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Cebu City
PROGRAM FOR ENHANCING NURSING SKILLS, INVOLVEMENT, AND VALUES
EDUCATION
Submitted by
Group IV
Abaquita, Mary Joe S.
Cabarce, Mark Jayson P.
Cinco, Junrey B.
Ponla, Jaypee A.
October 2018
TABLE OF CONTENTS
ABSTRACT
A newly diagnosed 1-year-old baby boy with Kawasaki disease (KD) came to the ER
accompanied by his parents. Chief complaints, which suit to qualifications of KD, include
intermittent fever unrelieved by analgesic, strawberry tongue, rashes on the palms of the
hands, soles of the feet and trunks. Human Immunoglobulin was then administered to prevent
cardiac complications and Paracetamol suspension for fever. Appropriate laboratories and
diagnostic work ups were done to understand and update patient’s status. By October 19,
echocardiographic result shows mild mitral regurgitation. Patient was discharged the next three
days and was given Aspirin as a home medication and have scheduled a follow up for
monitoring the condition. This case study aims to provide an in depth understanding of
Kawasaki disease in relation to patient’s condition and management.
INTRODUCTION
Kawasaki disease (mucocutaneous lymph node syndrome) is a form of vasculitis identified by an
acute febrile illness with multiple systems affected. The cause is unknown, but it is an
autoimmune disease. Factors such as infection, and genetic predisposition are believed to be a
risk factor to this disease. Kawasaki Disease affects mostly children between ages 3 months and
8 years; 80% are younger than age 5. It occurs more commonly in Japanese children or those of
Japanese descent and is a seasonal epidemic, usually in late winter and early spring. This
disease was first described in 1967 by Dr. Tomisaku Kawasaki in Japan. In Asia, Kawasaki disease
is felt throughout the world but the incidence in Asia specifically in Japan in the year 2000 is
reported as being 13 cases per 100,000 children under the age of 5 years which is the highest
concentrated number of cases in a single country worldwide.
The main system affected by the disease process is the cardiovascular system. Coronary artery
vasculitis, aneurysm development, thrombosis, and myocardial thrombosis progressing over
days to weeks can be observed in clients affected by this disease. Approximately 15% to 25% of
patients develop cardiac complications (coronary thrombosis or rupture, myocardial infarction,
heart failure, vasculitis of the aorta or peripheral arteries); but the good thing is mortality is
low.
The team is interested in studying the case due to its unknown etiology. The mystery of the
diagnosis of the disease through its signs and symptoms and lab results is a very exciting topic
to discuss. By presenting this case study, we would also like to use this chance to assist nurses
and nurse educators in promoting active learning about the disease process, its management,
and how to avoid its complication.
Source:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5412404/figure/ijms-18-00820-f001/
https://emedicine.medscape.com/article/965367-overview#a3
https://www.frontiersin.org/articles/10.3389/fped.2018.00198/full
https://europepmc.org/abstract/med/29461753
https://emedicine.medscape.com/article/965367-treatment
BIOGRAPHIC DATA
Mother 29 y o Father 34 y o
Uncle 1 Auntie 1
Uncle 2 Uncle 1
Uncle 3 Uncle 2
Uncle 4 Auntie 2
Auntie 1
Auntie 2
Uncle 5
PLAY (SOLITARY)
Patient is contented when playing on his own. Parents mentioned that their child is okay with
watching videos alone and most of the time baby spends his hour watching and listening
alphabetical song.
