Signs and Symptoms

KD progresses through three stages: acute, subacute, and convalescent. The acute stage presents with a prolonged high fever that is unresponsive to antimicrobials or acetaminophen or ibuprofen. Additional classic symptoms are conjunctival redness without drainage, strawberry tongue with oral and pharyngeal redness, red swollen hands and feet, rash on the trunk, enlarged cervical lymph nodes, and extreme irritability. The subacute stage begins after 1 to 2 weeks when the fever and acute signs resolve. Irritability, conjunctival redness, and anorexia continue with the appearance of desquamation of hands and feet, arthritis, thrombocytosis, and coronary aneurysms (Figure 19-1). This stage can last up to 4 weeks. The last stage of convalescence begins when all signs have disappeared and ends when erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) have returned to a normal value. This stage may last from 6 to 8 weeks.

There is no single diagnostic test for KD. Diagnosis is made based on the clinical signs and laboratory tests (ESR, CRP, WBC, RBC, and platelet counts). A two-dimensional echocardiogram is done for cardiac evaluation.

Treatment and Nursing Care

Treatment involves reducing inflammation with intravenous immunoglobulin (IVIG) and high-dose aspirin. It has been shown that IVIG and aspirin given within the first 10 days of onset has reduced the incidence of coronary disease (AAP, 2009). The aspirin dose is reduced after fever has been controlled for 48 hours, which usually occurs at about 14 days. Aspirin administration will continue for 6 to 8 weeks and is discontinued if there are no coronary abnormalities. Most children recover without long-term complications. Low-dose aspirin is continued indefinitely for children with coronary abnormalities, and they are followed for several months or years depending on severity.

Nursing care for the acute stage focuses on relief of symptoms. Irritation of the skin may be helped with loose-fitting clothes and cool cloths. Mouth care is important. Children may not want to eat but should be encouraged to take cool liquids and soft foods. Intake and output is monitored closely. Aspirin should be in liquid form. IVIG is administered per hospital protocol.

The most challenging nursing issue is the extreme irritability. Providing a quiet environment may be beneficial. Parents will need a lot of emotional support as they try to find ways to comfort their child. Parents need to understand that irritability is a classic symptom for KD and they should not feel embarrassed or guilty with their child’s behavior. Discharge planning should include instructing parents that they will have to administer aspirin at home for a length of time. Parents should be instructed to watch for side effects. While on antiplatelet therapy, contact activities should be avoided to prevent potential bleeding. Fevers should be reported to the physician.

Signs and Symptoms

This disorder presents with flulike symptoms of fever, malaise, fatigue, and sore throat. Mucosal lesions erupt in the eyes, mouth, and entire gastrointestinal tract (Figure 19-2). Pain can be severe. Lesions may appear in crops and may take weeks to heal. There is no definitive test for diagnosis. Laboratory testing may be done to assist with diagnosis.

Treatment and Nursing Care

Treatment is supportive. An ophthalmologist will monitor for any corneal scarring. Oral lesions benefit from mouthwashes and glycerin swabs. Topical anesthetics such as viscous lidocaine can provide pain relief. Lesions can be washed with saline or Burow’s solution. Hydrogel dressings can also be soothing. If the child is not able to ingest oral intake, IV fluids may be necessary. Nutritional support may require soft foods and liquids, and severe oral lesions may require parenteral feedings. Skin should be kept clean and dry and inspected for any secondary infections. Specialty mattresses may be necessary to help with skin integrity. Corticosteroids may be used to help with inflammation. Antimicrobials are not necessary unless there is a documented infection. The disease is self-limiting and will gradually disappear without scarring. Parents should be aware that their child is at risk for recurrence, and the medical record should reflect that the child is allergic to the specific medication.

Signs and Symptoms

The most common types of JIA are listed in Table 19-1. Symptoms vary from one child to the next, and each type has a distinct method of onset: systemic (acute febrile), oligoarticular (involving five joints or fewer), and polyarticular (involving more than five joints). The course is chronic, with remissions and exacerbations. Some children who present with oligoarticular progress to polyarticular. Children rarely have permanent joint deformity, although many have some functional limitations. In systemic JIA, joint symptoms may be absent at onset but do develop in most cases.

Affected joints are swollen, warm, and stiff (Figure 19-3). Joint stiffness occurs mainly in the morning or after a period of inactivity (the “gel” phenomenon). Joint effusion and thickening synovial membrane eventually erode cartilage and can cause joint destruction.

Children with oligoarticular disease are at risk for iridocyclitis, an inflammation of the iris and ciliary body of the eye. Symptoms include redness, pain, photophobia, decreased visual acuity, and nonreactive pupils. This condition occurs most frequently in young girls. Its course is unpredictable. All children with oligoarticular arthritis need slit-lamp eye examinations several times a year for at least the first 5 years after the diagnosis of JIA. Distortion of the pupil and cataracts may occur. The long-term visual prognosis is uncertain.

