Peds Cardio Musculoskeletal
Terms
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- Congenital defects that can cause increased pulmonary blood flow?
- Patent ductus arteriosus and Atrial Septal defect
- Blood flows from right to left in the atria through the ______.
- Foramen ovale
- Parent teaching of a child with CHF
- Frequent changing of position to prevent skin breakdown, check apical pulse before administering digoxin, feeding in a more upright position.
- Post cardiac catheterization interventions
- Avoid flexion of the hip for first 6 hours, keep child quite and flat.
- Hypertension in children under 13 is most commonly due to organ abnormalities in the_______.
- Renal System
- Most likely cause of decreased urinary output?
- Decreased cardiac output
- Changes in feeding habits that may indicate deteriorating cardiac status;
- decreased intake, vomiting, sleeping through feedings, increased perspiration with feeding
- What are the signs and symptoms that CHF is worsening?
- Increased feeding difficulty, irritability, lethargy, breathing difficulty, and puffiness around the eyes or extremities.
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An increased pulse rate indicates_____________?
A decrease in pulse rate can indicate________? -
CHF
Digoxin toxicity - Congestive Heart Failure (CHF)
- a disorder of circulation in which CO is inadequate to support the body's circulatory and metabolic needs. May result from a congenital heart defect that cuases increased pulmonary blood flow or obstruction to the systemic blood outflow tract, from problems with heart contractility, or from pathologic conditions that require high cardiac output, such as severe anemia, acidosis, or respiratory distress. CHF also results from acquired heart disease such as cardiomyopathy or Kawasaki disease.
- Congenital Heart Disease
- Refers to a defect in the heart of great vessels, or persistence of a fetal structure after birth.
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Congenital Heart Disease
Categories and page #'s in book -
Increased pulmonary blood flow (p 1454)
Decreased pulmonary blood flow (p 1460)
Obstructed systemic blood flow (p 1496)
Mixed defects in which infant survival is dependent upon misxing of systemic and pulmonary blood (p1460) - What defects increase pulmonary blood flow?
- PDA(patent ductus ateriosus), ASD (atrial septal defect), VSD (ventricular septal defect)
- What defects decrease pulmonary blood flow?
- Pulmonic stenosis, tetralogy of Fallot, pulmonary atresia, tricuspid atresia, transposition of the great arteries
- What causes obstruction to systemic blood flow?
- Aortic stenosis, hypoplastic left heart syndrome, mitral stenosis, interrupted aortic arch
- What defects are mixed and postnatal survival is dependent upon mixing of systemic and pulmonary blood?
- Transposition of great arteries, total anomalous pulmonary venous connection
- Child presents with tachypnea, tachycardia, murmur, poor weight gain, diaphoresis, periorbital edema and frequent resp infections, what type of defects could this be
- Defects causing increased blood flow
- Child presents with cyanosis, hypercyanotic spells, poor weight gain, and polycythemia, what type of heart defects could be present?
- Defects causing decreased pulmonary blood flow
- Child is admitted in the ER with diminished pulses, poor color, delayed cap refill time, decreased urinary output, CHF with pulmonary edema, what type of defects could be ptesent?
- Defects causing obstruction to systemic blood flow
- What defects cause the following s/s: cyanosis, poor weight gain, pulmonary congestion, congestive heart failure may occur with increased shunting?
- Mixed defects
- What are some of the potential complications of a cardiac catherterization?
- Arrhythmia, bleeding, hematoma development, thrombus formation, and infection. No bleeding should occur at the catherterization site.
- Post cardiac cath- Nursing
- Apply direct pressure for 15 min
- What is PDA?
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Patent ductus ateriosus, is a persistent connection between the aorta and the pulmonary artery. It is 'persistent' in that a PDA is a normal connection in utero, or when the baby was still in the uterus. In utero, the baby depends on the PDA to get oxygen from the mother, since the lungs are not working (baby can't breathe in utero). When the baby is born, there are hormonal changes in the baby that normally close off the PDA, since the baby is now breathing, and no longer needs the PDA.
