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)

 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)

IV. 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/mm3) 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/mm3)
 Hypoalbuminemia and hyponatremia
 Plasma lipid abnormalities
 Sterile pyuria
 Elevated serum transaminases
5
 The medical treatment for Kawasaki Disease is intravenous
immunoglobulin (IVIG) with supportive medication of aspirin for anti-platelet
therapy:
DRUG DOSAGE FREQUENCY
IVIG  2g/kg infusion over 10 to 12  Single dose
hours OR;
 400mg/kg/day  For 4 days
* IVIG may be repeated if fever
persists or recurs together with at
least one classic sign of KD
Aspirin  80-100mg/kg/day then;  In 4 divided
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. Low-
dose aspirin is used to inhibit platelet aggregation.

6
 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
Mother’s Name: Roselia Age: 33 y/o Occupation: Employee (Human Resources)
Father’s Name: Dante Age: 38y/o Occupation: Employee (Quality Control)

II. Admission Data and Notes

Hospital: Philippine Children’s 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 – 39.5°C
Cardiac Rate – 120 bpm
Respiration Rate – 30 cpm
Blood Pressure – 90/60 mmHg
Doctor’s 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
Children’s 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 patient’s 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

9
 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 physician’s notes, patient’s growth and development are
at par with age with no delays in development.

VII. Family Health History

Father’s Side: (+) cardiovascular accident

(+) hypertension
Mother’s Side: (+) hyperthyroidism

10
 PHYSICAL ASSESSMENT

Name: Patient CDC

Age: 1 ½ 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 38.4°C, 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 TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS
Skin Inspection  Color varies from light to  Erythematous and
and deep brown maculopapular rashes
Palpation are present on the back,
abdomen, chest, and
extremities
 No edema  Hands and feet are
reddish, edematous,
shiny, and dry-looking
 Moisture in skin folds and  Skin is moist especially on
axillae areas with folds; presence
of desquamation on
fingers, toes, and labial
area
 Skin temperature is  Skin temperature is
uniform within normal uniformly warm due to
range elevated body
temperature
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 38.4°C
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.
Head Inspection  Configuration is  Head is normocephalic in  Normal
and normocephalic shape
Palpation  No lesions or tenderness  Absence of lesions and no  Normal
signs of tenderness

12
  Anterior and posterior  Anterior and posterior  Normal
fontanels are flat and fontanels appear to be flat
closed and closed
Hair Inspection  Evenly distributed, thick  Hair is thick, smooth,  Normal
hair, silky, resilient, no moist, and with no signs of
infestation parasitic infestation
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,  Transparent, shiny,  Normal

smooth with corneal smooth; details apparent
details visible

Pupils Inspection  Black/brown in color;  Black in color; briskly  Normal

constricts when
illuminated and when
looking at near objects;
dilates when looking at far
objects
 Symmetrically aligned
constricts when illuminated
and dilates when not
illuminated
 Aligned

Eye Balls Inspection  Eyeballs are symmetrical  Eyeballs are symmetrical  Normal
in size in shape and size
 Not protruding  There is no protrusion
Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.

13
Palpebral Inspection  Smooth, pink or red  Bulbar conjunctiva are  Bilateral conjunctival
and Bulbar slightly reddish in color injection is one of the
Conjuctiva criteria in diagnosing
Kawasaki Disease

Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
Ears Inspecton  Auricles fair in color  Auricles are fair in color,  Normal
and  Symmetrical and aligned symmetrical in shape,
Palpation with outer canthus of eyes flexible with no tenderness
 Auricles are flexible, firm,  There is no discharge from  Normal
no tenderness the ear canal
 Absence of purulent  Responds to the voice of  Normal
discharge in the external mother and father
canal
 Patient responds to sound
Nose Inspection  Nares are patent  Patent nares with septum  Normal
and  Septum on the midline on the midline
Palpation  Mucosa is pinkish in color  Mucosa is pinkish  Normal
Mouth Inspection  Lips are moist and pinkish  Lips are red in color, dry,  Changes in the mouth
and in color and cracked and oral mucosa are
Palpation  Oral mucosa is pinkish  Oral mucosa is also deep some of the signs of
with no ulcerations red in color Kawasaki Disease
 Tongue is red and has
strawberry-like texture Source: Textbook of
 No ulcerations in oral Pediatric Infectious
mucosa Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.

