NU651 Unit 9 Reflective Narrative on Anaphylaxis Example

Two Minutes Between Knowing and Doing: A Reflective Narrative on Anaphylaxis to a First Dose of Piperacillin-Tazobactam

[Student Name]

Purdue University Global

NU651: AGACNP Introduction to Acute Care Management Clinical I

Unit 9 Reflective Narrative

[Instructor Name]

[Date]

The patient and the encounter are composite; times, doses and vital signs are bracketed.

Description

Ms. [J.] was a [37]-year-old woman admitted with pyelonephritis, whose antibiotic was changed to piperacillin-tazobactam after her culture grew a resistant organism. She had no recorded allergies. At [14:02] her nurse started the infusion. At [14:06] the nurse called us to the room: Ms. [J.] was flushed, had hives across her chest and arms, and said her throat felt tight. I listened to her chest and heard wheezing. Her blood pressure was [82/46] and her pulse [128].

At minute one, I recognized anaphylaxis. I knew she met the clinical criteria: acute skin involvement with respiratory compromise and low blood pressure after a likely allergen (Sampson et al., 2006). What I said out loud was a question: "Have you ever had penicillin before, or any reaction to antibiotics?" While she answered, the nurse stopped the infusion. At about minute two my preceptor, who had followed us in, said, "Epinephrine, point five, IM, thigh, now." The nurse gave intramuscular epinephrine [0.5] mg into the anterolateral thigh at [14:10], four minutes after the nurse's call. Her wheeze eased and her pressure rose to [104/64] within [ten] minutes. She was monitored overnight and did not need a second dose.

Reflection: What Was I Trying to Achieve?

I was trying to be thorough. I wanted to confirm that the reaction fit an allergy before treating it, and asking about prior penicillin exposure felt like diligence. But the diagnosis was already clear, and no answer to my question would have changed the first treatment. I kept gathering information after the decision had been made, because gathering is what I know how to do while I am uncertain about my right to act.

Influencing Factors

Johns' model asks what internal and external factors influenced the response (Johns, 1995). I can name three.

The first is a habit from [ten] years of bedside nursing, where I completed a picture before calling a provider, since the provider would ask for it. That habit served me well as a nurse and served the patient badly here.

The second is role uncertainty. I was not sure whether a student could call for a drug aloud with a preceptor about to arrive. That hesitation cost time, and it is the factor I most need to address, because in an emergency the first person to name the treatment is the one who starts it.

The third is that the history question felt productive. It was a real question with a real use later, for her allergy record, and that made it easy to mistake for the next step.

Johns' model also asks how others were feeling. The nurse had stopped the infusion before I spoke, which told me she had recognized the reaction too and was waiting for someone to name the drug. Ms. [J.] was frightened and struggling to answer my question while her throat tightened. Looking back, my question asked her to do work that helped no one at that moment.

Evidence and What Could Have Been Done Differently

The World Allergy Organization guidance is unambiguous: epinephrine injected into the thigh muscle comes first in anaphylaxis and should be given without delay, at 0.01 mg per kilogram up to 0.5 mg in adults (Cardona et al., 2020). Delay matters. In a review of fatal reactions in the United Kingdom, the median time from exposure to respiratory or cardiac arrest was five minutes for reactions caused by drugs given in hospital (Pumphrey, 2000). Ms. [J.] was about four minutes into her reaction when the epinephrine went in, which is close to that median.

A better sequence would have been: stop the infusion, say "this is anaphylaxis, epinephrine [0.5] milligrams IM now," position her lying down with legs raised, give oxygen and call for help, and ask the history question afterward. None of those steps required anything I did not know.

Learning

I have written and rehearsed one sentence for the next time: "This is anaphylaxis; epinephrine point five IM now; I will stay with her." My preceptor agreed that a student may and should say it, and that she would rather stop an unnecessary dose than wait for a necessary one. I have also asked the unit educator whether our anaphylaxis kit can be checked on my next shift, so that I know where it is before I need it.

What I take from this encounter is that knowing the answer and saying it are different skills. The second one needs practice, and it needs permission I can give myself.

References

Cardona, V., Ansotegui, I. J., Ebisawa, M., El-Gamal, Y., Fernandez Rivas, M., Fineman, S., Geller, M., Gonzalez-Estrada, A., Greenberger, P. A., Sanchez Borges, M., Senna, G., Sheikh, A., Tanno, L. K., Thong, B. Y., Turner, P. J., & Worm, M. (2020). World Allergy Organization anaphylaxis guidance 2020. World Allergy Organization Journal, 13(10), Article 100472. https://doi.org/10.1016/j.waojou.2020.100472

Johns, C. (1995). Framing learning through reflection within Carper's fundamental ways of knowing in nursing. Journal of Advanced Nursing, 22(2), 226-234. https://doi.org/10.1046/j.1365-2648.1995.22020226.x

Pumphrey, R. S. H. (2000). Lessons for management of anaphylaxis from a study of fatal reactions. Clinical & Experimental Allergy, 30(8), 1144-1150. https://doi.org/10.1046/j.1365-2222.2000.00864.x

Sampson, H. A., Muñoz-Furlong, A., Campbell, R. L., Adkinson, N. F., Jr., Bock, S. A., Branum, A., Brown, S. G. A., Camargo, C. A., Jr., Cydulka, R., Galli, S. J., Gidudu, J., Gruchalla, R. S., Harlor, A. D., Jr., Hepner, D. L., Lewis, L. M., Lieberman, P. L., Metcalfe, D. D., O'Connor, R., Muraro, A., . . . Decker, W. W. (2006). Second symposium on the definition and management of anaphylaxis: Summary report. Journal of Allergy and Clinical Immunology, 117(2), 391-397. https://doi.org/10.1016/j.jaci.2005.12.1303