A PDA is when this ductus doesn't close as it normally should. Persistence of the PDA may cause an excessive amount of blood to go to the lungs. Depending on the size of the PDA and the condition on the lung, the baby may have no symptoms, or be in severe heart failure. Heart failure in a baby is most typically manifested by poor eating habits and poor weight gain. However, almost all PDA should be closed, even if they are very small, because there is a real risk of endocarditis, or a heart infection, over the course of a lifetime.
PDA's are now often closed in the cardiac catheterization laboratory, by the insertion of specially designed coils. These coils sit in the PDA, and expand to the point where they occlude all the blood flow. The traditional way of closing a ductus is through an operation and closure under direct vision, although this method is now typically reserved for premature neonates and if an interventional cardiac catheterization laboratory is not readily available. - What is ASD?
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is a persistent connection between the aorta and the pulmonary artery. It is 'persistent' in that a PDA is a normal connection in utero, or when the baby was still in the uterus. In utero, the baby depends on the PDA to get oxygen from the mother, since the lungs are not working (baby can't breathe in utero). When the baby is born, there are hormonal changes in the baby that normally close off the PDA, since the baby is now breathing, and no longer needs the PDA.
A PDA is when this ductus doesn't close as it normally should. Persistence of the PDA may cause an excessive amount of blood to go to the lungs. Depending on the size of the PDA and the condition on the lung, the baby may have no symptoms, or be in severe heart failure. Heart failure in a baby is most typically manifested by poor eating habits and poor weight gain. However, almost all PDA should be closed, even if they are very small, because there is a real risk of endocarditis, or a heart infection, over the course of a lifetime.
PDA's are now often closed in the cardiac catheterization laboratory, by the insertion of specially designed coils. These coils sit in the PDA, and expand to the point where they occlude all the blood flow. The traditional way of closing a ductus is through an operation and closure under direct vision, although this method is now typically reserved for premature neonates and if an interventional cardiac catheterization laboratory is not readily available. - What is VSD?
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A ventricular septal defect, or VSD, is the most common kind of congenital heart defect. This is what many people refer to as the 'hole-in-the-heart'. The septum is the wall that separates the right and left sides of the heart. A hole in the wall between the two lower chambers is called a ventricular septal defect, or VSD for short.
Normally, blood entering the right side of the heart stays on the right side (this is low oxygen blood), and blood on the left side of the heart stays on the left side (this is oxygen rich blood) which is then pumped to the rest of the body. When a defect or "hole" is present between the ventricles (or lower chambers), blood from the left side of the heart is forced through the defect to the right side every time the heart beats. It then goes back to the lungs even though it is already rich in oxygen. Because of this, blood that is not yet oxygen rich can’t get to the lungs.
The most common signs and symptoms are trouble eating and gaining weight, breathlessness and easy fatigability. A baby with a large VSD tires quickly after not eating very much, falls asleep, wakes us in a short while quite hungry, tries to eat again, tires easily, and the cycle is repeated.
Because the heart has to pump extra blood, it may enlarge. Also, because there’s more blood going to the lungs, high pressure may occur in the blood vessels there. This may cause permanent damage to the walls of the blood vessels over time.
Many, if not most, of all VSDs will close on their own. Those that close on their own are usually small and do so in the first year of life. Large VSDs, especially those that don't close in the first year of life, will usually need to be closed surgically. VSD closure is one of the most commonly performed congenital heart operations, and is a safe and effective operation. The child would be expected to have virtually normal growth, development, and life expectancy following repair. - What are the defects that cause decreased pulmonary blood flow or mixed effects?
- Tetralogy of Fallot, transposition of the great arteries,
- Describe the anatomy and physiology of the cardiovascular system, focusing on the flow of blood and the action of heart valves.
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1. Unoxygenated blood enters the right atrium from the superior and inferior vena cavae.
2. Blood flows through the tricuspid valve into the right ventricle.
3. The blood then moves through the pulmonary valve into the pulmonary artery to the lungs.
4. The blood receives oxygen in the lungs and then enters the left atrium.
5. The blood then travels through the mitral valve and enters the left ventricle.
6. Blood is pumped from the left ventricle through the aortic valve into the aorta and into the rest of the body. - Recognize the signs of congestive heart failure in an infant and child.
