Anaphylactic shock

Cagayan de Oro College-PHINMA

Cagayan de Oro College-PHINMA

College of Nursing

A Case Study of

Anaphylactic Shock

Submitted to:

Mr. Arsenio S. Poral, Jr., RN, MAN (c)

Submitted by:

Carmelli Mariae H. Calugay

BSN-IV

September 1, 2015

I. INTRODUCTION

a. Overview

Anaphylaxisis an alarming emergency situation because of its rapid onset which may lead to death within a short

period of time. Despite of its fatalities, death and the irreversible damage it caused, anaphylaxis is not always recognized thus, studies may underestimate the incidence (Soar et al, 2008). Anaphylaxis is not a reportable disease and the true incidence is unknown as concluded by Sheikh and colleagues (2012)due to perplexity of its diagnosis, treatment and investigation; limited data on fatal anaphylaxis; and non-compliance for outpatient follow-up of its victims. Time trends for anaphylaxis fatalities are not properly presented.Definition

Anaphylactic shockis a severe, life-threatening, generalized or systemic hypersensitivity reaction characterized by rapidly developing critical tribulations on airway / breathing and circulation usually associated with skin and mucosal changes, as defined by theEuropean Academy of Allergology and Clinical Immunology Nomeclature Committee.It is a circulatory shock state resulting from severe allergic reaction producing an overwhelming systemic vasodilatation and hypovolemia (Smeltzer & Bare, 2004).Epidemiology

In the study of Soar and colleagues (2008), the American College of Allergy,Asthmaand Immunology reported that the overall frequency of episodes of anaphylaxis lies between 30 and 950 cases per 100, 000 persons per year and a lifetime prevalence of between 50 and 2000 episodes per 100, 000 persons or 0.05-2.0%.Death immediately occurs after the contact with the trigger if anaphylaxis is fatal, called anaphylactic shock. From a case-series, fatal food reactions cause respiratory arrest typically after 30-35 min; insect stings cause collapse from shock after 10-15 min; and deaths caused byintravenous medicationoccur most commonly within 5 min. Death never occurred more than 6 hours after contact with the trigger (Soar et al, 2008).Causative Agents

Trigger factors include foods, insect venoms (sting), medications, anesthetics, natural rubber latex and exercise (Sheikh et al, 2012); allergens such as plant pollens, dust, mold spores and chemicals in cosmetics (Scanlon & Sanders, 2007);blood products and contrast agents (Smeltzer & Bare, 2004).b. Objective of the Study

The objective of this study is to be able to:

1. Acquire knowledge about the disease process.

2. Discuss thoroughly the disease process.

3. Formulate realistic and appropriate nursing care plans.

4. Identify and learn more about the treatment and modalities of the said disease

5. Apply the nursing process and appreciate its significance in nursing practice.

c. Scope and Limitation of the Study

This study covers about facts related to patients condition. It includes the nature, causes, signs and symptoms, Pathophysiology, prognosis, treatment and the nursing interventions appropriate for his condition. A nursing care plan is also provided which serves as a guide for the interventions to be applied to the patient to aid in recovery and it will also serve as basis for the evaluation of client care outcomes. Health teachings including referrals were also imparted to the patient and the watcher to ensure his recovery during hospital stay and after discharge.

It is limited only to the case of our client. For the completion of this study, some information was taken from significant others. The assessment and so with the interventions rendered to the patient were also limited due to time constraint, with a total of 2 days, dated January 26 and 27 of 2015. Thus, weve supplemented our study with facts from various references.

d. Patients Profile

Name:

L.S.

Address:

Block-3, Puntod, Cagayan de Oro, Misamis Oriental

Sex:

Female

Age:

48 years old

Birth date:

March 26, 1966

Place of Birth:

Iligan City

Occupation:

None

Civil status:

Married

Nationality:

Filipino

Religion:

Roman Catholic

Date of Admission:

January 18, 2015

Time of Admission:

1:30 am

Chief Complaint:

Loss of consciousness

Admitting Diagnosis:T/C Hemorrhagic stroke at the right fronto-temporal area; hypertension; Intracranial hemorrhage left basal ganglia

Attending Physician: Dr. Talabucon

e. Medical History

Upon assessment, significant others said that the client is known to be hypertensive. She has maintenance of antihypertensive drugs. At first, she religiously takes those but later on, she only complies whenever she felt the symptoms of hypertension.

f. Social History

The patient is reasonably sociable. According to her daughters, their mother is caring and kind. She used to be friendly and kind to people.

g. Family History

According to the patients daughters, they have a family history of hypertension. Therefore, it is hereditary.

h. History of Present Illness

This is the case of patient L.S., who was admitted in Polymedic Medical Plaza at their Intensive Care Unit area last January. She was already known for being hypertensive. She has maintenance of antihypertensive drugs like vascor and Metoprolol.

For straight three days prior to admission, she had headache, until she suddenly lost her consciousness prior to admission.

She was brought to the hospital by her family. They were the ones assisted her on the emergency room.

Upon her arrival at the hospital at the emergency department, she was catered under the care of Dr. Talabucon. They just found out after checking her vital signs and signs and symptoms that she just had a stroke (Hemorrhagic stroke).

i. Chief Complaint

The patient lost her consciousness, and was brought to the hospital because of this.j. Diagnosis/Impression

She was then diagnosed to have hemorrhagic stroke at right fronto-temporal area; Intracranial hemorrhage at left basal ganglia.

II. GROWTH AND DEVELOPMENT

Developmental theories of learning have to do with the additional learning tasks individuals can accomplish as they mature mentally, emotionally, and physically. Although this maturation actually progresses in slow, continuous fashion, it is often described as proceeding in stages.

