Anaphylaxis Nursing Care Plan

Explore effective anaphylaxis management strategies, symptoms, causes, and essential nursing interventions in our detailed guide.

By Russell Tan on Jun 03, 2024.

Fact Checked by Ericka Pingol.

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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.

Printable Anaphylaxis Nursing Care Plan

Download this Anaphylaxis Nursing Care Plan to ensure rapid and effective response to anaphylactic emergencies.

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.

Anaphylaxis Nursing Care Plan example

The Anaphylaxis Nursing Care Plan template provides a structured approach to managing severe allergic reactions, emphasizing rapid identification and response. It outlines how to recognize signs of anaphylaxis such as hives, swelling, and breathing difficulties, and underscores the importance of immediate treatment with epinephrine and emergency support. This quick action is crucial for preventing symptom progression and stabilizing the patient.

Additionally, the template guides ongoing patient monitoring and follow-up care. It includes steps for continuous evaluation of the patient's response to interventions, ensuring stabilization and recovery. Educating patients and families on avoiding allergens and using epinephrine auto-injectors effectively is also highlighted, crucial for reducing the risk of future anaphylactic episodes and ensuring patient safety.

Download our free Anaphylaxis Nursing Care Plan example here

Anaphylaxis Nursing Care Plan example

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What is anaphylaxis?
What is anaphylaxis?

Commonly asked questions

What is anaphylaxis?

Anaphylaxis is a severe, potentially life-threatening allergic reaction that can occur suddenly after exposure to an allergen, such as certain foods, insect stings, or medications.

What are the common signs of anaphylaxis?

Common signs include difficulty breathing, hives or swelling, a sense of impending doom, rapid heartbeat, and dizziness or fainting. It’s crucial to recognize these symptoms early to manage the reaction promptly.

How is anaphylaxis treated?

Anaphylaxis is treated with an immediate injection of epinephrine (adrenaline) using an auto-injector, such as an EpiPen; it’s important to call emergency services and get the person to a hospital for further treatment and observation.

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