Age: 34.0
Sex: F
Vaccine: COVID19
Symptoms: Hypoaesthesia, Injection site erythema, Nausea, Nervousness, Peripheral coldness
Clinical narrative: After the vaccine, the client reported that her arm felt "numb" to Lead Ancillary and she stated that "I didn't feel the shot." The client then reported feeling "high" to lead Ancillary. Lead Ancillary notified RN and RN, who then responded to the client. The client reported feeling, "Like I'm on a cloud and dizzy." RN asked if the client's vision was clear, and the client reported "You're a little foggy." The client was sitting in an office chair with her right leg elevated. The client had a boot on her right foot and a right knee brace from a previous injury. The client denied any history of syncope. The client reported a history of hypertension, which is not controlled with medication. The client stated that she has recently been taking Ibuprofen for pain, but did not take any ibuprofen today. The client has no known allergies. Vitals obtained at 7:27PM were as follows: HR 105 and automatic BP 136/80. The client also reported feeling "cold and shaky." RN felt the client's hands which felt cool. RN did not see any visible shaking of the client's hands or body. The client reported a stomach ache. The client last ate a salad at 3:00PM. Respiration rate was 16 per minute at 7:30PM. The client began eating a personal protein bar at 7:31PM. The client stated that "It's helping to eat, the fog is kind of going away." RN arrived on scene. Repeat vitals obtained at 7:38PM were as follows: automatic BP 132/77, HR 82, and O2 99%. The client was alert and oriented to person, place, time, and situation. The client reported that she was still "cold," that her vision was clear, mild dizziness, and feeling tired. The client denied any s/s of anaphylaxis. RN assessed the client's skin near the vaccination site. RN noted redness about 2 inches below where the vaccine was administered, that was approximately 1 inch long and 0.5 inches wide. The client denied any itching at the site and stated she had not seen that red spot before. RN noted no other signs of redness or a rash across the client's neck, chest, or arms. Repeat vitals obtained at 7:47PM were as follows: BP 138/83, HR 88, O2 99%. The client stated "I feel like I drank wine. I feel tired, and cold." The client also reported that her vision was "foggy in areas." The client reported that she was "starting to feel a little headache." The client denied any pain associated with the headache. The client was continuing to eat her protein bar. The client stated that when the vaccine was administered, "I felt like it went all through my body." The client reported persistent feeling "foggy and dizzy." The client reports a history of dizziness after not eating for a while. The client reported "weakness" while trying to open her bottle of water. RN assisted the client and opened the water bottle. At 7:52PM the client was drinking water provided to staff. At 7:55PM the client reported feeling "dizzy after I use energy." The client stated that the cold feeling was "going down, and I'm still a little shaky." Vitals obtained at 7:58PM were as follows: BP 125/79, HR 83, and O2 97%. The client reported that she still felt dizzy and tired. She stated "I feel like I'm in slow motion." The client denied any foggy vision spots, but stated that the "fog is in my head." The client stated she did not drive to the vaccination site, and called someone to come and pick her up. At 8:04PM the client stated that she needed to use the restroom. The client stood up without assistance, placed her right knee on her knee walker, and began ambulating with the use of the knee walker to the restroom. The client reported she felt, "A little dizzy standing." RN accompanied the client to the restroom. The client returned from the restroom and sat in the anti-gravity chair. RN  and RN reclined the anti-gravity chair to a semi-fowler's position. Vitals obtained at 8:09PM were as follows: BP 122/75, HR 81, O2 98%, and RR 18. The client reported a stomach ache and nausea and requested to sit up. The anti-gravity chair was adjusted to a high fowler's position. The client reports a history of anxiety and states that she experiences dizziness with her anxiety. RN offered to activate EMS due to the client's persistent symptoms and the client declined. RN discussed options for the client including activating EMS or going to urgent care on her own.  The client stated that sometimes she goes to the pharmacy to check her "blood sugar." The client stated her plan after leaving the vaccination site was to go to the pharmacy to get her blood glucose checked, and that she would go to urgent care if her blood glucose was high. The client denied any persistent nausea or stomach ache. RN educated the client regarding s/s of anaphylaxis, when to seek EMS, and V-Safe. The client voiced understanding of this education. The client stated, "Okay, I want to leave." The client stood up with the assistance of her scooter, placed her knee on the knee walker. The client ambulated with the use of the knee walker outside of the building and stated that someone was picker her up. RN accompanied the client outside the vaccination site, and visualized the client ambulate with the use of the knee scooter off of the property at 8:30PM. RN did not visualize the client get into a vehicle.