I.

INTRODUCTION

Our human body is a very complex system. One functions for the benefit and or expense of another. Our subsystem is a vital as the other thus they are interrelated. Considering this fact, we have look into the reality that in this diverse physiological wonder lays the infinite possibility of not only optimum functioning but of disparities and deviations as well. In life, one continues to exist via oblivion. There are always uncertainties in every events and occurrences that whirl through our lives. We do not know the exact point in time where our bodily homeostasis will be disturbed and when change will ease to happen. Some of the surprising changes can be considered blessing but most of the time they are what we fervently hope would not occur especially those that concern our health. Kawasaki disease (mucocutaneous lymph node syndrome) is a form of vasculitis identified by an acute febrile illness with multiple system affected. The cause is unknown, but autoimmunity, infection, and genetic predisposition are believed to be involved. It affects mostly children between ages 3 months and 8 years; 80 % are younger than age 5. It was first described in 1967 by Dr. Tomisaku Kawasaki in Japan.

A. BACKGROUND OF THE CASE STUDY This is a case of a 2 years and 9 months old male child suffering from Kawasaki Disease; this condition mostly occurs in children ages 5 years and below. Kawasaki disease is a rare disease that occurs in children and leads to vasculitis, in which there is an inflammation of the blood vessels of the body. This blood vessel inflammation can result in many manifestations in different organs and body systems and can lead to serious complications, such as aneurysms and heart attacks

Kawasaki disease is also known as lymph node syndrome, and Kawasaki syndrome. Kawasaki disease has no known cause, but it is suspected to be an autoimmune disease, in which the body's immune system mistakes healthy cells of the body as dangerous invaders and attacks them.

Kawasaki disease is very rare in the Philippines. On June 19, 2010, 10 cases of highly suspicious Kawasaki disease cases were reported to the National Epidemiology Center. An FETP team was sent to conduct an epidemiological investigation. The objectives were to verify the disease, identify the clinical manifestations and recommend control and preventive measures. Methods: A descriptive study was gone. An ill patient was a resident of 3 municipalities in Nueva Ecija with fever of 5 or more days and the presence of at least 4 of the following: edema or desquamation of extremities, polymorphic exanthema, bilateral conjunctival congestion, oral mucosal changes and/or cervical lymphadenopathy from February 4 to June 24, 2010. Medical records from two hospitals were reviewed.

Like all immune diseases the cause of Kawasaki disease is presumably the interaction of genetic and environmental factors, possibly including an infection. The specific cause is unknown, but current theories center primarily on the immunological causes for the disease. Evidence increasingly points to an infectious etiology, but debate continues on whether the cause is a conventional antigenic substance or a superantigen. Childrens Hospital Boston reports that some studies have found associations between the occurrence of Kawasaki disease and recent exposure to carpet cleaning or residence near a body of stagnant water; however, cause and effect have not been established.

B.OBJECTIVES OF THE CASE STUDY The objectives of the study are: 1. To determine the predisposing and precipitating factors of Kawasaki disease. 2. To identify previous interventions provided to the case. 3. To describe the pathophysiology, signs and symptoms, and typical progression of Kawasaki disease. 4. To determine the Nursing Care Plan appropriate for the case

C.SIGNIFICANCE OF THE CASE STUDY The result of this case study will be significant to the following: Patient with similar illness the results of the study will contribute to the improvement of services provided to succeeding patient with similar disease. Nursing Students the results of the study may contribute to the base knowledge of nursing care plan and basis for modification of nursing actions and activities toward patient particularly with Kawasaki disease. Nursing Professions the result of the study may contribute to the base knowledge nursing care and basis for modification of nursing actions and activities toward patient particularly with history of Kawasaki Disease. Nursing Researches the study will provide significant literature and may serve as for further and related studies on Kawasaki disease. direction

D.SCOPE AND DELIMITATION This case covers August 31, 2011 from 7am to 3am at VLGH; at pediatrics ward. The clients history of present illness, including family history, was carefully studied. Information and details regarding the patients disease such as pathophysiology, precipitating and predisposing factors, clinical manifestations signs and symptoms were considered before intervening with the clients condition. Proper nursing intervention and health teachings were given to be able to provide quality nursing care. Furthermore, the limitation of the study lies on the time given since we just have one day exposure at pediatrics ward. The nursing intervention is within 8 hours with response to the patients main concern.

