NANDA-NursingPlan Area 11 Safety/Defense

NANDA-Nursing Plan 00218 Rsik for adverse reaction to indinated contrast madia

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

Area 11 “Safety/Defense”
Category 5 Defense function Process of protecting the self from the non-self

00218 Rsik for adverse reaction to indicated contrast madia

Nursing plan: Rsik for adverse reaction to indinated contrast madia
Definition: A condition in which adverse or unexpected reactions associated with the use of iodine-contrast agents are likely to occur within 7 days after injection of the contrast agent and may compromise hea lth.

1. About iodinated contrast media

1) What is an iodinated contrast agent?

 Contrast with other tissues by using the fact that the contrast agent absorbs more X-rays than other tissues (or vice versa, absorbs less than other tissues). Blood vessel ruptures and tumors can be detected by the difference in contrast.

2) Side effects of iodinated contrast media

The mechanism of anaphylactic shock (see ★1) due to contrast media is unknown, and accidents cannot be completely predicted.

The maximum incidence of mild side effects is 3%, and the incidence of severe side effects is 0.004%.

・Severe allergic reaction: anaphylactic shocks route

⑦ Cardiopulmonary resuscitation (if it is determined that cardiac arrest or respiratory arrest has occurred in ①)

3) Contraindications and principle contraindications for iodinated contrast media

① Contraindications

-History of hypersensitivity to iodine or iodinated contrast media

・Severe thyroid disease

・Oral biquanide hypoglycemic agents (metgluco, metformin, dibetos, dibetone)

② Principle contraindications

・Extremely bad general condition

・bronchial asthma

・Serious renal disorder (serum Cre = 1.5mg/dl or more)

・Severe liver damage

・Serious heart disorder

・Acute pancreatitis

・Macroglobulinemia (abnormal production of IgM due to abnormal B cells)

・Multiple myeloma (a disease in which plasma cells differentiated from B cells become cancerous and produce M-protein (an antibody that is incapable of attacking foreign substances))

・Tetany (hypocalcemia that excites peripheral nerves, causing persistent muscle stiffness and muscle cramps. Hypocalcemia is caused by hypoparathyroidism, hyperventilation, and vitamin D). deficiency, etc.)

Pheochromocytoma (a tumor in the medulla of the adrenal gland that causes overproduction of catecholamines (adrenaline, noradrenaline))

③ Careful administration

・If you, your parents, or relatives are prone to allergies such as bronchial asthma, rashes, or hives.

-History of drug hypersensitivity

・Dehydration symptoms

・High blood pressure

·Arteriosclerosis

·Diabetes

・Thyroid disease

・decreased liver function

・decreased renal function

・Elderly people, children, pregnant women

 

★ 1  What is anaphylactic shock?

Quoted from the Japanese Society of Allergology “Anaphylaxis Guidelines”

https://anaphylaxis-guideline.jp/pdf/guideline_slide.pdf

1) Definition

①What is anaphylaxis? A hypersensitivity reaction in which systemic allergic symptoms are induced in multiple organs due to the intrusion of an allergen, etc., and can be life-threatening.

② What is anaphylactic shock? When anaphylaxis is accompanied by a drop in blood pressure or disturbance of consciousness

2) Diagnostic criteria for anaphylaxis

Diagnose anaphylaxis if the following three conditions are met.

①Skin symptoms (systemic redness, itching, erythema) or mucosal symptoms (swelling of the lip, tongue, or uvula) that develop rapidly

② Dyspnea (airway narrowing, wheezing, hypoxemia)

③Decreased blood pressure, disturbed consciousness

3) Anaphylaxis aggravating factor

①Age: infants, adolescents, pregnancy/childbirth, the elderly

② Underlying disease; asthma, cardiovascular disease, mastocytosis, allergic rhinitis, eczema, psychiatric disease

③ Drugs: β-adrenergic blockers, ACE inhibitors, antidepressants

④Luxury items: alcohol

⑤Exercise, acute infection, mental stress, unusual activities, menstrual period

4) Initial response when anaphylaxis occurs

① Vital sign confirmation

② Call for help (composition team, ambulance)

③ Intramuscular injection of adrenaline (0.01 mg/kg; maximum dose is 0.5 mg for adults and 0.3 mg for children)

④Put the patient in supine position and raise the leg (about 30 cm). Raises the condition a little when breathing is difficult.

⑤ Oxygen administration (6 to 8 L)

⑥Securing a venou

n with your dominant hand and remove the blue safety cap.

5) How to use the EpiPen

① Open the cover and take out the EpiPen from the case.

② Hold the center of the pen with your dominant hand and remove the blue safety cap.

(3) Press the orange tip firmly against the front of the thigh perpendicularly until it clicks. Press for 5 seconds.

