After an IM, vitals to be assessed after 15 min

Nursing Students Student Assist

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1st Semester nursing....

Hello,

My school does first rotations with clinics before hospitals, but I had a question regarding a patient I saw today.

I performed my first IM of antibiotics and we had the patient sit and wait 15 min and re-take vitals, then we let the patient leave.

Now I know for any allergic reactions, skin assessment should be noted, but my the nurse I was working with only looked at the vitals and let her go home.

LOOKING AT VITALS ONLY... what is something that would cue you that the pt. is having a reaction to the medication? and why?

I'll take references if you have any.

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Specializes in OB.

Think about this. What are the types of allergic reactions? What are the signs of each type of reactions?

Now, which of these signs might you see while assessing vital signs?

Thinking this through for yourself is part of the process of learning. Post your thoughts and we can tell you if you are heading in the right direction.

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... with an allergy reaction a patient may begin to feel flushed, swelling and hives.

..so with vitals I would think...

Elevated hr, rr bp and even temp.

I would also think the patient may start feeling anxious...

I should compare these vitals to the initial vitals and see if these numbers are different.

.... someone had mentioned dropped bp, and I couldn't understand why.. which initially brought me to post my question.

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... with an allergy reaction a patient may begin to feel flushed, swelling and hives.

..so with vitals I would think...

Elevated hr, rr bp and even temp.

I would also think the patient may start feeling anxious...

I should compare these vitals to the initial vitals and see if these numbers are different.

.... someone had mentioned dropped bp, and I couldn't understand why.. which initially brought me to post my question.

With low BP think about a severe allergic reaction in which someone has anaphylactic shock. What happens with shock, what changes do you see in blood pressure. Also if you haven't already look up the antibiotic that was given in a drug book, what are the side effects of that particular drug what are the nursing considerations it gives? At least in my program before we give any type of medication with our instructor to a patient we need to be able to verbalize why we are giving the med, what we expect it to do, what we need to assess before and after giving the med, some of the most concerning side effects of that med for that patient.

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1st semester students probably aren't familiar with shock yet, (I know I certainly wasn't).

Better to ask Ruby: Why does the patient become flushed?

What's the body doing that makes the skin change color?

Now think about what would happen in a severe allergic response, where this response can become system-wide.

Others have clued you in that it's anaphylactic shock, so try looking at what that means if you're coming up blank/haven't been exposed to this stuff yet.

Personally, I wonder if systemic signs of anaphylaxis would be showing up just 15 minutes after an IM. Can anyone confirm that?

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