Age: 14.0
Sex: F
Vaccine: COVID19
Symptoms: Erythema, Lacrimation increased, Limb discomfort, Oropharyngeal pain, Pruritus
Clinical narrative: Client reported that her legs felt "heavy" at 17:55 after completing her 15 minute observation period. The client denied any other s/s of anaphylaxis. The client stated that she spent several hours in the car on the way to the vaccination site. The client stated that her parents were in the vaccination room and that she was waiting for them. RN recommended the client stay in the observation area until her parents arrive. RN asked the client to report any changes in her symptoms or new onset of symptoms. The client voiced understanding of this. RN checked in with the client about 5 minutes later and the client stated the feeling was gone. At 18:30 the client reported itchiness and noticed redness on her thighs and neck. The client ambulated and sat down in the anti-gravity chair. RN responded. The client denied any shortness of breath or throat tightness. Vitals obtained at 18:30 were as follows: BP 137/87, HR 113, and O2 99%. The client stated she was concerned about a "rash on my legs." The client has no known allergies. She has no chronic conditions or medications. RN assessed the client's skin around the vaccination site, over her chest, neck, ankles, and face. RN did not note any urticaria or hives. The client showed RN a picture of her thighs which the client had taken while in the bathroom previously. RN viewed the picture and was unable to discern if there was a rash or redness present. The client's mother viewed the picture and stated that it looked abnormal for the client. The client was wearing jeans and RN was unable to view the client's thighs in person at the time. The client stated the itching was localized to her right knee and described it as intermittent. RN responded. Repeat vitals obtained at 18:35 were as follows: BP 137/97, HR 110, and O2 99%. RN discussed potential administration of Diphenhydramine. The client and her mother stated that she has not taken Diphenhydramine before. The client asked, "What will that help?" RN discussed the risks, benefits, and potential side effects of Diphenhydramine. RN noticed tears in the client's eyes. The client stated, "My throat kind of hurts, but it feels like I'm going to cry." The client denied any difficulty swallowing, shortness of breath, or constriction of her throat. The client requested to go to the restroom to look at her legs and requested RN accompany her. The client, RN, and the client's mother viewed the client's thighs with the client's permission in the restroom. RN noted stretch marks on the client's thigh which the client confirmed were normal for her. The client stated that her legs "look better." The client's mother stated the client's legs appeared normal. RN did not note any other redness or rash on the client's legs. Repeat vitals obtained at 18:45 PM were as follows: BP 133/94, HR 105, O2 99%. RN educated the client's mother in Spanish regarding s/s of anaphylaxis and when to seek EMS. The client's mother voiced understanding of this education. RN provided education to the client regarding s/s of anaphylaxis, when to seek EMS, and V-safe. The client's voiced understanding of this education. Vitals obtained at 18:54 were as follows: BP 127/71, HR 96, O2 98%. The client denied any current symptoms. The client was alert and oriented to person, place, time, and situation. The client stood up at 19:00 and walked unassisted with a steady gait out of the observation area.