A Pediatric Assessment of Kawasaki Disease

Introduction

Kawasaki Disease is a rare condition that affects children typically from an infant to 5 years of age.  The disease is named after a Japanese pediatrician Dr. Tomisaku Kawasaki who defined this specific pattern of signs and indicators in 1967. Kawasaki disease is most frequently among Japanese children. The disease has occurred in all racial and ethnic groups in the United States but occurs most often among children of Asian-American background.

This disease causes the inflammation of the blood vessels, which is a type of vasculitis.  The origin of the disease is currently unknown, but it can affect every blood vessel in the body.  The inflammation of blood vessels in the coronary arteries can lead to aneurysms. Without the proper treatment, children can develop heart problems, but if the disease is discovered promptly, most children recover with no long-term effects.

Many researchers believe an infectious agent is responsible for Kawasaki Disease due to the seasonal increases during the winter and spring which coincide with the increase of viruses.   The clinical manifestations of Kawasaki disease include fever, dry conjunctivitis, erythema of oral mucosa and lips, rash, and cervical lymphadenopathy (Schaar, 2013).  The way that Kawasaki disease is diagnosis is based on clinical conditions, including fever for at least five days and four or more of the five major clinical features i.e., dry conjunctivitis, erythema of oral mucosa and lips, rash, and cervical lymphadenopathy.  Incomplete Kawasaki disease is the same as Kawasaki disease, except they don’t meet the full diagnostic criteria of Kawasaki disease.

This study will consist of a comprehensive physical assessment, pathophysiology, examination and, interpretation of diagnostic and lab testing, nursing and medical interventions, safe dosed medication cards, and a thorough explanation describing the means of monitoring, measuring, and supporting the hospitalized child.

Determining the Severity of the Patient’s Condition

Pathophysiology

In this particular case study, a 3-year-old boy of Latino, Hispanic descent, with an admitting diagnosis of Incomplete Kawasaki disease. He was admitted to the hospital for the reason of nausea, vomiting, diarrhea, redness in the eyes, cracked lips, pain in mid-lower abdomen and fever.  The patient has a medical history of Chronic Otitis Media.

Kawasaki Disease is considered an autoimmune disease because it activates several proinflammatory responses in the body.  This patient was exhibiting a fever and rash in response to the body, sending cells and chemicals to defend against an attack against the body.  Inflammation is the main way the body defends itself against harmful stimuli.  The primary physical appearances of inflammation are redness, swelling, heat, and pain.

The patient was admitted to the hospital and was suffering from abdominal pain, nausea and vomiting.  The pain associated with these symptoms, caused the patient to complain of pain and it often disrupted the normal activities of a 3-year-old child.  The patients eating patterns were also disrupted due to severe abdominal pain.   There were no clinical indications of damage to the coronary arteries.  Kawasaki disease can develop inflammation of the coronary arteries that transport blood to the heart muscle, and also cause damage to the heart muscle.

The patient’s level of activity was limited due to vomiting, nausea, and, abdominal pain.  The patient is between babyhood and early childhood stage a period of rapid physical growth.

Diagnostic Test Interpretations

The diagnostic test results will be presented below.  Table 1 shows all of the abnormal lab values of the patient.  Each lab result with regards to the overall diagnosis will be discussed.

The diagnostic test results showed an increase in Neutrophils and a decease in Lymphocytes.  The key role of neutrophils is ingesting and destroying infectious agents.  The abnormal values of the white blood cells suggest an inflammatory condition in the body.

The CBC test is done under many diverse conditions to help assess many different diseases.  CBC with differential evaluates the different cells circulating in our blood.  There are three main types of cells in the blood, red blood cells, white blood cells and platelets.  The differential is a count of all of the different types of white blood cells.  The doctor would have ordered this test for a couple of reasons, one would be to rule out other diseases and conditions and the other would be to confirm the current diagnosis of incomplete Kawasaki disease.   The high level of white blood cells indicated an infection and inflammation.

Erythrocyte sedimentation rate and C-reactive protein CRP were ordered for the patient and the abnormal elevated test results suggest inflammation in the patient. Erythrocyte sedimentation rate and C-reactive protein CRP are tests that indirectly measures how much inflammation is in the body and would be used as a general test to validate an inflammatory condition.  This test is usually elevated to a degree not typically found in common viral infections, so the tests would be beneficial in confirming the diagnosis.  In some cases, the CRP test is more accurate than the ESR.

Typical initial laboratory evaluation may include a urinalysis and microscopic urinalysis, and a comprehensive blood panel, for a pre-diagnosis to ruling out other diseases that cause similar signs and symptoms, and also to strengthen the pre-diagnosis.  A comprehensive blood panel was ordered and the abnormal results showed increased liver enzymes, and it was noted in the patient profile that the gall bladder may be dysfunctional due to Kawasaki disease.

