Estes Case Study

Tyler Steele Background scenario

It is 4:30 pm on a warm spring day in northwestern Washington State. You are a community health nurse watching your teenage son play baseball. One of the coaches approaches you with his arm around the shortstop, a 16 -year-old boy named Tyler Steele. He says that Tyler is not feeling well. You lay Tyler down on the bench. Tyler's friend Greg runs up to join you and the coach.

Interview

Tyler:

"I feel so weird. I'm scared."

"My skin is really itchy. It's getting worse really fast."

"It feels like my throat is swelling up."

"I'm having a hard time seeing. I can only see in the very middle."

"I'm having trouble breathing. I feel like I have asthma. I had it as a kid, but it went away."

"I took a bunch of ibuprofen earlier so I could play."

Coach:

"He's never been sick during baseball. None of our players have been ill."

"He was fine during practice."

"He has had a strained Achilles tendon. We have been watching him quite a bit."

"I have his mom's phone number. I'll give her a call."

"Let me pull out his registration form. Here it is. It says he isn't allergic to anything."

"Tyler! Did you get stung by one of those bees in the outfield?"

1 "Are you allergic to bee stings? My brother is and he gets itchy."

"Tyler took a couple of pills my dad gave me. I think it's called cats-flam or something like that. It's just strong ibuprofen."

Examination

Vital signs:

Respiration: 21 Pulse: 120

Observation:

Client appears restless and seems to be getting "spacey". He is itching and rubbing his arms and appears apprehensive. Skin appears to have acquired a generalized edema. There are small hives appearing on his neck area. Occasionally, client places his hands on his upper chest. He appears to be having some difficulty breathing. Client is lying down and does not wish to lift his head. He says he is dizzy. He is slow to answer questions, lethargic and appears to be losing consciousness.

As time passes

You call 911 as Tyler loses consciousness. You monitor his airway, breathing, and pulse until the paramedics arrive, about 3 minutes later. The paramedics record his blood pressure as 76/40. They immediately administer Epinephrine 0.005 mg/kg 1:1000, and started an IV with normal saline. They administer Benadryl 50 mg IV and transport Tyler to the hospital. The physician diagnoses Tyler as having a severe allergic reaction to the Cataflam, an NSAID taken in addition to the ibuprofen he had taken earlier.

Background education

Cataflam is a pain medication that contains the potassium salt of diclofenac. Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) that belongs to the phenylacetic acid group. Cataflam has strong analgesic, anti-inflammatory, and antipyretic properties. It is an inflammatory degenerative and used for other painful conditions. Its mechanism of action is the inhibition of the body's ability to synthesize prostaglandins, a family of hormone-like chemicals created in response to cell injury. It also decreases lipooxygenase products by enhancing the uptake of arachidonic acid into triglycerides. Approximately 65% of the dose is excreted in the urine, and approximately 35% in the bile. The common unwanted side effects are gastritis, peptic ulceration, and depression of renal function. Anaphylaxis to diclofenac is an idiosyncratic reaction and is a very

2 rare event, but can occur in patients without prior exposure to diclofenac. Safety data from clinical trials in the United States have shown that diclofenac has lower rates of adverse reactions comparative NSAIDs.

In pain studies, the efficacy of Cataflam in 50-mg dose and 100-mg dosages is comparable to aspirin 650 mg for immediate pain relief, but tended to provide a longer duration of pain relief than aspirin. Cataflam 50 mg t.i.d. (three times a day) was comparable in efficacy to ibuprofen 800 mg t.i.d. The dose of Cataflam in children over 14 years of age is up to 75 mg daily in divided doses. Cataflam is not recommended for use in children 14 years of age or younger.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are very commonly used for pain relief. Commonly known over the counter (OTC) NSAIDs include ibuprofen (Advil), aspirin (Bayer), and naproxen (Naprosyn/Aleve). Prescription strength NSAIDs include celecoxib (Celebrex), diclofenac sodium (Voltaren), indomethacin (Indocin) and diclofenac potassium (Cataflam). NSAIDs allergic-type reactions occur in approximately 0.3% of the population.

Patients reacting to NSAIDs have anaphylactoid reactions which are believed not to be immunologically mediated but due to direct suppression of prostaglandin synthesis. The term anaphylaxis is commonly used for hypersensitivity reactions typically mediated by immunoglobulin E (IgE). Anaphylactoid reactions are similar, but not related to immune response hypersensitivity. These reactions are acute and include one or more of the following: hypotension, bronchospasm, diffuse skin erythema, hives, itching, laryngeal edema, or cardiac dysrrhythmia.

There is evidence that cross reactive to NSAIDs can occur in some aspirin sensitive patients. Diclofenac is not recommended for asthmatic patients who experience rhinitis with or without nasal polyps, or who exhibit bronchospasm after taking aspirin or other nonsteroidal anti-inflammatory drugs. Fatal reactions have been reported in such patients. It is not true, however, that an individual allergic to one NSAID is allergic to all NSAIDs. Some individuals, who are allergic to one, can tolerate another type with no adverse effects.