Many names are associated with developmental research. The following people and their stages of development are important in the field of development theoryFREUDS PSYCHOSEXUAL THEORY

Genital Stage: 13 yrs and above

Freuds advanced a theory of personality development that centered on the effects of the sexual pleasure drive on the individual psyche. At particular points in the developmental process, he claimed, a single body part is particularly sensitive to sexual, erotic stimulation.

Based on Sigmund Freuds Psychosexual Stages of development our client belongs to the genital Stage. Characteristics of this stage are that energy of a person is directed toward full sexual maturity and function and development of skills needed to cope with environment as well as its demands. The patient is able to achieve independence and able to practice decision-making. But this condition the patient needs support from family in activities of daily living as well as decision making to his present condition.

PIAGETS COGNITIVE DEVELOPMENT THEORY

Formal Operations Phase: 11- 15 and above

In this developmental theory, our patient belongs to FORMAL-OPERATIONAL wherein logical reasoning processes are applied to abstract ideas as well as concrete objects. This is the time when people are most capable of forming new concepts and shifting their thinking in order to solve problems and general concepts are related to specific situations and alternatives are considered.

III. ANATOMY AND PHYSIOLOGY

Anatomy and PhysiologyAnaphylactic shockis a multisystem failure resulted from inadequate tissue perfusion involving function shut-down of cardiovascular system, respiratory system, urinary system, circulatory system, nervous system, integumentary system and gastrointestinal system. The principal reason for anaphylactic shock is the over-activity of the immune system resulting in a systemic inability to thrive.An allergyis a hypersensitivity to a particular foreign antigen, called anallergen. When the immune system over-reacts to the allergen, it causes hypersensitivity producing tissue damage. Theantigenis a chemical marker that identify cells whether self or non-self (foreign body).Antibodies, also called immune globulins (IgE) or gamma globulins, attached to antigens to label them for destruction of foreign body (Scanlon & Sanders, 2007).During an allergic response, the immune system produce areIgE antibodies, which bond to mast cells. Mast cells release chemicals such as histamine and leukotrienes. These chemicals contribute to the process of inflammation by increasing the permeability of capillaries and venules. Tissue fluid collects and more WBCs are brought to the damaged area. In the case of anaphylactic shock, allergy mediators flooded the body causing severe inflammation (Scanlon & Sanders, 2007; Sheir et al, 2006).IV. PATHOPHYSIOLOGY

Definition

In intracerebral hemorrhage, bleeding occurs directly into the brain parenchyma. The usual mechanism is thought to be leakage from small intracerebral arteries damaged by chronic hypertension. Other mechanisms include bleeding diatheses, iatrogenic anticoagulation, cerebral amyloidosis, and cocaine abuse.

Intracerebral hemorrhage has a predilection for certain sites in the brain, including the thalamus, putamen, cerebellum, and brainstem. In addition to the area of the brain injured by the hemorrhage, the surrounding brain can be damaged by pressure produced by the mass effect of the hematoma. A general increase in intracranial pressure may occur.

Precipitating and Predisposing Factors

Pathophysiological DiagramPathophysiologyAnaphylactic agentsmay enter the body through ingestion, inhalation, direct skin contact/topical, sting, transfusion and injections. Antigen will identify the allergens as non-self (foreign body). Mast cells will release chemicals and binds with antibodies IgE leading to an inflammatory reaction. Anaphylactic shock occurs when overresponding of allergy mediators occur, causing systemic vasodilatation and increase capillary permeability resulting to poor tissue perfusion. Poor tissue perfusion and hypovolemia resulted to shock (Scanlon & Sanders, 2007; Sheir et al, 2006; Smeltzer & Bare, 2004).V. MEDICAL MANAGEMENT

A. Doctors Order

Progress NotesDoctors OrderImplication

1-17-2015

12:30 pm

BP = 180/100

HR = 116

RR = unstable

T= 38.0C

Wt.= not taken

Please admit to ICU under Dr. Talabucon

Secure consent

Vital signs every hour

BP every 30 minutes

NPO

IVF: PNSS iL @ 30 gtts/min

LABS:

Cranial CT-scan

CBC, U/A, BUN, Na, K

Chest x-ray, AP

ECG

HGT

MEDS:

Omeprazole 40 mg IVTT now then OD 7am

Citicoline i gm IVTT now then q8HParacetamol 300 mg IVTT now then q4H PRN> Admit the pt. to an appropriate department for care; for management

> Agreement that the patient will submit to the care; for legal purposes

> Monitors vital signs, normal and abnormal values

> Appropriate diet, nothing per orem

> For fluid and electrolyte balance

> To check for possible cause of illness/ relation to disease condition

> Pharmacologic management

1-17-2015

4:40 pmInsert NGT> For nutrition; feeding

1-25-2015

3:20 am

BP = 160/100Resume Nicadipine drip: 10mg/10ml Amp + PNSS 90ml @ 3 cc/hr

Hold Nicardipine drip if BP < 140 mmHg> Pharmacologic management;

To have target BP of 140-150 mmHg

> To prevent fluctuation of BP

1-25-2015

2:30 pmChange EVO bottle and tubing> To prevent infection

B. Laboratory result

Date: 1-23-15ResultNormal RangeInterpretation

HemoglobinLow - 11.8 g/dL12.2-16.2 g/dLDecrease in hemoglobin is a sign hemorrhage.

HematocritLow - 36.7 %37.7 47.9 %

Decreased hematocrit is a sign of hemorrhage.

