NUM2409 Adult Health 2 Assessment Answer

Introduction

This essay emphasizes the case study of Jade, a 60-year-old female who was admitted to the emergency department following an emergency left femus open reduction and fixation (ORIF). She has been suspected for anaphylactic reaction due to which she has been given IV adrenaline and hyrodcortisone. Code blue was initiated as she was unresponsive. She also has a medical history of osteoporosis, wrist fracture post fall and hypercholesterolemia. Based on the evaluation of the patient's presentation and clinical manifestation, the essay will discuss the pathophysiology of the patient's present condition and evaluate the pharmacology behind the medications being taken by Jade. In addition, the essay will discuss the nursing intervention for the patient during the code blue and after the stabilization of Jade. Lastly, discharge education will be provided to the Jade linked to osteoporosis.

Pathophysiology

Jade was found to be admitted into the surgical ward after ORIF. Post the surgery, she was on analgesia, prophylactic antibiotics and anticoagulant. She was found to be unresponsive and the clinical manifestations revealed a suspected anaphylactic reaction. Some of the vital observations were tachycardia, signs of hypotension, swollen tongue, lips and wheezing on auscultation. All the above symptoms are indicative of anaphylactic shock. According to Gouel-Chéron et al. (2016), some of the manifestations of anaphylactic shock are loss of consciousness, shallow breathing, clammy skin, fast heartbeat and wheezing. An anaphylactic shock is a form of severe allergic reaction that leads to a drop-in blood pressure and a narrowing of the airways. According to DeTurk et al. (2019), the pathophysiological changes taking place due to anaphylaxis are the extensive release of biochemical mediators from mast cells and basophils. The activation of the mast cells takes place when the IgE binds to the FcεRI receptors. There are multiple activation pathways in the process such as immunologic and non-immunologic activation. In case of immunological activation, antigens such as NSAIDs, opiates and other allergens may initiate the anaphylactic reaction. In the case of non-IgE mediated anaphylaxis, the symptoms take place during first exposure to an antigen. In the case of Jade, drugs such as opioids, antibiotics or NSAIDs could be the triggers of IgE-mediated anaphylaxis.

The pathophysiological mechanism is linked to the current presentation and clinical manifestation of Jade. The molecular mechanism behind anaphylaxis is the IgE-mediated reaction involving mast cells and basophils. During the exposure to the allergen, the immune sensitization process is initiated and antigen-specific Ig-E antibodies are released. In case of repeated exposure. The cross-linking of FcϵRI-bound allergen-IgE complexes takes place leading to the release of different mediators such as histamine, platelet-activating factor (PAF), tryptase, antigen-presenting cells and platelet-activating factor. Histamine is a chemical mediator that leads to vasodilation, bronchoconstriction and mucus secretion. This could be the cause behind the significant drop in blood pressure for the patient (Li et al., 2022). The release of chemical mediators also results in various other clinical manifestations such as weak pulse, narrow airways and skin rashes. The clinical manifestations of hives, swollen tongues and bilateral wheezing on auscultation could be due to the release of different mediators in response to the immune system (Nuñez-Borque et al., 2022; Reber, Hernandez & Galli, 2017).

Pharmacology

Some of the pharmacological drugs that the patient was taking were Clexane, paracetamol, fentanyl, cephazolin and atorvastatin. Fentanyl and cephazolin could be one of the causes behind anaphylactic reactions in Jade.

Evidence shows that the use of an opioid is associated with immune-mediated reaction and it leads to symptoms such as hives, rash, hypotension, anaphylaxis, bronchospasm and angioedema (Topaz et al., 2015). Thus, fentanyl could be the cause behind the clinical manifestations of anaphylactic shock in patients. The mechanism of action of fentanyl involves action on the μ-opioid receptor. The drug is known to target a subclass of opioid receptor systems localized in the brain. It involves the control of emotions and pain in the patient. It can activate other opioid system receptors such as the delta and the kappa receptors. The activation of these receptors is the primary cause behind producing analgesia (Ramos-Matos, Bistas & Lopez-Ojeda, 2022). Some of the side effects of fentanyl are drowsiness, constipation, sedation, addiction and unconsciousness. In addition, the adverse drug reaction includes the risk of anaphylaxis, bradycardia, depression and apnoea. The ideal dose for the drug is 100 mcg. The nursing consideration that is important while giving fentanyl to patients is to observe patients regarding peak respiratory depressant effect and avoid the drug in patients with intolerance to fentanyl or other opioid agonists. Patients like Jade require postoperative monitoring and regular vital sign measurement post-surgery (Varshneya et al., 2022).

Intravenous cefazolin has been found to be associated with allergic responses in 3-5% of patients It has a broad-spectrum antibiotic due to it’s ability to inhibit bacterial cell wall synthesis. It binds to penicillin binding proteins on the cells wall and inhibits the last stage of bacterial cell wall synthesis (Tribuddharat et al., 2016). The normal dose of cephazolin is 25 to 50 mg/kg/day IV or IM in 3 or 4 divided doses. Some adverse reactions seen in patients following cefazolin administration are headache, dizziness, headache, swelling of the face, tongue or throat. Thus, the nursing consideration that is important while looking after the patient is to monitor patient after administration of the drug. In addition, patient should be monitored for symptoms of diarrhoea and colitis. The patient should be educated about the adverse signs such as vomiting, diarrhea and prlonged skin problems (Michaud et al., 2023).

Two drugs that were used to manage anaphylactic reactions in patients are IV adrenaline which is also known as epinephrine and hydrocortisone.

Antihistamines can be beneficial in improving breathing symptoms and epinephrine can minimize the allergic response. The antihistamines work by crossing the blood-brain barrier and antagonizing the H-1 receptors in the central nervous system leading to a different therapeutic profile. Antagonization of H1-recptor could be the cause behind clinical benefit. However, H1 mechanism alone is not the therapeutic mechanism behind the drug. These drugs also have sedative, local anaesthetic and anticholinergic properties which might be favourable for the symptom of allergi response (Sanchez-Borges & Ansotegui, 2019). The normal dosage of anthistamine is 25 to 50 mg after every two-three hours. Some of the common adverse effects of the drug are dry mouth, blurred vision, difficulty in urination, dizziness, euphoria and low coordination. The important nursing considerations are to adjust the dose and observe patients for anticholinergic effects. In addition, the nurse should review medications of patient and take precaution while administering to lactating mothers as the drug is known to contraindicate in pregnancy and breastfeeding. Due to the sedative effect of the drug, the drug should be used with precaution in elderly patients as it can expose them to fall risk (Koh et al., 2019).

Hydrocortisone is a common drug that is recommended for use in case of anaphylaxis. It is recommended to administer 200 mg by intrasmuscular or slow intravenous injection for treating adults or children above 10 years (Choo et al., 2013). The drug exert it’s effect by binding to the glucocorticoid receptor and initiating downstream effects. It contributed to the inhibition of phospholipase A2, NF-kappa and other transcription factors and promotes anti-inflammatory genes. It had moderate duration of action and the drug is associated with decrease in vasodilation and permeability of the capillaries. It results in decrease in leukocyte migration to the site of inflammation. The drug also inhibits neutrophils apoptosis and inhibits phospholipase A2 action (Venkatesh & Cohen, 2019).

Some of the adverse effects of the drug include changes in mood and personality, aggression and hallucination. The nursing considerations that are required during the use of the drugs are educating patient about the exact dose of drugs as reduction in dose may lead to diarrhoea and vomiting. In addition, the patient should be advised to take it with meals to prevent gastrointestinal upser. The patient should be educated about side-effects of weight gain, indigestion, hurt burn and increased susceptibility to infection. The patient should be encouraged to seek immediate medical help if the symptoms persist. Proper diet and fluid intake is important to promote bowel function Venkatesh & Cohen, 2019).

Specific nursing care

The patient Jade was found to be irresponsive and code blue was initiated. Code blue is an announcement for a medical emergency. The key interventions that were important for Jade after initiating code blue were to administer the drug for anaphylactic shock. It is planned to give the patient epinephrine which is a drug for the treatment of anaphylaxis. The use of this drug is essential to prevent hypotension and manage shock. The drug has a vasoconstrictor effect, bronchodilator effect and chronotropic effects. It is important to administer epinephrine as soon as possible as a delay in the administration of anaphylaxis could lead to hospitalization and poor outcomes. In contrast, prompt epinephrine injection is associated with a low risk of hospitalization and fatality (Brown, Simons & Rudders, 2020). According to Whyte et al. (2022), the recommended dose of anaphylaxis in epinephrine is 0.3 to 0.5 mg intramuscularly for adults a duration of every 5 to 10 minutes. Thus, antihistamines can provide Jade relief from symptoms of anaphylactic shock such as hypotension and hives. In addition, the second high-priority nursing intervention for the patient is fluid resuscitation by frequently administering normal saline. Patients with severe reactions need aggressive fluid resuscitation and the same is considered important for Jade during the initiation of the code blue. As the patient had wheezing, bronchodilators can be administered to provide relief from wheezing and decrease mucous production too.

After the stabilization of the condition, nursing interventions such as airway assessment, vital sign monitoring, positioning and monitoring of urine output would be important. An airway assessment needs to be done to evaluate the progress of the patient and estimate the improvement in breathing patterns. In addition, vital sign monitoring is important to get clues about any physiological abnormalities and implement actions accordingly.

Discharge education

Jade is found to have medical history of osteoporosis and hypercholesterolemia. He lacks knowledge about the diseases, and it causes. Due to the above issue, he is non-compliant with osteoporosis treatment. It has been planned to implement proper discharge education so that he can manage his problems at home. Some of the risk factors of osteoporosis includes cigarette smoking, alcohol intake, use of medications, calcium and vitamin D intake and sedentary lifestyle. Most of the risk factors such as smoking, alcohol intake and sedentary lifestyle was presented for Jade also. In discharge education, it is planned to provide Jade detail about the cause and risk factors of osteoporosis. Then he will be encouraged to reduce smoking and drinking habit gradually as it could further complicate his outcomes. The ill-effects of continuing with the habit will be explained. The rationale for the medication needs to be provided to improve compliant with treatment. The patient will be recommended to engage simple exercise at home to strengthen joints and use relevant website to get more information (Pouresmaeili et al., 2018).