LIFESTYLE AND ACTIVITIES OF DAILY LIVING portrait next to physical assessment
NUTRITION Starts to eat solid food at 5 Patient does not like the food Has decreased appetite since
months and now can eat being served onset of fever
variety of foods
Is bottle fed (consumes
First introduced solid food is almost 4 bottles of a 250-
cerelac bottle of milk)
Prior to admission, patient
can consume 1/2 to 3/4 bowl
of prepared meal and since
onset of fever, fever has
lessen its intake
Is bottle fed and can
consume up to 70 to 150 ml
of milk and (3x/day) and
since day 1 of fever milk
intake decreased
Eats 3x a day
With vitamins taken daily
(tiki-tiki star)
No known allergies to food
and medications
No dental carries and teeth
are whitish in color
Doens’t toothbrush yet
Height is 81 cm
Weight is 9.8 kg
BMI is 14
ELIMINATION Patient has no problem in Daily output of urine ranges Patient has not change its usual
urinating and defecating from 650- 1000 cc number of diaper used thus
patient has normal bowel
Uses diaper always, even Defecates browny and mostly
elimination
when sleeping solid stool (uses 5-6x of
diaper/day)
Usually urinates 5-6x with
yellowish in color and no foul
odor
Usually defecates browny
solid stool with no difficulty
ACTIVITY Usually every morning after Has limited physical activity Patient activity and space is
waking up, patient walks with limited thus this degrades his
He spends most of his time in
his father as their exercise chance to perform active motion
doodling and watching videos
(30 mins/day)
specifically alphabetical
songs
SLEEP AND REST Patient usually sleeps from 8 Sleeps late most of the time Patients sleeping pattern is
to 10pm and wakes up at 8 to (9-12pm) due to noisy disrupted.
9 in the morning environment
Always takes an afternoon Wakes up usually 8-9 in the
nap morning
Still takes afternoon
naps/rest
ROLE RELATIONSHIP Patient is living in an As observed, his parents are Patient has good communication
extended family (parents in loving. They cuddle and they and relationship to his family
addition with his uncle, carry the child during the
auntie and grandmother) interview
Has older brother which is 4 His mother and father are
years old now present in the room, as
watchers
COPING/ STRESS TOLERANCE As reported by the mother, When stress or angry, he Patient can express his feelings
when the baby is somewhat cries appropriately. When he’s angry,
stress or combative, he cries he’s frowning and when he’s
most of the time and throws happy, he smiles
out things everywhere
VALUES/BELIEF PATTERN Patient is roman catholic Did not notice any rosaries or Patient has good morality
other religious activities
Mother mentioned that they
go to church occasionally but
they believe in God
And when they go out to
church they always carry
their sons with them
Follows catholic beliefs
PHYSICAL ASSESSMENT please portrait
Temperature 38.1°C
Heart rate 131 BPM
Respiratory rate 30 CPM
Blood pressure not taken
Oxygen saturation 96%
Pain score 0
Fall risk High
Height 81 cm
Weight 9.80 kg
BMI
Allergies no known allergies
Nutritional patterns decrease appetite since onset of fever
Elimination patterns essentially in normal range of output
Hygiene patterns has soiled nails
Rest/sleep patterns sleep 8-14 hours per day, always takes an afternoon nap
Polymorphous rash noted, most concentrated in palms of hands and soles of feet
Hot, flushed skin with temperature of 39°C
Red palpebral conjunctiva
Strawberry tongue
reflexes
head to toe
ANATOMY AND PHYSIOLOGY
IMMUNE SYSTEM FUNCTION
Immune system
Monocytes
Cell mediated Humoral
Macrophages
Neutrophils
Cell mediated Complement B lymphocyte
Phagocytosis
T lymphocyte Death of antigen Antibodies
Skin and mucous
membrane
T helper Chemical barrier
T suppresor Inflammatory response
T cytotoxic Interferon
Lymphokines
Viral, fungal,
protozoan, and some
bacterial protection
Graft rejection
Skin hypersensitivity
Immune surveillance
IgA IgD IgE IgG IgM
Humoral response
Humoral response is immediate. This type of response provides protection against acute,
rapidly developing bacterial and viral infections.
Cellular response
Cellular response is delayed. This is also called delayed hypersensitivity.
This type of response is active against slowly developing bacterial infections and is involved in
autoimmune responses, some allergic reactions, and rejection of foreign cells.
Immunity
Innate immunity is also called native or natural immunity. It is present at birth and includes
biochemical, physical, and mechanical barriers of defense, as well as the inflammatory
response.
Acquired immunity also known as adaptive immunity is received passively from the mother’s
antibodies, animal serum, or antibodies produced in response to a disease. Immunization
produces active acquired immunity.
Endothelial cells and function
The endothelial cells form a one-cell thick walled layer called endothelium that lines all of our
blood vessels such as arteries, arterioles, venules, veins and capillaries. Smooth muscle cells
layer beneath the endothelial cells. The exception to this is the capillaries where endothelium
makes up the entire blood vessel wall.