White Blood CellsHigh- 10.98 x 10^9/L5.0-10.0 x 10^9/LIncreased no. of WBC is a sign of infection, or leukocytosis

SegmentersHigh - 74.30.5-0.7Increased no. may be a sign of infection, or inflammation

CreatinineLow 0.63 0.70 1.30Decreased no. may be a sign of low muscle mass

PotassiumLow - 3.253.50 - 5.50Decreases no. may be a sign of hypokalemia

CT scans (without contrast enhancements)

Sensitivity= 16%

Specificity= 96%

MRI scan

Sensitivity= 83%

Specificity= 98%

C. Drug Study

Name of Drug:

Citicoline (Zynerva) i gm/tabClassification:

Central Nervous System Drugs (CNS stimulants /Neurotonics)Mechanism of Action: increase dopamine receptor densities, and suggest that CDP-choline supplementation can ameliorate memory impairment caused by environmental conditions.Specific Indication: CVA in acute and recovery phase.w/ symptoms and signs of

cerebral insuffiency; dizziness, headache and recent crania

trauma.

Contraindication: Hypersensitivity; Contraindicated in hypertonia of the

parasympathetic meclofenoxate (clophexonate).

Side Effects/Toxic Effects: It stimulates parasympathetic action and fleeting and discreet hypotensor effect.

Nursing Precaution: Use cautiously in patients& observe proper dosage, take vital signs

Before Giving the medication can cause sudden drop of vital signs.

Name of Drug:

Metoprolol (Metoprolol Tartate) 100mg i tabClassification:

antihypertensive, anti- anginas

Mechanism of Action: Bocks stimulation of beta adrenergic receptor; doest not usually affect beta2- adrenergic receptor sites.

Specific Indication:

Hypertension, prevention of M.I. and decreased mortality in

patients with recent M.I. management of stable angina,

Symptomatic heart failure due to ischemic hypertensive or

cardiomyopathic origin

Contraindication:

Hypersensitivity

Side Effects/Toxic Effects: Dizziness, fatigue, anxiety, drowsiness, nervousness, erectile

Dysfunction, hyperglycemia, back pain, dry mouth

Nursing Precaution: Monitor for possible drug induced adverse reactionsName of Drug:

Captopril (Conamid) 25mg tab i tabClassification:

Angiotensin- converting enzyme ace inhibitorsMechanism of Action: It blocks the conversion of angiotensin1 to the vasoconstrictor angiotensin2. It also prevents degradation of bradykinin and other vasodilatory prostaglandins.


alone or with other agents in the management of hypertension.

Contraindication:

hypersensitivity; history of angioedema with previous use of ace

Inhibitors

Side Effects/Toxic Effects: dizziness, drowsiness, fatigue, headache, weakness, cough, dyspnea

Nursing Precaution: Monitor for possible drug induced adverse reactionsName of Drug:

Valsartan 20mg Classification:

Angiotensin 2 receptor antagonist; AntihypertensivesMechanism of Action: blocks vasoconstrictor and aldosterone producing effects of angiotensin 2 at receptor sites including vascular smooth muscles and adrenal glands.


alone or with other agent in the management of hypertension

Contraindication: Hypersensitivity

Side Effects/Toxic Effects: Headache, dizziness, anxiety, depression, fatigue, weakness

Nursing Precaution:

use cautiously in CHF patients may result oliguria, acute renal

Failure.

Name of Drug:

Tranexamic acid / Hemostan 800 mg

Classification:

cardiovascular drugs/ hemostaticsMechanism of Action: Tranexamic acid is a competitive inhibitor of plasminogen activation, and at much higher concentrations, a noncompetitive inhibitor of plasmin.Specific Indication: control of hemorrhage in surgical and clinical cases, hemostatics for traumatic injuries.

Contraindication: severe renal insufficiency, patients with microscopic hematuria

Side Effects/Toxic Effects: GI disturbances, giddiness, hypotension, color vision disturbances.

Nursing Precaution: Use with caution in patients with thromboembolic disease.NURSING ASSESSMENT

Complete Physical Assessment

Time Assessed: 3:00 P.M.

Initial Vital Signs:

Temperature: 36.3 C

Pulse Rate: 77 cpm

Respiratory Rate: 16 cpm

Blood Pressure: 160/90 mmHg

General Appearance:

The pt. is lying on bed, stuporous with an IVF of PNSS regulated @ 20cc/hr 840ml. level infusing well @ right hand.

With Nasogastric Tube inserted.

With Foley catheter inserted.

With endotracheal tube inserted.

With EVO bottle at left side of head.

Area AssessedTechnique UsedNormal FindingsActual FindingsAnalysis

SKIN

colorInspectionTanPale Due to decrease oxygen supply.

Texture PalpationSmooth, softSmooth, softNormal

TurgorPalpationSkin snaps back immediately

When pinchedSkin snaps back immediately

When pinchedNormal

Hair DistributionInspectionEvenly distributedEvenly distributedNormal

TemperaturePalpationWarm to touchWarm to touchNormal

MoisturePalpationDry, skin folds are normally moistDry, skin folds are normally moistNormal

NAILS

Color of Nail bedInspectionPink and clearPink and clearNormal

Texture PalpationSmoothSmooth Normal

Shape InspectionConvex curvatureConvex curvatureNormal

Nail base InspectionFirm FirmNormal

Capillary refill timeBlanch test2-3 seconds4 sec.Due to decrease oxygen supply.

HAIR

Color Inspection Black (varies)Black (varies)Normal

Distribution InspectionEvenly distributedEvenly distributedNormal

MoistureInspectionNeither excessively dry nor oilyNeither

excessively dry nor oilyNormal

Texture Inspection Silky, resilientSilky, resilientNormal

HEAD

Scalp symmetryInspection

Symmetrical

Symmetrical

Normal

Skull sizeInspection NormocephalicNormocephalicNormal

Shape Inspection and PalpationRoundRound Normal

Nodules/ massesPalpation Absence of nodules and massesAbsence of nodules and massesNormal

FACE

Symmetry

Inspection

Symmetrical SymmetricalNormal

Facial movementInspection

SymmetricalSymmetricalNormal

Skin colorInspection Tan Pale Due to decrease oxygen supply.

