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.
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.
- Prolonged capillary refill.
- Client will display hemodynamic stability, as evidenced by strong peripheral pulses; HR 60 to 100 beats/min with regular rhythm; systolic BP withing 20 mm Hg of baseline; urine output greater than 30 ml/hr; warm, dry skin; and alert, responsive mentation.
|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.|
|Assess the client’s ECG for dysrhythmias.||Cardiac dysrhythmias may occur from the low perfusion state, acidosis, or hypoxia.|
|Assess the client’s level of consciousness.||Early signs of cerebral hypoxia are restlessness and anxiety while confusion and loss of memory occurs in late stage.|
|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.|
|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.|
|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.|
|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.|
|Administer volume expanders as ordered.||Volume expanders are used to correct hypovolemia.|
|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.|
|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.|
|Administer medications as ordered.|
||Steroids may be used to suppress immune and inflammatory responses and reduce capillary permeability.|
||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.|
|Glucagon reverses hypotension in clients taking beta blocker medications who are unresponsive to fluid administration and epinephrine.|
||Antihistamine blocks the action of histamine and reverses their adverse effects.|
Recommended nursing diagnosis and nursing care plan books and resources.
- 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, 2021-2023 (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.
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