Neck Inspection  Neck is symmetrical  Neck is symmetrical  Normal

and  Thyroid glands are not  Presence of a swollen  Unilateral cervical
14
 Palpation tender and enlarged lymph node on the left lymphodenopathy
side of the neck ; size of appears in 50% to 75%
the lymph node is of patients with
approximately 1.5cm Kawasaki Disease
 Neck muscles are equal  Neck muscles are equal in  Normal
in size size
 Trachea is positioned  Trachea is positioned  Normal
midline upon palpation midline
Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
Chest Inspection,  Full and symmetric and  Chest is not bulging and  Normal
Palpation, not bulging appears symmetrical
Auscultation
 Breathing is abdominal  Abdominal breathing is  Normal
and posterior mobility and present (pediatric) with
posture of thorax is thoracic movement
symmetrical upon symmetrical
respiration

 Clear breath sounds  No presence of harsh  Normal

breath sounds; patient was
crying and irritable during
assessment
Heart Auscultation  S1 usually heard at all  S1 and S2 are heard  Normal
sites but louder at apical audibly on apical and base
area areas of the heart
 S2 usually heard at all  No murmur or gallops (S3
sites but louder at base of and S4)
the heart
Breast Inspection  Symmetrical in size and  Symmetrical in size and  Normal
shape shape

15
  Areola is round or oval  Areola is small and brown  Normal
and color is light pink to in color
dark brown
 Nipples are round, and  Nipples are round and  Normal
equal in size almost in size

Finger and Inspection  Vascular and pinkish in  Fingers and toes are  Changes in
Toe Nails and color desquamated, extremities such as
Palpation edematous, and reddish edema, desquamation,
in color and redness are signs
of Kawasaki Disease
 Smooth texture  Smooth texture  Normal
 Intact epidermis  Intact epidermis  Normal
 Capillary refill in 3-5  Capillary refill of 3 seconds  Normal
seconds
Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.
Abdomen Inspection,  Unblemished skin,  Presence of  Presence of
Auscultation, uniform in color erythematous and polymorphous
Palpation polymorphous rashes on exanthema or rashes
the trunk is one sign of
Kawasaki Disease
 no evidence of liver  no evidence of liver  Normal
enlargement enlargement
 Audible bowel sounds  Audible bowel sounds at  Normal
12 per minute; abdomen
produces a growling sound Source: Textbook of
Pediatric Infectious
Diseases, Fifth Edition by
Feigin, Ralph D. and
Cherry, James D.

16
Muscles Inspection,  Equal size on both sides  Symmetrical in size on  Normal
Palpation 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 FUNCTION
Superior Vena Cava (SVC)  One of the two main veins that drains un-
oxygenated blood to the right atrium
 Blood from the head and upper body
drain into the SVC
Inferior Vena Cava (IVC)  The second main vein that drains un-
oxygenated blood to the right atrium
 Blood from the legs and lower torso drain
into the IVC
Aorta  The largest single blood vessel in the
body
 Passageway for oxygen-rich blood from
the left ventricle into the systemic
circulation
Pulmonary Artery  The only artery in the body that carries
deoxygenated blood
 Passageway of deoxygenated blood from
the right ventricle to the lungs
Pulmonary Vein  The only vein in the body that carries
oxygenated blood
 Carries oxygenated blood from the lungs
to the left atrium
Right Atrium  A chamber of the heart that receives
deoxygenated blood from the SVC and
IVC
 Pumps blood into the right ventricle via
the tricuspid valve
Right Ventricle  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
pulmonary artery
Left Atrium  Receives oxygenated blood from the
pulmonary vein
 Blood from this chamber empties into the
left ventricle via the mitral valve
Left Ventricle  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 circulation
Atrioventricular Valves  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
 The mitral valve is the gateway between
the left atrium and the left ventricle
Semilunar Valves  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 PARTS SUPPLIED

