4 Anaphylactic Shock Nursing Care Plans


As a nurse, understanding the nursing care plans and nursing diagnosis for anaphylactic shock is crucial to providing the best care for patients. This guide provides a comprehensive overview of anaphylactic shock nursing care plans and nursing diagnosis, including common symptoms and treatment options.

What is Anaphylactic Shock?

Anaphylactic Shock also known as distributive shock, or vasogenic shock is a life-threatening allergic reaction that is caused by a systemic antigen-antibody immune response to a foreign substance (antigen) introduced into the body. It is characterized by smooth muscle contraction, massive vasodilation, and increased capillary permeability triggered by a release of histamine. It occurs within seconds to minutes after contact with antigenic substances and progresses rapidly to respiratory distress, vascular collapse, systemic shock, and possibly death if emergency treatment is not initiated. Causative agents include severe reactions to a sensitive substance such as a drug, vaccine, food (e.g., eggs, milk, peanuts, shellfish), insect venom, dyes or contrast media, or blood products.

Nursing Care Plans

Anaphylactic shock is a medical emergency that requires immediate attention and intervention. Nursing care management is dependent on the severity of the initial reaction and the treatment response.

Here are four (4) nursing care plans (NCP) and nursing diagnoses for patients with anaphylactic shock:

  1. Ineffective Breathing Pattern
  2. Impaired Gas Exchange
  3. Decreased Cardiac Output
  4. Deficient Knowledge

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.


Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.

NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is reviewed and approved by NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.

Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care 
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health 
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.

See also

Other recommended site resources for this nursing care plan:

Other care plans for hematologic and lymphatic system disorders:


Paul Martin R.N. brings his wealth of experience from five years as a medical-surgical nurse to his role as a nursing instructor and writer for Nurseslabs, where he shares his expertise in nursing management, emergency care, critical care, infection control, and public health to help students and nurses become the best version of themselves and elevate the nursing profession.

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