lymph nodes are part of
the hematologic and immune systems because large numbers of lymphocytes,
monocytes, and macrophages reside in these nodes. These cells are mobilized
and join the circulating blood during infection or inflammation.
In Kawasaki Disease, there is unilateral lymphodenopathy, meaning that
the lymph nodes enlarge due to inflammation. What causes this inflammation is
still unknown, but since unilateral lymphodenopathy is one criterion in diagnosing
KD, it is worth to include it in the anatomy section of this study.
Figure 6: Parts of a Lymph Node

26

27

PATHOPHYSIOLOGY
Signs and symptoms in
patient

Diagnosis of Kawasaki
Disease based on
diagnostic criteria of
disease;
Age is the only probable
predisposing factor in
patient

Complications if untreated
without IVIG 10 days after onset
of fever

Diagnostic indicators
(+) fever

(+) maculopapular
erythematous rashes on
hands, feet, trunk, and
abdomen;
(+) edema of hands and
feet;
(+) desquamation of
fingers, toes, and
periungual area

Remittent fever for 6

days PTA;
T = 39.5C on DOA

Coronary aneurysm;
Coronary thrombosis;
Coronary stenosis;
Coronary arteritis

Platelet level of 411 x

103 g/L based on CBC;
ESR of 112 mm/hr
based on CBC

Myocardial infarction;
Congestive heart
failure;
Death

(+) cracked lips;

(+) strawberry tongue;

(+) palpable unilateral

cervical
lymphadenopathy at
1.5cm

WBC count of 19.7 g/L

based on CBC;
Segmenter count of 0.85
hpf based on CBC

(+) bilateral nonpurulent

conjunctivitis

Sources:
1. Textbook of Pediatric Infectious Diseases Fifth Edition by Feigin, Ralph D. and
Cherry, James D.
2. Kawasaki Disease by Scheinfeld, Noah S. and Jones, Elena L.
http://emedicine.medscape.com/article/965367-overview

28

Discussion:
The etiology of Kawasaki Disease is still unknown. Studies have failed to identify
a pathologic agent that causes the disease. Most clinicians believe the disease has an
infectious nature due to the presence of seasonal outbreaks in Japan. The only nonmodifiable risk factors with considerable theoretical basis are age and race. Most cases
involve children below 10 years of age and Japanese children appear to be at a higher
risk of acquiring the disease. However, the incidence of KD in Asians and other Pacific
Islanders is higher compared to Westerners of Caucasian or African descent.
The patient manifested 5 out of the 6 signs in the criteria for diagnosing
Kawasaki Disease. The patient had remittent fever for 6 days, had rashes that started
in the arms and spread to the trunk, oral cavity changes manifested by cracked lips,
strawberry tongue, and reddened oral mucosa, bilateral conjunctivitis, and a palpable
lymph node on the lefts side of the neck. These clinical manifestations were supported
by the hematological test and vital signs of the patient: a temperature of 39.5C,
elevated platelet (thrombocytosis) and ESR (inflammatory response) levels, and a left
shift (increased production of mature leukocytes) in the patients WBC differential
results. The hematological results further provide evidence of the multi-system
affectations of the disease indicating signs of inflammation (vasculitis in KD), formation
of blood clots, and abnormal increase in WBCs (manifested in lymphadenopathy.
Twenty-five percent (25%) of cases result to coronary artery complications
without IVIG therapy and 3% of cases lead to the same complications even with IVIG
therapy. The coronary artery complications include formation of blood clots, arterial
stenosis, arteritis, and aneurysms. If these complications are not detected, the worstcase prognoses are myocardial infarction, congestive heart failure, and death. KD has a
0.1 to 2% mortality rate globally.

29

DIAGNOSTIC EXAMINATIONS
Hematology Section - PCMC
Name: Patient CDC
Date received: January 26, 2010 - 9:34 pm
Date released: January 26, 2010 - 10:34 pm
PARAMETERS

RESULTS

NORMAL
VALUES

Hemoglobin
(HGB)

107.6

116-140g/L

Hematocrit
(HCT)

