This is a medical case study of a 53-year-old farmer called Jim who was diagnosed with Anaphylaxis. Jim developed the disease after receiving two doses of Flucloxacillin, which were intended to suppress the bacteria that caused Cellulitis. Cellulitis is a bacterial illness that manifests itself as a swollen area that is red in color, painful, and hot to the touch.
Jim's condition will be examined utilizing the ABCDE technique to investigate the signs and symptoms of Anaphylaxis that he was displaying. The ABCDE strategy will also be implemented to determine the physiological changes and parapsychological transformation experienced by Jim’s body after the infection.
The ISBAR approach will be employed to recommend necessary medical equipment to treat Jim and to suggest the most appropriate interventions and therapy that should be administered to stabilize his condition. The ISBAR approach will also help recommend necessary medication to treat Anaphylaxis (Khan, & Kemp, 2011).
ABCDE Case Study Analysis
Airway
On ringing the bell Jim complained of experiencing a tight feeling from the inner part of his throat. A physical examination had to be performed on Jim to establish the cause of the tight feeling on his throat. The examination revealed that Jim had asymmetric chest movements which left him struggling to draw air in and out of his body. When Jim was asked to take a deep breath, a hoarse sound was heard from his lungs. Jim was asked to breathe through a spirometer which indicated that his rate of respiration had risen from the normal range of 12-20 bpm, to 26 bpm. This further affirmed his respiratory track was clogged. According to Craft, et al., (2016), the chocking and obstruction feeling that Jim was experiencing on his throat is a major symptom of anaphylaxis which is caused by the spasm of bronchi and the swelling of the throat, lips or tongue.
Breathing.
Jim was seen to be breathless when the physician arrived after the bell ring. The physician observed that Jim had bilateral chest movements and the depth of his breathing was getting shallow. He was noted to be using the accessory muscle for breathing which was causing him to suffer tachypnoea (Panesar, & Sheikh, 2014). These were clear signs that Jim was not breathing normally and his level of drawing breath was dwindling rendering him breathless. Therefore, little oxygen was going into his body to sustain his organs. The inability to breathe was also evident from an audible wheeze which was emanating from Jim’s respiratory system. According to Estes, & Schaefer, (2016), this symptom occurs due to the constriction in the smooth muscles of the lower airways. As a result of inadequate oxygen reaching the body tissues, a condition known as hypoxia, Jim became dizzy and sulked.
Circulation.
When Jim’s blood pressure was examined using a sphygmomanometer, it was observed to have dropped from 120mmHg to 99mmHg. Therefore, Jim was suffering from hypotension as a result of his body’s allergen reaction (Metcalfe, Peavy, & Gilfillan, 2009). This was leading to hypoxia which was reducing Jim’s level of consciousness and causing to feel weak, drowsy and drained. The physician also examined Jim’s heart-beat rate using a stethoscope and observed that his heart-beat rate had risen to 130bpm which was above the normal heart-beat (Robson-Ansley, & Du Toit, 2010). This confirmed that Jim was experiencing tachycardia which is a common sign of anaphylaxis. Jim’s blood glucose was also examined through a BSGM (Blood Sugar Glucose Meter) and it was observed to have dropped from the normal 7.8mmol/l to 5.3mmol/l. This was attributed to the anaphylactic shock which was limiting blood circulation and oxygen deficiency due to difficulty in breathing.
Jim was experiencing anaphylactic shock which increased his capillary refill time from the normal (less than) 4 seconds after pressure was removed. This caused him to feel lightheaded. The anaphylactic shock caused Jim’s peripherals to get cold and clammy (Castells, 2010). According to Higashi, et al. (2010), inadequate oxygen into Jim’s bloodstream and poor blood circulation resulted into a blueish discoloration of his skin around his fingers and toes, a condition known as cyanosis.
Jim was also experiencing dizziness and loss of consciousness due to dilation in blood vessels which was caused by the drop-in blood pressure. Low blood pressure was also responsible for tachycardia and the drop-in glucose level in Jim’s blood stream (Castells, 2010).
Disability.
Jim was seen to be falling drowsy and his level of consciousness was drastically reducing. He was also suffocating due to difficulty in breathing which was rendering him breathless. The physician assessed Jim’s level of consciousness using the AVPU approach to determine his responsiveness (Higashi, et al. 2010). Jim was discovered to be awake but his level of alertness was dwindling as the allergic reaction continued to spread throughout his body system. The physician observed Jim’s eyes through an ophthalmoscope and observed that the size of Jim’s pupils had shrunk and the pupils not of the same size in both eyes. Jim’s pupils had become sensitive to light as he quivered when his eyes met the light of the ophthalmoscope. His eyelids were sullen and dehydrated.