EYES

EyebrowsInspection Symmetrically aligned, equal movementSymmetrically aligned, equal movementNormal

Eyelashes InspectionSlightly curved upwardSlightly curved upwardNormal

EyelidsInspectionSmooth, tan, do not cover pupil as sclera, close symmetricallySmooth, tan, do not cover pupil as sclera, close symmetricallyNormal

Ability to blinkInspectionBlinks voluntarily and bilaterallyBlinks involuntarily.Due to damage of Brocas area.

Frequency of blinkingInspection20 blinks per min.To speech.Due to damage of Brocas area.

Ocular movement Inspection Eye moves freely Lack of eye movementDue to damage of Brocas area.

Position Inspection Drawn from lateral angleDrawn from lateral angleNormal

Size InspectionMedium Medium Normal

Texture PalpationMobile, firm and non-tenderMobile, firm and non-tenderNormal

CONJUCTIVA

Color Inspection Transparent with light colorTransparent with light colorNormal

Texture Inspection Shiny and smoothShiny and smoothNormal

Presence of lesionsInspection No lesionsNo lesionsNormal

APPARATUS

Cornea

Color Inspection Black Black Normal

Texture Inspection Shiny and smoothShiny and smoothNormal

PUPILSColor Inspection Black BlackNormal

Reaction to light Inspection Pupils Equally Round and React to Light Accommodation (PERRLA)Pupils Equally Round and React to Light Accommodation (PERRLA)Normal

Size Inspection EqualEqual Normal

Shape Inspection Round and constrict brisklyRound and constrict brisklyNormal

Symmetry InspectionEqual in sizeEqual in sizeNormal

Visual Acuity InspectionAble to real news printCannot able to real news print.Due to damage of the left hemisphere of the brain.

Visual FieldsInspection When looking straight ahead, client can see objects in peripheryWith clear vision and can classify objects in periphery.Normal

Ocular Inspection Eyes move freelyEyes move freelyNormal

NOSE

Symmetry, shape, size and colorInspection Symmetrical, smooth and tanSymmetrical, smooth and tanNormal

Mucosa colorInspection

Reddish to pinkishReddish to pinkishNormal

NASAL SEPTUM

NaresInspection Oval, symmetricalOval, symmetricalNormal

Nasal dischargeInspection No dischargeNo dischargeNormal

SinusesInspectionNot tenderNot tenderNormal

MOUTH

Secretion

Inspection

(neutral in color) without mucus production

With mucus production

Due to tracheobronchial secretion

Lips

Color Inspection Pinkish to slightly brownDark and brown and cracking lipsDue to decrease oxygen level

Symmetry Palpation Symmetrical SymmetricalNormal

Texture Palpation Soft, moist, smoothCrack, rough sNormal

Moisture Palpation Soft and moistDry Due to decrease oxygen.

HEART

Heart rateAuscultation 60-100bpm77 bpmNormal

Heart soundsAuscultation Clear, without cracklesClear Normal

Lung fieldAuscultation Resonant Resonant Normal

THORAX & LUNGS POSTERIOR THORAX

Symmetry Inspection

Symmetrical Symmetrical

Normal

Respiratory rateInspection 12-20cpm16 cpmNormal

Spinal AlignmentInspection Spine vertically alignSpine vertically alignNormal

Skin integrity Inspection Skin intact Skin intactNormal

ANTERIOR THORAX

Breathing patternAuscultation Breathing is automatic and effortless, regular and even and produces no noiseBreathing is with effort, and produces

noiseDue to orthopnea

Lung/ breath soundsAuscultation Bronchia-vesicular, produces no noiseHas cracklesDue to retained secretions

ABDOMEN

Contour Inspection Flat Flat Normal

Texture PalpationSmooth Smooth Normal

Frequency and characterAuscultation

Audible; soft gurgling sound occur irregularly and rages from 5-30 minsAudible; soft gurgling sound occur irregularly and rages from 5-30 minsNormal

UPPER EXTREMITY

Skin color

Movement Inspection

Inspection Tan

With ROM and sensation Pale

With no ROM and sensationDue to decrease oxygen

Due to neuromuscular impairment

Size (arms)InspectionEqualEqual Normal

Symmetry InspectionSymmetricalSymmetricalNormal

Hair distributionInspectionEvenly distributedEvenly distributedNormal

LOWER EXTREMITY

Skin color

Movement Inspection

Inspection Tan

With ROM and sensationPale

With no ROM and sensationDue to decrease oxygen

Due to neuromuscular impairment and (+) weakness on right lower extremities.

Size (legs)InspectionEqualEqualNormal

SymmetryInspectionSymmetricalSymmetricalNormal

Hair distributionInspectionEvenly distributedEvenly distributedNormal

NEUROLOGICAL

Level of consciousnessInterview Can follow instructions and commandsUnconsciousDue to decrease level of consciousness.

Behavioral and appearanceInterview Makes eye contact with the examinerDoes not make eye contact with the examiner.Due to decrease level of consciousness

Mood Interview Expresses feelings which corresponds to the examinerExpresses feelings which corresponds to the examinerNormal

MENTAL STATUS

Orientation Interview Oriented with timeDisoriented with time Due to decrease level of consciousness

TIME

Recall recent and remote memoryInterview Recall events readily, immediate recall of remote informationCannot recall events readily, immediate recall of remote informationDue to aphasia.

