Assignment 3 – Case Study (essay)

Word limit: 3000 Grade Worth: 35 %

Due Date: Friday June 8th 5pm (South Australia Time zone)

This assignment requires students to critically review a case study and answer the questions in the format of an essay as detailed below.

In reviewing the case study and answering the questions, you should draw on the fundamental concepts related to allergic conditions and allergy nursing best practice that you have learned in the course, including additional evidence-based resources and scholarly literature.

Your essay should demonstrate critical analysis, evaluation, and synthesis of the findings from your review of the relevant evidence-based resources, course materials, and scholarly literature.

Ensure that you review the marking criteria, as well as these assignment instructions, when planning and completing the assignment. The assignment will be noticeable according to the assessment criteria set out in the Assignment 3 Marking Criteria and Feedback Form, found in the learn online course site.

Assignment Structure:

The introduction to your essay should provide a succinct overview of the case study, its relevance to allergy nursing, how the essay is organized and the significance of the topic for the reader.

In the body of the article students should demonstrate their understanding and integration of the following relevant concepts related to allergic conditions and allergy nursing practice:

• path physiology of the conditions
• health assessment data
• health management
• patient education
• patient and staff safety
• role and professional responsibilities of the allergy nurse
• the scope of practice and decision making related to allergy nursing
• any other concepts relevant to the case study

The conclusion should summarise your findings and discussion, drawing on the critical analysis presented in the debate in the body of the essay.

Case Study: Jim

Jim, a 24-year-old Caucasian male, has been receiving subcutaneous immunotherapy treatment (SCIT) for allergic rhinitis, for one month.

Past medical history

Jim developed eczema as a baby, which still flares on occasions and he does experience itching most days. He uses a non-soap-based cleanser in the shower. He shampoos his hair twice weekly. He changes brands of shampoo, as some make his head feel itchy. He usually buys the one that is the price reduced. He admits he does not apply moisturizer very regularly. He remembers his mother used to ‘nag’ him to apply his ‘creams’ when he lived at home. He now lives alone. He developed mild asthma as a child and this continued through adolescence. During those years, he was prescribed Symbicort as a Turbuhaler, used it when symptomatic, but he has been asymptomatic in adulthood. He plays tennis weekly, goes running 3 times a week and experiences no asthma symptoms when he exercises. At 20 years of age, he developed allergic rhinitis, which has worsened over the past 4 years. He needed to take days off work when the symptoms were severe, usually in Springtime. The prescribed oral and intra-nasal corticosteroid treatments did not provide much symptom relief. Following referral to an allergist at a local, private, allergy clinic, skin testing identified Jim’s allergies to spring pollinating grasses and house dust mite (HDM) in December.

Jim’s decision:

Subcutaneous immunotherapy treatment (SCIT) was discussed as a treatment option, including the risks and benefits. Jim decided to proceed, starting in March. Written, informed consent was obtained by the allergy specialist, following explanation of the proposed treatments to Jim. The doctor stressed to Jim, that Jim must take one Cetirizine tablet, on the day of his injections and that Jim must wait, in the clinic, for at least 30 minutes after administration of the needles. Jim agreed to these measured when he signed the consent form.

Current Medications

Cetirizine 10mg on the day of immunotherapy injection. Aspirin for an occasional headache and Ibuprofen, if any joints hurt after tennis or running.

Current Immunotherapy situation:

Jim is attending the clinic for his weekly immunotherapy injections. Emergency resuscitation equipment is available. The nurses (who are not nurse practitioners) in this clinic undertake annual, Cardio-Pulmonary Resuscitation (CPR) and anaphylaxis emergency management training.

The nurse undertook base-line observations before Jim commenced the immunotherapy course and documented Jim’s comments on his patient notes and immunotherapy record chart.

Baseline spirometry was not undertaken. The doctor’s rationale was that Jim has not had asthma for many years and had no active symptoms.

Immunotherapy Treatment:

Jim’s weekly subcutaneous immunotherapy treatment (SCIT) consists of one injection, of each extract:

• grass mix (vial A)
• House dust mite HDM (vial B).

Jim has not yet reached the maintenance dose of each extract. He is up to week 4. The SCIT dose of each extract has been gradually increased weekly, according to the manufacturer’s recommended schedule.

 

Jim’s immunotherapy chart

JIM ZOLLIE DOB 1/1/1994

Baseline observations 10/3/2018

BP 130/80: PR 72bpm: RR 16 breaths per minute. Height 180cm: Weight 80kg

 

extract	Anti Histamine	Batch number	Date given	conc	dose	Time given	ReactionMeasured 30 mins after Inj	comments
HDM	Y 0600	123 exp 1/2/19	10/3/18	Bottle 11000TU/ml	0.1	0900	nil
HDM	Y 0600	123 exp 1/2/19	17/3/18	Bottle 1 1000TU/ml	0.3	0910	5mm lump/10 mm redness	Pt report lump grew to golf ball size lump the night of injection. Did not contact dr or clinic
HDM	Y 0800	123 exp 1/2/19	21/3/18	Bottle 1 1000TU/ml	0.5	0915	20mm lump/30mm redness
HDM	Y 0845	123 exp 1/2/19	29/3/18	Bottle 210,000 TU/ml	0.1	0900

 

 

JIM ZOLLIE DOB 1/1/1994

Baseline observations 10/3/2018

BP 130/80: PR 72bpm: RR 16 breaths per minute. Height 180cm: Weight 80kg.

