Anaphylaxis Nursing Diagnosis & Care Plan

Anaphylaxis is an acute hypersensitivity reaction with potentially life-threatening consequences. It is often a sudden, multi-system, widespread allergic reaction. Anaphylaxis frequently results in death if untreated because it quickly progresses to respiratory failure

Anaphylactic reactions have traditionally been classified as Immunoglobulin E (IgE)-mediated responses, whereas anaphylactoid reactions are IgE-independent responses. The clinical condition and treatment for each reaction are the same regardless of the cause. Anaphylaxis is now used as a standard term for both reactions.

Exposure to specific medications, a particular food, insect bites, or latex are examples of common triggers. Hyper-acute reactions can result from immunotherapy injections intended to improve overall allergic response. Idiopathic anaphylaxis is the term for reactions in which the causative agent is not always known.

A hyperactive immune response causes anaphylaxis. The release of mast cells, basophils, and chemical mediators occurs after the re-exposure to an antigen, causing an overactive immune response. These symptoms typically affect just one part of the body. However, some people may experience a far more severe reaction which is anaphylaxis. Usually, more than one area of the body is affected simultaneously by this reaction.

Symptoms typically occur within 5-30 minutes of exposure and include:

  • Headache, dizziness, paresthesia, feeling of impending doom
  • Pruritus, angioedema, erythema, urticaria
  • Hoarseness, coughing, wheezing stridor, dyspnea, tachypnea, a sensation of airway narrowing, respiratory arrest
  • Hypotension, dysrhythmias, tachycardia, cardiac arrest
  • Cramping, abdominal pain, nausea, vomiting, diarrhea

Anaphylaxis can be identified through physical examination. Hence no lab tests or other diagnostic procedures are required.

Epinephrine is the drug of choice for anaphylaxis and should be given immediately when anaphylaxis is suspected or identified.

Nursing Process

Anaphylaxis requires prompt rapid diagnosis and care since cardiac or respiratory arrest and death can occur. Anaphylaxis is most treatable in its early stages. Initial management includes removal of the trigger, administering epinephrine as soon as possible, and managing the airway. It is crucial to provide health teaching with an epinephrine auto-injector on how to use it. Referral to an allergist and immunologist should also be considered. An allergist will help determine triggering allergens and prevent future reoccurrences through short-term desensitization.

Nursing Care Plans

Ineffective Airway Clearance

Ineffective airway clearance associated with anaphylaxis can be caused by airway spasms and laryngeal edema or swelling, leading to airway constriction and decreased oxygenation.

Nursing Diagnosis: Ineffective Airway Clearance

Related to:

  • Inflammatory reaction
  • Airway spasm
  • Laryngeal edema or swelling

As evidenced by:

  • Diminished breath sounds
  • Adventitious breath sounds 
  • Ineffective cough 
  • Difficulty speaking
  • Open, wide eyes
  • Cyanosis 
  • Labored breathing
  • Stridor
  • Use of accessory muscles

Expected outcomes:

  • Patient will maintain an oxygen saturation of 95-100%
  • Patient will be able to demonstrate clear breath sounds upon auscultation
  • Patient will be able to speak clearly without signs of difficulty

Assessment:

1. Rapidly assess the respiratory status.
Anaphylaxis causes swelling in the airway leading to obstruction in breathing. Suspect the patient to be in respiratory distress when there is a “lump in the throat,” observed clearing of the throat frequently, and any difficulty breathing. 

2. Locate the cause or trigger.
Knowing what causes anaphylaxis is crucial for management and future prevention. Common triggers are food, medications, insect stings, and latex.

3. Monitor vital signs.
An increased respiratory rate with oxygen saturation of less than 92% on pulse oximetry indicates respiratory distress and hypoxia caused by anaphylaxis.

4. Inspect for any signs and symptoms.
Look for signs and symptoms of a compromised airway: difficulty speaking, ineffective cough, cyanosis, labored breathing, use of accessory muscles, and presence of adventitious sounds (wheezing and stridor). 

Interventions:

1. Manage the airway.
Managing the airway is a priority. Delay may increase the danger of a surgical airway and decrease the likelihood of successful intubation as swelling persists.