Judgments and thoughtsInterview Can make logical decisionsCannot make logical decisionsDue to decrease level of consciousness

VI. NURSING MANAGEMENT

IDEAL NURSING CARE PLAN

Nursing DiagnosisDesired OutcomeInterventionsRationale

Altered Cerebral Tissue Perfusion related to interruption of blood flow as evidenced by altered level of consciousness and changes of motor responses The patient will be able to demonstrate behaviors, and verbalizes knowledge condition, therapy regimen.INDEPENDENT:

> Monitor patients vital signs and changes in mentation.

>Observe a close monitoring for any signs of sudden chest pain, respiratory distress and restlessness.

>Assess visual personality, sensory / motor changes such as headaches, dizziness, and altered mental status.

>Elevate the bed about 30 degrees and maintain head /neck in midline or neutral position.

DEPENDENT:

>Administer medications as prescribed by the attending physician.-This is to check the patients condition and mental status for further treatment to be rendered.

-This is to ensure that he patient is safe from getting worse of the condition and to be given management in early time

-This is to ensure that the patients condition is monitor and to check for any progress in the status.

- This is to promote circulation and venous drainage.

-This is for the treatment of the present disease condition.


Impaired Physical Mobility related to neuromuscular involvement, weakness, limited range of motion and impaired coordinationThe patient will be able to verbalize and demonstrate willingness to participate activities.INDEPENDENT:

>Assess degree of immobility in relation behavioral responses.

> Position the patient for optimum comfort or side turnings in every 2hours

>Monitor circulation / nerve function in the affected body parts noting the temperatures color, sensation and movement.

>Place a side rails each side of the bed of the patient and encourages the patient to do range of motion exercises.

DEPENDENT:

> Give medications as prescribed by the attending physician-This is to check the patients behavioral responses and its degree of mobility for further treatment.

- This is to promote ventilation and to prevent any bedsores of the patients back.

-This is to know the present condition at the affected body parts for treatment.

- This is to protect the patient from falling from the bed to the floor and ROM exercise promotes blood circulation of the body.

- For the treatment of the present illness


Impaired Verbal Communication related to motor deficits and generalized weakness as evidenced by inability to speak words.The patient will be able to established method of communication in which needs can be expressed INDEPENDENT:

> Observe the degree of

Impairment and

Assess the style of speech that the patient shows

> Establish relationship with the patient listening carefully to patients verbal / nonverbal expressions.

>Anticipate needs until effective communication is reestablished

>Provide environmental stimuli as needed to maintain contact with reality or reduce stimuli to lessen anxiety

DEPENDENT:

>Administer medication as order by the attending physician

-Helps evaluate degree of the impairment of the patient and to identify its type of speech for further treatment to be given.

> To have the best way in communicating the patient and have his/her cooperation and also to know the patients needs.

> this is to make sure that if earlier methods are not very effective make more of the best of it until it will be met.

> this to reduce or lessen the patients anxiety.

> This is for therapeutic treatment of the patient for the present illness that she/ he have.

ACTUAL NURSING CARE PLAN

SNo subject cues. The patient is unable to speak due to the endotracheal tube inserted.

ORestless, facial grimace, chest pain

AAcute Pain related to Head Injury as evidence by facial grimace when head is touch specifically the forehead area

PShort term: At the end of 30 minutes the patient will be relieve from pain.

Long term: At the end of 8 hours the patient will be shows less stressful and relieved from pain that he was experiencing.

I1. Monitored the patient closely by taking vital signs

- This is to check the patients status to prevent any complication and to know if there progress of the status of the patient.

2. Provided comfort measures such as back rub

- Massage and backrubs helps to relieved pain that he was experiencing

3. provided a quite and comfortable place to relieved the patient from getting irritated

4. Provide diversional activities, like encouraging expressing the feeling in other form of communication through actions to lessen the feeling of having the pain.

5. Administered medication as ordered by the attending physician

- This is for the treatment of the present illness of the patient

EAt the end of 30 minutes the patient shows gestures and facial expressions that indicates no pain.


ORespiratory difficulties, dry mouth, weakness

A Anxiety related to the situational crisis, change in physical and emotional condition.

PShort term: At the end of 30 minutes the patient will be have lesser feeling of anxiety.

Long term: At the end of 8 hours the patient will be shows less stress and anxiety.

I1. Monitored the patient closely by taking vital signs

- This is to check the patients status to prevent any complication and to know if there progress of the status of the patient.

2. Provided comfort measures such as back rub

- Massage and backrubs decreases anxiety and tension

3. provided a quite and comfortable place to prevent the patient from getting irritation

4.Given oral care/ mouth care to the patient especially that its dry

- This is to prevent halitosis and make sure to prevent cracks of the lips which are very painful.

5. Administered medication as ordered by the attending physician

- This is for the treatment of the present illness of the patient

EAt the end of 30 minutes the patient shows gestures and facial expressions that reflects decrease distress.


ONasogastric tubing attached in the left nostrils for feeding and per orem medications

Altered facial muscle function

AImpaired swallowing related to neuromuscular dysfunction as evidenced by traumatic head injury

PShort term: At the end of 72 hours the patient will be able to pass food from the mouth to the stomach instead of using feedings through Nasogastric tubing.

Long term: At the end of 5 days the patient will be able to demonstrate feeding methods appropriate to the individual situation.

I1. Checked the oral mucosa for any abnormalities.

- this is to identify the abnormalities that can be found and basis for the care to be given

2.Positioned the bed about 30 degrees in the head part especially when giving feedings

- this is to prevent aspiration

3.Turned the patient in every 2 hours in the sides and monitored neurovital signs hourly

- This is to prevent bed sores and pressure ulcers and to check the neurological status of the patient

4.Applied baby powder to patients back and give back tapping

- This is to maintain the patients back dry and prevent aspiration in the lungs

5. Administer medication as ordered by the attending physician

To treat the present illness

EAt the end of 5 days the patient was able to maintain adequate hydration and achieve the desired body weight and good skin turgor.