Barrier Function.The endothelium acts as a barrier between the blood and the rest of the body
tissue while being selectively permeable for certain chemicals and white blood cells to move
across from blood to tissue or for waste and carbon-dioxide to move from tissue to blood. This
property of endothelial cells is especially investigated in the blood-brain-barrier system. In
certain neuro-degenerative diseases, it is difficult to develop drugs that can cross the
endothelial barrier efficiently. Research is focused on better mimicking and understanding the
functions of blood brain barrier systems to increase the efficacy of drug development.
Regulating blood flow. Endothelial cells generate an anti-thrombotic surface that facilitates
transit of plasma and cellular constituents throughout the vasculature. The endothelium is also
responsible for maintaining homeostasis and formation of new blood vessels (process referred
to as angiogenesis). Angiogenesis has key applications in cancer research. Tumor growth is
supported by formation of new blood vessels that provide nutrients for these cells to expand.
Current research and drug discovery areas are focused on understanding how inhibiting
angiogenesis can have implications on tumor expansion.
Endothelial cells consist of "cobblestone" morphology, stain positive for Factors VIII (an
essential blood-clotting protein synthesized by endothelial cells) and take up acetylated low-
density lipoprotein (Lonza Group Ltd , 2018)
Inflammatory response. Endothelial cells are also active participants in and regulators of the
inflammatory processes.
PATHOPHYSIOLOGY
Strawberry Tongue
Mouth Sores
Treatment:
IVIG
-minimal rashes
-Lymph nodes normal in size
- Sclera white in color and the palpebral conjunctiva appears pink
- Patient is afebrile (36. 5 degree Celsius)
Complication:
Mild Mitral Valve Regurgitation
Legends:
Urinalysis Report
Date & time: 10/17/2018; 5:16 pm
Physical Result Normal Values Significance
characteristics 10/17/2018; 5:16
pm
Color Yellow Urine naturally has some
yellow pigments called
urobilin or urochrome. The
darker urine is the more
concentrated, it tends to be
due to dehydration.
Transparency Clear If urine is clear probably it is
caused by drinking too much
water which can throw off
electrloyte balance in
potentially harmful ways.
ph 7 4.6-8.0 Within normal range
Specific gravity 1.01 1.003-1.035
Within normal range
Chemical Characteristics
Protein Negative Negative Within normal range
Glucose Negative Negative Within normal range
Microscopic Findings
Red blood cells 8 0-11 Within normal range.
White blood cells 8 0-11 Within normal range.
Bacteria 5 0-111 Within normal range.
Echocardiographic Report
Summary of Interpretation
Result:
• Situs solitus
• Levocardia
• Intact/interatrial and ventricular septum
• Atrioventricular and ventriculoarterial concordance
• Normal chamber sizes
• Mitral regurgitation, mild
• Good left ventricular systolic function
• Normal size coronary arteries
• LCA
Proximal 0.23cm ( Z-score +1 SD)
distal 0.22CM
• RCA
proximal 0.21
distal 0.19
• No pericardial effusion
IMPRESSION:
Collaborative:
- monitor periodic - assist them with
CBC lab reports correcting/
relative to general minimizing
well-being and status conditional and
of specific problems optimal healing
1. Actual NCP
Dependent:
- keeps the lips
- apply soothing lubricated to avoid
ointments to the lips, sore
- 2 OTHERS as prescribed
ADD
DISCHARGE PLANNING
ENVIRONMENT
Advised significant others to keep surroundings clean and stress free as possible
Encouraged parents to maintain safety for baby- any object that fits in a tissue tube is
considered choking hazard
TREATMENT
Advised parents to have their child a regular check up with their pediatrician
Reminded the parents to religiously follow the discharged medicines as ordered
HEALTH TEACHINGS
Instructed the parents to take the 1 tab Aspilet every after breakfast, lunch, supper and at
bedtime
While taking the 1/2 tab of Aspilet after lunch only
Educated about bleeding precautions like the use of knee pads and soft bristle toothbrush
Encouraged the parents to regularly monitor the child’s condition and to report unusual
signs
Instructed the parents to take the medications with meals
Discussed with the parents the adverse effects of the medication to be taken such as easy
bruising or bleeding, difficulty of hearing, and signs of kidney problems like change in
the amount of urine
DIET
No restrictions and encouraged to eat variety of foods daily
Advised to limit fat intake
Educated about green leafy vegetables which could potentiate bleeding
Fluid intake