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

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.

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 the 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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