4 Anaphylactic Shock Nursing Care Plans

Ineffective Breathing Pattern

Ineffective breathing pattern can occur in patients with anaphylactic shock due to bronchospasm, bronchoconstriction, laryngeal edema, and facial angioedema. These conditions can cause the airways to narrow and the tissues in the throat and face to swell, making it difficult to breathe. This can lead to shortness of breath, wheezing, and in severe cases, respiratory failure.

Nursing Diagnosis

• Ineffective Breathing Pattern

May be related to

• Bronchospasm
• Bronchoconstriction
• Facial angioedema
• Laryngeal edema

Possibly evidenced by

• Chest tightness
• Cyanosis
• Coughing
• Dyspnea
• Hoarseness
• Respiratory distress
• Stridor
• Tachypnea
• Use of accessory muscles
• Wheezing

Desired Outcomes

• The client will maintain an effective breathing pattern, as evidenced by relaxed breathing at a normal rate and depth and the absence of adventitious breath sounds.

Nursing Assessment and Rationales

1. Assess the respiratory rate, rhythm, and depth, and note for changes such as coughing, dyspnea, increased shortness of breath, stridor, tachypnea, wheezing, and use of accessory muscles.
Histamine is the primary mediator of anaphylactic shock. It causes smooth muscle contraction in the bronchi as a result of the stimulation of histamine receptors (H1). As the anaphylactic reaction progresses, the client develops dyspnea, wheezing, and increased pulmonary secretions. Vascular to interstitial fluid shifts contribute to respiratory distress through swelling in the upper airways.

2. Auscultate breath sounds.
By auscultation, wheezing can be heard over the entire chest. But when the bronchial constriction worsens, there will be decreased audible wheezing and respiratory distress will heighten. Therefore it is also important to auscultate for decreasing air movement.

3. Assess the client’s anxiety level.
Life-threatening situations such as respiratory distress and shock can produce elevated levels of anxiety within the client.

4. Assess the client for the sensation of a narrowed airway.
A systemic antigen-antibody immune response can result in severe bronchial airway narrowing, edema, and obstruction. As the airway gets narrow, the client demonstrates increase respiratory effort.

5. Observe for changes in the color of the skin, tongue, and mucosa.
Bluish discoloration of these body parts is considered a medical emergency.

6. Assess the presence of angioedema.
Angioedema is characterized by the swelling of the skin, lips, tongue, hands, eyelids, and feet.

7. Monitor oxygen saturation and arterial blood gases.
Pulse oximetry is used to monitor oxygen saturation. It should be kept at least 90% or higher. As shock progresses, aerobic metabolism stops and lactic acidosis occurs, resulting in an increased level of carbon dioxide and decreasing pH.

Nursing Interventions and Rationales

1. Maintain a calm, assured manner. Assure the client and significant others of close, continuous monitoring that will ensure prompt intervention.
The staff’s anxiety may be easily perceived by the client. The client’s feeling of stability increases in a calm, non-threatening environment. The presence of a trusted person can help the client feel less threatened.

2. Provide assurance and alleviate anxiety by staying with the client during acute distress.
Air hunger can produce an extremely anxious state that leads to rapid and shallow respirations.

3. Instruct the client to breathe slowly and deeply.
Focus breathing may help calm the client, and the increased tidal volume facilitates improved gas exchange.

4. Position the client upright.
This position provides oxygenation by promoting maximum chest expansion and is the position of choice during respiratory distress.

5. Administer IV fluids as ordered.
Hypotension caused by vasodilation and distributive shock responds to fluid resuscitation.

6. Administer oxygen as prescribed.
Oxygen increases arterial saturation. Oxygen saturation that is less than 90% results in tissue hypoxia, acidosis, dysrhythmias, and changes in the level of consciousness.

7. Administer medications as ordered:

• 7.1. Bronchodilators
  These medications reduce bronchospasm and help open the airways in the lungs by relaxing smooth muscle around the airways.

• 7.2. Corticosteroids
  Steroids stabilize the cell membrane and decrease cellular permeability, vasomotor response, and inflammation.

• 7.3. Epinephrine
  Epinephrine is the cornerstone of anaphylaxis management. It is fast-acting and relaxes pulmonary vessels to improve air exchange and stabilizes cellular permeability.

• 7.4. H₁-receptor blockers/antihistamines
  These medications block the action of histamine and decrease cellular edema.

8. Maintain a patent airway. Anticipate an emergency intubation or tracheostomy if stridor occurs.
Respiratory distress may progress rapidly. If laryngeal edema is present, endotracheal intubation will be required to maintain a patent airway.

Home care: 

9. Provide information about emergency medications and plans that should be considered should a crisis reoccur.
Adequate preparation decreases risks.

10. Assist the client and/or family in identifying factors that precipitate and/or exacerbate crises.
Knowledge can facilitate prompt intervention.