Case study - Anaphylaxis: Nursing

Nurse Milagros works on a Medical-Surgical unit and is caring for Jessica, a 32-year-old female with a history of intravenous drug use, who was recently admitted for endocarditis. After settling Jessica in her room, Nurse Milagros goes through the steps of the Clinical Judgement Measurement Model to make clinical decisions about Jessica’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes. 

First, Nurse Milagros recognizes important cues including Jessica’s vital signs, which are blood pressure 86/42 mmHg, heart rate 112 beats per minute, respirations 36 breaths per minute, and pulse oximetry 89 percent on room air.  

Upon auscultation, Nurse Milagros hears expiratory wheezes in all of Jessica’s lung fields and she also notes Jessica’s restless, fearful appearance. On closer inspection, Jessica appears flushed, and her lips are swollen.  

Next, Nurse Milagros analyzes these cues. She reviews the electronic health record, or EHR, and notes that Jessica has no known allergies to foods or medications. Also, Jessica hasn’t received any medications except the infusion of penicillin in the last four hours. Based on her assessment and recent infusion of penicillin, Nurse Milagros realizes Jessica is likely experiencing anaphylaxis.  

Now, using the information she's gathered along with Jessica’s medical history, Nurse Milagros chooses a priority hypothesis of impaired gas exchange. 

Then, she generates solutions to address Jessica's impaired gas exchange that will include pharmacologic and nonpharmacologic interventions; and she establishes the expected outcome that 30 minutes after intervening, Jessica’s respiratory status will stabilize.  

Nurse Milagros then takes action to implement these solutions. First, she stops the infusion of penicillin. Then, she calls the hospital operator and requests that a rapid response be called to Jessica’s room.  

Next, the intensivist arrives at the bedside, and gives a verbal order for a one-time injection of intramuscular epinephrine STAT. The nurse from the rapid response team retrieves the epinephrine from the unit’s crash cart and confirms the dose with Nurse Milagros. Nurse Milagros then injects it into Jessica’s left vastus lateralis muscle.  

Other staff members in the room assist Nurse Milagros, by placing Jessica in low-Fowler position, placing a non-rebreather mask over her nose and mouth and providing 100% oxygen at 10 liters per minute, infusing a rapid bolus of normal saline to expand Jessica’s circulating volume, administering the ordered IV diphenhydramine to block the release of histamine, and monitoring her vital signs every five minutes.  

After fifteen minutes, Jessica’s breathing becomes more regulated and she's able to speak.