Case Study

[ruby_jane]

This happened in real time this AM....I will post my nursing dx later but am curious to see what you all think of this.

Student with no reported history of asthma or allergies presents stating "I'm having an allergy attack or asthma." Student is a frequent enough visitor that I know her face but has had no unusual occurrences.

Initial VS BP 137/94, HR 116 RR 15, PSO2 98%. Breath sounds diminished at the tops of lung fields bilaterally, nothing adventitious at the bases of lungs. Lips pink, arms flushed, conjunctiva reddened, student stating throat is swelling and tongue is swelling. She reports chest tightness but is able to make 10-word sentences and is not tripod positioning for comfort. She denies nausea.

I am armed with two EpiPens for "unknown allergens." I have no standing orders for Benadryl or albuterol.

Reassessment 12 minutes later after calming her down, calling dad (on the way) and cold water to drink: BP 141/81, HR 113, RR 12, PSO2 98%, diminishment of itching sensation on tongue, throat is itching but reduction in the sensation of swelling. Bilateral breath sounds WNL on the left upper and lower lung fields. Right upper lung fields diminished sounds, front and back, no diminishment on the lower right fields. She is reporting that "it's easier to breathe." No nausea.

Reassessment as dad arrived to take her away (10 minutes after second reassessment) BP 134/84, HR 116, more profound flushing of face, and conjunctiva are pronouncedly reddened, but reduced sensation of swelling tongue. Throat is "itching," skin on her arms is flushed. Dad left to take her to the doctor.

What do you think? Asthma, panic attack, or something else?

[OldDude]

I'm sticking with anxiety

[NutmeggeRN, BSN]

Anxiety can cause the skin to itch, have chest tightness, and feelings of throat closing. Tough read with teenage girls. I would just have the epi ready in case the O2 sat dropped or there was visible swelling of the lips.

Esme12 Nice to see you on the school nursing thread!!! Have missed you!

[JenTheSchoolRN, BSN, RN]

She did not administer the Benadryl, her parent did. School nursing is unique that the community is overall healthy and, unlike acute or chronic care, you don't assume the worst first. You also don't have the luxury of another licensed person to consult with. You get a little bit more liberal in your treatments. Anxiety presents many different ways AND children, gasp!, sometimes cry wolf. I wouldn't feel bad activating 911 for an Oscar worthy performance, but my job is to keep butts in seats.

This. I have told other nurses our thinking process is slightly different in school nursing. In a hospital setting, you may assume the worst and work down. In a school setting, you may assume the least and work up. Oh, sure you are ready to call 911 if needed, but 99% of the time, it is something lower on the totem pole, so to speak.

For example, I have a lovely parent who is also a cardiac nurse. Her child was complaining of sudden moderate consistent sternum pain just before school; parent's cardiac training kicked in and she was running worst care scenario in her head. She was calling her pediatrician. She called me in the AM to talk with me about her child's health for the school day and I asked if she had any previous signs of acid reflux. Mom's sigh was huge. She was like - yes! I did still recommend follow-up with her pediatrician and sure enough, child had gastroesophageal reflux.

[ruby_jane, BSN, RN]

Perhaps I'd have been overreacting, but I would have called 911 because this girl needed Benadryl and you had no order for it,

and no way to quickly get an order. I think you risked your license and her life.

I risked neither my license or her life. It's about assessment and reassessment. Did she need Benadryl or Epi? Epi treats the anaphylaxis, Benadryl may mask it. If I had both, best practice in the face of a potential unknown allergen that might be causing anaphylaxis is Epi. This is a school setting. In order to get standing orders I'd have to 1) be in charge; and 2) fork over thousands of dollars (I think a neighboring district pays $4K for their SOs for albuterol and Epi.)

My license does not allow me to diagnose or prescribe. Fortunately, I had what I might have needed....had I needed it. Had dad not been on his way...for sure EMS.

I mostly posted to get the awesome tips like another poster shared - anxiety can cause the throat swelling and the itchies.

[ruby_jane, BSN, RN]

In a hospital setting, you may assume the worst and work down. In a school setting, you may assume the least and work up. Oh, sure you are ready to call 911 if needed, but 99% of the time, it is something lower on the totem pole, so to speak.

I am prepared for the worst....but the best thing about this job is that my assessment skills have been honed so sharply because I might need to give report to EMS or to convince a parent that they need to take the kid to the hospital.

Had dad not arrived, with her being bright pink and itchy....EMS it would have been. Because she wasn't worsening but she wasn't getting much better, either.

[3ringnursing, BSN]

I'm going with noxious odor reaction given it was science class, continuing reddening conjunctiva, and flushed, itchy skin.

Did she seem anxious? Diaphoretic?

I had a coworker who went into full blown anaphylactic reaction to the smell of oil of peppermint.

Any updates on this? I'm curious to know what the final Dx was.

[JessiJam]

Any update on how this turned out?

[OhioBPH]

I am interested in any update or additional info on this. I have an incredibly anxious 7th grader here who is also nut allergic. He had an episode of anaphylaxis due to unknown source over the summer, that mom assumed was trace trasfer contact on the remote. Didn't think much of that until he came in complaining of allergy symptoms due to unknown cause, but a chat with his counselor got that under control (after monitoring for a while with improvement whenever we werent talking about how he was feeling).

This is the same kid I gave epi to and the squad took him. I am a MA, not a nurse, so I don't assess vitals, but I'm not sure it wasn't a panic attack.

[WineRN]

Oooops...this is the one I read. If Raw Fruits Or Veggies Give You A Tingly Mouth, It's A Real Syndrome : The Salt : NPR

Oddly enough, I was talking today about oral allergy syndrome. And this may fit here. Does the student have a history of seasonal allergies?

Oral Allergy Syndrome | Symptoms & Treatment | ACAAI Public Website

Both of those articles are super interesting!

I was leaning towards anaphylaxis and needing the epi at the beginning (esp with the possible tongue swelling). But it definitely sounds like something triggered by an allergen to me. She might have been panicking because of her symptoms causing the elevated heart rate and BP.