Nursing Care Plan (NCP) for Anaphylaxis

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Anaphylaxis Intervention (Picmonic)

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Outline

Lesson Objective for Anaphylaxis Nursing Care:

Recognition of Anaphylactic Triggers:
- Identify and educate individuals at risk of anaphylaxis about common triggers, including food allergens, insect stings, medications, and latex, to facilitate early recognition and prevention.
Emergency Response Preparedness:
- Equip healthcare providers, individuals at risk, and caregivers with the knowledge and skills necessary for prompt and effective emergency response to anaphylactic reactions, including the administration of epinephrine.
Prevention and Allergen Avoidance:
- Implement strategies to prevent anaphylactic episodes by educating individuals on allergen avoidance, reading food labels, and ensuring the availability of auto-injectable epinephrine at all times.
Individualized Anaphylaxis Action Plan:
- Collaborate with individuals at risk and their healthcare providers to develop individualized anaphylaxis action plans outlining specific steps to take in the event of an allergic reaction, including when to use epinephrine and when to seek emergency medical assistance.
Community Education and Awareness:
- Raise awareness about anaphylaxis within the community by providing education on recognizing symptoms, administering epinephrine, and fostering a supportive environment for individuals at risk.

Pathophysiology of Anaphylaxis:

Immediate Immune Response:
- Anaphylaxis is a rapid and severe allergic reaction triggered by the immune system’s exaggerated response to an allergen. It involves the activation of mast cells and basophils, leading to the release of histamine and other mediators.
Histamine Release:
- Mast cells and basophils release histamine, prostaglandins, and other inflammatory substances. Histamine causes vasodilation, increased vascular permeability, and smooth muscle contraction, contributing to the characteristic symptoms of anaphylaxis.
Systemic Vasodilation:
- The release of vasodilatory mediators results in widespread vasodilation, leading to a rapid drop in blood pressure (hypotension). This can cause inadequate perfusion of vital organs and tissues.
Bronchoconstriction:
- Anaphylaxis often involves bronchoconstriction, causing respiratory symptoms such as wheezing, shortness of breath, and chest tightness. Severe bronchoconstriction can lead to respiratory failure.
Multi-organ Involvement:
- Anaphylaxis can affect multiple organ systems, leading to symptoms ranging from skin manifestations (hives, itching) and gastrointestinal symptoms (nausea, vomiting) to cardiovascular collapse. The rapid progression of symptoms requires immediate intervention to prevent life-threatening complications.

Etiology of Anaphylaxis:

Allergen Exposure:
- Anaphylaxis is primarily triggered by exposure to specific allergens that the individual’s immune system recognizes as harmful. Common allergens include certain foods (e.g., peanuts, shellfish), insect stings (e.g., bees, wasps), medications (e.g., antibiotics, NSAIDs), and latex.
Previous Sensitization:
- Individuals who have previously been sensitized to an allergen through exposure may develop an exaggerated immune response upon subsequent exposure. Sensitization involves the production of specific antibodies, such as immunoglobulin E (IgE), in response to the allergen.
Cross-Reactivity:
- Cross-reactivity can occur when proteins in different allergens share similar structures. For example, someone allergic to birch pollen may experience an allergic reaction to certain fruits due to cross-reactivity.
Inherited Predisposition:
- Genetic factors may contribute to an individual’s predisposition to allergies and anaphylaxis. A family history of allergies or atopic conditions can increase the likelihood of developing an allergic response.
Idiopathic Cases:
- In some cases, the cause of anaphylaxis may remain unknown (idiopathic). Idiopathic anaphylaxis occurs when an individual experiences severe allergic reactions without an identified trigger, making it challenging to predict and prevent.

Desired Outcome for Anaphylaxis Nursing Care:

Rapid Symptom Resolution:
- The immediate and primary goal is the prompt resolution of anaphylactic symptoms, including respiratory distress, skin manifestations, and cardiovascular instability, through the administration of epinephrine and other appropriate interventions.
Restoration of Hemodynamic Stability:
- Achieve and maintain hemodynamic stability by addressing hypotension and preventing cardiovascular collapse. Administer fluids and vasoactive medications as needed to restore adequate perfusion to vital organs.
Prevention of Recurrence:
- Implement measures to prevent the recurrence of anaphylaxis by identifying and avoiding specific allergens, educating individuals at risk and their caregivers, and ensuring the availability and proper use of emergency medications, such as epinephrine auto-injectors.
Optimal Respiratory Function:
- Ensure optimal respiratory function by alleviating bronchoconstriction and addressing any respiratory distress. Continuous monitoring and appropriate interventions, including bronchodilators, may be necessary to maintain clear airways.
Psychosocial Support and Education:
- Provide psychosocial support and education to individuals at risk and their caregivers to reduce anxiety, improve quality of life, and enhance overall well-being. Education should focus on recognizing early symptoms, using emergency medications, and seeking prompt medical attention.