S. . No subject cues the patient cant able to speak due to the head injury where speech is affected.

ODifficulty in forming words/ verbalizes with difficulty

AImpaired Verbal communication patterns and motor coordination related to central nervous system alteration as evidenced by traumatic head injury

PShort term: at the end of 30 minutes the patient will be able to use alternative methods of communication effectively

Long term: at the end of 8 hours the patient will be able to use effective communication techniques.

I1. Assessed the patients condition that involves the communication status

- This is to check the patients communication status to be given

2.Used simple communication ; speak in a well modulated voice that shows concern

- This will encourage the client to have active participation and to prevent confusion

3. Encouraged to have a ROM exercises

- This will promote blood circulation to the body

4. Established rapport with the patient by listening carefully through nonverbal cues

- This will help you identify what the patient needs and feels

5. Administer medication as ordered

- This is for the treatment of the present illness

EAt the end of 30 minutes the patient was able to establish effective methods of communication needs can be expressed.

VII. HEALTH TEACHINGS

MEDICATIONSInstructed complete procurement of stocks of medicine and take it on right time, dosage, route as prescribed. Emphasized the importance of following proper protocol and consideration upon taking the medicine.

EXERCISEEncouraged to have range of motion exercises to promote blood circulation throughout the body.

Encouraged also to have adequate balance between sleep and daily exercise to prevent further stress that can more complicate the situation.

TREATMENTInstructed to follow what has been ordered by the doctor and stressed the importance of strict compliance of all the medications and treatment prescribed by the physician.

OUT-PATIENT

(Check-up)With patients critical case. He should see the doctor regularly for check-up. Doing so will help foresee probable readmission and management. Proper compliance to every instruction given before discharge will help prevent untoward complications, and help patient live a normal life again.

DIETEat well-balanced diet for proper nutrition; nutritious foods like fruits and green leafy vegetables (eg. pechay, Malunggay, and oranges, apple, banana, etc.)

Instructed to avoid foods that are high in cholesterol, fats, and sodium.

VIII. RECOMMENDATION

Mrs. L.S. will be referred to a doctor (internist) after discharge persistence of chief complaints reoccurs and complicates. Schedules for follow-up visits should not be overlooked to evaluate progress of the patients health condition after termed medical and nursing management. She should have check up at the nearest hospital a week after discharge as scheduled by her physician. The physician also ordered to continue on using all the medications prescribed.

IX. CONCLUSION

I, therefore conclude, that CVA or stroke may lead to permanent brain damage or death to individuals with sedentary lifestyle. People who consumed large amount of food high in cholesterol, alcohol, cigarette smoking, obesity, and high blood pressure can increase the possibility of stroke. This may also lead to heart disease and maybe worsen if we dont prevent the common factors that cause stroke. Self-discipline is very important for us not to acquire this feared or killing disease.

X. PROGNOSIS

CRITERIAGOOD PROGNOSISPOOR PROGNOSIS

A.) Onset of Illness/

B.) Duration of Illness/

C.) Precipitating Factor/

D.) Attitude and Willingness toward taking medication and treatment/

E.) Family Support/

On the criteria listed above, it shows only 2 out of 5 criteria falls under poor prognosis therefore the clients prognosis is good.

XI. BIBLIOGRAPHY Brunner and Suddarth Textbook of Medical-Surgical Nursing, 11th Edition by Johnson pages, 1000; 1500; 2013; 2089

Pocket Guide Nursing Diagnosis with Interventions, 3rd Edition by M. Doenges, pages,123; 423; 543; 589; 1002; 1570

Nursing 2010 Drug Handbook, 20th Anniversary Edition by Davis drug guide, pages, 23; 58; 348; 479; 996; 998

Medical Surgical Nursing, 7th Edition by Black and Hawks ,pages,1589; 5090Manual of Nursing Practice, 7th edition, Volume 1, Lippincott, pages 899; 900DOCUMENTATIONI wasnt able to take any pictures with the patient due to the request of the significant others for confidentiality purposes.

