6 Kawasaki Disease Nursing Care Plans

Kawasaki Disease (mucocutaneous lymph node syndrome) is an acute systemic vasculitis of unknown origin that occurs usually in children less than 5 years of age. The disease is self-limiting, however, about 20% of those untreated will likely develop a cardiac complication such as coronary arteritis and aneurysm formation.

The disease is divided into 3 phases: the acute phase is described by progressive small blood vessels inflammation (vasculitis) accompanied by high fever, inflammation of the pharynx, dry, reddened eyes, swollen hands and feet, rash, and cervical lymphadenopathy. In the subacute phase, the manifestations disappear, but there is inflammation of larger vessels and the child is at highest risk of developing coronary aneurysms. In the convalescent phase (6-8 weeks after onset), signs and symptoms slowly go away, but laboratory values are not completely normal.

There are no specific tests to confirm Kawasaki disease, but normally the diagnosis is established on the basis of the child exhibiting at least 5 of 6 criterion manifestations. Treatment started within 10 days of symptoms often prevents the development of complications.

Nursing Care Plans

Nursing goals for a child with Kawasaki disease may include increased understanding of the parents and child about the disease condition, medical treatment and planned follow-up care, relief of pain, improved physical mobility, adequate coping, and absence of complications.

Here are six (6) nursing care plans (NCP) for Kawasaki Disease:

1. Hyperthermia

Hyperthermia: Body temperature elevated above normal range.

May be related to

- Inflammatory disease process.

Possibly evidenced by

- Fever as high as 104°F that lasts for more than 5 days
- Hot, flushed skin
- Chills or shivering
- Loss of appetite

Desired Outcomes

- Child will maintain a normal temperature.

Nursing Interventions	Rationale
Monitor temperature every 4 hours; every 2 hours if elevated.	Kawasaki disease initially begins with a high fever (102° to 104°F) for 5 or more days in duration.
Provide sponge baths for temperature over 101°F.	Tepid sponge bath promotes heat loss through conduction and evaporation.
Provide adequate rest periods.	Bed rest decreases metabolic demands and oxygen consumption.
Use a cooling blanket for higher temperatures that do not respond to antipyretics.	Extra wrapping of extremities prevents shivering; shivering promotes further heat.
Encourage adequate fluid intake as indicated.	If the child is dehydrated or diaphoretic, fluid loss contributes to fever.
Administer medication as indicated.
- Aspirin	It is an anti-inflammatory drug that is given to reduce inflammation.
- IV immunoglobulin	It is given in single dose to treat and reduce inflammation and thereby lessen the duration of fever.

2. Acute Pain

Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6 months.

May be related to

- Inflammatory process (dry mucous membranes, conjunctivitis, pharyngitis, fever, joint pain, swollen hands and feet).

Possibly evidenced by

- Crying
- Extreme irritability
- Refusal to play
- Cries when being touched or moved
- Increased rating on pain scale

Desired Outcomes

- Child will experience less pain.

Nursing Interventions	Rationale
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.	Provides information upon which valid pain assessments and treatment effectiveness can be based.
Maintain the child’s room distraction-free and keep it dim.	Darkness reduces eye discomfort caused by conjunctivitis.
Explain to parents reason for child’s discomfort/irritability.	Promotes understanding and cooperation.
Explain to parents that irritability may persist for up to 2 months; that peeling skin on hands and feet is normal and not painful.	Promotes understanding and allows parents to anticipate needs.
Explain to parents that joint pain may continue for several weeks; Teach parents on passive ROM exercises in a warm bath.	Prolonged joint pain is not uncommon; ROM with heat helps increase flexibility.
Apply cool cloths to the skin, lotion, and soft, loose clothing on the child.	Alleviate skin itching, therefore, promotes comfort.
Handle child gently and avoid unnecessary movements.	Movement causes discomfort.
Apply lubricating lip ointments and glycerin swabs to the oral mucosa; offer cool liquids and soft foods.	Moistens dry oral mucosa to lessen discomfort and promote oral intake.
Administer IV immunoglobulin and high dose ASA therapy as indicated.	Decreases inflammatory process and helps decrease fever.

3. Impaired Skin Integrity

Impaired Skin Integrity: Altered epidermis and/or dermis [The integumentary system is the largest multifunctional organ of the body.] May be related to

- Altered circulation
- Peripheral erythema
- Edema formation

Possibly evidenced by

- Erythematous generalized rash
- Edema of hands and feet
- Dry, cracked lips with fissures

Desired Outcomes

- Child will manifest healing of peripheral erythema.

