facial edema and difficulty breathing

Esme12, ASN, BSN, RN · Jan 20, 2013

A 69 yr old Mexican American woman is admitted for total knee replacement surgery. Following surgery, an order was written for cefazolin sodium (Ancef) 2 gm intravenous piggybank every 8 hrs for 24 hrs. She received her first dose after surgery. Thirty mins after the medication was started, the patient calls the nurse and reports "itching all over" and difficulty breathing. The nurse notes facial edema and audible wheezing. The skin is red with large swollen blotches over her arms, trunk and back. Patient states, "I had this happen to me before when I took a drug called amoxil. The doctor said i am allergic to amoxi

Ok look at the data.....facial swelling blotches...What does that affect? what serious skin reaction can be cause by allergic reactions?....like Steven Johnson...Stevens-Johnson syndrome - MayoClinic.com

What can intense itching cause to happen to the skin integrity from scratching? Even though you are not supposed to do the care plan about anapahlyxis...you need to know about it.... to know what else it can do to the body. It is called anaphalytic shock...what does shock do...what does that affect. Anaphylaxis - MayoClinic.com

So you have might have.........

Ineffective Breathing pattern....swelling of the airway

Decreased Cardiac output....shock

Deficient Fluid volume....shock

Impaired Gas exchange....swelling

Impaired Skin integrity.....braking integrity from itching

Impaired Tissue integrity...poor perfusion from swelling.

Do you see where I am gong with this?

What about her surgery? Doe she have pain? Is she at risk for infection?

Do you see where this is going?

Esme12, ASN, BSN, RN · Jan 20, 2013

Hi I am only in my second week of nursing school and I am having trouble with my first case study. I have a case study about a patient who is having an allergic reaction to a medication. She is experiencing facial edema, red swollen blotches over her arms, trunk and back, itching, and difficulty breathing. Im suppose to have a nursing diagnoses and 3 interventions with rationales. The nursing diagnoses i decided to do is risk for impaired skin integrity but i don't really know what interventions to choose. For one intervention i was thinking to reduce sodium intake but i am not sure. My books I have dont have much on facial edema. Please help me. Ill take any tips. Thanks.

YOu still need to look up allergic reactions and anaphylaxis and understand that process to best develop a care plan. The swelling in allergic reactions have nothing to to with sodium consumption.

An allergy is a hypersensitivity disorder of the immune system.Allergic reactions occur when a person's immune system reacts to normally harmless substances in the environment. A substance that causes a reaction is called an allergen. These reactions are acquired, predictable, and rapid. Allergy is one of four forms of hypersensitivity and is formally called type I (or immediate) hypersensitivity. Allergic reactions are distinctive because of excessive activation of certain white blood cells called mast cells and basophils by a type of antibody called Immunoglobulin E (IgE). This reaction results in an inflammatory response which can range from uncomfortable to dangerous.
In some people, severe allergies to environmental or dietary allergens or to medication may result in life-threatening reactions called anaphylaxis.
Allergies - MayoClinic.com

nursingstu14 · Jan 20, 2013

yes, i do know where this is going thank you VERY MUCH! The case study has no information about pain or risk for infection and no further info on her surgery...

nursingstu14 · Jan 20, 2013

@psu_213 : I agree with you too now diuretics.I was confused about that i was just reading it from my care plan book.

During anaphylactic reaction certain interaction of chemicals with receptors on the surface of blood vessels causes the vessels to leak fluid into surrounding tissues, causing fluid accumulation, redness, and swelling. On the smooth muscle cells of the airways and digestive system, they cause constriction. On nerve endings, they increase sensitivity and cause itching.

Esme12, ASN, BSN, RN · Jan 20, 2013

yes, i do know where this is going thank you VERY MUCH! The case study has no information about pain or risk for infection and no further info on her surgery...

is this a real patient?

nurseprnRN, BSN, RN · Jan 20, 2013

I am looking in my NANDA-I book right now (and if you don't have one, this is the time to go online and get it, free 2-day shipping from Amazon for students) and find the following diagnoses that might (MIGHT) apply, based on the little you've told us.

(readiness for enhanced self-health management

impaired gas exchange

ineffective breathing pattern

risk for activity intolerance

ineffective airway clearance

risk for injury

risk for shock

impaired oral mucous membrane

risk for suffocation

impaired tissue integrity

impaired comfort

Note, the way you choose nursing diagnoses and write care plans is not "Pick diagnosis first, look for support second." You CANNOT use any of these unless you have support for them in the form of data from your assessment of the patient (including what you find in her chart).

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis (in your case, "Allergic reaction" is the medical diagnosis) and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it.

Yes, experienced nurses will use a patient's medical diagnosis to give them ideas about what to expect and assess for, but that's part of the nursing assessment, not a consequence of a medical assessment.

For example, if I admit a 55-year-old with diabetes and heart disease, I recall what I know about DM pathophysiology. I'm pretty sure I will probably see a constellation of nursing diagnoses related to these effects, and I will certainly assess for them-- ineffective tissue perfusion, activity intolerance, knowledge deficit, fear, altered role processes, and ineffective health management for starters. I might find readiness to improve health status, or ineffective coping, or risk for falls, too. These are all things you often see in diabetics who come in with complications. They are all things that NURSING treats independently of medicine, regardless of whether a medical plan of care includes measures to ameliorate the physiological cause of some of them. But I can't put them in any individual's plan for nursing care until *I* assess for the symptoms that indicate them, the defining characteristics of each.

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse. Even if your faculty forgot to put it on the bookstore list, get it anyway. Fake them out by how fast you learn to think like a nurse because of it.

nursingstu14 · Jan 20, 2013

This is not a real patient.

nurseprnRN, BSN, RN · Jan 20, 2013

And your point is? They must have given you some data. If they didn't then you can say things like, "IF the patient has thus-and-such data points, that is/those are defining characteristics of the nursing diagnosis X, and so my interventions would be Y, Z, A, B, C ..."

nursingstu14 · Jan 20, 2013

@GrnTea: i was responding to Esme12 about it being a real patient or not. Now, about what you responded I wasn't trying to choose diagnoses first and support second. From what information I was given I decided to have risk for skin integrity as my nursing diagnoses. I decided on that just because i believe its the best I can do based off from the background info provided. I wasn't given VS or anything of that sort so i cant really get much from what the case study included. Im trying my best. Im new to this and reading all the text books in trying to find good nursing interventions. I hope i didnt offend you in any way. I hope you dont think Im just trying to get answers. I really have no one to help me and I found this website and so far its helping me. I did however and take your advice and purchased the NANDA-l Nursing Diagnoses to help me. THank you.

Esme12, ASN, BSN, RN · Jan 20, 2013

This is not a real patient.

I actually think that makes it much harder.

Esme12, ASN, BSN, RN · Jan 20, 2013

@GrnTea: i was responding to Esme12 about it being a real patient or not. Now, about what you responded I wasn't trying to choose diagnoses first and support second. From what information I was given I decided to have risk for skin integrity as my nursing diagnoses. I decided on that just because i believe its the best I can do based off from the background info provided. I wasn't given VS or anything of that sort so i cant really get much from what the case study included. Im trying my best. Im new to this and reading all the text books in trying to find good nursing interventions. I hope i didnt offend you in any way. I hope you dont think Im just trying to get answers. I really have no one to help me and I found this website and so far its helping me. I did however and take your advice and purchased the NANDA-l Nursing Diagnoses to help me. THank you.

You do need a good care plan book......I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition they both have online care paln constructors that can be VERY helpful. GrnTea isn't' offended ....she and I tag team here helping the students....we like to have the students show us first so we best know where you are going off track to make you the best nurse you can be......((HUGS)).

We are here to help. give us the whole picture from the start and we'll guide you:)

KelRN215, BSN, RN · Jan 21, 2013

I cannot use the diagnoses of airway obstruction since its the most obvious diagnoses (according to my professor). That is the reason why i chose risk for impaired skin integrity. Thanks though =)
Since she has facial edema, excessive fluid retentions of the face, Im thinking for an intervention would be drug therapy on removing the excess fluid retention. My rationale would be if diuretics were prescribed it will increase kidney water and sodium excretion. Another intervention could be nutrition therapy, which can involve restrictions of both fluid and sodium intake to control fluid volume. And since she has itching and red swollen blotches an intervention can be some sort of ointment/medication to reduce the itching which will prevent the patient from scratching and making her blotches worse. If patient continues to scratch they can tear skin which will increase chance of skin infection/ integrity.
What do you guys think?

No. Can you, as a nurse, prescribe diuretics? Your interventions need to be NURSING interventions. Medications are medical interventions. "Medicate as ordered" may be an appropriate nursing intervention in some situations (mainly pain) but if you- as a nurse- cannot intervene by deciding that the patient needs diuretics or ointment. This patient will undoubtedly receive an antihistamine but that has to be ordered by the physician.

Also, this patient is not experiencing edema because of an issue with fluid retention. You need to look up the pathophysiology of anaphylaxis. The patient also doesn't have a chronic problem with edema that would warrant dietary modifications... this patient has something acute going on that needs to be addressed NOW before she arrests.

Impaired skin integrity is WAY DOWN on your list of priority nursing diagnoses for this patient.