Clinical Manifestations(Sheikh et al, 2012; Soar et al, 2008; Decker et al, 2008; NHTA, 1990).Integumentary System erythema patch, generalized, red rash-edema (localized, anasarca) urticaria (hives, nettle rash, weals, welts) pale, pink or red, may look like nettle stings, different shapes and sizes, surrounded by a red flare, pruritic angioedema swelling of deeper tissues in the eyelids, lips, mouth and throat*Skin and mucosal changes often the first feature and present in over 80% of anaphylactic reactions (Soar et al, 2008).Respiratory System pharyngeal/laryngeal edema difficulty of breathing (dyspnea) / shortness of breath tachypnea hypoventilation labored breathing using accessory muscles abnormal retractions prolonged expirations difficulty of swallowing, tightness in the throat, congestion hoarseness of voice aphonia stridor (upper airway) wheeze (lower airway) diminished lung sounds increase respiratory rate respiratory arrest (late stage)Cardiovascular system myocardial ischemia with ECG changeschest pain presyncope, syncope orthostasis tachycardia (compensatory) arrhythmia (late sign) hypotension (late sign) bradycardia (late sign) cardiac arrest (late stage)Nervous System confusion, agitation, dis-oriented, loss of consciousness dizziness, fainting seizuresCirculatory System cold, pale and clammy cyanosis (late sign)Gastrointestinal System oral mucosal pruritus intraoral angioedema of buccal mucosa, tongue, palate or oropharynx nausea emesis dysphagia abdominal cramps diarrheaUrinary System increase GFR increase urinary output (hypovolemia late stage)Assessment(NHTA, 1990)*Not all signs and symptoms are present in every caseA. Historyprevious exposureprevious experience to exposureonset of symptomsB. Presenting signs and symptomsC. Glasgow coma scale (level of consciousness), general condition, vital signsD. Assessment toolscardiac monitorpulse oximetry (usually low)end tidal CO2(usually high)non-invasive blood pressure to monitor hypotension12-lead ECG to monitor cardiac arrestDiagnostic ExaminationThe diagnosis of anaphylaxis is based largely onhistoryandphysical findings. Laboratory procedures have proven to be not always reliable in the diagnosis. Elevatedplasma histamineis only reliable within one hour of onset.Serum or plasma tryptaselevels greater than 15ng/ml within 12 hours (ideally within 3 hours) of onset is more widely used as a confirmatory test but usually negative in food-induced anaphylaxis.Serial total serum or plasma tryptasemeasurements are more advisable that single measurement. Provenskin tests to allergensand elevatedallergen-specific IgE levelsin serum are not a reliable diagnostic of anaphylaxis, moreover these tests provides clinical relevance in the prevention of anaphylaxis (Sheikh et al, 2012).Mast cell tryptaseis the laboratory procedure that will confirm a diagnosis of anaphylactic reaction. Medical emergency investigations such as arterial blood gases, ECG, chest x-ray, urea and electrolytes may also be helpful in the treatment (Soar et al, 2008).Medical ManagementPatients having an anaphylactic reaction should be treated using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach (Soar et al, 2008).Remove the trigger, if possible.Immediate intervention for anaphylaxis is the removal of the causative agent, although it is not always feasible. Once first sign of reaction occur, immediately stop/discontinue any drug, infusion and/or transfusion suspected of causing the allergic reaction. Remove the stinger after a bee sting. For food-induced anaphylaxis, force vomiting is not recommended because of the possibility of aspiration due to esophageal edema. Do not delay definitive treatment if removing the trigger is not possible (Soar et al, 2008; NHTA, 1990).PositioningPatient should be placed in a comfortable position to promote ventilation and circulation. Patient with airway and breathing problems may assume fowlers position for maximal breathing (for early stage), unless not contraindicated, e.g. hypovolemia and hypotension (late stage). Lying flat with or without leg elevation or trendelenburg position is helpful for patients with hypotension and other circulatory problems. Patient with anaphylactic shock should not be placed on sitting and never on standing up, as these can deteriorate patients condition leading to cardiac arrest. Victims that are breathing and unconscious should be place on their side, recovery position. Pregnant patients should lie on their left side to prevent caval compression (Soar et al, 2008; NHTA, 1990). In the study of Zhao et al (2007), it was concluded that the head-down tilt posture (trendelenburg position) can facilitate venous return from the splanchnic organs and lower extremities and is recommended for the treatment of hypotension in anaphylactic shock.Assist on Ventilation and Advanced AirwayDue to laryngeal edema and inflammation of the bronchial passages, endotracheal intubation or tracheostomy may be necessary to establish an airway and promote ventilation (Smeltzer & Bare, 2004).CirculationInitiating venous access is a must for fluid resuscitation and administration of medications. Central venous line is also important in monitoring central venous pressure.Managing Cardio-pulmonary arrestIf cardio-pulmonary arrest occurred, CPR is immediately performed. Start CPR according to current guidelines (Soar et al, 2008; Smeltzer & Bare, 2004).Pharmacological ManagementPharmacological treatment aims to decrease vascular permeability, restore vascular tone and provide emergency support to basic life functions (Smeltzer & Bare, 2004; NHTA, 1990).OxygenHighest concentration of oxygen is immediately administered, preferably using a mask with an oxygen reservoir which gives 60%-100% O2concentration. Use self-inflating bag for patient with tracheostomy or endotracheal tube (Soar et al, 2008). Anaphylactic shock and the other types of shock are characterized by generalized cellular hypoxia resulted from poor tissue perfusion and decrease oxygen. The severity, irreversible damage and mortality after shock are strongly associated with depleted oxygen level in the brain (Cui et al, 2006).Fluid ResuscitationLarge volumes of fluid may leak from the patients circulation during anaphylactic reaction because of fluid shift during systemic inflammatory process and increase urinary output resulting to hypovolemia. There will also be vasodilatation. A large volume of fluid may be needed to treat hypovolemia and promote circulation. Fluid resuscitation should be infused immediately. Hartmanns solution or 0.9% saline are advised for fluid management. Be careful with the use of colloids and crystalloids as this may cause anaphylaxis (Soar et al, 2008).Adrenaline (Epinephrine)Adrenaline is widely used as the first-line and main stay treatment of choice for anaphylaxis. It is administered for the purpose of its vasoconstrictive action (Sheikh et al, 2012; Soar et al, 2008; Smeltzer & Bare, 2004; NHTA, 1990).AntihistamineAntihistamines are the second line of treatment. Anti-histamines may help counter histamine-mediated bronchoconstriction and vasodilatation, thereby reducing capillary permeability. Chlorpheniramine maleate and Diphenhydramine are the drugs of choice for anaphylactic reaction (Soar et al, 2008; Smeltzer & Bare, 2004).BronchodilatorBronchodilators can be given to reverse histamine-induced bronchospasm. Aminophylline per IV can be given for severe cases. Nebulization is administered using albuterol, salbutamol and ipratropium. Although intravenous magnesium is a vasodilator, contraindicated in anaphylactic shock since it can cause hot flushes and make hypotension worse (Soar et al, 2008; Smeltzer & Bare, 2004).Anti-inflammatory / ImmunosuppressantSteroids management using corticosteroids may help prevent or shorten anaphylactic reactions. This works by decreasing inflammation and reducing the activity of the immune system (Soar et al, 2008; Smeltzer & Bare, 2004; NHTA, 1990).VasopressorVasopressors and inotropes (noradrenaline, vasopressin, metarminol and glucagon) are used when initial resuscitation with adrenaline and fluids are not effective. Glucagon is given for patients who are taking beta-blockers. For patients who develop severe bradycardia after an anaphylactic reaction, atropine IV can treat this condition (Soar et al, 2008)Anaphylaxis Algorithm

