Charlie Snow v Sim CP PDF

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CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) Anaphylaxis is an acute clinical syndrome resulting from the interaction of the allergen and a patient who is hypersensitive to that allergen. When the antigen enters the circulatory system, a generalized reaction rapidly takes place. Vasoactive amines (principally histamine or a histamine like substance) are released and cause vasodilation, bronchoconstriction, an increased capillary permeability. Severe reactions are immediate onset; are often life threatening; and frequently involve multiple systems, primarily the cardiovascular, respiratory, gastrointestinal, and integumentary systems. Exposure to the antigen can be by ingestion, inhalation, skin contact, or injection. Examples of common allergens associated with anaphylaxis include drugs (e.g. antibiotics, chemotherapeutic agents, radiologic contrast media), latex, food, venom from bees or snakes, and biologic agents (antisera, enzymes, hormones, blood products).

DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) Allergy Blood Test to measure the amount of tryptase that can be elevated up to three hours after anaphylaxis Allergy Blood Test to identify the allergen trigger e.g. IgE test, ELISA test, RAST test) Allergy Skin Test

PATIENT INFORMATION Patient: Charlie Snow Gender: Male DOB: 5/5/2014 Allergies: Peanuts, perfumes, and dyes Immunizations:Up to date Adm Dx: Anaphyla xis

ANTICIPATED PHYSICAL FINDINGS The onset of clinical symptoms usually occurs within seconds or minutes of exposure to antigen. The sooner the onset, the more severe the reaction. S&S: uneasiness, restlessness, irritability, severe anxiety, headache, dizziness, paresthesia, and disorientation, LOC, flushing, urticaria, angioedema, bronchiolar constriction, pulmonary edema and hemorrhage, laryngeal edema, shock

Adm On: 4/5/2021

ANTICIPATED NURSING INTERVENTIONS • Obtain a thorough health hx of child from caregiver and child, including previous reactions to allergies and what the patient is or may be allergic to •Document and chart all known allergies (e.g. food, medications, environment, etc. and obtain allergy bracelet for child to wear. • Encourage the child to talk about fears and concerns • Provide support and guidance to the child and family •Full set of vitals: Temp, HR, RR, BP, Pulse ox, Pain •Respiratory Assessment e.g. Breath sounds, assess for cyanosis •Cardiac Assessment: e.g. all peripheral pulses, HR, BP •Assess for dehydration e.g. Capillary refill, Skin Assessment •Further allergic reactions e.g. Swelling, Hives After 2nd contact with provider: •Monitor VS q 5 min •Administer NS, epinephrine, diphenhydramine, ranitidine, and methylprednisolone as prescribed. Administer O2 as prescribed to keep O2 sat >94% via NC or non-rebreather •HOB elevated •Continuously monitor saturations and keep eye on RR as this can be affected by swelling of throat •Recheck BP frequently •Give fluids will assist in maintaining BP if needed. Quick direct rapid administration of needed medications

vSim ISBAR ACTIVITY

STUDENT

WORKSHEET INTRODUCTION

Catherine Espinosa, RN, Pediatric Unit

Your name, position (RN), unit you are working on

I wash my hands upon entering the room. After introducing myself, I identify the relative accompanied with the child and relationship between the relative and child.

SITUATION

Charlie Snow is a 6-year-old Caucasian male staying with his aunt and hile his parents are serving overseas in the military uncle while military. Charlie presents in the emergency department with tachycardia and dyspnea with mild stridor. His aunt and uncle report that he accidentally ate a cookie containing peanuts, and he has peanut allergies. When Charlie began having difficulty breathing, they rushed him to the emergency department. He is accompanied by his aunt Judith Smith. Consent should be obtained because the caregivers at the moment are not the patient’s parents.