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1. Infant:
* Tires easily, especially during feedings.
* Weight loss or lack of weight gain.
* Diaphoresis.
* Irritability.
* Frequent infections.
* Tachycardia and tachypnea.
* Pallor or cyanosis.
* Nasal flaring.
* Grunting.
* Retractions.
2. Child:
* Exercise intolerance.
* Abdominal pain.
* Peripheral edema.
* Mottling or pallor.
* Periorbital or facial edema.
* Jugular vein distention.
* Hepatomegaly. - Nursing considerations for CHF
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1. Obtain a detailed history of onset of symptoms.
2. Assess vital signs.
3. Assess heart by observation, palpation, and auscultation.
4. Monitor intake and output.
5. Weigh child daily.
6. Turn child frequently and assess skin.
7. Organize nursing actions to provide rest periods.
8. Provide small, frequent feedings. - Pathophysiology of Defects with increased pulmonary circulation
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* A connection occurs between the right and left side of the heart, or between the great arteries, which allows blood to flow between the right and left sides of the heart.
* Blood is shunted to the right side of the heart, which increases blood flow to the lungs.
* This causes increased pulmonary resistance and pulmonary hypertension.
* Right ventricular hypertrophy develops. - Pathophysiology of Defects with decreased pulmonary circulation:
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* Structural defects decrease blood flow to the lungs, which decreases systemic oxygen content.
* If a septal opening is present, increased right-sided pressure causes right-to-left shunting.
* Decreased oxygen content causes the kidneys to produce a hormonal response, which increases the number of red blood cells leading to polycythemia, increasing the risk for thromboembolism.
* Abrupt decreases in pulmonary blood flow and systemic vascular resistance combined with activity may cause hypercyanotic episodes. - Pathophysiology of Defects with obstructed blood flow:
- Decreased cardiac output results from the increased pressure load on the ventricle caused by the obstructed blood flow.
- nursing care plan for the infant with a congenital heart defect cared for at home prior to corrective surgery.
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1. Instruct parents in the administration of necessary medications.
2. Instruct parents concerning the need for frequent small feedings.
3. Instruct parents concerning the signs and symptoms of congestive heart failure.
4. Instruct parents concerning the management of hypercyanotic episodes. - Nursing care after open heart surgery
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1. Frequent assessment of:
* Arterial and venous pressures.
* Vital signs.
* Oxygen saturation.
* Core body temperature.
* Level of consciousness.
2. Auscultate heart and lungs:
* Observe and monitor for arrhythmias.
3. Monitor cardiac output.
4. Monitor intake and output:
* Urine.
* Chest tube bleeding and draining.
5. Assess pain level and treat accordingly.
6. Observe for signs and symptoms of infection. - Describe pediatric variations in the musculoskeletal system.
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1. A fibrous membrane exists between the cranial bones to allow for skull growth.
2. Ends of the long bones remain cartilaginous.
3. Long bones are porous and less dense.
4. Bones can bend, buckle, or break due to a simple fall.
5. Muscles increase only in length and circumference. - Plan nursing care for children with structural deformities of the foot, hip, and spine.
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Foot:
1. Instruct parents in simple stretching exercises.
2. Provide cast care and instruct parents in cast care.
Hip:
1. Provide frequent assessment of the skin and neurovascular status of the affected leg or legs after surgery, or if placed in cast or harness.
2. Maintain traction, if ordered.
3. Increase fluids and fiber in the child’s diet.
4. Instruct parents in the use of the Pavlik harness and have them return demonstration of application.
Spine:
1. Support self-image if placed in brace.
2. Instruct in exercises to strengthen muscles of spine.
3. Monitor respiratory and circulatory status after fusion surgery.
4. Provide adequate pain medication and instruct in use of PCA.
5. Instruct family in use of brace postoperatively. - Describe the reasons why children are more vulnerable than adults to infectious and communicable diseases.
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1. Infants and children have immature immune systems.
