Anaphylaxis Nursing Care Plan

What is anaphylaxis?

Anaphylaxis is a severe, potentially life-threatening allergic reaction that can occur rapidly after exposure to an allergen. It affects multiple body systems, including the respiratory, gastrointestinal, skin, and cardiovascular systems. Because of its sudden onset and severe symptoms, anaphylaxis is considered a medical emergency requiring immediate emergency treatment only.

Symptoms of anaphylaxis

The symptoms of anaphylaxis can vary from person to person but typically include one or more of the following:

• Skin reactions, including hives, itching, and flushed or pale skin
• Swelling of the face, eyes, lips, or throat
• Respiratory problems, such as wheezing, shortness of breath, a tight throat, or a hoarse voice
• Gastrointestinal symptoms, such as nausea, vomiting, diarrhea, and abdominal pain
• Cardiovascular symptoms, such as a rapid heartbeat, dizziness, fainting, or a severe drop in blood pressure

Causes of anaphylaxis

Anaphylaxis can be triggered by various allergens. Common triggers include:

• Food allergies, such as to nuts, shellfish, milk, eggs, and wheat
• Insect stings, particularly from bees, wasps, and fire ants
• Medications, including antibiotics like penicillin and non-steroidal anti-inflammatory drugs (NSAIDs)
• Latex found in some medical or dental supplies and condoms

Some people may have idiopathic anaphylaxis, where the cause of a severe allergic reaction is unknown.

Dangers of anaphylaxis

The primary danger of anaphylaxis lies in severe reaction and its rapid escalation, which can lead to life-threatening conditions if not promptly treated. The most severe complications include:

• Anaphylactic shock, where a severe drop in blood pressure occurs, leading to insufficient blood flow to vital organs.
• Airway constriction, making it difficult or impossible to breathe.
• Cardiac arrest due to severe cardiovascular reactions.

Immediate administration of epinephrine (adrenaline), typically through an auto-injector like an EpiPen, is crucial for treating anaphylactic reactions and should be followed by professional medical treatment to ensure stability and monitor for any further reactions.

How nurses assess and diagnose anaphylaxis

Anaphylaxis is a rapid-onset, life-threatening allergic reaction that requires immediate medical attention. Nurses are critical in assessing, diagnosing, and managing anaphylaxis, especially in emergencies.

When a patient presents with symptoms suggestive of anaphylaxis, nurses perform several crucial evaluations:

Step 1: Initial assessment

Nurses quickly assess the patient’s airway, breathing, and circulation (ABCs) to determine the severity of the reaction. This involves checking for signs of respiratory distress, measuring pulse and blood pressure, and observing skin color and condition.

Step 2: Symptom review

Nurses gather a detailed history of the symptoms, including their onset and progression. They ask about known allergies, the possibility of recent exposures to allergens, and any previous medical history because of allergic reactions.

Step 3: Physical examination

The examination identifies physical signs of anaphylaxis, such as hives, swelling (especially around the face and throat), and respiratory distress. Listening to the chest for wheezing and observing the cardiovascular system for signs of shock are also critical.

Step 4: Use of triage tools

Tools like the Anaphylaxis Emergency Action Plan can help the assessment. This plan includes criteria for identifying anaphylaxis and provides guidelines for following steps.

Step 5: Diagnostic tests

While the immediate allergic response due to potential anaphylaxis is not dependent on lab tests, blood tests (like tryptase levels) and imaging may be used later to confirm the diagnosis or assess the extent of the reaction.

Next steps after diagnosis

Once anaphylaxis is diagnosed, the following steps are crucial:

Step 1: Immediate treatment

Administration of epinephrine is the first-line treatment for anaphylaxis and should be administered as soon as the nursing diagnosis of anaphylaxis is suspected. Nurses ensure that epinephrine is given promptly and prepare for possible additional doses if symptoms do not improve.

Step 2: Monitoring

Continuous monitoring is necessary to watch for changes in the patient’s condition and response to treatment. Vital signs, oxygen saturation levels, and respiratory status are closely monitored.

Step 3: Secondary treatment

Additional treatments may include oxygen therapy, intravenous fluids, and medications like antihistamines and corticosteroids to manage symptoms and prevent worsening of the reaction.

Step 4: Preparation for advanced care

Nurses prepare for potential escalation of critical care there, including securing an airway or supporting blood pressure. They also prepare the patient for possible transfer to a higher level of care, such as an intensive care unit.

