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 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 occurs more commonly in Japanese children or those of Japanese decent. It has seasonal epidemics, usually in late winter and early spring. It was first described in 1967 by Dr. Tomisaku Kawasaki in Japan.

Although Kawasaki disease is a multisystem disease, the cardiovascular system appears to be the primary site with coronary artery vasculitis, aneurysm development, thrombosis, and myocardial thrombosis progressing over days to weeks. Approximately 15% to 25% of patients develop cardiac complications (coronary thrombosis or rupture, myocardial infarction, heart failure, vasculitis of the aorta or peripheral arteries); however mortality is low.

Incidence and Risk Factors:

By far, the highest incidence of Kawasaki disease occurs in Japan (175 per 100,000), though its incidence in the United States is increasing. Kawasaki disease is predominantly a disease of young children, with 80% of patients younger than 5 years of age.

The disease affects boys more than girls. Approximately 2000-4000 cases are identified in the United States each year.

Causes:

The causative agent of Kawasaki disease is still unknown, but current theories center primarily on 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. Per a Children’s Hospital Boston / Harvard Medical school information page on the disease, “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.”

An association has been identified with an SNP in the ITPKC gene, which codes an enzyme that negatively regulates T-cell activation. An additional factor that suggests genetic susceptibility is the fact that regardless of where they are living, Japanese children are more likely than other children to contract the disease. The HLA-B51 serotype has been found to be associated with endemic instances of the disease.

Signs and symptoms:

Stage I – Acute Febrile Phase (First 10 days)

• The child appears severely ill and irritable.
• Major diagnostic criteria established by the Centers for Disease Control and Prevention (CDC) are as follows:

a. High, spiking fever for 5 days or more.

b. Bilateral conjunctival injection.

c. Oropharyngeal erythema, “Strawberry “ tongue, or red dry lips.

d. Erythema and edema of hands and feet, periungal desquamation.

e. Erythematous generalized rash.

f. Cervical lymphadenopathy greather than 0.6 inch (1.5cm)

• Pericarditis, myocarditis, cardiomegaly, heart failure, and pleural effusion.
• Other associated findings include meningitis, arthritis, sterile pyuria, vomiting, and diarrhea.

Stage II – Subacute Phase (Days 11 to 25)

• Acute symptoms of stage I subside as temperature returns normal. The child remains irritable and anorectic.
• Dry, cracked lips with fissures.
• Desquamation of toes and fingers.
• Coronary thrombus, aneurysm, myocardial infarction, and heart failure.
• Thrombocytosis peaks at 2 weeks.

Stage III – Convalescent Phase (Until sedimentation rate and platelet count normalize)

• The child appears well.
• Transverse grooves of fingers and toenails (Beau’s lines).
• Coronary thrombosis, aneurysms may occur.

Diagnostic evaluation:

• The diagnostic of Kawasaki disease is based on clinical manifestations. The CDC requires that fever and four of the six other criteria listed above in stage I be demonstrated.
• Electrocardiogram, echocardiogram, cardiac catheterization, and angiocarddiography may be required to diagnose cardiac abnormalities.
• Although there are no specific laboratory tests, the following may help support diagnosis or rule out other disease.

1. CBC – leukocytosis during acute stage.

2. Erythrocytes and hemoglobin – slight decrease.

3. Platelet count – increased during second to fourth week of illness.

4. IgM, IgA, IgG, and IgF – transiently elevated.

5. Urine – protein and leukocytes present.

6. Acute phase reactants (ESR, C-reactive protein, alpha I antitrypsin) are elevated during the acute phase.

7. Myocardial enzyme levels (serum CK-MB) suggest MI if elevated.

8. Liver enzymes (AST, ALT) – moderately elevated.

9. Lipid profile – low high density lipoprotein and high triglyceride level.

Pharmacologic interventions:

• Immune globulin (gamma globulin) I.V. therapy – IVGG (2g/kg/day) is initiated during stage I in one 8 to 10 hour infusion to reduce the incidence of coronary artery abnormalities.
• Aspirin therapy
• Thrombolytic therapy may be required during stages I, II, or III.

Nursing Interventions:

Monitoring

1. Monitor pain level and child’s response to analgesics.
2. Institute continual cardiac monitoring and assessment for complications; report arrhythmias.
   • Take vital signs as directed by condition; report abnormalities.
   • Assess for signs of myocarditis (tachycardia, gallop rhythm, chest pain).
   • Monitor for heart failure (dyspnea, nasal flaring, grunting, retractions, cyanosis, orthopnea, crackles, moist respirations, distended jugular veins, edema).
3. Closely monitor intake and output, and administer oral and I.V fluids as ordered.
4. Monitor hydration staus by checking skin turgor, weight, urinary output, specific gravity, and presence of tears.
5. Observe mouth and skin frequently for signs of infection.

