Nursing care plan for anaphylactic shock

Introduction to Nursing Care Plan for Anaphylactic Shock

Anaphylaxis is a severe, life-threatening allergic reaction caused by the release of chemicals such as histamine that can affect breathing and lead to shock.

Assessment of Anaphylactic Shock

The nurse should assess the patient’s condition and history on admission. The assessment should include evaluation of the patient’s vital signs, symptoms, medications taken and possible exposure to allergens. A physical examination should be performed to assess for any swelling and difficulty in breathing.

Nursing Diagnosis for Anaphylactic Shock

The most common nursing diagnosis related to anaphylaxis is Airway Clearance deficits due to edema or secondhand smoke due to the inciting allergen. Other possible nursing diagnoses include: Impaired Gas Exchange secondary to anaphylaxis, Risk for Fluid Volume Deficit due to vomiting, diarrhea and loss of fluid through sweating, and Ineffective Therapeutic Regimen Management related to lack of knowledge of emergency management.

Outcomes for Anaphylactic Shock

The patient should demonstrate verbalized understanding of the triggers of anaphylaxis, effective airway clearance, adequate oxygenation, elimination of risk factors, and effective therapeutic regimen management.

Interventions for Anaphylactic Shock

• Assess patient’s vital signs.
• Administer ordered medications such as epinephrine and antihistamines.
• Administer supplemental oxygen as necessary.
• Provide emotional support to the patient and family.
• Monitor patient for any changes in respiratory status.

Rationales for Anaphylactic Shock

• Assessment of vital signs helps to detect abnormal hemodynamic changes.
• Medications reduce the severity of the reaction and prevent further symptoms.
• Oxygen helps to maintain adequate oxygenation as the patient may be having difficulty breathing.
• Providing emotional support helps to reduce the patient’s anxiety and fear.
• Monitoring the patient’s respiratory status helps to detect any deterioration in the patient’s condition.

Evaluation for Anaphylactic Shock

The nurse should evaluate the patient’s response to treatment at regular intervals. The patient should demonstrate improved respiratory status, reduced swelling and improved oxygenation.

Conclusion

Anaphylaxis is a severe, life-threatening allergic reaction that requires immediate medical attention. An effective nursing care plan for anaphylactic shock includes assessment of the patient’s condition, diagnosing and managing airway clearance deficits, eliminating risk factors, providing emotional support, administering medications, monitoring the patient’s respiratory status, and evaluating the patient’s response to treatment.

FAQs

• What are the symptoms of anaphylaxis?
  The symptoms of anaphylaxis include difficulty breathing, swelling of the throat, hives, itching, tightness in the chest, wheezing, and dizziness.
• What are the signs of anaphylactic shock?
  The signs of anaphylactic shock include sudden drop in blood pressure, rapid heart rate, and loss of consciousness.
• What is the treatment for anaphylaxis?
  The treatment for anaphylaxis includes administration of epinephrine and antihistamines, oxygen therapy, and supportive care.
• How long does it take for anaphylaxis to resolve?
  Anaphylaxis usually resolves within 30 minutes with proper medical treatment and supportive care.
• What are the risks of anaphylaxis?
  The risks of anaphylaxis include death due to asphyxiation, shock, or cardiac arrest.