II. PATIENTS DATABASE A. CLIENTS PROFILE Patients Name Age Birthday Birth place Sex Religion : LJN

: 2 years old and 9 months : November 09, 2008 : Lapu-lapu City : Male : Roman Catholic

B. History of Present Illness Patient present condition started 8 days prior to admission when patient have fever at 37.8C associated with rash that started from face to neck. No consultation was done but was given paracetamol at 10 ml dose. Until 7 days prior to admission, patient had no fever, the rash progresses up to chest area, scrotum and inguinal area, itch associated with dry lips, red, cracked. Consultation was done at PAFGH and was diagnosed to have measles given cetrizine; CBC count was also done but revealed normal thus the patient was sent home. 4 days prior to admission, still with fever documented at 38.3C and rash. Swelling of the face and lips still cracked and bleeding; later with progression of the swelling. Patient was brought back for consultation at PAFGH wherein plumberry tongue was noted upon physical examination. Impression then was Kawasaki disease. Patient was advised for admission but refused and sought for second opinion consult at San Juan de Dios for second opinion wherein Kawasaki disease was also entertained. Thus patient was brought back to PAFGH for admission and was eventually evaluated here in our institution VLGH, for admission.

C. Client History

Past Medical History Patients mother verbalized that all needed immunization since birth has been done to the patient. The patient has no previous hospitalization. The only time he was admitted to the hospital was when he was diagnosed of having Kawasaki disease. The patient has been taking Paracetamol prior to admission to treat fever. He doesnt have any allergies with any certain type of food or medicine.

1. Family Health History A. Genogram

Ledger: Male family member

29 years old

30 years old Siblings

Patient

Female family member

Diseased

Parents 5 years old 4 years old 2 years old 1 year old

2. Psychological History The patient is not aware of himself being hospitalized because he was not informed by his significant other. He just knows that his mother has taken him to a different place. He has no complaints about his stay in the hospital and enjoys playing with the other children at the kiddie corner. He is associative and cooperative during playtime and has no favoritism to any toy. The patient is easy to handle and doesnt react negatively to the interventions performed.

Physical Examination: Awake, active Bp:100/60mm/Hg CR:134bpm Wt: 15 kg

Aug 23, 2011 RR:50cpm

Temp: 37.4C

Skin: warm, moist (-) cyanosis (+)rashes (+)crush lesions in perioral area (+)palpable lymph nodes HEENT: anecteric sclera, pink palpebral conjunctiva, dry cracked lips. Chest: symmetrical chest expansion no retraction, harsh breath sounds. Heart: adynamic precordium normal rate rhythm. Abdomen: globular NABS, soft, non tender, no organomegaly Extremities: Grossly normal, full equal pulses (+) periinguinal desquamation and inguinal desquamation.

E. Laboratory/Diagnostic Procedures CBC Result Hemoglobin Hematocrit RBC count WBC count Differential count Segmenters Lymphocytes Eosinophils Monocytes Basophils Stabs Atypical cells MUCU MCH MCHC RDU Platelet count ESR PTT INR activity APTT Reticulocyte count Blood type Clotting time Bleeding time 130 0.36 4.73 20.07 0.81 0.07 0.01 0.11 0.00

August 23, 2011 Reference values 137-175 0.40-0.51 4.63-6.08 5.0-10.0 0.55-0.65 0.25-0.35 0.02-0.04 0.02-0.10 0.00-0.01 0.03-0.07 80-100 27-31 31-36 11.0-15.0 130-500

gms/l

79.3 27.5 35 14.30 400

74-94 25.3-32.3 5-20

2-7 2-4

Analysis: The patients hemoglobin and hematocrit are less than normal range that can be referred to as anemia and or hemorrhage, He has high count of WBC that indicates infection. for the segmenters, high count indicates viral infection, while low lymphocytes are caused by immunity problems or infection. Low lymphocytes can also sometimes indicate a blood disorder.

III. Clinical Discussion A. Anatomy and Physiology ANATOMY AND PHYSIOLOGY

B. Kawasaki Disease is poorly understood condition that affects young children. It causes severe inflammation in different areas of the body, including the heart and coronary arteries. C. The skin is a soft outer layer covering of our body. The adjective cutaneous literally means of the skin. Skin is the largest organ of the integumentary system made up of multiple layers of the ectodermal tissue, and guards the underlying muscles, bones, ligaments and internal organ. Because it interfaces with the environment, skin plays a key role in protecting the body against pathogen and excessive water loss. Its other functions are insulation, temperature regulation, sensation, and the protection of Vit .B folates. D. Red rash usually seen on the palms and soles then spreads to involve area within a couple days. The most common appearance is a hive-like rash; however it may also resemble measles, it is more visible on the hands and feet than the torso. Hands and feet generally develop some swelling as well. E. The heart may be affected in as many as one five children who develop Kawasaki Disease. Damage sometimes occurs to the blood vessels that supply the heart
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muscle (coronary arteries) and to heart muscle itself. A weakening of coronary artery can result in an enlargement or swelling of the blood vessel wall (an aneurysm). Infant less than 1 year old are usually the most seriously ill and are greatest risk for heart involvement. The acute phase of Kawasaki disease commonly lasts 10-14 days or more. Most children recover fully. F. The tongue, characteristics of strawberry tongue are sloughing of filiform papillae (caused by the systemic inflammatory process) and persistence of the fungi form papillae which form the seeds of the strawberry tongue. G. The Lymph nodes. Edema is often seen in the hands and feet and cervical lymph nodes are often enlarges