0.34

0.35-0.41g/L

RBC

4.36

3.6-50g/L

WBC

19.7

5-10g/L

Differential Count
30

FINDINGS

ANALYSIS

Below normal

Indicative of
anemia, which
is a diagnostic
predictor of
Kawasaki
Disease

Slightly below
normal

Lysis of RBC
is possibly
due to
vasculitic
affects of
disease

Normal

There is no
abnormal
finding

Remarkably
above normal

Indicative of
leukocytosis
secondary to
infection or
inflammation

PARAMETERS

RESULTS

NORMAL
VALUES

FINDINGS

ANALYSIS

Eosinophils

0.01

0.02-0.07hpf

Slightly below
normal

Possibly due to
allergic
reactions

Segmenter

0.85

0.55-0.65 hpf

Remarkably
above normal

Overproduction
of mature
leukocytes
indicative of
increased
autoimmune
response

Lymphocytes

0.14

0.25-0.35 hpf

Remarkably
below normal

Indicative of
immunosuppression

Platelet Count

411

150-350 x
103 /L hpf

Remarkably
above normal

Indicative of
thrombocytosis,
which appears
on the 2nd week
of Kawasaki
Disease

ESR

112

0 -20 mm/hr

Remarkably
above normal

Indicative of
inflammatory
response

ASJ Medical and Diagnostic Clinic

Hematology
31

Date of Release: January 25, 2010

PARAMETERS

RESULTS

NORMAL
VALUES

Hemoglobin
(HGB)

106

Hematocrit
(HCT)

0.32

0.35-0.41g/L

Erythrocyte
Count

3.7

Leukocyte
Count
Platelet Count

116-140g/L

FINDINGS

ANALYSIS

Below normal

Indicative of
anemia

Slightly below
normal

Indicative of
low RBC
count due to
hematologic
factors

3.6-50g/L

Normal

Within normal
range

5.75

5-10g/L

Normal

Within normal
range

98,000

150,000
300,000

Below normal

Indicative of
thrombocytopenia

Differential Count
PARAMETERS

RESULTS

NORMAL
VALUES

Eosinophils

0.03

0.02-0.07hpf

Normal

Within normal
range

Segmenter

0.55

0.55-0.65 hpf

Normal

Within normal
range

Lymphocytes

0.40

0.25-0.35 hpf

Slightly above
normal

Indicative of
autoimmune
response

Monocytes

0.02

0.02-0.05

Normal

Within normal

32

FINDINGS

ANALYSIS

range

33

DRUG STUDY

DRUG

DOSAGE

MECHANISM OF
ACTION

Drug Name:

2.5g/50ml 10 vials:

IMMUNOGLOBULIN IV

Test Dose I:
0.01x11.5kgx60
= 7cc for 30mins

Improves immunity
by binding to and
neutralizing
pathogens, thereby
increasing
antibodies against
bacterial, viral,
parasitic, and
mycoplasmic
antigens. Acts
through
antimicrobial and
antitoxin
neutralization.

Drug Class:
Passive immuneglobulin

Test Dose II:

0.02x11.5kgx60
=14cc
Test Dose III:
0.03x11.5kgx60
=21cc
Test Dose IV:
0.04x11.5kgx60
=28cc

INDICATION

Kawasaki
Syndrome
Prophylaxis after
exposure to
Hepatitis A
B-cell chronic
lymphocytic
leukemia

CONTRAINDICATION

Patients with
anaphylactic reaction to
IGIV

ADVERSE
EFFECT

Tenderness,
muscle stiffness at
injection site,
nausea, vomiting,
chills, fever,
headache.

NURSING
RESPONSIBILITIES

- Do not administer to
patients with history of
allergy to gammaglobulin
- Instruct patient to report
symptoms occurring
during or after therapy.
- Use with caution in
pregnant womenPregnancy C; safety not
established

Pediatric HIV
infection

- Have epinephrine 1:1000

immediately available at
time of injection in case of
anaphylactic reaction

Translate
remaining 390cc to
24cc/hr for 16hrs

- Do not mix immune

globulin with any other
medications
- Monitor patients VS
continuously
- Provide or teach patient
to provide safety
measures.

34

- Advise patient to avoid

live-virus vaccines for 3
months after therapy; drug
may delay or inhibit body's
response to vaccine.
- Provide patient with
written record of injection
and dates for follow-up
injections as needed.

DRUG

Drug Name:
ASPIRIN
Classification:
Antipyretic,
analgesic, NSAID

DOSAGE

300mg/tab; 1 tab
q6 PO

MECHANISM OF
ACTION
It acts in the
thermoregulatory
center of the
hypothalamus to
block effects of
pyrogen
Also has antiinflammatory, antiplatelet, and
analgesic
properties

INDICATION

CONTRAINDICATION

Mild to moderate
pain

Allergy to NSAID or
salicylates

Fever

Hemophilia;
hemorrhagic states;
impaired renal function;
chickenpox; pregnancy

Inflammatory
conditionsrheumatic fever,
rheumatoid
arthritis,
osteoarthritis

35

ADVERSE
EFFECT
Acute aspirin
toxicity: tachypnea,
hemorrhage,
excitement,
confusion
GI: nausea,
dyspepsia,
heartburn,
epigastric
discomfort,
anorexia

NURSING
RESPONSIBILITIES
- Give drug with food or
after meals if GI upset
occurs.
- Use the drug only as
suggested; avoid
overdose.