Anaphylaxis Nursing Care Plan

Subjective Data:

Chest tightness
Difficulty swallowing
Stomach cramping
Shortness of breath
Dizziness
The feeling of impending doom

Objective Data:

Rash, hives (usually itchy)
Weak, rapid pulse
Hypotension
Swollen throat
Hoarse voice
Coughing
Vomiting
Diarrhea
Pale or red color to the face and body

Nursing Assessment for Anaphylaxis:

Initial Assessment:
- Conduct a rapid and comprehensive initial assessment, including airway, breathing, and circulation (ABCs). Prioritize interventions based on the severity of symptoms and potential life-threatening complications.
Identify Triggers and Allergens:
- Gather information about the individual’s medical history and known allergens. Identify potential triggers, including specific foods, insect stings, medications, or environmental factors.
Assess Respiratory Status:
- Monitor respiratory status closely for signs of bronchoconstriction, wheezing, shortness of breath, or respiratory distress. Evaluate lung sounds and oxygen saturation.
Evaluate Cardiovascular Function:
- Assess cardiovascular status, including blood pressure, heart rate, and peripheral perfusion. Identify signs of hypotension, tachycardia, or other cardiovascular instability.
Skin Examination:
- Examine the skin for allergic reactions, including hives (urticaria), redness, swelling (angioedema), and itching. Document the distribution and progression of skin manifestations.
Neurological Assessment:
- Conduct a neurological assessment to detect any changes in consciousness, confusion, or neurological deficits. These may indicate inadequate perfusion to the brain.
Gastrointestinal Assessment:
- Assess the gastrointestinal system for symptoms such as nausea, vomiting, abdominal pain, or diarrhea, which may indicate systemic involvement.
Psychosocial Assessment:
- Consider the psychosocial impact of anaphylaxis, including anxiety and fear associated with future allergic reactions. Evaluate the individual’s and caregivers’ understanding of the condition and their ability to manage emergency situations.
Follow-Up Assessment:
- Perform ongoing assessments to monitor the individual’s response to interventions, identify any delayed or recurrent symptoms, and address evolving needs during recovery.

Implementation for Anaphylaxis Nursing Care:

Administer Epinephrine Promptly:
- Administer epinephrine intramuscularly as the first-line treatment for anaphylaxis. Ensure proper dosage based on the individual’s weight and severity of symptoms. Repeat as necessary, following established protocols.
Establish and Maintain Airway:
- Ensure a patent airway by positioning the individual appropriately and, if necessary, providing airway support with interventions such as chin lift, jaw thrust, or the insertion of an oropharyngeal or nasopharyngeal airway.
Provide Oxygen Support:
- Administer supplemental oxygen to maintain adequate oxygen saturation levels. Monitor respiratory status continuously and be prepared to escalate interventions, including advanced airway management.
Initiate Intravenous Access:
- Establish intravenous (IV) access to administer fluids and medications. Administer isotonic crystalloid solutions to address hypotension and improve perfusion to vital organs.
Administer Additional Medications:
- Depending on the severity of symptoms, antihistamines for skin manifestations, bronchodilators for bronchoconstriction, and corticosteroids to address inflammation may be indicated. Continuously monitor vital signs and response to interventions.
Educate Patient on Preventing Future Episodes:
- Collaborate with the healthcare team to determine trigger for anaphylaxis. Referral to an allergist may be necessary. Educate the patient on avoiding triggers and how to self-administer epinephrine, if prescribed.

Nursing Interventions and Rationales

Administer epinephrine or EpiPen autoinjector if available

Antihistamines are not adequate to treat true anaphylaxis. Administer epinephrine or EpiPen immediately.

Remove antigen/causative allergen

If medication is the trigger, discontinue the medication immediately; remove, but do not squeeze the stinger of an insect

Initiate IV access and maintain patency

Medications and fluids will need to be given quickly. IV access allows uniform and quick dosing.

Monitor airway and oxygenation status; prepare for intubation or tracheostomy if necessary to maintain airway

The swelling of the throat may be caused by acute inflammation. Airway obstruction is the most common manifestation of anaphylaxis and can be fatal. Monitor ABG and oxygen saturation.

Perform CPR if necessary

Anaphylaxis may occur quickly and result in cardiac or respiratory arrest. Provide CPR or rescue breathing as necessary

Position patient upright in high-Fowler’s position if conscious

Positioning is to lessen airway obstruction and encourage optimal gas exchange by promoting maximum chest expansion.

Monitor vital signs; assess for signs of shock

A drop in blood pressure and elevation of heart rate are signs of shock.

Administer medications as appropriate
- Epinephrine
- Diphenhydramine
- Albuterol

Medications are given for vasoconstriction and to reverse the effects of histamine. Albuterol may be given to reverse histamine-induced bronchospasm.

Educate patient regarding avoidance of allergens; how to use EpiPen

Teach patient to read nutrition labels and the importance of wearing a Medic Alert bracelet to prevent future anaphylactic reactions. Patients should have EpiPen available and be aware of how to use it.

