4 Anaphylactic Shock Nursing Care Plans

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.

For some people with severe allergies, when they’re exposed to something they’re allergic to, they may experience a potentially life-threatening reaction called anaphylaxis. As a result, their immune system releases chemicals that flood the body. This can lead to anaphylactic shock.

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When your body goes into anaphylactic shock, your blood pressure suddenly drops and your airways narrow, possibly blocking normal breathing.

This condition is dangerous. If it isn’t treated immediately, it can result in serious complications and even be fatal.

What are the symptoms of anaphylactic shock?

You’ll experience symptoms of anaphylaxis before anaphylactic shock sets in. These symptoms shouldn’t be ignored.

Symptoms of anaphylaxis include:

Skin reactions such as hives, flushed skin, or paleness

Suddenly feeling too warm

Feeling like you have a lump in your throat or difficulty swallowing

Nausea, vomiting, or diarrhea

Abdominal pain

A weak and rapid pulse

Runny nose and sneezing

Swollen tongue or lips

Wheezing or difficulty breathing

A sense that something is wrong with your body

Tingling hands, feet, mouth, or scalp

If you think you’re experiencing anaphylaxis, seek medical attention immediately. If anaphylaxis has progressed to anaphylactic shock, the symptoms include:

Struggling to breathe

Dizziness

Confusion

Sudden feeling of weakness

Loss of consciousness

What are the causes and risk factors of anaphylaxis?

Anaphylaxis is caused by an overreaction of your immune system to an allergen, or something your body is allergic to. In turn, anaphylaxis can result in anaphylactic shock.

Common triggers for anaphylaxis include:

Certain medications such as penicillin

Insect stings

Foods such as:

Tree nuts

Shellfish

Milk

Eggs

Agents used in immunotherapy

Latex

In rare cases, exercise and aerobic activity such as running can trigger anaphylaxis.

Sometimes a cause for this reaction is never identified. This type of anaphylaxis is called idiopathic.

If you aren’t sure what’s triggering your allergy attacks, your doctor may order an allergy test to look for what’s causing them.

Risk factors for severe anaphylaxis and anaphylactic shock include:

A previous anaphylactic reaction

Allergies or asthma

A family history of anaphylaxis

What are the complications of anaphylactic shock?

Anaphylactic shock is extremely serious. It can block your airways and prevent you from breathing. It can also stop your heart. This is due to the decrease in blood pressure that prevents the heart from receiving enough oxygen.

This can contribute to potential complications such as:

Brain damage

Kidney failure

Cardiogenic shock, a condition that causes your heart to not pump enough blood to your body

Arrhythmias, a heartbeat that is either too fast or too slow

Heart attacks

Death

In some cases, you’ll experience a worsening of pre-existing medical conditions.

This is especially true for conditions of the respiratory system. For example, if you have COPD, you may experience a lack of oxygen that can quickly do irreversible damage to the lungs.

Anaphylactic shock can also permanently worsen symptoms in people with multiple sclerosis.

The sooner you get treatment for anaphylactic shock, the fewer complications you’re likely to experience.

What to do in cases of anaphylactic shock

If you’re experiencing severe anaphylaxis, seek emergency care immediately.

If you have an epinephrine auto-injector (EpiPen), use it at the onset of your symptoms. Don’t try to take any type of oral medication if you’re having difficulty breathing.

Even if you seem better after you use the EpiPen, you must still get medical attention. There’s a significant risk of the reaction coming back as soon as the medication wears off.

If anaphylactic shock is occurring because of an insect sting, remove the stinger if possible. Use a plastic card, such as a credit card. Press the card against the skin, slide it upward toward the stinger, and flick the card up once underneath it.

Don’t squeeze the stinger, as this can release more venom.

If someone appears to be going into anaphylactic shock, call 911 and then:

Get them into a comfortable position and elevate their legs. This keeps blood flowing to the vital organs.

If they have an EpiPen, administer it immediately.

Give them CPR if they aren’t breathing until the emergency medical team arrives.

How is anaphylactic shock treated?

The first step for treating anaphylactic shock will likely be injecting epinephrine (adrenaline) immediately. This can reduce the severity of the allergic reaction.

At the hospital, you’ll receive more epinephrine intravenously (through an IV). You may also receive glucocorticoid and antihistamines intravenously. These medications help to reduce inflammation in the air passages, improving your ability to breathe.

Your doctor may give you beta-agonists such as albuterol to make breathing easier. You may also receive supplemental oxygen to help your body get the oxygen it needs.

Any complications you’ve developed as a result of anaphylactic shock will also be treated.

What’s the outlook for anaphylactic shock?