A severe anaphylactic reaction will cause rapid acute respiratory and circulatory collapse, and can be fatal within minutes. Symptoms can be wide ranging. Often the earliest symptoms are itching and warmth all over the body, accompanied by a feeling of anxiety or panic. Other symptoms often seen in anaphylactic reaction include: hives, flushing, wheezing, shortness of breath, bronchoconstriction, abdominal pain, nausea, difficulty swallowing, vomiting, diarrhea, hypotension, dizziness or lightheadedness, weakness, shock, pulmonary edema, angioedema, swelling of the face, eyes, or tongue, unconsciousness seizures, coma, and death. Treatment begins with the basics. Immediately stop the exposure or administration of any substances that might be causing the reaction. Establish airway, breathing, and circulation. Administer oxygen by face mask at 6 to 8 L/minute, administer epinephrine

3 subcutaneously, start an IV, intubate if needed, administer a rapidly acting steroid IV, administer an antihistamine IV, and monitor the client. Epinephrine is a key treatment to reverse the symptoms of aphylactic reactions. As an alpha-receptor agonist, it reverses peripheral vasodilatation and swelling. It opens the airways, and increases the force of myocardial contraction. Individuals who have experienced allergic reactions to a food or medication need to be vigilant to avoid a repeat experience. Community health nurses can help them identify what caused the reaction and work with employers, teachers, or family members to help the individual avoid another exposure. This includes informing others of the allergy. Individuals may wear a medic-alert bracelet or necklace or carry a medic-alert card in purse or wallet. In addition, the physician may prescribe emergency Epinephrine for the individual to keep at hand in case another reaction occurs. Epinephrine is available in auto-injectors, commonly known as EpiPens. These are disposable drug systems with spring activation of a concealed needle for a rapid, convenient dose of Epinephrine in an emergency situation. The EpiPen is pushed firmly into the thigh, and held for 10 seconds. It is then removed and discarded. The expiration date on the EpiPen must be checked, and the device replaced when it is outdated. List your findings and conclusions:

Acute and severe anaphylactoid response secondary to high dose of prescription NSAID

Nursing diagnoses:

00030 Impaired gas exchange 00146 Anxiety 00148 Fear 00032 Ineffective breathing pattern 00051 Impaired verbal communication

1. The doctor prescribes Cataflam for a client. The nurse knows that Cataflam has analgesic, anti-inflammatory, and antipyretic properties. The drug is also in the NSAID group and the nurse knows that NSAID stands for a. Non-specific anti-inflammatory drug b. Nonsteroidal aspirin immunosuppressive drug c. Nonsteroidal anti-inflammatory drug d. None of the above

2. An 18-year-old high school athlete reports that he has been taking a nonsteroidal anti-inflammatory drug (NSAID). The nurse knows that NSAIDs are available

4 a. Only by prescription b. Over the counter c. Restricted as narcotics d. Prescription and non-prescription

3. A high school athlete reports to the school nurse that he has been taking Cataflim The nurse knows that Cataflam is: a. An OTC NSAID b. A prescription NSAID c. An OTC steroid d. A prescription steroid

4. A 16-year-old female reports to the community health nurse at a youth center complaining of breathing problems. She tells the nurse that she took several Cataflam and ibuprofen pills to help with the pain and swelling of a sore leg. The nurse knows that cross sensitivity between NSAIDs a. Always occurs b. Rarely occurs c. Never occurs d. Has been known to occur but does not always occur

5. NSAIDs are believed to cause anaphylactoid reactions. How are anaphylactoid reactions different from anaphylactic reactions? a. Anaphylactoid reactions are believed not to be immunologically mediated. b. Anaphylactoid reactions are less severe. c. Anaphylactoid reactions are usually limited to skin reactions. d. Anaphylactoid reactions are usually limited to cardiovascular reactions.

6. When treating acute anaphylactoid reaction, the nurse knows to first a. Start an IV. b. Get the client some fresh air. c. Administer IV Epinephrine. d. Assess airway breathing and circulation.

7. Which of the following is not a symptom of acute anaphylactoid reaction? a. Hives b. Shortness of breath c. Gastrointestinal bleeding d. Nausea

5 8. A doctor prescribes Cataflam for pain relief for a client with a severely broken leg. The client asks the nurse about the drug and its pain relief compares to aspirin. The nurse knows that in pain studies, Cataflam has been shown to have a longer duration of pain relief than aspirin. She also knows that 50 mg and 100 mg dosages of Cataflam provided comparable pain relief to a. 650 mg aspirin b. 50 mg aspirin c. 100 mg aspirin d. 8 baby aspirin

9. The doctor prescribes Cataflam for a client. The nurse knows that the generic name for Cataflam is a. Diclofenac sodium b. Diclofenac potassium c. Indomethacin d. Celecoxib

10. Anaphylactoid reactions to NSAIDs occur in approximately how much of the population? a. 25% b. 10% c. 3% d. 0.3%