Nursing Interventions	Rationale
Assess skin for texture, turgor, color, moisture, and integrity.	Classical skin features of Kawasaki disease involves erythema, swelling, and desquamation affecting the skin of the extremities and a polymorphous rash.
Dress the child in a light clothing.	Heavy clothing may constrict and irritate the rashes.
Discourage the use of soaps.	The use of soaps makes the skin dry and predispose to skin breakdown.
Remove wet and wrinkled bed linens.	Moisture promotes skin breakdown.
Apply cool, moist compress to the itching skin areas.	Provide comfort and reduces itchiness.
Encourage adequate fluid intake.	Extra fluid intake helps maintain hydration and decrease mouth tenderness.
Encourage intake of protein-rich foods such as eggs, beans, chicken.	Protein is essential for the formation, repair, and maintenance of the skin

4. Impaired Physical Mobility

Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities. May be related to

- Joint pain

Possibly evidenced by

- Difficulty in walking
- Limited ROM

Desired Outcomes

- Child will perform activity independently or within the limit of disease.

Nursing Interventions	Rationale
Assess the child’s energy level and ability to perform ADL.	Restricted movement brought about by the joint pain affects the ability to perform ADLs effectively.
Provide joint support using pillows.	Pillows can be used to stabilize a joint and to minimize the risk of pressure ulcers.
Provide client with sufficient time to accomplish mobility-related activities and encourage to rest in between.	Maximize the child’s commitment and participation in the activity; Promotes conservation of energy and decrease fatigue.
Assist with passive ROM exercises as tolerated.	Maintains and improves joint function, muscle strength, and overall stamina.
Provide instruction in the use of appropriate assistive devices as indicated.	Use of adjunct devices assist the client during ambulation and enhances safety while walking.
Encourage intake of foods such as salmon, tuna, whole grains, carrots.	These food items help strengthen mobility and maximize energy production.

5. Impaired Oral Mucous Membrane

Impaired Oral Mucous Membrane: Disruption of the lips and/or soft tissue of the oral cavity.

May be related to

- Inflamed oral mucosa
- Dehydration

Possibly evidenced by

- Dry mouth
- Red strawberry tongue
- Inflamed tongue

Desired Outcomes

- Child’s oral mucosa will be free from dryness and irritation.

Nursing Interventions	Rationale
Assess for changes in the lips and oral cavity.	Typical changes of the mucous membrane include redness of the mouth, strawberry tongue, and red, dry fissured lips.
Provide soft, nonirritating foods such as gelatin.	Soft food requires less chewing and provides less irritation to the oral mucosa.
Provide cool liquids such as ice chips.	Maintains hydration and decreases mouth tenderness.
Apply soothing ointments to the lips.	Keep the lips lubricated to avoid soreness.
Instruct the use a soft-bristle brush or a padded tongue blade during mouth care.	Soft-bristle brush limits mucosal irritation.
Provide regular oral care with alcohol-free mouthwash.	Limits the bacterial accumulation that can cause infection.

6. Anxiety

Anxiety: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response.

May be related to

- Acute, serious illness of unknown origin with possible cardiac sequelae.

Possibly evidenced by

- Verbalization of anxiety, use quotes.

Desired Outcomes

- Client will experience decreased anxiety.

Nursing Interventions	Rationale
Assess anxiety level of parents by asking them to rate their anxiety on a scale from 1 to 5 with 1 being no interventions.	Assessment provides baseline information for the design of anxiety.
Educate the parents about information on the disease condition, signs and symptoms, diagnostics, and management.	Promotes understanding; Explaining the unknown cause of the disease helps alleviate any guilt feelings of the parents regarding the acquisition of the disease.
Inform the parents of gentle handling of the child as needed.	Provides information parents need to give comfort and avoid unnecessary touching to their child.
Encourage parents to express their feelings freely. Reassure parents that some anxiety is appropriate when their child is ill.	Encouragement and reassurance help the parents to identify and regain control of their emotions.
Explain to parents that the child may experience recurrent fever at home and teach them how to take the child’s temperature and when to notify physician (temp. greater than 38.4° C/101° F).	Ensure the child will obtain efficient care at home. Empowers the parent and reduces anxiety associated with uncertainty.
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.	Provides support and relief to parents in times of a stressful event.
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).	Gamma globulin is a blood product and requires the same close observation for safe administration to prevent a reaction; this reassures parents that their child is receiving appropriate care.
Demonstrate ASA administration to parents and instruct them to report any signs of toxicity (tinnitus, headache, dizziness, confusion). Explain that ASA may cause easy bruising and that the ASA should be discontinued and the physician notified if child exposed to chickenpox or influenza (risk of Reye’s syndrome).	Helps ensure safe, proper administration of ASA at home. Empowers parents.
Assist parents to make any referral and follow-up appointments for child.

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