Supportive care

1. Allow the child periods of uninterrupted rest. Offer pain medication routinely rather than as needed during stage I. Avoid NSAIDS if the child is in aspirin therapy.
2. Perform comfort measures related to the eyes.
   • Conjunctivities can cause photosensitivity, so darken the room, offer sunglasses.
   • Apply cool compress.
   • Discourage rubbing the eyes.
   • Instill artificial tears to soothe conjunctiva.
3. Monitor temperature every 4 hours. Provide sponge bath if temperature above normal.
4. Perform passive range of motion exercises every 4 hours while the child is awake because movement may be restricted.
5. Provide quiet and peaceful environment with diversional activities.
6. Provide care measures for oral mucous membrane.
   • Offer cool liquids like ice chips and ice pops.
   • Use soft toothbrush only.
   • Apply petroleum jelly to dried, cracked lips.
7. Provide skin measures to improve skin integrity.
   • Avoid use of soap because it tends to dry skin and make it more likely to breakdown.
   • Elevate edematous extremities.
   • Use smooth sheets.
   • Apply emollients to skin as ordered.
   • Protect peeling of skin, observe for signs of infection.
8. Offer clear liquids every hour when the child is awake.
9. Encourage the child to eat meals and snack with adequate protein.
10. Infuse I.V fluids through a volume control device if dehydration is present, and check the site and amount hourly.
11. Explain all procedures to the child and family.
12. Encourage the parents and child to verbalize their concerns, fears, and questions.
13. Practice relaxation techniques with child, such as relaxation breathing, guided imagery, and distraction.
14. Prepare the child for cardiac surgery or thrombolytic therapy if complications develop.
15. Keep the family informed about progress and reinforce stages and prognosis.

Image by courtesy of:

http://www.chw.edu.au/

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I. Pre-entry Phase

A. Is the initial phase of the organizing process where the community/organizer looks for communities to serve/help.

B. It is considered the simplest phase in terms of actual outputs, activities and strategies and time spent for it.

Activities include:

1. Designing a plan for community development including all its activities and strategies for care development.

2. Designing criteria for the selection of site

3. Actually selecting the site for community care

II. Entry Phase

A. Sometimes called the social preparation phase as to the activities done here includes the sensitization of the people on the critical events in their life, innovating them to share their dreams and ideas on how to manage their concerns and eventually mobilizing them to take collective action on these.

B. This phase signals the actual entry of the community worker/organizer into the community. She must be guided by the following guidelines however.

1. Recognizes the role of local authorities by paying them visits to inform them of their presence and activities.

2. The appearance, speech, behavior and lifestyle should be in keeping with those of the community residents without disregard of their being role models.

3. Avoid raising the consciousness of the community residents; adopt a low-key profile.

III. Organization Building Phase

A. Entails the formation of more formal structures and the inclusion of more formal procedures of planning, implementation, and evaluating community-wide activities. It is at this phase where the organized leaders or groups are being given trainings (formal, informal, OJT) to develop their skills and in managing their own concerns/programs.

IV. Sustenance and Strengthening Phase

A. Occurs when the community organization has already been established and the community members are already actively participating in community-wide undertakings. At this point, the different communities setup in the organization building phase are already expected to be functioning by way of planning, implementing and evaluating their own programs with the overall guidance from the community-wide organization.

1. Strategies used may include:

a. Education and training

b. Networking and linkaging

c. Conduct of mobilization on health and development concerns

d. Implementing of livelihood projects

e.   Developing secondary leaders

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Definitions of COPAR:

· A social development approach that aims to transform the apathetic, individualistic and voiceless poor into dynamic, participatory and politically responsive community.

· A collective, participatory, transformative, liberative, sustained and systematic process of building people’s organizations by mobilizing and enhancing the capabilities and resources of the people for the resolution of their issues and concerns towards effecting change in their existing oppressive and exploitative conditions (1994 National Rural Conference)

· A process by which a community identifies its needs and objectives, develops confidence to take action in respect to them and in doing so, extends and develops cooperative and collaborative attitudes and practices in the community (Ross 1967)

· A continuous and sustained process of educating the people to understand and develop their critical awareness of their existing condition, working with the people collectively and efficiently on their immediate and long-term problems, and mobilizing the people to develop their capability and readiness to respond and take action on their immediate needs towards solving their long-term problems (CO: A manual of experience, PCPD)

Importance of COPAR:

1. COPAR is an important tool for community development and people empowerment as this helps the community workers to generate community participation in development activities.