However, Jim was observed to be responsive to verbal stimuli since he was seen to follow verbal instructions from the physician. The physician later applied supra-orbital pressure on Jim’s supraorbital notch to test for his level of response to pain stimuli. It was observed that Jim’s supra-orbital nerves were not fully responding to pain stimuli as he was seen to remain still when little pain was imposed on him. In order to fully assert Jim’s level of consciousness, the physician finally applied the Glasgow Coma Scale (GCS) (Stone, et al. 2009). Jim motor response was seen mild and he was seen to stay localized to pain stimuli.
The reduction in Jim’s level of consciousness is a common symptom of Anaphylaxis which is brought about by hypoxia. Metcalfe, Peavy, & Gilfillan, (2009) assert that due to hypotension, which is also common in cases of anaphylaxis, Jim suffered cyanosis which caused his peripherals to become clammy and cold making him unresponsive to touch stimuli. The drop in Jim’s blood pressure caused dilation in his blood vessels which reduced blood circulation to his organs making him drowsy and causing a drop in his level of consciousness.
Exposure.
The physician observed that Jim’s skin was flushed and there was an urticarial rash that was spreading throughout his body. Due to the flushed condition, Jim’s skin was felt to be hot thereby rising his general body temperature to 37.4°C (Khan, & Kemp, 2011). The physician helped to relieve Jim off some of his heavy clothing in order to contain his rise of body temperature. Since Jim was already in the hospital he was helped into some light patient robes and put in an airconditioned room of the hospital to further calm his body temperature. Jim was observed to be developing an itch throughout his body since he was reaching out to different parts of his body to make a scratch. According to Panesar, & Sheikh, (2014), the flash and the itching effect on Jim’s skin are also prevalent symptoms of anaphylaxis which are brought about by the allergic reaction of the body to antigens of foreign antibodies when the body is acting to counter them.
ISBAR Framework for the Case Study.
Introduction
I am a nursing student in third year of college, my role involves working as a medical physician dealing with a case study of a patient suffering from Anaphylaxis. I am in a hospital facility where the patient involved in the case study has visited requiring a medical attention. I am communicating to make recommendations to the medical team on how to handle the anaphylactic condition, the equipment to use and the necessary medication to administer to the patient to suppress the situation.
Situation
Jim is observed to be flushed, and a spreading urticarial rush is evident on his skin. This has been accompanied by a rise in body temperature to 37.4°C. Jim is complaining of a chocking feeling in his throat which is obstructing him from breathing freely. When Jim’s rate of respiration is measured using a spirometer, it is observed to be 26 bpm which is above the normal rate. There has been evidence of swelling on Jim’s lips and fingers and a bluish discoloration around his peripherals due to cyanosis. Jim’s blood pressure is noted to have dropped, when measured using a sphygmomanometer, from 120mmHg to 99mmHg which indicates that he has hypotension. The depth of Jim’s breathing is seen to be dwindling and an audible wheezing sound is heard while he breathes. It is observed that he has bilateral chest movements and is employing accessory muscles to breathe. His heart rate, when measured using a stethoscope, is observed to have risen to 130 bpm. Jim levels of consciousness, when measured using a Glasgow Coma Scale (GCS), it is seen to be reducing making him dizzy and drowsy (Robson-Ansley, & Du Toit, 2010).
Background
Jim Palmer a 53-year-old farmer, is admitted to the hospital for suffering severe cellulitis on the lower part of his left leg. On arrival at the hospital Jim was received at emergency department and was administered with a single dose of 1gram flucloxacillin IV to kill the bacteria which has caused the infection. After a short while, Jim was administered with another dose of flucloxacillin to further ease the severity of the infection. Ten minutes later after the injection, Jim’s body reacts to the medication and suffers an anaphylactic shock. Jim rings the emergency bell to reach out for medical assistance where he is found to be in a deteriorating medical state.
Assessment
Jim is allergic to chemicals contained in Flucloxacillin drug therefore, his body became hypersensitive and his immune system overreacted hence producing antibodies to suppress allergens of chemicals contained in Flucloxacillin. According Estes, & Schaefer, (2016), this is one of the side effects of Flucloxacillin where patients may develop allergies which often translate to anaphylaxis.
Recommendation
According to Simons, (2011), the doctor should administer a quick injection of epinephrine. To clear Jim’s airway the doctor should administer airway opening maneuvers, and airway suction to try clearing Jim’s windpipe (Clark, Rudders, Camargo, 2014). In case that fails, the doctor should insert a nasopharyngeal or oropharyngeal airway to help Jim breath comfortably. In the event Jim’s conditions worsens a tracheal intubation should be administered (Simons, 2010). Jim should be administered with an oxygen reservoir mask, if his SpO2 is below 94%, to provide him with sufficient flow of oxygen into his body system. The flow of oxygen in the mask should be maintained at 15 L min-1, this will ensure the oxygen reservoir does not collapse during Jim’s inspiration (Clark, Rudders, Camargo, 2014).