Evaluation for Anaphylaxis Nursing Care:

Assess Symptom Resolution:
- Evaluate the resolution of anaphylactic symptoms, including improvement in respiratory distress, relief from skin manifestations, and stabilization of cardiovascular parameters. Monitor for any residual or recurrent symptoms.
Monitor Vital Signs:
- Continuously monitor vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation. Evaluate for any signs of instability or recurrence of symptoms, particularly within the first few hours after initial treatment.
Evaluate Response to Medications:
- Assess the individual’s response to medications administered during the acute phase, such as epinephrine, antihistamines, bronchodilators, and corticosteroids. Ensure that these interventions effectively contributed to symptom relief.
Assess Psychosocial Impact:
- Consider the psychosocial impact of the anaphylactic event on the individual and their caregivers. Evaluate anxiety levels, concerns about future exposures, and the understanding of emergency management strategies.
Review Follow-Up Plan:
- Discuss and review the individual’s follow-up plan, including the need for allergen identification, avoidance strategies, and education on the proper use of epinephrine auto-injectors. Provide resources for ongoing support and education.

References

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Transcript

All right, today, we are going to be talking about anaphylaxis. Anaphylaxis, what's happening? Anaphylaxis, the pathophysiology behind it is it's just an allergic reaction, but it's an extreme allergic reaction once a person is exposed to an allergen. Some nursing considerations that we want to consider are all tied to the airway and maintaining the airway. So, we want to maintain the airway. We want to monitor the vital signs. We want to administer the EpiPen. We want to get an ABG. We want to get any other medications and administer them as ordered. And then, we want to also remove the causative factors. So whatever's causing the allergy reaction, we want to get it as far away as possible. A more desired outcome is to restore an effective breathing pattern, and we want to improve that ventilation and just maintain that hemodynamics. Okay?

Some things that a patient would tell you when they are feeling the effects of anaphylaxis is they're going to complain of some chest tightness. They're going to have some difficulty swallowing. They are going to complain of some stomach cramping, and they are going to complain of dizziness. And as with most respiratory conditions, they're going to have this unknown feeling of impending doom. And it's just because of that lack of oxygen. Some things that we're going to observe as nurses, some objective data, we're going to see some rash, hives. Usually, the hives are itchy. We're going to see some low BP, some hypotension. We're going to see a swollen throat. We're going to be able to assess that. We're going to hear a hoarse voice, coughing. There might be some vomiting, some diarrhea. And then we're going to also see a pale or reddish color to the face and the body.

First things first. Remember this, if you don't remember anything else. When it comes to anaphylaxis, we're going to get that EpiPen, and we are going to give it. Okay? We are going to give EpiPen. Okay? So EpiPen, EpiPen is short for epinephrine, and that's just going to immediately start to release those muscles that are contracted from the anaphylaxis.

Next up, we're going to monitor the oxygenation, and we're going to monitor the airway status. So airway, remember ABCs, airway, breathing, and circulation? We're on our A now. We're going to focus on the airway. We are going to want to intubate or have an emergent, a trach, if necessary, but most important is we want to monitor to make sure that they are getting properly oxygenated. Okay? Next thing is we are going to be ready for CPR. Oftentimes with respiratory conditions, the heart will give... We want to be ready to give rescue breaths or compressions as necessary. Okay?

Next we're going to monitor those vital signs. Primarily, we're going to focus on signs of shock. A patient with anaphylaxis can go into shock, which means their BP's going to drop. They're going to have a heart rate increase. So they're going to be tachycardic. These are signs of shock that we want to be aware of. Finally, we want to make sure that we give the patient the best chance of oxygenating. So we're going to sit them up in high Fowler's, as high as possible that they would tolerate, so anything 90 degrees or better is the best. And the reason why we're doing this is we are positioning them to lessen the airway obstruction and also improve and optimize gas exchange.

So, let's go over some of the key points. The pathophysiology, anaphylaxis is just an overreaction. Think about your body is just overreacting to an allergen. Some of the subjective and objective things that we're going to focus on remember the patient's going to complain of some chest tightness, some difficulty in breathing, some dizziness. They're going to have that sense of impending doom. What we're going to see is we're going to assess rash, hives, cough, low BP, and an increased heart rate.

We're going to focus on airway protection because airway obstruction is the most common with anaphylaxis. We're going to prepare for intubation, if necessary, and have the necessary tools at the bedside. And then, we are going to focus on stopping anaphylaxis. Do you see? Stopping anaphylaxis, and that's going to include administering EpiPens. We may want to follow up with some steroids, some Benadryl, and albuterol. But the number one after EpiPen is removing that causative allergen, so whatever's causing that allergic reaction.

We love you guys. Go out, be your best self today. And as always, Happy Nursing.

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“Would suggest to all nursing students . . . Guaranteed to ease the stress!”

~Jordan