2. Infants’ protection from maternal antibodies decrease with age.
3. Incomplete immunization status.
4. Lack of prior exposure to infectious agents.
5. Poor hygiene practices of infants and children. - Chickenpox (Varicella):
- Causes fluid-filled vesicles with elevated temperature and itching.
- a nursing care plan for a child with a common infectious disease.
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1. Isolate child from others as much as possible.
2. Treat high fever and other symptoms with non-aspirin antipyretic medications.
3. Cut fingernails short to discourage scratching.
4. Encourage use of tepid or colloidal baths to treat itching.
5. Medicate with antihistamines to assist with complaints of itching. - Erythema Infectiosum (Fifth disease):
- Begins with mild, flu-like illness and ends with a red rash on the cheeks.
- Emergency Management for Poisoning
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Stabilize the child. Assess ABCs (airway, breathing, and circulation).
Provide ventilatory and oxygen support.
2. Perform a rapid physical examination, start an IV infusion, draw blood
for toxicology screen, and apply a cardiac monitor.
3. Obtain a history of the ingestion, including substance ingested, where
child was found, by whom, position, when, how long unsupervised,
history of depression or suicide, allergies, and any other medical
problems.
4. Reverse or eliminate the toxic substance using the appropriate method:
a. Antidotes and agonists
Mucomyst (for acetaminophen poisoning)
Narcan (for opioid overdose)
Romaxicon (for benzodiazepine overdose)
b. Gastric lavage
➤ A gastric tube is inserted through the mouth.
➤ Normal saline solution is instilled and aspirated until the return
is clear. Considered a less effective method of removing
ingested substances from the stomach than vomiting. Reserved
for children with central nervous system depression, diminished
or absent gag reflex, or unwillingness to cooperate with other
measures.
➤ Contraindicated in children who have ingested alkaline
corrosive substances, as insertion of the tube may cause
esophageal perforation.
Used in children who have ingested acids to decrease continued
damage and potential perforation of stomach and intestines.
Activated charcoal
➤ Given to absorb and remove any remaining particles of toxic
substances.
➤ Usual dosage administration is 1 g/kg of body weight.
➤ A commercial preparation of activated charcoal is administered
orally or through a gastric tube.
➤ Available as a ready-to-drink solution in an opaque container.
➤ May be mixed with apple juice or soda if protocol allows to
encourage consumption.
➤ A covered cup and straw is used for oral ingestion to prevent
the child from seeing the black liquid and to minimize spillage.
➤ Activated charcoal is administered only after the child has
stopped vomiting, because aspiration of charcoal is damaging
to lung tissue.
➤ Should not be administered for ingestion of caustic substances
or hydrocarbons.
c. Cathartics
➤ Hasten excretion of a toxic substance and minimize absorption.
The most commonly used cathartic is magnesium sulfate.
Note: Syrup of ipecac The use of ipecac is no longer recommended because
it may not remove all poison and can be harmful in some situations.
Encourage parents to remove it from their homes.
5. Other measures will depend on the child’s condition, the nature of the
ingested substance, and the time since ingestion. May include diuresis,
fluid loading, cooling or warming measures, anticonvulsive measures,
antiarrhythmic therapy, hemodialysis, or exchange transfusions.
6. The child’s total condition is constantly evaluated to maintain airway,
breathing, and circulation. Therapeutic management is adjusted as
needed to treat evolving condition.
7. Consider the emotional status of the family. Provide information about
the child, involve the child in care when possible, and arrange for
support persons and services to be available to the child. - Influenza:
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* Very contagious.
* Sudden onset of respiratory symptoms. - Measles (Rubeola):
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* High fever, red rash.
* Recognized by presence of Koplik spots on buccal mucosa. - Assessing a child with a cardiac condition
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QUALITY OF RESPIRATIONS
➤ Inspect the rate, depth, and respiratory effort.
➤ Is a cough present?
➤ Identify the signs of increased respiratory effort: tachypnea (abnormally
rapid rate of respirations), dyspnea, retractions, nasal flaring, expiratory
grunting.
