Sarah Pipman is a 49 year old female who was gardening in her yard and was stung

Question

Sarah Pipman is a 49 year old female who was gardening in her yard and was stung by a bee. She washed the area thoroughly, did not see a stinger, and applied ice immediately. Sarah informed her husband and within 5 minutes, the site became increasingly swollen, her face flushed, and she became short of breath and eyesight became blurry. He became alarmed and drove to Harper Medical Center.

Subjective Data:

·       “I can’t breathe and my vision is blurry and I’m going to vomit”.

·       “I got stung by a bee about 20 minutes ago”.

·       “I feel like I am going to die – please help me”.

Objective Data:

              Physical examination

·       Cardiovascular: B/P – 68/58        AP – 136             Temperature – 99.5   O2 sat – 89%

Carotid pulse palpable but weak and absent radial and femoral pulses.

·       RR – 40/min and labored with audible inspiratory and expiratory wheezing.

·       Vomited 150ml of brownish vomitus

1.           Upon arrival to the emergency room, the triage nurse assesses the situation and deems that this is ______________________________________________. What should the triage nurse do next?

2.           What is the data obtained from the primary assessment?

3.           What is the data that is obtained from the secondary assessment?

4.           What is the diagnosis that the nurse suspects and why does it occur? Interpret and explain all the data presented and its significance.

5.           What are some other causes of this diagnosis and what is your role in preventing it in other patients?

6.           What are the initial nursing responsibilities for Sarah?

7.           What nursing assessments are essential and at what frequency should they be performed?

8.           List and prioritize three nursing diagnoses for this patient.

9.           What are some other collaborative problems that may occur and what would you anticipate for discharge?

10.         Document your findings on the flow sheet and also document your findings using narrative format.

Explanation / Answer

1. The triage nurse deems this as a case of an allergic reaction due to bee sting. The next step the triage nurse takes is to provide oxygen.
2. Primary assessment data are vital signs, oxygen saturation and physical examination.
3. Secondary assessment data are general physical examination.

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