2. COPAR prepares people/clients to eventually take over the management of a development programs in the future.

3. COPAR maximizes community participation and involvement; community resources are mobilized for community services.

Principles of COPAR:

1. People, especially the most oppressed, exploited and deprived sectors are open to change, have the capacity to change and are able to bring about change.

2. COPAR should be based on the interest of the poorest sectors of society

3. COPAR should lead to a self-reliant community and society.

COPAR Process:

· A progressive cycle of action-reflection action which begins with small, local and concrete issues identified by the people and the evaluation and the reflection of and on the action taken by them.

· Consciousness through experimental learning central to the COPAR process because it places emphasis on learning that emerges from concrete action and which enriches succeeding action.

· COPAR is participatory and mass-based because it is primarily directed towards and biased in favor of the poor, the powerless and oppressed.

· COPAR is group-centered and not leader-oriented. Leaders are identified, emerge and are tested through action rather than appointed or selected by some external force or entity.

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Primary Prevention

Providing specific protection against disease to prevent its occurrence is the most desirable form of prevention. Primary preventive efforts spare the client the cost, discomfort and the threat to the quality of life that illness poses or at least delay the onset of illness. Preventive measures consist of counseling, education and adoption of specific health practices or changes in lifestyle.

Examples:

a. Mandatory immunization of children belonging to the age range of 0 – 50 months old to control acute infection diseases.

b. Minimizing contamination of the work or general environment by asbestos dust, silicone dust, smoke, chemical pollutants and excessive noise.

Secondary Prevention

It consist of organized, direct screening efforts or education of the public to promote early case finding of an individual with disease so that prompt intervention can be instituted to halt pathologic processes and limit disability. Early diagnosis of a health problem can decrease the catastrophic effects that might otherwise result for the individual and the family from advanced illness and its many complications.

Examples:

a. Public education to promote breast self-examination, use of home kits for detection of occult blood in stool specimens and familiarity with the seven cancer danger signals.

b. Screening programs for hypertension, diabetes. Uterine cancer (pap smear), breast cancer (examination and mammography), glaucoma and sexually transmitted disease.

Tertiary Prevention

It begins early in the period of recovery from illness and consists of such activities as consistent and appropriate administration of medications to optimize therapeutic effects, moving and positioning to prevent complications of immobility and passive and active exercise to prevent disability. Continuing health supervision during rehabilitation to restore an individual to an optimal level of functioning. Minimizing residual disability and helping the client learn to live productively with limitations are the goals of tertiary prevention. (Pender, 1987)

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Definition:

Malaria is an acute and chronic parasitic disease transmitted by the bite of infected mosquitoes and it is confined mainly to tropical and subtropical areas.

This disease causes more disability and heavier economic burden than any parasitic disease.

Countries where malaria is endemic as of 2003 Malaria generally occurs in areas where environmental conditions allow parasite multiplication in the vector. Thus, malaria is usually restricted to tropical and subtropical areas (see map) and altitudes below 1,500 m. However, this distribution might be affected by climatic changes, especially global warming, and population movements. Both Plasmodium falciparum and P. malariae are encountered in all shaded areas of the map (with P. falciparum by far the most prevalent). Plasmodium vivax and P. ovale are traditionally thought to occupy complementary niches, with P. ovale predominating in Sub-Saharan Africa and P. vivax in the other areas; however these two species are not always distinguishable on the basis of morphologic characteristics alone; the use of molecular tools will help clarify their exact distribution.

Etiologic Agent:

Protozoa of genus plasmodia

1. The disease is caused by four species of protozoa:

a. Plasmodium falciparum (malignant tertian)

· This is considered as the most serious malarial infection because of the development of high parasitic densities in blood (RBC) with tendency to agglutinate and form into microemboli.

· This is most common in the Philippines.

b. Plasmodium vivax (Benign tertian)

· This is nonlife threatening except for the very young and the old.

· It is manifested by chills every 48 hours on the 3^rd day onward especially if untreated.

c. Plasmodium malariae (Quartan)

· It is less frequently seen.

· This specie is nonlife threatening.

· Fever and chills usually occur every 72 hours usually on the 4^th day after onset.

d. Plasmodium ovale is the rare type of protozoan species.

· This is rarely seen in the Philippines.

2. The primary vector of malaria is the female Anopheles mosquito which has the following characteristics:

a. It breeds in clear, flowing, and shaded streams usually in the mountains.

b. It is bigger in size than the ordinary mosquito.

c. It is brown in color.

d. It is a night-biting mosquito.

e. It usually does not bite a person in motion.

f. It assumes a 36º position when it alights on walls, trees, curtains, and the like.