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B. Pathophysiology
Predisosing factors: factors: Predisposing Age- 2Age- 2 9 months years, years, 9 months Sex- Male Sex- Male Race- Asian Race- Asian

Precipitating factor Unknown

Autoimmune Response Releases of Chemical Mediators Histamine Bradykinin Prostaglandin Phagocytis by Neutrophils and Macrophages (Antigens are localized & inflammation Phagocytes and WBC Antigens

Vasodilation & Cellular permeability attraction

Entry of antigen on Lymphatic capillaries. S/S Redness, Swelling and Heat

Increase pressure Lymphatic circulation due to inflammation and entry of antibodies

Systemic blood vessels involvement (inflammation of small & medium size vessels).

Kawasaki disease

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C. Theoretical framework Human-to-Human Relationship model (Joyce Travelbee) Original Encounter This is described as the first impression by the nurse of the sick person and vice- versa. The nurse and patient see each other in stereotyped or traditional roles. Emerging identities This phase is described by the nurse and patient perceiving each other other as unique individuals. At this time, the link of relationship begins to form. Empathy Travelbee proposed that two qualities that enhance the emphaty process are similarities of experience and the desired to understand another person. This phase is described as the ability to share in the persons experience. The result of the emphatic process is the ability to expect the behavior of the individuals with whom he or she empathized. Sympathy Sympathy happens when the nurse wants to lessen the cause of the patients suffering. It goes beyond emphaty. When one sympathizes, one is involved but not incapacitated by the involvement. The nurse should use a disciplined intellectual approach together with therapeutic use of self to make helpful nursing action. Rapport Rapport is described as nursing interventions that lessen the patients suffering. The nurse and the sick person are relating as human being to human being. The sick person shows trust and confidence in the nurse. A nurse is able to establish rapport because she possesses the necessary knowledge and skills required to assist ill persons and because she is able to perceive, respond to, and appreciate the uniqueness of the ill human being.

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Application: Original encounter This phase shows the first impression of us and LJN. To each other. Since it is just their firt encounter, both of them are not yey comfortable talking and expressing dep thoughts and feelings. Emeging identeties In this phase the closeness of us and LJN. is being established. There is a concious awareness between the nurses and the patient that both of them have different thoughts and feelings. LJN. must develop awareness and a valuing of the uniqueness of others. Emphaty Experiencing childhood is one way of knowing what patient LJN. is feeling even though he is not vocal about what he feels, oviously, he is expeeriencing discomfort because of the bleeding in his pere oral area, we can say that he knows that it is not normal to wipe it minute by minute. Even if he was not informed about his situition. Symphaty We have shown symphaty by interacting with the patient as if w are only an older pal so that he wouldnt feel inferiority, and by asking things that would lessen his discomfort and boerdom because that time he was actually skephical, about his situition. We ask if he wants to play at the kiddie corner he said yes but he was not comfortable with us accompanying him, he looked around, he was looking for his nanny, so we ask his nanny to accompany him. Rapport He was brought at the kiddie corner by his nanny and with us following them. We were just watching them but little by little started to interact, he responded by handing one in our group a toy and thats the start of establishing rapport until he became completely comfortable playing with us.

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E. Course in the Ward 31 August, 2011 Received patient sitting in bed accompanied by nanny, Conscious and coherent, with no contraptions, but noticed to have rashes and crush lesions in perioral area Vital signs were taken and as follows: 0800H BP: 110/70mm/Hg CR: 95bpm RR:20cpm Temp:36.5C.

Established rapport to the patient, Accompanied at Kiddie corner during therapeutic play. Nursing History and the Physical Assessment was done by the time the patients mother arrived at around 1100H. Vital signs were taken and as follows:1200H BP:120/80mm/Hg CR:90bpm RR: 22cpm Temp:36.1C, Monitored intake and output per shift,Intake:300cc, Output:280cc Continuous monitoring was done, no complaints made during the whole shift.