Patient’s name, age, specific reason for visit

BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient

ASSESSMENT Current pertinent assessment data using headto toe approach, pertinent diagnostics, vital signs

RECOMMENDATION

Charlie’s admission diagnosis is anaphylaxis. Date of admission is 4/5/2021. 4/5/2021 The patient is allergic to peanuts, peanuts perfumes, perfumes and dyes. dyes The patient is currently able to talk through the dyspnea and is on a nasal cannula at 2 liters. A saline lock has been placed in his left arm. He has been connected to a cardiac/apnea monitor with a SpO2 probe in place. Charlie is in bed, and the health care provider has been notified of Charlie's arrival. Current orders for the patient include continuous O2 sat observation via pulse ox, NC O2 2L bur may switch to nonrebreather, titrating O2 to maintain SpO2 >94%, and continuous cardiac/apnea monitoring. Upon initial assessment at 1500, the patient stated that he felt that his th t was swelling lli and d could ld nott bbreathe. th Hi ll O2 throat His VS were as ffollows: sat 89% with NC 2 L, HR 145, BP 113/75. He has retractions, a prolonged expiration phase, and a lot of audible wheezing. He is breathing 27 breaths per min. There is increased respiratory effort. HR and rhythm are regular without murmurs but tachycardic. Pain assessment and scale used. The patient answered 0 on the FACES scale with a range of 0-5. At 1500, patient was given 420 mL of NS IV bolus over 30 min, 0.3 mg epinephrine (1:10,000) IV stat, 25 mg of diphenhydramine IV stat, Ranitidine 20 mg IV stat, 10 mg of methylprednisolone IV stat. Post medication at 1518, VS are as follows: O2 sat 98% NC 2L , BP is 158/128, HR is 162. There is no airway obstruction. The breath sounds are clear and equal bilaterally. He is breathing at 13 bpm, the chest is moving equally. The peak flow is 175 L/min. The brachial pulse is strong, 120 per min and regular, carotid pulse at 100 per minute and regular. Both HR and rhythm are regular without murmurs. The child replied 0 on the FACES pain scale. Patient is conscious. The muscle strength, sensation, and deep tendon reflexes are normal. There are no signs of clonus. The temperature is 99 F. The IV saline lock site on the left forearm exhibited no signs of redness, swelling, infiltration, bleeding or drainage. An infusion of 420 NS over 30 min is currently running. The dressing is dry and intact. Mucous membranes show no signs of dehydration. The capillary refill time is approx 5 sec. There is normal elasticity of the skin. The color is normal and he is not sweating. At 15:21 VS are as follows: O2 sat NC 2L 98%, BP 109/85, HR 97.

Any orders or recommendations you mayhave for this patient

Continuous monitoring of VS q 5 min unless provider says otherwise. Maintain O2 saturation above 94%. Monitor PO Fluid intake & output. Daily Weight. Assess for lingering allergic reactions. Ensure that patient and parent are properly educated on what foods to avoid to prevent allergy attack and what to do during the emergent situation in any event, if it occurs again. Avoiding foods containing peanuts or may potentially contain peanuts, or peanut oil and avoiding perfumes and dyes.

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Epinephrine

CLASSIFICATION: Therapeutic: Antiasthmatics, bronchodilators, vasopressors; Pharmacologic: adrenergics

PROTOTYPE: Epinephrine

SAFE DOSE OR DOSE RANGE, SAFE ROUTE Safe Dose: Junior: 33lbs -66lbs (0.15mg) Max: 0.3 mg/dose. May repeat every 5 to 15 minutes as needed for up to 3 injections; more frequent administration may be appropriate in certain circumstances, as judged by the clinician. If there is no response after 3 to 4 injections, consider an intravenous infusion. Monitor for reaction severity and cardiac effects. Patient’s Dose: 0.3 mg (1:10,000) IV stat. The patient weighs 46.2 lbs (21 kg) so the prescription dose is appropriate for the patient. 0.3 mg is the max limit within 24 hrs so the patient will not be taking anymore of this medication unless otherwise indicated PURPOSE FOR TAKING THIS MEDICATION Bronchodilation. Maintenance of HR and BP. Used for hemodynamic/inotropic support. Drug of choice for anaphylaxis; not routinely recommended for asthma

PATIENT EDUCATION WHILE TAKING THIS MEDICATION Instruct patient and caregiver to contact HCP if shortness of breath is not relieved by medication or is accompanied by diaphoresis, dizziness, palpations, and chest pain. Advise patient and caregiver to help encourage patient to maintain adequate fluid intake to help liquefy tenacious secretions Advise patient and caregiver to consult HCP if respiratory symptoms are not relived or worsen after treatment or if chest pain, headache, severe dizziness, palpitations, nervousness, or weakness occurs

