4 Anaphylactic Shock Nursing Care Plans

Decreased Cardiac Output

Decreased cardiac output can occur in patients with anaphylactic shock due to generalized vasodilation and increased capillary permeability. These conditions can cause blood vessels to dilate, which can lead to a decrease in blood pressure and cardiac output. This can result in decreased blood flow to vital organs, including the heart, and can lead to shock and organ failure if not treated promptly.

Nursing Diagnosis

• Decreased Cardiac Output

May be related to

• Generalized vasodilation (decreased preload and afterload)
• Increased capillary permeability (fluid shifts)

Possibly evidenced by

• Cyanosis; pallor
• Decreased central venous pressure (CVP)
• Decreased peripheral pulses
• Decreased pulmonary pressures
• Dizziness
• Hypotension
• Oliguria
• Prolonged capillary refill
• Restlessness
• Tachycardia

Desired Outcomes

• The client will display hemodynamic stability, as evidenced by strong peripheral pulses; HR 60 to 100 beats/min with regular rhythm; systolic BP within 20 mm Hg of baseline; urine output greater than 30 ml/hr; warm, dry skin; and alert, responsive mentation.

Nursing Assessment and Rationales

1. Assess the client’s HR and BP, including peripheral pulses.
Severe hypovolemia and hypotension result from the intense vasodilation; Pulses are weak with decreased stroke volume and cardiac output.

2. Assess the client’s ECG for dysrhythmias.
Cardiac dysrhythmias may occur from the low perfusion state, acidosis, or hypoxia.

3. Assess the client’s level of consciousness.
Early signs of cerebral hypoxia are restlessness and anxiety while confusion and loss of memory occur in the late stage.

4. Assess the skin temperature and signs of any cyanosis.
Massive vasodilation and increased capillary permeability can lead to decreased peripheral blood flow and ineffective tissue perfusion.

5. Monitor the client’s urine output.
The renal system compensates for low blood pressure by retaining Water. Oliguria is a classic sign of inadequate renal perfusion.

6. Monitor the client’s central venous pressure (CVP), pulmonary artery diastolic pressure (PADP), pulmonary capillary wedge pressure, and cardiac output/cardiac index.
Hemodynamic parameters provide information aiding in the differentiation of decreased cardiac output secondary to the fluid deficit (fluid shifts) or fluid overload (aggressive IV therapy). CVP is used as an estimate of right ventricular preload; pulmonary capillary wedge pressure and pulmonary artery diastolic pressure indicate left-sided fluid volumes.

Nursing Interventions and Rationales

1. Place the client with the head of the bed flat, with the trunk horizontal and the lower extremities elevated 20 to 30 degrees with the knees straight.
This position promotes optimal venous return.

2. Administer volume expanders as ordered.
Volume expanders are used to correct hypovolemia.

3. Administer parenteral fluids using a large-bore needle. Avoid fluid overload in older clients.
Volume therapy is essential to maintain sufficient filling pressures and adequate cardiac output.

4. If a blood transfusion is causing the reaction, immediately terminate the infusion and keep the vein open using a normal saline solution then notify the physician.
These safety measures must be done to eliminate further complications.

5. Administer medications as ordered.

• 5.1. Corticosteroids
  Steroids may be used to suppress immune and inflammatory responses and reduce capillary permeability.

• 5.2. Epinephrine
  Epinephrine is an endogenous catecholamine with both alpha- and beta-receptor-stimulating actions that provide rapid relief of hypersensitivity reactions. It is unknown whether epinephrine prevents mediator release or whether it reverses the action of mediators on the target tissues., but its early administration is critical. For prolonged reactions, it may be necessary to repeat the dose.

• 5.3. Glucagon
  Glucagon reverses hypotension in clients taking beta-blocker medications who are unresponsive to fluid administration and epinephrine.

• 5.4. H₁-receptor blockers and/or an antihistamine (diphenhydramine)
  Antihistamine blocks the action of histamine and reverses its adverse effects.