Video Case Study - Caring for Patients With Anaphylaxis

Nurse McKenzie works on an inpatient medical-surgical unit, and is caring for Demetrius, a 56-year-old, who was admitted for pyelonephritis. In collaboration with the registered nurse, RN Anita, Nurse McKenzie goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Demetrius’ care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse McKenzie recognizes important cues, including Demetrius’ vital signs, which include temperature 100.4 F or 39 C, heart rate 110 beats per minute, respirations 23 breaths per minute, blood pressure 100/58 mmHg, and oxygen saturation of 91 percent on room air.

She notices that Demetrius’ face is flushed, he has a has a worried expression, and that he’s short of breath. Nurse McKenzie auscultates his lung sounds and notes expiratory wheezes bilaterally. She also sees that ceftriaxone is currently infusing through Demetrius’ intravenous line along with normal saline.

Next, Nurse McKenzie analyzes these cues. She reviews the electronic health record, or EHR, and notes that the infusion of ceftriaxone was started 10 minutes ago by RN Anita. She also sees that Demetrius has no documented allergy to ceftriaxone but understands that if Demetrius received the antibiotic in the past, that this first exposure may have caused his body to produce antibodies against it, sensitizing him, a process where certain immune cells, called T lymphocytes are activated and stimulate B lymphocytes to secrete IgE antibodies into the bloodstream.

These IgE antibodies then bind to the surface of other cells, called mast cells and basophils, which are full of granules that contain proinflammatory molecules like histamine. Then, on his second exposure, the mast cells and basophils, which already have IgE antibodies on their surface, release their proinflammatory molecules, triggering an allergic reaction.

Nurse McKenzie also understands that histamine plays a major role in allergic reactions by causing blood vessel dilation and increased permeability, meaning that while blood vessel diameter and blood flow to the affected area increase, fluid is also allowed to leak out the blood vessel wall more easily and get into the interstitial space between cells. This can manifest as erythema, or redness; swelling called angioedema; and a drop in blood pressure. At the same time histamine can cause the smooth muscle that lines the bronchi to constrict, making it harder for air to get through, resulting in respiratory symptoms like shortness of breath, coughing, or wheezing. Nurse McKenzie realizes Demetrius is likely experiencing anaphylaxis and needs immediate airway management.

Now, using the information she has gathered, along with Demetrius’ medical history, Nurse McKenzie stops the infusion of ceftriaxone and reports her findings to RN Anita; and together they choose a priority hypothesis of ineffective breathing pattern.

Then, they generate solutions to address Demetrius’ ineffective breathing pattern that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Demetrius will maintain a patent airway.