Test	Norms	Results
CRP	0.0-1.0 mg/L	16.8 mg/L
Neutrophils	12.0-40.0%	88.6%
Lymphocytes	45.0-77.0%	4.9%
ESR	0-15 mm/h	78 mm/h
Microscopic Urinalysis (WBC)	0-5/HPF	16-20/HPF
Urinalysis (Ketones)	Negative	Trace
Urinalysis (Bilirubin)	Negative	Positive
Urinalysis (Urobilinogen)	Negative	2.0
Total Bilirubin	0.2-1.2 mg/dl	2.1 mg/dl
Albumin	3.5-4.7 g/dl	3.0 g/dl
BUN	6-23 mg/dl	5 mg/dl
Glucose	65-99 mg/dl	104 mg/dl
AST	0-70 U/L	151 U/L
ALT	3-45  U/L	254 U/L

Table 1

The laboratory tests revealed elevated white blood cell count with neutrophil predominance and elevated C-reactive protein and erythrocyte sedimentation rate.  These findings are typical for the acute phase of Kawasaki disease.  Even though there is no specific test for Kawasaki disease, there are several markers that will be similar, that the physician can look for that will make the diagnosis.

The family should be told that based on the results of the pre-diagnosis tests that we suspect Incomplete Kawasaki disease, but further testing and will need to be done over the next few weeks as more symptoms can occur during the different phases of Kawasaki disease.

Medications

Nurses play an important role in the administration of timely medication. A timely administration of medication to children diagnosed with KD assists in altering or slowing down the progress of Kawasaki disease.

Aspirin

chewable ordered 162mg., P.O., the patient’s weight was 17.7 kg. and a safe dosage for the patient is 30 to 50 mg/kg/day. The patient was on a higher dose due to Tylenol not ordered because of his increase in liver enzymes and the benefit outweighed the risk to help control patient’s fevers. The medication was ordered for pain, inflammation and fevers specific to this patient with some common side effects including bleeding, tachycardia, and more severe duodenal ulcers. Signs of toxicity include (tinnitus, headache, dizziness, confusion). ASA may cause easy bruising and physician should be notified if the child exposed to chickenpox or influenza (risk of Reye’s syndrome). Nursing Implications include administering medication with water, food or milk to decrease GI upset. Monitor pertinent labs while on this medication, for example, platelets, CBC and monitor the patient for any signs or symptoms of bleeding.

Pepcid

(famotidine) ordered 1.11ml., P.O., the patient’s weight was 17.7kg. and a safe dosage for the patient is 1 mg/kg/day. Treats GERD, prevent GI ulcers, heartburn, acid reflux or sour stomach. Common side effects can include dizziness, tachycardia, headache or abnormal heartbeat. May be taken without regards to meals, do not chew or shake vigorously for 10 to 15 seconds before each use. Relevant labs and assessment data contain abdominal pain and tenderness, CBC, gastric PH, occult blood with GI bleeding and renal function.

Zofran

(ondansetron HCL) ordered 1.33ml. I.V. infusion with safe dosing at 0.15mg/kg/dose. The patient’s weight was 17.7kg. Used for this patient to treat or prevent upset stomach, nausea/vomiting by way of blocking serotonin. Common side effects include injection site reaction, anxiety, agitation, dizziness, drowsiness, fatigue, headache, malaise, constipation, diarrhea, increased AST or ALT, fever and abdominal pain. The nurse may administer without meals and monitor labs renal and liver function tests.

Nursing Interventions

• Monitor vital signs (paying special attention to the temperature and pain)
• Monitor Intake and Output each shift
• Encourage oral hydration, adequate fluid intake as indicated
• Administer antipyretics, analgesics, antiemetics, I.V. fluids, medications as ordered and monitor effectiveness
• Repositioning as tolerated to decrease discomfort
• Encourage coping mechanisms and distractions to reduce pain (e.g. car ride in the hallway, playing with stuffed animals in crib)
• Assess I.V. site (redness, swelling, itching)
• Implement standard precautions (Handwashing)
• Educate mom on hygiene that’s appropriate
• Monitor temperature every 4 hours; every 2 hours if elevated
• Provide adequate rest periods
• Administer IV immunoglobulin single dose if ordered (Monitor child’s vital signs closely during IV immunoglobulin administration. Terminate the infusion and report immediately for untoward reactions such as fever, chills, urticaria, chest tightness, dyspnea, nausea/vomiting
• Assess pain level through observation (verbal expressions of pain, facial grimace), utilizing pain scale assessment, and by obtaining relevant pain information from parents about child’s expression of pain
• Maintain the child’s room distraction-free and keep it dim
• Handle the child gently and avoid unnecessary movements
• Apply lubricating lip ointments and glycerin swabs to the oral mucosa; offer cool liquids and soft foods
• Remove wet and wrinkled bed linens
• Family teaching on Kawasaki Disease and it’s treatments (e.g. information on the disease condition, signs and symptoms, diagnostics, and management)
• Encourage intake of protein-rich foods such as eggs, beans, chicken
• Assess skin for texture, turgor, color, moisture, and integrity
• Encourage intake of foods such as salmon, tuna, whole grains, carrots (strengthen mobility and maximize energy production)
• Assess the child’s energy level and ability to perform ADL
• Provide client with sufficient time to accomplish mobility-related activities and encourage to rest in between
• Assist parent(s) with follow up appointments for the child
• Explain to the parents that irritability is a symptom of Kawasaki disease and that they should avoid feelings of guilt; Encourage them to take some rest while the nurse cares for the child
• Explain to parents that the child may experience a recurrent fever at home and teach them how to take the child’s temperature and when to notify the physician (temp. greater than 38.4° C/101° F)
• Encourage parents to express their feelings freely. Reassure parents that some anxiety is appropriate when their child is ill
• Inform the parents of gentle handling of the child as needed
• Assess the anxiety level of parents by asking them to rate their anxiety on a scale from 1 to 5

