A patient with iron poisoning is receiving infusion of deferoxamine intravenously. Suddenly patient feels flushing of face, urticaria, hypotension and headache. What would be the initial nursing action?

1. A

   Stop the Infusion

2. B

   Continue the Infusion

3. C

   Assess the vital signs

4. D

   Inform to the physician

Appeared in: NORCET 3 - 2022 (Shift-1)

Explanation

Listen in Hindi

• The patient is exhibiting classic signs of an anaphylactoid or severe hypersensitivity reaction to the deferoxamine infusion, including flushing, urticaria, and hypotension.
• The absolute first priority in any acute IV infusion reaction is to stop the administration of the causative agent to prevent further harm and the progression of the reaction.
• This action removes the trigger for the systemic reaction, which is the most critical step before any other assessment or intervention can be effective.
• Deferoxamine, especially when infused too rapidly, is known to cause these hypotensive and histamine-release-related symptoms.

Why Other Options Were Wrong

• Option B: Continuing the infusion would deliver more of the drug, which would intensify the life-threatening reaction and could lead to cardiovascular collapse and shock.
• Option C: While assessing vital signs is a critical step, it is not the initial action. The cause of the instability must be removed first. Delaying stopping the infusion to assess vitals allows more of the drug to enter the system and worsen the reaction.
• Option D: Informing the physician is essential, but it must not precede the immediate, life-saving action of stopping the infusion. The nurse's first duty is to intervene to prevent immediate harm to the patient.

Related Visual

• Visual 1: Flowchart - A flowchart detailing the step-by-step management of an anaphylactic/anaphylactoid reaction, with the first box clearly stating 'Stop the offending agent'.

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Nursing priorities in managing an acute intravenous (IV) infusion reaction in acute care settings.
• Recognizing and immediately acting on acute infusion reactions is a critical nursing responsibility for patient safety. The principle 'stop the infusion first' applies to many situations, including blood transfusion reactions and chemotherapy reactions.
• The nurse must always stay with the patient, call for help (e.g., rapid response team), and be prepared to initiate basic life support.
• What if? If the patient reported only mild flushing with stable vital signs (no urticaria or hypotension), the initial action might be to slow the infusion rate significantly and then notify the physician. This is because some side effects of deferoxamine are rate-related. However, the presence of hypotension and urticaria in the question indicates a severe reaction requiring immediate cessation.

How to Approach the Question

• First, identify the question type. This is a priority-setting question asking for the 'initial' nursing action.
• Analyze the clinical scenario: A patient is receiving an IV medication (deferoxamine) and develops sudden, severe symptoms (flushing, urticaria, hypotension).
• Recognize these symptoms as signs of a serious, systemic adverse reaction (anaphylactoid reaction).
• Apply the core nursing principle for managing acute infusion reactions: the first and most important step is always to remove the cause. Therefore, the infusion must be stopped.
• Evaluate the other options based on priority. Assessing vitals and informing the physician are crucial but are secondary actions. Continuing the infusion is contraindicated and dangerous.

Concept Tested & Keywords

• Concept Tested: Nursing priorities in managing an acute intravenous (IV) infusion reaction.
• Stem keywords: deferoxamine, iron poisoning, infusion, flushing, urticaria, hypotension, headache
• Lead-in keywords: initial nursing action
• Clinical cues: The combination of flushing, urticaria, and hypotension strongly suggests a systemic, life-threatening reaction rather than a minor side effect.
• Negative lead-in flag: false

Question ID

Q-7w2sIAuUZMADAMJActcU

Copy ID