NURSING CARE PLAN

The following nursing problems were based on the data gathered for this study:
I.

Actual Nursing Problems

1. Elevated body temperature related to systemic inflammation of blood
vessels secondary to present disease
2. Impaired skin integrity related to accumulation of fluid in the interstitial
spaces of hands and feet secondary to present disease
3. Impaired oral mucous membrane related to inflammation of oral mucosa
secondary to present disease

II.

Potential Nursing Problems

1. Risk for decreased cardiac output related to possible coronary artery
complications secondary to present disease

36

ACTUAL NURSING PROBLEMS

1. Elevated body temperature related to systemic inflammation of blood vessels secondary to present disease
ASSESSMENT
Subjective:
NONE
Objective:
Temp 38.4C;
Warm to touch;
Irritable and
restless;
Uncontrolled
crying

DIAGNOSIS
Elevated body
temperature
related to
systemic
inflammation
of blood
vessels
secondary to
present
disease

INFERENCE
Present
disease
Systemic
inflammation
of blood
vessels

PLANNING
Short-term:

INTERVENTION
Independent:

After 2 hours
of nursing
intervention,
the patients
temperature
will normalize
at 37.5C.

Check
temperature and
other vital signs
prior to
interventions;

Assessment
of all vital
signs is
integral to
planning and
intervention;

Administer tepid
sponge bath to
lower
temperature;

TSB is an
independent
nursing
function that
lowers core
temperature;

Provide a change
of clothes and
sheets to promote
increased
comfort;

Increasing
patient
comfort can
ease irritability
and
restlessness
associated
with fever;

Regularly check
diapers if soiled;

Soiled diapers
cause
additional
discomfort;

Release of
pyrogens

Elevated body
temperature

37

RATIONALE

EVALUATION
After 2 hours of
nursing
intervention, the
patients body
temperature
was lowered to
37.8C; to
continue
interventions
until body
temperature
normalizes

Follow feeding
schedule to
provide nutritional
support;

Infants require
sufficient
nutrition
especially
during times
of illness and
immunosuppression;

Watch out for

signs of
dehydration

Dehydration is
common in
infants with
persistent
fever

Dependent:
Administer aspirin
as ordered;

Aspirin serves
as an
antipyretic,
antiinflammatory
and antiplatelet drug
in Kawasaki
Disease
Check the flow
Proper
rate of IVIG and
regulation of
watch out for
IVIG infusion
signs of adverse
is important to
effects
prevent side
effects
2. Impaired skin integrity related to accumulation of fluid in the interstitial spaces of hands and feet secondary to
present disease
38

ASSESSMENT
Subjective:
NONE
Objective:
+ 1 edema of
hands and feet;
Skin appears dry
and shiny;
With erythema of
hands and feet;
desquamation of
fingers and toes

DIAGNOSIS
Impaired skin
integrity
related to
accumulation
of fluids in
interstitial
spaces of
hands and
feet
secondary to
present
disease

INFERENCE
Present
disease
Systemic
inflammation
of blood
vessels
Increase in
histamine
release
Greater
permeability
of blood
vessels
Vascular fluid
moving to
interstitial
spaces of
hands and
feet

PLANNING
Short-term:
After 6 hours
of nursing
intervention,
skin integrity
improved as
evidenced by
controlled
dryness of the
skin
Long-term:
After 3 to 4
days of
nursing
intervention,
skin integrity
problems
related to
edema will
resolve as
evidenced by
edema score
of 0 from +1

Impaired skin
39

INTERVENTION
Independent:

RATIONALE

Assess the hands

and feet for extent
of dryness and
edema;

Assessment
of sites of
edema will
dictate
provision
interventions;

Assess mobility of
fingers, toes,
hands, feet,
wrists, and
ankles;

Mobility is a
sign of
sufficient
blood flow to
sites;

Apply RICE
technique in
management of
edema;

R- rest;
I ice to
decrease
inflammation;
C
compression
to promote
venous return
and lymphatic
drainage of
fluid;
E elevate
above the
heart for
venous return;