Incubation period:

1. 12 days for P. Falciparum
2. 14 days for P. vivax and ovale
3. 30 days for P. malariae

Period of Communicability:

Untreated or insufficiently treated patient may be the source of mosquito infection for more than three years in P. malariae, one to two years in P. vivax, and not more than one year on P. falciparum.

Mode of Transmission:

1. The disease is transmitted mechanically through the bite of an infected female anopheles mosquito
2. It can be transmitted parenterally through blood transfusion.
3. On rare occasions, it is transmitted from shared contaminated needles.
4. However, transplacental transmission of congenital malaria is a rare case.

Clinical Manifestations:

1. Paroxysms with shaking chills
2. Rapidly rising fever with severe headache
3. Profuse sweating
4. Myalgia, with feeling of well-being in between
5. Splenomegally, hepatomegally
6. Orthostatic hypotension
7. Paroxysms may last for 12 hours, then, maybe repeated daily or after a day or two.
8. In children:
   1. Fever maybe continuous
   2. Convulsions and gastrointestinal symptoms are prominent
   3. Splenomegally
9. In cerebral malaria
   1. Changes in sensorium, severe headache, and vomiting
   2. Jacksonian or grand mal seizure may occur

Diagnostic Procedure:

1. Malarial smear – In this procedure, a film of blood is placed on a slide, stained, and examined microscopically.
2. Rapid diagnostic test (RDT) – This is a blood test for malaria that can be conducted outside the laboratory and in the field. It gives a result within 10 to 15 minutes. This is done to detect malarial parasite antigen in the blood.

Pathogenesis:

1. The parasite enters the mosquito’s stomach through the infected human blood obtained by biting or during blood meal.
2. The parasite undergoes sexual conjugation.
3. After 10 to 14 days, a number of young parasites are released which work their way into the salivary gland of the mosquito.
4. The organisms are carried in the saliva into the victim when the mosquito bites again.
5. The female alone plays the role of a vector and definitive host in conveying the disease from man to man (sexual propagation).
6. In humans, the organisms invade the RBC where they grow and undergo sexual schizogony.
7. Erythrocytic merozoites are produced leading to the rupture of RBC upon the release of the tiny organisms.
8. Young merozoites invade a new batch of RBC, to start another schizonic cycle.

Nursing Management:

1. The patient must be closely monitored.

a. Intake and output should be closely monitored to prevent pulmonary edema.

b. Daily monitoring of patient’s serum bilirubin, BUN creatinine, and parasitic count

2. If the patient exhibits respiratory and renal symptoms, determine the arterial blood gas and plasma electrolyte

3. During the febrile stage, tepid sponges, alcohol rubs, and ice cap on the head will help bring the temperature down.

4. Application of external heat and offering hot drinks during chilling stage is helpful.

5. Provide comfort and psychological support.

6. Encourage the patient to take plenty of fluids.

7. As the temperature falls and sweating begins, warm sponge bath maybe given.

8. The bed and clothing should be kept dry.

9. Watch for neurologic toxicity (from quinine infusion) like muscular twitching, delirium, confusion, convulsion, and coma.

10. Evaluate the degree of anemia.

11. Watch for any signs especially abnormal bleeding.

12. Consider severe malaria as medical emergency that requires close monitoring of vital signs.

Treatment and Medications:
Anti-Malarial Drugs

• Artemether-lumefantrine (Therapy only, commercial names Coartem and Riamet)
• Artesunate-amodiaquine (Therapy only)
• Artesunate-mefloquine (Therapy only)
• Artesunate-Sulfadoxine/pyrimethamine (Therapy only)
• Atovaquone-proguanil, trade name Malarone (Therapy and prophylaxis)
• Quinine (Therapy only)
• Chloroquine (Therapy and prophylaxis; usefulness now reduced due to resistance)
• Cotrifazid (Therapy and prophylaxis)
• Doxycycline (Therapy and prophylaxis)
• Mefloquine, trade name Lariam (Therapy and prophylaxis)
• Primaquine (Therapy in P. vivax and P. ovale only; not for prophylaxis)
• Proguanil (Prophylaxis only)
• Sulfadoxine-pyrimethamine (Therapy; prophylaxis for semi-immune pregnant women in endemic countries as “Intermittent Preventive Treatment” - IPT)
• Hydroxychloroquine, trade name Plaquenil (Therapy and prophylaxis)

Prevention and Control:

1. Malaria cases should be reported.
2. A thorough screening of all infected persons from mosquitoes is important.
3. Mosquito breeding places must be destroyed.
4. Homes should be sprayed with effective insecticides which have residual actions on the walls.
5. Mosquito nets should be used especially when in infected areas.
6. Insect repellents must be applied to the exposed portion of the body.
7. People living in malaria-infested areas should not donate blood for at least three years.
8. Blood donors should be properly screened.