Bone mass increases most during adolescence, and the process is related to weight, amount of exercise, and diet. Because children with JIA are less mobile than other children their age, they are likely to experience anorexia and reduced nutritional intake. Medications they are taking for their disease makes them more susceptible to osteopenia (low bone mass). If adequate bone mass is not attained during the teen years, osteoporosis in adulthood is more likely. The skeletal bone mass should be monitored closely.

There are no specific tests for JIA. The diagnosis is determined from clinical manifestations, radiographs, laboratory test results (CBC, ESR, rheumatoid factor [RF] assay, antinuclear antibody [ANA] assay), and the exclusion of other disorders. Aspirated joint fluid is yellow to green and cloudy and has a low viscosity. The goals of therapy are to reduce pain and swelling, to promote mobility, to preserve joint function, to educate the child and family, and to help the child and family adjust to living with a chronic disease.

Treatment and Nursing Care

Treatment is supportive. Drug therapy and exercise are the mainstays of therapy. First-line medications used to treat JIA are the NSAIDs, which include ibuprofen (Advil, Motrin), naproxen (Naprosyn), and tolmetin. Ibuprofen now comes in liquid form, making it easier to give to small children. Aspirin is given less frequently than previously because of its association with Reye’s syndrome. These agents do not change the course of the disease but reduce pain and stiffness. Along with the NSAIDs, intraarticular long-acting corticosteroid injections may be administered to preserve joint function.

If initial treatment with NSAIDs fails after adequate trial (at least 2 to 3 months of each medication chosen), other approaches are used. Systemic corticosteroids are usually avoided unless extreme disease presents. Disease-modifying antirheumatic drugs (DMARDs) have demonstrated effectiveness; these include hydroxychloroquin (Plaquenil) and sulfasalazine (Azulfidine). Biologics (anti-TNF agents) can be effective and include etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira) (Abramson, 2008).

Regular monitoring of all medications is imperative. NSAIDs are given with meals to avoid gastric irritation. Parents should be informed of the side effects, which include tinnitus, lethargy, hyperventilation, dizziness, headaches, nausea, and vomiting.

The nurse functions as a member of a team that includes the pediatrician, rheumatologist, social worker, physical therapist, occupational therapist, psychologist, ophthalmologist, and school and community nurses. The child may be hospitalized during an acute episode or for an unrelated illness. Treatment consists of medications, warm tub baths, joint exercises, and rest. Physical and occupational therapy are included in the treatment. Their purpose is to maintain function and reduce pain. The physical therapist oversees the type and amount of exercise performed. Daily range-of-motion exercises and play activities that incorporate specific routines help preserve function, maintain muscle strength, and prevent deformities. Morning tub baths and the application of moist hot packs help lessen stiffness. Resting splints may be ordered to prevent flexion contractures and preserve functional alignment. Proper body alignment with a regular change to the prone position (unless contraindicated) facilitates comfort. Either no pillow or a small flat pillow is advocated. Measures to alleviate boredom should be undertaken.

Signs and Symptoms

Symptoms vary from mild to moderately severe and may last for several weeks. They include low-grade fever, sore throat, headache, fatigue, skin rash, and general malaise. The lymph glands enlarge. Splenomegaly develops in approximately half the children. Liver involvement with mild jaundice occurs in a small number of persons and requires bed rest until liver function returns to normal.

The diagnosis is confirmed with the examination of peripheral blood. Lymphocytosis and the presence of atypical lymphocytes are seen. A rising titer of antibody to EBV is also indicative; the MonoSpot test is rapid, can detect the infection earlier than the heterophile antibody test, and is now widely used. Complications, although uncommon, include rupture of the spleen, secondary pneumonia, neurologic manifestations, and heart involvement.

Treatment and Nursing Care

Treatment is supportive because the disease is self-limiting. Acetaminophen, aspirin, or an NSAID such as ibuprofen is given as needed. An antipyretic is given to reduce fever and discomfort. An initial period of rest or restricted activities is usually needed, and returning to usual activities is based on the child’s energy level. Gargling with warm saline solution and sucking on throat lozenges can be helpful for pharyngitis. Adequate fluid intake is necessary, in particular, bland, cool liquids that are not irritating to the throat. Smoking should be discouraged. There is no special diet. Isolation is not necessary. The child is alerted to signs of secondary infection. Activities are increased as the fever and fatigue diminish. The child with an enlarged spleen is cautioned to avoid heavy lifting, trauma to the abdomen, and vigorous athletics until the splenomegaly subsides. For the athlete with an enlarged spleen, contact or collision activities should be restricted for at least 3 to 4 weeks. Severe abdominal pain is unusual, except in the presence of splenic rupture, which requires immediate attention.

The teenager with mononucleosis may be discouraged and depressed. The teenager worries about job, schoolwork, and the ability to continue extracurricular activities of importance. Open communication with school officials and classmates helps alleviate some of the anxieties. The prognosis in mononucleosis is good. It is no longer considered a prolonged, debilitating disease. Many cases go unrecognized.