Nursing ManagementPromotive and PreventiveThe nurse should identify the patients history on allergy, assessing patients for allergies or previous reactions to antigens plays an important role in the prevention of anaphylactic shock.Patients and familys education to prevent further exposure to antigens and the immediate actions to be taken.Provide record keeping. When allergies are identified, it is important that the patient keeps a record with him/her or wear an identification band.CurativeEarly recognition with accurate assessment and diagnosis.Render immediate treatment without any delay using the ABCDE approach.Knowledge and skills in the medical treatment and pharmacological management of anaphylactic shock.Expertise onIV therapy, BLS and ACLS.RehabilitativePsychological support and support system.Disability rehabilitation.ComplicationsThe most distressing complication of anaphylactic shock is the disability and the irreversible damage following poor brain tissue perfusion. Respiratory complications may occur, and patient may have tracheostomy or much worst with the support of mechanical ventilator. Physical disability is possible, and physical rehabilitation is a must. Autoimmune disorders following prolonged medications and renal complications may occur after severe hypovolemia and anaphylactic shock.Discharge Plan and Patients EducationMedicationsCompliance with medical regimen.Pharmacokinetics and pharmacodynamics of medications, including emphasis on actions and side-effects.Provide instructions and training for the patient and family on the use of adrenaline auto-injector, administration of emergency medications and injection of anti-histamine for patients with repeated history of anaphylactic shocks and high risk cases (Soar et al, 2008; Smeltzer & Bare, 2004)EnvironmentTo prevent anaphylactic shock, avoid the triggers (allergens). Provide an allergen free environment or keep away from any sources of allergy.TreatmentEarly recognition of allergic reaction.An early call for help.Immediate first aid measures.Avoidance of allergens.Health TeachingPatients need to know the allergens and how to avoid it.Patient and family need to recognize the early symptoms and how to manage it.Importance of early detection and management.Avoid contact with allergens.Out-patient CareAdherence to follow up consultation after confinement.Referral to specialist.DietHypo-allergenic diet.Eat organic foods, fruits, meats and vegetables, whenever possible.Avoid anything with sugar, glucose, fructose, EDTA, MSG, flavoring, color, or other additives or preservatives.Provide a hypo-allergenic food guidelines or what foods to eat and what foods to avoid.Statistics shows that anaphylaxis mortality rate is low and stable, despite the increasing prevalencebut, its irreversible damage and the life-long disability which can occur after anaphylactic shock can never be ignored. The emergency state of anaphylactic shock remains to be an alarming truth of disability causing financial, physical and emotional burden. The reaction occurs without any warning and can be a frightening experience for those at risk and for their families.The most important requirements in the treatment of anaphylactic shock are early detection, early diagnosis and immediate interventions without any delay of each procedure. The aim of resuscitation is to restore and maintain the vital organ perfusion and prevent complications of irreversible damage. Thus, the patient and family should be aware of the condition and knowledgeable on immediate first aid measures before the patient reach health care facilities. Health care providers such as physicians, nurses and other anxillary health team should be knowledgeable enough with proper training and expertise in handling emergency situations like anaphylactic shock. They should base their decisions on both clinical situation and comprehensive advance knowledge on the pharmacologic background and the rationale of every intervention.TIME COUNTS TO SAVE THE PATIENT ON THE IMPENDING DOOM OF ANAPHYLACTIC SHOCK.References:Spectrophotometer, Decreases Independently of Venoconstriction During Hepatic Anaphylaxis in Perfused Rat Liver. Shock, 26(1), 6268. Decker, W.W. et al (2008).The Etiology and Incidence of Anaphylaxis in Rochester, Minnesota: A Report from the Rochester Epidemiology Project. Journal of Allergy and Clinical Immnunology, 122(6), 11611165.National Highway Traffic Administration (1990). Emergency Medical Technician-Basic:National Standard Curriculum Instructors Course Guide. United States Department of Transportation. Scanlon, V.C. & Sanders, T. (2007). Essentials of Anatomy and Physiology, 5th ed. Philadelphia: F.A. Davis Company, 327336. Sheikh, A. et al (2012).Adrenaline (Epinephrine) for the Treatment of Anaphylaxis With or Without Shock (Review). The Cochrane Library, 4: JohnWiley & Sons, Ltd. http://summaries.cochrane.org/CD006312/adrenaline-for-the-emergency-treatment-of-anaphylaxis Sheir, D.N. et al (2006). Holes Essentials of Human Anatomy & Physiology, 9th ed. New York: McGraw-Hill Companies, Inc. Smeltzer, S.C. & Bare, B.G. (2004). Brunner & Suddarths Textbook of Medical-SurgicalNursing, 10th ed. PA: Lippincott Williams & Wilkins, 296, 311312. Soar, J. et al. (2008). Emergency Treatment of Anaphylactic ReactionsGuidelines for Healthcare Providers. Resuscitation, 77(2), 157169. Zhao, Z. et al (2007). Head-Down Tilt Posture Attenuates Anaphylactic Hypotension in Mice and Rats. Journal of Physiological Sciences, 57(5), 269274.

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Anaphylactic shock