It is incumbent on the health care team to identify
patient allergies. Actions on the part of the nurse would include the
following:
1. Read the admission history and physical to
seek and identify patient allergies.
2. Question the
patient yourself about allergies.
3. Ensure that any
allergies are clearly marked on the outer cover of the patient’s chart. It is also
safest to have the allergy indicated on the patient’s
bracelet.
4. Make use of the bar code on the patient’s
bracelet to identify the patient during every encounter such as drawing blood or giving
medications/injections.
5. During these encounters, ask
the patient to state their name. Do NOT ask the patient, “Are your Mrs. Jones”. A
confused patient might give an affirmative answer even though she is actually Mrs.
Smith.
6. As you are about to give the medication, ask the
patient if they are allergic to that medication or similar medications. Be sure to use
common names for the mediation that the patient would
recognize.
Although your question seemed to be limited to
patient identification and documentation of allergies, the following suggestions
regarding the nurse’s activity when allergic reaction occurs may be of
interest.
1. If the patient is having an allergic
reaction, the nurse should immediately discontinue any medication that is being given at
the moment (such as IV medications or blood
transfusions).
2. Report the possible allergic reaction to
the physician and note the reaction in your nurse’s
notes.
3. Call for help if the reaction is severe or life
threatening.
4. Institute treatment when appropriate which
could range from antihistamine such as Benadryl, use of adrenaline (epinephrine) or, in
severe reactions, life support measures such as intubation or
tracheostomy.
Your question is a good because it recognizes
that the commonest cause of adverse allergic reaction due to medication is from failure
to properly document the patient’s allergy, and/or correctly identify the
patient.
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