Nursing Care Plan for Anaphylaxis
Anaphylaxis is an acute, multiorgan, life-threatening allergic reaction. Initial symptoms may look like a normal allergy with runny nose or rash and usually occur within minutes of exposure to an allergen. Within a few minutes, symptoms get more severe and can be deadly if not treated. Anaphylaxis requires immediate medical attention.
Anaphylaxis is caused by an overreaction of the immune system to a particular allergen. Triggers may be different for each person, but the most common triggers are peanuts, insect stings, latex, shellfish and eggs, and medications such as penicillin.
Restore effective breathing pattern and improved ventilation and maintain hemodynamic stability
Anaphylaxis Nursing Care Plan
- Chest tightness
- Difficulty swallowing
- Stomach cramping
- Shortness of breath
- The feeling of impending doom
- Rash, hives (usually itchy)
- Weak, rapid pulse
- Swollen throat
- Hoarse voice
- Pale or red color to the face and body
Nursing Interventions and Rationales
- Administer epinephrine or EpiPen autoinjector if available
- Remove antigen/causative allergen
- Initiate IV access and maintain patency
- Monitor airway and oxygenation status; prepare for intubation or tracheostomy if necessary to maintain airway
- Perform CPR if necessary
- Position patient upright in high-Fowler’s position if conscious
- Monitor vital signs; assess for signs of shock
- Administer medications as appropriate
- Educate patient regarding avoidance of allergens; how to use EpiPen
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell