V SIM SCENARIO

V SIM SCENARIO

Attend VSim Scenario meeting . During the Meeting the instructor will
1. VSim Scenario Pre Quiz Completion and Discussion
2. Pre-Conference discussion Patient
3. V-Sim Scenario Completion and Discussion
4. Post Conference Discussion
5. Post Quiz Completion and Discussion
6. Once Completed, Please complete the Post Scenario Documentation

SCENARIO 1
Scenario Overview
Patient: Charlie Snow
Diagnosis: Anaphylaxis
Brief Summary: This case presents a 6-year-old Caucasian male admitted to the emergency department for an anaphylactic reaction after ingesting peanuts. He presents with tachycardia and dyspnea with mild stridor.
The student will be expected to recognize the signs and symptoms of anaphylaxis, perform a general assessment, notify the provider of alterations in the patient’s status, provide appropriate interventions, and observe for potential complications. The student should provide education on the emergency plan for recurrent or worsening symptoms.
Learning Objectives
General:
• Identifies the primary nursing diagnosis
• Identifies relevant patient history information
• Identifies physical findings and diagnostics related to patient condition
• Prioritizes nursing interventions
• Identifies developmentally appropriate and culturally competent nursing interventions based on patient care needs
• Implements provider orders appropriately
• Implements patient safety measures
• Provides family-centered education
• Recognizes therapeutic and confidential communication techniques
• Reports findings directly and accurately to interprofessional team members
• Utilizes members of the health care team when appropriate

Scenario Specific:
• Recognizes signs and symptoms of anaphylaxis
• Performs focused respiratory and cardiovascular assessments
• Initiates respiratory support, utilizing assistive oxygen delivery devices as needed
• Implements safe administration of epinephrine as a primary treatment for anaphylaxis
• Educates patient and family on:
• Identification and removal/avoidance of allergen as key to the patient’s treatment
• Emergency plan for recurrent symptoms
Patient Case Introduction to Students
Location: Emergency department 3:00 PM
Charlie Snow is a 6-year-old Caucasian male staying with his aunt and uncle while his parents are serving overseas in the military.
Charlie presents in the emergency department with tachycardia and dyspnea with mild stridor. His aunt and uncle report that he accidentally ate a cookie containing peanuts, and he has peanut allergies. When Charlie began having difficulty breathing, they rushed him to the emergency department.
He is currently able to talk through the dyspnea and is on a nasal cannula at 2 liters. A saline lock has been placed in his left arm. He has been connected to a cardiac/apnea monitor with a SpO2 probe in place.
Charlie is in bed, and the health care provider has been notified of Charlie’s arrival.
Patient Details
Patient Data: Male age 6 years. Weight 46.2 lbs (21 kg). Height 47 in. (120 cm).
DOB: 5/5/XX
Allergies: Perfumes, dyes, peanuts
Immunizations: Up to date
Past Medical History: Charlie has a known hypersensitivity to perfumes and dyes and an allergy to peanuts. The remainder of his medical history is unremarkable.
Provider’s Orders 1
• Place patient on cardiac/apnea monitor
• Continuous pulse ox
• Obtain IV access
• Place on nasal cannula 2 L O2/min. May switch to nonrebreather, titrating O2 to maintain SpO2 >94%
Provider’s Orders 2
• Monitor vital signs every 5 minutes
• Give one 20 mL/kg of normal saline (420 mL) IV now over 30 min
• Give 0.21 mg epinephrine (1:1000) IM stat
• Give 25 mg of diphenhydramine IV stat
• Give 10 mg of methylprednisolone IV
Nursing Diagnoses
• Ineffective Airway Clearance related to laryngeal edema and bronchospasm
• Caregiver Role Strain related to life-threatening emergent condition
• Risk for Ineffective Cerebral Tissue Perfusion related to decreased blood flow, hypotension, and possible shock
Overview of Proposed Correct Treatment
• Wash hands
• Introduce self
• Identify patient and relatives
• Obtain legal consent from the relatives
• Obtain vital signs, RR, SpO2, pulse, blood pressure, temperature
• Ask the patient if he has difficulty breathing
• Assess IV site and fluids
• Assess pain using FACES Scale
• Ask about known allergies and health problems
• Ask the relative if the patient has eaten anything unusual
• Phone the provider in order to discuss the patient
• Receive and review orders
• Administer epinephrine as ordered using the rights of medication administration
• Administer normal saline as ordered using the rights of medication administration
• Administer diphenhydramine as ordered using the rights of medication administration
• Administer methylprednisolone as ordered using the rights of medication administration
• Reassess the patient’s breathing and blood pressure
• Provide education for child and relatives whenever possible
Case Considerations
Anaphylaxis is a potentially life-threatening systemic reaction to an allergen. It presents with systemic manifestations involving alterations to the skin, respiratory, gastrointestinal, and cardiovascular systems. The symptoms associated with anaphylaxis can occur minutes or up to two hours following exposure to the allergen. Approximately 5% to 20% of patients can experience a recurrence of anaphylaxis eight to 12 hours after the initial presentation.
Prevention of anaphylaxis is a priority and can be achieved through avoidance of allergen exposure. Patients and families must be educated about the risks of exposure to allergens, initial care if exposure occurs, and access to health care. If anaphylaxis occurs, timely administration of epinephrine becomes the most important component of care. Additional initial management should focus on stabilization of the patient’s airway. In case of hypoxia, the patient should be administered oxygen. Advanced airway placement must be considered if the hypoxia worsens or if the patient is unable to maintain his or her airway. Nebulized epinephrine can be used for stridor secondary to laryngeal edema, and nebulized albuterol may be used for bronchospasms (cough or wheezing) not responsive to epinephrine.
If treated early, the outcomes of anaphylaxis are good. As such, patients and families should be advised to call 911 or seek medical attention after self-administration of epinephrine.