CORONARY ARTERIES
Left Coronary Artery
Left Anterior Descending Artery
Circumflex Artery
Right Coronary Artery
 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
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
media
Thicker than the tunica
adventitia allowing
vasoconstriction and
vasodilation
Same
Narrower
Absent
Fastest in arteries and gets
slower when entering the
arterioles and capillaries
Aorta (largest), pulmonary
artery, carotid arteries,
subclavian artery,
brachiocephalic, abdominal
aorta, common iliac, brachial
PARTS VEINS
Tunica Adventitia (outer Thickest layer
layer)
Tunica Media (middle Thinner in veins
layer)
Tunica Intima (inner layer) Same
Lumen Wider to accommodate
valves
Presence of Valves Present; to ensure the one-
way flow of blood back to
the heart
Blood Flow Slow in the venules, but
increases speed as it
passes through the veins
(valve-related)
Major Blood Vessels Superior and inferior vena
cavae, jugular veins,
subclavian veins, hepatic,
iliac, femoral, hepatic portal
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
Diagnosis of Kawasaki Complications if untreated
Signs and symptoms in Disease based on without IVIG 10 days after onset
patient diagnostic criteria of of fever
disease;
Age is the only probable
predisposing factor in
patient
Diagnostic indicators

Remittent fever for 6 Coronary aneurysm;

(+) fever days PTA; Coronary thrombosis;
T = 39.5°C on DOA Coronary stenosis;
Coronary arteritis
(+) maculopapular
erythematous rashes on
hands, feet, trunk, and
abdomen;
(+) edema of hands and
feet;
(+) desquamation of
Platelet level of 411 x Myocardial infarction;
fingers, toes, and
103 g/L based on CBC; Congestive heart
periungual area
ESR of 112 mm/hr failure;
based on CBC Death
(+) cracked lips;
(+) strawberry tongue;

(+) palpable unilateral WBC count of 19.7 g/L

cervical based on CBC;
lymphadenopathy at Segmenter count of 0.85
1.5cm 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 non-
modifiable 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 39.5°C,
elevated platelet (thrombocytosis) and ESR (inflammatory response) levels, and a “left
shift” (increased production of mature leukocytes) in the patient’s 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 worst-
case 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 FINDINGS ANALYSIS

VALUES

Hemoglobin 107.6 116-140g/L Below normal Indicative of

(HGB) anemia, which
is a diagnostic
predictor of
Kawasaki
Disease

Hematocrit 0.34 0.35-0.41g/L Slightly below Lysis of RBC

(HCT) normal is possibly
due to
vasculitic
affects of
disease

RBC 4.36 3.6-50g/L Normal There is no

abnormal
finding

WBC 19.7 5-10g/L Remarkably Indicative of

above normal leukocytosis
secondary to
infection or
inflammation

Differential Count

30
PARAMETERS RESULTS NORMAL FINDINGS ANALYSIS
VALUES

Eosinophils 0.01 0.02-0.07hpf Slightly below Possibly due to

normal allergic
reactions

Segmenter 0.85 0.55-0.65 hpf Remarkably Overproduction

above normal of mature
leukocytes
indicative of
increased
autoimmune
response

Lymphocytes 0.14 0.25-0.35 hpf Remarkably Indicative of

below normal immunosupp-
ression

Platelet Count 411 150-350 x Remarkably Indicative of

103 /L hpf above normal thrombocytosis,
which appears
on the 2nd week
of Kawasaki
Disease

