Jim Mueller, 13 years old, is at a family picnic and drinking soda out of a can. When Jim swallows some soda, he realizes that a bee was in the soda can because he feels it sting him inside his throat. Jim has a history of allergy to bees. His mom rushes him to the emergency room.
Data Obtained From Nursing Assessment
Vital signs: pulse, 100; respirations, 24 and shallow; blood pressure, 88/58
Dyspnea
Lung sounds barely audible at bases
Cyanotic at lips and fingertips
Pale, cool skin
Pulse oximetry: 88%
History of hypertension
Lab Data
CBC and electrolytes within normal limits
Arterial blood gases
Pco2 50
Po2 70
pH 7.3
Current Drug Therapy
Propranolol, 40 mg PO bid
Plan
He is started on epinephrine, 0.3 mg of a 1:1,000 solution SC every 20 minutes until his blood pressure stabilizes and respiratory distress is no longer evident.
Data Obtained from Nursing Assessment (after two doses of epinephrine)
Vital signs: pulse, 90; respirations, 18 and regular; blood pressure, 110/72
Lung sounds clear, slightly diminished at bases
No cyanosis
Skin is pink, slightly cool
Pulse oximetry: 97%
Lab Data
No new data
Current Drug Therapy
Unchanged
CONSIDER THE CORE DRUG KNOWLEDGE FOR THIS DRUG
Why is Jim on this drug?
Are there any contraindications or precautions that would eliminate the use of this drug for Jim?
CONSIDER THE CORE PATIENT VARIABLES FOR THIS DRUG
What patient variables are most important to consider for Jim when assessing his drug therapy?
Are there any aspects of core drug knowledge that are especially relevant to consider because they may interact with the core patient variables?
Which of the findings from the nursing assessment demonstrate effectiveness of drug therapy?
Which of the findings from the nursing assessment demonstrate possible adverse effects from drug therapy?
CONSIDER THE NURSING MANAGEMENT NEEDED WITH THIS DRUG THERAPY
What actions are indicated to maximize therapeutic effects?
What actions are indicated to minimize adverse effects?
What teaching is required for Jim regarding his drug therapy? Do you need any additional data to determine appropriate teaching?
Question 1. Why is jim on this drug?
Answer . Jim was showing the signs of anaphylactic shock. There would be systemic vasodilation and broncho-spasm as a result of allergic reaction. Anaphylactic shock is lower down of Blood Pressure due to allergic reaction. As the Jim has history of allergic to bee, he might have preformed IgE antibody coating mast cells and basophills. And when these came in contact with bee poision immediate type 1 hypersensitive reaction starts due to profuse release of histamine and other inflammatory cytokines. First in the throat then systemic. It starts in seconds and spread in vascular system in minutes. These inflammatory cytokines and histamin cause bronchospasm that was reason of Dyspnea, diminshed lung sound which leads to decrease Partial pressure of Oxigen in blood results in cynosis (cynotic lips and finger tips) and low pulse oximetery. Reflexly respiratory rate wws also increased. It was also evident by pulse oximetry. As well as systemic vasodilation caused decrease in blood pressure. That was 88/58 against normal value of 110/70 mmHg. Reflexly heart rate increased by baro-receptor reflex . Here it was increased to 100/min against normal value of 70/min. It resulted in decreased perfusion to body organ so the skin is pale and cold.
Now to reverse this anaphylactic reaction. Therapeutic Agent which cause bronchodialation and systemic vasoconstriction was given. Stimulation of beta adrenergic receptor present in trachea, and lung as well as in vessels result in bronchodilation and vasoconstriction. Epinephrine is fast acting beta adrenergic receptor stimulant. It works in minutes. As soon as bronchodialation occured, There was relieve in respiration and blood Oxygen level. As soon as there was vaso constriction in the systemic vessels, Blood pressure was maintained.
Q2. Precautions and contraindications?
Epinephrine should be given precautionly who are on non-selective Beta receptor blocker. Jin have history of hypertension and taking propranalol. Propranalol is non selective beta blocker. Propranol and epinephrin are antagonist of each other. Epinephrine may remove the effect of propranalol and result in hypertension. So close monitoring on blood pressure needed if epinephrine is given to the patients who have history of hypertension and taking propranalol or other non selective beta blocker.
Cerebral hemorrhage and coronary may also occur if patient on non selective beta blocker.
Q3. Patient variables to consider?
1. Jin is 13 year old . So weight of Jim should be meaure to adjust the dose of adrenalin. Jim is given dose recommended for adult and childech more than 30 kg.
2. Jim is hypertensive so close monitoring is need .
Q4. Patient variable interactions?
1. Weight and height of patient: it is to consider to maintain bioavailability of drug in therapeutic range. Because volume of distribution is depend on size of body compartments whose depend on body weight and Height.
2. Hypertension with propranlol : epinephrin worsen the hypertension. Because epinephrin is beta agonist and propranalol is beta antagonist. Discussed in answer of Question 2
Q5. Finding to asses effectiveness
Answer : Blood pressure goes down from 88/58 to 110/72mmHg, showing there is vasoconstriction effect was adequate.
Diminished lung sound, pulseoximeter 88% to clear lung sound and 97% showing adequate bronchodilation effect.
Mechanism discussed in answer of Question1
Q.6. Finding of possible adverse effect.
Answer : pulse was 90/min after therapy. Which was 100/min before therapy. Blood presure is restored to normal but not pulse. It may be due to possible side effect of adrenaline. Adrenalin cause tachycardia. So pulse rate increases. Adrenalin act on beta receptor in heart and increase activity of pacemaker i.e. SA node. And result in increase heart rate. Which is responsible for high pulse rate.
Q7. To maximise therapeutic effect?
1. IV fluid may be given . It may help in restoring blood pressure.
2. Supplimented oxygen therapy should be given as Po2 level were decreasing as well as oxigen saturation .
These two additional intervention can increase the therapeutic effect.
Q8. Minimise side effect.?
Short acting beta blockers like esmolol , and calcium channle blocker like verapamil, diltiazam should be keep ready. And be used cautionly if there is hypertension, tachycardia after epinephrine shots.
Dose adjust by weight , height, drug history and , disease history can minimise the side effect. As in this case weight, height and history of hypertension and propranolol should be consider for dose calculation and time interval calculation. Interval may be increased to 30 min instead of 20 min to minimise side effects.
Q9 Patient teaching?
Answer :Patients would taught that he warn nurse if feel anxiety, palpitation, Nausea vomiting, chest pain, head ache, light headness, and diziness etc. These are possible side effects of adrenalin.
Q10. Additional data required?
These Data may required
Patient history of previous epinephrine therapy and side effect may help in patient teaching.
Family history of epinephrine therapy and side effect, chronic disease like asthma, hypertension, heart attack, myocardial ifraction may also help in managment strategy.
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