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:
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
- Client will demonstrate improved ventilation as evidenced by an absence of shortness of breath and respiratory distress.
Nursing Interventions | Rationale |
---|---|
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. |
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.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use. - Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively. - NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023Â (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales. - Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates. - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing. - Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans. - Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you. - Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023. - All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
See also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. - Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans for hematologic and lymphatic system disorders:
- Anaphylactic Shock | 4 Care Plans
- Anemia | 4 Care Plans
- Aortic Aneurysm | 4 Care Plans
- Deep Vein Thrombosis | 5 Care Plans
- Disseminated Intravascular Coagulation | 4 Care Plans
- Hemophilia | 5 Care Plans
- Leukemia | 5 Care Plans
- Lymphoma | 3 Care Plans
- Sepsis and Septicemia | 6 Care Plans
- Sickle Cell Anemia Crisis | 6 Care Plans