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Diphenhydramine

CLASSIFICATION: Therapeutic: antihistamines, antitussives

PROTOTYPE: Diphenhydramine

SAFE DOSE OR DOSE RANGE, SAFE ROUTE Safe Dose: 6-12 years - 12.5-25mg/dose every 4-6 hours max 300mg/day Patient’s Dose: 25 mg IV stat. The provider’s prescribed dose is within safe limits. It should be taken every 4-6 hrs. The maximum amount in 24 hrs that the patient can have is 300 mg. PURPOSE FOR TAKING THIS MEDICATION Decreased symptoms of histamine excess (sneezing, rhinorrhea, nasal, and ocular tearing and redness, urticaria. Relief of acute dystonic reactions. Prevention of motion sickness. Suppression of cough.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION May cause drowsiness. Inform caregiver that they may need to assist the patient when ambulating to prevent falls. May cause dry mouth. Inform patient and caregiver that frequent oral rinses, good oral hygiene, and sugarless gum or candy may minimize this effect. Instruct to inform HCP if dry mouth persists more than 2 wks. Can cause excitation in children. Caution parents or caregivers about proper dose calculation; overdose and can cause hallucinations, seizures, and death.

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Ranitidine

CLASSIFICATION: Therapeutic: antiulcer agent; Pharmacologic: histamine H2 antagonists

PROTOTYPE: Ranitidine

SAFE DOSE OR DOSE RANGE, SAFE ROUTE Safe Dose: 0.25mg/kg/dose. Maximum of 20mg/dose Patient’s Dose: 20 mg IV stat. The prescription is within safe limits but the patient cannot have anymore unless otherwise indicated because the patient can only have 20mg within 24 hrs PURPOSE FOR TAKING THIS MEDICATION Inhibits the action of histamine at the H2 receptor site located primarily in gastric parietal cells resulting in inhibition of gastric acid secretion. Healing and prevention of ulcers. Decreased symptoms of gastroesophageal reflux. Decreased secretions of gastric acid. Most commonly given IV or PO for allergic reaction or anaphylaxis

PATIENT EDUCATION WHILE TAKING THIS MEDICATION May cause drowsiness. Inform caregiver that they may need to assist the patient when ambulating to prevent falls. Advise the caregiver not to give patient products containing aspirin or NSAIDs, and foods that may cause an increase in GI irritation. Inform the patient and caregiver that increased fluid and fiber intake and exercise may minimize constipation Advise patient and caregiver to report onset of black, tarry stools, fever, sore throat, diarrhea, dizziness, rash, confusion, or hallucinations to HCP promptly

PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Methylprednisolone

CLASSIFICATION: Therapeutic: antiasthmatics, corticosteroids; Pharmacologic: corticosteroids (systemic)

PROTOTYPE: Prednisone

SAFE DOSE OR DOSE RANGE, SAFE ROUTE Safe Dose: Dosing - 0.11 to 1.6 mg/kg/day in 3 – 4 divided doses Patient’s Dose: 10 mg IV. The patient weighs 21 kg so the safe dose range for the patient would be 2.31 to 33.6 mg a day. The patient’s prescribed dose is within the recommended range. The maximum dose the patient can have within 24 hrs is 33.6 mg. PURPOSE FOR TAKING THIS MEDICATION Anti-inflammatory and immunosuppressive properties. Suppression of inflammation and modification of normal immune response. Replacement therapy in adrenal insufficiency.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION Inform patient and caregiver to not alter established dosage regimen (i.e., not to increase, decrease, or omit doses or change dose intervals) and that stopping medication suddenly may result in adrenal insufficiency (anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). If these S&S appear, notify HCP immediately. They can be life threatening. Advise the patient and caregiver to avoid the consumption of grapefruit juice during therapy. Corticosteroids cause immunosuppression and may mask symptoms of infection. Instruct patient and caregiver to avoid people with known contagious illnesses and to report possible infections immediately. Instruct patient and caregiver ti report to HCP promptly if severe abdominal pain or tarry stools occur.

Clinical Worksheet Date: 4/5/2021 Initials: C.S.