Apply lotion to dry

Lotion can

EVALUATION
After 6 hours of
nursing
intervention,
skin integrity
improved with
controlled
dryness of the
skin ; skin is
more moist on
sites of edema

integrity

areas of skin for

moisture and
lubrication;

hasten further
drying of the
skin due to
edema;

Do not peel off

desquamated
skin;

Desquamated
skin will peel
off naturally;
you can cut
loose skin at
the ends;

Watch out for

wounds and signs
of infection and
loss of function

Edema and
dryness make
skin
susceptible to
wounds

Dependent:
Administer aspirin
as prescribed;

Check flow of
IVIG as
prescribed

Aspirin has
antiinflammatory
properties;
IVIG therapy
aids in abating
inflammation,
thus reducing
edema

3. Impaired oral mucous membrane related to inflamed oral mucosa secondary to present disease
ASSESSMENT
Subjective:

DIAGNOSIS
Impaired oral

INFERENCE
Present

PLANNING
Short-term:
40

INTERVENTION
Independent:

RATIONALE

EVALUATION
After 3 hours of

NONE
Objective:
With fissured,
cracked lips;
With
erythematous
lips;

mucous
membrane
related to
inflamed oral
mucosa
secondary to
present
disease

disease
Inflamed oral
mucosa
Poor blood
perfusion to
oral mucous
membrane

red and inflamed

oral mucosa;
Strawberry-like
tongue with
papules;
Irritable when
being given
feedings

Impaired oral
mucous
membrane
(evidenced by
cracked lips)

After 3 hours
of nursing
intervention,
fissures and
cracks in the
lips will be
controlled and
lessened
Long-term:
After 3 to 4
days of
nursing
intervention,
fissures and
cracks will
resolve as
evidenced by
moist lips with
the absence
of cracks and
fissures

41

Assess the extent,

characteristic, and
severity of the
fissures and
cracks on the lips;

Assessment
of the fissures
and cracks on
the lips will
affect
interventions
to be given;

Assess if there is
difficulty in
swallowing or
alterations in
feeding;

Fissured and
cracked lips
can cause
difficulty in
feeding,
especially in
infants;

Provide oral
rinses using tap
water or saline
drops to moisten
mucosa;

Moistening
dried mucosa
will prevent
worsening of
cracks and
prevent new
ones from
developing

Provide regular
oral care hygiene
by giving oral
rinses;
Encourage
sufficient fluid

Non-alcoholic
rinses will
prevent
infection
Dehydration
can contribute

nursing
interventions,
fissured and
cracked lips
were managed
as evidenced by
controlled
dryness of the
lips

intake as
prescribed and
tolerated;

to mucosal
dryness and
worsen
cracked lips;

Instruct mother to
avoid giving acidic
fluids;

Juices and
other acidic
beverages
cause pain in
open oral
mucosa;

Instruct mother to
continue feeding
practices as
prescribed by
physician

Feeding
practices
should be
encouraged in
spite of
condition

Watch out for

signs of infection

Further drying
of mucosa can
lead to ulcers
and result to
infection

Independent:
Administer aspirin
as prescribed

42

Aspirin has
analgesic and
antiinflammatory
properties

Potential Nursing Problems

1. Risk for decreased cardiac output related to possible coronary artery complications secondary to present disease
ASSESSMENT
Subjective:
None
Objective:

DIAGNOSIS
Risk for
decreased
cardiac output
related to

INFERENCE
Present
disease

PLANNING
Short-term:

INTERVENTION
Independent:

After 2 hours
of nursing

Assess the
patients cardiac

43

RATIONALE
It is important
to retrieve

EVALUATION
After 2 hours of
nursing
intervention, the
parents were

None

possible
coronary
artery
complications
secondary to
present
disease

Increased
platelet
production

intervention,
the parents
will be able to
verbalize
understanding
Formation of of the cardiac
blood clots in complications
blood vessels, of present
particularly
disease
the coronary
arteries
Blood clots
can cause
blockage,
aneurysms,
and stenosis
of coronary
arteries
All these
complications
can cause
decreased
cardiac output

vital signs prior to

discharge;

baseline VS
prior to
discharge for
reference;

Discuss with
parents the nature
of Kawasaki
Disease and the
possible
complications
even with IVIG
therapy;

Client
education is
important in
comprehension of illness

Provide parents
with an
information sheet
regarding postdrug therapy care
for patients with
Kawasaki
Disease;

A quick
reference
guide can
increase
understanding of
disease;

Instruct parents to Patients full

promote adequate recovery has
rest and sleep 2-3 to be ensured;
days after
discharge from
hospital;
Instruct parents to
gradually
44