PRE-CONFERENCE DISCUSSION
1. Who is my client? (for example: age, marital status).
 Patient’s initials

 Patient’s sex and gender

 Patient’s age

 Admission date

2. State significant events of this hospitalization (admitting diagnosis, surgery, emotional crises, fracture).
 Admission reason

 Pertinent medical and surgical history
Medical Hx
Surgical Hx=

3. What are your major concerns for this patient today?

Reason for seeking care (history of present illness)
.
 Paint a picture of the patient’s problem(s), including:

➢ Discussion of the pathophysiology

4. Discussion of how the medical and surgical history impacts the current problem(s)

 Impact on normal body function

 Signs and symptoms (and rationale for those signs and symptoms)

 Important laboratory and diagnostic exam results and the significance

 Discuss Common complications experienced because of your patient’s problem(s)
5. Patient’s current treatment plan (Discuss diet, activity, medications, therapy, etc.)

Discuss the nursing plan of care for your patient –
• What will you focus on?
• What are your key safety considerations for the day?

CONCEPT MAP WORKSHEET

DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)

DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS)

PATIENT INFORMATION

ANTICIPATED PHYSICAL FINDINGS

ANTICIPATED NURSING INTERVENTIONS

vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION
Your name, position (LPN), unit you are working on
SITUATION
Patient’s name, age, speciﬁc reason for visit
BACKGROUND
Patient’s primary diagnosis, date of
admission, current orders for patient
ASSESSMENT
Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs
RECOMMENDATION
Any orders or recommendations you may have for this patient

PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION:

CLASSIFICATION:

PROTOTYPE:
SAFE DOSE OR DOSE RANGE, SAFE ROUTE

PURPOSE FOR TAKING THIS MEDICATION

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

Date: Student Name: Assigned vSim:
Initials: Age: M/F:
Code Status: Diagnosis:

Length of Stay: Allergies: HCP:

Consults: Isolation:
Fall Risk: Transfer: IV Type: Location:

Fluid/Rate: Critical Labs: Other Services:

Consults Needed:

Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?:
Health History/Comorbities (that relate to this hospitalization):
Shift Goals/ Patient Education Needs: 1.

4.
Path to Discharge:
Path to Death or Injury:

Alerts:
What are you on alert for with this patient? (Signs & Symptoms)

What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?)

List Complications may occur related to dx, procedure, comorbidities:

What nursing or medical interventions may prevent the above Alert or complications?

4.
Management of Care: What needs to be done for this Patient Today? 1.
2.

Priorities for Managing the Patient’s Care Today
1.

What aspects of the patient care can be Delegated and who can do it?

• 1.Document your initial focused assessment of Charlie Snow.
• 2.Identify and document key nursing diagnoses for Charlie Snow.
• 3.Referring to your feedback log, document the nursing care you provided and Charlie Snow’s response.
• 4.Document the patient teaching that you would provide before discharge.
Opening Questions
How did the simulated experience of Charlie Snow’s case make you feel?
Discuss the actions you felt went well in this scenario.

Scenario Analysis Questions*
EBP List in order of priority your initial nursing actions identified for Charlie Snow based on physical findings and family interaction.
EBP What complications might Charlie Snow face if symptoms are not recognized and treated in a timely manner?
EBP Why was a glucocorticosteroid administered in this case? Would it have been appropriate to administer albuterol in this case? Why or why not?
PCC What communication techniques could be initiated to decrease the anxiety of Charlie Snow’s aunt?
S/QI Reflect on ways to improve safety and quality of care based on your experience with Charlie Snow’s case.
S/I Because Charlie Snow is accompanied by his aunt and not by a parent, what legal matter must be considered before performing treatment?
T&C What role do you feel Charlie Snow’s guardians and parents have as members of his health care team? (Explain your answer.)
T&C/I What key elements would you include in the handoff report for this patient? Consider the situation-background-assessment-recommendation (SBAR) format.

Concluding Questions
Reflecting on Charlie Snow’s case, were there any actions you would do differently? If so, what were these actions, and why would you do them differently?
Describe how you would apply the knowledge and skills that you obtained in Charlie Snow’s case to an actual patient care situation.

V SIM SCENARIO

Attend VSim Scenario meeting. During the Meeting the instructor will

VSim Scenario Pre Quiz Completion and Discussion
Pre-Conference discussion Patient
V-Sim Scenario Completion and Discussion
Post Conference Discussion
Post Quiz Completion and Discussion
Once Completed, Please complete the Post Scenario Documentation

SCENARIO 1

Scenario Overview

Patient: Charlie Snow

Diagnosis: Anaphylaxis

Brief Summary: This case presents a 6-year-old Caucasian male admitted to the emergency department for an anaphylactic reaction after ingesting peanuts. He presents with tachycardia and dyspnea with mild stridor.

The student will be expected to recognize the signs and symptoms of anaphylaxis, perform a general assessment, notify the provider of alterations in the patient’s status, provide appropriate interventions, and observe for potential complications. The student should provide education on the emergency plan for recurrent or worsening symptoms.

Learning Objectives

General:

Identifies the primary nursing diagnosis
Identifies relevant patient history information
Identifies physical findings and diagnostics related to patient t condition
Prioritizes nursing interventions
Identifies developmentally appropriate and culturally competent nursing interventions based on patient care needs
Implements provider orders appropriately
Implements patient safety measures
Provides family-centered education
Recognizes therapeutic and confidential communication techniques
Reports findings directly and accurately to interprofessional team members
Utilizes members of the health care team when appropriate

Scenario Specific:

Recognizes signs and symptoms of anaphylaxis
Performs focused respiratory and cardiovascular assessments
Initiates respiratory support, utilizing assistive oxygen delivery devices as needed
Implements safe administration of epinephrine as a primary treatment for anaphylaxis
Educates patient and family on:
- Identification and removal/avoidance of allergen as key to the patient’s treatment
- Emergency plan for recurrent symptoms

Patient Case Introduction to Students

Location: Emergency department 3:00 PM

Charlie Snow is a 6-year-old Caucasian male staying with his aunt and uncle while his parents are serving overseas in the military. Charlie presents in the emergency department with tachycardia and dyspnea with mild stridor. His aunt and uncle report that he accidentally ate a cookie containing peanuts, and he has peanut allergies. When Charlie began having difficulty breathing, they rushed him to the emergency department.

He is currently able to talk through the dyspnea and is on a nasal cannula at 2 liters. A saline lock has been placed in his left arm. He has been connected to a cardiac/apnea monitor with a SpO2 probe in place.

Charlie is in bed, and the health care provider has been notified of Charlie’s arrival.

Patient Details

Patient Data: Male age 6 years. Weight 46.2 lbs (21 kg). Height 47 in. (120 cm).

DOB: 5/5/XX

Allergies: Perfumes, dyes, peanuts

Immunizations: Up to date

Past Medical History: Charlie has a known hypersensitivity to perfumes and dyes and an allergy to peanuts. The remainder of his medical history is unremarkable.

Provider’s Orders 1

Place patient on cardiac/apnea monitor
Continuous pulse ox
Obtain IV access
Place on nasal cannula 2 L O2/min. May switch to nonrebreather, titrating O2 to maintain SpO2 >94%

Provider’s Orders 2

Monitor vital signs every 5 minutes
Give one 20 mL/kg of normal saline (420 mL) IV now over 30 min
Give 0.21 mg epinephrine (1:1000) IM stat
Give 25 mg of diphenhydramine IV stat
Give 10 mg of methylprednisolone IV

Nursing Diagnoses

Ineffective Airway Clearance related to laryngeal edema and bronchospasm
Caregiver Role Strain related to a life-threatening emergent condition
Risk for Ineffective Cerebral Tissue Perfusion related to decreased blood flow, hypotension, and possible shock

Overview of Proposed Correct Treatment

Wash hands
Introduce self
Identify patient and relatives
Obtain legal consent from the relatives
Obtain vital signs, RR, SpO₂, pulse, blood pressure, temperature
Ask the patient if he has difficulty breathing
Assess IV site and fluids
Assess pain using FACES Scale
Ask about known allergies and health problems
Ask the relative if the patient has eaten anything unusual
Phone the provider to discuss the patient
Receive and review orders
Administer epinephrine as ordered using the rights of medication administration
Administer normal saline as ordered using the rights of medication administration
Administer diphenhydramine as ordered using the rights of medication administration
Administer methylprednisolone as ordered using the rights of medication administration
Reassess the patient’s breathing and blood pressure
Provide education for children and relatives whenever possible

Case Considerations

Anaphylaxis is a potentially life-threatening systemic reaction to an allergen. It presents with systemic manifestations involving alterations to the skin, respiratory, gastrointestinal, and cardiovascular systems. The symptoms associated with anaphylaxis can occur minutes or up to two hours following exposure to the allergen. Approximately 5% to 20% of patients can experience a recurrence of anaphylaxis eight to 12 hours after the initial presentation.

Prevention of anaphylaxis is a priority and can be achieved through the avoidance of allergen exposure. Patients and families must be educated about the risks of exposure to allergens, initial care if exposure occurs, and access to health care. If anaphylaxis occurs, timely administration of epinephrine becomes the most important component of care. Additional initial management should focus on the stabilization of the patient’s airway. In case of hypoxia, the patient should be administered oxygen. Advanced airway placement must be considered if the hypoxia worsens or if the patient is unable to maintain his or her airway. Nebulized epinephrine can be used for stridor secondary to laryngeal edema, and nebulized albuterol may be used for bronchospasms (cough or wheezing) not responsive to epinephrine.

If treated early, the outcomes of anaphylaxis are good. As such, patients and families should be advised to call 911 or seek medical attention after self-administration of epinephrine.

PRE-CONFERENCE DISCUSSION

Who is my client? (for example age, marital status).

Patient’s initials

Charles Snow (C. S)

Patient’s sex and gender

Male

Patient’s age

Six years old

Admission date

Not mentioned

State significant events of this hospitalization (admitting diagnosis, surgery, emotional crises, fracture).

Admission reason

Anaphylactic reaction is caused by eating a cookie containing peanuts.

Pertinent medical and surgical history

Medical Hx : Hypersensitivity to dyes and perfumes and a peanut allergy. Otherwise the patient’s medical history is unremarkable.

Surgical Hx: No surgical history

What are your major concerns for this patient today?

The major concern for the patient today is to ensure that his vital signs remain stable and to promote effective airway clearance. The patient suffered from a severe allergic reaction after ingesting peanuts. The pathophysiology of anaphylaxis is attributed to the release of huge amounts of biochemical mediators from basophils and mast cells. Activation of the mast cells is caused by immunoglobin E (IgE) bound to FcεRI receptors crosslinking on the membrane of the body cells. The result is that multiple pathways are activated leading to non-immunologic or immunologic reactions. Immunologic reactions are mediated by IgE, while non-immunological reactions occur when there is degranulation of basophils and mast cells and are mostly caused by direct drug interaction with receptors. Allergic reactions caused by food are IgE-dependent. Anaphylaxis mediated by IgE occurs when IgE binds to the foreign body that causes the allergic reaction. The antigen-bound IgE then causes activation of the FcεRI receptors on both basophils and mast cells and inflammatory mediators are released. Examples of these mediators include eicosanoids and histamine which affects many body systems leading to vasodilation, fluid leakage from blood vessels, bronchial smooth muscle contraction, and depression of the heart muscles (Reber et al., 2017).

Discussion of how the medical and surgical history impacts the current problem(s)

The patient’s medical history has a direct impact on the current problem. The patient is allergic to peanuts and ingesting it resulted in an anaphylactic reaction. Allergic reactions have significant negative impacts on the body’s functioning. According to DeTurk et al. (2020), anaphylaxis results in systemic reactions that impact multiple body systems including the respiratory tract, gastrointestinal tract, central nervous system, and cardiovascular system. Respiratory and cardiovascular systems are the main shock organ systems that are associated with fatalities in anaphylaxis.