Student Name: Catherine Espinosa

Diagnosis: Anaphylaxis

HCP: Unknown

Isolation: No Fall Risk: Yes

Assigned vSim: IV Type: Saline Lock

Charlie Snow Critical Labs: N/A

Other Services: N/A

Age: 6 yo Length of Stay: M/F: M Code Status: Unknown

Admitted on

4/5/2021, 1 day

Consults: Unknown

Transfer: No

Location: Left Forearm

Consults Needed: Allergist

Fluid/Rate: 420 mL of NS IV bolus over 30 min

Allergies:

Speech Pathologist Respiratory Therapist Child life specialist Social Worker

Peanuts

Perfumes, and

dyes

Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Charlie is a 6 yo male admitted to the emergency department due to the onset of tachycardia and dyspnea with mild stridor. Aunt and uncle, Judith and James Smith report that he accidentally ate a cookie containing peanuts, and that he has peanut allergy. When Charlie began having difficulty breathing, they rushed him to the emergency department Health History/Comorbities (that relate to this hospitalization): Past medical history in unremarkable beyond known allergies. The patient’s aunt, Judith Smith reports that to her knowledge, Charlie is a healthy boy.

Shift Goals/ Patient Education Needs: 1. Patient will exhibit no further S&S of allergic reaction or anaphylactic shock 2. Patient will be provided adequate ventilation and will have restored circulation 3. Patient and caregiver will be provided adequate comfort and therapeutic measures to decrease anxiety 4. Patient and caregiver will be properly educated about diagnosis, treatment, and prevention strategies Path to Discharge: Identification of allergy and removal or allergen and/or triggers. Documentation of allergies. Identifying allergen bracelet for patient. Thorough assessment and monitoring focusing on respiratory and cardiac functions. Interventions performed in a quick, efficient, and timely manner to prevent further harm to patient. Effective communication between HCP, nurse, and other consults involved. Proper education to patient and caregivers about prevention strategies and interventions if the patient suffers from another anaphylactic shock. Providing the caregivers the proper equipment (e.g. EpiPen, Information packet) should the case arise again Path to Death or Injury: Failure to assess and monitor patient correctly, if at all. Failure to act quickly in emergent situation. Poor communication b/w HCP , nurse, and other consults. Failure to provide proper education.

Alerts: What are you on alert for with this patient? (Signs & Symptoms)

Management of Care: What needs to be

1. Decreased O2 saturation, SOB, Wheezing

done for this Patient Today?

2. Irritability, severe anxiety, any changes in LOC

1. Continuous monitoring of VS focusing

3. Itchiness, discomfort

on respiratory and cardiovascular

What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1. O2 saturation, lung and breath sounds, RR 2. Neurological Assessment to see if the patient is A&O and responsive 3. Integumentary Assessment searching for any redness, swelling, or hives List Complications may occur related to dx, procedure, comorbidities: 1. Laryngeal Edema

assessment. Monitoring BP and HR for any adverse effects from medication. 2. Assess for any lingering affects of allergic reaction 3. Elevating the HOB, maximizing patient and caregiver comfort and care 4. Documentation of allergies for patient and identifying that patient has an allergy (i.e. having Charlie wear an allergy bracelet) 5. Implementing fall risk precautions, assisting the child when ambulating 6. Educating patient and caregiver on diagnosis, prevention strategies, and what to do in case the emergent situation arises again.

2. Shock

Priorities for Managing the Patient’s Care Today 1. Maintaining O2 saturation >94%

3. Death

2. Maintaining VS (HR, BP, etc), within patient’s normal limits

What nursing or medical interventions may prevent the above Alert or complications?

3. Proper documentation and identification of allergies and obtaining Charlie’s allergy bracelet. 4. Reducing anxiety of patient and caregiver

1. Careful assessment focusing on respiratory (o2 sat, RR, lung sounds) and cardiovascular assessment (BP, HR) in order to What aspects of the patient care can be Delegated and who can do implement the proper interventions to prevent the above it? complications 2. Establishing a patent IV safely and as quickly as possible 3. Quickly, efficiently, and safely administering prescribed medications 4. Continuous monitoring of VS focusing on O2 sat, BP, and HR

Adjusting the HOB for maximum comfort, keeping the HOB elevated unless directed otherwise, washing the patient, providing adequate hygiene, monitoring I&O, assisting the patient ambulating to the BR can be delegated to the UAP....