Question

Case study: Allergies and Asthma

The school nurse is reviewing the medications of Dante,a fourth grader who has multiple allergies, including a severe nut allergy. Dante has asthma also and has been ordered the following metered dose inhalers:

  Ventolin (Salbutamol), 2 puffs, PO, TID, to be given at 0600, 1400 and, 2200.

  Atrovent (Ipratropium Bromide), 2 puffs, PO, TID, to be given at 0600, 1400 and, 2200.

  Flovent (Fluticasone), 2 puffs, PO, BID, to be given at 1000 and 2200

1. What education would be provided to the cafeteria staff to minimize the risk of Danté’s having an anaphylactic reaction?

2. What instructions would the school nurse provide to those who may be in a position to administer a single dose of epinephrine?

3. What assessment data would be essential to determine the effectiveness of the epinephrine for Danté before and after an anaphylactic reaction?

4. It is 2200 and your client should receive all three puffers. In what order would you administer these medications?5. If the patient developed acute asthma induced by beta-blockers, explain why he might not respond to being treated by a drug such as salbutamol.

6. Physician ordered 500mg of Levofloxacin IV. Pharmacy sent you a pre-made bag of Levofloxacin 500mg in a 100ml bag of NS for your patient. Physician order reads: administer Levofloxacin IV over 90 minutes. The drop factor of tubing is 60gtts/ml. What is the drip rate?

Answer 1

What education would be provided to the cafeteria staff to minimize the risk of Danté’s having an anaphylactic reaction?

Nut allergy is one of the most common food allergies. Tree nuts (almonds, cashews, walnuts, chest nuts, brazil nuts, pistachios, hazel nuts etc.) and pea nuts are not same, but usually occur in association means if one is allergic to nuts, there are higher chance of also being allergic to tree nuts or vice versa. But allergy to peanuts does not mean that there are higher chance of allergy to another legume.

Nuts can cause a severe, potentially life-threatening allergic reaction (anaphylaxis). Allergic reactions can be unpredictable, and even very small amounts of peanut can cause one. Hence it is important for cafeteria nurse to understand severity of nut allergy and manifestation of allergy and foods that can cause allergic reactions.

· Avoid obvious foods such as nuts, peanuts and products containing them like cookies,.

· Avoid butter(almond butter, peanut butter), sauces, sweets, puddings, ice creams, pizza, pancakes, and gravies like.

· Alternative nut butters, such as soy butter or sunflower seed butter can be used.

·

· Always read food labels to identify ingredients before giving if to child. Avoid labels which read as arachis oil (another name for peanut oil), goobers, ground nuts, lupin (a common flour substitute in gluten-free food), mandelonas (peanuts soaked in almond flavouring), mixed nuts, monkey nuts, nut meat, nut pieces, peanut butter, peanut flour, peanut protein hydrolysate

· Be careful for high risk of cross contact while cooking other dishes as a small amount may cause severe anaphylactic reaction.

· Highly refined peanut oil is not an allergen and studies show that most people with peanut allergy can safely eat this kind of peanut oil. But avoid cold-pressed, expelled or extruded peanut oil—sometimes called gourmet oils.

What instructions would the school nurse provide to those who may be in a position to administer a single dose of epinephrine?

· Anaphylaxis is unpredictable, and while a person may have a mild reaction one time, a serious or even life-threatening reaction can occur the next time. Person suffering with anaphylaxis may panic and be unable to assist with his/her own injection even if they have autoinjector with them.

· Epinephrine is the best treatment for anaphylaxis, and it works best if it is given within the first few minutes of a severe allergic reaction In addition, a quick response is necessary to prevent serious complications of anaphylaxis.

· Epinephrine should be stored at normal room temperature, away from extreme cold and heat.

· The epinephrine cartridge window should be examined periodically to ensure that the solution is colourless and contains no floating particles. Solutions that are discoloured or contain particles should be replaced.

· Other medicines that are used in the treatment of allergic reactions can help with some of the symptoms, like antihistamines in relieving itching, asthma inhalers can help with coughing and wheezing, but these medications do not treat the dangerous symptoms of throat swelling and low blood pressure and antihistamines when taken orally needs time to act.

· Epinephrine rapidly treats all of the most dangerous symptoms of anaphylaxis, however, it is not a perfect treatment, so allergic triggers should be avoided.

Seek medical assistance after administering injection.

3. What assessment data would be essential to determine the effectiveness of the epinephrine for Danté before and after an anaphylactic reaction?

A person who is having an allergic reaction needs epinephrine immediately if he/she:

· Is having trouble breathing, wheezing, repetitive coughing, swelling of the lips, tongue or throat

· Feels tightness in the throat.

· Feels lightheaded or thinks that he/she might pass out, is not responding,

· Confirmed history of eating a trigger food that previously caused very severe anaphylaxis and has any symptoms at all, even very mild symptoms.

· Has food allergies and is vomiting repeatedly shortly after eating, especially if these symptoms are accompanied by flushing or hives.

· or a combination of these symptoms.

For milder symptoms like a few hives, mild abdominal discomfort, or itching, your allergist may tell you to give another medication (eg antihistamine) first.

Post injection of Epinephrine:

Observe for improvement in symptoms- breathing difficulty will be relieved. Initially patient will improve within some minutes but still seek medical help. The reason for seeking medical attention is because of the allergic reaction, not because symptoms of the allergic reaction could return and require additional treatment.

It is 2200 and your client should receive all three puffers. In what order would you administer these medications?

Order should be :

First: Atrovent (Ipratropium Bromide), Anticholinergics, short acting, bronchodilator

Second: Flovent (Fluticasone), long acting Inhaled Corticosteroids

Third: Ventolin (Salbutamol), Beta–2 Agonists short acting, bronchodilator

If the patient developed acute asthma induced by beta-blockers, explain why he might not respond to being treated by a drug such as salbutamol.

Bronchoconstriction can occur, especially when non-selective beta-blockers are administered to asthmatic patients because b-blockers (inverse agonists) have an exactly opposite effect to b2-adrenoceptor agonists. This results from the fact that the acute administration of these drugs can produce bronchoconstriction by blocking the broncho dilating effects of endogenous adrenaline, or by inactivating constitutively active b2-ADRs, and can worsen asthma symptoms

Therefore, non-selective beta-blockers are contraindicated in patients with asthma or chronic obstructive pulmonary disease. Salbutamol has a preferential effect on beta2-adrenergic receptors so it will not be effective in treating the acute asthma because of drug interaction.

Physician ordered 500mg of Levofloxacin IV. Pharmacy sent you a pre-made bag of Levofloxacin 500mg in a 100ml bag of NS for your patient. Physician order reads: administer Levofloxacin IV over 90 minutes. The drop factor of tubing is 60gtts/ml. What is the drip rate?

Levofloxacin to be infused is 500 mg in 100 milliliter

Drop factor given is = 60 gtts / millilitre

Time in which it has to be infused = 90 minutes

Rate of infusion ?

On putting values in above formula – (since prescribed dose is 500 mg, supply is 500 mg in 100 ml so entire bottle has to be administered. Hence volume to be administered becomes100 ml)

= (100/90) X60

= 66.67 drops per minute

Can be rounded as 67 drops per minute.

Hence at the rate of 67 drops per minute is needed to infuse required dose over 90 minutes.