The main signs and symptoms of anaphylaxis include respiratory changes that result in symptoms such as dysphagia, stridor, rhinorrhea, and angioedema. If the lower respiratory tract is involved, the patient may experience a reduction in oxygen saturation. The main cause of airway obstruction includes mucous plugging, bronchospasm, and mucosal edema. Cardiovascular changes include vasodilation, increased heart rate, and tachycardia (DeTurk et al., 2020). The patient in the case study demonstrated various symptoms including mild stridor, tachycardia, and dyspnea. Stridor is an indication of obstruction in a patient’s upper airway attributed to mucosal edema leading to fluid extravasation. Dyspnea is attributed to airway obstruction caused by edema or narrowing of blood vessels. Tachycardia is attributed to a reduction in blood pressure that results in changes in heart rate.

The patient did not undergo any diagnostic test because he presented with symptoms of anaphylaxis and his caregivers presented information regarding the trigger to the allergic reaction. As per Cardona et al. (2020), some complications that may result from anaphylaxis may include brain damage caused by prolonged hypoxia, arrhythmias, heart attack, and cardiogenic shock. In some cases, anaphylactic shock may be fatal hence it is important to continuously assess the patient’s vital signs to determine if his condition is deteriorating.

Patient’s current treatment plan (Discuss diet, activity, medications, therapy, etc.)

The patient’s treatment plan should focus on promoting effective airway clearance and stabilizing the airway using medication. The patient’s breathing patterns and blood pressure should also be constantly assessed to determine the risk of anaphylactic shock. The main safety considerations include assessing for impaired gas exchange, effective breathing patterns, and altered tissue perfusion. The main interventions will include monitoring oxygenation status, the airway, and hemodynamic parameters.

DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
The pathophysiology of anaphylaxis caused by food allergens as the main trigger begins when one ingests food which binds to immunoglobulin E, activates FcεRI receptors on basophils and mast cells, and results in the release of inflammatory cytokines and mediators like histamine. The mediators trigger various symptoms in different body systems including fluid leakage from blood vessels, vasodilation, contraction of the smooth muscles in the bronchi. Patients exhibit respiratory difficulties such as dyspnea and tachycardia and extremely low blood pressure.
DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS)	PATIENT INFORMATION	ANTICIPATED PHYSICAL FINDINGS
Clinical criteria for anaphylaxis diagnosis: 1. acute onset of illness characterized by respiratory compromise 2. Low blood pressure minutes or hours after ingesting a known allergen. 3. Skin involvement: hives, swollen lips, uvula, or tongue. 4. Vomiting and abdominal cramps	He had ingested peanuts, a known allergen, and presented with respiratory symptoms.	The patient will exhibit at least two symptoms that will indicate that he has anaphylaxis.
ANTICIPATED NURSING INTERVENTIONS
· Monitor the patient’s arterial blood gas and oxygen saturation values. · Assess the patient for narrowed airway. · Help the patient to engage in deep breathing techniques. · Ensure that the patient is in an upright position that encourages adequate oxygenation and prevents respiratory distress. · Monitor the patient’s urine output to assess for signs of oliguria which would be an indicator of inadequate renal perfusion. · Assess and monitor hemodynamic parameters including pulmonary artery diastolic pressure, central venous pressure, cardiac output, and pulmonary capillary wedge pressure. · Educate the patient’s caregivers and the child on how to prevent ingestion of allergen in the future. · Educate the caregivers and patient on what to do in case of future allergic reactions.

vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION	Unit: Emergency Department
Your name, position (LPN), unit you are working on
SITUATION	Charlie Snow is a 6-year-old boy who presented to the emergency department with symptoms of an anaphylactic reaction after he ate peanuts.
Patient’s name, age, speciﬁc reason for the visit
BACKGROUND	The primary diagnosis for the patient is an anaphylactic reaction. The current orders for the patient include placing him on a cardiac monitor, continuous assessment of blood oxygen levels using a pulse oximeter, placing the patient on nasal cannula 2 L O2/min, and obtaining IV access. The patient’s vital signs should be monitored every 5 minutes.
Patient’s primary diagnosis, date of admission, current orders for patient
ASSESSMENT	The patient’s main symptoms include tachycardia, stridor, and dyspnea. These symptoms illustrate that he is suffering from a severe allergic reaction.
Current pertinent assessment data using head-to-toe approach, pertinent diagnostics, vital signs.
RECOMMENDATION	· The patient’s airway, oxygen saturation levels, and blood pressure should be monitored to rule out an anaphylactic shock. · The patient’s vital signs should be monitored. · All medications, specifically epinephrine, diphenhydramine, and methylprednisolone should be administered as per the provider’s orders. · The patient and his caregivers should be educated about avoiding allergen exposure. · The caregivers should be educated on how to administer epinephrine including dosage amounts in case of future allergic reactions. · Caregiver education should include the symptoms to watch out for.
Any orders or recommendations you may have for this patient

PATIENT EDUCATION WORKSHEET

NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: epinephrine

CLASSIFICATION: alpha- and beta-adrenergic agonists

PROTOTYPE: adrenergic agonists

SAFE DOSE OR DOSE RANGE, SAFE ROUTE

Dosage for adults: 0.3mg/0.3mL for prefilled syringes and autoinjectors, 0.1mg/mL for injectable solution.

Pediatric dosage for anaphylaxis: 0.01 mg/kg administered subcutaneously or intramuscularly

PURPOSE FOR TAKING THIS MEDICATION

Epinephrine is indicated for emergency treatment of anaphylaxis triggered by food, insect bites, and drugs. The purpose of taking this medication is to restore cardiac rhythm and to treat mucosal congestion. Epinephrine also helps with other symptoms of anaphylaxis such as shortness of breath.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

Always take the recommended dosage.

Keep the medication out of reach by children.

Do not allow anyone else to take the medication.

Contact the doctor in case of side effects such as nausea, vomiting, irregular heartbeat, anxiety, weakness, and headache.

PATIENT EDUCATION WORKSHEET

NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: diphenhydramine

CLASSIFICATION: Antihistamine

PROTOTYPE: First-generation antihistamines

SAFE DOSE OR DOSE RANGE, SAFE ROUTE

25 to 50mg administered orally twice a day for adults with the maximum daily dosage being 400mg, 25mg/min for IV injections.

Pediatric dosage: 12.5 to 25mg administered orally three times a day, maximum dosage is 300mg per day. 25 mg/min for IV injections.

PURPOSE FOR TAKING THIS MEDICATION

The medication blocks the action of histamine, the inflammatory mediator responsible for allergic symptoms.

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

Consult the physician if there is any chest tightness or wheezing.

Do not use the medication if you are allergic to it.

Do not overdose.

Consult a healthcare professional if you are taking other medications.

PATIENT EDUCATION WORKSHEET

NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: methylprednisolone

CLASSIFICATION: glucocorticoid

PROTOTYPE: Prednisone

SAFE DOSE OR DOSE RANGE, SAFE ROUTE

Adults: 2 to 60mg per day administered intramuscularly, orally, or through IV

Children: 0.5 to 1.7 mg per kg per day administered orally, intramuscularly, or intravenously (Kounis et al., 2018).

PURPOSE FOR TAKING THIS MEDICATION

The medication relieves inflammation including redness, swelling, pain, and heat. For anaphylactic patients, the medication helps to relieve symptoms such as swelling (Kounis et al., 2018).

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

Follow the recommended dosage regimen

Report any symptoms such as nausea, fatigue, muscular weakness, fever, joint pain

Take medication with milk or food.

Limit grapefruit consumption

Follow a low-salt, low-sodium, and protein-rich diet when taking the medication (Kounis et al., 2018).

Date: Student Name: Assigned vSim:

Initials: C. S Age: 6 years M/F: M

Code Status: Not mentioned

Diagnosis: Anaphylaxis

Length of Stay: Not mentioned

Allergies: Peanuts, dyes, perfumes

HCP:

Not mentioned

Consults: None

Isolation: No

Fall Risk: No Transfer: No

IV Type: Normal saline

Location:

Fluid/Rate: 20 mL/kg

Critical Labs: None

Other Services:

None

Consults Needed:

Allergy Specialists

Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?

The patient was in the hospital because he experienced an allergic reaction to peanuts. His main symptoms include dyspnea, tachycardia, and mild stridor.

Health History/Comorbidities (that relate to this hospitalization):

The patient is allergic to peanuts. He accidentally ate a cookie with peanuts and started having difficulty breathing. His guardians rushed him to the hospital after he experienced difficulty breathing.

Shift Goals/ Patient Education Needs:

1. Shift goal: patient will demonstrate improved ventilation and maintain effective breathing.

2. Shift goal: patient will remain hemodynamically stable.

3. Education needs: patient will be educated on the allergic reaction including its cause (eating peanuts) and how to prevent it. The patient is a child hence he should be educated on the importance of avoiding peanuts.

4. Education needs: Educate the patient’s caregivers on the importance of avoiding the allergen. The caregivers should also be educated on how to use epinephrine in case of future allergic reactions and when to seek medical advice.

Path to Discharge:

The patient should be observed until any of the symptoms he experienced are resolved after he is provided with the recommended medication. The patient will be discharged if he is hemodynamically stable and demonstrates alertness and responsive mentation.

Path to Death or Injury:

In anaphylactic patients, the cause of death could be respiratory compromise caused by airway obstruction and cardiovascular collapse. If the patient demonstrates extremely low blood pressure, low oxygen saturation, and poor breathing patterns, he may die.

Alerts:

What are you on alert for with this patient? (Signs & Symptoms)

1. Low blood pressure

2. Ineffective airway clearance

3. Possible anaphylactic shock

What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?)

1. Obtain vital signs

2. Use the pulse oximeter

3. As the patient, if he is experiencing any breathing difficulties

List Complications may occur related to dx, procedure, comorbidities:

1. Brain damage

2. Cardiogenic shock

3. Arrhythmias and heart attack

What nursing or medical interventions may prevent the above Alert or complications?

1. Monitor vital signs

2. Administer medication to clear the patient’s airway and improve blood pressure.

3. Monitor hemodynamic parameters

4. Instruct the patient to breathe deeply and slowly

Management of Care: What needs to be done for this Patient Today?

1. Monitor vital signs

2. Assess pain levels

3. Assess airway clearance

4. Monitor cardiac rhythm

5. Administer medication as required

6. Educate patients and caregivers on the importance of preventing future exposure to allergens.

Priorities for Managing the Patient’s Care Today

1. Monitor vital signs, especially oxygen saturation

2. Administer medications in the right dosage and frequency

3. Ensure that the patient’s breathing patterns are stable.

4. Assess the patient to ensure he is responding positively to the medication.

What aspects of patient care can be Delegated and who can do it?

Aspects of care that can be delegated include:

· Supervising the patient’s ambulation since he is young and may want to move around.

· Helping the patient clean up.

· Providing meals to the patient.

· Checking blood pressure

These aspects of care can be delegated to licensed vocational nurses and unlicensed assistive personnel. A practice nurse can help initiate and administer the patient’s medication.

Document your initial focused assessment of Charlie Snow.

The initial focused assessment for Charlie Snow’s case comprised of several body systems that are likely to be affected when a patient experiences anaphylaxis. These systems include the respiratory system, gastrointestinal system, mocucutaneous system, and cardiovascular system.

Respiratory system:

Assessment of the respiratory system entailed observing the child’s general appearance including his orientation, alertness, and activity level. Charlie Snow was alert and oriented and could even talk through the dyspnea. The assessment also included respiratory rate, respiratory effort, presence of any audible sounds, oxygen saturation monitoring, and use of accessory muscles. The patient presented with dyspnea characterized by breathlessness and chest tightness. He also presented with mild stridor especially when breathing in, and this was an indication that his upper airway was partially blocked.