Source:

Handbook of Common Communicable and Infectious Diseases 2006 Ed

http://en.wikipedia.org

http://www.doh.gov.ph

http://www.who.int

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According to the officials of Board of Nursing (BON), the upcoming November 28-29, 2008 Nursing Board Exam will be “leakage-free”, despite reports that text messages are being circulated that a review center in Baguio, Cebu and Surigao have some parts of the exam.

BON Chairperson, Carmencita Abaquin together with BON member Marco Sto.Tomas have assured the public the full credibility of the forthcoming examination. Security measures have been adopted to prevent another Nursing Board Exam Scandal.

Sto. Tomas said 500 questions per test have been encoded into the computer. These will enter certain parameters/framework per competency (for the 5 tests) and the computer will extract these questions based on the framework by which they have been entered.

“All these are done under quarantine meaning we have no communication outside,” Sto. Tomas said.

And then the questions will be extracted, printed, and sealed, he said.

Printing has been centralized unlike during the board exam controversy in 2006 when printing was done per region.

In transporting of questionnaires, there will be escorts from the Philippine National Police (PNP) and National Bureau of Investigation (NBI), Sto. Tomas said.

There are a total of 88,750 nursing graduates set to take the second licensure examination on November 29 and 30, with the figure considered to be the highest in PRC history.

November 2008 Nursing Board Exam Result will also be available here as soon as PRC released the list of successful examinees. To get your copy via email, just click here to enter your email address.

Reminders: Make sure to type in the correct email adress and please don’t forget to verify your account.

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Chronic Obstructive Pulmonary Disease (COPD) is a disease characterized by airflow limitation that is not fully reversible. Airflow limitation is usually progressive and associated with an inflammatory response in the lungs stimulated by irritants. COPD includes chronic bronchitis and pulmonary emphysema. Although sometimes included in COPD, asthma is a reversible disorder and is therefore considered elsewhere.

Chronic bronchitis is chronic inflammation of the lower airways characterized by excessive secretion of mucus, hypertrophy of mucous glands, and recurring infection, progressing to narrowing and obstruction of airflow. Emphysema is the enlargement of the air spaces distal to the terminal bronchioles, with breakdown of alveolar walls and loss of elastic recoil of the lungs. The two conditions may overlap, resulting in subsequent derangement of airways dynamics (e.g., obstruction to airflow). In pulmonary emphysema, lung function progressively deteriorates for many years before the illness becomes apparent.

The most common cause of COPD is cigarette smoking. Air pollution, occupational exposures, allergens, and infections may also act as irritants. Alpha1-antitrypsin deficient is an infrequent cause. Complications include respiratory failure, pneumonia or other overwhelming respiratory infection, right heart failure (cor pulmonale), arrhythmias, and depression.

Stage 1: Symptom Experience

The person is aware that something is wrong. A person usually recognizes a physical sensation or a limitation in functioning but does not suspect a specific diagnosis.

Stage 2: Assumption of the Sick People

If symptom persist and become severe, clients assume the sick role. At this point, the illness becomes a social phenomenon, and sick people seek confirmation from their families and social groups that they are indeed ill and that they be excused from normal duties and role expectations.

Stage 3: Medical Care Contact

If symptoms persist despite the home remedies, become severe or require emergency care, the person is motivated to seek professional health services. In this stage the client seeks expert acknowledgement of the illness as well as the treatment.

Stage 4: Dependent Client Role

The client depends on health care professionals for the relief of symptoms. The client accepts care, sympathy and protection from the demands and stresses of life. A client can adopt the dependent role in a health care institution, at home, or in a community setting. The client must also adjust to the disruption of a daily schedule.

Stage 5: Recovery and Rehabilitation

This stage can arrive suddenly, such as when the symptoms appeared. In the case of chronic illness, the final stage may involve in an adjustment to a prolong reduction in health and functioning.

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by: shelz, nursing crib moderator

Expended program for Immunization (EPI)

• Principles of EPI include:

1.      Epidemiological situation

2.      Mass approach

3.      Basic Health Service

• The 7 immunizable diseases are:

1.      Tuberculosis

2.      Diptheria

3.      Pertussis

4.      Measles

5.      Poliomyelitis

6.      Tetanus

7.      Hepatitis B

Administration of vaccines: