Anaphylaxis is an acute hypersensitivity reaction with potentially life-threatening consequences. It is often a sudden, multi-system, widespread allergic reaction. Anaphylaxis frequently results in death if untreated because it quickly progresses to respiratory failure.
Anaphylactic reactions have traditionally been classified as Immunoglobulin E (IgE)-mediated responses, whereas anaphylactoid reactions are IgE-independent responses. The clinical condition and treatment for each reaction are the same regardless of the cause. Anaphylaxis is now used as a standard term for both reactions.
Exposure to specific medications, a particular food, insect bites, or latex are examples of common triggers. Hyper-acute reactions can result from immunotherapy injections intended to improve overall allergic response. Idiopathic anaphylaxis is the term for reactions in which the causative agent is not always known.
A hyperactive immune response causes anaphylaxis. The release of mast cells, basophils, and chemical mediators occurs after the re-exposure to an antigen, causing an overactive immune response. These symptoms typically affect just one part of the body. However, some people may experience a far more severe reaction which is anaphylaxis. Usually, more than one area of the body is affected simultaneously by this reaction.
In this article:
- Signs and Symptoms
- Nursing Process
- Nursing Care Plans
- Deficient Knowledge
- Impaired Spontaneous Ventilation
- Ineffective Airway Clearance
- Risk for Adverse Reaction
Signs and Symptoms
Symptoms typically occur within 5-30 minutes of exposure and include:
- Headache, dizziness, paresthesia, feeling of impending doom
- Pruritus, angioedema, erythema, urticaria
- Hoarseness, coughing, wheezing stridor, dyspnea, tachypnea, a sensation of airway narrowing, respiratory arrest
- Hypotension, dysrhythmias, tachycardia, cardiac arrest
- Cramping, abdominal pain, nausea, vomiting, diarrhea
Anaphylaxis can be identified through physical examination. Hence no lab tests or other diagnostic procedures are required.
Nursing Process
Anaphylaxis requires prompt rapid diagnosis and care since cardiac or respiratory arrest and death can occur. Anaphylaxis is most treatable in its early stages. Initial management includes removal of the trigger, administering epinephrine as soon as possible, and managing the airway. It is crucial to provide health teaching with an epinephrine auto-injector on how to use it. Referral to an allergist and immunologist should also be considered. An allergist will help determine triggering allergens and prevent future reoccurrence through short-term desensitization.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for anaphylaxis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for anaphylaxis.
Decreased Cardiac Output
Decreased cardiac output associated with anaphylaxis can be caused by decreased preload due to a severe decrease in venous tone and fluid extravasation, histamine leakage causing blood vessels to leak fluid into the tissues, and vasodilation.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Decreased preload
- Leak of histamine causing blood vessels to leak fluid into the tissues (third spacing)
- Vasodilation
As evidenced by:
- Tachycardia
- Palpitations
- Hypotension
- Anxiety
- Restlessness
Expected outcomes:
- Patient will maintain pulse rate and blood pressure within therapeutic limits.
- Patient will be able to verbalize relief from anxiety and restlessness.
- Patient will be able to manifest a calm and well-rested appearance.
Assessment:
1. Monitor the pulse rate and blood pressure.
The patient’s blood pressure decreases, and their pulse rate increases during anaphylaxis. This may indicate anaphylactic shock.
2. Assess cardiovascular status.
Cardiovascular collapse is a frequent symptom resulting from vasodilatation and plasma loss from the blood compartment. This is an unusual reaction to intravenous medications or bee stings.
3. Assess mental status changes.
Anaphylaxis can cause changes in mental status due to decreased blood flow to the brain.
Interventions:
1. Check for IV access.
Ensure patent IV access for blood sampling, medication, and IV administration.
2. Immediately discontinue a suspected IV medication or infusion.
Colloid solutions are a known cause of anaphylaxis and are not advised for its treatment. Medications such as penicillin, aspirin, non-steroidal anti-inflammatory drugs, blood products, and anesthesia can also cause anaphylaxis.
