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
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Deficient Knowledge

Nursing Diagnosis

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May be related to

  • Lack of exposure.
  • Lack of recall.
  • Misinterpretation of information.

Possibly evidenced by

  • Inaccurate follow-through of instructions.
  • Inability to identify allergens.
  • Recurrent allergic reactions.

Desired Outcomes

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  • Client and significant others will verbalize understanding of allergic reaction, its prevention, and management.
  • Client and significant others will verbalize understanding of need to carry emergency components for intervention, need to inform health care providers of allergies, need to wear medical alert bracelet/necklace, and the importance of seeking emergency care.
Nursing InterventionsRationale
Assess the client’s knowledge of the condition and exposure to allergens.Present knowledge of the client provides a baseline for immediate treatment.
Explain factors that may increase the risk of anaphylaxis (e.g., certain drugs, blood products, insect venom, food and environmental control measures to be established).Information allows the client to take control and make needed lifestyle modifications. For example, if the trigger is pollen, the client will need to shower, change and wash clothes after they’ve spent time outdoors.
Instruct the client with known allergies to wear medical alert identification.In case of emergency, health care provider will be aware of this medical history.
Instruct the client or family members about factors that can precipitate a recurrence of shock and ways to prevent or avoid these precipitating factors.The client is at high risk for developing anaphylactic shock in the future if exposed to the same antigenic substance and needs self-help information to prevent anaphylactic shock.
Instruct the client in the use of insect sting kits (containing a chewable antihistamine), epinephrine in prefilled syringes, and instructions for use as appropriate, and indicate how they are to be obtained.In a situation in which the client cannot completely avoid exposure to allergens, he or she needs to have access to emergency treatment resources for immediate administration. These can be self-administered or given by someone else.
Notify the client or significant others to divulge in the medical history all their allergies (e.g., blood products, food, pollen, latex, medications, contrast dyes, dust mites).Safety measures reduce potential injury. Health care providers need to be aware of both history of the reaction, causative factors, symptoms, and severity, and the level of the treatment period.
Provide instruction in self-care measures to be performed at home during the initial attack:

  • During an episode of a drop in blood pressure (dizziness), lie down with the feet elevated.
  • During an episode of wheezing, use a prescribed inhaled bronchodilator.
  • During an episode of a severe reaction, inject self with epinephrine from the kit (EpiPen).
  • Minimize exposure to the trigger if possible.
  • Take an oral antihistamine (Benadryl) if swallowing is intact.
  • Call 911 for help, or have someone drive to the hospital before the attack increases.
During initial attacks, the client should be prepared to stay calm and follow safety instructions; The EpiPen is injected into the thigh muscle.
Discuss referral to an allergist if allergens are difficult to avoid.Skin tests are being used to identify the specific allergen. Clients may also benefit from desensitization.

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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:

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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