IV. Nursing Management y Problem List y Hyperthermia related to increased metabolic rate and dehydration, possibly evidenced by increase body temperature greater than normal range, flushed skin, increased respiratory rate and tachycardia. y Impaired skin integrity related to inflammatory process, as evidenced by disruption of skin surface, including macular rash and desquamation. y Impaired Oral Mucous Membrane related to inflammatory process, dehydration, and mouth breathing, possibly evidenced by pain, hyperthemia, and fissures of lips.

Long Term Objective y y y To be able maintain core temperature within normal range. To be able to maintain skin integrity at optimal level. To be able to maintain integrity of oral mucosa and to identify contributing factors affecting oral health.

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Nursing Care Plan 1. Nursing Intervention Assessment

Subjective: May lagnat yata sya as verbalized by the mother Objective: >Increased in body temperature above normal range >flushed skin; warm to touch >Increased RR, unstable BP

Nursing Diagnosis
>Hyperthermia Related to: Increased metabolic rate and dehydration, possibly as evidenced by increased body temperature greater than normal range, flushed skin, increased RR and tachycardia

Planning Independent:
After 8 hours of nursing interventions, the client will be able to: 1. Maintain core temperature within normal range 2. Identify predisposing and precipitating factors and importance of treatment 3. Demonstrate behaviors to monitor and promote normothermia

Rationale

Evaluation
After 8 hours of nursing interventions,

1.Monitor core temperature

2.Provide tepid sponge bath as necessary 3.Discuss the importance of adequate fluid intake to prevent dehydration Collaborative: 1.Administer paracetamol as ordered 2. Monitor periodic lab studies relative to general well-being & status of specific problems

-To evaluate the degree of hyperthermia -To assist with measures to reduce body temperature -To promote wellness

The patient has able to demonstrate temperature within normal range from 38.1 C to 36.5 C

The patient together with his significant others understands causes of the disease and ready -To reduce to practice fever/headache interventions to prevent hyperthermia

-To assist patient with correcting/minimizing condition & promote optimal healing
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2. Nursing Intervention Assessment

Subjective: Kamut sya ng kamot tapos nasusugat as verbalized by the mother. Objective: > Scaly skin, rough > Peeling > Itchiness > Reports of scratching of Upper and Lower extremities

Nursing Diagnosis Impaired Skin integrity Related to: inflammatory process as evidenced by disruption of skin surfaces, macular rash and skin desquamation

Planning
After 8 hours of nursing interventions, the patient will be able to participate in prevention measures and comply with treatments

Rationale

Evaluation

Independent: 1.Assess the wound frequently to observe any complications

After 8 hours of nursing -to monitor progress interventions: The patient able to of wound healing demonstrate optimum healing of rashes and skin desquamation

2.Keep the area clean and dry, carefully dress wounds to prevent infection, and stimulate circulation to surroundings areas 3. Encourage early ambulation/mobilization Collaborative: 1.Application of anti-itch ointment 2.Administer hydroxyzine as ordered

-to assist bodys natural process of repair

-to promote reduces associated immobility

and risks with

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3.

Assessment
Subjective: Nahihirapan syang kumain at masakit daw pag ngumunguya as verbalized by the mother.

Nursing Diagnosis

Planning
After 8 hours of nursing intervention the patient will be able to verbalize decreased oral pain and discomfort.

Nursing Intervention >Encourage patient to increase fluid intake.

Rationale

Evaluation

Impaired oral mucous membrane may be related to: Dehydration,decreased saliva production, poor oral hygiene, Objective: nutritional deficits > Pale skin possibly evidenced by > Oral lesions; bleeding >Discomfort/pain/difficulty dry mouth,oral discomfort,dry crusted in swallowing or inability inflamed lips and to swallow or chew > Dry lips. halitosis
>foul odor

-o prevent After 8 hours of nursing dehydration

>Assist patient in proper oral care after every meal.

interventions: The patient improved oral hygiene,decreased oral lesions, To prevent gradually improve accumulation of swallowing, feels bacteria that can decrease of worsen the discomfort in perioral area. inflammation

>Apply a watersoluble lubricant (K-Y jelly,aquaphor cream)

- To keep lips moist to prevent drying and cracking. To minimize risk of aspirating nonwater-soluble agent.

>Include food items with each meal that require chewing.

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>To stimulate gingival tissue and promote circulation

Drug Study

GENERIC NAME Diphenhydramine hydrochloride

BRAND NAME Alledryl, allermax, Benadryl

CLASSIFICATION

ACTION Interferes with histamine effects at histamine 1receptor sites, prevents but doesnt reverse histaminemediated response. Also possesses CNS depressant and anticholinergic properties.