2. Activate the Rapid Response Team (RRT).
The Rapid Response System (RRS) assists in identifying patients at risk of severe illnesses like anaphylaxis. Activating the RRT brings immediate expert assistance to perform interventions and lowers the mortality rate.

3. Elevate the head of the bed.
Elevate the head of the bed to 45 degrees or higher to improve ventilation.

4. Remove or discontinue the triggering allergen.
Any insect stinger left in the skin should be carefully removed. Advise the patient to rinse their mouth to remove food allergen residue.

5. Administer epinephrine as ordered.
Epinephrine is the gold standard for treating anaphylaxis since it lessens the reaction. Epinephrine should be administered intramuscularly (IM) immediately in the thigh. 

6. Give diphenhydramine as prescribed.
Antihistamines are commonly used, with a dosage of 25–50 mg via IV/IM administered to block histamine (a natural chemical the body produces when experiencing an allergic reaction).

7. Start oxygen therapy as ordered.
Cyanosis and hypoxia suggest severe anaphylaxis that requires high-flow oxygen.

8. Ensure airway management equipment is available.
Endotracheal intubation can help maintain airway patency, which almost always necessitates prompt and effective suctioning.


Decreased Cardiac Output

Decreased cardiac output associated with anaphylaxis can be caused by decreased preload due to a severe decrease in venous tone and fluid extravasation, histamine leakage causing blood vessels to leak fluid into the tissues, and vasodilation.

Nursing Diagnosis: Decreased Cardiac Output

Related to:

  • Decreased preload
  • Leak of histamine causing blood vessels to leak fluid into the tissues (third spacing)
  • Vasodilation

As evidenced by:

  • Tachycardia
  • Palpitations
  • Hypotension
  • Anxiety
  • Restlessness

Expected outcomes:

  • Patient will maintain pulse rate and blood pressure within therapeutic limits
  • Patient will be able to verbalize relief from anxiety and restlessness
  • Patient will be able to manifest a calm and well-rested appearance

Assessment:

1. Monitor the pulse rate and blood pressure.
The patient’s blood pressure decreases, and their pulse rate increases during anaphylaxis. This may indicate anaphylactic shock.

2. Assess cardiovascular status.
Cardiovascular collapse is a frequent symptom resulting from vasodilatation and plasma loss from the blood compartment. This is an unusual reaction to intravenous medications or bee stings.

3. Assess mental status changes.
Anaphylaxis can cause changes in mental status due to decreased blood flow to the brain.

Interventions:

1. Check for IV access.
Ensure patent IV access for blood sampling, medication, and IV administration. 

2. Immediately discontinue a suspected IV medication or infusion.
Colloid solutions are a known cause of anaphylaxis and are not advised for its treatment. Medications such as penicillin, aspirin, non-steroidal anti-inflammatory drugs, blood products, and anesthesia can also cause anaphylaxis. 

3. Administer IV fluids.
Fluid resuscitation is a central intervention for hypotension. Isotonic crystalloid bolus is recommended.

4. Administer vasopressors.
If additional doses of epinephrine are needed, but the patient is experiencing side effects, vasopressors may be given for hypotensive shock.

5. Prepare the emergency or crash cart at the bedside.
If first-line medications are not successful and the patient codes, additional life-saving interventions will be required. A crash cart should be at the bedside with all equipment available.


Deficient Knowledge

Deficient knowledge associated with anaphylaxis can result in a misunderstanding of triggers, symptoms, prevention, and management.

Nursing Diagnosis: Deficient Knowledge

Related to:

  • Insufficient knowledge about anaphylaxis
  • Inadequate understanding of signs and symptoms of anaphylaxis
  • Lack of information about emergency management of anaphylaxis
  • Misconception of anaphylactic triggers

As evidenced by:

  • Verbalization of concerns
  • Questions about anaphylaxis
  • Improper use of epinephrine auto-injector
  • Development of preventable complications such as anaphylactic shock
  • Nonadherence with prevention and management recommendations

Expected outcomes:

  • Patient will be able to verbalize an understanding of anaphylaxis and its signs and symptoms
  • Patient will verbalize two strategies to prevent anaphylaxis
  • Patient will not experience a recurrence of anaphylaxis

Assessment:

1. Determine the patient’s knowledge of anaphylaxis.
Before modifying health instructions, the nurse must first assess the patient’s knowledge of anaphylaxis and expectations for the treatment plan. The nurse can then develop pertinent and valuable instructions for the patient.

