Anaphylactic Shock Critical Care Case Study

Introduction (200 Words)

In this project a medical case is going to be studied deeply with literature support as a case study. My topic is about an anaphylactic shock that happened to patient in hospital while I was doing my clinical placement it is a very interesting case to be considered. An evidence-based information will be provided and identified such as: the definition, the symptoms, the diagnostic features and tests, the progress and the treatment and alternatives. The benefits behind studying a case is effectiveness of delivering the information. As stated by Davis and Wilcock, 2014 that it allows the application of theoretical concepts to be demonstrated and will encourage an active learning, increasing the student enjoyment and interest of the topic and their desire to learn and it also provide a developmental key in learning skills such as problem solving, communication and team work. It is an enjoyable and challenging way of studying filled with evidence-based practice that will enhance the level of doing researches and studies that will help in future studies.

Nursing Assessment (300 words)

The patient has been received in Accident & Emergency in resuscitation room (RR). J.A.M 52 years old Bahraini female. The patient had an insect bite in that day while she was walking in public walking area, she stopped walking and itching occurred all over the body. While driving home after the insect bite the patient felt drowsy and hit another car near her house and loss consciousness. J.A.M was brought to the unit by 999 ambulance fully awake, well oriented, alert, afebrile, no respiratory difficulties, no complains of pain, skin is warm and dry, pallor and shivering with rash on the face gave history of feeling nauseated and vomited 4 times. Vital signs Checked and recorded Temperature 37.4C, Spo2 98%, Pulse 118/Minute, BP 145/43, HGT 7.6 Mmol/L. The skin was mainly involved representing pale colour and rash on the face, the cardiovascular system represents tachycardia, and the immune system is responsible for this reaction against the insect bite. The patient denies any chest pain, denies shortness of breath, the patient is known case of dyslipidemia on tablet Lipitor, no other history of other illness, no history of surgery and no history of any allergy. The patient can handle the basics of activity daily living such as eating, bathing, toileting, dressing and she is able walk and get out of the bed but she is not able to perform certain activities such as food preparation, housekeeping and driving a car. After the acute symptoms have been treated the family should be given health education about how to prevent possible future allergic reaction and the importance of seeking help as quick as possible if they do not know how to deal with the situation. Physical examination was done for cardiovascular system representing chest is equal in shape, no bounding or heaving, no lifting with heartbeat. Upper & lower extremities are normal in color and capillary refill within 3 seconds, skin is warm periphery with no edema. S1 is heard in all sites and S2 is heard all sites but louder at base and tachycardia observed. Skin is pale, dry, soft, warm. No edema, lesions or odor, good turgor, no signs of insect bite, rashes on face.

Medical Diagnosis and other pertinent medical information (500 words)

When received the patient the physician has requested ECG, blood tests as following: Full blood count, Cardiac enzymes, Liver function test, Electrolytes, serum, PT + APTT, ESR. Some of the results was not approved but most of the results were normal, this table shows the most important values and abnormal findings:

Date	Diagnostic Test	Rationale	Findings
12/11/14	Electrocardiography (ECG)	Can be examined to detect dysrhythmias and alternations in conduction indicative of myocardial damage, enlargement of the heart or drug effects. (Kozier and Berman, 2012)	The result is Normal valves, no vegetation observed, the heart produces rapid electrical signal, tachycardia.
12/11/14	Complete blood count (CBC)	The CBC identifies the total number of blood cells (Leukocytes, erythrocytes and platelets) as well as the haemoglobin, haematocrit (percentage of blood volume consisting of erythrocytes), and RBC indices. Because cellular morphology (shape and appearance of the cells) is particularly important in accurately diagnosing most hematologic disorders, the blood cells involved must be examined. (Brunner and Smeltzer, 2010)	The results are normal except: WBC: 24.5 High. Platelet count: 536 High. Red cell size 20.6 High. Haemoglobin: 8.5 Low. Haematocrit: 0.27 Low. Mean cell volume, Hb, Haemoglobin Con are Low. Band forms: 15.
12/11/14	Fluid (Urea) & Electrolytes	Fluid and electrolyte balance is a dynamic process that is crucial for life and homeostasis. Potential and actual disorders of fluid and electrolyte balance occur in every setting, with every disorder, and with a variety of changes, that affect healthy people, (e.g., increased fluid and sodium loss with strenuous exercise and high environmental temperature, inadequate intake of fluid and electrolytes) as well as those who are ill. (Brunner and Smeltzer, 2010)	Patient Fluid (Urea) & electrolytes results are normal.
12/11/14	Serum	Initial diagnostic test begin with serum laboratory studies, including but not limited to CBC, complete metabolic panel, prothrombin time/partial thromboplastic time, triglycerides, liver function tests, amylase, and lipase. Studies such as carcinoembrynoic antigen (CEA) and cancer antigen (CA). (Brunner and Smeltzer, 2010)	Liver function test are normal. Cardiac enzymes are normal. Creatinine is normal.

