Physiological Adaptation Q 30


A patient is brought to the emergency department after a bee sting. The family reports a history of severe allergic reaction, and the patient appears to have some oral swelling. Which of the following is the most urgent nursing action?
  
     A. Consult a physician.
     B. Maintain a patent airway.
     C. Administer epinephrine subcutaneously.
     D. Administer diphenhydramine (Benadryl) orally.
    
    

Correct Answer: B. Maintain a patent airway.
The patient may be experiencing an anaphylactic reaction. Airway management is paramount. Thoroughly examine the patient for airway patency or any indications of an impending loss of airway. Perioral edema, stridor, and angioedema are very high risk, and obtaining a definitive airway is imperative. Delay may reduce the chances of successful intubation as continued swelling occurs, increasing the risk for a surgical airway.
Option A: The physician will see the patient as soon as possible with the above actions underway. Often when anaphylaxis is diagnosed co-treatment is initiated with steroids, antihistamines, inhaled bronchodilators, and vasopressors. Glucagon can also be used if indicated. These agents can assist in refractory initial anaphylaxis or aid in the prevention of recurrence and biphasic reactions.
Option C: The most urgent action is to maintain an airway, particularly with visible oral swelling, followed by the administration of epinephrine by subcutaneous injection. Epinephrine is given through intramuscular injection and at a dose of 0.3 to 0.5 mL of 1:1,000 concentration of epinephrine. Pediatric dosing is 0.01 mg/kg or 0.15 mg intramuscularly (IM) (epinephrine injection for pediatric dosage). Intramuscular delivery has proven to provide more rapid delivery and produce better outcomes than subcutaneous or intravascular.
Option D: Oral diphenhydramine is indicated for mild allergic reactions and is not appropriate for anaphylaxis. Antihistamines are often routinely used; most commonly is H­blocker administration of diphenhydramine 25 to 50 mg IV/IM. While the clinical benefit is unproven in anaphylaxis, its utility is evident in more minor allergic processes.