Gradual
reintroduction

able to
understand the
risk for cardiac
complications
as evidenced by
verbalization of
their
comprehension
of health
teachings

45

reintroduce
patient to
activities;

to activities
will help
patient adapt
efficiently after
illness;

Educate patients
on signs of
cardiac problems;

Signs of
cardiac
complications
involve
shortness of
breath, activity
intolerance,
difficulty in
breathing,
dizziness,
lethargy, and
chest pain;

Promote a
balanced diet with
low sodium
content;

Proper
nutrition will
ensure growth
and
development;

Advise parents
regarding follow
up check-up and
diagnostic
procedures

Follow up
check-ups will
help
determine
development
of any cardiac
abnormalities
or coronary

artery
affectations

46

DISCHARGE PLANNING
Medication

Discuss all take home medications to patient's mother

Aspirin: advise parents to give drug after meals to prevent gastric irritation

Aspirin: advise parents regarding side effects of drug such as nausea, vomiting,
abdominal pain, and headache

Aspirin: advise parents to adhere to frequency, dosage, and timeliness of drug

administration

IVIG: educate parents regarding immunosuppressive effects of drug

IVIG: educate parents regarding side effects of drug such as chills, fever, and
headache

Advise parents to report any changes in the patient related to drugs being taken

Exercise

Advise parents of adequate rest and sleep for up to 2 to 3 days after discharge to
promote recovery

Advise parents to gradually increase activities; start with light activities until
tolerated before engaging in more strenuous activities

Encourage parents to have patient engage in normal activities of daily living such
as self-feeding, dressing, and walking

Constantly monitor activity and exercise pattern to detect any abnormalities such
as cardiac affectations/sequelae of Kawasaki Disease

Treatment

Explain to the patients that drug therapy should continue as prescribed by

physician

Educate parents regarding potential sequelae of Kawasaki Disease such as

coronary artery and cardiac problems

Health Teachings

Advise parents to promote proper hygiene to decrease possibility of infection

47

Encourage parents to promote a safe, comfortable, and clean environment

conducive to recovery of patient

Provide nutritional teaching to parents to foster improved nutritional and fluid

intake as well as promote balanced diet

During recovery, patient should not be brought to crowded places to prevent

community-acquired infections

Advise mother to complete all immunizations and booster shots for patient once
cleared by physician

Promote regular hand washing especially during food preparation to avoid

contamination of food

Out Patient

Remind the family on their follow up check up with their physician

Encourage to take routine cardiac diagnostic examinations (i.e. MRI, CTscans of

the heart, and 2D echocardiography) to determine presence of cardiac
affectations/complications of disease

Diet

Encourage to have the three basic food groups in the diet while controlling salt
intake

Encourage to increase fluid intake

Encourage to prepare foods that are rich in vitamins and minerals to improve
immune system

Continue milk feeding and solid food combination and introduce new viands to
improve appetite and expand food variety

Spiritual

Guided by the family, help the patient to establish deep personal relationship with
God in everyday of her waking moment

With guidance from parents and family, help the patient find happiness in her
present situation
48

Aid patient in holistic development of self to promote overall wellness

REFERENCES
Books
Feigin, Ralph D. et al., Textbook of Pediatric Infectious Diseases Volume 1. Fifth
Edition. Elsevier Inc., Philadelphia, USA: 2004.
Huether, Sue E. and McCance, Kathryn L.,Understanding Pathophysiology 3rd Edition.
Mosby Inc., Singapore: 2004.
Kozier, Barbara et al., Fundamentals of Nursing: Concepts, Process, and Practice
Seventh Edition. Prentice Hall, New Jersey, USA: 2004.
Pillitteri, Adele, Maternal & Child Health Nursing: Care of the Childbrearing &
Childrearing Family Volume 2 Fifth Edition. Lippincott Williams & Wilkins, USA:
2007.
Internet
Gordon, John B. et al. When Children with Kawasaki Disease Grow Up: Myocardial and
Vascular Complications in Adulthood., Journal of the American College of Cardiology
as seen on http://www.medscape.com/viewarticle/712188
Moran, Adrian M. et al. Abnormal Myocardial Mechanics in Kawasaki Disease: Rapid
Response to Gamma-Globulin., American Heart Journal 02/01/2000 as seen on
http://www.medscape.com/viewarticle/409087
Scheinfeld, Noah S. and Jones, Elena L. Kawasaki Disease., 10/20/2009 as seen on
http://emedicine.medscape.com/article/965367-overview

Research Paper help

49

https://www.homeworkping.com/

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