Gastrointestinal system:

The focused assessment for the gastrointestinal system focused on determining if the patient had any signs of vomiting, cramping, diarrhea, or nausea. The patient is allergic to peanuts and he accidentally ingested them hence it was likely that there would be gastrointestinal system. However, the patient did not mention any gastrointestinal symptoms.

Mocucutaneous system

Assessment of the mocucutaneous system focused on determining any changes in the mucosal and skin areas including looking out for symptoms such as itching, hives, angioedema, rashes, and piloerection. The assessment also included tingling or itching of the uvula, tongue, and lips. For patients with anaphylaxis, it is also important to assess any itching around the eyes or in the ear canals. Charles Snow did not demonstrate any changes in the mocucutaneous system.

Cardiovascular system

Assessment of the cardiovascular system for anaphylactic patients includes looking out for symptoms such as abnormalities in heart rhythm, palpitations, low blood pressure, chest pain, changes in hearing and vision, loss of consciousness, and dizziness or faintness. The patient presented with tachycardia which is an abnormally high heart rate hence it was important to continuously monitor his pulse and blood pressure.

Identify and document key nursing diagnoses for Charlie Snow.

Ineffective breathing patterns associated with bronchoconstriction and bronchospasm as evidenced by mild stridor and dyspnea.
Impaired gas exchange as evidenced by tachycardia, dyspnea, and bronchospasm. The patient is at risk of respiratory distress if airway patency is not maintained and his arterial blood gases and oxygen levels continue decreasing.
Reduction in cardiac output as evidenced by tachycardia.
Ineffective airway clearance associated with bronchospasm and laryngeal edema.
Alterations in tissue perfusion attributed to reduction in blood flow. The patient is at high risk of ineffective Cerebral Tissue Perfusion
The patient is at risk of an anaphylactic shock.
Charlie suffered from a life-threatening condition hence his caregivers may experience role strain associated with the event.

Referring to your feedback log, document the nursing care you provided and Charlie Snow’s response.

Nursing care:

Asked the patient about how he felt when breathing: the patient indicated that he had difficulty breathing and felt some pain in his chest.
Assessed the patient’s respiratory rate, depth, and rhythm and noted any changes in stridor, dyspnea, and use of accessory muscles.
Obtained vital signs including respiratory rate, oxygen saturation, temperature, and blood pressure
Monitored arterial blood gases and oxygen saturation
Assessed pain levels using the FACES Scale
Administered medication as required including epinephrine, normal saline, diphenhydramine, and methylprednisolone.
Reassessed blood pressure and breathing continuously.

The patient responded positively to the care provided. The patient’s cardiac rhythm was restored and his blood pressure and pulse improved. He also noted a decrease in chest pain. The patient remained alert and oriented throughout his hospital stay.

Document the patient teaching that you would provide before discharge.

Patient teaching for Charles Snow should involve both Charlie and his caregivers since Charlie is still a child. The patient teaching should include:

Educating Charlie on the importance of staying away from peanuts and other things he is allergic to including dyes and perfumes. Charlie should be advised to avoid eating food items given to him at school or other places and always ask if there are any peanuts in the food. His caregivers should also be advised to keep all food items with peanuts away from Charlie’s reach.
Educating Charlie and his caregivers on the symptoms of anaphylaxis they should look out for in case of allergic reactions in the future.
Educate Charlie and his caregivers on the steps they should take in case of future anaphylaxis. This includes the use of an epinephrine autoinjector, correct dosage, and how to get refills after using it. Patient teaching should also include checking expiration dates and having at least two autoinjectors within reach.
Charlie should be advised to always wear a medical bracelet containing information about his allergy especially when in school and engaging in other activities where he is likely to encounter food.
Inform Charlie’s caregivers that his school including students, teachers, and school nurse must be aware of his allergy. His school nurse and teachers should be educated on what to do in case Charlie gets a severe allergic reaction in school

Opening Questions

How did the simulated experience of Charlie Snow’s case make you feel?

The simulated experience about Charlie Snow made me feel that allergic reactions can be extremely severe and should always be treated seriously. I also feel that it is important for people to be aware of any food stuffs, drugs, animal venomes, and other things they may be allergic to and to avoid these things as much as they can. The experience also illustrated the importance of being prepared in case of severe allergic reactions and seeking medical care as soon as possible. Preparedness includes having an epinephrine autoinjector close at all times and educating close friends and relatives on how to use it in case of emergencies. Furthermore, it may be difficult for children to avoid food or other things they may be allergic to hence educating them as well as their friends and teachers on allergic reactions and how to prevent and manage them is very important.
Discuss the actions you felt went well in this scenario.

In the scenario, the actions that went well include assessing Charlie’s symptoms and making accurate nursing diagnosis based on the symptoms. I also feel that the treatment process including administering medication, monitoring vital signs especially respiratory rate, cardiac rhythm, and breathing patterns went well and promoted positive outcomes for the patient.

Scenario Analysis Questions*
EBP List in order of priority your initial nursing actions identified for Charlie Snow based on physical findings and family interaction.

Order of nursing actions from priority to last priority:

Take vital signs
Monitor the airway to determine any sensation of the narrowed upper or lower airway.
Monitor oxygenation status, oxygen saturation, and ask the patient about how he feels when breathing
Administer medication, particularly epinephrine
Monitor cardiac rhythm
Reassess vital signs and breathing.
Continuously monitor the patient’s pulse, breathing, and other vital signs to determine any changes and take appropriate action if they go beyond normal levels.

EBP What complications might Charlie Snow face if symptoms are not recognized and treated in a timely manner?

Anaphylaxis can result in numerous complications if not recognized and treated early. According to Dodd et al. (2021), patients may go into anaphylactic shock if they are not treated. The main symptoms of anaphylactic shock include the inability to speak, extremely low blood pressure, use of accessory muscles to breath, severe dyspnea, weakness, confusion, and pale skin color. The patient may become unconscious. Other symptoms may include swollen lips, throat, mouth, or tongue and a choking sensation. Due to the poor flow of oxygen to body organs caused by cardiogenic shock, untreated anaphylaxis may lead to brain damage especially if the patient is unable to breathe properly for an extended time. Other complications include arrhythmias that may result in heart attacks and cardiac arrests. Patients may experience acute renal failure attributed to severe intravascular fluid loss. These complications are likely to result in death. Kidney damage resulting from anaphylaxis may be permanent even if the patient survives.
EBP Why was a glucocorticosteroid administered in this case? Would it have been appropriate to administer albuterol in this case? Why or why not?

Glucocorticosteroids are used to help relieve symptoms and to manage anaphylaxis. Glucocorticosteroids help fight inflammations caused by allergic reactions within the body. In a study conducted by Okubo et al. (2021), the use of glucocorticosteroids resulted in a longer length of stay in comparison to glucocorticoid use for pediatric patients with anaphylaxis. Positive impacts of glucocorticosteroid include reduced risk of biphasic anaphylactic reactions which can usually be fatal hence in the scenario, using a glucocorticosteroid was a good choice. Glucocorticosteroids should be used as second-line treatment after administration of epinephrine in the emergency treatment of anaphylaxis. In the case study, using albuterol would not have been an appropriate choice. According to Dribin et al. (2020), Albuterol is a bronchodilator whose role is to relax a patient’s airways to improve breathing. Albuterol, however, is not recommended for anaphylaxis because it does not relieve or prevent hypotension, upper airway edema, or anaphylactic shock. Notably, albuterol should never be used as a substitute for epinephrine when treating patients with anaphylaxis.
PCC What communication techniques could be initiated to decrease the anxiety of Charlie Snow’s aunt?

When communicating with anxious patients or family members, it is important to incorporate communication techniques such as active listening, empathy, relaxation techniques, and recognize any nonverbal cues such as posture and body language. Effective communication can help relieve anxiety among both patients and family members as care continues (Lukmanulhakim et al., 2016). The healthcare professional in the case study should introduce himself or herself to Charlie’s aunt and provide a full explanation of the care procedures provided to Charlie including their rationale and expected outcomes. Charlie’s aunt should be reassured that Charlie is in good hands and that they will do their best to restore his health. The main communication techniques that should be used in the situation include demonstrating empathy using verbal and non-verbal cues, acknowledging her current feelings, and responding clearly and concisely to any questions or concerns raised. The physical environment should also be calm and the healthcare professional should strive to maintain a calm and relaxed posture even if Charlie’s aunt seems agitated, angry, or begins to shout. It is also important to ask follow-up questions regarding previous allergic reactions and let Charlie’s aunt express her emotions. Furthermore, the healthcare professional should avoid setting unrealistic expectations regarding Charlie’s care outcomes.
S/QI Reflect on ways to improve safety and quality of care based on your experience with Charlie Snow’s case.

In Charlie Snow’s case, the quality of care could have been improved through prompt clinical analysis and faster administration of the medication. Anaphylaxis diagnosis is made through clinical assessment of symptoms hence faster assessment and treatment is likely to result in better outcomes for the patient. Charlie’s positioning should also have been a point of focus since positioning helps to improve blood pressure and may prevent further respiratory distress. Charlie should be informed about the importance of sitting still and monitored closely to ensure that he does not move around. Charlie should also remain under observation until all the symptoms he has are relieved. This is important mainly because some patients experience a second anaphylaxis episode without ingesting or contacting the trigger hence they may require more treatment with epinephrine, glucocorticoids, and antihistamines. Proper discharge management, including preventive measures and follow-up, are also critical components that promote safety and enhance the quality of care. The healthcare professionals in Charlie’s case should complete an anaphylaxis action plan and provide recommended education as explained above. The plan should be individualized based on what Charlie is allergic to and his school and home environments. Other factors that would improve the quality of care in Charlie’s case include engaging in collaboration and shared decision-making with Charlie, his aunt, and his parents.

S/I Because Charlie Snow is accompanied by his aunt and not by a parent, what legal matter must be considered before performing treatment?

When treating minors, one of the legal considerations is to obtain the consent of their parents or guardians (Varkey, 2020). In the case study, Charlie Snow was brought in by his aunt whom he lives with because his parents are deployed overseas. Therefore, the main legal consideration is to ask for proof of guardianship for Charlie. However, Charlie’s condition is an emergency and failure to provide immediate treatment may be life-threatening. In such a case, if his aunt does not have any way of proving her guardianship immediately, it would be safer to involve Charlie’s aunt in treatment and deal with proof of guardianship once he is stabilized. All medication records for Charlie should be sent to a physician or any other healthcare professional that will be designated by Charlie’s aunt and his parents because Charlie will require a follow-up visit to a clinician after being discharged from the emergency room.
T&C What role do you feel Charlie Snow’s guardians and parents have as members of his health care team? (Explain your answer.)

The main role that Charlie’s parents and guardians have as members of the care team include engaging in shared decision making with the other members of the healthcare team, helping with care activities, providing information regarding Charlie’s current health situation and other healthcare concerns, and continuity of care once Charlie is discharged from the emergency room. According to Melo et al. (2014), these roles are supported by the fact that parents and guardians interact more with children hence they have better knowledge regarding the patient’s health situation and any medical needs. In addition, parents and guardians understand their children’s daily routines hence they can help with care activities such as feeding and dressing. they are also aware of sleeping and feeding patterns hence they can easily detect any changes that may apply to the patient’s health situations. After pediatric patients are discharged from the hospital, they go home with their guardians or parents. Therefore, it is easier to involve parents in care continuity since they can communicate effectively with healthcare professionals to provide information on the patient’s progress and also plan for home visits. Parents are also more likely to understand any management education provided and can help the children implement them after being discharged. Involving parents and guardians as part of healthcare teams is crucial for better health outcomes, improved safety, and reduction of length of hospital stay as well as the risk for readmission.

