Acetaminophen (Tylenol) may also be used depending on hospital protocol From a practical perspective, the infusion of IVIG is started slowly (0.5 mL/kg per hour) and titrated upward every 30 minutes to an infusion rate of 2 mL/kg per hour If a reaction occurs, the infusion rate may have to be decreased and the overall time of administration prolonged Occasionally, for significant IVIG reactions, the infusion must be interrupted and a new lot number or different brand of IVIG will be required In addition, some patients develop a postintravenous immunoglobulin reaction, which may include a fever elevation, headache, and nausea/vomiting generally occurring within 24 to 36 hours after infusion During hospitalization, aspirin is given in higher doses on a 6-hour schedule It is important for the nurse to obtain an accurate temperature just prior to the administration of the aspirin dose, as fever is an important predictor of response to therapy Acetaminophen should be given only as needed so that temperature elevations are not “masked” and clinicians know if the child has responded to treatment As mentioned earlier in this chapter, additional antiinflammatory or antithrombotic treatments may be given to patients who continue to have fever and/or coronary enlargement in spite of an initial treatment with IVIG.2 Such patients are monitored in hospital until their clinical status is stable for discharge In addition to providing pharmacologic therapy, nursing care of the patient during hospitalization includes efforts aimed at symptomatic relief, emotional support, and parent and patient education about the illness Irritability is a hallmark of this illness and is typically the last symptom to disappear Children are often inconsolable during hospitalization, with temper flares and unhappiness occurring randomly in the weeks following hospitalization It is helpful for parents to know prior to discharge that this is an expected symptom so that they can be prepared for it While their child is hospitalized, parents may need to arrange additional support from family members or friends so that they can get some rest The severity of irritability varies from child to child and may be exacerbated by the procedures inherent in hospitalization, such as blood drawing or the placement of intravenous catheters Education regarding the expected course of illness, including the evolution of clinical signs and symptoms in Kawasaki disease, should be discussed with the parents The conjunctivitis generally resolves over time, but many children have complaints of photophobia Providing a darkened room may decrease discomfort A cool washcloth over the eyes may also help symptoms Oral changes such as dry cracked lips may last for a few weeks Spicy foods may irritate an already inflamed mouth Providing bland, soft foods may be preferable for some patients during this time Lip lubrication, as with petroleum jelly, helps decrease discomfort from lip cracking The rash often exacerbates with fever and can be itchy As the child recovers, the skin tends to be quite dry and flaky, with initial peeling in the groin area This area can be especially sensitive in children who are wearing diapers Parents can apply a protective lotion to the diaper area and a unscented lotion to the skin Subungual desquamation (peeling of the skin on the fingertips and toes) occurs beginning in the second week of illness, leaving new skin exposed This area may be tender and some children will pick at the peeling skin There is no specific therapy to lessen the peeling, but lotion or petroleum jelly may soothe the affected area In patients with lymphadenopathy, it should be explained to parents that the resolution of this symptom may take several weeks A self-limited arthritis is present in approximately one-third of children affected by Kawasaki disease.182 These children may have significant discomfort Often the fingers and toes are swollen initially, followed by the larger joints such as the knees or hips; this may result in difficulty walking Once the child is back home, warm baths may help with joint mobility, which is often worse on awakening More severely affected children may benefit from shortterm treatment with antiinflammatories However, it is important to note that nonsteroidal antiinflammatory drugs, such as ibuprofen, can decrease the efficacy of antiplatelet doses of aspirin The risks and benefits should be discussed for each individual case Parents should be informed that the arthritis in this illness is always temporary but can last for several weeks to a few months in some children Discharge Teaching The nurse should provide clear instructions and information to families prior to discharge It is helpful if written information is given for reinforcement as well as referral to web-based information for education and support (e.g., http://www.kdfoundation.org) It is helpful to let the parents know that the initial clinical signs and symptoms in Kawasaki disease are self-limited and resolve over time Parents should also be informed that the ultimate coronary prognosis cannot be known at the time of diagnosis Coronary artery enlargement may be progressive over the first 4 to 8 weeks of illness In patients with a normal baseline echocardiogram and a good response to IVIG treatment, a follow-up echocardiogram is recommended 1 to 2 weeks after discharge This timing is important, and this appointment should be made prior to discharge If normal, another echocardiogram is recommended in approximately another month In patients who already have documented coronary dilation on their initial echocardiogram, additional treatments and more frequent imaging (e.g., twice a week) is indicated until coronary dimensions have stabilized Prior to discharge, it is particularly important to instruct the parents to monitor the child's temperature in the week or two after discharge Ongoing fever is an indicator of ongoing inflammation and fever duration is strongly correlated with the development of coronary enlargement Further treatment may be indicated in patients who continue to have fever or who develop recrudescent fever The child's temperature should be taken each afternoon/early evening when fever curves are generally the highest, or if the child “feels warm.” Parents should be instructed to contact their healthcare provider if the child has a temperature over 100.5°F (38.5°C) Generally it takes approximately 6 to 8 weeks for all clinical symptoms and laboratory parameters to return to baseline Recommendations regarding the timing for a child to return to day care or school should be made on an individual basis, with some basic parameters During the initial week or two at home, if a child develops a fever, it may necessitate return to the hospital for evaluation and possibly readmission An intercurrent illness may confuse the clinical picture In addition, irritability is often the last symptom to leave and the child may not be able to tolerate a full day of day care or school shortly after discharge, when he or she is not yet fully recovered Therefore it may be prudent to recommend staying out of group settings until the child is feeling better and the first followup echocardiogram has been completed With few exceptions, all patients take low-dose aspirin for its antiplatelet effects until the ultimate coronary outcome is known (~4 to 8 weeks after illness onset) Side effects of aspirin therapy include easy bruising In addition, if a child has chickenpox or influenza, aspirin may have to be interrupted and another medication (such as clopidogrel) prescribed to reduce the risk of Reye syndrome Live viral vaccines such as mumps, measles, and rubella (MMR) should be deferred for 11 months after IVIG administration to mount adequate immunity Other vaccines can be given once the child is back to baseline (~6 to 8 weeks) For the child without aneurysms at any time during the illness, the long-term