RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS
FOR DESSERTATION
1. / Name of the candidate and address / Mr.ANOOP M ALEX1 Year M.Sc Nursing
Faran College Of Nursing
Bangalore -49.
2. / Name of the institution / Faran College Of Nursing
3. / Course of study and subject. / M.Sc NURSING
MEDICAL SURGIAL NURSING.
4. / Date of Admission to course. / 15 July 2011
5. / Title of the topic / “A descriptive study to assess the knowledge of staff nurses regarding the management of anaphylatic shock in selected hospitals at Bangalore with a view to develop an information book let ”
6. BRIEF RESUME OF THE INTENDED WORK:
INTRODUCTION:
Shock is an acute, widespread process of impaired tissue perfusion that results in cellular, metabolic and hemodynamic derangements. Impaired tissue perfusion occurs when an imbalance develops between cellular oxygen supply and cellular oxygen demand. This imbalance can occur for a variety of reasons and eventually result in cellular dysfunction and multiple organ dysfunction syndrome (MODS). Shocks are classified as cardiogenic shock, hypovolemic shock, anaphylactic shock, neurogenic shock and septic shock.1
Anaphylaxis is a clinical response to an immediate (type 1 hypersensitivity) immunologic reaction between a specific antigen and antibody. The reaction results from a rapid release of IgE-mediated chemicals, which can induce a severe allergic reaction. Substances that most commonly cause anaphylaxis include food (33%), medication (13%), insect stings (14%), exercise (7%) and latex. Foods that are common causes of anaphylaxis include peanuts, shell fish, milk, eggs and wheat. Medications include antibiotics (eg.pencillin(75%)), radio contrast agents, intravenous (IV) anesthetics, aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids.2
Anaphylatic shock results from an immediate hypersensitivity reaction; it is a life threatening event that requires prominent intervention. Severe antigen-antibody response leads to decreased tissue perfusion and initiation of the general shock response. The major life threatening components of anaphylaxis are hypotension, bronchospasm and upper airway angioedema. The most common of these is cardiovascular collapse. Anaphylaxis is a medical emergency which may require resuscitation measures such as airway management, supplement oxygen, large volumes of intravenous fluids and close monitoring.3
World allergy organization estimated that the number of episodes of anaphylaxis seen in emergency rooms ranged from 222 known episodes per annum in Hungary, for a population of 10.2 million; through 300-350 episodes per annum in Japan, for a population of 100 million; to 3,000 episodes per annum in China, in a population of 1,200 million. Estimated prevalence rates ranged from 2% of the population in the United States of America, to 0.1% of the population in Korea, and 0.6-1% of the population in Australia.4
In India recent estimate suggest that IgE mediated food allergy affects 6-8% in children and 3-4% in adults, the mortality ranges from 3% to 9% during anesthesia the incidence of anaphylaxis has been estimated that 1 in 10000. Ninety percent of the anaphylatic reactions occur at the time of induction of anesthesia.5
All people, particularly health care professionals must maintain vigilance to anaphylaxis. Management is focused on recognizing, preventing and intervening complications. Nurses need to have a sound knowledge and competent skills to manage anaphylaxis. As patient’s advocates and the primary care givers there should be a standardized education provided for the nurses to prevent complications. This Information book let helps to improve the knowledge and there by skills and confidence among nurses in managing anaphylatic shock.