SIDE EFFECTS

Capsule: 25mg,50mg Elixir: 12.5 mg/ml Injection: 10mg/ml, 50mg/ml Syrup: 12.5mg/ml Tablets: 25mg,50mg Tablets: (chewable) 12.5mg

ADVERSE REACTION CNS: drowsiness,diz ziness,headach e,paradoxical stimulation (especially in children) EENT: blurred vision, tinnitus GI: diarrhea,consti pation,dryy mouth GU: dysuria,urinar y frequency or retention Skin: photosensitivit y Other: decreased appetite, pain at IM injection site.

NURSING RESPONSIBILITY -monitor cardiovascular status,especially in patients with cardiovascular disease -supervise patient during ambulation. Use side rails as necessary -advise patient to take during and other hazardous activities until how drugs affects concentration and alertness. -as appropriate review all other significant adverse reactions and interactions,esp.those related to the drugs, tests, herbs.

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GENERIC NAME Nystatin

BRAND NAME Mycostatin Nadostine

CLASSIFICATION Cream Ointment Powder Suspension Tablets

ACTION Interferes with fungal cell wall synthesis, inhibiting formation of ergo sterols, increasing cell wall permeability, and causing osmotic instability.

SIDE ADVERSE EFFECTS REACTION Hypersensitivity GI: to drugs or its Nausea components. Vomiting Diarrhea GI distress Oral irritation Skin: Pruritus Rash

NURSING RESPONSIBILITY -Advise patient to continue for taking at least 48 hrs after symptom resolve -Instruct patient to let lozenge dissolve slowly in mouth. Tell patient not to chew or swallow it. -If misses a dose, tell the patient to take a dose as soon as possible and then his regular dosing schedule.

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GENERIC NAME Acetaminophen

BRAND NAME Abenol, Acephen Tylenol Tempra

CLASSIFICATION Oral liquid, oral syrup Children: 1-3 y/o 50mg P.R q 4-6 hrs,prn

ACTION Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CVS or on other substances that sentisize pain receptors to stimulation. The drug my relieve fever through central action in the hypothalamic heat regulation.

SIDE EFFECTS

ADVERSE REACTION Hematologic anemia, neutropenia, leucopenia, pancytopenia Hepatic: Jaundice Metabolic: hypoglycemia Skin: rash

NURSING RESPONSIBILITY Advise patient that drug is only for short term and to consult prescribed if giving to children for longer than 5 days. Tell patient not to use for marked fever (temp higher than 103.1C) or 39C, fever persisting longer than 3 days or recurrent fever unless directed by prescribed.

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GENERIC NAME Cetirizine hydrochloride

BRAND NAME zyrtec

CLASSIFICATION Oral solutions: 5mg/5ml. Tablets: 5mg,10 mg Tablets: (chewable) 5mg,10mg

SIDE ADVERSE EFFECTS REACTION Long acting non- Hypersensitivity CNS: sedating antito drug or Somnolence, histamine, that hydroxyzine Fatigue, selectively dizziness inhibits Acute asthma headache peripheral H1 EENT: receptors. Pharyngitis GI: Route: P.O Dry mouth, Onset: 20nausea 60min. Vomiting Peak: 30-90min. abdominal Duration: 24hr. Distress.

ACTION

NURSING RESPONSIBILITY Warn patient not to perform hazardous activities until CNS effects of drug are known. Somnolence is a common adverse reaction. Inform patient that sugarless gum, hard candy or ice chips may relieve dry mouth.

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E. Discharge Plan Medications       Discuss all take home medications to the patient and significant others. Encourage to take drugs with food if not contraindicated. Inform them that the drugs may exhibit undesirable side effects. This enables them to know what drugs to be taken and its desired doses. Some drugs may cause GI irritation if taken with empty stomach. Adverse reactions with life threatening effects to the patient. Immediate consultation is necessary to prevent untoward injuries.

Exercise  Have adequate rest and sleep.  This recharges the energies to function better, both physical and mentally. Treatment  Explain the treatment and medication purpose to be continued at home.  It is needed for maintenance and control of disease.

Health Teachings  Instruct significant other to increase fluid intake to 8 glasses of water a day.  Emphasize the importance of hand washing.  Encourage significant other to prepare foods that is nutritious such as vegetables and fruits. Outpatient Orders       Diet  Encourage to have three basic food groups in the diet with low salt, low fat.  Instruct the significant other about the prescribed diet as ordered by the physician. Remind the family on their follow-up check-up with their physician. Encourage them to carry out follow-up diagnostic exam. Maintain good and safe environment. To evaluate the progress of the treatment. To evaluate worsening condition of the patient that needs medical attention. May facilitate fast recovery and prevent the patient from further injury.

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