Clinical assessment

Clinical Evaluation and Anaphylaxis Symptoms

Clinical evaluation is a critical procedure in the healthcare system, with health professionals needed to make an accurate diagnosis of a patient's condition before arranging therapy (Estes, 2013).

The Airway, Breathing, Circulation, Disability, and Exposure (ABCDE) technique is indicated as an important tool for first patient evaluation, in which the circumstances impacting the various systems in the body are examined in the order mentioned (Thim, Krarup, Grove, Rohde, and Lfgren, 2012).

This research examines the symptoms of anaphylaxis as observed in Jim Palmer, a 53-year-old patient. The symptoms listed following Flucloxacillin delivery reflect the patient's allergic reaction to the medicine. Anaphylaxis is an allergic reaction that occurs after exposure to various triggers. According to Meng, Rotiroti, Burdett, and Lukawska (2017), Flucloxacillin is contraindicated in patients, who had cases of allergies before and can thus lead to anaphylaxis. It is among the medications that trigger anaphylactic reactions in individuals others being analgesics (aspirin and ibuprofen) (Huether & McCance, 2017). The associated symptoms observed are examined using the ABCDE approach.

ABCDE Approach to the Anaphylaxis Condition

Airway (A)

The airway is analyzed to determine any form of obstruction. Obstructed airwaves may lead to conditions like cardiac arrest if not treated fast enough. Some symptoms of airwave obstruction may include difficulty in breathing, cyanosis, unconsciousness, and seesaw respiration movement (Lewis et al., 2016). The case of Jim Palmer indicates an obstructed airwave. The patient has an audible wheeze with some central cyanosis, difficulty in breathing as demonstrated in the shallow breaths, and a dropping level of consciousness. Wheezing and difficulty in breathing occur due to the blockage of the airway due to the histaminic reactions in which swelling and inflammation of the tracts are encountered. Depressed consciousness may lead to the blocking of the airway especially in the patients, who are critically ill. The bilateral chest movements encountered in the patient may also be associated with a defect on the airway. The abnormal movements are related to the lack of clear passage for the air (Craft, Gordon, Huether, McCance, & Brashers, 2016). The obstruction of the air passage should be treated as a medical emergency. The blocking of the air passage in anaphylaxis is caused by swelling and inflammation of the tissues. The obstruction of passages like the trachea may also occur due to the excess secretion of mucus in response to the allergen.

Breathing (B)

The breathing of the patient is assessed to ascertain whether the breath is sufficient and is at regular rates. The assessment is conducted by observing the respiratory rates, movement of the thoracic walls, and percussing the chest for symptoms of lateral dullness and resonance. Jim Palmer has a respiratory rate of 26 breaths per minute (bpm). A normal respiratory rate is considered to be at 10-20 bpm. The rate greater than 25 bpm is a sign of deteriorating health condition and should be treated as an emergency. On the same note, it can be seen that the patient has pain in the throat that is mainly caused by the inflammation of the thoracic cells due to allergic reaction (Panesar & Sheikh, 2014). The abnormality of Jim’s is also evident in the shallow breaths and is increasingly becomingly breathless. Breathing difficulties arise mainly due to the blockage of the air passage, as already described in section above. Labored breathing is encountered, as the individual tries to exhale and inhale forcefully through restricted air passages due to the swelling or inflammation (Fineman, 2014).

Circulation (C)

Circulation should be assessed in the patient to determine the normality of the perfusion in the patient. Some of the symptoms of the abnormality in circulation may include skin color change (the patient is flushed), decreased the level of consciousness, and sweating among others (Lumley, D’Cruz, Hoballah, & Scott-Connor, 2016). The case of Jim may present problems with circulation due to the flushed nature of the patient. At the same time, the patient’s level of consciousness is decreasing and is becoming drowsy. Anaphylactic shock is responsible for the circulatory problems that are observed in the patient (Crawford & Harris, 2015). The allergic reactions lead to the impairment of the functioning of the blood vessels muscles, hence causing the difficulties in the blood flow found in the patient’s system.

Disability (D)

Disability is assessed using the level of consciousness of the patient. The AVPU system is used in which the individual is graded as alert (A), voice responsive (V), pain responsive (P), or unresponsive (U) (Holbery & Newcombe, 2016). The Glasgow Coma Score may also be used as an alternative. Instability of the airway, breathing, and circulation may be responsible for the reduced conscious levels in a patient. In the presented case, Jim Palmer’s level of consciousness is observed as voice responsive. In the voice response the individual start to respond when he/she talked to. The response may be in the form of the reaction in the measurement of the motor (body/limb movement), eye, and or voice. The level of alertness is reduced in the case of anaphylaxis due to the impact on consciousness by the abnormalities in the airway, breath, and circulation (Guilarte, Sala-Cunill, Luengo, Labrador-Horrillo, & Cardona, 2017). Insufficient air supply is caused by slow breathing and blocked the airway; thus, the body and brain tissues are deprived of enough oxygen to sustain consciousness. Impaired circulation deprives the tissues of essential nutrients and hence reduced levels of alertness (Emiru, Suarez, & Qureshi, 2016). Disability is, therefore, treated by mainly controlling the ABCs.

Exposure (E)

After the overall examination clues are explored to explain the cause of the patient’s condition. The stage allows the examiner to observe signs of trauma like bodily marks, skin reactions (rashes), bleeding, and so on. Body temperature is taken using a thermometer. While the examination may entail the removal of the patient’s clothing, the dignity of the individual must be taken into account. The patient has a body temperature of 37.4°C that is above the normal range of 36.1°C and 37.2°C, an indication of allergic reactions. Other signs of allergic reactions include swelling of lips, toes, fingers, and a wide spread urticarial rash (Baldo & Pham, 2013). Further signs are noted in the cool and clammy skin as well as reduced capillary refill time that is less than f seconds. Even though the sugar level is observed as normal (5.3mmol/L), within a normal range of 4.0 to 6.0mmol/L, a study by Tang et al.(2015) indicates that there is a significant increase in blood glucose levels that are associated with the anaphylactic condition.

ISBAR Handover to the Doctor

The handover below is written using the mnemonic, ISBAR, to represent the Identity, Situation, Background, Assessment, and Recommendation, as shown in the table.

I - Identity

Nurse Details: Marion Papoty, RN, Cleveland Health Center. Ward Six.

Patient Details: Jim Palmer, 53 years old, male.

S - Situation

The patient is currently in need of urgent medical attention given the nature of his condition that is rapidly deteriorating. The rapid deterioration is due to the significant obstruction of the airway leading to complications like difficulty in breathing and loss of consciousness. The blockage of the air passages can result in cardiac arrest if not treated fast enough.

Urgent attention is further required to stop the allergic reactions that are leading to severe symptoms like anaphylactic shock demonstrated in the impairment of the blood vessels muscles functioning; hence, it explains malfunctioning of the circulatory system.

B - Background

The patient was admitted for severe cellulitis to his left lower leg and was given one dose of Flucloxacillin 1gram IV as a slow bolus in the Emergency Department. A second dose of Flucloxacillin was given, but ten minutes later, the nurse was alerted by Jim’s call bell.

Some of the symptoms observed by the nurse on arrival include flushed skin, difficulty in breathing, shallow breathe, and an audible wheezing sound. The patient was also complaining of a tight feeling in the throat and feeling lightheaded and dizzy. It was also evident that patient had some central cyanosis. Further examination also revealed that client’s consciousness level was increasingly reducing, with responsiveness primarily associated with the voice as patient became drowsier.

A - Assessment

Based on the evaluation of the presented, it is clear that the patient is suffering from anaphylaxis. Anaphylaxis is seen as an allergic reaction that is triggered by various substances in different individuals. Alongside food and other materials, some medications like Flucloxacillin are also known to trigger anaphylactic reactions.

The skin rashes represent the allergic responses, in this case, swelling of the lips, fingers, and toes as well as the constriction of the airway due to the inflammation and swelling of the respiratory organs as the cells release histamine and hence the allergy symptoms. The allergy reactions may also be associated with the secretion of substances like mucus that arise due to the histamine intolerance.

The condition was also ascertained as anaphylaxis because the patient was experiencing lightheadedness and dizziness. Further examination revealed rashes as well as cool and clammy peripheries.

R - Recommendations

An urgent medical attention is recommended to the patient. The doctor should treat the condition by administering an epinephrine (adrenaline) immediately.

Intravenous (IV) antihistamines and cortisone should also be administered to help in the clearing of the air passages, thus assisting the patient in breathing.

Should the client’s heart stop beating, cardiopulmonary resuscitation (CPR) may be performed.

To avoid similar cases, the patient should avoid medication by Flucloxacillin and other drugs that are known to trigger anaphylactic reactions in him. Instead, alternatives antibiotics should be applied. The patient should also be advised to identify other triggers in his life like food and other substance, so that he can avoid them to prevent the reoccurrence of anaphylaxis.


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Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International Journal of General Medicine, 5, 117.

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