Assignment 3 – Case Study (essay)

 

 

Assignment 3 – Case Study (essay)

Word limit: 3000               

Grade Worth: 35 %

 

This assignment requires students to critically review this set case study and answer the questions in the format of an essay as detailed below. You should draw on the key 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 on the Marking Criteria and feedback form, as well as these assignment instructions, when planning and completing the assignment. The assignment will be marked according to these assessment criteria set out in the Assignment 3 Marking Guide and Feedback Form, found in the learnonline 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 organised and why the topic is important.

 

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

• basic outline of the pathophysiology of the conditions
• health assessment data
• health management
• patient education
• patient and staff safety
• professional responsibilities and role of the allergy nurse
• 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 discussion in the body of the essay.

 

 

 

Case Study: Anna

Anna, a 17 year old girl whose parents migrated from China before Anna was born.  Anna has been receiving sub-cutaneous immunotherapy treatment (SCIT) for allergic rhinitis, for one month.

Past medical history

Anna developed eczema as a baby, but this resolved by the time she attended high school.  She did have egg and cow milk allergy as a baby but could tolerate those foods, in cooked and uncooked form, by the time she was 2 years old. Anna uses a non-soap-based cleanser in the shower as it is what her mum buys.

Anna had episodes of asthma as young child usually triggered by viruses.  She was prescribed an inhaler that she used over one or two spring seasons but had not needed any inhalers for 5 years.  Anna is the netball captain, plays twice a week, including a practice session on Tuesday after school.

Anna developed rhinitis when she was 10 years old. Her mum noticed her daughter’s ‘springtime hayfever’ got much worse, when Anna reached puberty. It seemed to affect Anna’s sleeping. Anna seemed blocked in the nose when she woke each day and rubbed her nose a lot. In springtime the sneezing and runny, itchy eyes were worse. Anna’s mum asked the GP to refer Anna to an allergist. The GP performed a blood test to see if the referral was really warranted. That test showed allergy to tree pollen and house dust mites. The GP warned mum it might take some time to get an appointment, so he prescribed an intranasal topical corticosteroid preparation asking Anna to use one spray in each nostril daily over springtime. Anna was also prescribed the antihistamine, fexofenadine 180mg, one daily when the symptoms occurred.

 

Anna finally saw the allergist at a private, suburban allergy clinic. The skin prick test established Anna’s allergy to house dust mites (HDM) and birch tree pollen. The allergist asked if the nasal spray had helped her hayfever. Anna thought it did not make much difference and confessed she did not always remember to use it.

Subcutaneous immunotherapy treatment (SCIT) was discussed as a treatment option. The allergist explained the schedule involved weekly injections for six (6) weeks, then the injections would continue monthly for 3 years. Anna wanted to proceed, and her mum agreed. Consent was obtained by the allergist, following explanation of the proposed treatments to Anna and her mother. The doctor stressed to them, that Anna must take one Fexofenadine tablet, on the day of her injections and that she must wait, in the clinic, for 30 minutes, after administration of the injections. Anna and her mum agreed to these measures when the consent form was signed.

Current Medications

Fexofenadine 180mg on the day of immunotherapy injection. Nurofen (Ibubrofen) for an occasional headache.

Current Immunotherapy situation:

Anna is attending the clinic for her weekly immunotherapy injections. Epinephrine, portable oxygen and suction are available in the treatment room. The nurses (who are not nurse practitioners) in this clinic undertake annual, Cardio-Pulmonary Resuscitation (CPR) training and anaphylaxis emergency management training.

The nurse undertook base-line vital signs observations before Anna commenced the immunotherapy course and documented Anna’s observations on her patient notes and immunotherapy record chart.

Immunotherapy Treatment:

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

• Birch Pollen (vial A)
• house dust mite HDM (vial B).

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

 

Anna’s immunotherapy chart (**Note I have put ‘autumn’ instead of the numerical month as we have students in both hemispheres where seasons are opposite)

Anna Xu DOB 1/1/2003

Baseline observations: Date 10/autumn/2020

BP 120/70:  PR 70 bpm: RR 16 breaths per minute. Height 170cm: Weight 65kg.

extract	Anti Histamine	Batch number	Date given	conc	dose	Time given	Reaction Measured 30 mins after Inj	comments
HDM	Y  0600	123 exp 1/2/21	10/autumn/2Ø	Bottle 1 1000TU/ml	0.1ml	1600	nil
HDM	Y 0600	123 exp 1/2/21	17/autumn/2Ø	Bottle 1 1000TU/ml	0.3ml	1600	5mm lump/10 mm redness	Pt report lump grew to walnut size lump the night of injection. Did not contact dr or clinic
HDM	Y 0800	123 exp 1/2/2Ø	21/autumn/2Ø	Bottle 1 1000TU/ml	0.5ml	1600	15mm lump/30mm redness
HDM	Y 0845	123 exp 1/2/2Ø	29/autumn/2Ø	Bottle 2 10,000 TU/ml	0.1ml	1600

 

Anna Xu DOB 1/1/2003

Baseline observations: date 10/autumn/2020

BP 120/70:  PR 70 bpm: RR 16 breaths per minute. Height 170cm: Weight 65kg.