 

extract	Anti Histamine	Batch number	Date given	conc	dose	Time given	reaction	comments
Grass Mix	Y 0600	789 exp 3/3/19	10/3/2018	Bottle 11000 TU/ml	0.1ml	0900	2mm lump 2mm redness
Grass mix	Y 0600	789 exp 3/3/19	17/3/2018	Bottle 11000 TU/ml	0.2ml	0910	2mm lump 2mm redness	See HDM chart
Grass mix	Y 0800	789 exp 3/3/19	21/3/2018	Bottle 11000 TU/ml	0.5	0915	2mm lump 2mm redness
Grass mix	Y 0845	789 exp 3/3/19	29/3/2018	Bottle10,000 TU/ml	0.1	0900

When Jim returned for his injection in week 3, he reported to the nurse that by the evening on the day of the needles the previous week (in week 2), he noticed a massive, itchy reaction on the ‘HDM arm,’ the size of a ‘golf ball.’ The swelling and itchiness lasted for 3 days. He did not contact the allergy clinic or take any medication as he said it was ‘fine, just itchy’ and it went down in a couple of days. The nurse double checked that Jim had taken his anti-histamine several hours before that injection, as it was recorded. Jim’s responded that he had. The nurse documented Jim’s comments in his patient notes and injection chart and reported this information to the doctor. The doctor, sitting in his office, considered this new information, what had been documented on the day of the week 2 injection, that the ‘lump went down’ after a couple of days. The doctor then determined that week 3 dose could proceed at the recommended scheduled increase for the schedule, provided Jim had taken his antihistamine. At 30 minutes the reaction was measured (see chart), and Jim left the surgery and went to work.

Jim came for his injection in week 4 on a very busy clinic day when a different nurse was working. The nurse checked that Jim had taken his antihistamine and asked if he was making any new medications. Jim said he had taken the anti-histamine, but mentioned only carried it 15 minutes ago, when he set off for this appointment. The nurse drew up the scheduled dose, went and checked the extracts doses with the doctor, at the treatment recommended in the manufacturer’s schedule (see chart).

What happened today?

Today, week 4, at 0900, Jim received his two injections of immunotherapy, at the increased, scheduled doses. Within 10 minutes of the injections, Jim was agitated, reported he was feeling stomach cramps, like when he had a stomach bug when he went to Bali. His throat was itchy. Inside his ears also felt itchy. Jim was assessed immediately (0915), by the nurse, who noted Jim’s itchy, red conjunctiva, flushed face, neck and hands, persistent cough and diffuse, bilateral expiratory wheezing and scratching of his skin. Jim’s vital signs were BP: 100/55, HR: 102bpm, RR: 26, at 0915. The nurse summoned the allergist, who came out to see Jim. The allergist and nurse helped Jim walk to a consultation room.

Jim’s treatment and management:

The nurse drew up 0.3 mg of 1:1000 Epinephrines, from an ampoule, into a syringe, checked it with the doctor and administered the medication, by intramuscular injection, in the anterolateral thigh, at 0920. The nurse administered four puffs of salbutamol, via a metered dose inhaler, at 0930. At 10:00, Jim was given a single dose of 40 mg of oral prednisone, on the doctor’s order. The route, dose, date, time and types of medications were documented in Jim’s notes by the nurse.

What happened next?

At 10.15 the patient reported that his throat was feeling less itchy, cramps have subsided, and he was ‘less wheezy.’ Jim’s BP was 120/65, PR 98, RR 26. The nurse noted and recorded a local reaction of 30mm x 35mm for wheal and 60 x 60mm diameter of erythema on the arm where HDM was administered. There was no local reaction at the site of the grass injection.

At 11:15 am, the patient’s vital signs were: BP 130/75, PR 88 and RR 22. On physical examination, Jim had no more wheezing. Jim said he ‘felt fine now’ and asked when he could go home.

The doctor gave Jim a prescription for prednisone 40 mg orally, asking Jim to take the medication once daily, for three days. When Jim asked why, the doctor explained, that the medication should ‘prevent any symptoms of a late or delayed reaction to the injections.’ Jim was also asked to take Cetirizine, 10 mg orally, daily, for seven days. Jim was required to attend the clinic the next week for usual, weekly appointment. The allergist advised Jim that he would be assessed by the nurse and the doctor, at subsequent visits. The doctor may adjust his injection dose. The patient was discharged from the clinic at 12:30 pm.

Final diagnosis:

Anaphylaxis to subcutaneous immunotherapy.

Answer the following questions about Case Study B

1. Using the knowledge, you have gained in this course, additional evidence-based resources and scholarly literature, identify and critically evaluate the aspects of the treatment and management of Jim’s situation that are not consistent with best practice recommendations. Explain how they would have compromised Jim’s safety.

2. Critically discuss the role of the nurse, in the health assessment and clinical decision-making process throughout Jim’s scenario, integrating your supporting evidence.