Step 5: Education and prevention

Before discharge, nurses educate patients and caregivers on avoiding known allergens and the importance of carrying an epinephrine auto-injector. They also provide training on recognizing and responding to future allergic reactions.

How to use our Anaphylaxis Nursing Care Plan template

To effectively utilize the Anaphylaxis Nursing Care Plan template, begin by completing the patient information section with details like name, age, gender, and the date of evaluation. This foundational data supports personalized and precise care.

In the Assessment section, diligently note any symptoms of anaphylaxis, such as hives, swelling, and difficulty breathing, and identify any potential triggers. This information is crucial for accurately diagnosing and initiating the appropriate response.

In the Planning and Intervention sections, the focus shifts to preventing symptom progression and maintaining vital functions. Immediate steps include administering epinephrine, summoning emergency assistance, and preparing for possible advanced interventions like oxygen support or CPR.

The interventions are justified in the Rationale section, emphasizing the importance of rapid action and the effectiveness of treatments in managing anaphylactic reactions. Continuous monitoring in the Evaluation stage assesses the patient's response, aiming for symptom resolution and stabilization, while the Follow-up ensures ongoing observation, education on trigger avoidance, and proper use of epinephrine auto-injectors to prevent future episodes.

Common nursing interventions for anaphylaxis

Anaphylaxis is a severe, potentially life-threatening allergic reaction that requires immediate medical attention. As first responders in the emergency department, nurses are critical in promptly recognizing and managing anaphylaxis. Here are the essential nursing interventions:

Rapid assessment and monitoring of airway, breathing, and circulation (ABCs)

The first step in managing anaphylaxis is the rapid assessment of the patient’s ABCs. For the airway, assess for any signs of compromise, such as swelling, stridor, or difficulty breathing, and maintain a patent airway using adjuncts if necessary. Monitoring breathing involves closely observing the respiratory rate, oxygen saturation, and breath sounds while watching for signs of respiratory distress like wheezing or cyanosis. In terms of circulation, check the heart rate, blood pressure, and skin perfusion, and be vigilant for signs of shock such as hypotension or tachycardia.

Immediate administration of epinephrine

Epinephrine is the first-line treatment for anaphylaxis and should be administered without delay. It is typically given via intramuscular (IM) injection in the thigh. The recommended dosage is 0.3–0.5 mg for adults and 0.01 mg/kg for children, with repeat injections every 5-15 minutes as necessary until symptoms improve.

Supplemental oxygen therapy

Supplemental oxygen therapy should be provided using a high-flow delivery system, such as a non-rebreather mask. The goal is maintaining an oxygen saturation (SpO2) above 92%, ensuring adequate tissue oxygenation.

Patient positioning

Proper positioning of the patient is crucial in managing anaphylaxis. If the patient is hypotensive, placing them in a supine position with legs elevated can improve circulation. For those experiencing respiratory distress, positioning in a semi-Fowler position helps ease breathing.

Establishing intravenous access

Large-bore intravenous (IV) access should be established promptly for fluid resuscitation and medication administration. Normal saline or lactatRinger’sr’s solution is typically used to keep blood vessels and maintain adequate blood pressure and circulation.

Administration of additional medications

Several additional medications are used in conjunction with epinephrine to manage anaphylaxis. Antihistamines like diphenhydramine (25–50 mg IV/IM for adults, 1 mg/kg for children) and H2 blockers (e.g., ranitidine) help reduce the effects of histamine. Corticosteroids such as methylprednisolone or hydrocortisone are given to minimize inflammation and reduce the risk of biphasic reactions. Inhaled beta-agonists like albuterol are used if bronchospasm is present, and vasopressors such as norepinephrine may be required if the patient remains hypotensive despite fluid resuscitation and epinephrine.

Continuous monitoring of vital signs and symptoms

Continuous monitoring of heart rate, blood pressure, respiratory rate, and oxygen saturation is essential. Observing for any changes or improvements in symptoms throughout treatment is important.

Patient education and support

Providing reassurance and emotional support to the patient is vital in managing the stress and anxiety associated with anaphylaxis. Additionally, educating them about anaphylaxis triggers, emergency management, and the proper use of an epinephrine auto-injector helps them be better prepared for future emergencies.

Documentation and handoff

Documenting the patients’ initial assessment, interventions provided, and their response to treatment is crucial for the continuity of care. Ensure that the time and dosage of each medication are recorded, and provide a comprehensive handoff report if the patient requires a transfer to a higher level of care.

Nurses play a pivotal role in anaphylaxis management. Swift assessment and appropriate interventions can significantly improve outcomes for patients experiencing this life-threatening emergency.