ESR 112 0 -20 mm/hr Remarkably Indicative of

above normal inflammatory
response

ASJ Medical and Diagnostic Clinic

Hematology

31
Date of Release: January 25, 2010

PARAMETERS RESULTS NORMAL FINDINGS ANALYSIS

VALUES

Hemoglobin 106 116-140g/L Below normal Indicative of

(HGB) anemia

Hematocrit 0.32 0.35-0.41g/L Slightly below Indicative of

(HCT) normal low RBC
count due to
hematologic
factors

Erythrocyte 3.7 3.6-50g/L Normal Within normal

Count range

Leukocyte 5.75 5-10g/L Normal Within normal

Count range

Platelet Count 98,000 150,000 – Below normal Indicative of

300,000 thrombocyto-
penia

Differential Count

PARAMETERS RESULTS NORMAL FINDINGS ANALYSIS

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 Indicative of

normal autoimmune
response

Monocytes 0.02 0.02-0.05 Normal Within normal

32
 range

33
 DRUG STUDY

DRUG DOSAGE MECHANISM OF INDICATION CONTRAINDICATION ADVERSE NURSING

ACTION EFFECT RESPONSIBILITIES

Drug Name: 2.5g/50ml 10 vials: Improves immunity Kawasaki Patients with Tenderness, - Do not administer to
by binding to and Syndrome anaphylactic reaction to muscle stiffness at patients with history of
IMMUNOGLOB- Test Dose I: neutralizing IGIV injection site, allergy to gammaglobulin
ULIN IV 0.01x11.5kgx60 Prophylaxis after
pathogens, thereby nausea, vomiting,
= 7cc for 30mins exposure to - Instruct patient to report
Drug Class: increasing chills, fever,
antibodies against Hepatitis A headache. symptoms occurring
Test Dose II:
Passive immune- 0.02x11.5kgx60 bacterial, viral, during or after therapy.
globulin B-cell chronic
=14cc parasitic, and
lymphocytic - Use with caution in
mycoplasmic
Test Dose III: leukemia pregnant women-
antigens. Acts
0.03x11.5kgx60 Pregnancy C; safety not
through Pediatric HIV
=21cc established
antimicrobial and infection
Test Dose IV: antitoxin - Have epinephrine 1:1000
0.04x11.5kgx60 neutralization. immediately available at
=28cc time of injection in case of
anaphylactic reaction
Translate
remaining 390cc to
- Do not mix immune
24cc/hr for 16hrs
globulin with any other
medications

- Monitor patient’s 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 DOSAGE MECHANISM OF INDICATION CONTRAINDICATION ADVERSE NURSING

ACTION EFFECT RESPONSIBILITIES

Drug Name: 300mg/tab; 1 tab It acts in the Mild to moderate Allergy to NSAID or Acute aspirin - Give drug with food or
q6 PO thermoregulatory pain salicylates toxicity: tachypnea, after meals if GI upset
ASPIRIN center of the hemorrhage, occurs.
hypothalamus to Fever Hemophilia; excitement,
Classification:
block effects of hemorrhagic states; confusion - Use the drug only as
Antipyretic, Inflammatory impaired renal function; suggested; avoid
pyrogen
analgesic, NSAID conditions- chickenpox; pregnancy GI: nausea, overdose.
Also has anti- rheumatic fever, dyspepsia,
inflammatory, anti- rheumatoid heartburn,
platelet, and arthritis, epigastric
analgesic osteoarthritis discomfort,
properties anorexia

35
 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 DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Elevated body Present Short-term: Independent: After 2 hours of
NONE temperature disease nursing
related to After 2 hours Check Assessment intervention, the
Objective: systemic of nursing temperature and of all vital patient’s body
Temp – 38.4°C; inflammation Systemic intervention, other vital signs signs is temperature
of blood inflammation the patient’s prior to integral to was lowered to
Warm to touch; vessels of blood temperature interventions; planning and 37.8°C; to
secondary to vessels will normalize intervention; continue
Irritable and present at 37.5°C. interventions
restless; disease Administer tepid TSB is an until body
Release of sponge bath to independent temperature
Uncontrolled pyrogens lower nursing normalizes
crying temperature; function that
lowers core
temperature;
Elevated body
temperature Provide a change Increasing
of clothes and patient
sheets to promote comfort can
increased ease irritability
comfort; and
restlessness
associated
with fever;

Regularly check Soiled diapers

diapers if soiled; cause
additional
discomfort;
37
 Follow feeding Infants require
schedule to sufficient
provide nutritional nutrition
support; especially
during times
of illness and
immuno-
suppression;

Watch out for Dehydration is

signs of common in
dehydration infants with
persistent
fever

Dependent:
Administer aspirin Aspirin serves
as ordered; as an
antipyretic,
anti-
inflammatory
and anti-
platelet 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 DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Impaired skin Present Short-term: Independent: After 6 hours of
NONE integrity disease After 6 hours nursing
related to of nursing Assess the hands Assessment intervention,
Objective: accumulation intervention, and feet for extent of sites of skin integrity
of fluids in Systemic skin integrity of dryness and edema will improved with
+ 1 edema of interstitial inflammation improved as edema; dictate controlled
hands and feet; spaces of of blood evidenced by provision dryness of the
hands and vessels controlled interventions; skin ; skin is
Skin appears dry feet dryness of the more moist on
and shiny; secondary to skin Assess mobility of Mobility is a sites of edema
present Increase in fingers, toes, sign of
With erythema of disease histamine Long-term: hands, feet, sufficient
hands and feet; release wrists, and blood flow to
After 3 to 4 ankles; sites;
desquamation of days of
fingers and toes Greater nursing Apply RICE R- rest;
permeability intervention, technique in I – ice to
of blood skin integrity management of decrease
vessels problems edema; inflammation;
related to C–
edema will compression
Vascular fluid resolve as to promote
moving to evidenced by venous return
interstitial edema score and lymphatic
spaces of of 0 from +1 drainage of
hands and fluid;
feet E – elevate
above the
heart for
venous return;