 

extract	Anti Histamine	Batch number	Date given	conc	dose	Time given	reaction	comments
Birch Pollen Mix	Y  0600	789 exp 3/3/21	10/autumn/2Ø	Bottle 1 1000 TU/ml	0.1ml	1600	nil
Birch Pollen mix	Y 0600	789 exp 3/3/21	17/autumn/2Ø	Bottle 1 1000 TU/ml	0.3ml	1600	nil	See HDM chart
Birch Pollen mix	Y 0800	789 exp 3/3/21	21/autumn/2Ø	Bottle 1 1000 TU/ml	0.5ml	1600	2mm lump 2mm redness
Birch Pollen mix	Y 0845	789 exp 3/3/21	29/autumn/2Ø	Bottle 10,000 TU /ml	0.1ml	1600

 

When Anna returned for her injection in week 3, she reported to the nurse that by the evening on the day of the injections the previous week (week 2), she noticed a large, itchy reaction on the ‘HDM arm’, the size of a walnut. The swelling and itchiness lasted for 2 days. No contact was made with the clinic as this resolved once an antihistamine had been administered. The nurse double checked that Anna had taken her anti-histamine several hours before that injection, as it was recorded. Anna responded that she had. The nurse documented Anna’s comments in her patient notes and injection chart and reported this information to the doctor. The doctor, sitting in his office, considered this new information, looked back at what had been documented on the day of the ‘week 2 injection’, that the ‘lump went down’ next day. The doctor then determined that the week 3 dose could proceed at the recommended increase suggested on the schedule, provided Anna had taken her antihistamine. At 30 minutes the reaction was measured (see chart) and Anna left the surgery as she had to go to netball practice.

 

What happened today?

Anna came for her injection in week 4 on a very busy clinic afternoon when a different nurse was working. Anna travelled by bus to the appointment and was catching the bus home as her mum was working. The nurse checked that Anna had taken her antihistamine and asked if she was taking any new medications. Anna said she had only taken the anti-histamine 15 minutes prior to her appointment and had a headache a few hours ago, so she took two Aspirin from her friend at school, as she did not have her ibuprofen tablets with her. The nurse drew up the scheduled dose from both vials at the dose recommended in the manufacturer’s schedule (see chart). She went and checked the extracts doses with the doctor.

 

Today, week 4, at 1600, Anna received her two injections of immunotherapy, at the increased, scheduled doses. Within 10 minutes of the injections, the nurse noticed Anna’s face was flushed and she had an intermittent cough.  The nurse asked Anna if she felt OK, and Anna reported that she needed to go to the bathroom urgently. Anna said her throat also felt itchy and she couldn’t breathe properly.  Anna was assessed by the nurse immediately (1615) who noted Anna now had a wheeze. Anna’s vital signs were BP: 90/50, HR: 102bpm, RR: 26, at 1620. The nurse walked Anna to a treatment room where the resuscitation trolley was situated. The nurse summoned the doctor.

 

Anna’s treatment and management:

The nurse drew up 0.3 mg of 1:1000 Epinephrine, from an ampoule, into a syringe, checked it with the doctor and administered the medication, by intramuscular injection, in the anterolateral thigh, at 1630. The nurse administered four puffs of salbutamol, via a metered dose inhaler, at 1635. At 17:00, the doctor suggested Anna have a single dose of 40 mg of oral prednisone.

What happened next?
At 1730 the patient reported that her throat was feeling less itchy and she felt ‘less wheezy’. Anna’s BP was 115/60, PR 98, RR 20. The nurse noted and recorded a local reaction of 30mm wheal and 60mm diameter of erythema on the arm where HDM was administered. There was no local reaction at the site of the birch pollen injection.

At 1815, the patient’s vital signs were: BP 130/75, PR 88 and RR 22. On physical examination, Anna had no more wheezing and said she ‘felt fine’ now. The nurse rang Anna’s mother to alert her to what had happened and to ask her to collect Anna.
The doctor gave Anna a prescription for prednisone 40 mg orally, asking her to take the medication once daily, for three days. When Anna asked why, the doctor explained, that the medication should ‘prevent any symptoms of a late or delayed reaction to the injections’. Anna was also asked to take Fexofenadine 180mg orally, daily, for seven days. Anna was required to attend the clinic the next week for usual, weekly appointment. Anna’s mother arrived at 1830. The nurse explained what had happened, outlined verbally the treatments the doctor suggested, and the medication Anna must take over the next few days. Anna reassured her mother she felt fine now.

The allergist advised Anna and her mother that at the next visit she would be assessed by the nurse and the doctor. The doctor may adjust her next injection dose. The patient was discharged home from the clinic at 1915.

 

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 Anna’s situation that are not consistent with best practice recommendations. Explain how they would have compromised Anna’s safety.
2. Critically discuss the role of the nurse, in the health assessment and clinical decision-making process throughout Anna’s scenario, integrating your supporting evidence.

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