Nursing Care Plan for Anaphylaxis

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
  • 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

  1. Administer epinephrine or EpiPen autojector if available

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

  3. Remove antigen/causative allergen

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

  5. Initiate IV access and maintain patency

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

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

  8. 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.

  9. Perform CPR if necessary

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

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

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

  13. Monitor vital signs; assess for signs of shock

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

  15. Administer medications as appropriate

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

  17. Educate patient regarding avoidance of allergens; how to use EpiPen

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


References

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