T&C/I What key elements would you include in the handoff report for this patient? Consider the situation-background-assessment-recommendation (SBAR) format.

Situation	Charlie Snow, a six-year-old boy who was brought by his aunt and uncle to the emergency department with symptoms of anaphylaxis including dyspnea, mild stridor, and tachycardia.
Background	The patient suffered from an allergic reaction after accidentally ingesting a cookie with peanuts. The patient has several allergies including a peanut, dye, and perfume allergy.
Assessment	The patient could still talk through the dyspnea. The patient was administered with a nasal cannula to help with oxygenation. His vital signs were monitored every five minutes and the main purpose of care was to maintain oxygen saturation above 94%. The patient was placed on 0.21 mg epinephrine (1:1000) IM stat, 10 mg of methylprednisolone IV, and 25 mg of diphenhydramine IV stat.
Recommendation	· The patient and his caregivers should be educated on how to use an epinephrine autoinjector for future cases. · The patient’s guardians should be informed on when and where to refill the autoinjector. · The patient be provided with a band with information about his allergies to wear on his arm. · The patient and his guardians should be educated on the importance of avoiding peanuts to prevent future allergic triggers.

Concluding Questions

Reflecting on Charlie Snow’s case, were there any actions you would do differently? If so, what were these actions, and why would you do them differently?

When assessing Charlie Snow’s case, the main action I would do differently is recording the time from the onset of the allergic reaction to when he was completely relieved of all symptoms. As per Smith et al. (2016), recording the time would help to determine the severity of the allergic reaction. For instance, if the symptoms began suddenly, progressed quickly, and were relieved in a shorter time, then Charlie had a case of mild to moderate anaphylaxis. Patients who experience severe cases of anaphylaxis are at a higher risk of fatal events when they experience allergic reactions in the future. Smith et al. (2016) adds that a patient’s anaphylaxis history also impacts interventions such as oral food immunotherapy such that those with severe anaphylaxis are unlikely to tolerate any amounts of the allergen hence immunotherapy would be ineffective.

It is also important to compare the severity of allergic reactions when they occur again and to determine to assess the risk of severe reactions in the future to ensure that the patient is adequately prepared to mitigate the impacts of the allergic reaction.
Describe how you would apply the knowledge and skills that you obtained in Charlie Snow’s case to an actual patient care situation.

I would apply the knowledge gained from the case of Charlie to provide effective care for patients with anaphylaxis. I would use the knowledge gained about assessing various body systems including the respiratory system, cardiovascular, gastrointestinal system, and mocucutaneous system to gather sufficient information regarding the allergic reaction and to provide effective interventions. I also learned about the importance of using epinephrine as first-line treatment and incorporating glucocorticosteroids as a second-line treatment to reduce the risk of biphasic anaphylactic reactions. I believe that this information will influence positive outcomes for any patient I encounter. When completing the scenario analysis situation, I learned about legal steps that must be followed when working with pediatric patients and I intend to implement them. I also plan on incorporating communication skills when working with patients and their families to help reveal anxiety associated with illness.

References

Cardona, V., Ansotegui, I., Ebisawa, M., El-Gamal, Y., Fernandez Rivas, M., & Fineman, S. et al. (2020). World Allergy Organization Anaphylaxis Guidance 2020. World Allergy Organization Journal, 13(10), 100472. https://doi.org/10.1016/j.waojou.2020.100472

DeTurk, S., Reddy, S., Ng Pellegrino, A., & Wilson, J. (2020). Anaphylactic Shock. Clinical Management Of Shock – The Science And Art Of Physiological Restoration. https://doi.org/10.5772/intechopen.88284

Dodd, A., Hughes, A., Sargant, N., Whyte, A., Soar, J., & Turner, P. (2021). Evidence update for the treatment of anaphylaxis. Resuscitation, 163, 86-96. https://doi.org/10.1016/j.resuscitation.2021.04.010

Dribin, T., Michelson, K., Zhang, Y., Schnadower, D., & Neuman, M. (2020). Are Children with a History of Asthma More Likely to Have Severe Anaphylactic Reactions? A Retrospective Cohort Study. The Journal Of Pediatrics, 220, 159-164. https://doi.org/10.1016/j.jpeds.2019.12.019

Kounis, N., Koniari, I., Soufras, G., & Chourdakis, E. (2018). Anaphylactic shock with methylprednisolone, Kounis syndrome and hypersensitivity to corticosteroids: a clinical paradox. Italian Journal Of Pediatrics, 44(1). https://doi.org/10.1186/s13052-018-0579-5

Lukmanulhakim, L., Suryani, S., & Anna, A. (2016). The relationship between communication of nurses and level of anxiety of patient’s family in emergency room dr. Dradjat Prawiranegara hospital, Serang Banten, Indonesia. International Journal Of Research In Medical Sciences, 5456-5462. https://doi.org/10.18203/2320-6012.ijrms20164228

Melo, E., Ferreira, P., Lima, R., & Mello, D. (2014). The involvement of parents in the healthcare provided to hospitalized children. Revista Latino-Americana De Enfermagem, 22(3), 432-439. https://doi.org/10.1590/0104-1169.3308.2434

Reber, L., Hernandez, J., & Galli, S. (2017). The pathophysiology of anaphylaxis. Journal Of Allergy And Clinical Immunology, 140(2), 335-348. https://doi.org/10.1016/j.jaci.2017.06.003

Smith, P., Hourihane, J., & Lieberman, P. (2016). Risk multipliers for severe food anaphylaxis. World Allergy Organization Journal, 8, 30. https://doi.org/10.1186/s40413-015-0081-0

Varkey, B. (2020). Principles of clinical ethics and their application to practice. Medical Principles And Practice. https://doi.org/10.1159/000509119

References

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