Anaphylaxis Nursing Diagnosis and Nursing Care Plan

Anaphylaxis Nursing Care Plans Diagnosis and Interventions

Anaphylaxis NCLEX Review and Nursing Care Plans

Anaphylaxis is an emergency condition wherein the body reacts to an allergen within seconds of exposure. Bee stings, nuts, latex, venom, chemotherapeutic agents and other medications are some of the common causes of anaphylactic reaction.

During anaphylaxis, the immune system is triggered to release chemicals that it perceives to be effective to eliminate the allergen from the body. However, this flood of chemical substances, such as histamine, can cause the body to enter a state of anaphylactic shock, which is indicated by a huge drop in blood pressure level, called hypotension, as well as skin rash, nausea and vomiting, and a rapid but weak pulse.

The anaphylactic reaction can last up to 30 minutes. In rare cases, the signs and symptoms of anaphylaxis last for days.

Anaphylaxis can be life-threatening and requires immediate medical intervention, which may include an injecting epinephrine to counter the effects of anaphylactic shock. The patient may need to be treated in an emergency room as he she would likely required intravenous fluid therapy and other medications and procedures.

Signs and Symptoms of Anaphylaxis

The following are the signs and symptoms of anaphylaxis, which can be observed within seconds or minutes following allergen exposure:

  • Hypotension – blood pressure level suddenly drops
  • Edema – swelling of the lips, periorbital area (skin around the eyes), tongue, or the larynx/ throat
  • Central cyanosis – bluish discoloration of the lips
  • Difficulty of breathing or shortness of breath– airways become constricted as the tongue and/or throat become swollen
  • Cough
  • Wheezing – if the airways are severely constricted
  • Skin reactions – rash, hives, pruritus or itching, pale or flushed skin
  • Tachycardia – the pulse becomes rapid but is weak
  • Syncope – fainting or dizziness
  • Feeling of impending doom or dread
  • Nausea and vomiting
  • Diarrhea – occurs sometimes due to edematous episodes in the gastrointestinal regions
  • Uterine cramps

It is also important to note that the above signs and symptoms of anaphylaxis may be evident 30 minutes or more after allergen exposure due to delayed body reaction.

Types of Anaphylaxis

The following are the types of anaphylaxis based on severity:

  • Mild anaphylaxis – evidenced by variable wheezing, minor or mild shortness of breath, and able to speak in sentences
  • Moderate anaphylaxis – evidenced by moderate to loud wheezing, apparent shortness of breath, and able to speak in short sentences of phrases only
  • Severe anaphylaxis – evidenced by anxiety, syncope, severe shortness of breath, and able to speak in a few words or unable to speak at all

Causes and Risk Factors of Anaphylaxis

The body’s immune system has the primary function to protect it against foreign substances, which is important in the preservation of the body against pathogens.

However, substances that do not normally trigger an allergic reaction may cause the immune system to overreact. The following are the five common triggers of anaphylaxis:

  • Foods – nuts, seafood (fish and shellfish), eggs, milk (usually cow’s milk), fruits
  • Stings of insects – such as bees and wasps
  • Medications – includes antimicrobials such as antibiotics and antifungals, non-steroidal anti-inflammatory drugs (NSAIDs), anesthetics, and chemotherapeutic drugs such as doxorubicin and oxaliplatin
  • Latex – usually found in items that contain rubber, such as gloves and condoms; hence, many of these products have now been changes and marketed as “latex-free”
  • Contrast dyes – used during diagnostic procedures such as CT scan

If there is no apparent allergen that has triggered the anaphylactic reaction, the event is called idiopathic anaphylaxis.

Diagnosis of Anaphylaxis

  • Patient interview – to check for allergy history, including allergies and previous reactions to them
  • Physical exam – to check for the signs and symptoms of anaphylaxis and their severity
  • Blood test – to verify the amount of tryptase, an enzyme which can have elevated serum levels up to 3 hours following an anaphylactic episode
  • Skin tests – if the trigger is unknown, skin tests may be done to help identity the allergen