Monitoring and Measuring

Nursing monitoring of Kawasaki disease patients involved checking the pulse rate, respiratory rate, blood pressure, body temperature, and completion of the pediatric early warning score every 4 hours. (Ford, 2000) Monitor for fever as high as 104°F that lasts for more than 5 days, hot, flushed skin, chills or shivering, loss of appetite. Measure with a thermometer used to assess temperature frequently and support with medication administration, for example, aspirin or an IV immunoglobulin, give sponge baths for temperature over 101°F, use a cooling blanket for higher temperatures that do not respond to antipyretics, encourage adequate fluid intake as indicated and provide adequate rest periods.

The patient should follow-up with cardiology after discharge. The patient should be seen at two weeks and then at 6 weeks.  An echocardiogram and electrocardiogram will be done during these visits to check the child’s coronary arteries. If there is no evidence of cardiac involvement, your child’s cardiac risks are extremely low.

Nurses play a vital role in helping to manage Kawasaki disease as they can help make early referral to pediatric department when they suspect Kawasaki disease nurses are responsible for administering medication on a timely basis for easier management, nurses monitor and evaluate the progress of recovering patients while at the same time giving assurances to patients’ family members that Kawasaki disease is manageable. This helps to reduce the probability of parents and relatives of children diagnosed with Kawasaki disease from suffering depression and anxiety due to fear of losing their loved ones.

When a child treated of Kawasaki disease is being discharged from the hospital, the nurse clearly explains a follow-up plan to the parents or relatives of the child being discharged, emphasizing on the need to monitor the child’s temperature at home.

Patient Routines Disrupted

For a young child or infant, being sick and hospitalized can be traumatic.  Being ill and hospitalized can cause a significant amount of stress.  For a young infant that is tired and sick and worn out they need the safety, support and comfort of their home to cope.  When an infant or a child is in the hospital, they may be afraid, lonely in need of their family.

Depending on the child’s age, there will be different activities that get disrupted by a hospital stay.  A child’s playtime and exercise can be disrupted.  As much as possible a child should be encouraged to play to help the child keep their mind off from pain, the illness and the surroundings.  The child’s eating patterns will be changed and the types of foods that they are used to.  This child’s appetite can be affected by the stay at the hospital and the child at times may need to be encouraged to eat and stay healthy.  A child’s sleep patterns can be affected due to medication schedules, foot traffic, and other non-planned interruptions.

The whole family can suffer from stress when a child is in the hospital.  Parents can feel overwhelmed, by the unknown health of their child.  Families oftentimes become anxious when they begin to worry about the illness that their child is facing.  This is a common reaction, but can oftentime tilt a family out of balance.  The parent might begin to feel guilty about the child’s sickness, such as did they cause the illness, or what could they have done differently to prevent the illness.  If the family has to spend a large amount of time in the hospital, it can disrupt the family’s routines, such as work schedules, school schedules and every other routine schedule that the family has been observed.  It can oftentimes become overwhelming trying to balance the demands of work, medical appointments and other necessary medical appointments and meetings.

Attending to the needs of all of your children when your child who is ill requires much of your time and can cause less time to be spent with a partner.   Caring for your child can also leave less time for recreational and social activities.  With all of the anxiety, meetings, time spent in the hospital can bring challenges in looking after your health and well-being.  Depending on the family’s financial condition, insurance, the illness, and financial concerns, can also be a big stressor upon the family.

Parents oftentimes struggle with feelings about the illness that their child is facing, while maintaining a positive attitude to the child.   It is normal for parents to feel some guilt and disappointment for the way your child’s illness if affecting them.  Divorce can be common among families that face serious illness with their children, due to all of the stresses that come upon the family.

Conclusion

This case study presents a 3-year boy of Hispanic descent that was admitted to the hospital with nausea, vomiting, diarrhea, redness in the eyes, cracked lips, pain in mid-lower abdomen and fever.  The admitting diagnose was incomplete Kawasaki disease.  There were several diagnostic tests that were ordered including, CBC with differential, complete blood panel, ESR, CRP, urinalysis, microscopic urinalysis.  The results of the tests help to confirm the diagnosis of incomplete Kawasaki disease based on high white blood cells, high ESR and CRP, high fever for 5 days, and redness in the eyes, cracked lips and abdomen pain.

Nurses play a vital role in helping to manage Kawasaki disease as they are responsible for administering medication on a timely basis for easier management, nurses monitor and evaluate the progress of recovering patients while at the same time giving assurances to patients’ family members that Kawasaki disease is manageable.

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