➤ Auscultate breath sounds: Note if adventitious sounds are present
(wheezes, crackles).
QUALITY OF PULSE
➤ Assess the rate, rhythm, and quality.
➤ Compare pulse sites (apical to brachial or radial) for strength and rate.
➤ Compare strength of pulse between upper and lower extremities
(brachial to femoral). A weaker femoral pulse is associated with
coarctation of aorta.
EVALUATE THE BLOOD PRESSURE
➤ Compare the blood pressure to expected value for age, sex, and
height. (See Table 8–00∞.)
➤ Compare blood pressure values between upper and lower extremities.
A lower systolic blood pressure in the legs in comparison to the arms is
associated with coarctation of aorta.
COLOR
➤ Observe overall color: Note pallor, dusky color, or cyanosis.
➤ Compare peripheral and central color: assess capillary refill and nailbed
color and inspect mucous membranes. Central cyanosis in mucous
membranes is seen in cyanotic heart conditions.
➤ Note whether crying improves or worsens color. In cyanotic conditions
crying worsens the cyanosis.
ASSESS THE HEART
➤ Inspect the anterior chest. Bulging on the left side or heaving (lifting of
the chest wall during contraction) may indicate an enlarged heart.
➤ Palpate the chest wall over the heart for any pulsations, heaves, or
vibrations. A thrill is caused by turbulent blood flow from a defective heart
valve and a heart murmur.
➤ Locate the point of maximum intensity using topographical landmarks.
➤ Auscultate the heart for the heart sounds and their quality (loud versus
weak, distinct versus muffled). Muffled or indistinct sounds are associated
with congestive heart failure or a heart defect.
➤ Determine if any extra heart sounds are present (a third or fourth heart
sound, murmurs). See Table 8–00∞for information on grading the
loudness of murmurs. Extra heart sounds and murmurs are associated
with various cardiac conditions.
➤ Describe murmurs present by intensity, location, radiation, timing,
and quality.
➤ Auscultate the heart with the child in sitting and reclining positions to
detect differences in heart sounds.
SIGNS OF FLUID STATUS
➤ Observe for signs of periorbital, facial, or peripheral edema.
➤ Observe for abdominal distention.
➤ Palpate the liver to detect hepatomegaly.
➤ Observe for signs of dehydration with acute illnesses. Dehydration is
especially dangerous in children with polycythemia.
ACTIVITY AND BEHAVIOR
➤ Determine if exercise intolerance is present or if the child tires with
feeding.
➤ Identify changes in activity level. Reduction in usual activity level may
indicate increased hypoxia.
➤ Watch for abrupt behavior changes. Restlessness, irritability, and lowered
level of consciousness may indicate increasing hypoxia.
GENERAL
➤ Assess pattern of growth.
➤ Note presence of diaphoresis and when it occurs. - A yound child with a defect that reduces pulmonary blood may __blank__?
- Squat
- Tetralogy of Fallot
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Tetralogy of Fallot, or TOF, is one of the most common forms of complex congenital heart defects that causes cyanosis, or a blue baby. Tetralogy of Fallot is comprised of four separate components. The first one is a ventricular septal defect (VSD). The second one is pulmonary stenosis (PS). The third component is right ventricular hypertrophy, which is an increase in the size of the right ventricle. The final component is an overriding aorta (Ao), which means that the aorta lies directly over the ventricular septal defect.
The ventricular septal defect is usually large and blood flows from the right ventricle through this VSD into the left ventricle. This occurs because of the resistance of blood flow through the pulmonary valve. Once the blood flows into the left ventricle, it is ejected into the aorta and delivers de-oxygenated blood into the body. Because there is de-oxygenated blood being delivered to the body, these babies may appear cyanotic, or "blue". This cyanosis may increase in severity with crying, agitation or bowel movements.
Open heart surgery is needed to correct this defect - Transposition of the Great Vessels
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In this congenital heart defect, the aorta (the main artery that carries blood to the body) originates from the right ventricle and the pulmonary artery (the artery that carries low oxygen blood to the lungs) from the left ventricle, resulting in two separate circulation’s.