3. Administer IV fluids.
Fluid resuscitation is a central intervention for hypotension. Isotonic crystalloid bolus is recommended.
4. Administer vasopressors.
If additional doses of epinephrine are needed, but the patient is experiencing side effects, vasopressors may be given for hypotensive shock.
5. Prepare the emergency or crash cart at the bedside.
If first-line medications are not successful and the patient codes, additional life-saving interventions will be required. A crash cart should be at the bedside with all equipment available.
Deficient Knowledge
Deficient knowledge associated with anaphylaxis can result in a misunderstanding of triggers, symptoms, prevention, and management.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Insufficient knowledge about anaphylaxis
- Inadequate understanding of signs and symptoms of anaphylaxis
- Lack of information about emergency management of anaphylaxis
- Misconception of anaphylactic triggers
As evidenced by:
- Verbalization of concerns
- Questions about anaphylaxis
- Improper use of epinephrine auto-injector
- Development of preventable complications such as anaphylactic shock
- Nonadherence with prevention and management recommendations
Expected outcomes:
- Patient will be able to verbalize an understanding of anaphylaxis and its signs and symptoms.
- Patient will verbalize two strategies to prevent anaphylaxis.
- Patient will not experience a recurrence of anaphylaxis.
Assessment:
1. Determine the patient’s knowledge of anaphylaxis.
Before modifying health instructions, the nurse must first assess the patient’s knowledge of anaphylaxis and expectations for the treatment plan. The nurse can then develop pertinent and valuable instructions for the patient.
2. Identify the factors affecting learning.
The nurse must assess the patient’s attitude, capability, and limitations to learning about anaphylaxis. Ensure the patient is motivated to learn and is emotionally and mentally ready since this requires a lifetime commitment and adherence to prevention.
3. Assess for misconceptions and beliefs about anaphylaxis.
The nurse can assess the patient’s practices and beliefs to analyze their knowledge and differentiate between facts and myths. The nurse must emphasize accurate information about the causative allergens and actions to be taken for prevention and during an emergency.
4. Assess the patient’s skills in using the epinephrine auto-injector.
The self-administration of epinephrine is part of the emergency plan. It is essential to maintain the epinephrine auto-injector within the expiration date. Knowing how to use the epinephrine auto-injector is crucial for the patient, their family, and anyone else who interacts with the patient.
Interventions:
1. Develop the care plan with the patient.
Patient involvement includes the patient in decision-making. A lifetime commitment to avoiding triggers and compliance with desensitization procedures are necessary for fulfilling long-term goals.
2. Consider the patient’s learning factors in health teaching.
Adapt the teaching plan to the patient’s education level, attitude, strengths, and obstacles in learning anaphylaxis. Consider teaching methods for young or school-age children. Anaphylaxis can be prevented once the patient knows how to avoid and manage it.
3. Encourage inquiries.
Patients’ inquiries should be welcomed. Encourage queries by acting in a friendly, open manner. Anxiety is common in patients with anaphylaxis, and clarification can ease worry.
4. Reinforce positive comments.
When the patient’s health objectives are attained and complications are avoided, show appreciation for their efforts and adherence to their care plan.
5. Ask the patient to list the preventive measures of anaphylaxis.
The best method to prevent anaphylaxis is to avoid it. By letting the patient enumerate the precautions they can take to prevent anaphylaxis, the nurse can assess for effective learning.
6. Refer to an allergist.
An allergist can detect and create avoidance strategies appropriate for the patient’s age, activities, career, interests, living arrangements, and access to healthcare.
7. Discuss when to use an epinephrine injector in an emergency.
The patient should be given access to epinephrine auto-injectors at all times and should be comfortable using them.
8. Encourage them to carry two epinephrine auto-injectors if possible.
Although most patients only need one dose, further doses may be administered as needed every 5 to 10 minutes until symptoms subside.
9. Encourage wearing a medical alert bracelet.
Patients should be informed of the value of wearing a medical alert bracelet or identification in the event of an emergency.
Impaired Spontaneous Ventilation
Anaphylaxis can become life-threatening quickly if not recognized or treated immediately, causing airway obstruction requiring intubation and ventilation.
Nursing Diagnosis: Impaired Spontaneous Ventilation
Related to:
- Angioedema
- Narrowing of the airways
- Respiratory failure
- Airway obstruction
- Bronchospasm
As evidenced by:
- Dyspnea
- Adventitious lung sounds (wheezes or stridor)
- Hypoxia
- Cough
- Tachycardia
- Cyanosis
- Restlessness
Expected outcomes:
- Patient will demonstrate respiratory rate and oxygen saturation within normal limits.
- Patient will demonstrate clear lung sounds upon auscultation.
Assessment:
1. Monitor the respiratory rate and oxygen saturation.
Changes in respiratory rate and oxygen saturation indicate impairment of spontaneous ventilation. Monitor for accessory muscle use, cyanosis, nasal flaring, and restlessness that signal decompensation.
2. Auscultate lung sounds.
In anaphylaxis, airways may become constricted, and wheezing or stridor may be heard on auscultation.
3. Educate the patient and family on the necessity of intubation.
Anaphylaxis can be extremely frightening, especially when the airway is compromised and intubation is imminent. Educate the patient and family members on the process of intubation and ventilation to decrease anxiety.
Interventions:
1. Ensure patency of the airway.
Suction any secretions if present to encourage spontaneous ventilation and prevent complications like aspiration. Anaphylaxis releases inflammatory mediators, causing increased mucus production and airway constriction.
2. Administer medications as prescribed.
An infusion of epinephrine may be necessary if respiratory symptoms do not improve with IM epinephrine. Bronchodilators like albuterol are administered via nebulizer to dilate the airways and relieve wheezing and stridor.
3. Collaborate with respiratory therapy.
The nurse works in collaboration with respiratory therapists to ensure ventilator, oxygen, and alarm settings are correct.
4. Obtain ABGs.
Monitor arterial blood gas (ABG) results to ensure proper oxygenation and acid-base balance.
Ineffective Airway Clearance
Ineffective airway clearance associated with anaphylaxis can be caused by airway spasms and laryngeal edema or swelling, leading to airway constriction and decreased oxygenation.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Inflammatory reaction
- Airway spasm
- Laryngeal edema or swelling
As evidenced by:
- Diminished breath sounds
- Adventitious breath sounds
- Ineffective cough
- Difficulty speaking
- Open, wide eyes
- Cyanosis
- Labored breathing
- Stridor
- Use of accessory muscles
Expected outcomes:
- Patient will maintain an oxygen saturation of 95-100%
- Patient will be able to demonstrate clear breath sounds upon auscultation
- Patient will be able to speak clearly without signs of difficulty
Assessment:
1. Rapidly assess the respiratory status.
Anaphylaxis causes swelling in the airway leading to obstruction in breathing. Suspect the patient to be in respiratory distress when there is a “lump in the throat,” observed clearing of the throat frequently, and any difficulty breathing.
2. Locate the cause or trigger.
Knowing what causes anaphylaxis is crucial for management and future prevention. Common triggers are food, medications, insect stings, and latex.
3. Monitor vital signs.
An increased respiratory rate with oxygen saturation of less than 92% on pulse oximetry indicates respiratory distress and hypoxia caused by anaphylaxis.
4. Inspect for any signs and symptoms.
Look for signs and symptoms of a compromised airway: difficulty speaking, ineffective cough, cyanosis, labored breathing, use of accessory muscles, and presence of adventitious sounds (wheezing and stridor).
Interventions:
1. Manage the airway.
Managing the airway is a priority. Delay may increase the danger of a surgical airway and decrease the likelihood of successful intubation as swelling persists.