Conclusion

The essay provided a case analysis of a patient with osteoporosis and anaphylactic shock. The pathophysiology behind anaphylactic shock involves the initiation of Ig-E-mediated immune response in response to exposure to the allergen. It contributes to the release of many mediators that is responsible for hypotension and other clinical manifestations of anaphylactic shock. The drugs that caused the symptoms were Fentanyl and Cephazolin. The essay discussed nursing care and discharge education to support patients’ recovery at home. It is recommended that patients with anaphylactic shock should be actively monitored for triggers initiation the reaction and eliminating those triggers or allergens. In the case scenario above, the main allergen contributing to the anaphylactic reaction was the use of opioid drug called fentanyl.

References

Brown, J. C., Simons, E., & Rudders, S. A. (2020). Epinephrine in the Management of Anaphylaxis. The Journal of Allergy and Clinical Immunology: In Practice , 8 (4), 1186-1195.

Choo, K. J. L., Simons, F. E. R., & Sheikh, A. (2013). Glucocorticoids for the treatment of anaphylaxis. Evidence‐Based Child Health: A Cochrane Review Journal , 8 (4), 1276-1294.

Dalal, R., & Grujic, D. (2022). Epinephrine. In StatPearls [Internet] . StatPearls Publishing.

DeTurk, S., Reddy, S., Pellegrino, A. N., & Wilson, J. (2019). Anaphylactic shock. Clinical Management of Shock-The Science and Art of Physiological Restoration .

Gouel-Chéron, A., Harpan, A., Mertes, P. M., & Longrois, D. (2016). Management of anaphylactic shock in the operating room. La Presse Médicale , 45 (9), 774-783.

Koh, Y. P., Tian, E. A., & Oon, H. H. (2019). New changes in pregnancy and lactation labelling: Review of dermatologic drugs. International journal of women's dermatology , 5 (4), 216-226.

Li, Y., Leung, P. S., Gershwin, M. E., & Song, J. (2022). New Mechanistic Advances in FcεRI-Mast Cell–Mediated Allergic Signaling. Clinical Reviews in Allergy & Immunology , 63 (3), 431-446.

Michaud, L., Yen, H. H., Engen, D. A., & Yen, D. (2023). Outcome of preoperative cefazolin use for infection prophylaxis in patients with self-reported penicillin allergy. BMC surgery , 23 (1), 32.

Nuñez-Borque, E., Fernandez-Bravo, S., Yuste-Montalvo, A. and Esteban, V., 2022. Pathophysiological, cellular, and molecular events of the vascular system in anaphylaxis. Frontiers in Immunology , 13 .

Pouresmaeili, F., Kamalidehghan, B., Kamarehei, M., & Goh, Y. M. (2018). A comprehensive overview on osteoporosis and its risk factors. Therapeutics and clinical risk management , 2029-2049.

Ramos-Matos, C. F., Bistas, K. G., & Lopez-Ojeda, W. (2022). Fentanyl. In StatPearls [Internet] . StatPearls Publishing.

Reber, L. L., Hernandez, J. D., & Galli, S. J. (2017). The pathophysiology of anaphylaxis. Journal of Allergy and Clinical Immunology , 140 (2), 335-348.

Sanchez-Borges, M., & Ansotegui, I. J. (2019). Second generation antihistamines: an update. Current opinion in allergy and clinical immunology , 19 (4), 358-364.

Sanchez-Borges, M., & Ansotegui, I. J. (2019). Second generation antihistamines: an update. Current opinion in allergy and clinical immunology , 19 (4), 358-364.

Topaz, M., Seger, D. L., Lai, K., Wickner, P. G., Goss, F., Dhopeshwarkar, N., ... & Zhou, L. (2015). High override rate for opioid drug-allergy interaction alerts: current trends and recommendations for future. Studies in health technology and informatics , 216 , 242.

Tribuddharat, S., Sathitkarnmanee, T., Kitkhuandee, A., Theerapongpakdee, S., Ngamsaengsirisup, K., & Chanthawong, S. (2016). A fatal adverse effect of cefazolin administration: severe brain edema in a patient with multiple meningiomas. Drug, Healthcare and Patient Safety , 9-12.

Varshneya, N. B., Hassanien, S. H., Holt, M. C., Stevens, D. L., Layle, N. K., Bassman, J. R., ... & Beardsley, P. M. (2022). Respiratory depressant effects of fentanyl analogs are opioid receptor mediated. Biochemical pharmacology , 195 , 114805.

Venkatesh, B., & Cohen, J. (2019). Hydrocortisone in vasodilatory shock. Critical Care Clinics , 35 (2), 263-275.

Whyte, A. F., Soar, J., Dodd, A., Hughes, A., Sargant, N., & Turner, P. J. (2022). Emergency treatment of anaphylaxis: concise clinical guidance. Clinical Medicine , 22 (4), 332.

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