Because the great arteries are reversed, the aorta carries blood from the right ventricle. This low oxygen rich blood and likewise the pulmonary artery carries blood from the left ventricle. This is already oxygen rich blood that is being carried back to the lungs. In order for the infant born with transposition of the great arteries to survive, they must have some communication between the right and the left sides of the heart to allow oxygen rich blood to reach the body. This mixing of blood is possible through any of the following: ASD, VSD, PDA. Even though there is mixing of oxygenated and de-oxygenated blood, it is often not adequate to sustain life for an extended period of time. Babies with transposition are extremely blue at birth.
The most common surgical procedure to correct this defect is called an arterial switch operation. That is, the major arteries are "switched". The aorta is connected to the left ventricle. This allows oxygen rich blood to be pumped to the body. The pulmonary artery is connected to the right ventricle. This allows low oxygen blood to go to the lungs where it can be oxygenated. Other surgical defects may also be needed to correct the communication between the left and right sides of the heart that was once needed for survival. - Hypoplastic Left Heart Syndrome
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Hypoplastic left heart syndrome, or HLHS for short, means that the whole left side of the heart did not develop normally. Therefore, the mitral and aortic valves are tiny or absent, as are the the left ventricle and the first part of the aorta.
HLHS is not a survivable lesion without major open heart surgery. There are two options, one is cardiac transplantation, in which the entire heart is replaced by a donated heart, and the other is called staged palliation, which is explained below. Your doctor should advise you about the risks and benefits to each of these two options.
For HLHS, staged palliation involves three operations. In order, these are the Norwood operation, bidirectional Glenn operation, and the Fontan operation. The Norwood operation is done very soon after birth, and converts the right ventricle into the main, or systemic ventricle. The bidirectional Glenn operation is done next, and diverts half of the blood returning from the body to the lungs. It is typically done at about six months of age. The Fontan operation is the last stage of the staged palliation, and diverts all of the blood returning from the body to the lungs. It is typically done around 2 years of age. The timing of these operations is variable, and depends on many clinical and social factors.
Staged palliation for HLHS is one of the great achievements of congenital heart surgery in the 90's. In what used to be a uniformly fatal disease, consider the following: Survival following a Norwood operation is around 80%, following a bidirectional Glenn operation around 100%, and following a Fontan operation around 95%. Overall, survival at 5 years of age is around 70 - 75%. Most patients who get through the three stages do quite well: Very few are on medications, almost all have normal growth and development, and very few have any exercise or other kinds of limitations. - Kawasaki Disease
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Kawasaki disease is the most common form of vasculitis that primarily affects children. The disease produces irritation and inflammation of many tissues of the body including the hands, feet, whites of the eyes, mouth, lips, and throat. High fever and swelling of the lymph nodes in the neck also are characteristic of this illness. The inflammation is uncomfortable, but resolves with time. However, the main threat from Kawasaki disease comes from its effect on the heart and blood vessels. Heart-related complications can be temporary or may affect the child long-term. The heart, particularly the coronary arteries, is affected in as many as 20 percent of children with Kawasaki disease. Another name for Kawasaki disease is mucocutaneous lymph node syndrome.
Kawasaki disease is fairly common in the US. According to the American Heart Association, the illness is a major cause of heart disease in children. About 1,800 new cases are diagnosed in the US each year, and the incidence is on the rise. Kawasaki disease has replaced acute rheumatic fever as the leading cause of acquired heart disease in children in the US and Japan. - Rheumatic fever
- a serious inflammatory condition that can affect many parts of your body — heart, joints, nervous system and skin
- Patho of rheumatic fever
- Symptoms of rheumatic fever generally appear within five weeks after an untreated streptococcal (strep) throat infection. Most cases of strep throat don't lead to rheumatic fever.
- Treatment of rheumatic fever
- In many cases, rheumatic fever may affect the heart valves (rheumatic carditis) and interfere with normal blood flow through the heart. There's no cure for rheumatic fever. But it can be prevented by prompt and thorough treatment of a strep throat infection with antibiotics.