Since Jim’s rate of breathing and blood circulation was dropping, it is recommended that he is given a pocket mask ventilation or a bag mask ventilation to help improve ventilation and oxygenation in his capillaries (Song, Worm, & Lieberman, 2014). In case Jim’s throat chocking is extreme, an Non-invasive ventilation technique may be considered in place of tracheal intubation. Sheikh, Shehata, Brown, & Simons, (2009), advice that small doses of morphine may be administered to prevent respiratory depression and reduce sedation.
Since Jim was found to be hypotensive, he should be administered with a warm crystalloid solution using a 500Ml bolus at continuous intervals while reassessing his blood pressure and heartrate after every 5 minutes (Song, Worm, & Lieberman, 2014). In case Jim is seen to develop an ACS and a chest pain, a 12-lead ECG should be recorded immediately. It is very advisable to assess if Jim has suffered hypoglycemia by measuring the level of his blood glucose again (Simons, & World Allergy Organization. 2010).
Conclusion.
The ABCDE medical technique helped to systematically analyze the anaphylactic condition which Jim was suffering from. This was necessary in order to attend to all the symptoms and disabilities that arose from his body’s allergen reaction.
The ISBAR approach is used to communicate medical information in the hospital by analyzing the logical flow of a medical situation. Using the ISBAR approach, medical practitioners attending to Jim should be in a position to understand his anaphylactic condition and logically implement necessary intervention procedures to treat the condition.
References.
Castells, M. C. (Ed.). (2010). Anaphylaxis and hypersensitivity reactions. Springer Science & Business Media.
Clark, S., Wei, W., Rudders, S. A., & Camargo, C. A. (2014). Risk factors for severe anaphylaxis in patients receiving anaphylaxis treatment in US emergency departments and hospitals. Journal of Allergy and Clinical Immunology, 134(5), 1125-1130.
Craft, J., Gordon, C., Huether, S. E., McCance, K. L., Brashers, V. L., (2016) Understanding Pathophysiology 2nd edition. Australia, Australia: Elsevier Health Sciences.
Estes, M. E. Z. & Schaefer, K. P. (2016) Health Assessment and Physical Examination 5th edition. Virginia, Virginia: Cengage Learning, Inc.
Higashi, N., Mita, H., Ono, E., Fukutomi, Y., Yamaguchi, H., Kajiwara, K., ... & Taniguchi, M. (2010). Profile of eicosanoid generation in aspirin-intolerant asthma and anaphylaxis assessed by new biomarkers. Journal of Allergy and Clinical Immunology, 125(5), 1084-1091.
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Metcalfe, D. D., Peavy, R. D., & Gilfillan, A. M. (2009). Mechanisms of mast cell signaling in anaphylaxis. Journal of Allergy and Clinical Immunology, 124(4), 639-646.
Panesar, S. S., & Sheikh, A. (2014). Pathophysiology of Anaphylaxis. In Encyclopedia of Medical Immunology (pp. 557-558). Springer New York.
Robson-Ansley, P., & Du Toit, G. (2010). Pathophysiology, diagnosis and management of exercise-induced anaphylaxis. Current opinion in allergy and clinical immunology, 10(4), 312-317.
Sheikh, A., Shehata, Y. A., Brown, S. G. A., & Simons, F. E. R. (2009). Adrenaline for the treatment of anaphylaxis: Cochrane systematic review. Allergy, 64(2), 204-212.
Simons, F. (2011). Anaphylaxis pathogenesis and treatment. Allergy, 66(s95), 31-34.
Simons, F. E. R. (2010). Pharmacologic treatment of anaphylaxis: can the evidence base be strengthened?. Current opinion in allergy and clinical immunology, 10(4), 384-393.
Simons, F. E. R., & World Allergy Organization. (2010). World Allergy Organization survey on global availability of essentials for the assessment and management of anaphylaxis by allergy-immunology specialists in health care settings. Annals of Allergy, Asthma & Immunology, 104(5), 405-412.
Song, T. T., Worm, M., & Lieberman, P. (2014). Anaphylaxis treatment: current barriers to adrenaline auto‐injector use. Allergy, 69(8), 983-991.
Stone, S. F., Cotterell, C., Isbister, G. K., Holdgate, A., Brown, S. G., & Emergency Department Anaphylaxis Investigators. (2009). Elevated serum cytokines during human anaphylaxis: identification of potential mediators of acute allergic reactions. Journal of Allergy and Clinical Immunology, 124(4), 786-792.
