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4 Anaphylactic Shock Nursing Care Plans

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By Paul Martin, BSN, R.N.
4 Anaphylactic Shock Nursing Care Plans
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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 a smooth muscle contraction, massive vasodilation and increased capillary permeability triggered by a release of histamine. It occurs within seconds to minutes after contact with an 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 diagnosis for patients with anaphylactic shock:

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

2. Impaired Gas Exchange

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Impaired Gas Exchange

Nursing Diagnosis

  • Impaired Gas Exchange

May be related to

  • Ventilation-perfusion imbalance.

Possibly evidenced by

  • Bronchospasm.
  • Dyspnea.
  • Hypotension.
  • Shock.
  • Shortness of breath.
  • Tachycardia.

Desired Outcomes

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  • Client will demonstrate improved ventilation as evidenced by an absence of shortness of breath and respiratory distress.
Nursing InterventionsRationale
Note respiratory rate, frequency, depth and ease breathing.Increased respiratory effort may show the extent of the level of hypoxemia and useful in evaluating the degree of compromise.
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.
Assess the level of consciousness/mental changes.Anxiety or restlessness, confusion, and headaches are other common effects of mild hypoxemia.
Monitor oxygen saturation and arterial blood gasses.Pulse oximetry is used to monitor oxygen saturation. It should be kept at least 90% or higher. As shock increases, aerobic metabolism stops and lactic acidosis happens, resulting in the increased level of carbon dioxide and decreasing pH.
Maintain the patency of the airway.Airway obstruction may alter ventilation and impairs gas exchange.
Elevate head of bed; Provide airway adjuncts and suction as indicated.This position promotes adequate oxygenation; Airway adjuncts such as oropharyngeal airway (OPA) and nasopharyngeal airway (NPA) are designed to maintain airway patency, allowing spontaneous respiration or facilitating bag-mask ventilation.
Provide oxygen therapy correctly as indicated.Oxygen therapy will maintain PaO2 above 60 mm Hg.
Encourage adequate rest and limit activities to within client’s tolerance.This will promote calm and restful environment and will limit the client’s oxygen needs.
Administer medications as ordered (corticosteroids, bronchodilators, antihistamines).Used to prevent allergic reactions / inhibit histamine release, reduces airway spasm, and inflammation.
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2. Impaired Gas Exchange

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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See also

Other recommended site resources for this nursing care plan:

Other care plans for hematologic and lymphatic system disorders:

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Paul Martin, BSN, R.N.
Paul Martin is a registered nurse with a bachelor of science in nursing since 2007. Having worked as a medical-surgical nurse for five years, he handled different kinds of patients and learned how to provide individualized care to them. Now, his experiences working in the hospital is carried over to his writings to help aspiring students achieve their goals. He is currently working as a nursing instructor and have a particular interest in nursing management, emergency care, critical care, infection control, and public health. As a writer at Nurseslabs, his goal is to impart his clinical knowledge and skills to students and nurses helping them become the best version of themselves and ultimately make an impact in uplifting the nursing profession.
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