Case Study 3 BWs Online Case Study Nursing Assessment

Case Study 3 BWs

A fundamental check-in drugs administration is to inquire if there are any allergies. My case study concerns a baby who was admitted to our unit with a diagnosis of query meningitis following a visit to the pediatrician who prescribed intravenous antibiotics. I will aim to show the vital process of critical thinking and judgment which led to an avoidance of ‘adverse events and patient harm.’(Benner, Hughes &Sutphen 2008).

Case study

Baby M was a 5-month-old little girl who was brought to the pediatrician with a 24-hour history of being 'extremely hot, crying, refused food and began vomiting and I noticed she was breathing very fast ’as reported by her mother. On examination by the doctor, she was found to have a temp of 39.4C and was very drowsy. Her response reaction to voice and pain stimulus was slower than normal. Blood was taken to assess her status, but a lumbar puncture was not ordered at this stage.

Due to her high temperature and an absence of any rash, bulging eardrums, redness in her throat or other obvious physical symptoms she was referred for admission and the order was given to begin intravenous antibiotics (IV ABS) 6 hourly. Our practice in this hospital was to admit a sick child with a pending diagnosis in order for observation and treatment to be facilitated as fast as possible while definitive investigations and observations could confirm a diagnosis.

She arrived in our unit with cannulation in situ. On examination I found her temp to be slightly improved to 38.4C. She was very fretful and miserable, but her normal reflexes remained slow as confirmed by her mother. At this age, the Moro reflex is disappearing, and the expectation is that the baby would reach out to grasp an item of fascination (D’Amico &Barbarito 2012). She did not. Mother was present and assisting with handling and comforting the baby. The preparation was made for the administration of the IV ABS.

Discussion

The seven rights of medication administration Nurses adhere to are: the right medication, right client, right dose, right route, right reason, right time and right documentation. (NMBA 2016). Employing critical judgment, drawing on the experience of incidents as well as the logic of life experiences, equips one to use assessment techniques more expanded than these basic rights. Allergic reactions can happen in a time frame from minutes to hours (Anagnostou& Turner 2018). Because of the age of Baby M, I intuitively recognized the probability of her never having had an antibiotic, a form of critical thinking drawing on assessment of the context.  If a person has never had an exposure to a drug, especially an antibiotic which has a reputation associated with allergic reactions, there has to be vigilant monitoring of the interaction. This involves the use of critically discriminating against evidence which may or may not be relevant and important in progressing the treatment.

I initiated the delivery of the IV ABS using a syringe driver as the dose was very small(5mg/kg/dose given 6 hourly) but I only administered 1ml at a time while I observed for any reaction in the baby using assessments of analyzing and information seeking. (Benner, Hughes &Sutphen 2008). An allergic reaction can be a systemic reaction which may not be anaphylactic (Anagnostou& Turner 2018).

There was not an instant reaction. Assessing the collective signs of the beginnings of urticaria and an increasing respiration rate (Klimek et al 2017), within minutes, I used clinical judgement that there was the start of an adverse effect, the term used to describe a reaction which has yet to be classified as an allergic reaction, or only an intolerance. (Caimmi et al. 2011, Klimek et al. 2017). The reaction could be consequential to the dose. But using logical reasoning, I deemed that ceasing the infusion was a safer option as delivery of a greater dose may have triggered a larger catastrophic anaphylactic outcome.

I communicated my observations, reasoning, and conclusion to the mother reassuring her constantly. I communicated the episode to the doctor. Utilising the knowledge I had, led me to save the original medication bottle, giving set and syringe driver using predictive assessment in case there were further inquiries required.

Clinical reasoning and assessment are skills which require time and effort to develop and hone. The absence or paucity of them can result in missing valuable cues outside the box of linear information and thinking (Levett-Jones et al. 2010). Baby M missed a possible adverse reaction due to my collective assessment skills of context analysis, interpretation, evaluation, clinical knowledge, and potential predictive foresight. It gave the doctor the time in a controlled environment to further test her for true allergy or only intolerance.

References:

Anagnostou, K, Turner, P.J 2018, ’Myths, facts and controversies in the diagnosis and

management of anaphylaxis.’ Archives of  Disease in Childhood ,pp.1–8.

Benner, P, Hughes, R.G, Sutphen, M 2009, ‘ Clinical Reasoning, Decisionmaking, and Action: Thinking Critically and Clinically,’ in Patient Safety & Quality: An Evidence-Based Handbook for Nurses, vol.1.

Caimmi,S, Caimmi, D,Lombardi, E, Crisafulli, G, Franceschini, F, Ricci, G, Marseglia, G.L 2011, ‘ANTIBIOTIC ALLERGY’ ,International journal of immunopathology and pharmacology, vol. 24,no. 3,pp.47-53.

D’Amico, D, Barbarito, C 2012, ’Health Assessment Across the Life Span,’ in  Health & physical assessment in nursing.Pearson Education, Inc.

Klimek, L, Aderhold, C, Sperl, A, Trautmann A 2017, ‘Allergic reactions to antibiotics – two sides of the same coin: clearly diagnose or reliably rule out,’ Allegro Journal  International, vol. 26, pp.212-218.

Levett-Jones, T ,Hoffman, K , Dempsey, J , Jeong, S , Noble, D , Norton, C , Roche, J , Hickey, N  2010, ‘The 'five rights' of clinical reasoning: An educational model to enhance nursing students' ability to identify and manage clinically 'at risk' patients’, Nurse Education Today, vol.30,no.6, pp.515.