Impaired skin Apply lotion to dry Lotion can

39
 integrity areas of skin for hasten further
moisture and drying of the
lubrication; skin due to
edema;

Do not peel off Desquamated

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

Watch out for Edema and

wounds and signs dryness make
of infection and skin
loss of function susceptible to
wounds
Dependent:
Administer aspirin Aspirin has
as prescribed; anti-
inflammatory
properties;

Check flow of IVIG therapy

IVIG as aids in abating
prescribed inflammation,
thus reducing
edema

3. Impaired oral mucous membrane related to inflamed oral mucosa secondary to present disease
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Impaired oral Present Short-term: Independent: After 3 hours of
40
NONE mucous disease nursing
membrane After 3 hours Assess the extent, Assessment interventions,
Objective: related to of nursing characteristic, and of the fissures fissured and
inflamed oral Inflamed oral intervention, severity of the and cracks on cracked lips
With fissured, mucosa mucosa fissures and fissures and the lips will were managed
cracked lips; secondary to cracks in the cracks on the lips; affect as evidenced by
present lips will be interventions controlled
With disease Poor blood controlled and to be given; dryness of the
erythematous perfusion to lessened lips
lips; oral mucous Assess if there is Fissured and
membrane Long-term: difficulty in cracked lips
red and inflamed swallowing or can cause
oral mucosa; After 3 to 4 alterations in difficulty in
Impaired oral days of feeding; feeding,
Strawberry-like mucous nursing especially in
tongue with membrane intervention, infants;
papules; (evidenced by fissures and
cracked lips) cracks will Provide oral Moistening
Irritable when resolve as rinses using tap dried mucosa
being given evidenced by water or saline will prevent
feedings moist lips with drops to moisten worsening of
the absence mucosa; cracks and
of cracks and prevent new
fissures ones from
developing

Provide regular Non-alcoholic

oral care hygiene rinses will
by giving oral prevent
rinses; infection
Encourage Dehydration
sufficient fluid can contribute
41
 intake as to mucosal
prescribed and dryness and
tolerated; worsen
cracked lips;

Instruct mother to Juices and

avoid giving acidic other acidic
fluids; beverages
cause pain in
open oral
mucosa;

Instruct mother to Feeding

continue feeding practices
practices as should be
prescribed by encouraged in
physician spite of
condition

Watch out for Further drying

signs of infection of mucosa can
lead to ulcers
and result to
infection

Independent:

Administer aspirin Aspirin has

as prescribed analgesic and
anti-
inflammatory
properties
42
 Potential Nursing Problems
1. Risk for decreased cardiac output related to possible coronary artery complications secondary to present disease
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Risk for Present Short-term: Independent: After 2 hours of
None decreased disease nursing
cardiac output After 2 hours Assess the It is important intervention, the
Objective: related to of nursing patient’s cardiac to retrieve parents were
43
None possible Increased intervention, vital signs prior to baseline VS able to
coronary platelet the parents discharge; prior to understand the
artery production will be able to discharge for risk for cardiac
complications verbalize reference; complications
secondary to understanding as evidenced by
present Formation of of the cardiac Discuss with Client verbalization of
disease blood clots in complications parents the nature education is their
blood vessels, of present of Kawasaki important in comprehension
particularly disease Disease and the comprehen- of health
the coronary possible sion of illness teachings
arteries complications
even with IVIG
therapy;
Blood clots
can cause Provide parents A quick
blockage, with an reference
aneurysms, information sheet guide can
and stenosis regarding post- increase
of coronary drug therapy care understan-
arteries for patients with ding of
Kawasaki disease;
Disease;
All these
complications
can cause Instruct parents to Patient’s full
decreased promote adequate recovery has
cardiac output rest and sleep 2-3 to be ensured;
days after
discharge from
hospital;

Instruct parents to Gradual

gradually reintroduction
44
 reintroduce to activities
patient to will help
activities; patient adapt
efficiently after
illness;

Educate patients Signs of

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

Promote a Proper
balanced diet with nutrition will
low sodium ensure growth
content; and
development;

Advise parents Follow up

regarding follow check-ups will
up check-up and help
diagnostic determine
procedures development
of any cardiac
abnormalities
or coronary
45
 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
 Aid patient in holistic development of self to promote overall wellness

48
 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

49