Which intervention is a priority for a nurse caring for a child with anaphylaxis?
Show
Anaphylaxis is a severe and potentially life-threatening reaction which may be the result of hypersensitivity.1 The hypersensitive reaction may be generalised or systemic, and tends to occur within minutes. It can be considered an allergic reaction, which may or may not have an immunological basis.2 The airway is often compromised as a result of pharyngeal or laryngeal oedema causing breathing difficulty. Increased respiratory rate or bronchospasm can cause these breathing difficulties. There might be evidence of circulatory compromise, such as hypotension and an increased heart rate. In most cases of anaphylaxis, skin and mucosal changes occur. Skin changes include flushing and urticaria. Symptoms can worsen rapidly. It is of note that the incidence of anaphylactic reactions in the UK is increasing, according to data from the Resuscitation Council (UK).2 Patients that have previously had an allergic reaction may be at an increased risk of developing an anaphylactic reaction. There is an increased risk of anaphylaxis associated with other comorbidities, such as asthma. The risk of anaphylaxis is increased if asthma is poorly controlled.2
Anaphylaxis Nursing Care Plans Diagnosis and InterventionsAnaphylaxis 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 AnaphylaxisThe following are the signs and symptoms of anaphylaxis, which can be observed within seconds or minutes following allergen exposure:
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 AnaphylaxisThe following are the types of anaphylaxis based on severity:
Causes and Risk Factors of AnaphylaxisThe 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:
If there is no apparent allergen that has triggered the anaphylactic reaction, the event is called idiopathic anaphylaxis.
Treatment for Anaphylaxis
Nursing Diagnosis for AnaphylaxisAnaphylaxis Nursing Care Plan 1Ineffective 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 Care Plan 2Impaired 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 Care Plan 3Decreased 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 Care Plan 4Deficient 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 Care Plan 5Nausea 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
Nursing ReferencesAckley, 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. What is nursing intervention for anaphylaxis?Nursing interventions for the patient are: Monitor client's airway. Assess the client for the sensation of a narrowed airway. Monitor the oxygenation status. Monitor oxygen saturation and arterial blood gas values.
Which interventions should be used for anaphylactic shock?Call 911 or emergency medical help. Use an epinephrine autoinjector, if available, by pressing it into the person's thigh. Make sure the person is lying down and elevate the legs. Check the person's pulse and breathing and, if necessary, administer CPR or other first-aid measures.
When caring for a child experiencing anaphylactic shock the most important nursing action when would be to?The nurse would want to call a rapid response, place the patient on oxygen, and prepare for the administration of Epinephrine. This drug is the first-line treatment for anaphylactic shock. It will increase the blood pressure, decrease swelling, and dilate the airway. 7.
Which is the highest priority nursing intervention for the patient who is having an anaphylactic reaction?Death from anaphylaxis may occur as a result of severe respiratory complications, cardiovascular collapse, or both. Early administration of intramuscular (IM) Epinephrine is first line treatment for anaphylaxis to prevent death and there is no known equivalent substitute.
|