Anaphylactic shock can be extremely dangerous, even fatal. It’s an immediate medical emergency. Recovery will depend on how quickly you get help.

If you’re at risk for anaphylaxis, work with your doctor to come up with an emergency plan.

Long term, you may be prescribed antihistamines or other allergy medication to reduce the likelihood or severity of future attacks. You should always take the allergy medications prescribed to you by your doctor and consult them before stopping.

Your doctor may suggest carrying an EpiPen in case of a future attack. They may also help you identify what caused the reaction so you can avoid triggers in the future.

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 2018-2019: The Complete List” href=”https://nursingessays.us/nursing-diagnosis/” target=”_self” rel=”noopener noreferrer” data-ail=”44280″>nursing diagnosis for patients with anaphylactic shock:

  1. Ineffective Breathing Pattern
  2. Impaired Gas Exchange
  3. Decreased Cardiac Output
  4. Deficient Knowledge

Ineffective Breathing Pattern

Nursing Diagnosis

May be related to

  • Bronchospasm.
  • Bronchoconstriction.
  • Facial angioedema.
  • Laryngeal edema.

Possibly evidenced by

  • Chest tightness.
  • Cyanosis.
  • Coughing.
  • Dyspnea.
  • Hoarseness.
  • Respiratory distress.
  • Stridor.
  • Tachypnea.
  • Use of accessory muscles.
  • Wheezing.

Desired Outcomes

  • Client will maintain an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of adventitious breath sounds.
Nursing Interventions Rationale
Assess the respiratory rate, rhythm, and depth, and note for changes such as:

  • Coughing.
  • Dyspnea.
  • Increased shortness of breath.
  • Stridor.
  • Tachypnea.
  • Use of accessory muscles.
  • Wheezing.
Histamine is the primary mediator of anaphylactic shock. It causes smooth muscle contraction in the bronchi as a result of the stimulation of histamine receptors (H1). As the anaphylactic reaction progresses, the client develops dyspnea, wheezing, and increased pulmonary secretions. Vascular to interstitial fluid shifts to contribute to respiratory distress through swelling in the upper airways.
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 client’s anxiety level. Life-threatening situations such as respiratory distress and shock can produce elevated levels of anxiety within the client.
Assess the client for the sensation of a narrowed airway. Systemic antigen-antibody immune response can result in severe bronchial airway narrowing, edema, and obstruction. As airway gets narrow, client demonstrates increase respiratory effort.
Observe for changes in color of the skin, tongue, and mucosa. Bluish discoloration of these body parts is considered a medical emergency.
Assess the presence of angioedema. Angioedema is characterized by the swelling of the skin, lips, tongue, hands, eyelids, and feet.
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 progresses, aerobic metabolism stops and lactic acidosis occurs, resulting in the increased level of carbon dioxide and decreasing pH.
Maintain a calm, assured manner. Assure the client and significant others of close, continuous monitoring that will ensure prompt intervention. The staff’s anxiety may be easily perceived by the client. The client’s feeling of stability increases in a calm, non-threatening environment. The presence of a trusted person can help the client feel less threatened.
Provide assurance and alleviate anxiety by staying with the client during acute distress. Air hunger can produce an extremely anxious state that leads to rapid and shallow respirations.
Instruct the client to breathe slowly and deeply. Focus breathing may help calm the client, and the increase tidal volume facilitates improved gas exchange.
Position the client upright. This position provides oxygenation by promoting maximum chest expansion and is the position of choice during respiratory distress.
Administer IV fluids as ordered. Hypotension caused by vasodilation and distributive shock responds to fluid resuscitation.
Administer oxygen as prescribed. Oxygen increase arterial saturation. Oxygen saturation that is less than 90% results to tissue hypoxia, acidosis, dysrhythmias, and changes in the level of consciousness.
Administer medications as ordered:
  • Bronchodilators.
These medications reduce bronchospasm and help open the airways in the lungs by relaxing smooth muscle around the airways.
  • Corticosteroids.
Steroids stabilize the cell membrane and decrease cellular permeability, vasomotor response, and inflammation.
Epinephrine is the cornerstone of anaphylaxis management. It is fast-acting and relaxes pulmonary vessels to improve air exchange and stabilizes cellular permeability.
These medications block the action of histamine and decrease cellular edema.
Maintain a patent airway. Anticipate an emergency intubation or tracheostomy if stridor occurs. Respiratory distress may progress rapidly. If laryngeal edema is present, endotracheal intubation will be required to maintain a patent airway.
Home care: 
  • Provide information about emergency medications and plans that should be considered should a crisis reoccur.
Adequate preparation decreases risks.
  • Assist the client and/or family in identifying factors that precipitate and/or exacerbate crises.
Knowledge can facilitate prompt intervention.

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