HELP: anaphylactic attack

sharona97, BSN, RN · Mar 4, 2010

Within my scope of licensure I would contact MD in a clinic setting, have the epi already there , (I'm assuming since you know it's a full blown ana shock you've done the ABC's) give it and of course from there continue assessing the ABC's. Also I would have been monitoring vitals post-epi. Clinical settings in an emergency are set up so differently with protocol than say a hospital or I'm guessing a nursing home.....I really don't know. In my case when I have done clinical work I've followed that protocol. In the hospital I've followed that protocol.

Sharona

Stacey1234 · Oct 7, 2016

My answer will probably take more than one person. I work in acute care so that is usually available

1 open the patients airway ABCs

2 vital signs. Since you will need this for calling the md

3 notify md since you will need orders for meds

4 Epi subq

5 Benadryl oral

6 methypredisolone iv

oxygen will not help if the airway is blocked and iv access will not help if the patient is not breathing Immediate action is necessary and these questions are tough. As always the right answer is not right. The most correct answer is right a la nclex

allnurses Guide · Oct 7, 2016

You won't be able to open the airway if it is due to swelling from anaphylactisis. You have to stop the reaction or at least get it under control ASAP. You can then secure the airway with an ETT if necessary, but jaw thrust/head tilt are going to have little to no effect in this type of patient.

AliNajaCat · Oct 8, 2016

a. Initiate oxygen at 2L/min per nasal cannula
b. Administer albuterol (Proventil) via a nebulizer
c. Initiate IV access with a large-bore (18 ga.) catheter
d. Administer epinephrine (Adrenalin) 0.3 mL subcutaneously
e. Obtain a full set of vital signs
f. Initiate oxygen at 15L/min per non-rebreather mask
g. Administer cimetidine (Tagament) IV piggyback
h. Notify the physician
i. Initiate an epinephrine infusion intravenously
j. Administer diphenhydramine (Benadryl) orally
k. Apply an ice pack to the site of the skin test
l. Apply zinc & iron oxide (Calamine) lotion to the reddened blotches
m. Open the patient's airway
n. Attach the patient to the cardiac monitor
o. Administer methylprednisolone (Solumedrol) intravenously

Basic problem with this question as formatted: Most of those actions are not within the registered nurse's scope of practice unless there are standing protocols for every patient there. Even then, the protocols need to say something like, "If airway impingement, give this med / O2..." YOU cannot decide to give epinephrine or SoluMedrol or oxygen or any of those meds without such legal backup.

So. When your instructor asks you this question, you have two choices. First, you say, "I would have somebody else call the physician/rapid response team/911 (depends on where you are) and get the code cart, sit the patient up, get him on the monitor for EKG and SpO2 and check vital signs, and not take my eyes off him for a second, and when the code cart gets there, start the IV before he crashes." Second, whether or not she asks you about all those meds or other actions, say, "They aren't in my scope of practice to prescribe, but I would anticipate the physician to call for X for this reason then Y for this reason, then Z for this reason." Then justify the rest of the list in priority order-- airway first, VS maintenance second, reversing/blocking the allergic reaction concomitant.

Take the Calamine home for when your kid gets poison ivy out back.

allnurses Guide · Oct 8, 2016

Basic problem with this question as formatted: Most of those actions are not within the registered nurse's scope of practice unless there are standing protocols for every patient there. Even then, the protocols need to say something like, "If airway impingement, give this med / O2..." YOU cannot decide to give epinephrine or SoluMedrol or oxygen or any of those meds without such legal backup.
So. When your instructor asks you this question, you have two choices. First, you say, "I would have somebody else call the physician/rapid response team/911 (depends on where you are) and get the code cart, sit the patient up, get him on the monitor for EKG and SpO2 and check vital signs, and not take my eyes off him for a second, and when the code cart gets there, start the IV before he crashes." Second, whether or not she asks you about all those meds or other actions, say, "They aren't in my scope of practice to prescribe, but I would anticipate the physician to call for X for this reason then Y for this reason, then Z for this reason." Then justify the rest of the list in priority order-- airway first, VS maintenance second, reversing/blocking the allergic reaction concomitant.
Take the Calamine home for when your kid gets poison ivy out back.

This isn't prescribing a medication. This is responding to an emergency. This could be an instance where a prescribing provider wasn't immediately available, and most healthcare facilities have a system in place for such emergencies i.e. standing protocols. This also just ACLS algorithms/medications, which could be what the student is being tested on.

Double-Helix, BSN, RN · Oct 10, 2016

Nursing school questions will generally assume you have an order unless told otherwise. If the NCLEX asks: "After administering an IM injection, your patient develops urticaria, becomes hypotensive and complains of shortness of breath. What medication do you anticipate administering first?" You better believe they aren't looking for an answer of "Whatever the physician orders."

AliNajaCat · Oct 10, 2016

This isn't prescribing a medication. This is responding to an emergency. This could be an instance where a prescribing provider wasn't immediately available, and most healthcare facilities have a system in place for such emergencies i.e. standing protocols. This also just ACLS algorithms/medications, which could be what the student is being tested on.

Nursing school questions will generally assume you have an order unless told otherwise. If the NCLEX asks: "After administering an IM injection, your patient develops urticaria, becomes hypotensive and complains of shortness of breath. What medication do you anticipate administering first?" You better believe they aren't looking for an answer of "Whatever the physician orders."

I disagree with both of these outlooks. I could tell you hair-raising legal stories about people "responding to an emergency" with medications and other treatments for which there were no prescriptions or protocols in place. You can NEVER assume that, and teaching students that you can does them a grave disservice. Also, NCLEX makes no such assumptions about protocols being in place. The student who responds to such a question by acting outside nursing scope of practice has just gotten that one very wrong. You are correct, they do say, "What medication do you anticipate administering first?" for precisely that reason. If the question doesn't say that, then it doesn't say that.

The way the question was original posted, the question wasn't, "What do you anticipate...?" Nor does it say, "We're doing ACLS."

What are the top three priority nursing interventions and brief rational? (sic) (it's "rationale.")

You will note that I did say,

When your instructor asks you this question, you have two choices. First, you say, "I would have somebody else call the physician/rapid response team/911 (depends on where you are) and get the code cart, sit the patient up, get him on the monitor for EKG and SpO2 and check vital signs, and not take my eyes off him for a second, and when the code cart gets there, start the IV before he crashes." Second, whether or not she asks you about all those meds or other actions, say, "They aren't in my scope of practice to prescribe, but I would anticipate the physician to call for X for this reason, then Y for this reason, then Z for this reason." Then justify the rest of the list in priority order-- airway first, VS maintenance second, reversing/blocking the allergic reaction concomitant.

Critical thinking is key here, both in answering test questions and in responding to threads with clinical components.