Anaphylaxis
Ana, a 34-year-old client, is admitted to a medical-surgical unit with cellulitis of the left lower leg. She has never taken penicillin before. Twelve minutes into her first IV penicillin infusion, she presses the call light and says her chest itches and her voice "sounds funny."
Recognize cues
The nurse finds hives spreading across the chest and neck. Her lips are swollen, her voice is hoarse, and she says her throat feels "thick" when she swallows. Vital signs: BP 118/74, HR 96, RR 20, SpO2 97% on room air, temperature 37.0 C.
Which finding requires the most immediate follow-up?
Take action
Four minutes later she has audible stridor and expiratory wheezing, and the hives have spread to her face and trunk. Vital signs: BP 82/40, HR 130, RR 30, SpO2 90% on room air. The provider is being notified, the rapid response team is on its way, and standing orders for a severe allergic reaction are available.
Which two actions should the nurse take first?
Evaluate outcomes
After IM epinephrine, IV fluids, diphenhydramine and methylprednisolone, her stridor resolves and her BP recovers to 112/70. Hours later the hoarseness and hives briefly return and are treated again; after a second dose of epinephrine and continued observation she is reassessed before transfer.
Which finding best indicates the treatment is working?
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