Treatment for Anaphylaxis

  1. Call for help. The first thing to do is to call 911 for emergency medical assistance outside a medical facility. When inside the hospital, staff follows hospital protocols during anaphylaxis, which may include verbally calling others for help and/or pressing the emergency button. If the patient is unconscious, perform CPR and other first-aid procedures. Elevate the legs while the patient is lying down to help manage hypotension.
  2. Epinephrine or adrenaline. This medication is part of the first line treatment to reverse the effect of anaphylaxis. It is usually available in pens or autoinjectors, which make it easier to administer on the thigh area not only by medical professionals but even civilians and bystanders.
  3. Oxygen therapy. Oxygen is another part of the first line treatment for anaphylaxis, as the patient will usually manifest ineffective airway clearance and difficulty of breathing. A non-rebreather mask is commonly the first device used to deliver oxygen during an anaphylactic episode.
  4. Medications. Other medications that may be administered include:
  5. Intravenous antihistamines and steroids – to suppress the immune as well as inflammatory responses of the body to the allergens; steroids help reduce edema on the airways, hence improving the patient’s ability to breathe
  6. Beta-agonists – to regain normal breathing capacity
  7. Antiemetics – to treat nausea and vomiting
  8. Intravenous fluids – to manage hypotension and normalize blood pressure levels
  9. Bronchodilators – to treat constricted airways

Nursing Diagnosis for Anaphylaxis

Anaphylaxis Nursing Care Plan 1

Ineffective Breathing Pattern

Nursing Diagnosis: Ineffective Breathing Pattern related to constriction of edematous airways secondary to anaphylaxis as manifested by dyspnea or difficulty of breathing, oxygen saturation of 82%, edema of lips, tongue and throat, and tachypnea.

Desired outcome: The patient will be able to regain effective respiratory pattern: noted to be free from dyspnea and cyanosis, with ABG’s and respiratory function within acceptable limits.

Anaphylaxis Nursing InterventionsRationale
Assess and monitor respirations, including the rate, depth and effort.Provides for baseline data in evaluating respiratory function.
Ensure that patient’s mouth is free from dentures or foreign objects (e.g., chewing gum or removable retainers).This ensures lessening the risk of aspirations during anaphylaxis.
If the patient is unconscious during the anaphylactic episode, ensure that the patient is lying on a flat surface, turning the head to the side and legs elevated.           If the patient is conscious, ensure that he/she is in high Fowler’s position.  This position helps in the drainage of pooled secretions in the mouth during anaphylaxis. It also allows for the tongue from obstructing the airway. Elevating the legs can help reverse hypotension.   A high Fowler’s or upright sitting position helps facilitate maximum expansion of the chest.
Immediately administer epinephrine and other medications as ordered.To treat bronchospasm and laryngeal edema.
Provide oxygen support as needed and as indicated.To treat or prevent decreasing oxygen levels caused by vascular spasm during an anaphylaxis event.
Anticipate in assisting for non-invasive mechanical ventilation.Prolonged anaphylaxis may result to apnea, which may indicate the need for non-invasive mechanical ventilation with the use of nasal mask, face mask, or helmet to deliver air and support the oxygen needs of the body.

Anaphylaxis Nursing Care Plan 2

Impaired Gas Exchange

Nursing Diagnosis: Impaired Gas Exchange related to an imbalance between ventilation and perfusion secondary to anaphylaxis as evidenced by shortness of breath, fast and labored breathing, cyanosis of the lips, rapid and weak pulse, oxygen saturation of 80%, and anxiety

Desired Outcome: The patient will demonstrate adequate oxygenation as evidenced by an oxygen saturation within the target range set by the physician as well as normalized ABG levels.

Anaphylaxis Nursing Interventions Rationales
Assess the patient’s vital signs, especially the respiratory rate and depth. Auscultate the lungs and monitor for wheezing or other abnormal breath sounds.To create a baseline set of observations for patient, and to monitor any changes in the vital signs as the patient receives medical treatment.
Monitor the color of skin and mucous membrane.Central cyanosis (bluish discoloration of the lips and oral muvcosa) may be evident with hypoxemia.
Monitor blood chemistry and arterial blood gases (ABG levels).Respiratory acidosis and hypoxemia are evidenced by increasing PaCO2 and decreasing PaO2. Decreasing oxygen saturation levels mean hypoxia.
Assist the physician to initiate either a non-invasive mechanical ventilation, or intubation and invasive mechanical ventilation of the patient, if required.To maintain adequate oxygen supply by delivering proper ventilation and oxygenation while allowing the lungs to heal.
Reposition the patient by elevating the head of the bed and encouraging him/her to sit on an upright position. Encourage pursed lip breathing and deep breathing exercises.To improve the delivery of oxygen in the airways and to reduce shortness of breath and risk for airway collapse.

Anaphylaxis Nursing Care Plan 3

Decreased Cardiac Output

Nursing Diagnosis: Decreased Cardiac Output related to generalized vasodilation secondary to anaphylaxis as evidenced by low blood pressure level of 82/55, dizziness, capillary refill times of greater than 2 seconds, syncope, rapid and weak pulse.

Desired outcome: The patient will be able to regain adequate cardiac output.