The patient was diagnosed as having an anaphylactic shock, the case was chosen because it is very common and could happen to anyone by exposure to an allergen of any kind which is in this case an insect bite. The community may not be aware about how dangerous is developing a serious reaction from a small allergen such as insect bite. The statistics was not specified in Bahrain but in some countries worldwide: “Systemic allergic reactions to insect stings are reported by 0.3% to 7.5% of persons in the United States and Europe’’. (Ruëff et al., 2009) An anaphylactic reaction is an acute systematic hypersensitivity that occurs within seconds or minutes after exposure to an allergen or foreign substance. It is a result of the relationship between Antigen and Antibody, The immunoglobin E is the responsible for human allergic reaction. The person may have a hypersensitivity to the venoms of insects (hymenoptera), stings in any part of the body can trigger anaphylaxis. The signs and symptoms includes Itching, nasal congestion, chest tightness, wheezing, cyanosis, dyspnea, generalized itching over the body, urticarial, tacky or bradycardia, pallor, decreased blood pressure, circulatory failure leading to coma and death, nausea, vomiting and diarrhoea. (Brunner and Smeltzer, 2010) All the required tests has been done to the patient in RR except antibody screening which refers to a special protein that is found on the surface of RBC to check for RH positive or negative. (Mayoclinic.org, 2014) IV cannula inserted once received the patient, Injection Hydrocortisone 300mg IV given, Injection promethazine 50mg IV given, Injection adrenaline 0.5mg s/c given, Injection Ranitidine 50mg IV given. Patient put on Cardiac monitor, Dexamethasone 10mg IV given, old file requested, chest x-ray requested, Paracetamol 1g IV, changed the patient and kept clean, Injection rocephin 2g given on Right Arm. The physician advised to be kept on 1.5 litres of Normal Saline for 12 hours, 2-4 litres of Oxygen on nasal cannula, kept the patient covered with necessary blanket to keep her warm and comfortable.

Impact of the condition on the patient’s Quality of Life (200 words)

The patient may move on to anaphylaxis which is dangerous fatal stage thus the treatment did a great job in reducing this effect by using drugs such as: epinephrine (Adrenaline) which inhibits the mediator release from mast cell and basophils and protect the patient from upgrading to anaphylaxis. The hydrocortisone prevented relapse or protracted anaphylaxis. Lockey, 2014 states that the oxygen therapy will deliver the required oxygen to the patient which makes her comfortable. Promethazine will act on receptor as antihistamine which will reduce the itching and has a sedation effect will put the patient into more comfort. Ranitidine will prevent gastric acid secretion which reduces the nausea and vomiting. Rocephin is an antibiotic which inhibits the bacterial cell wall synthesis and will lead to cell death (Skidmore-Roth, 2012). Normal saline to maintain hydration of the patient. After receiving the treatment patient is feeling better, nausea and vomiting reduced, itching reduced, the patient is comfortable with the treatment.

Discussion (700 words)

The patient treatment started with requesting blood tests which shows any abnormal values to be treated. Brunner and Smeltzer, 2010 advised that treatment starts with removing the causative agent which is the insect venom but the patient did not know the exact site of the bite thus physical examination clarified that there is no proof of an insect bite. Brunner and Smeltzer, 2010 admits that the patient should be given the necessary emergency support of basic life functions which was given already to the patient, Epinephrine was given as vasoconstrictive. Brunner and Smeltzer, 2010 states another drug named Diphenhydramine (Benadryl) included in treatment of this condition to reverse the effect of histamine and reducing the capillary permeability but replacement alternative was given which were Promethazine and Ranitidine that acts on H1 and H2 receptors (Antihistamine) (Skidmore-Roth, 2012). Another medication which was stated by Brunner and Smeltzer, 2010 albuterol through nebulization to reverse the histamine bronchospasm if occurred. Brunner and Smeltzer, 2010 recommended that IV lines should be inserted to provide access to administer fluids and medication, IV cannula was inserted to the patient. They also state that respiratory status is measured by monitoring respiratory rate and if there is any abnormal lung sound and pulse rate any rhythm to be monitored regularly, cardiac monitor was put on the patient to assess the respiratory status and vital signs of the patient. The physical examination of the chest clarify that lung sounds are normal. Oxygen was applied to the patient to help compensate breathing pattern. The patient was assessed for previous allergies or exposure to such antigens and the understanding of the patient about this condition to prevent any future complications. Locky, R. 2014 recommended that the family should be educated about how to avoid the allergen and know the underlying causes of any allergy. Lockey, 2014 recommends that the patient should be given an auto injector which is a syringe that automatically injects single dose of medication when triggered and to be educated about it and the necessary information such as: dose, expiry date, route of administration. Such device is given to many people that are at high risk of developing anaphylaxis only during an anaphylactic emergency. The patient and the family should be also educated about prevention of exposing to the allergen by wearing protective clothes that is covering all the skin when needed to do such sport in public area and the onset symptoms that occurs when already exposed to such allergen. As stated in Brunner and Smeltzer, 2010 there is early simple management that could be done by the patient or the relative by removing the venom or stinger of the insect when found, wound care to be done using water and soap, scratching to be avoided to prevent histamine, to apply ice on the bite site as it will reduce the swelling and decreases the venom absorption by the body. In my opinion, the patient should be identified by wearing an allergy warning band that contains emergency information in case if the patient fainted or lose consciousness. The allergy should be documented in the patient file to avoid any further exposure to allergy and to avoid using the venom immunotherapy (VIT) which treats certain medical conditions. The patient should be monitored carefully during hospitalization because any adverse complication may occur suddenly. The patient should be referred to an allergist or immunologist to follow up regularly to maximize the quality of life.

Conclusion and recommendations (100 words)

An allergic reaction could develop anywhere in the nursing practice such as administering certain drug that the patient allergic to or using and device that has an allergen element. Nurses must highly prioritize the general assessment done when receiving patients specially asking for allergy for any medication or substance or any allergic reaction that occurred in the past, because we held such responsibilities to prevent any fatal complications that occurs because of anaphylactic reaction, shock or anaphylaxis. Nurses must be aware of such symptoms to detect an early reaction which could be preventable as soon as possible. This will be beneficial to the patients and nurses to deliver the maximum health outcomes.

References

Brunner, L. and Smeltzer, S. (2010). Brunner & Suddarth’s textbook of medical-surgical nursing. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

Davis, C. and Wilcock, E. (2014). Teaching Materials Using Case Studies. [Online] Materials.ac.uk. Available at:

http://www.materials.ac.uk/guides/casestudies.asp

[Accessed 30 Nov. 2014].

Kozier, B. and Berman, A. (2012). Kozier & Erb’s fundamentals of nursing. Boston: Pearson.

Lockey, R. (2014). Anaphylaxis. [Online] Mayoclinic.org. Available at:

http://www.mayoclinic.org/diseases-conditions/anaphylaxis/basics/treatment/con-20014324

[Accessed 30 Nov. 2014].

Lockey, R. (2014). Anaphylaxis: Synopsis. [Online] Worldallergy.org. Available at:

http://www.worldallergy.org/professional/allergic_diseases_center/anaphylaxis/anaphylaxissynopsis.php

[Accessed 30 Nov. 2014].

Mayoclinic.org, (2014). Rh factor blood test Why it’s done. [Online] Available at:

http://www.mayoclinic.org/tests-procedures/rh-factor/basics/why-its-done/prc-20013476

[Accessed 30 Nov. 2014].

Ruëff, F., Przybilla, B., Biló, M., Müller, U., Scheipl, F., Aberer, W., Birnbaum, J., Bodzenta-Lukaszyk, A., Bonifazi, F. and Bucher, C. (2009). Predictors of severe systemic anaphylactic reactions in patients with Hymenoptera venom allergy: Importance of baseline serum tryptase—a study of the European Academy of Allergology and Clinical Immunology Interest Group on Insect Venom Hypersensitivity. Journal of Allergy and Clinical Immunology, 124(5), pp.1047-1054.

Skidmore-Roth, L. (2012). Mosby’s 2012 nursing drug reference. St. Louis, Mo.: Elsevier/Mosby.

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