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Nursing Care Plan for Anaphylaxis

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Pathophysiology

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.

Etiology

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.

Desired Outcome

Restore effective breathing pattern and improved ventilation and maintain hemodynamic stability

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 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.  

References

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  • Question 1 of 5

While eating dinner in a restaurant, a customer develops an anaphylactic reaction. A nurse nearby notices the problem and stops to help. The first action of the nurse should be which of the following?

  • Question 2 of 5

45 minutes after receiving a transfusion of whole blood, a client develops an anaphylactic transfusion reaction. During this reaction, the nurse would most likely expect to see:

  • Question 3 of 5

A client presents to the emergency department in anaphylactic shock. Which medication should the nurse prepare for the client?

  • Question 4 of 5

The nurse is caring for a client who is having an anaphylactic reaction. The provider has placed orders. Which of the following orders is the priority?

  • Question 5 of 5

A client presents to the emergency department in anaphylactic shock. The nurse calls for assistance, grabs the crash cart, obtains vital signs, and starts an IV. Vital signs are as follows: Blood pressure 75/48, pulse 115, oxygen 73%, respiratory rate 30. Labs are drawn. The nurse suspects respiratory acidosis. Which of the following actions by the nurse are appropriate to help correct this client’s condition? Select all that apply.

Module 0 – Nursing Care Plans Course Introduction
Module Obstetrics (OB) & Pediatrics (Peds) Care Plans

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