6.1 NEED FOR THE STUDY
Anaphylactic shock is a worldwide problem and a true medical emergency that results in a significant number of deaths in each year. The major causative allergens are common to all populations. Prophylactic therapy in the form of epinephrine/adrenaline auto-injectors with antihistamines and steroids often used as adjuncents. Epinephrine (adrenaline) is the primary treatment of anaphylaxis.6
Anaphylaxis is a severe systemic allergic reaction that can involve multiple systems of the body. Anaphylaxis is often unpredictable, it can have a rapid onset and if serious enough can have life threatening consequences. If an anaphylatic reaction is the result of antigen- antibody response, it is considered as anaphylaxis. If reaction is caused by non antibody trigger it is considered to be anaphylactoid. Clinically both responses appear to be the same and require the same management and treatment. With the new protein drugs and their use as therapeutic agents the risk of anaphylaxis has increased. For this reason nurses need to have the knowledge and skill to recognize and respond appropriately when anaphylaxis occurs.7
Anaphylatic reactions occur commonly with the administration of monoclonal antibody therapy and can vary in severity. Nurses should have experience in hypersensitivity reactions with different chemotherapy agents in the treatment of various cancers. Anaphylatic reaction is a challenging occurrence it also can increase hospitalization costs. Strategies to manage reactions have included patient desensitization, alteration of infusion rates, skin testing, and the use of premedication and allergy history, are important in reducing or preventing hypersensitivity reactions. Established guidelines can help to familiarize staff with appropriate responses to anaphylatic reactions and nurses should be aware of the variety of symptoms which can indicate hypersensitivity reactions. Nurses should understand the management of hypersensitivity and anaphylaxis Knowledge of emergency drugs and mechanism of action is vital.8
An epidemiological study was conducted to find a severe anaphylactic and anaphylactoid reaction among hospital patients due to drugs and other exposures. Confirmed cases are classified as definite, probable, or possible anaphylaxis. 123 cases were enrolled in that 99 were classified as definite or probable anaphylaxis, and 24 as possible. Two of the 123 cases were fatal (2%). The result indicates that severe anaphylaxis occurs frequently among hospitalized patients and is rarely fatal. The risk was higher among women, and it varied, although not linearly according to age. The researcher concluded as this can be prevented by increasing the knowledge of the nurses at hospitals.9
A retrospective study was conducted on incidence of anaphylaxis among adult patients at hospital with sample of 448,211 from a last 10 years inpatient. The results revels that the incidence had increased from 2.6 to 46 per 100000 inpatients. It is mainly due to antibiotics and non steroidal anti inflammatory drugs (48%) and food (31%) the researcher concluded by rising the awareness of anaphylatic management among health care providers especially nurses the incidence can be reduced.10
Since the nurses are the primary care givers, they should have an adequate knowledge to identify and provide an initial management such as putting the patient in the supine position, administering intramuscular adrenaline into the lateral thigh, resuscitation with intravenous fluid, support of the airway and ventilation by giving supplementary oxygen. If the response to initial management is inadequate, intravenous infusion of adrenaline should be commenced. Use of vasopressors should be considered if hypotension persists. The patient should be observed for at least 4 hours after symptom resolution.11
From the available literature review it is evident that managing the patient with anaphylatic shock is a great challenge for the health care providers. The researcher felt it is relevant and necessary to look at the educational needs of the nurses on prevention, early identification and management of hospitalized patient on anaphylatic shock so the researcher has planned to prepare information booklet on anaphylatic shock. This information book let is expected to improve the knowledge on management of anaphylactic shock among staff nurses.
6.2 REVIEW OF LITERATURE
Review of literature is the key step in research process. It is the analysis and synthesis of research sources to generate a picture of what is known about a particular situation. The primary purpose of reviewing relevant literature is to gain broad background or understanding of the information that is available related to problem in conducting research. The literature review facilitates selecting a problem, developing a frame work and formulating a research plan.12
A retrospective study conducted to estimate the incidence of anaphylaxis in an emergency department within one year at university hospital. The study reveals there were 64 patients who experienced 65 anaphylactic episodes during the 1-year period. The anaphylaxis occurrence rate was 223 per 100,000 patients per year. The most common manifestations were cutaneous symptoms and signs, followed by respiratory expression. Food allergy was the most common cause of anaphylaxis. 85% of admitted cases had monophasic anaphylaxis. The researcher concluded that improving the knowledge of the health care providers will help to reduce the anaphylaxis incidence .13
A study was conducted at University of South Florida College of Medicine regarding the substances causing anaphylactic shock. The result of the study shows that food items, antibiotics, muscle relaxants, insect bites, latex, foreign proteins, Whole blood, serum, plasma, fractionated serum products, immunoglobulin, dextran, Radiocontrast media, low-molecular weight chemicals, Aspirin, indomethacin and other non-steroidal anti-inflammatory agents (NSAIDs) are causing anaphylactic shock and Idiopathic Causes.14
A retrospective study was conducted to find the clinical features and causes of anaphylaxis in consecutive adult patients. 67 consecutive adults sample with anaphylaxis were selected for this study. The result reveals the mean age of the patient was 32.9 +_10.9 (range 19-57) years. There were 44 (65.7 percent) males and 23(34.3 percent) females. The main causes were food (44.3 percent), insect stings (32.8 percent) and idiopathic (22.8 percent). There were no causes drugs or natural rubber latex. Sea food comprised 66.7 percent of food induced anaphylaxis. Honeybee and wasp stings together comprised 45 percent of insect venom anaphylaxis. The most common manifestations were dyspnoea(59%), uriticaria (58.2%), angioedema(44.8%), and syncope(43.3%). Hypotension was documented in only 28.4% of cases. The study concluded that food was the most common cause followed by insect stings or bites.15
A research project was undertaken as the final part of a Masters in nursing degree programme. The study explored operating department nurses knowledge of Natural Rubber Latex (NRL) allergies, and the management of patients at risk of NRL allergies, within the operating department. The quantitative research approach was adopted for this study, and a simple random sampling approach was taken in selecting 50% (n=466) population of operating department nurses in this study. A response rate of 68% (N=312) was achieved. Analysis of the questionnaire showed that at the time of the study 26% of participants were found to have sufficient knowledge to enable them to safely manage the care of a patient who has a known NRL allergy in the operating department once appropriate guidelines/guidance were available to support practice. Just 9% of participants were identified as being capable of identifying patients at risk of NRL allergy and of providing independent care (no guidelines/guidance required), and 65% participants were found to have insufficient knowledge within the operating . The study concluded that by providing proper guidelines the nurses knowledge will be improved on anaphylaxis and its prevention.16
A study was conducted to assist clinical nurses in understanding the complex nature of chemotherapy-induced anaphylactic reactions and shock as well as effectively preventing or managing these reactions. Most available chemotherapy drugs can cause anaphylactic reactions, but certain drug groups frequently are associated with these reactions (e.g., asparaginases, taxanes, platinum compounds, epipodophyllotoxins). Preventing anaphylactic reactions is the primary goal; however, understanding the principles of managing these reactions is critical because anaphylactic reactions can occur despite using appropriate prevention strategies. Study concluded that the potentially life-threatening nature of anaphylactic reaction and shock to chemotherapy requires that nurses have a plan to manage them. Nurses working with chemotherapy drugs must understand which drugs are associated with high risk of causing hypersensitivity reactions and must be prepared to attempt to prevent or manage reaction. This may include a written policy on staff education and training, appropriate equipment, and medications.17
An experimental study was conducted in intensive care unit regarding acute transfusion reactions. Three independent experts retrospectively reviewed all transfusion event reports and hospital charts. The totals of 2509 transfusions were administered to 305 patients during this study. The study result shows forty transfusion events (1.6%) were confirmed to be acute transfusion reactions by expert consensus: 24 febrile nonhemolytic, 6 minor allergic, 4 isolated hypotension, 3 bacterial contaminations, 1 major allergic anaphylactic shock and 1 hemolytic reaction. Imputability of acute transfusion reactions was probable or possible in 35 cases (88%). Acute transfusion reactions lead to an immediate vital threat in 15 percent of cases. The researcher concluded the better knowledge about these reactions by health care professionals will improve the safety of transfusions in the ICU.18
A study conducted on knowledge of public health nurses on prevention of anaphylatic shock due to vaccination. A survey design was used with 405 participants the data were collected by using a structured questionnaire. The results shows 83% of the nurses has adequate knowledge on anaphylatic shock prevention during vaccination. The researcher concluded that further training should be organized in to other areas of anaphylatic shock to the staff nurses.19
A prospective study was conducted to assess the severity and nature of allergic reactions associated with home IV antibiotic therapy. Data were collected from 770 patients who received 1000 courses of therapy with 25 different antibiotics for 37 conditions, for a total of more than 21000 patient days of antibiotic therapy. Allergic reaction occurred in 2% of pencillin courses, 3.2% of the cephalosporin courses and 5.8% of the vancomycin courses. Reaction to vancomycin occurred 2.5 times more often (p=.0374) than reaction to other antibiotics. Delayed oral angioedema occurred in 3 patients (0.4%) and resolved with discontinuation of antibiotic. The researcher suggested that the health care providers should have sufficient knowledge on IV antibiotic therapy at home and emergency management of anaphylaxis.20
A study was conducted on management of anaphylaxis in child care centers. 39 child centers were selected for this study. The objective of this study was to determine wheatear child care centers can recognize, evaluate and treat anaphylatic episodes in children aged 1 to 6 years 6 months and 1 year after attending an allergy seminar. The result shows that 77% of people knew how to correctly administer intramuscular epinephrine 4 weeks after the seminar, only 48% after 6 months and only 31% after one year. The researcher concluded that there is a need for renewed anaphylaxis education among child care center staffs to recognize, evaluate, and treat anaphylaxis.21