2. Identify the factors affecting learning.
The nurse must assess the patient’s attitude, capability, and limitations to learning about anaphylaxis. Ensure the patient is motivated to learn and is emotionally and mentally ready since this requires a lifetime commitment and adherence to prevention.

3. Assess for misconceptions and beliefs about anaphylaxis.
The nurse can assess the patient’s practices and beliefs to analyze their knowledge and differentiate between facts and myths. The nurse must emphasize accurate information about the causative allergens and actions to be taken for prevention and during an emergency.

4. Assess the patient’s skills in using the epinephrine auto-injector.
The self-administration of epinephrine is part of the emergency plan. It is essential to maintain the epinephrine auto-injector within the expiration date. Knowing how to use the epinephrine auto-injector is crucial for the patient, their family, and anyone else who interacts with the patient.

Interventions:

1. Develop the care plan with the patient.
Patient involvement includes the patient in decision-making. A lifetime commitment to avoiding triggers and compliance with desensitization procedures are necessary for fulfilling long-term goals.

2. Consider the patient’s learning factors in health teaching.
Adapt the teaching plan to the patient’s education level, attitude, strengths, and obstacles in learning anaphylaxis. Consider teaching methods for young or school-age children. Anaphylaxis can be prevented once the patient knows how to avoid and manage it.

3. Encourage inquiries.
Patients’ inquiries should be welcomed. Encourage queries by acting in a friendly, open manner. Anxiety is common in patients with anaphylaxis, and clarification can ease worry.

4. Reinforce positive comments.
When the patient’s health objectives are attained and complications are avoided, show appreciation for their efforts and adherence to their care plan.

5. Ask the patient to list the preventive measures of anaphylaxis.
The best method to prevent anaphylaxis is to avoid it. By letting the patient enumerate the precautions they can take to prevent anaphylaxis, the nurse can assess for effective learning.

6. Refer to an allergist.
An allergist can detect and create avoidance strategies appropriate for the patient’s age, activities, career, interests, living arrangements, and access to healthcare.

7. Discuss when to use an epinephrine injector in an emergency.
The patient should be given access to epinephrine auto-injectors at all times and should be comfortable using them.

8. Encourage them to carry two epinephrine auto-injectors if possible.
Although most patients only need one dose, further doses may be administered as needed every 5 to 10 minutes until symptoms subside.

9. Encourage wearing a medical alert bracelet.
Patients should be informed of the value of wearing a medical alert bracelet or identification in the event of an emergency.


References

  1. American Academy of Allergy, Asthma & Immunology. (2022). Anaphylaxis. AAAAI | American Academy of Allergy, Asthma & Immunology. https://www.aaaai.org/conditions-treatments/allergies/anaphylaxis
  2. Campbell, R. L., & Kelso, J. M. (2022). Anaphylaxis: Emergency treatment. Evidence-Based Clinical Decision Support System| UpToDate | Wolters Kluwer. https://www.uptodate.com/contents/anaphylaxis-emergency-treatment
  3. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
  4. Gardner, A. (2016). Everything you need to know about life-threatening anaphylaxis. WebMD. https://www.webmd.com/allergies/anaphylaxis
  5. National Center for Biotechnology Information. (2022). Anaphylaxis – StatPearls – NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK482124/
  6. NHS UK. (2017). Anaphylaxis. https://www.nhs.uk/conditions/anaphylaxis/
  7. Silvestri, L. A., & Silvestri, A. E. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
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Kathleen Salvador, MSN, RN

Kathleen Salvador is a registered nurse and a nurse educator holding a Master’s degree. She has more than 10 years of clinical and teaching experience and worked as a licensed Nursing Specialist in JCI-accredited hospitals in the Middle East. Her nursing career has brought her through a variety of specializations, including medical-surgical, emergency, outpatient, oncology, and long-term care.