Anaphylaxis Nursing Interventions Rationale
Assess the patient’s vital signs and characteristics of heart beat at least every 4 hours. Assess heart sounds via auscultation. Observe for signs of decreasing peripheral tissue perfusion such as slow capillary refill, facial pallor, cyanosis, and cool, clammy skin.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. The presence of signs of decreasing peripheral tissue perfusion indicate deterioration of the patient’s status which require immediate referral to the physician.
Administer prescribed medications for anaphylaxis. Initiate intravenous fluid therapy as ordered.  Intravenous fluids – to manage hypotension and normalize blood pressure levelsBronchodilators and beta agonists – to treat constricted airwaysSteroids – to suppress the immune as well as inflammatory responses of the body to the allergen  
Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.To increase the oxygen level and achieve an SpO2 value within the target range.
Reassure the patient and family that medical treatment will highly be able to reverse hypotension and decreased cardiac output. To manage patient’s anxiety.

Anaphylaxis Nursing Care Plan 4

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to diagnosis and need for emergency treatment secondary to anaphylaxis as evidenced by patient’s verbalization of “I do not know what’s happening?”

Desired Outcome: The patient will be able to have sufficient knowledge of anaphylaxis and its management.

Anaphylaxis Nursing Interventions Rationales
Assess the patient’s readiness to learn, misconceptions, and blocks to learning.To address the patient’s cognition and mental status towards anaphylaxis and to help the patient overcome blocks to learning.
Explain what anaphylaxis is, and how it affects the vital organs such as the lungs. Avoid using medical jargons and explain in layman’s terms.To provide information on anaphylaxis and its pathophysiology in the simplest way possible.
Educate the patient and family or significant others about common allergens and measures on how to prevent them.To give the patient enough information on how to prevent anaphylaxis in the future.  
Instruct the patient and significant others on how to call for help during another anaphylactic reaction. Demonstrate on how to use an epinephrine autoinjector should the patient be recommended to bring one always.To facilitate immediate treatment of anaphylaxis if ever the patient is exposed to the allergen again.
Inform the patient the details about the prescribed medications (i.e., drug class, use, benefits, side effects, and risks) that are being given to treat anaphylaxis.To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, and any possible adverse events.

Anaphylaxis Nursing Care Plan 5

Nausea and Vomiting

Nursing Diagnosis: Nausea and Vomiting related to edema of the gastrointestinal region secondary to anaphylaxis as evidenced by verbal complaint of nausea, vomiting, feeling faint, and abdominal cramping

Desired Outcome: The patient will be able to state relief of nausea and will be able to explain methods that can be used to decrease nausea and vomiting

Anaphylaxis Nursing Interventions Rationale
Administer appropriate antiemetics, according to emetic cause, by most effective route which is usually the intravenous route.Antiemetic drugs are effective at different receptor sites and treat the different causes of nausea and vomiting. A combination of medications may be more effective than a single drug.
Determine the allergen that caused nausea and vomiting.Nausea and vomiting are clinically identifiable symptoms, it is essential for the cause to be determined and appropriate plan and interventions be developed.
Document each episode of nausea and/or vomiting separately, as well as the effectiveness of interventions. Use of an assessment tool is needed for the consistency of evaluation.A systematic approach can provide consistency, accuracy, and measurement needed for the direction of care. It is important to recognize that nausea is an experience that is subjective.
Identify and eliminate contributing factors such as a stressful environment.Elimination of these contributing factors may provide the patient relief from stimulus that causes the nausea and vomiting.
After the anaphylaxis event, advise the patient to have only small, frequent meals.Implementing small but frequent meals gives the gastrointestinal system of the patient time to recover from nausea and vomiting.
Recognize and implement interventions and monitor complications associated with nausea and vomiting. This may include the administration of intravenous fluids and electrolytes.Recognizing the complications of nausea and vomiting in relation to anaphylaxis is critical in the prevention and management of the complications such as further hypotension, dehydration, and electrolyte imbalance.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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Anna C. RN, BSN, PHN

Anna C. RN, BSN, PHN
Clinical Nurse Instructor

Emergency Room Registered Nurse
Critical Care Transport Nurse
Clinical Nurse Instructor for LVN and BSN students

Anna began writing extra materials to help her BSN and LVN students with their studies. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process.

Her experience spans almost 30 years in nursing, starting as an LVN in 1993. She received her RN license in 1997. She has worked in Medical-Surgical, Telemetry, ICU and the ER. She found a passion in the ER and has stayed in this department for 30 years.

She is a clinical instructor for LVN and BSN students along with a critical care transport nurse.

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