2. Activate the Rapid Response Team (RRT).
The Rapid Response System (RRS) assists in identifying patients at risk of severe illnesses like anaphylaxis. Activating the RRT brings immediate expert assistance to perform interventions and lowers the mortality rate.
3. Elevate the head of the bed.
Elevate the head of the bed to 45 degrees or higher to improve ventilation.
Note: If the patient with anaphylaxis is not experiencing respiratory distress, they should be left in a recumbent position as a rapid incline could result in severe hypoperfusion and immediate death.
4. Remove or discontinue the triggering allergen.
Any insect stinger left in the skin should be carefully removed. Advise the patient to rinse their mouth to remove food allergen residue.
5. Administer epinephrine as ordered.
Epinephrine is the gold standard for treating anaphylaxis since it lessens the reaction. Epinephrine should be administered intramuscularly (IM) immediately in the thigh.
6. Give diphenhydramine as prescribed.
Antihistamines are commonly used, with a dosage of 25–50 mg via IV/IM administered to block histamine (a natural chemical the body produces when experiencing an allergic reaction).
7. Start oxygen therapy as ordered.
Cyanosis and hypoxia suggest severe anaphylaxis that requires high-flow oxygen.
8. Ensure airway management equipment is available.
Endotracheal intubation can help maintain airway patency, which almost always necessitates prompt and effective suctioning.
Risk for Adverse Reaction
Iodinated contrast media is a common cause of anaphylaxis.
Nursing Diagnosis: Risk for Adverse Reaction
Related to:
- Iodinated contrast media formulation
- Previous reaction to IV contrast media
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will not develop anaphylaxis related to iodinated contrast media.
- Patient will not experience dyspnea, hives, itching, or hypotension during and after iodinated contrast media administration.
Assessment:
1. Assess the patient’s risk.
Assess if the patient has ever had a reaction to iodinated contrast. Most reactions are not related to prior exposure. Patients with a history of asthma and atopic dermatitis are at a higher risk for reaction.
2. Educate that shellfish and iodine allergies are not contraindications.
Shellfish and iodine allergies were once thought to be a contraindication to receiving IV contrast, but this has been disproven. Educate the patient that allergies to iodine don’t exist (this is a mineral in the body) and that allergies to shellfish don’t disqualify them from receiving IV contrast.
3. Assess the patient’s knowledge about anaphylaxis symptoms.
Ask the patient to verbalize the following signs and symptoms of anaphylaxis:
- CNS:
- Dizziness
- Headache
- Anxiety
- Sense of impending doom
- Respiratory:
- Shortness of breath
- Coughing
- Throat swelling
- Cardiovascular:
- Palpitations
- Chest discomfort
- Gastrointestinal:
- Abdominal cramps
- Nausea and vomiting
- Integumentary:
- Itching (pruritus)
- Hives (urticaria)
- Facial swelling
Interventions:
1. Administer premedication before the procedure.
Patients allergic to iodinated contrast media should receive pretreatment with antihistamines or corticosteroids.
2. Consider low-osmolar iodinated contrast media.
Adverse reactions to contrast media have significantly decreased with the emergence of nonionic low-osmolar iodinated contrast media.
3. Monitor the patient during and after the procedure.
Observe the patient for any signs of anaphylaxis during and after the procedure. Closely monitor vital signs for tachycardia or hypotension.
4. Keep emergency medical equipment available.
If the patient is at an increased risk for IV contrast reactions, keep epinephrine, medications, an intubation kit, oxygen, and supplies readily available for intervention.
References
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- Mayo Clinic. (2021, October 2). Anaphylaxis – Diagnosis and treatment – Mayo Clinic. Retrieved August 2023, from https://www.mayoclinic.org/diseases-conditions/anaphylaxis/diagnosis-treatment/drc-20351474
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- Silvestri, L. A., & Silvestri, A. E. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
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