2. Indication of nursing diagnosis “Rsik for adverse reaction to indinated contrast madia”

① Contraindications

・History of hypersensitivity to iodine or iodine contrast

・Severe thyroid disease

・Oral biquanide hypoglycemic agents (metgluco, metformin, dibetos, dibetone)

②Principle contraindications

・Extremely bad general condition

・bronchial asthma

・Serious renal disorder (serum Cre = 1.5 mg/dl or more), or taking renal metabolism drugs

・Severe liver damage

・Serious heart disorder

・Acute pancreatitis

・Macroglobulinemia (abnormal production of IgM due to abnormal B cells)

・Multiple myeloma (a disease in which plasma cells differentiated from B cells become cancerous and produce M-protein (an antibody that is incapable of attacking foreign substances))

・Tetany (hypocalcemia that excites peripheral nerves, causing persistent muscle stiffness and muscle cramps. Hypocalcemia is caused by hypoparathyroidism, hyperventilation, and vitamin D). deficiency, etc.)

Pheochromocytoma (a tumor in the medulla of the adrenal gland that causes overproduction of catecholamines (adrenaline, noradrenaline))

③ Careful administration

・If you, your parents, or relatives are prone to allergies such as bronchial asthma, rashes, or hives.

-History of drug hypersensitivity

・Dehydration symptoms

・High blood pressure

·Arteriosclerosis

·Diabetes

・Thyroid disease

・decreased liver function

・decreased renal function

・Elderly people, children, pregnant women

④ that

・Weak blood vessel walls (continuous drip infusion, administration of anticancer drugs, arteriosclerosis)

・Children and the elderly

 

3. setting a goal

Goal setting by linkage (listed in the second half of the NOC)

* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).

1) Linkage achievements

・Allergic reaction: systemic (0706)

(Definition: severity of systemic hypersensitivity immune response to specific environmental (exogenous) antigens)

・Allergic reaction: local (0705)

(Definition: severity of local hypersensitivity immune response to specific environmental (exogenous) antigens)

Severity of shock: anaphylaxis (0417)

(Definition: severity of symptoms and signs suggestive of inadequate blood conditions for tissue perfusion caused by vasodilatation associated with acute onset of systemic hypersensitivity reactions and increased capillary permeability)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”

・It is possible to convey to the medical staff any abnormalities felt after using the contrast medium, such as discomfort in the throat, difficulty breathing, and itching.

*Nurse goals include:

・Promote understanding by explaining according to the “Information and Consent” document for the use of iodinated contrast media.

・Efforts will be made for early detection of abnormalities due to the use of iodinated contrast media.

 

4. nursing plan

1) Observation Plan 《OP》

We will draft an observation plan (OP) for each outcome of the linkage.

★ Allergic reaction: systemic 0706>

★ Allergic reaction: topical 0705>

・pharyngeal edema, dyspnea, choke sign

・ Decrease in SPO2

・Facial edema

・Dyspnea at rest

・Wheezing

・Constriction sound

・Secondary noise

・Tachycardia

・Low blood pressure

·arrhythmia

・Pulmonary edema

・ Decreased level of consciousness

・Itching all over the body

・hives

・ Whole body desquamation

・petechial bleeding

・Erythema

・Rise in skin temperature

・fever

・chills

·nausea

·vomiting

·diarrhea

・Anaphylactic shock

★ Severity of shock: anaphylaxis 0417>

・Low blood pressure

・Increased heart rate

·arrhythmia

・Decreased urine volume

・ Decreased level of consciousness

・Delirium

・Rhinitis

・Wheezing (wheezing, wheezing)

・pharyngeal spasm

・Bronchospasm

・Difficulty breathing

・Lower PaO2

– Warm, flushed skin

・Edema of the lips, eyelids, and tongue

・Angioedema

・Edema of hands and feet

・Public edema・

・ paresthesia

・Pruritus

・Abdominal spasm

·vomiting

·diarrhea

 

2) Action plan 《TP》

・Confirm that there is a consent form for the use of iodine.

・If you are present during the administration of iodinated contrast media and observe any abnormalities in respiratory condition, skin condition, altered level of consciousness, or abnormal vital signs, immediately report them to your doctor.

・If the victim is unconscious, call the staff and start CPR.

・According to the doctor’s instructions, cooperate while speaking, such as observation, recording, time measurement, chest compression, bag valve mask, securing peripheral veins, drug preparation and administration, DC (defibrillation) preparation, intubation preparation, blood sampling, etc. do.

・ Organize routes such as intravenous drips and gastric tubes, and manage them cleanly and safely.

・Contact your family.

・Even if it is not an emergency, if you find persistent abdominal symptoms or skin symptoms after administration, report them to your doctor.

 

3) Education plan 《EP》

・Confirm the contents of the instruction manual and the consent form together before taking the iodine test.

・Instruct the patient to raise his/her hand or make a nurse call if there are any abnormal symptoms such as difficulty breathing, feeling unwell, or fainting.

・Tell them to let you know if they have abdominal pain or diarrhea.



References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Toru Yamaguchi, Mitsuo Kitahara, Tsuguya Fukui. (2012). Today’s treatment guidelines. Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008).

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